Chapter 72 Terrorism, Mass Casualty, and Disaster Nursing

1. Chapter 72Terrorism, Mass Casualty, and Disaster Nursing

2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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