JOANNA MAE M. CAROLINO
Upon Ingestion:
BSN 4

If ingested, do not induce vomiting or
drink fluids.

Administer activated charcoal
DISASTER NURSING
PRELIM
Definition: Action: and Management of the ff
1. Phosgene

It is an organic chemical compound
with the formula COCl₂. It is a colorless gas used
as a major industrial chemical used to make
plastics and pesticides. It is extremely toxic by
acute (short-term) inhalation exposure. Severe
respiratory effects, including pulmonary edema,
pulmonary emphysema, and death have been
reported in humans. Severe ocular irritation and
dermal burns may result following eye or skin
exposure.
Management:
Upon Exposure:

If exposed, immediately remove from
the source or place and remove clothing,
rapidly wash the entire body with soap and
water.

If exposed, protect others from getting
exposed to Phosgene by sealing the clothing in
a plastic bag. Then seal the first plastic bag in a
second plastic bag. Removing and sealing the
clothing in this way will help protect you and
other people from contamination that might be
on the clothes.

If eyes are exposed and causes burning
or blurry vision, rinse the eyes with plain water
for 10 to 15 minutes. If wearing contacts,
remove them and place them in the bags with
the contaminated clothing. Do not put the
contacts back in the eyes. If wearing eyeglasses,
wash them with soap and water. This can be
put back on after washing them thoroughly.
Upon Inhalation:

Cover nose with damp cloth while
moving away from the place and go to the
highest ground possible, because phosgene is
heavier than air and will sink to low-lying areas.

Assess change in LOC and airway
immediately and assess for respiratory distress

Assess for s/sx of pulmonary
emphysema and pulmonary congestion

Administer O2 at 100% via venturi mask

Administer bronchodilators for patients
with evidenced of bronchospasm

Administer corticosteroid to reduce
inflammation
Others:

Administer antibiotics and antifungals
as prophylaxis for risk of superinfection

For liquid exposure where it causes
frostbite:
 Remove from the source
 Soak affected area in warm water (temp:
37-39)10-30 mins and should maintain
constant temperature NOTE: Do not
rewarm if possibility of refreezing exist 9it
worsens tissue damage)
 Provide analgesic (NSAID/OPIOD)
 Cover the affected area with bandage
 Antibiotic as prophylaxis (high risk for
infection)
Phosgene Precautions:




Wear chemical splash goggles
Impermeable gloves
Lab gown
Mask

Containers of phosgene
solutions should be stored in secondary
containers
2. Lewiste



Lewisite is a vesicant or a
blistering-type military poison
that is extremely toxic by all
routes of exposure.
Lewisite is a type of chemical
warfare agent. · Lewisite is an
oily, colorless liquid in its pure
form and can appear amber to
black in its impure form.
Signs and Symptoms:
NEUROLOGIC

VITAL SIGNS


ACUTE EXPOSURE
o A) Hypotension, tachycardia,
and hypothermia may develop.
HEENT

ACUTE EXPOSURE
o A) Lacrimation, burns and/or
strong irritation may occur after
eye exposure. A geranium-like
odor may be detectable on the
victim.
ACUTE EXPOSURE
o A) "Lewisite shock" (refractory
hypotension) may result due to
increased capillary permeability
and subsequent leakage
following Lewisite exposures.
RESPIRATORY

ACUTE EXPOSURE
o A) Severe respiratory irritation
leading to acute lung injury
ACUTE EXPOSURE
o A) Restlessness and weakness
may occur following systemic
CHRONIC EXPOSURE
o A) Toxic encephalopathy and
peripheral neuropathy may also
occur with chronic arsenic
poisoning. Seizures have
occurred in the children of one
family.
GASTROINTESTINAL

CARDIOVASCULAR

(ALI) or acute respiratory
distress syndrome (ARDS) and
chemical pneumonitis may
occur following acute exposure
to
CHRONIC EXPOSURE
o A) The incidence of chronic
obstructive lung disease and
bronchitis have been elevated
in former poison gas
employees. Recurrent
pneumonia has been described
in a family, but the relationship
to arsenic exposure is not clear.

