Care of Patients During Disasters, Bioterrorism Attacks, and Pandemic Infections

1
Chapter 44

• Care of Patients During Disasters, Bioterrorism
  Attacks, and Pandemic Infections
• Jodi Olenginski MSN, RN

2
Theory Objectives

• State the difference between an emergency
  situation and a disaster.
• Discuss an emergency preparedness plan for a
  health care facility.
• Compare the stages of psychological response that
  occur with a disaster.
• Describe the parameters used in the triage system
  for victims after a disaster.

3
Theory Objectives (cont.)

• Identify responsibilities and duties of the nurse
  in the care of disaster victims.
• Explain safety measures to be employed for a
  chemical emergency or an earthquake.
• Demonstrate knowledge of measures to be taken in
  the event of a nuclear disaster.
• Explain warning signs that suggest a bioterrorism
  attack has occurred.

4
Theory Objectives (cont.)

• Differentiate the signs and symptoms of the
  various agents that could be used for a terrorist
  attack.
• Explain the importance of debriefing of health
  care personnel after a disaster.

5
Clinical Practice Objectives

• Participate in a disaster drill.
• Teach a group of adults how to prepare safe water
  after a disaster has disrupted the water supply.
• Identify the measures you would take for your own
  safety when assisting others after a disaster has
  occurred.

6
Disaster Preparedness and Response

• A disaster exists when the number of casualties
  exceeds the resource capabilities of the area
• Natural disasters include epidemics, earthquakes,
  explosions, hurricanes, tornadoes, fires, floods,
  and transportation accidents

7
Disaster Preparedness and Response (cont.)

• Man-made disasters may result from attacks with
  chemical, biologic, nuclear, and conventional
  weapons
• Terrorist attacks are classified as disasters

8
Governmental Agencies

• Dept of Homeland Security
• Office of Domestic Preparedness
• American Red Cross (voluntary)
• Salvation Army
• CDC
• FEMA

9
Disaster Preparedness and Response (cont.)

• Preparing disaster supplies (refer to pg 997)
• - If family is separated, need a common person to
  call.
• Community preparedness
• Fire safety (get out without belongings, stay low
  to ground)
• Earthquake safety- get under desk or stand in
  corner or door frame. If driving stay in car
• Tornado, hurricane, and flood safety-Get out of
  area with meds and bedding

10
Hurricane Teaching

• Watch
• Get out of mobile home. Bring in patio furniture
  etc., Have cash, batteries, non-perishable food,
  water
• Warning
• - Stay inside from windows, eye of storm is
  deceiving. Be alert for lying debris. Stay in a
  room with no windows

11
After a hurricane

• If water is rising, move to higher ground
• Do not play in floodwater
• Use tap water until officials say it is safe

12
Red Cross Volunteers
13
Hospital Preparedness

• Surge capacity- maximum services a facility can
  offer when every resource is utilized
• Joint Commission requires all hopitals have a
  plan and that it is tested twice a year

14
Psychological Response

• Shock
• -headache, nausea, chest pain
• -pre-existing medical conditions may worsen

15
Audience Response Question 1

• In reviewing disaster preparedness information,
  the nurse asks community members, If there is a
  hurricane watch, what would you do? Which
  response(s) would be correct? (Select all that
  apply.)
• Bring inside any outdoor furniture, trash cans,
  potted plants, toys, etc., that could be picked
  up by the wind.
• Fill your cars gas tank.
• Have cash on hand.
• Check batteries and stock up on canned food,
  first-aid supplies, drinking water, and
  medications.
• Stay in a mobile home.

16
Psychological Responses to Disaster

• Signs and symptoms of emotional shock
• Stages
• Impact stage-survivors are stunned and
  disorganized. May have difficulty following
  direction
• Heroic stage- want to be helpful and may minimize
  their own injuries. May demonstrate risky
  behavior
• Honeymoon stage-Grateful, brotherhood spirit

17
Stages cont

• Disillusionment stage. Reality of loss occurs.
  Ongoing physical and emotional fatigue can result
  in substance abuse and discouragement. Survivors
  feel abandoned and ignored by the larger
  community because of the gap between resources
  and need.
• Reconstruction stage. This stage may continue for
  years as people rebuild lives and even begin to
  see the crisis, in retrospect, as a growth and
  opportunity period.

