23193584 nursing in disasters

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 Natural

Tornadoes

Hurricanes

Earthquakes

Blizzards

Epidemics

o 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


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 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

o Delayed/ Priority 2/ Yellow Tagged

Significant injuries that are survivable with medical care, but arent 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

o Minimal/ Priority 3/ Green Tagged

Minor injuries, treatment can be delayed for hours or days without death

Examples: sprains, cuts, fractures that dont have to be reduced surgically, psych people

o 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 dont get medically treated. Usually the walking wounded are trying to care of the dying.

o After triage category decided the person is tagged and treated and / or transported, triage continues at each point of care.

Disaster Levels


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


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

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

o Ingestion

Signs and symptoms

Fever

Nausea and vomiting

Abdominal pain

Bloody diarrhea (occ. Ascites)

Massive diarrhea can result in volume depletion


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

o 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


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


Feel fine

Contagious after patient develops fever

o 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

o 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

o 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


Once scabs are gone, patient is no longer contagious

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

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

o Infection control

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 Cant be spread from person to person

o S/S

Develop 3-5 days


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

o 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


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

severe bronchospasms

chest pain

dyspnea, cough

hemoptysis

100% mortality if not treated within first 24 hours after exposure, even with treatment mortality is 50%

o Treatment

Symptomatic


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

o 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 hour to 18 hours

Bilateral miosis

Visual disturbances

GI motility

N&V, and diarrhea

Substernal spasm

Bradycardia

AV block

Bronchoconstriction

Laryngeal spasm

Seizures

Death really bad death

o Nursing Care

Decontamination at site with copious amounts of water or NS for 8-20 minutes

Blot to dry


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

Flushing

Tachycardia

Nonspecific neurologic symptoms

Seizure

Respiratory arrest

o 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


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

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

o 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


o Nursing Care

Supportive

Airway management

Intubate

ventilate

o 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


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 doesnt become radioactive

o Contamination-body has been exposed to source of radiation, dont 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 CBC, discharge with possible instructions to return for certain s/s

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 Shock, neurological symptoms

Decontamination

First decontamination then triage, should occur at the scene


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

o 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


Hematopoietic system affected first

o Outcome indicators

Lymphocyte count 48 hours after exposure-300-1200=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

o 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 RBCs

Isolation as needed

Frequent rest periods

O2 PRN

Bleeding precautions


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

ABCs

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23193584 nursing in disasters

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