ACUTE EXPOSURE
o A) Nausea, vomiting and
salivation may occur with
exposure to Lewisite.
o B) Gastroenteritis, sometimes
with watery or bloody diarrhea,
may occur after acute exposure
to Lewisite.
CHRONIC EXPOSURE
o A) A sensation of dryness or
burning in the mouth, and
nausea and vomiting may occur
with chronic exposure to
arsenic.
HEPATIC

ACUTE EXPOSURE
o A) Hepatic necrosis has been
reported in exposed animals.
IMMUNOLOGIC

ACUTE EXPOSURE
o A) Unlike mustard gas, Lewisite
does NOT produce
immunosuppression.

CHRONIC EXPOSURE
o A) Lewisite was allergenic in
occupational exposures.
GENITOURINARY

ACUTE EXPOSURE
o A) Acute toxic exposures may
result in renal dysfunction.
FLUID-ELECTROLYTE

ACUTE EXPOSURE
o A) Significant intravascular
volume depletion may occur.
o B) Electrolyte abnormalities
may occur in conjunction with
fluid losses.
HEMATOLOGIC

ACUTE EXPOSURE
o A) Hemolytic anemia due to
"Lewisite shock" with
subsequent hemoconcentration
has been reported in one case.
Lewisite does NOT cause bone
marrow damage.
REPRODUCTIVE HAZARDS

CARCINOGENICITY



ACUTE EXPOSURE
o A) Severe blistering and
chemical burns have occurred
following liquid and vapor
exposure to Lewisite.
CHRONIC EXPOSURE
o A) Lewisite can cause contact
dermatitis. Painful irritation or
ulceration of the skin may
occur. Basal cell and squamous
cell cancers of the skin may also
be seen years after exposure.
HUMAN OVERVIEW
o A) Lewisite is considered a
suspect carcinogen because of
its arsenic content.
GENOTOXICITY

DERMATOLOGIC
A) At the time of this review, no human
reproductive studies were found for
Lewisite.
A) Lewisite was inactive in the Ames
Salmonella assay and proved
inconclusive in D melanogaster for sexlinked lethal mutations assay.
MANAGEMENT:
Upon Exposure:

If exposed, immediately remove from
the source or place and remove clothing,
rapidly wash the entire body with soap and
water.

If exposed, protect others from getting
exposed to Phosgene by sealing the clothing in
a plastic bag. Then seal the first plastic bag in a
second plastic bag. Removing and sealing the
clothing in this way will help protect you and
other people from contamination that might be
on the clothes.

If eyes are exposed and causes burning
or blurry vision, rinse the eyes with plain water
for 10 to 15 minutes. If wearing contacts,
remove them and place them in the bags with
the contaminated clothing. Do not put the
contacts back in the eyes. If wearing eyeglasses,
wash them with soap and water. This can be
put back on after washing them thoroughly.
FOR LEWISTE SHOCK:



Emergency management is needed
Proper Cross-matching and blood
transfusion
Assess for any BT transfusion reaction
3. Tabun

Upon Ingestion:

If ingested, do not induce vomiting or
drink fluids.

Administer activated charcoal
Upon Inhalation:

Cover nose with damp cloth while
moving away from the place and go to the
highest ground possible, because phosgene is
heavier than air and will sink to low-lying areas.

Assess change in LOC and airway
immediately and assess for respiratory distress

Assess for s/sx of pulmonary
emphysema and pulmonary congestion

Administer O2 at 100% via venturi mask

Administer bronchodilators for patients
with evidenced of bronchospasm

Administer corticosteroid to reduce
inflammation
Tabun is a man-made chemical
warfare agent classified as a
nerve agent. Nerve agents are
the most toxic and rapidly
acting of the known chemical
warfare agents. They are similar
to insecticides (insect killing
chemicals) called
organophosphates in the way
they work and the harmful
effects they cause.
MANAGEMENT:

Antidote: Administer 2 mg
atropine sulfate every 30
minutes to treat tabun
exposure
0.4.2 ORAL/PARENTERAL EXPOSURE