18
Disaster Triage System

• Class I Emergent (red)-immediate threat to life,
  airway, hemorrhagic shock
• Class II Urgent (yellow)-major inuries, large
  wounds, open fractures
• Class III Non-urgent (green)-walking wounded
• Class IV Minor (white)-minor injuries like
  abrasions etc. Wil be dismissed
• Class V Dead or expected to die (black)

19
Triage Tags
20
Triage During Disasters

• Victims with life-threatening conditions and a
  good chance of survival are cared for first
• When there are more victims of a disaster than
  medical personnel to treat them, those who are
  likely to survive are treated first these
  patients are given green tags
• The mortally wounded and those who are not
  expected to survive are attended later, and these
  patients are issued a black tag

21
Disasters

• Nursing responsibilities- nursing care,
  secretarial
• Nursing roles and management
• Care of special populations-elderly,
  immuno-compromised, infants

22
Purification for Safe Water

• Boil water for 3-5 minutes and let cool
• Add 16 drops of bleach to a gallon and let sit
  for 30 minutes
• TO distill- fill a large pot halfway with water.
  Tie cup on lid and place upside down in pot.
  Boil for 20 min. Water in the cup is now
  distilled

23
Communicable disease with epidemic potential

• Cholera, Hepatitis A and E Fecal/oral
• Typhoid fever
• Pneumonia-Resp
• Measles and Bacterial meningitis- direct contact
  airborne droplet
• Malaria, Dengue fever, Yellow Fever Vector
  Borne (mosquito)

24
Management in Reconstruction

• Self-help, community, work therapy,
• Controlling environmental hazards
• Understanding of disaster plans

25
Keeping foods safe to eat

• Food should not be kept about 40 degrees for
  greater than 2 hours.
• Full freezer will stay for 48 hours, half full 24
  hours
• Pack perishables in ice
• Throw away anything that has come in contact with
  flood water

26
Chemical Disaster

• Indications that a chemical attack has occurred
  might include
• Fog-like or low-lying cloud suddenly appearing in
  the atmosphere
• Many dead birds, domestic animals, or insects
  within a particular area
• Many dead, dying, or sick people in an area or
  downwind from a suspicious cloud or fog
• An atypical, unexplained odor for the location

27
Chemical Agent

• Phosgene, mustard, lewisite

28
Mustard
29
Lewisite
30
Lewisite

• BAL- British anti-lewisite ointment, IM

31
Other agents

• Nerve- Sarin (Toyoko subway)
• Blood- Cyanide
• Pulmonary choking agent - chlorine

32
If a chemical disaster occurs

• Close all windows and doors
• Turn off all fans, heaters
• Wet towels and fill in cracks od doorways
• Cover outlets and heat registers , AC units with
  plastic
• Go above ground with few windows

33
Removal and Decontamination for Chemicals

• Take off clothing quickly. Try not to touch
  contaminated parts.
• Wash chemicals from skin with soap and water..
  If eyes burn, rinse with water for 15 min
• Remove contacts
• Place all clothing in bag without touching it
• Dress in uncontaminated clothes

34
Nuclear Disaster

• Amount of damage to each person (depends on type,
  dose, length of time exposed and route).
• Some radiation produces particle others rays
• -particles adhere to airborne dust and may be
  inhaled and will settle on crops, clothes and
  water

35
Nuclear

• Decontamination for particles. Wash with soap
  and water. Non needed for rays. Rays cause
  internal damage
• Acute radiation sickness syndrome
• Bone marrow syndrome
• Gastrointestinal syndrome
• Cardiovascular/central nervous system syndrome

36
Signs and symptoms of ARS

• Nausea, vomiting, diarhhea
• Hemorrhage, confusion, ataxia
• Respiratory complications with fever and
  pneumonia
• Hair loss

37
Nursing care

• Maintain accurate record of event
• Record hair loss, erythema
• Antiemetics
• Blood products

38
Agents to treat radiation agents

• Chelating- bind to material to be excreted
  without being absorbed into tissue
• Radioactive iodine is treated with potassium
  iodinethis blocks the agent and prevents thyroid
  cancer
• Excretion- used when material is ingested. Reduce
  time in GI tract
• Diluting- ie. Water ( becareful about runoff)

39
Decontamination Drill
40
Decontamination Drill (cont.)
41
Biologic Disaster

• Bioterrorism- relaeasing microorganisms or toxins
  that could cause disease or death
• Examples-180 known..anthrax, smallpox, botulism

42
Recognizing a Bioterrorism Event

• Certain signs or events may present a warning
  that a bioterrorism attack has occurred. Some of
  the signs include (Peterman, 2010)
• Rapidly progressing flu-like illness,
  particularly in the young and among those
  previously healthy
• Rapidly progressive respiratory illness,
  especially in young, previously healthy people

