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)

Terrorism• International -– 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

ChemicalBiological

RadiologicalExplosive

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

ObservationsAssumptions

• 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 EventsIdentification 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 Fire-causing)

• 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 canister-equipped 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 ZoneHot 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 ZoneWarm Zone (yellow zone) – contamination reduction corridor, where decontamination process takes place

•Cold ZoneCold 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 AgentsNerve Agents (worst)

Vesicants (blistering agents)Blood Agents

Choking Agents (asphyxiates)Irritants

Chemical Agent Route of Chemical Agent Route of Entry 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 AGENTSSARIN (GB)SOMAN (GD)TABUN (GA)V AGENT (VX) (pg. 2391)

NERVE AGENTSSigns 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

MustardLewisite

Phosgene oxime(pg. 2391, 2394-2395)

VESICANT AGENTSSigns and symptomsSigns 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 AGENTSGases:

Hydrogen cyanideCyanogen chloride

Crystals:Sodium Cyanide

Potassium Cyanide

(pg. 2395)

BLOOD AGENTSSigns 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 AGENTSBLOOD 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

AmmoniaChlorine

Phosgene(pg. 2395-2396)

CHOKING AGENTSSigns 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 AGENTS3 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 AGENTSBacteria: Anthrax, Brucellosis, Plague, Q Fever, TularemiaViral: Small Pox, Venezuelan equine encephalitis (VEE), Viral

hemorrhagic feversToxins: 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 AGENTSAcute Radiation

Syndrome• Four Phases

1. Prodromal Phase2. Latent Phase (Transient Phase)3. Illness Phase4. Recovery or death

RADIOLOGIC AGENTSTreatments

• 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

Liaison Officer

Safety and Security Officer

Public Information Officer

Medical or Technical Officer

ID METriage Description Color

ImmediateImmediate Respirations are present, very serious injury that can be fixed quick with out a lot of resources

RED

DelayedDelayed Can wait to be treated for hours to days, dislocations, minor fractures

YELLOW

MinorMinor “walking Wounded”, cuts, minor wounds

GREEN

Expectant/Expectant/DeceasedDeceased

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/DMORTSDisaster 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.