FOR SEVERE BLISTERING AND CHEMICAL
BURNS:
A) Treatment should include
recommendations listed in the
INHALATION EXPOSURE section.
INHALATION EXPOSURE
 Avoid touching and puncture the blister
to prevent infection
 Wash the affected area with cool
running water for 10-15 mins
 Provide proper wound hygiene
 Don’t use ointments as this can cause
further burn
 Put topical analgesic to relieve pain

A) MANAGEMENT OF MILD TO
MODERATE TOXICITY
o 1) Treatment is symptomatic
and supportive, including
treatment with atropine and
oximes (eg, pralidoxime in the
US and obidoxime and HI-6
internationally).
o
o
o
o
o
Monitor the patient for
respiratory distress (from
bronchospasm, increased
bronchial secretion, or muscle
weakness).
Administer IV fluids and
electrolytes as needed to
replace fluid losses.
Administer atropine for
muscarinic manifestations (eg,
salivation, diarrhea,
bronchospasm, bronchorrhea,
bradycardia) and pralidoxime
for nicotinic manifestations (eg,
weakness, fasciculations).
If atropine is unavailable or if
central anticholinergic toxicity
is present, glycopyrrolate is a
reasonable alternative.
Supplemental therapy with
oxygen and beta-2 adrenergic
agonist aerosols (eg, albuterol)
may be helpful.
o
o

C) DECONTAMINATION
o 1) UNIVERSAL PRECAUTIONS
should be followed by all staff
members caring for the patient;
nitrile gloves are suggested.
2) PREHOSPITAL:
o
o
o

B) MANAGEMENT OF SEVERE TOXICITY
o 1) Treatment is symptomatic
and supportive, including
treatment with atropine and
oximes (eg, pralidoxime in the
US and obidoxime and HI-6
internationally).
o If induction of paralysis with
muscle relaxing agents is
required for intubation,
succinylcholine should be
avoided because of potential
for prolonged duration of
paralysis. In contrast,
nondepolarizing neuromuscular
blockers such as pancuronium
may protect the neuromuscular
junction from injury.
o If seizure develops, administer a
benzodiazepine IV.
o Consider phenobarbital or
propofol if seizures recur.
Monitor for hypotension,
dysrhythmias, respiratory
depression, and need for
endotracheal intubation.
Evaluate for hypoglycemia,
electrolyte disturbances, and
hypoxia.
o
o
Induction of emesis is not
recommended.
Move patient from the toxic
environment to fresh air.
Patients who may have passed
through a droplet cloud should
have external decontamination.
Potentially contaminated
clothing should be removed
and the skin, face, and hair
washed with soap and water or
a dilute (less than 1%) sodium
hypochlorite solution.
Monitor for respiratory distress.
HOSPITAL: ORAL EXPOSURE:


Induction of emesis is not
recommended.
Administration of activated
charcoal is not recommended
due to the rapidity of
absorption and the risk of
charcoal aspirations.
INHALATION EXPOSURE:

After external decontamination (see
above), carefully observe patients with
inhalation exposure for the
development of any systemic signs or
symptoms and administer symptomatic
treatment as necessary.
water rinse. 0.5% Hypochlorite solution
(prepared by adding one 6 ounce bottle
of calcium hypochlorite granules to 5
gallons of water).

EYE EXPOSURE:






Remove contact lenses and irrigate
exposed eyes with copious amounts of
room temperature 0.9% saline or water
for at least 15 minutes.
If irritation, pain, swelling, lacrimation,
or photophobia persists after 15
minutes of irrigation, an
ophthalmologic examination should be
performed.
Do not instill sodium hypochlorite into
the eye. Ocular symptoms caused by
local absorption of nerve agents do not
respond to systemic administration of
atropine; symptomatic miosis may be
relieved by local instillation of 2%
homatropine or 1% atropine or 1%
cyclopentolate hydrochloride or an eye
mixture of 0.5% tropicamide and 0.5%
phenylephrine hydrochloride, repeated
several times daily for up to 3 days.
Carefully observe patients with eye
exposure for the development of
systemic toxicity. DERMAL EXPOSURE:
After external decontamination (see
above), a physician may need to
examine the area if irritation or pain
persists.
Discard contaminated clothing.
Carefully observe patient for the
development of systemic toxicity.
Other alternatives are the following:
M291 Skin Decontaminating Kit (for
military and civil defense use
manufactured by Rohm and Haas).
Diluted hypochlorite (household bleach
1:10 in water) followed by a thorough
D) AIRWAY MANAGEMENT
o 1) Administer 100% humidified
supplemental oxygen, perform
endotracheal intubation and
provide assisted ventilation as
required.
o Administer IV or IM atropine
and inhaled beta-2 adrenergic
agonists if bronchospasm
develops. Give atropine to
reduce hypersecretion and
bronchial secretion. Avoid
succinylcholine for rapid
sequence intubation as
prolonged paralysis may result.
o
BENZODIAZEPINES are indicated for
agitation and seizures.
F) ATROPINE SULFATE
o
1) Titrate to resolution of
bronchospasm, bronchorrhea,
and severe bradycardia. Double
dose as needed; no maximum
dose. IV route is preferred if
available. Autoinjectors may
also be used. Primarily effective
for muscarinic effects. It will not
reverse nicotinic effects.
DERMAL EXPOSURE

OVERVIEW
o 1) Dermal exposure may cause
severe toxicity; treatment
should include
recommendations listed in the
INHALATION EXPOSURE
section.
o 2) Remove contaminated
clothing and jewelry.
o
o
o
Wash the skin, face, nails, and
hair repeatedly and vigorously
with soap and water.
A physician may need to
examine the area if irritation or
pain persists.
Discard contaminated clothing.
Carefully observe patient for
the development of systemic
toxicity. Other alternatives are
the following:
 a) M291 Skin
Decontaminating Kit
(for military and civil
defense use
manufactured by Rohm
and Haas).
 b) Diluted hypochlorite
(household bleach 1:10
in water) followed by a
thorough water rinse.
 c) 0.5% Hypochlorite
solution (prepared by
adding one 6 ounce
bottle of calcium
hypochlorite granules
to 5 gallons of water).
hydrogen cyanide) and CK (for
cyanogen chloride).
MANAGEMENT:






4. Cyanide




Cyanide is a rapidly acting,
potentially deadly chemical that
can exist in various forms.
Cyanide can be a colorless gas,
such as hydrogen cyanide (HCN)
or cyanogen chloride (CNCl), or
a crystal form such as sodium
cyanide (NaCN) or potassium
cyanide (KCN).
Cyanide sometimes is described
as having a “bitter almond”
smell, but it does not always
give off an odor, and not
everyone can detect this odor.
Cyanide is also known by the
military designations AC (for
Immediately leave from the source
Move to an area with high and fresh air
If exposed, remove clothing and put it
sealed plastic bag and take a bath
immediately with soap
Avoid contamination of other materials
For eyes exposure: rinse your eyes with
plain water for 10 to 15 minutes. If you
wear contacts, remove them and put
them with the contaminated clothing.
Do not put the contacts back in your
eyes (even if they are not disposable
contacts). If you wear eyeglasses, wash
them with soap and water. You can put
your eyeglasses back on after you wash
them. If you are wearing jewelry that
you can wash with soap and water, you
can wash it and put it back on. If it
cannot be washed, it should be put with
the contaminated clothing.
For Cyanide poisoning: Administer
Hydroxocobalamin, sodium nitrite, and
sodium thiosulfate given via
intravenous (IV) infusion
5. Sulfur mustard




Sulfur mustard is a type of chemical
warfare agent. These kinds of agents
cause blistering of the skin and mucous
membranes on contact. They are called
vesicants or blistering agents.
Sulfur mustard is also known as
“mustard gas or mustard agent,” or by
the military designations H, HD, and HT.
Sulfur mustard sometimes smells like
garlic, onions, or mustard and
sometimes has no odor. It can be a
vapor (the gaseous form of a liquid), an
oily-textured liquid, or a solid.
Sulfur mustard can be clear to yellow or
brown when it is in liquid or solid form.
6. Nitrogen mustard

