CHAPTER 72
Botulism and anthrax symptoms
A client with a mild to moderate case of botulism experiences dry mouth, double vision, unfocused vision, weakness, a sense of paralysis, and an unsteady gait. Anthrax symptoms include fever, flulike symptoms, cough, and a sore throat. Ebola symptoms include malaise, fatigue, headache, sore throat, and nausea.
After a radiation exposure, a patient has been assessed and determined to be a possible survivor. Following the resolution of the patients initial symptoms, the care team should anticipate what event?
A latent phase commonly follows the prodromal phase of radiation exposure. The patient is deemed a possible survivor, not a probable survivor, so an immediate return to health is unlikely. However, internal bleeding and massive tissue necrosis would not be expected in a patient categorized as a possible survivor.
The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for?
A person exposed to a blistering agent or vesicant must be decontaminated immediately, with clothing removed and bagged. Irrigation of the victim's eyes and application of topical analgesia, antibiotics, and lubricants to the skin occur. Simultaneously, the nurse is assessing the respiratory system for airway obstruction because blisters from inhaled toxics can swell obstructing respiratory passages.
Mass Casualty Incident (MCI)
An incident where the number and severity of casualties exceeds the capability of the responder's initial resources
Nurses should have a heightened awareness of trends that may suggest deliberate dispersal of toxic or infectious agents or pandemic onset that may include the following:
An unusual increase in the number of people seeking care for fever, respiratory, or gastrointestinal symptoms Clusters of patients who present with the same unusual illness from a single location. For example, clusters can be from a specific geographic location, such as a city, or from a single sporting or entertainment event. A large number of fatalities, especially when death occurs within 72 hours after hospital admission Any increase in disease incidence in a normally healthy population. These cases should be reported to the state health department and to the CDC.
Anthrax Clinical Manifestations
Anthrax is caused by replicating bacteria that release toxin, resulting in hemorrhage, edema, and necrosis. The incubation period is 1 to 6 days. There are three main methods of infection: skin contact, gastrointestinal ingestion, and inhalation. Skin lesions (the most common infection) cause edema with pruritus and macule or papule formation, resulting in ulceration with 1- to 3-mm vesicles. A painless eschar develops, which falls off in 1 to 2 weeks
Inhalation of anthrax mimics which disease process?
Anthrax symptoms mimic those of the flu, and usually treatment is sought only when the second stage of severe respiratory distress occurs. Burns occur with sulfur mustard. Bronchospasm can occur with phosgene or chlorine. Respiratory distress may occur with cyanide.
treatment for anthrax
At present, anthrax is penicillin sensitive; however, strains of penicillin-resistant anthrax are thought to exist. Recommended treatment includes penicillin (Penicillin V), erythromycin (Erythrocin), gentamicin (Garamycin), or doxycycline (Vibramycin). If antibiotic treatment begins within 24 hours after exposure, death can be prevented. In a mass casualty situation, treatment with ciprofloxacin (Cipro) or doxycycline is recommended, because these easily given oral antibiotic agents are stockpiled and there should be sufficient dosages to fully treat many patients who have been anthrax-exposed. Treatment is continued for 60 days. For patients who have been directly exposed to anthrax but have no signs and symptoms of disease, ciprofloxacin or doxycycline is used for prophylaxis for 60 days
medication for nerve agents (sarin, and soman)
Atropine is administered when a patient is exposed to a nerve agent. Exposure to blood agents, such as cyanide, requires treatment with amyl nitrate, sodium nitrite, and sodium thiosulfate. Dimercaprol is administered IV for systemic toxicity and topically for skin lesions when
Botulism
Botulism is a disease that develops from the neurotoxin produced by Clostridium botulinum.
critical incident stress management:
CISM is an approach to preventing and treating the emotional trauma that can affect emergency responders as a consequence of their jobs and that can also occur to anyone involved in a disaster or MCI.
chemical weapons
Chemical weapons include cyanide (a blood agent), phosgene (a vesicant and pulmonary agent), and sarin (a nerve agent). Anthrax and tularemia are examples of biologic agents of terror.
As a member of a disaster response team that is responding to a large industrial fire that may involve chemical exposure, a nurse is gathering information from several bystanders. Which statement would lead the nurse to suspect that cyanide is involved?
