1. Copyright © 2008 Lippincott Williams & Wilkins. Chapter 72 Terrorism, Mass Casualty, and Disaster Nursing

2. Copyright © 2008 Lippincott Williams & Wilkins. Emergency Operations Plan (EOP) Health care facilities are required by the Joint Commission on Accreditation of Healthcare Organizations to create a plan for emergency preparedness and to practice this plan twice a year Essential components of the plan: –An activation response –An internal/external communication plan –A plan for coordinated patient care –Security plans –Identification of external resources –A plan for people management and traffic flow

3. Copyright © 2008 Lippincott Williams & Wilkins. Emergency Operations Plan (EOP) (cont.) Essential components of the plan: –A data management strategy –Deactivation response –Post-incident response –A plan for practice drills –Anticipated resources –Mass casualty incident planning –An education for all of the above

4. Copyright © 2008 Lippincott Williams & Wilkins. Triage The sorting of patients to determine priority health care needs and the proper site of treatment In nondisaster situations, health care workers assign the highest priority and allocate the most resources to the most critically ill In disaster situations with large numbers of casualties, decisions are based on the likelihood of survival and the consumption of resources Triage categories: see Table 72-1

5. Copyright © 2008 Lippincott Williams & Wilkins. Managing Short- and Long-Term 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

6. Copyright © 2008 Lippincott Williams & Wilkins. Managing Short- and Long-Term Psychological Effects After a Disaster (cont.) Critical incident stress management (CISM) –Programs that include education, field support, defusing, debriefing, demobilization, and follow-up components Persons with ongoing stress reactions should be referred to mental health specialists

7. Copyright © 2008 Lippincott Williams & Wilkins. Personal Protective Equipment (PPE) Purpose: to shield the health care provider from chemical, physical, biological, and radiologic hazards that may exist when caring for contaminated patients Categories of protective equipment: –Level A: self-contained breathing apparatus (SCBA) and vapor-tight chemical-resistant suit, gloves, and boots –Level B: high level of respiratory protection (SCBA) but lesser skin and eye protection; chemical-resistant suit –Level C: air-purified respirator, coverall with splash hood, and chemical-resistant gloves and boots –Level D: typical work uniform

8. Copyright © 2008 Lippincott Williams & Wilkins. Isolation Precautions for Biological Terrorism Agents Biological agents may be delivered or spread in a number of ways 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 weapon dissemination; signs and symptoms are similar to those of common disease process 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

9. Copyright © 2008 Lippincott Williams & Wilkins. Chemical Weapons Chemical substances that quickly cause injury and/or death and cause panic and social disruption Agents: see Table 72-3 –Nerve agents –Blood agents –Vesicants –Pulmonary agents Agents vary in volatility, persistence, toxicity, and period of latency Limitation of exposure is essential with evacuation and decontamination as soon possible and as close to the scene of the incident as possible

10. Copyright © 2008 Lippincott Williams & Wilkins. Nerve Agents Sarin and soman organophosphates Inhibit cholinesterase-causing cholinergic symptoms progressing to loss of consciousness, seizures, copious secretions, apnea, and death Treatment: supportive care, atropine, benzodiazepine, and pralidoxime Decontaminate with copious amounts of soap and water or saline for at least 20 minutes Blot; do not wipe off Plastic equipment will absorb sarin gas

11. Copyright © 2008 Lippincott Williams & Wilkins. Vesicants Lewisite, sulfur mustard, nitrogen mustard, and phosgene Cause blistering and burning Respiratory effects can be serious and cause death Decontaminate with soap and water; do not scrub or use hypochlorite solutions Eye exposure requires copious irrigation Treatment for lewisite exposure: dimercaprol IV or topically

12. Copyright © 2008 Lippincott Williams & Wilkins. Radiation Exposure Radiation exposure may occur due to nuclear weapons, nuclear reactor incidents, or exposure to radioactive samples Exposure to radiation is affected by time, distance, and shielding Types of radiation exposure: –External radiation: all or part of the body is exposed to radiation; as decontamination is not necessary, it is not a medical emergency

13. Copyright © 2008 Lippincott Williams & Wilkins. Radiation Exposure (cont.) Types of radiation exposure (cont.): –Contamination: exposure to radioactive gases liquids or solids; requires immediate medical management to prevent incorporation –Incorporation: uptake of the radioactive material into the body

14. Copyright © 2008 Lippincott Williams & Wilkins. Radiation 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 Staff protection –Water-resistant gowns, 2 pairs of gloves, caps, goggles, masks, and booties –Dosimetry devices

15. Copyright © 2008 Lippincott Williams & Wilkins. Radiation Decontamination (cont.) Patients are surveyed for radiation and directed to the decontamination area Each patient is decontaminated with a shower outside the ED Water, tarps, towels, soap, gowns, all the patient’s belongings, etc., must be collected and contained Patients are surveyed and showered again as necessary Showering should be performed so as not to contaminate clean areas with runoff from the showering Biologic samples: nasal and throat swabs; blood Internal contamination requires additional treatment: catharsis and gastric lavage with chelating agents

16. Copyright © 2008 Lippincott Williams & Wilkins. Radiation Injuries Acute radiation syndrome (ARS): dose of radiation determines if ARS will develop All body systems are affected by ARS Presenting signs and symptoms determine predicted survival Probable survivors have no initial symptoms or only minimal symptoms Possible survivors present with nausea and vomiting that persists for 24 to 48 hours Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock; neurologic symptoms suggest lethal dose; and survival time is variable