emergency preparedness and poisonings

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Emergency Preparedness and Poisonings


Drugs Are Powerful Tools

• Prevent or control global disease outbreaks

– Biological, chemical, or nuclear attack


The Nature of Bioterrorism

• After 9/11 attacks, awareness of outbreaks and treatments expanded to include bioterrorism

• Bioterrorism—intentional use of infectious biologic agents, chemical substances, or radiation to cause widespread harm or illness


Table 11.1 Deadly Diseases in Human History (1 of 2)

Table 11.1 Deadly Diseases in Human History

Disease/Event Cause Target

Acquired immune deficiency

syndrome (AIDS)

Human immunodeficiency virus

(HIV)

Immune response

Bubonic plague Yersinia pestis, flea and rodent

vectors

Immune response and

respiratory system

Cholera Vibrio cholerae Digestive tract

Dengue fever and yellow fever Flavivirus Entire body (fever)

Ebola Zaire ebolavirus (filovirus) Immune response and

cardiovascular system

Hepatitis B Hepatitis B virus (HBV) Liver

Influenza (flu) Haemophilus influenza, avian and

swine vectors

Respiratory system

Leprosy Mycobacterium leprae Skin, nervous system, muscular

system


Table 11.1 Deadly Diseases in Human History (2 of 2)

Table 11.1 Deadly Diseases in Human History

Disease/Event Cause Target

Malaria Plasmodium falciparum, female

Anopheles mosquito vector

Blood disorder

Measles Rubeola virus Lungs and meninges

SARS (severe acute respiratory

syndrome)

SARS coronavirus (SARS CoV) Respiratory system

Smallpox Variola virus Skin, mucosa, lymphoid tissue

Syphilis Treponema pallidum Genitalia, mucous membranes,

central nervous system

Tetanus (lockjaw) Clostridium tetani Entire body (infections)

Tuberculosis Mycobacterium tuberculosis Lungs

Whooping cough Bordetella pertussis Respiratory system


Emergency Preparedness

• Not a new concept

• Hospitals required to have disaster plans

• Plans changed recently to include how health care system might change during a crisis

• Cooperation between different health care professionals is essential during a bioterrorist attack


Key Roles of Nurse in Preparing for and Responding to Bioterrorist Attack

• Education

– Current knowledge/understanding of emergency management

• Resources

– Current list of contacts in health and law enforcement


Key Roles of Nurse in Preparing for and Responding to Bioterrorist Attack

• Diagnosis and treatment

– Awareness of signs, symptoms, and treatment of chemical/biological agents

• Planning

– Involvement in emergency-management plans


Table 11.2 Categories of Infectious Agents (1 of 2)

Table 11.2 Categories of Infectious Agents

Category Description Examples

A Agents that can easily be disseminated or

transmitted person to person; cause high

mortality, with potential for major public health

impact; might cause public panic and social

disruption; or require special action for public

health preparedness

Bacillus anthracis (anthrax)

Clostridium botulinum toxin (botulism)

Francisella tularensis (tularemia)

Variola major (smallpox)

Viral hemorrhagic fevers such as Marburg and Ebola

Yersinia pestis (plague)


Table 11.2 Categories of Infectious Agents (2 of 2)

Table 11.2 Categories of Infectious Agents

Category Description Examples

B Agents that are moderately easy to

disseminate; cause moderate

morbidity and low mortality; or require

specific enhancements of

the CDC’s diagnostic capacity and

enhanced disease surveillance

Brucella species (brucellosis)

Burkholderia mallei (glanders)

Burkholderia pseudomallei (melioidosis)

Chlamydia psittaci (psittacosis)

Coxiella burnetii (Q fever)

Epsilon toxin of Clostridium perfringens

Food safety threats such as Salmonella and E. coli

Ricin toxin from Ricinus communis

Staphylococcus enterotoxin B

Viral encephalitis

Water safety threats such as Vibrio cholerae and

Cryptosporidium parvum

C Emerging pathogens that could be

engineered for mass dissemination

because of their availability, ease of

production and dissemination, and

potential for high morbidity and mortality

rates

and major health impacts

Hantaviruses

Multidrug-resistant tuberculosis

Nipah virus (NiV)