Cyanide is often associated with the smell of bitter almonds. Therefore, the statement of the air having a strange smell would suggest cyanide involvement. Burning and stinging of the skin would be associated with exposure to vesicants. Gastrointestinal upset and vomiting would lead to suspicions of nerve gas involvement. Coughing and shortness of breath would be related to exposure to pulmonary agents.
A 44-year-old male patient has been exposed to severe amount of radiation after a leak in a reactor plant.
Damage to the hematopoietic system following radiation exposure creates a serious risk for infection.
treatment for nerve agents
Decontamination with copious amounts of soap and water or saline solution for 8 to 20 minutes is essential.Fresh 0.5% hypochlorite solution (bleach) can also be used. The airway is maintained, and suctioning is frequently required. Plastic airway equipment should not be used, because plastic will absorb sarin gas and may result in continued exposure to the agent.Atropine 2 to 4 mg is administered by IV, followed by 2 mg every 3 to 8 minutes for up to 24 hours of treatment. Alternatively, IV atropine 1 to 2 mg per hour may be given until clear signs of anticholinergic activity have returned (decreased secretions, tachycardia, and decreased gastrointestinal motility). Another medication that may serve as an antidote is pralidoxime (Protopam), which allows cholinesterase to become active against acetylcholine. Pralidoxime 1 to 2 g in 100 to 150 mL of normal saline solution is given over 15 to 30 minutes. Pralidoxime has no effect on secretions and may have any of the following side effects: hypertension, tachycardia, weakness, dizziness, blurred vision, and diplopia. Diazepam (Valium) or other benzodiazepines are used to control seizures, to decrease fasciculations, and to alleviate apprehension and agitation
management plan after incident:
Defusing is a process by which the person receives education about recognition of stress reactions and management strategies for handling stress. Debriefing is a more complicated intervention; it involves a 2- to 3-hour process during which participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing (e.g., flashbacks, difficulty sleeping, intrusive thoughts), and other psychological ramifications.
which chemical is a vesicant
Examples of vesicants are phosgene, nitrogen mustard, and sulfur mustard. Sarin is a nerve agent. Hydrogen cyanide is a blood agent. Chlorine is a pulmonary agent.
Three types of radiation-induced injury can occur
External irradiation exposure occurs when all or part of the body is exposed to radiation that penetrates or passes completely through the body. In this type of exposure, the person is not radioactive and does not require special isolation or decontamination measures. Irradiation does not necessarily constitute a medical emergency. 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. Contamination requires immediate medical management to prevent incorporation. Incorporation is the actual uptake of radioactive material into the cells, tissues, and susceptible organs. The organs involved are usually the kidneys, bones, liver, and thyroid.
Cyanide treatment
First, the patient is intubated and placed on a ventilator. Next, amyl nitrate pearls are crushed and placed in the ventilator reservoir to induce methemoglobinemia. Cyanide binds methemoglobin to form either cyanomethemoglobin or sulfmethemoglobin. The cyanomethemoglobin is then detoxified in the liver by the enzyme rhodanese. Next, IV sodium nitrite is given to induce the rapid formation of methemoglobin. IV sodium thiosulfate is then given; it has a higher affinity for cyanide than methemoglobin and stimulates the conversion of cyanide to sodium thiocyanate, which can be excreted by the kidneys Although they may be lifesaving, these emergency medications do have side effects—sodium nitrite can result in severe hypotension, and thiocyanate can cause vomiting, psychosis, arthralgia, and myalgia.
The North Atlantic Treaty Organization (NATO) triage system
It consists of four colors: red, yellow, green, and black
Latency
Latency is the time from absorption to the appearance of signs and symptoms. Sulfur mustards and pulmonary agents have the longest latency, whereas vesicants, nerve agents, and cyanide produce signs and symptoms within seconds.
What should you advise a patient to do during a biochemical terrorist attack?
Most chemicals are heavier than air, except for hydrogen cyanide. Therefore, in the presence of most chemicals, people should stand up to avoid heavy exposure because the chemical will sink toward the floor or ground. For this reason, covering their eyes, putting on a PPE mask, or crawling to an exit will not decrease exposure.
A patient was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The patients skin will eventually show what manifestation?
Necrosis of the skin will become evident within a few days to months at doses of more than 5,000 rads. With 600 to 1,000 rads, erythema will occur; it can disappear within hours and then reappear. At greater than 1,000 rads, desquamation (radiation dermatitis) of the skin will occur. Ecchymosis does not occur.
The nurse is caring for a client affected by a nerve agent. The nurse quickly gives a tutorial on the neurotransmitters and nervous system affected. Which couplet is most correct?
Nerve agents cause fatal consequences by inhibiting acetyl cholinesterase. Acetyl cholinesterase is an enzyme that inactivates acetylcholine, a neurotransmitter of the parasympathetic nervous system. No other option is correct.
There has been a radiation-based terrorist attack and a patient is experiencing vomiting, diarrhea, and shock after the attack. How will the patients likelihood of survival be characterized?
Patients who experience vomiting, diarrhea, and shock after radiation exposure are categorized as improbable survival, because they are demonstrating symptoms of exposure levels of more than 800 rads of total body-penetrating irradiation.
A client has been exposed to and inhaled botulism. When providing care to this client, which of the following would be necessary for the nurse to follow?
Standard precautions are used when providing care to clients with botulism because the agent is not contagious through human-to-human contact.
The nurse is assessing a victim who is reported to have been exposed to sulfur mustard. The nurse's assessment should include evaluation for
Sulfur mustard causes superficial to partial-thickness burns with vesicles that coalesce. Phosgene causes pulmonary edema. Sarin causes increased gastrointestinal motility and diarrhea. Cyanide causes cardiac arrest and death.
common chemical agents
Sulfur mustard is a vesicant chemical that causes blistering and results in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death. Nerve agents include sarin, soman, tabun, VX, and organophosphates (pesticides). Hydrogen cyanide is a blood agent that has a direct effect on cellular metabolism, resulting in asphyxiation through alterations in hemoglobin. Chlorine is a pulmonary agent, which destroys the pulmonary membrane that separates the alveolus from the capillary bed.
A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated. The supervisor will need to work with what organization responsible for coordinating interagency relief assistance?
The Office of Emergency Management coordinates the disaster relief efforts at state and local levels. The Incident Command System is a management tool to organize personnel, facilities, equipment, and communication in an emergency situation. The CDC is the agency for disease prevention and control and it supports state and local health departments. The American Red Cross provides additional support.
Types of Explosive Devices:
The bomb most commonly utilized by terrorists is the pipe bomb, which contains low-velocity explosives and may also contain nails or other implements that cause more damage when the explosive ignites. Molotov cocktail, which uses a common flammable liquid such as gasoline in a glass bottle and a source of ignition, such as a rag. This forms a simple yet effective incendiary(causing fire) device. Other types of explosive devices include fertilizer bombs and dirty bombs, which include a radioactive source that spreads radiation after the initial blast
The announcement is made that the facility may return to normal functioning after a local disaster. In the emergency operations plan, what is this referred to as?
The demobilization response occurs when it is deemed that the facility may return to normal daily functioning.
casualties arrive in hospitals in 3 waves:
The first wave consists of people who are minimally (generally) injured who arrive of their own accord. The second wave consists of patients who are severely injured. The third wave consists of patients who are injured and who arrive after they are discovered by rescuers. For example, in the event of earthquakes, buildings collapse and cause the majority of fatalities from injuries primarily involving the head and ches
If a client has been exposed to radiation, the presenting symptoms, such as nausea, vomiting, loss of appetite, diarrhea, or fatigue, can be expected to occur within how many hours after exposure?
The prodromal phase (presenting symptoms) of radiation exposure occurs within 48 to 72 hours after exposure. Signs and symptoms include nausea, vomiting, loss of appetite, diarrhea, and fatigue. With high-dose radiation exposure, the signs and symptoms may include fever, respiratory distress, and increased excitability.
A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments?
The second stage of anthrax infection by inhalation includes severe respiratory distress, including stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock. The first stage includes flu-like symptoms.
The student nurse is completing a simulation where a client is the victim of nerve gas. The instructions are for the student to set up the room and have all needed supplies available. Which medication does the student nurse ensure is in the medication administration system to control seizures?
The students nurse is correct to have Valium intravenously on hand for seizure activity. When seizure activity occurs, the intravenous route is the best option to deliver the medication safely and rapidly into the system.
