CHEMICAL DISASTERS: NURSING MANAGEMENT

1. CHEMICAL DISASTERS: NURSING MANAGEMENT Nerve Agents Part I

2. OBJECTIVES • Identify common nerve agents • Discuss signs and symptoms • Discuss nursing management and treatment • Discuss the nurse roles and responsibilities • Discuss personal safety risk exposure

3. Emergency Support Function (ESF) 8 OVERVIEW • DHH has the role of providing leadership for planning, directing and coordinating the overall State efforts to provide public health and medical assistance. • The Secretary of Health and Human Services through the Office of Public Health Emergency Preparedness is responsible for the federal coordination. • The command and control of operations are consistent with the National Response Framework and compliant with National Incident Management System requirements.

4. Command Chain/ICS

5. Unified Command • Enables all agencies with responsibility to manage an incident together by establishing a common set of incident objectives and strategies. • Allows Incident Commanders to make joint decisions by establishing a single command structure. • Maintains unity of command. Each employee only reports to one supervisor. Agency 2 Incident Commander Agency 1 Incident Commander Agency 3 Incident Commander

6. Disaster Management Continuum

7. Chemical Disasters • May result from industrial accidents, accidental exposure, or terrorist acts • Chemical Agents of Concern • Nerve agents • Blister agents/vesicants • Blood agents • Choking/lung/ • pulmonary agents

8. Agencies/Partners Involved • Federal Bureau of Investigation (FBI) • Military • US Department of Health and Human Services (HHS)-Centers for Disease Control and Prevention (CDC) • Other Federal partners • Governors Office of Homeland Security and Emergency Preparedness • Fire/Hazmat

9. Agencies/Partners Involved • Department of Environmental Quality • Department of Health and Hospitals • Law Enforcement: Louisiana State Police • Louisiana State National Guard • Department of Public Works • Department of Wildlife and Fisheries • Department of Agriculture and Forestry • Other state agencies

10. Agencies/Partners Involved • Local Parish Office of Homeland Security and Emergency Preparedness Office • Louisiana Poison Center • Healthcare facilities • Medical Examiners/Coroners • Animal Control • Local Partners • LAVA: Volunteers agencies/volunteers

11. Nerve Agents • Most toxic of chemical warfare agents and inhibit the body’s normal functions • Dangerous to humans and can be utilized as potential weapons by terrorist • Act as acetylcholinesterase inhibitors which produce the same signs and symptoms of organophosphate poisioning

12. Nerve Agents • Sarin • Soman • Tabun • VX • Odorless • Slight camphor odor • Faint fruity odor • Odorless

13. Nerve Agents Exposure • Inhalation • Can be dispersed as aerosols, vapors, or liquids • Vapors: absorbed by inhalation and vapor contact • Immediate onset of symptoms

14. Nerve Agents Exposure • Ingestion • Readily absorbed • Skin/eye • Onset depends on concentration; can be delayed for several hours

15. Safety Risk • First responders are trained individuals who will respond to the event • Nurses should not be first responders unless you have been trained on hazardous materials or part of a fire response team

16. Signs and Symptoms

17. Signs and Symptoms • Mild • Miosis • Nausea • Diarrhea • Severe • Muscle weakness • Fasciculations • Respiratory failure • Coma • Seizures • Permanent damage to the CNS after high toxic exposure

18. Real Life Incidents • Sarin incident in Tokyo-1995 • Carbamate insecticide methomyl was added to salt at a restaurant in Fresno, California-1999

19. Exposure to Healthcare Workers • Tokyo incident several people were exposed. Contaminated individuals may self present to a facility. • Healthcare workers must wear PPE and use it correctly • Contaminated individuals must be decontaminated

20. Exposure to Healthcare Workers • Sudden and severe symptoms may occur hours after treatment/contamination (through skin) • You must have appropriate PPE to approach any contaminated victim

21. Precautions • Standard • Airborne • Droplet • Contact

22. PPE Equipment • Determined by the type and level of exposure and duration of exposure • Nerve agents are absorbed through intact skin and even through the clinical examination gloves