43
Recognizing a Bioterrorism Event (cont.)

• Unusual or extensive rashes, especially if
  preceded by flu-like symptoms
• Flaccid muscle paralysis
• Severe bleeding disorders
• A large group of patients with food-borne illness
• Sudden death of many animals in the community

44
Bioterrorism

• Nursing management
• Strict adherence to infection control procedures
  and policies
• Debriefing

45
Biologic Agents

• Category A agents-Easily disseminated, and some
  may be transmitted from person to person as well.
  These could cause mass casualties and require a
  well-organized and extensive health care system
  response for management
• Category B agents Delivered through water and
  food sources. These produce moderate amounts of
  illness and low death rates. Public health
  department action is needed for management.
  Examples are Q fever, brucellosis, glanders,
  ricin toxin, epsilon toxin of Clostridium
  perfringens, and Staphylococcus aureus
  enterotoxin B.
• Category C Agents that have not been weaponized
  as yet, but have the potential for high morbidity
  and mortality. These agents are plentiful and
  easy to produce and disseminate. Examples include
  Hantavirus, tick-borne encephalitis, yellow
  fever, and multidrug-resistant tuberculosis.

46
Biologic Disaster

• Anthrax-spores. Primarily sheep and cow. Vaccine.
  3 forms-GI, inhaled, cutaneous
• -flu like symptoms with rapid downhill
  progression. Differentiate with SOB, NP cough,
  chest discomfort, fatique
• - TX with Cipro or Vibramycin-may continue for 60
  days. Vaccine reserved for high risk
• Botulism- Bloodborne, wound and inhaled. Not
  contagious. Removed by boiling water
• -SS Double vision, diff swallowing and speaking

47
Botulism Triad

• Symmetrical descending flaccid paralysis
  progressing to respiratory weakness
• No fever
• Awake and alert with no sensory deficits
• A or B antitoxin available. Does not reverse
  paralysis. Cost about 25,000 per treatment

48
Agents cont

• Plague-bubonic form start on skin and goes to
  lymph nodes
• -naturally transmitted by infected fleas that
  bite rodents or people
• Pneumonic plague-terrorist-aerosolized but are
  killed by sunlight. DIC and MS organ failure
  Death within 24 hours if treatment is not
  started. Treated with gentamicin first line.
  Transmitted person to person and droplet

49
Plague
50
Smallpox

• Variola virus
• Communicable, no tx, and high mortality
• Thought to be eradicated
• Fever, rash, headache, vomiting, delerium
• Rash starts on buccal and pharyngeal mucisa and
  spreads

51
Smallpox vs. chickenpox

• Chickenpox-lesions appear before symptoms and are
  concentrated on trunk. Usually more superficial.
  DO NOT appear on palms and soles of feet.
  Various stages of lesions
• Smallpox- firm lesions. Lesions all same stage
• No treatment but vaccine may may reduce the
  severity of the disease
• VACCINE provides immunity for3-5 years

52
Face Lesions on a Boy with Smallpox
53
Comparison of Smallpox and Chickenpox Lesions
54
Tularemia

• Transmitted by infected tick, mosquito,
  contaminated tissues or contaminated water or
  food
• NO person to person contact
• Aerorsolized for attack
• Cutaneous, pneumonic or typhoidal
• Pneumonic fever, chills, NP cough, muscle aches.
  First line- Streptomycin and gentamicin

55
Viral Hemorrhagic fever

• Four families of viruses
• Ebola
• No vaccine. Geographic southern hemisphere
• Rodents arthropods are reservoirs
• Once contracted person to person
• Early symptoms-malaise, fever, LOS, diarrhea
• Bleeding starts, Shock, seizures, coma death

56
Pandemic (Airborne Respiratory) Infection

• Teach people to be prepared to stay at home for
  at least two weeks
• Reassure people that basic measures for
  prevention of respiratory infection can be
  effective
• Healthy lifestyle to support the immune system
• Washing hands and covering the mouth during
  coughing or sneezing, disposing of tissues, and
  staying away from public places if at all
  possible

57
Nurses Role

• Knowledge
• Recognize clusters of cases
• Communicate with infection control
• Notify supervisor. Standard precautions, mask if
  necessary
• DECONAMINATE Wash with soap and water at least
  30 seconds. Soap hair multiple times
• Dispose of material in biohazard bags

58
Debriefing

• PTSD
• Allow participants to discuss feelings and talk
  about events and how they feel.
• May need time off from work, avoid alcohol or
  drug use, proper diet

59
PPE

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