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Emergency/Disaster Preparedness

Lisa Randall, RN, MSN, ACNS-BC RNSG 2432. Emergency/Disaster Preparedness. Objectives. Compare and contrast interdisciplinary roles and responsibilities associated with emergency and disaster situations. Compare and contrast risk factors associated with need for emergency care.

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Emergency/Disaster Preparedness

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  1. Lisa Randall, RN, MSN, ACNS-BC RNSG 2432 Emergency/DisasterPreparedness

  2. Objectives • Compare and contrast interdisciplinary roles and responsibilities associated with emergency and disaster situations. • Compare and contrast risk factors associated with need for emergency care. • Analyze etiology, pathophysiology, and signs/symptoms of bioterrorism, chemical and radiation exposure, and other emergencies. • Discuss nursing care and diagnoses associated with emergency care.

  3. Definitions • Emergency • MCI • Bioterrorism • Chemical and radiation exposure • Primary survey • Secondary survey

  4. Emergency and Mass Casualty Incident Preparedness • Emergency • