Nursing In Disasters
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4-25-08
Kathy Batton
Nursing in Disasters •
•
Disasters and Nursing o
A sudden and massive disruption in health care service because of hostile elements of any kind (natural and man-made) requiring survival resources be brought into action in the shortest possible time using the fewest resources
o
Does not necessarily mean numerous injured or dead. It may be 5 critically injured MVA clients taken to a small community hospital.
Disaster Types o
o
•
Natural
Tornadoes
Hurricanes
Earthquakes
Blizzards
Epidemics
Man-Made
Fires
Explosions
Nuclear accidents
Bombings
Biological
Chemical
Radiation
War
Nurses Role in Disaster Triage o
Triage will be based on utilization of resources to treat the MOST people
o
Good of the “whole” becomes more important than good of the individual
4-25-08
•
Kathy Batton o
Potential outcomes/ survivability and available resources is the issue-not degree of injury
o
Nurses will still be involved with assessment and basic treatment
Disaster Triage Categories o
o
o
o
o •
Immediate/ Priority 1/ Red Tagged
Life threatening injuries that are survivable with minimal interventions
Examples: airway obstruction, sucking chest wounds, tension pneumothorax, hemothorax, open fractures of long bones, burns (2nd and 3rd degree as long as it is 15%-40% of the TBSA)
This group can rapidly deteriorate without treatment and become black tagged
Delayed/ Priority 2/ Yellow Tagged
Significant injuries that are survivable with medical care, but aren’t going to die immediately without care
Examples: stable abdominal injuries, fractures that need reducing, eye injuries, soft tissue injuries, facial injuries without airway difficulties
Can go from yellow to red as they get sicker
Minimal/ Priority 3/ Green Tagged
Minor injuries, treatment can be delayed for hours or days without death
Examples: sprains, cuts, fractures that don’t have to be reduced surgically, psych people
Expectant/ Priority 4/ Black Tagged
Significant injuries, chances of survival are minimal even with immediate care or walking wounded
Examples: nursing home patients who are DNR, unresponsive people with penetrating head wounds, major burns over 60% of body, fixed and dilated pupils, brain matter coming out of ears, this is also the walking wounded
People that will be fine even if they don’t get medically treated. Usually the walking wounded are trying to care of the dying.
After triage category decided the person is tagged and treated and / or transported, triage continues at each point of care.
Disaster Levels
4-25-08
•
•
Kathy Batton o
Level I-local emergency response personnel and organizations can contain and effectively manage the disaster and its aftermath
o
Level II-regional efforts and aide from surrounding communities are sufficient to manage the effects of the disaster
o
Level III- local and regional assets are overwhelmed; state wide or federal assistance is required
Terrorism Recognition and Awareness o
Be aware of an unusual increase in the number of people with fever of GI problems
o
Unusual illness for time of year
o
Cluster of client from a specific location
o
Large number of rapidly fatal cases with death in 72 hours
o
Increase in disease in otherwise healthy population
Levels of protection for health care workers o
Level A- highest level of respiratory, skin, eye, mucus membrane protection
•
Covered from head to toe, breathing apparatus, chemical resistant
o
Level B-same respiratory but less skin and eye protection, still wear chemical resistant suit
o
Level C-air purified respirator, with filters that remove harmful substances and a chemical resistant coverall, gloves, boots, and splash hood
o
Level D- what you would normally wear plus universal precautions
Weapons of Terror o
Biological Weapons
Easily obtained
Easily disseminated
Significant morbidity and mortality
Signs and symptoms similar to common diseases
May be liquid, dry, applied to foods or water or vaporized
4-25-08
Kathy Batton
Vector may be animal, insect, or human or direct contact with agent itself.
Types •
Anthrax/Bacillus Anthracis o
Most likely weapon to be used (has been used before)
o
Naturally occurring in soil
o
As an aerosol it is odorless and invisible and can travel for miles
o
Causes hemorrhage, edema and necrosis
o
Incubation period is 1-6 days
o
Use standard precautions
o
Skin contact
o
Signs and symptoms •
edema with pruritis
•
macule, papule formation resulting in ulceration with 1-3mm vesicles
•
eschar (painless) develops and falls off in 1-2 weeks
Nursing care •
Treat symptoms
•
Maybe antibiotics
Ingestion
Signs and symptoms •
Fever
•
Nausea and vomiting
•
Abdominal pain
•
Bloody diarrhea (occ. Ascites)
•
Massive diarrhea can result in volume depletion
4-25-08
Kathy Batton
o
•
Can result in sepsis
•
Frequently fatal due to sepsis
Nursing care •
Assess for and maintain adequate fluid status
•
Treat symptoms
•
Assess for sepsis
Medications •
Fluoroquinolones
•
Tetracycline
•
Penicillin
Inhalation
Signs and symptoms •
•
Mimics flu-in first stage o
Headache, syncope
o
Cough, dyspnea (no rhinorrhea or nasal congestion)
o
Fever, chills
o
Vomiting, weakness
After initial s/s brief recover period then 1-3 days o
Fever
o
Severe respiratory distress, strider, hypoxia, cyanosis
o
50% have hemorrhagic mediastinitis on x-ray
o
Diaphoresis
4-25-08
Kathy Batton
•
o
Hypotension
o
Shock
o
May progress to meningitis with SA hemorrhage
o
Death 24-35 hours
o
Mortality rate near 100%
Nursing Care •
Use standard precautions
•
If antibiotics started within 24 hours after exposure death can usually be prevented
•
Nurses must be vigilant in surveillance
•
Penicillin, chloramphenicol, gentamicin or doxycycline
•
For mass exposure and persons exposed but without s/s-doxycycline or ciprofloxacin for 60 days
•
Cremation for the dead
Smallpox/ Variola Major o
DNA virus
o
Highly contagious
o
Lives 24 hours in cool temperatures
o
30% Mortality rate, morbidity rate extremely high
o
Spread by direct contact and contact with clothing, linens, or by droplet
o
Contact precautions and droplet precautions
o
Incubation period
7-17 days
Not contagious during this time
4-25-08
Kathy Batton
o
o
o
Feel fine
Contagious after patient develops fever
Prodrome Phase
Sometimes contagious
Lasts 2-4 days
Fever (high 101-104F) highest when rash starts
Malaise, head and body aches
Feel too sick to carry
Rash phase
4 days
Most contagious during rash phase
Starts as small red spots on tongue and in mouth, these rupture and spreads virus into mouth and throat, rash then starts of face and spreads to arms and legs and then hands and feet
Rash is everywhere in 24 hours
As rash appears fever decreases they feel better
3rd day of rash is raised bumps
4th day bumps fill with thick opaque fluid and have depression in center (looks like a belly button and a major characteristic)
Fever will rise again and stay high until scabs form over the bumps
Pustular Rash Phase
Duration -5 days
Bumps become pustules-raised, usually round and firm
Crust and scabs form (duration about 5 days,) by end of the second week of the rash most of the sores have formed scabs
4-25-08
Kathy Batton •
Hemorrhagic smallpox o
Same s/s as variola major except dusky erythema and petechiae to frank hemorrhage of the skin and mucus membranes
o
Death usually within 5-6 days
o
Nursing Care for both types of Smallpox
o
Protect yourself (contact and airborne precautions)
Symptomatic care
Assess for additional infection-if present administer antibiotics
Vaccine administered up to 4 days after exposure-before the rash appears will help prevent and or decrease disease symptoms
Chemotherapeutic agent-Cidofovir is being used experimentally in the lab
Bodies should be cremated
Infection control
•
Once scabs are gone, patient is no longer contagious
Wear gloves, caps, gowns, and surgical masks
Tularemia o
Also known as deerfly or rabbit fever
o
Naturally found in small mammals and the insects that bite them
o
Can survive for weeks at low temps in water, moist soil, hay, straw, or decaying animal carcasses
o
Can be aerosolized for biological weapon use
o
Mortality rate not high
o
Can’t be spread from person to person
o
S/S
Develop 3-5 days
4-25-08
Kathy Batton
o
•
May be mild illness or acute sepsis and rapid death
Sudden fever, chills, headache, diarrhea, generalized aching, dry cough sore throat without adenopathy, then progressive weakness, pneumonia to chest pain, blood sputum and dyspnea
If inhaled death due to pneumonitis, sepsis and shock
Nursing care
For inhaled, treatment within 48 hours
Treat symptomatically
Streptomycin or gentamicin for 10-14 days
For mass casualty, doxycline or cipro for 14 days
Botulism o
Produces a neurotoxin
o
Exposure results in flaccid paralysis
o
May be ingested or inhaled
o
Spread via direct contact
o
Not contagious via human to human
o
Use standard precautions
o
If skin contact use soap and water or bleach solution to clean
o
S/S
GI-abdominal cramps, N&V, diarrhea
Inhaled (manmade) •
Symmetric descending paralysis
•
Diploplia
•
Dysphagia, dry mouth, altered mental status
•
death from airway obstruction and decreased tidal volume
4-25-08
Kathy Batton
•
may or may not have fever
•
usually responsive initially
Nursing care •
•
Supportive care o
Mechanical ventilation
o
Fluids and nutrition
o
Do not give aminoglycosides or clindamycin
o
No isolation required
Antitoxin o
•
Equine antitoxin given to decrease nerve damage-check allergies
Plague o
Necrosis and destroys the lymph nodes
o
Pneumonic plague type most likely to be used in terrorism
o
Will likely be aerosolized
o
Pneumonic is contagious through human to human contact
o
Transmitted via respiratory droplet contact
o
s/s
o
severe bronchospasms
chest pain
dyspnea, cough
hemoptysis
100% mortality if not treated within first 24 hours after exposure, even with treatment mortality is 50%
Treatment
Symptomatic
4-25-08
Kathy Batton
o
Utilize barrier precautions with full face respirators
Have client wear mask
Streptomycin or gentamicin for 10-14 days
After close contact give doxycycline for 7 days
Chemical Weapons
Nerve Agents •
Sarin Gas-heavier than area, settles in low areas o
Evaporates into a colorless, odorless, vapor
o
Can be inhaled or absorbed
o
Results in continuous stimulation of the nerve endings
o
S/S start in ½ hour to 18 hours
o
Bilateral miosis
Visual disturbances
GI motility
N&V, and diarrhea
Substernal spasm
Bradycardia
AV block
Bronchoconstriction
Laryngeal spasm
Seizures
Death –really bad death
Nursing Care
Decontamination at site with copious amounts of water or NS for 8-20 minutes
Blot to dry
4-25-08
Kathy Batton
•
Maintain airway
Suction PRN
Decontamination at hospital
IV atropine 2-4 mg, Then 2 mg every 3-8 minutes for up to 24 hours or atropine 1-2 mg every hour until resolution
Pralidoxime 1-2mg in NS IVPB over 15-30 minutes
Diazepam (valium) or benzodiazepines for seizures
Cyanide o
Affect cellular metabolism resulting in alterations of hemoglobin that leads to asphyxiation
o
Has a bitter almond odor
o
Can be ingested inhaled or absorbed through skin and mucus membranes
o
Inhalation symptoms
o
Flushing
Tachycardia
Nonspecific neurologic symptoms
Seizure
Respiratory arrest
Nursing Care
Intubate
Ventilate
Nitrate pearls-put in reservoir of ventilator
Sodium nitrate-given IV 300mg over 2-4 minutes
Sodium thiosulfate-given IV 12.5mg over 5 minutes
Alternative treatment-vitamin B12
4-25-08
Kathy Batton •
Chemical Vesicants (mustards, phosgene, lewisite-contains arsenic) o
Cause blistering and burning
o
Minimal mortality but large morbidity
o
Sulfa mustard smells like garlic
o
Signs and Symptoms
o
•
Initially presents like a large superficial partial thickness burn in warm, moist areas
Then pruritus painful burning and vesicle formation
Possibly a purulent fibrinous discharge that may obstruct airway
Nursing Care
Treated as a burn
Decontaminate with soap and water
Do not rub skin
Irrigate eyes if exposed
If respiratory exposure-intubate, ventilate, and prepare for bronchoscopy
Observe all mustard exposures for 24 hours due to possible latent effects
Chemical Pulmonary Agents (phosgene, chlorine) o
Destroy pulmonary membrane that separates alveolus from the capillary bed
o
Capillary leaks result in fluid filled alveoli
o
Phosgene smell like fresh-mown hay
o
S/S
Pulmonary edema with SOB
Hacking cough that progresses to frothy sputum
4-25-08
Kathy Batton o
o
Nursing Care
Supportive
Airway management
Intubate
ventilate
Radiation Weapons
Types •
•
•
•
Alpha o
Low level
o
Localized damage only
Beta o
Moderately penetrates the skin
o
Skin damage if prolonged exposure
Gamma o
Penetrates
o
Difficult to shield from
o
Often accompanies alpha and beta emissions
Measurement and Detection o
Rad-basic unit of measurement
o
Rem-type of radiation and potential for damage
o
Half life-time it takes to lose half of radioactivity
o
Geiger counter-detects gamma and some beta radiation
o
Personal dosimeters-worn by radiology personnel to detect exposure
o
It is the dose rather than the source that determines if ARS will develop
4-25-08
Kathy Batton •
Radiation Exposure/ injury o
Time-how long they were exposed
o
Distance-how close they were to the source
o
Shielding-decreasing exposure by stopping at shield
o
External Irradiation-when body itself exposed, all the way through the body, but the patient doesn’t become radioactive
o
Contamination-body has been exposed to source of radiation, don’t touch someone who is contaminated-need to be decontaminated-need medical attention very quickly to prevent incorporation
o
Incorporation – patient will have radiation that goes into the cells of their body-will kill off liver, kidneys, bone, and thyroid
o
Nursing care should begin at the scene
Decontaminate without contamination of rescuers
Assess presenting symptoms to determine triage
Triage based on predicted survival •
Probable-minimal or no initial s/s o
•
•
Possible-N/V for 24-48 hrs o
Start supportive measures
o
Probably go ahead and isolate them (reverse isolation)
Improbable-greater than 800 rad of total body penetrating irradiation-death o
CBC, discharge with possible instructions to return for certain s/s
Shock, neurological symptoms
Decontamination •
First decontamination then triage, should occur at the scene
4-25-08
Kathy Batton
o
•
Disaster plan should be in effect
•
Immediately notify hospital radiation safety officer
•
Survey for exposure
•
Triage outside the hospital if possible to prevent facility contamination
•
Cover floors
•
Strict isolation
•
Control waste
•
Staff should wear dosimeter badges, and protective covering
•
Decontamination should occur outside the hospital (shower, collection pool, tarp collection containers for belongings). Provide soap, towels, disposable paper gowns
•
Then survey-decontaminate until free of contamination
•
After survey indicates no external contamination victim can be sent into hospital
•
Biologic samples should be taken
•
If client has internal contamination or incorporation then catharsis and/ or gastric lavage with chelating agents
•
Sample of urine feces, and vomitus may be surveyed to determine internal effects
Acute Radiation Syndrome (ARS)
Severity determined by dose,, rate, total body exposure and penetrating type radiation
Age, medical history, and genetics
Cells that multiply rapidly are most affected
4-25-08
Kathy Batton o
o
Hematopoietic system affected first
Outcome indicators
Lymphocyte count 48 hours after exposure-3001200=significant exposure
600 rad or more=GI symptoms=NV in 2 hours post exposure
1000 rad or more = CNS symptoms
600-1000 rad effects skin
5000 rad or more= necrosis in a few days to months
Secondary injury may be present if exposure due to blast or burn-trauma increases mortality
Phases of ARS
Prodromal phase •
s/s 48-72 hours post exposure o
•
NV, decreased appetite, fatigue, high dose=fever, resp distress, excitability
Monitor lymphocyte count, provide fluids and electrolytes, if significant exposure isolate to prevent infection, bleeding precautions
Latent phase •
Symptom free period
•
Lasts up to 3 wks-less if significant exposure
•
Decreasing lymphocytes, platelets, leukocytes, thrombocytes, and RBC’s
•
Isolation as needed
•
Frequent rest periods
•
O2 PRN
•
Bleeding precautions
4-25-08
Kathy Batton •
•
Supportive measures
Illness phase •
Infections
•
Fluid and electrolyte imbalances
•
S/S =bleeding, shock, change in LOC
•
Treat symptomatically
•
Isolation precautions
Recovery phase or death •
Can take weeks or months to recover or die
•
S/S=increasing ICP is ominous sign of impending death
•
Supportive care
•
ABC’s
www.thepodgame.com o
Can become a disaster worker to see how well you manage your disasters
Kathy Batton
Nursing in Disasters •
•
Disasters and Nursing o
A sudden and massive disruption in health care service because of hostile elements of any kind (natural and man-made) requiring survival resources be brought into action in the shortest possible time using the fewest resources
o
Does not necessarily mean numerous injured or dead. It may be 5 critically injured MVA clients taken to a small community hospital.
Disaster Types o
o
•
Natural
Tornadoes
Hurricanes
Earthquakes
Blizzards
Epidemics
Man-Made
Fires
Explosions
Nuclear accidents
Bombings
Biological
Chemical
Radiation
War
Nurses Role in Disaster Triage o
Triage will be based on utilization of resources to treat the MOST people
o
Good of the “whole” becomes more important than good of the individual
4-25-08
•
Kathy Batton o
Potential outcomes/ survivability and available resources is the issue-not degree of injury
o
Nurses will still be involved with assessment and basic treatment
Disaster Triage Categories o
o
o
o
o •
Immediate/ Priority 1/ Red Tagged
Life threatening injuries that are survivable with minimal interventions
Examples: airway obstruction, sucking chest wounds, tension pneumothorax, hemothorax, open fractures of long bones, burns (2nd and 3rd degree as long as it is 15%-40% of the TBSA)
This group can rapidly deteriorate without treatment and become black tagged
Delayed/ Priority 2/ Yellow Tagged
Significant injuries that are survivable with medical care, but aren’t going to die immediately without care
Examples: stable abdominal injuries, fractures that need reducing, eye injuries, soft tissue injuries, facial injuries without airway difficulties
Can go from yellow to red as they get sicker
Minimal/ Priority 3/ Green Tagged
Minor injuries, treatment can be delayed for hours or days without death
Examples: sprains, cuts, fractures that don’t have to be reduced surgically, psych people
Expectant/ Priority 4/ Black Tagged
Significant injuries, chances of survival are minimal even with immediate care or walking wounded
Examples: nursing home patients who are DNR, unresponsive people with penetrating head wounds, major burns over 60% of body, fixed and dilated pupils, brain matter coming out of ears, this is also the walking wounded
People that will be fine even if they don’t get medically treated. Usually the walking wounded are trying to care of the dying.
After triage category decided the person is tagged and treated and / or transported, triage continues at each point of care.
Disaster Levels
4-25-08
•
•
Kathy Batton o
Level I-local emergency response personnel and organizations can contain and effectively manage the disaster and its aftermath
o
Level II-regional efforts and aide from surrounding communities are sufficient to manage the effects of the disaster
o
Level III- local and regional assets are overwhelmed; state wide or federal assistance is required
Terrorism Recognition and Awareness o
Be aware of an unusual increase in the number of people with fever of GI problems
o
Unusual illness for time of year
o
Cluster of client from a specific location
o
Large number of rapidly fatal cases with death in 72 hours
o
Increase in disease in otherwise healthy population
Levels of protection for health care workers o
Level A- highest level of respiratory, skin, eye, mucus membrane protection
•
Covered from head to toe, breathing apparatus, chemical resistant
o
Level B-same respiratory but less skin and eye protection, still wear chemical resistant suit
o
Level C-air purified respirator, with filters that remove harmful substances and a chemical resistant coverall, gloves, boots, and splash hood
o
Level D- what you would normally wear plus universal precautions
Weapons of Terror o
Biological Weapons
Easily obtained
Easily disseminated
Significant morbidity and mortality
Signs and symptoms similar to common diseases
May be liquid, dry, applied to foods or water or vaporized
4-25-08
Kathy Batton
Vector may be animal, insect, or human or direct contact with agent itself.
Types •
Anthrax/Bacillus Anthracis o
Most likely weapon to be used (has been used before)
o
Naturally occurring in soil
o
As an aerosol it is odorless and invisible and can travel for miles
o
Causes hemorrhage, edema and necrosis
o
Incubation period is 1-6 days
o
Use standard precautions
o
Skin contact
o
Signs and symptoms •
edema with pruritis
•
macule, papule formation resulting in ulceration with 1-3mm vesicles
•
eschar (painless) develops and falls off in 1-2 weeks
Nursing care •
Treat symptoms
•
Maybe antibiotics
Ingestion
Signs and symptoms •
Fever
•
Nausea and vomiting
•
Abdominal pain
•
Bloody diarrhea (occ. Ascites)
•
Massive diarrhea can result in volume depletion
4-25-08
Kathy Batton
o
•
Can result in sepsis
•
Frequently fatal due to sepsis
Nursing care •
Assess for and maintain adequate fluid status
•
Treat symptoms
•
Assess for sepsis
Medications •
Fluoroquinolones
•
Tetracycline
•
Penicillin
Inhalation
Signs and symptoms •
•
Mimics flu-in first stage o
Headache, syncope
o
Cough, dyspnea (no rhinorrhea or nasal congestion)
o
Fever, chills
o
Vomiting, weakness
After initial s/s brief recover period then 1-3 days o
Fever
o
Severe respiratory distress, strider, hypoxia, cyanosis
o
50% have hemorrhagic mediastinitis on x-ray
o
Diaphoresis
4-25-08
Kathy Batton
•
o
Hypotension
o
Shock
o
May progress to meningitis with SA hemorrhage
o
Death 24-35 hours
o
Mortality rate near 100%
Nursing Care •
Use standard precautions
•
If antibiotics started within 24 hours after exposure death can usually be prevented
•
Nurses must be vigilant in surveillance
•
Penicillin, chloramphenicol, gentamicin or doxycycline
•
For mass exposure and persons exposed but without s/s-doxycycline or ciprofloxacin for 60 days
•
Cremation for the dead
Smallpox/ Variola Major o
DNA virus
o
Highly contagious
o
Lives 24 hours in cool temperatures
o
30% Mortality rate, morbidity rate extremely high
o
Spread by direct contact and contact with clothing, linens, or by droplet
o
Contact precautions and droplet precautions
o
Incubation period
7-17 days
Not contagious during this time
4-25-08
Kathy Batton
o
o
o
Feel fine
Contagious after patient develops fever
Prodrome Phase
Sometimes contagious
Lasts 2-4 days
Fever (high 101-104F) highest when rash starts
Malaise, head and body aches
Feel too sick to carry
Rash phase
4 days
Most contagious during rash phase
Starts as small red spots on tongue and in mouth, these rupture and spreads virus into mouth and throat, rash then starts of face and spreads to arms and legs and then hands and feet
Rash is everywhere in 24 hours
As rash appears fever decreases they feel better
3rd day of rash is raised bumps
4th day bumps fill with thick opaque fluid and have depression in center (looks like a belly button and a major characteristic)
Fever will rise again and stay high until scabs form over the bumps
Pustular Rash Phase
Duration -5 days
Bumps become pustules-raised, usually round and firm
Crust and scabs form (duration about 5 days,) by end of the second week of the rash most of the sores have formed scabs
4-25-08
Kathy Batton •
Hemorrhagic smallpox o
Same s/s as variola major except dusky erythema and petechiae to frank hemorrhage of the skin and mucus membranes
o
Death usually within 5-6 days
o
Nursing Care for both types of Smallpox
o
Protect yourself (contact and airborne precautions)
Symptomatic care
Assess for additional infection-if present administer antibiotics
Vaccine administered up to 4 days after exposure-before the rash appears will help prevent and or decrease disease symptoms
Chemotherapeutic agent-Cidofovir is being used experimentally in the lab
Bodies should be cremated
Infection control
•
Once scabs are gone, patient is no longer contagious
Wear gloves, caps, gowns, and surgical masks
Tularemia o
Also known as deerfly or rabbit fever
o
Naturally found in small mammals and the insects that bite them
o
Can survive for weeks at low temps in water, moist soil, hay, straw, or decaying animal carcasses
o
Can be aerosolized for biological weapon use
o
Mortality rate not high
o
Can’t be spread from person to person
o
S/S
Develop 3-5 days
4-25-08
Kathy Batton
o
•
May be mild illness or acute sepsis and rapid death
Sudden fever, chills, headache, diarrhea, generalized aching, dry cough sore throat without adenopathy, then progressive weakness, pneumonia to chest pain, blood sputum and dyspnea
If inhaled death due to pneumonitis, sepsis and shock
Nursing care
For inhaled, treatment within 48 hours
Treat symptomatically
Streptomycin or gentamicin for 10-14 days
For mass casualty, doxycline or cipro for 14 days
Botulism o
Produces a neurotoxin
o
Exposure results in flaccid paralysis
o
May be ingested or inhaled
o
Spread via direct contact
o
Not contagious via human to human
o
Use standard precautions
o
If skin contact use soap and water or bleach solution to clean
o
S/S
GI-abdominal cramps, N&V, diarrhea
Inhaled (manmade) •
Symmetric descending paralysis
•
Diploplia
•
Dysphagia, dry mouth, altered mental status
•
death from airway obstruction and decreased tidal volume
4-25-08
Kathy Batton
•
may or may not have fever
•
usually responsive initially
Nursing care •
•
Supportive care o
Mechanical ventilation
o
Fluids and nutrition
o
Do not give aminoglycosides or clindamycin
o
No isolation required
Antitoxin o
•
Equine antitoxin given to decrease nerve damage-check allergies
Plague o
Necrosis and destroys the lymph nodes
o
Pneumonic plague type most likely to be used in terrorism
o
Will likely be aerosolized
o
Pneumonic is contagious through human to human contact
o
Transmitted via respiratory droplet contact
o
s/s
o
severe bronchospasms
chest pain
dyspnea, cough
hemoptysis
100% mortality if not treated within first 24 hours after exposure, even with treatment mortality is 50%
Treatment
Symptomatic
4-25-08
Kathy Batton
o
Utilize barrier precautions with full face respirators
Have client wear mask
Streptomycin or gentamicin for 10-14 days
After close contact give doxycycline for 7 days
Chemical Weapons
Nerve Agents •
Sarin Gas-heavier than area, settles in low areas o
Evaporates into a colorless, odorless, vapor
o
Can be inhaled or absorbed
o
Results in continuous stimulation of the nerve endings
o
S/S start in ½ hour to 18 hours
o
Bilateral miosis
Visual disturbances
GI motility
N&V, and diarrhea
Substernal spasm
Bradycardia
AV block
Bronchoconstriction
Laryngeal spasm
Seizures
Death –really bad death
Nursing Care
Decontamination at site with copious amounts of water or NS for 8-20 minutes
Blot to dry
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Kathy Batton
•
Maintain airway
Suction PRN
Decontamination at hospital
IV atropine 2-4 mg, Then 2 mg every 3-8 minutes for up to 24 hours or atropine 1-2 mg every hour until resolution
Pralidoxime 1-2mg in NS IVPB over 15-30 minutes
Diazepam (valium) or benzodiazepines for seizures
Cyanide o
Affect cellular metabolism resulting in alterations of hemoglobin that leads to asphyxiation
o
Has a bitter almond odor
o
Can be ingested inhaled or absorbed through skin and mucus membranes
o
Inhalation symptoms
o
Flushing
Tachycardia
Nonspecific neurologic symptoms
Seizure
Respiratory arrest
Nursing Care
Intubate
Ventilate
Nitrate pearls-put in reservoir of ventilator
Sodium nitrate-given IV 300mg over 2-4 minutes
Sodium thiosulfate-given IV 12.5mg over 5 minutes
Alternative treatment-vitamin B12
4-25-08
Kathy Batton •
Chemical Vesicants (mustards, phosgene, lewisite-contains arsenic) o
Cause blistering and burning
o
Minimal mortality but large morbidity
o
Sulfa mustard smells like garlic
o
Signs and Symptoms
o
•
Initially presents like a large superficial partial thickness burn in warm, moist areas
Then pruritus painful burning and vesicle formation
Possibly a purulent fibrinous discharge that may obstruct airway
Nursing Care
Treated as a burn
Decontaminate with soap and water
Do not rub skin
Irrigate eyes if exposed
If respiratory exposure-intubate, ventilate, and prepare for bronchoscopy
Observe all mustard exposures for 24 hours due to possible latent effects
Chemical Pulmonary Agents (phosgene, chlorine) o
Destroy pulmonary membrane that separates alveolus from the capillary bed
o
Capillary leaks result in fluid filled alveoli
o
Phosgene smell like fresh-mown hay
o
S/S
Pulmonary edema with SOB
Hacking cough that progresses to frothy sputum
4-25-08
Kathy Batton o
o
Nursing Care
Supportive
Airway management
Intubate
ventilate
Radiation Weapons
Types •
•
•
•
Alpha o
Low level
o
Localized damage only
Beta o
Moderately penetrates the skin
o
Skin damage if prolonged exposure
Gamma o
Penetrates
o
Difficult to shield from
o
Often accompanies alpha and beta emissions
Measurement and Detection o
Rad-basic unit of measurement
o
Rem-type of radiation and potential for damage
o
Half life-time it takes to lose half of radioactivity
o
Geiger counter-detects gamma and some beta radiation
o
Personal dosimeters-worn by radiology personnel to detect exposure
o
It is the dose rather than the source that determines if ARS will develop
4-25-08
Kathy Batton •
Radiation Exposure/ injury o
Time-how long they were exposed
o
Distance-how close they were to the source
o
Shielding-decreasing exposure by stopping at shield
o
External Irradiation-when body itself exposed, all the way through the body, but the patient doesn’t become radioactive
o
Contamination-body has been exposed to source of radiation, don’t touch someone who is contaminated-need to be decontaminated-need medical attention very quickly to prevent incorporation
o
Incorporation – patient will have radiation that goes into the cells of their body-will kill off liver, kidneys, bone, and thyroid
o
Nursing care should begin at the scene
Decontaminate without contamination of rescuers
Assess presenting symptoms to determine triage
Triage based on predicted survival •
Probable-minimal or no initial s/s o
•
•
Possible-N/V for 24-48 hrs o
Start supportive measures
o
Probably go ahead and isolate them (reverse isolation)
Improbable-greater than 800 rad of total body penetrating irradiation-death o
CBC, discharge with possible instructions to return for certain s/s
Shock, neurological symptoms
Decontamination •
First decontamination then triage, should occur at the scene
4-25-08
Kathy Batton
o
•
Disaster plan should be in effect
•
Immediately notify hospital radiation safety officer
•
Survey for exposure
•
Triage outside the hospital if possible to prevent facility contamination
•
Cover floors
•
Strict isolation
•
Control waste
•
Staff should wear dosimeter badges, and protective covering
•
Decontamination should occur outside the hospital (shower, collection pool, tarp collection containers for belongings). Provide soap, towels, disposable paper gowns
•
Then survey-decontaminate until free of contamination
•
After survey indicates no external contamination victim can be sent into hospital
•
Biologic samples should be taken
•
If client has internal contamination or incorporation then catharsis and/ or gastric lavage with chelating agents
•
Sample of urine feces, and vomitus may be surveyed to determine internal effects
Acute Radiation Syndrome (ARS)
Severity determined by dose,, rate, total body exposure and penetrating type radiation
Age, medical history, and genetics
Cells that multiply rapidly are most affected
4-25-08
Kathy Batton o
o
Hematopoietic system affected first
Outcome indicators
Lymphocyte count 48 hours after exposure-3001200=significant exposure
600 rad or more=GI symptoms=NV in 2 hours post exposure
1000 rad or more = CNS symptoms
600-1000 rad effects skin
5000 rad or more= necrosis in a few days to months
Secondary injury may be present if exposure due to blast or burn-trauma increases mortality
Phases of ARS
Prodromal phase •
s/s 48-72 hours post exposure o
•
NV, decreased appetite, fatigue, high dose=fever, resp distress, excitability
Monitor lymphocyte count, provide fluids and electrolytes, if significant exposure isolate to prevent infection, bleeding precautions
Latent phase •
Symptom free period
•
Lasts up to 3 wks-less if significant exposure
•
Decreasing lymphocytes, platelets, leukocytes, thrombocytes, and RBC’s
•
Isolation as needed
•
Frequent rest periods
•
O2 PRN
•
Bleeding precautions
4-25-08
Kathy Batton •
•
Supportive measures
Illness phase •
Infections
•
Fluid and electrolyte imbalances
•
S/S =bleeding, shock, change in LOC
•
Treat symptomatically
•
Isolation precautions
Recovery phase or death •
Can take weeks or months to recover or die
•
S/S=increasing ICP is ominous sign of impending death
•
Supportive care
•
ABC’s
www.thepodgame.com o
Can become a disaster worker to see how well you manage your disasters
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