DISASTER and
BIOTERRORISM NURSING
Terrorism
• Disrupt Daily Life & Cause Widespread Terror
and Panic
• FBI – “the unlawful use of force or violence
against person’s or property to intimidate or
coerce a government, the civilian population,
or any segment thereof, in furtherance of
political or social objectives” (FBI 2006)
• International -
Terrorism
– al Qaeda, Irish Republic Army, Suicide Bombers
• Domestic – Klux Klux Klan, Greenpeace, and Individuals like
the OK City Federal Building Bomber
Targets
•
Anything & Anywhere that causes large scale
disruption
•
Large crowds/gatherings of people
•
Nuclear/Chemical Plants
•
Federal Systems
•
Military Installations
•
Religious Buildings
•
Controversial businesses (Abortion Clinics)
Purpose
• Attract Media Attention
• Increase support for Cause
• Undermine the Government or Agency
attacked
• Influence Policy
• Create a sense of vulnerability or fear
• Solely For Revenge
History of Agents
Chemical
Biological
Radiological
Explosive
National Standards of Nursing
Education
• Pre-September 11, 2001 – considered
unnecessary
• Now Emergency and Disaster Preparedness
Core Competencies for Nurses are standard
and have been added to Education
Curriculums
• Core Competencies pg. 2386 Chart 72-2
Disaster Planning
Assumptions versus Observations
•
•
•
•
•
•
Assumptions
Dispatchers will send emergency
response units once notified
Trained Emergency personnel will
carry out field search and rescue
Trained EMS personnel will carry out
triage, first aid, medically stabilize
and decontaminate before transport
Casualties will be transported via
ambulance to the appropriate facility
or hospital in an appropriate amount
that the facility or hospital can
accommodate
Hospitals will be properly notified
Most serious casualties will arrive
first
Observations
•
•
•
•
•
•
Emergency Response Units will self dispatch
(local and distant)
Initial search and rescue is carried out by the
survivors themselves
Casualties are likely to bypass on-the-site
triage, first aid and decontamination stations
and go directly to hospitals
Most casualties are not transported by
ambulance. Most go by private vehicles,
police vehicles, buses or on foot. Most
casualties will go to the nearest hospital or
the most familiar hospital.
Hospitals most often are notified by arriving
victims and/or by news media
The least serious casualties often arrive first
Types of Events
Identification and Delivery
• Weapons of Mass Destruction (WMD)
• Because they cause massive destruction and injury
• CBRNE (Department of Justice) – Chemical, Biological,
Radiological, Nuclear and Explosive (includes Firecausing)
• Delivery of agent – spraying devices, packages,
contaminating water and food, animals and the wind
• Identifying an event –
– Biological – Delayed onset, epidemiology, public health
– Chemical – symptoms suggestive of chemical agent used
– Radiological – clustering of symptoms resembling
radiological exposure (could be delayed)
– Explosive – boom! Trauma causalities
Personal Protective Equipment
•
•
•
•
•
Level A
highest level of respiratory,
skin, mucous membranes and
eye protection
fully encapsulated vapor and
chemical resistant suit
full face piece and supplied air
(self-contained breathing
apparatus or SCBA)
Chemical resistant
boots/gloves, hard hat
Two-way communication
system (most)
•
•
•
•
•
Level B
Same respiratory as level A
except chemical protective
equipment is used instead of
the fully encapsulating suit.
Provides splash protection
but not vapor resistant
Supplied air is used (SCBA),
with full face mask
Inner Chemical Resistive and
Outer Chemical Protective
clothing, gloves and boots.
Acceptable minimum level
PPE for initial entry into sites
till the hazardous agent is
identified
Level C
• Full face piece with air
purifying canisterequipped respirator,
• chemical-resistant
inner clothing,
chemical protective
outer clothing,
• inner and outer
protective gloves and
chemical resistant
boots or boot covers.
Level D
• Regular work clothing,
safety shoes, isolation
gowns, goggles/splash
shield, N95 TB Masks
Decontamination
• Reduction or removal of
contamination agents.
• Radioactive agents – the
runoff also needs to be
contained
• All victims and personnel will
be decontaminated before
they can enter or be
admitted to the emergency
facility or hospital (green
zone)
Zones of Decontamination
• Hot Zone (red zone) – the area of highest
contamination, point of entry, waiting to be decontaminated,
initial disrobing, may have a triage area or initial first aid,
patient gets a numbered tag.