Tick-borne encephalitis viruses

Yellow fever

Source: Emergency Preparedness & Response: Bioterrorism Agents/Diseases, Centers for Disease Control and Prevention, 2014. Retrieved from

http://www.bt.cdc.gov/agent/agentlist-category.asp


Strategic National Stockpile (SNS)

• Managed by the U.S. Centers for Disease Control and Prevention (CDC)

– Stockpile consists of antibiotics, vaccines, and medical, surgical, and patient supplies

– Designed to ensure immediate deployment of essential medical materials in case of biologic or chemical attack


SNS Has Two Components

• Push package—first component

– Supplies and pharmaceuticals for unknown chemical or biological threat

– Arrives within 12 hours after attack

• Vendor-managed inventory (VMI) package—second component

– Supplies and pharmaceuticals for specific chemical or biological agent

– Arrives within 24 to 36 hours


Anthrax

• Used as part of bioterrorist attacks in 2001

• Caused by Bacillus anthracis

• Can cause serious damage to body tissues


Table 11.3 Clinical Manifestations of Anthrax

Table 11.3 Clinical Manifestations of Anthrax

Type Description Symptoms

Cutaneous anthrax Most common but least complicated

form of anthrax; almost always

curable if treated within the first few

weeks of exposure; results from

direct contact of contaminated

products with an open wound or cut

Small skin lesions develop and turn

into black scabs; inoculation takes less

than 1 week; cannot be spread by

person-toperson contact

Gastrointestinal

anthrax

Rare form of anthrax; without

treatment, can be lethal in up to 50%

of cases; results from eating

anthrax-contaminated food, usually

meat

Sore throat, difficulty swallowing,

cramping diarrhea, and abdominal

swelling

Inhalation anthrax Least common but the most

dangerous form of anthrax; can be

successfully treated if identified

within the first few days after

exposure; results from inhaling

anthrax spores

Initially, fatigue and fever for several

days, followed by persistent cough and

shortness of breath; without treatment,

death can result within 4–6 days


Transmitted to Humans

• Exposure to open wound

• Through contaminated food

• By inhalation

• Causes disease by emission of two types of toxins—edema toxin and lethal toxin


Anthrax Survivability

• Bacterium can form spores

– Spores can be viable in soil for hundreds or thousands of years

• Resistant to drying, heat, and some harsh chemicals

• Found in contaminated animal products such as wool, hair, dander, and bonemeal, but can also be packaged in other forms


Clinical Manifestations of Anthrax

• Cutaneous anthrax

– Small skin lesions that turn into black scabs

• Gastrointestinal anthrax

– Sore throat, difficulty swallowing

– Cramping diarrhea, abdominal swelling


Clinical Manifestations of Anthrax

• Inhalation anthrax

– Initially fatigue and fever

– Then persistent cough and shortness of breath


Treatment for Anthrax

• Ciprofloxacin (Cipro)

– Prophylaxis—500 mg PO, every 12 hours for 60 days

– Confirmed case—400 mg IV, every 12 hours

• Other antibiotics that are effective

– Penicillin, vancomycin, ampicillin, erythromycin, tetracycline, and doxycycline



• Combination of ciprofloxacin and doxycycline approved

– For inhalation anthrax

• Discourage use of antibiotics where anthrax has not been found

– Can promote antibiotic-resistant strains



• Vaccines licensed by FDA for about 40 years, but little used because of low incidence of anthrax infection

– Recommended for very few people, such as laboratory staff who work with anthrax


Polio and Smallpox Viruses

• Polio virus mostly eliminated, still found in some underdeveloped pockets of world

• Fear that bioterrorists will engineer a strain for use

– Mutated strain would not have a vaccine

• Smallpox virus maintained in some labs

– Highly contagious, easily spread


Ebola Virus

• Bioterrorists have easy access to the Ebola virus

– Multiple ways to spread infection

– Ebola has 21-day incubation period (enough time for terrorists to infect selves and enter U.S.)