23. Treatment/Exposure

24. Treatment/Exposure

25. Treatment • Adults • Atropine 2mg (antimuscarinic) • Pralidoxime (2 Pam) 600mg • Children • Pediatric atropine autoinjector is now available • Supportive therapy and assisted ventilation as need • Benzos for prevention of seizures

26. STRATEGIC NATIONAL STOCKPILE

27. Strategic National Stockpile • CHEMPACK • Managed Inventory • Antivirals • Vaccines • Federal Medical Stations

28. Pharmacy’s Role

29. CHEMPACK • Hospital/EMS Containers (contents are different) • Mark 1 Kits • Atropine Sulfate 0.4mg/mL • Pralidoxime 1gram vials • Atropen® 0.5mg auto-injectors • Atropen® 1mg auto-injectors • Diazepam 10mg/2mL auto-injectors • Diazepam 5mg/mL 10mL • Sterile Water for Injection 20mL single use vials

30. CHEMPACK • Prepositioned across the state. Locations are confidential. • Louisiana Poison Control • 1-800-222-1222 • Will provide consultation on symptoms of nerve agents and organophosphate poisoning to first responders and health care professionals. • Will provide assistance regarding dosing questions.

31. Labeled Containers with Buffers

32. Treatment • Duodote eventually will replace Mark I Kits

33. PREHOSPITAL MANAGEMENT

34. Scene Safety Management • Minimize casualties • Decontamination • Triage • Antidote therapy • Crisis scene management

35. Emergency Medical Service's (EMS) Role • EMS has 2 Mark I Kits available on the ambulance • State Police will pick up EMS container if CHEMPACK is needed • Administer Mark 1 Kit per protocol • Airway support and ventilation. Perform endotracheal intubation if needed. • Circulatory support: IV therapy and pulse oximetry monitoring • Consultation with Louisiana Poison Control

36. Field Treatment

37. Transport

38. HOSPITAL MANAGEMENT

39. Hospital’s Role • Ventilatory support: patients with respiratory failure and compromised airways will require immediate endotracheal intubation and positive pressure ventilation. • Oxygen supplement • Decontamination before entering the emergency department • Suctioning for removal of bronchial secretions • Gastric decontamination-activated charcoal

40. Hospital’s Role • Observation • Treatment-Atropine and Pralidoxime • Monitoring for seizure activity (administering anticonvulsants for prevention) • Recovery may take several months • Risk of permanent damage to the Central Nervous System (high dose exposure) • Consult with the Louisiana Poison Center

42. Hospital’s Role • Employee training • Hospitals are going to be reserved for your critically ill individuals • Medical Surge • Decontamination • Treatment/Supportive Measures/Assisted Ventilation

43. PUBLIC HEALTH

44. Public Health Preparedness • Strategic National Stockpile • Exercises, drills, trainings • State and local planning efforts • Paradigm shift to all hazards approach

45. Public Health’s Role • Promote life safety through education, information and planning • Goal is to prevent illness by minimizing exposure and rapid, effective response • Provide medical intelligence such as knowledge of antidotes and symptoms of exposure • Procure resources available to the State with forward placement whenever possible

46. Public Health’s Role • Provide guidance for use of assets under the direction of the State Health Officer • Participate as ESF 8 in Incident Command and/or Unified Command • Assist in the development of factual communication for multiple audiences during response • Promote behavioral health

47. Public Health’s Role • Conduct epidemiological investigations • Coordinate laboratory services • Participate assessments and actions to minimize the health and environmental impacts

48. Office of Public Health Nurse’s Role • Planning, preparedness, and response • Assessment • Triage • Treatment/Education • Sheltering

49. Personal Safety • Having a family emergency plan • Decontamination of self • PPE • Emergency Communication Devices

50. Vulnerable Populations • Communication • Establish safe shelter • Food and water • Shelter in place versus Medical Special Needs Shelters, General Population Shelters, Critical Transportation Needs Shelters • Rely on existing agencies • Will need assistance if decontamination is needed • Time of day when incident happens