• Warm Zone (yellow zone) – contamination reduction
corridor, where decontamination process takes place
• Cold Zone (green zone) – support zone –
decontaminated, ambulatory or non-ambulatory, clean
treatment area, clean evacuation, staging for personnel (the
ED, Hospital are considered Green/Cold zones).
Decontamination
Chemical Agents
Nerve Agents (worst)
Vesicants (blistering agents)
Blood Agents
Choking Agents (asphyxiates)
Irritants
Chemical Agent Route of Entry
4 ways of entry into body:
• Ingestion (food and water supply)
• Inhalation (aerosols, sprays, crop dusters)
• Injection (projectiles from bombs,
contaminated bullets, needles, darts, knives)
• Dermal Exposure – (contaminated items,
powders, sprays, intentional spills)
NERVE AGENTS
• Most toxic of chemical agents
• Most common routes of exposure are inhales
and topical
• Inactivates acetylcholinesterase
increases
acetylcholine at the receptor site
results in
overstimulation at the synapse - causing
cholinergic symptoms
• Signs and Symptoms: SLUDGM: salivation,
lacrimation, urination, defecation, gastric upset,
emesis, miosis
NERVE AGENTS
SARIN (GB)
SOMAN (GD)
TABUN (GA)
V AGENT (VX)
(pg. 2391)
NERVE AGENTS
Signs and Symptoms
• SLUDGEM: salivation, lacrimation, urination, defecation,
gastric upset, emesis, and miosis
• Dim vision
• Cardiac dysrhythmias, confusion and convulsions, along
with unconsciousness
• Runny nose and shortness of breath
• Pinpoint pupils and muscle fasciculations (muscle
twitching)
NERVE AGENTS - Treatment
– Oxime reversal agents: Protopam chloride (2-PAM
chloride)
– MARK I kit: atropine and protopam
– Diazepam (Convulsions and muscle twitching)
– Full decontamination of body and clothing
– Hydration: electrolyte and fluid replacement as
needed
– Reassure patient, to decrease anxiety and promote
rest
– Do not induce vomiting if ingested
VESICANT AGENTS
• Are blistering agents that cause burning,
conjunctivitis, bronchitis, pneumonia,
hematopoietic (stem cell) suppression and
death.
• Inhalation, Topical (skin damage irreversible
but seldom fatal)
VESICANT AGENTS
Mustard
Lewisite
Phosgene oxime
(pg. 2391, 2394-2395)
VESICANT AGENTS
Signs and symptoms
– Eyes: irritation, conjunctivitis, corneal burns, blindness
– Skin: erythema, itching, areas of increased pigmentation,
blisters
– Mucosal sloughing and airway obstruction
– Bone marrow suppression
– Respiratory effects: irritation/burning of nares, sinus pain
or irritation, nosebleeds, and irritation of the pharynx,
dyspnea and increased sputum production
– Damage to the trachea and upper airways, laryngitis
– Headache, nausea, vomiting, and diarrhea
– Blood-stained emesis and feces
VESICANT AGENTS
Treatment
• Supportive
– Treat skin – wound care, burn care
– Treat respiratory – O2 support,
Airway support, mechanical
ventilation if necessary
– Support bone marrow and immune
response
– Antibacterial for secondary infections
– Treat symptoms
– Decontaminate with soap and water
– Eye irrigations
BLOOD AGENTS
• Effects cellular metabolism and hemoglobin – results
in lactic acidosis and reduced intracellular ATP
• Primary route of entry – Inhalation
• Liquid forms may be absorbed though dermal routes,
eyes and oral mucosa.