Four effects of a blast wave
These include 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 of different body tissues, dependent on their density; and irreversible work, which refers to the presence of forces that exceed the tensile strength of an organ or tissue.
small pox treatment
Treatment includes supportive care with antibiotic agents for any additional infection. The patient must be isolated with the use of transmission precautions. Laundry and biologic wastes should be autoclaved before being washed with hot water and bleach. Standard decontamination of the room is effective. All people who have household or face-to-face contact with the patient after the fever begins should be vaccinated within 4 days to prevent infection and death. A patient with a temperature of 38°C (101°F) or higher within 17 days after exposure must be placed in isolation. Cremation is preferred for all deaths, because the virus can survive in scabs for up to 13 years
Types of radiation
alpha-Alpha particles cannot penetrate the skin. A thin layer of paper or clothing is all that is necessary to protect the skin from alpha radiation. However, this low-level radiation can enter the body through inhalation, ingestion, or injection (open wound). Only localized damage occurs. beta-Beta particles have the ability to moderately penetrate the skin to the layer in which skin cells are being produced. This high-energy radiation can cause skin damage if the skin is exposed for a prolonged period and can cause injury if beta particles penetrate the skin. gamma-Gamma radiation is a short-wavelength electromagnetic energy that is emitted when there is excess core nucleus energy. Gamma particles are penetrating. Therefore, it is difficult to shield against gamma radiation. X-rays are an example of gamma radiation. Gamma radiation often accompanies both alpha particle and beta particle emission.
disaster tags
are numbered and include triage priority, name, address, age, location and description of injuries, and treatments or medications given, are used to communicate patient information
Incident Command System (ICS)
federally mandated command structure that coordinates personnel, facilities, equipment, and communication in any emergency situation. The ICS is the center of operations for organization,planning, and transport of patients in the event of a specific local MCI.
shrapnel
fragments of a bomb, shell, or other object thrown out by an explosion.
clinical manifestations of small pox
include high fever, malaise, headache, backache, and prostration. After 1 to 2 days, a maculopapular rash appears, beginning on the face, mouth, pharynx, and forearms. Only then does the rash progress to the trunk and also become vesicular to pustular . There is a large amount of the virus in the saliva and pustules. Smallpox is contagious only after the appearance of the rash. There are two forms of smallpox: variola major and variola minor. Variola major is more common, results in a higher fever and more extensive rash, and has a 30% case fatality rate . Hemorrhagic smallpox, a subtype of variola major, includes all of the above signs and symptoms plus a dusky erythema and petechiae leading to frank hemorrhage of the skin and mucous membranes, and it results in death by day 5 or 6
The U.S. Environmental Protection Agency (EPA) has divided protective clothing and respiratory protection into the following four categories, levels A through D
level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. This includes a self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots. Level B protection requires the highest level of respiratory protection but a lesser level of skin and eye protection than with level A situations. This level of protection includes the SCBA and a chemical-resistant suit, but the suit is not vapor tight. Level C protection requires the air-purified respirator, which uses filters or sorbent materials to remove harmful substances from the air. A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots are included in level C protection. Level D protection is the typical work uniform. Levels C and D PPE are the levels most often used in hospital facilities.
Weapons of Mass Destruction (WMD)
nuclear, biological, and chemical weapons intended to kill or harm on a large scale
what substance to be ordered to reduce radiologic organ damage?
potassium iodide
A client who develops an air embolism secondary to a blast injury should be positioned in the
prone left lateral position to prevent the embolus from migrating
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
Small pox (variola)
smallpox (variola) is classified as a deoxyribonucleic acid (DNA) virus. It has an incubation period of approximately 12 days. It is extremely contagious and is spread by direct contact, by contact with clothing or linens, or by droplets from person to person only after the fever has decreased and the rash phase has begun.
2 steps of decontamination
the first step is removal of the patient's clothing and jewelry and then rinsing the patient with water. The second step consists of a thorough soap-and-water wash and rinse.
characteristics of chemicals:
volatility- Volatility is the tendency for a chemical to become a vapor. The most common volatile agents are phosgene and cyanide. persistence- Persistence means that the chemical is less likely to vaporize and disperse. toxicity-Toxicity is the potential of an agent to cause injury to the body. The median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed. For example, cyanogen chloride has the highest LD50, twice that of hydrogen cyanide and eight times higher than sulfur mustard (ACS, 2010). The median effective dose (ED50) is the amount of the chemical that will cause signs and symptoms in 50% of those who are exposed. latency- Latency is the time from absorption to the appearance of signs and symptoms. Sulfur mustards and pulmonary agents have the longest latency, whereas other vesicants, nerve agents, and cyanide produce signs and symptoms within seconds.