MANAGEMENT:








No antidote available thus it is fatal,
supportive care is needed
Because no antidote exists for sulfur
mustard exposure, the best thing to do
is avoid it. Immediately leave the area
where the sulfur mustard was released.
Try to find higher ground, because
sulfur mustard is heavier than air and
will settle in low-lying areas.
If avoiding sulfur mustard exposure is
not possible, rapidly remove the sulfur
mustard from the body. Getting the
sulfur mustard off as soon as possible
after exposure is the only effective way
to prevent or decrease tissue damage
to the body.
Quickly remove any clothing that has
liquid sulfur mustard on it. If possible,
seal the clothing in a plastic bag, and
then seal that bag inside a second
plastic bag.
Immediately wash any exposed part of
the body (eyes, skin, etc.) thoroughly
with plain, clean water. Eyes need to be
flushed with water for 5 to 10 minutes.
Do NOT cover eyes with bandages, but
do protect them with dark glasses or
goggles.
If someone has ingested sulfur mustard,
do NOT induce vomiting. Give the
person some water or milk to drink, if
they can swallow.
Seek medical attention right away.
One complication is
immunosuppression, thus infection
prevention is highly important



Nitrogen mustards were produced
in the 1920s and 1930s as potential
chemical warfare weapons. They
are vesicants (or blister agents)
similar to the sulfur mustards.
Nitrogen mustards come in
different forms that can smell fishy,
musty, soapy, or fruity. They can be
in the form of an oily-textured
liquid, a vapor (the gaseous form of
a liquid), or a solid. Nitrogen
mustards are liquids at normal
room temperature (70ºF).
Nitrogen mustards can be clear,
pale amber, or yellow-colored when
in liquid or solid form.
The nitrogen mustards are also
known by their military
designations of HN-1, HN-2, and
HN-3.
Signs and Symptoms:
o
o
o
o
o
Skin: redness usually develops within
several hours after exposure followed
by blistering within 6 to 12 hours.
Eyes: irritation, pain, swelling, and
tearing may occur. High
concentrations can cause burns and
blindness.
Respiratory tract: nose and sinus pain,
cough, sore throat, and shortness of
breath may occur within hours. Fluid in
the lungs is uncommon.
Digestive tract: abdominal pain,
diarrhea, nausea, and vomiting.
Brain: tremors, incoordination, and
seizures are possible following a large
exposure.
MANAGEMENT









No antidote available
Do not induce vomiting and do not give
any fluids
Give activated Charcoal
Because no antidote exists for sulfur
mustard exposure, the best thing to do
is avoid it. Immediately leave the area
where the sulfur mustard was released.
Try to find higher ground, because
sulfur mustard is heavier than air and
will settle in low-lying areas.
If avoiding sulfur mustard exposure is
not possible, rapidly remove the sulfur
mustard from the body. Getting the
sulfur mustard off as soon as possible
after exposure is the only effective way
to prevent or decrease tissue damage
to the body.
Quickly remove any clothing that has
liquid sulfur mustard on it. If possible,
seal the clothing in a plastic bag, and
then seal that bag inside a second
plastic bag.
Immediately wash any exposed part of
the body (eyes, skin, etc.) thoroughly
with plain, clean water. Eyes need to be
flushed with water for 5 to 10 minutes.
Do NOT cover eyes with bandages, but
do protect them with dark glasses or
goggles.
If respiration is compromised,
administer high flow rate of O2
For burns, assess burn area, administer
IVF and wound care
7. Sodium Nitrite

Odorless, yellowish white,
crystalline granule, rod or
powder. It is used in heat
transfer salts, metal treatment
and fishing and preservatives
MANAGEMENT:

Eye Contact: For eyes exposure: rinse
your eyes with plain water for 10 to 15
minutes. If you wear contacts, remove
them and put them with the
contaminated clothing. Do not put the
contacts back in your eyes (even if they
are not disposable contacts). If you
wear eyeglasses, wash them with soap
and water. You can put your eyeglasses
back on after you wash them. If you are
wearing jewelry that you can wash with
soap and water, you can wash it and
put it back on. If it cannot be washed, it
should be put with the contaminated
clothing.