• Liquid exposure – requires decontamination
• High exposures – death results in 3-8 minutes
BLOOD AGENTS
Gases:
Hydrogen cyanide
Cyanogen chloride
Crystals:
Sodium Cyanide
Potassium Cyanide
(pg. 2395)
BLOOD AGENTS
Signs and Symptoms
• Initial transient rapid respiratory rate
• Apprehension, anxiety, agitation, and vertigo
• Feeling of general weakness, nausea with or
without vomiting, and muscular trembling
• Slowing respirations, loss of consciousness,
convulsions, and apnea with cardiac standstill
BLOOD AGENTS
Treatment
– 100% oxygen administration
– Amyl nitrate by inhalation or sodium nitrate by
intravenous injection
– Sodium thiosulfate
– Hyperbaric oxygen treatment
– Supportive therapy: IV bicarbonate for severe
acidosis, vasopressors, valium
CHOKING AGENTS
• Destroys the pulmonary membrane that
separates the alveolus from the capillary bed
• Results in fluid filled alveoli
• Inhaled
CHOKING AGENTS
Ammonia
Chlorine
Phosgene
(pg. 2395-2396)
CHOKING AGENTS
Signs and Symptoms
– Irritation of the nasopharynx, causing sneezing,
pain, and erythema
– Dysphagia, cough
– Hoarseness, stridor, and coarse rhonchi,
lacrimation and rhinorrhea, swelling of the throat
and bronchi
– Pulmonary edema - large amounts of white to
pink frothy sputum
– Chemical pneumonitis and lung hemorrhage
CHOKING AGENTS
Treatment
• Supportive
–Oxygen, ventilation support,
bronchodilators
–Bed rest
–Steroids (anti-inflammatory) and
ibuprofen
IRRITANTS
• Commonly known as – “riot controlling agents”
• Produces transient discomfort – to render an opponent
incapable of resistance or fighting back
• Examples
– Mace
– Tear gas
– Pepper spray
• Signs and symptoms
– Pain, eye and nasal burning, lacrimation, or discomfort
on exposure to mucous membranes
• Treatment is fresh air, washing away the irritant
BIOLOGICAL AGENTS
– Bacteria, Viruses and Toxins
– Category A, B, C based on risk for
national security, mortality,
dissemination and cause public
panic
– Illness lasts longer than with
chemical agents
– Impact/demands on health care
are much longer and larger than
with chemicals
– Dispersed – aerosol, oral,
injection, dermal, vector
transmission (by a carrier of the
disease)
BIOLOGICAL AGENTS
• Bacteria - Anthrax, Brucellosis (Black Death),
Cholera, Glanders, Plague, Q Fever,
Rickettsia, Tularemia, Typhus
• Viruses - Dengue Fever, Ebola, Rift Valley
Fever, Small Pox, Venezuelan
Equine, Encephalitis (VEE) Virus,
Viral Hemorrhagic Fever (VHF)
• Toxins - Botulinum, Ricin, Saxitoxin,
Staphylococcal Enterotoxin B (SEB),
Trichothecene Mycotoxinx
(pgs. 2397 – 2401)
BIOLOGICAL AGENTS
3 categories:
– A: HIGH PRIORITY
• High mortality, with major public health effects/action
• Easily disseminated from person to person
• Cause widespread panic, public disruption
(anthrax, botulism, plague, smallpox, hemorrhagic fever,
tularemia)
– B: SECOND HIGHEST PRIORITY
• Moderately disseminated from person to person
• Moderate morbidity, low mortality
• Enhancements for prevention (CDC)
(Salmonella, e coli, Q fever, Ricin toxin)
– C: THIRD HIGHEST PRIORITY
• Emerging pathogens that could be engineered in the future
• Easily produced and easily disseminated
• Potential for high mortality and major health impact
(hantavirus, tick born encephalitis virus, yellow fever)
BIOLOGICAL AGENTS
Bacteria: Anthrax, Brucellosis, Plague, Q Fever, Tularemia
Viral: Small Pox, Venezuelan equine encephalitis (VEE), Viral
hemorrhagic fevers
Toxins: Botulinim, Staphylococcal
enterotoxin B (SEB), Ricin,
Trichothecene (T-2) mycotoxins
BIOLOGICAL AGENTS
• Signs and Symptoms
– Vary by infecting organism and route of infection
• Treatment involves vaccine for primary
prevention, antibiotic therapy and supportive
care for active cases
Isolation Precautions for
Biological Terrorism
• Due to modern travel, spread of infection may occur in areas
thousands of miles apart
• Health care providers need to be aware of potential signs of
biological weapons
– signs and symptoms are similar to those of the disease
• Isolation practices depend upon the infecting agent
• Always use Standard Precautions
• Some agents require Transmission-Based Precautions
• Terminal disinfection and disposal of wastes depends on the
infecting agent
BIOLOGICAL AGENTS
Treatment• Isolation
• Vaccines
• Antibiotics
RADIOLOGIC AGENTS
• Radiation that can be used as a weapon
• RDD - Radiological Dispersion Device or “Dirty
Bomb” – an explosive device that releases
radioactive material into the environment
• Creates trauma from the explosion, complicates
evacuation and care of victims due to the
contamination
• Causes wide spread panic and terror
RADIOLOGIC AGENTS
– Nuclear explosion –
» Trauma from the blast
» thermal burns from the heat and light
» acute radiation syndrome from exposure to the nuclear radiation
– Exposure to radiation Is affected by time, distance, and
shielding
RADIOLOGIC AGENTS
• Nonionizing - low energy and non-harmful
• Ionizing – Alpha, Beta and Gamma
– Alpha – poorly penetrates skin, travel 1-2 inches, very harmful to
kidneys lungs and skeletal system if introduced through broken
skin or ingested
• Blocked by clothing or paper
– Beta – can penetrate skin at short distances causing burns, travels
up to 10 ft., can be harmful if ingested or inhaled
• Blocked by heavy clothing, walls, or thin metals
– Gamma – emitted during nuclear detonation and are present in
fall out, travel several 100 ft., are penetrating through tissue to
deep organs.