Possible Responses to Ebola Outbreak

• Brincidofovir: given to first patients with Ebola without success

• Favipiravir: tested on Ebola patients in Guinea

• ZMapp: mixture of three synthetic antibodies to Ebola virus, some success, but some failures in 2014

• TKM-Ebola: used after ZMapp was exhausted, undergoing FDA phase one clinical trials


Possible Responses to Ebola Outbreak

• Convalescent serum: contains Ebola-fighting antibodies, to be given to patient who has survived Ebola incident

• AVI-7537: experimental Ebola antiviral drug, targets protein responsible for replicating Ebola virus in host

• BCX4430: antiviral drug from Biocryst Pharmaceuticals, targets a key enzyme in Ebola virus


Vaccination

• No effective therapies for patients infected by most viruses that could be used in a bioterrorist attack

• Vaccines can be created for some viruses

– Stimulate immune system to produce antibodies to prevent disease


Contraindications to Receiving Smallpox Vaccine

• History of atopic dermatitis or eczema

• Acute, active, or exfoliative skin conditions

• Altered immune states

• Pregnant/breast-feeding women

• Children younger than 1 year

• Serious allergy to any component of the vaccine


Disadvantages of Vaccination

• Concern about effectiveness against mutant strains of viruses

• Side effects possible

• Could provide terrorists with partial virus that could be engineered further


Nerve Agents

• Can cause convulsions and loss of consciousness within seconds, respiratory failure within minutes

• Relate to overstimulation by the neurotransmitter acetylcholine at central and peripheral sites in body

– Blocks AchE, increasing action of acetylcholine in the synaptic space


Nerve Agents and Treatment

• GA (Tabun), GB (Sarin), GD (Soman), VX treatment

– Give atropine injection

– Flush eyes with water

– Apply sodium bicarbonate or 5% liquid bleach solution to skin

– Do not induce vomiting


Blood Agents and Treatment

• Hydrogen cyanide treatment

– Flush eyes and wash skin with water

– Give oxygen and amyl nitrate if mist inhaled

– If ingested, give 1% sodium thiosulfate to induce vomiting


Blood Agents and Treatment

• Cyanogen chloride treatment

– Give oxygen and amyl nitrate

– Give milk or water; do not induce vomiting


Choking/Vomiting Agents and Treatment

• Phosgene treatment

– Provide fresh air, and administer oxygen

– Flush eyes with normal saline or water

– Keep patient warm and calm


Choking/Vomiting Agents and Treatment

• Adamsite (DM) treatment

– Rinse nose and throat with saline, water, or 10% solution of sodium bicarbonate

– Treat skin with borated talcum powder


Blister/Vesicant Agents Treatment

• Phosgene oxime, Mustard-lewisite, Mixture-HL, Nitrogen mustard (HN-1, HN-2, HN-3), Sulfur mustard agents

– Flush affected areas with water

– Treat skin with 5% solution of sodium hypochlorite or household bleach

– Give milk to drink; do not induce vomiting

– For skin contact with Lewisite, treat with 10% solution of sodium carbonate


Table 11.4 Chemical Warfare Agents and Treatments (1 of 2)

Table 11.4 Chemical Warfare Agents and Treatments

Category Signs of Discomfort/Fatality Antidotes/First Aid

NERVE AGENTS

GA—Tabun (liquid)

GB—Sarin (gaseous liquid)

GD—Soman (liquid)

VX (gaseous liquid)

Depending on the nerve agent,

symptoms may be slower to appear

and cumulative depending on

exposure time: miosis, runny nose,

difficulty breathing, excessive

salivation, nausea, vomiting,

cramping, involuntary urination and

defecation, twitching and jerking of

muscles, headaches, confusion,

convulsion, coma, death

Nerve agent antidote and Mark I injector kits

with atropine are available. Flush eyes

immediately with water. Apply sodium

bicarbonate or 5% liquid bleach solution to

the skin. Do not induce vomiting.

BLOOD AGENTS

Hydrogen cyanide (liquid)

Cyanogen chloride (gas)

Red eyes, flushing of the skin,

nausea, headaches, weakness,

hypoxic convulsions, death

Loss of appetite, irritation of the

respiratory tract, pulmonary edema,

death

Flush eyes and wash skin with water. For

inhalation of mist, oxygen and amyl nitrate

may be given. For ingestion of cyanide

liquid, 1% sodium thiosulfate may be given

to induce vomiting.