Skin contact: Remove contaminate
clothing, wash with large amount of
water and soap. Seal the clothing in a
plastic bag, and then seal that bag
inside a second plastic bag.
Inhalation: Remove the person from
exposure, begin rescue breathing
Transfer immediately to the emergency
department


8. Amyl nitrate

Amyl nitrite is
a depressant which means it
slows down the messages
travelling between the brain
and body. Classified as
an inhalant, it belongs to a class
of drugs known as alkyl nitrites,
which also includes butyl
nitrite, isobutyl nitrite and
isopropyl nitrite.
MANAGEMENT:


If ingested, do not induce
vomiting
Administer Activated charcoal
9. Sarin


Sarin is a human-made chemical
warfare agent classified as a nerve
agent. Nerve agents are the most toxic
and rapidly acting of the known
chemical warfare agents. They are
similar to certain kinds of insecticides
(insect killers) called organophosphates
in terms of how they work and what
kind of harmful effects they cause.
However, nerve agents are much more
potent than organophosphate
pesticides.
Sarin is a clear, colorless, and tasteless
liquid that has no odor in its pure form.
However, sarin can evaporate into a
vapor (gas) and spread into the
environment.
o
o
o
o
o
o

Confusion
Drowsiness
Weakness
Headache
Slow or fast heart rate
Low or high blood pressure
Even a small drop of sarin on the skin
can cause sweating and muscle
twitching where sarin touched the skin.
 Exposure to large doses of sarin by any
route may result in the following
harmful health effects:
o Loss of consciousness
o Convulsions
o Paralysis
o Respiratory failure possibly leading to
death
MANAGEMENT:



Signs and Symptoms:
o
o
o
o
o
o
o
o
o
o
o
o
Runny nose
Watery eyes
Small, pinpoint pupils
Eye pain
Blurred vision
Drooling and excessive sweating
Cough
Chest tightness
Rapid breathing
Diarrhea
Nausea, vomiting, and/or abdominal
pain
Increased urination


Antidotes: Atropine and pralidoxime
chloride (2-PAM Cl)
Immediately remove from exposure
Eye Contact: For eyes exposure: rinse
your eyes with plain water for 10 to 15
minutes. If you wear contacts, remove
them and put them with the
contaminated clothing. Do not put the
contacts back in your eyes (even if they
are not disposable contacts). If you
wear eyeglasses, wash them with soap
and water. You can put your eyeglasses
back on after you wash them. If you are
wearing jewelry that you can wash with
soap and water, you can wash it and
put it back on. If it cannot be washed, it
should be put with the contaminated
clothing.
Skin contact: Remove contaminate
clothing, wash with large amount of
water and soap. Seal the clothing in a
plastic bag, and then seal that bag
inside a second plastic bag.
Inhalation: Remove the person from
exposure, begin rescue breathing




Transfer immediately to the emergency
department
If respiration is compromised,
administer high flow rate of O2
For burns, assess burn area, administer
IVF and wound care
Assess muscle weakness and provide
safety to prevent fall accidents
10. Bhopal
MANAGEMENT:







Immediately remove from exposure
Eye Contact: For eyes exposure: rinse
your eyes with plain water for 10 to 15
minutes. If you wear contacts, remove
them and put them with the
contaminated clothing. Do not put the
contacts back in your eyes (even if they
are not disposable contacts). If you
wear eyeglasses, wash them with soap
and water. You can put your eyeglasses
back on after you wash them. If you are
wearing jewelry that you can wash with
soap and water, you can wash it and
put it back on. If it cannot be washed, it
should be put with the contaminated
clothing.
Skin contact: Remove contaminate
clothing, wash with large amount of
water and soap. Seal the clothing in a
plastic bag, and then seal that bag
inside a second plastic bag.
Inhalation: Remove the person from
exposure, begin rescue breathing
Transfer immediately to the emergency
department
If respiration is compromised,
administer high flow rate of O2
For burns, assess burn area, administer
IVF and wound care