• Blocked by dense materials – lead, concrete, and steel
RADIOLOGIC AGENTS
Acute Radiation Syndrome
• An acute illness that occurs when the entire body
(or most of it) receives or is exposed to a high
dose of radiation.
• Generates highly reactive free radicals, damages
messenger RNA (mRNA) and DNA and interferes
with cell growth, or even causes cell death.
• Severity varies with the amount of exposure, age
and overall heath of an individual
RADIOLOGIC AGENTS
Acute Radiation Syndrome
• Four Phases
1.
2.
3.
4.
Prodromal Phase
Latent Phase (Transient Phase)
Illness Phase
Recovery or death
RADIOLOGIC AGENTS
Treatments
• Burn unit
• Possible anticoagulants
• Antibiotics to prevent
secondary infection
• Corticosteroids
• Anti emetics, anti seizure,
and analgesics
• Fluid and electrolyte
replacements
• Psychological support
RADIOLOGIC AGENTS
Decontamination
• Triage outside the hospital
• Cover floor and use strict isolation
precautions to prevent the tracking of
contaminants
• Seal air ducts and vents
• Waste is double bagged and put in a
container labeled radiation waste, needs
to be contained
• Staff protection -water-resistant gowns,
2 pairs of gloves, caps, goggles, masks,
and booties
EXPLOSIVE AGENTS
• High Order Explosive
(nitroglycerin) and Low
Order Explosives
(pyrotechnics,
gunpowder)
• High Order Explosive
Injuries are classified into
Primary, Secondary and
Tertiary.
EXPLOSIVE AGENTS
Nail Bomb or Jar Bomb
Blast Injuries from High Order
Explosives
• Primary – Impact of the
over-pressurization wave
with body surfaces –
lungs, ears, GI, TBI (most)
• Secondary – Flying debris and bomb
fragments
• Tertiary – Injuries incurred from
being thrown by the blast.
• Quaternary – explosion related
injuries that are
complication of the
previous injuries
Hospital Incident Command
Incident Commander
Public Information
Officer
Liaison Officer
Medical or Technical Officer
Safety and
Security
Officer
Operations
Planning
Finance
Logistics
ID ME
Triage
Description
Color
Immediate
Respirations are present, very
serious injury that can be fixed
quick with out a lot of resources
RED
Delayed
Can wait to be treated for hours
to days, dislocations, minor
fractures
YELLOW
Minor
“walking Wounded”, cuts, minor
wounds
GREEN
Expectant/
Deceased
Not breathing, Massive Head
trauma, would take massive
resources away from many
others to save one
BLACK
START TRIAGE
National Resources
(was national pharmaceutical stock pile)
• Strategic National Stock Pile
– Push Packs-shipped within 12 hours of the decision to
deploy 4% of the stockpile
DMAT/DMORTS
Disaster Management Assistance Teams/Disaster
Management Mortuary Teams
– Health care providers, nurses, EMT’s, Technical Staff, and other
health care professionals.
– DMORTS – management and identification of the dead
Psychological Effects
After a Disaster
• Provide active listening and emotional support
• Provide information as appropriate
• Refer to therapist or other resources
• Discourage repeated exposure to media regarding
the event
• Encourage return to normal activities and social
roles
The point is
to save as
many as you
can.