Oxygen and amyl nitrate may be given. Give

the patient milk or water. Do not induce

vomiting.


Table 11.4 Chemical Warfare Agents and Treatments (2 of 2)

Table 11.4 Chemical Warfare Agents and Treatments

Category Signs of Discomfort/Fatality Antidotes/First Aid

CHOKING/VOMITING AGENTS

Phosgene (gas)

Adamsite—DM (crystalline

dispensed in aerosol)

Dizziness, burning eyes, thirst,

throat irritation, chills, respiratory

and circulatory failure, cyanosis,

frostbite-type lesions

Irritation of the eyes and respiratory

tract, tightness of the chest, nausea,

and vomiting

Provide fresh air. Administer oxygen. Flush

eyes with normal saline or water. Keep the

patient warm and calm.

Rinse nose and throat with saline, water,

10% solution of sodium bicarbonate. Treat

the skin with borated talcum powder.

BLISTER/VESICANT AGENTS

Phosgene oxime (crystalline or

liquid)

Mustard—lewisite

Mixture—HL

Nitrogen mustard—HN-1, HN-2,

HN-3

Sulfur mustard agents

Destruction of mucous membranes,

eye tissue, and skin (subcutaneous

edema), followed by scab formation;

irritation of the eyes, nasal

membranes, and lungs; nausea and

vomiting; formation of blisters on the

skin; cytotoxic reactions in

hematopoietic tissues including bone

marrow, lymph nodes, spleen, and

endocrine glands

Flush affected area with copious

quantities of water. If ingested, do not

induce vomiting. Treat the skin with 5%

solution of sodium hypochlorite or

household bleach. Give milk to drink. Do

not induce vomiting. Skin contact with

lewisite may be treated with 10% solution

of sodium carbonate.

Based on: Detailed Chemical Fact Sheets, U.S. Army Center for Health Promotion and Preventive Medicine, 1998. Retrieved from

https://www.hsdl.org/?view&did=1088


Ionizing Radiation

• Can result from hundreds of different radioisotopes created by nuclear explosion


Immediate Symptoms of Acute Radiation Syndrome

• Occur hours or days after exposure

• Nausea, vomiting, diarrhea


Later Symptoms of Acute Radiation Exposure

• Weight loss, anorexia, fatigue, bone-marrow suppression


Survivors of Acute Radiation Exposure

• High risk for developing cancers, particularly leukemia


Treating Radiation Exposure

• Symptoms are some of the most difficult to treat pharmacologically

• Potassium iodide (KI) tablets are one of the few recognized approaches

– Prevents radioactive iodine (I-131) from entering thyroid gland

– Protects only thyroid gland


Management of Poisoning

• Nurses must be familiar with basic elements of toxicity treatment

• Pharmacologic agents approach toxicity when doses exceed recommended range

• Poisonings intentional or accidental


Basic Supportive Care for Toxicity

• One of the first elements of toxicity treatment

• Maintain airway, breathing, and circulation

• Maintain proper blood glucose levels

• Provide treatment of developing seizures

• Agents may be used to facilitate removal of some toxins


Table 11.5 2012 Data: Top 25 Substances

Involved in Human Exposures (1 of 3)

Table 11.5 2012 Data: Top 25 Substances Involved in Human Exposures

Substance Number Percentages*

Analgesics 289,786 28.26

Information calls 130,853 12.76

Sedative–hypnotics/antipsychotics 116,392 11.35

Stimulants and street drugs 59,587 5.81

Unknown drug 46,528 4.54

Muscle relaxants 40,587 3.96

Cardiovascular drugs 40,436 3.94

Invalid/missing 40,358 3.94

Antidepressants 38,479 3.75






Antihistamines 33,683 3.28

Antimicrobials 29,520 2.88

Anticonvulsants 19,069 1.86

Hormones and hormone antagonists 18,528 1.81

Gastrointestinal preparations 17,747 1.73

Pesticides 9,859 0.96

Cold and cough preparations 8,765 0.85

Diuretics 8,344 0.81

Miscellaneous drugs 7,966 0.78






Foreign bodies/toys/miscellaneous 6,634 0.65

Cleaning substances (household) 5,111 0.50

Plants 4,524 0.44

Bites and envenomations 3,902 0.38

Chemicals 3,757 0.37

Other/unknown nondrug substances 3,735 0.36

Cosmetics/personal care products 3,497 0.34

*Percentages are based on 1,025,575 exposures.

Source: ―2012 Annual Report of the American Association of Poison Control Centers’

National Poison Data System (NPDS): 30th Annual Report,‖ by J. B. Mowry, D. A. Spyker,

L. R. Cantilena, J. E. Bailey, and M. Ford, 2013, Clinical Toxicology, 51, pp. 940–1229.


Surface Decontamination

• Remove clothes

• Flush with water

• Soap-and-water and alcohol washes for undamaged skin


Syrup of Ipecac

• Used to induce vomiting

• Benefits questionable, especially with caustic poisonings


Further Poisoning Treatments

• Gastric lavage and aspiration

– Used if patient has ingested a potentially life-threatening amount of poison

– Must be done within 60 minutes

• Single-dose activated charcoal

– Used if poison is carbon-based

– Greatest benefit within 60 minutes


Further Poisoning Treatments

• Whole-bowel irrigation

– For potentially toxic ingestions of sustained-release or enteric-coated drugs

– For toxic ingestions of iron, lead, zinc, or illicit drugs

• Specific antidotes counter effects of poisons or toxins in cases such as heavy metal poisoning


Table 11.6 Specific Antidotes for Overdosed Substances or Toxins (1 of 2)

Table 11.6 Specific Antidotes for Overdosed Substances or Toxins

Generic Name Trade Name Overdosed Substance or Toxin

(Pharmacologic/Toxicity Group)

acetylcysteine Acetadote Acetaminophen (nonopioid analgesic)

atropine sulfate Acetylcholine; cholinergic receptor agents;

acetylcholinesterase inhibitors (parasympathomimetic)

calcium EDTA Calcium Disodium Versenate Lead toxicity (heavy metal poisoning)

deferoxamine Desferal Iron toxicity (heavy metal poisoning)

digoxin immune Fab Digibind Digoxin (cardiac glycoside)

dimercaprol BAL in Oil Arsenic, gold and mercury toxicity (heavy metal poisoning)

flumazenil Romazicon Benzodiazepines (sedative–hypnotic)

fomepizole Antizole Ethylene glycol toxicity (antifreeze poisoning)

glucagon Insulin (hypoglycemia)

leucovorin Wellcovorin Methotrexate; folic acid blocking agents

(antineoplastic/antimetabolite)

naloxone Narcan Opioid agents; morphine (opioid analgesic)


Table 11.6 Specific Antidotes for Overdosed Substances or Toxins (2 of 2)

Table 11.6 Specific Antidotes for Overdosed Substances or Toxins

Generic Name Trade Name Overdosed Substance or Toxin

(Pharmacologic/Toxicity Group)

neostigmine Prostigmin Neuromuscular blocking agents (nondepolarizing blocker)

penetrate calcium trisodium Radioactive plutonium, americium and curium (radioactive

exposure)

penetrate zinc trisodium Radioactive plutonium, americium and curium (radioactive

exposure)

penicillamine Cuprimine, Depen Copper, iron, lead, arsenic, gold and mercury toxicity (heavy metal

poisoning)

physostigmine Antilirium Cholinergic blocking agents; atropine sulfate (anticholinergic)

potassium iodide Radioactive iodine toxicity (nuclear bomb; radioactive exposure)

pralidoxime Protopam Cholinesterase inhibitors; organophosphates; neostigmine;

physostigmine (parasympathomimetic)

protamine sulfate Heparin (parenteral anticoagulant)

prussian blue Radiogardase Radioactive cesium-137; nonradioactive thallium (radioactive

cesium exposure; thallium poisoning)

succimer Chemet Lead, mercury, and arsenic toxicity (heavy metal poisoning)

vitamin K Coumadin; warfarin (oral anticoagulant)

emergency preparedness and poisonings

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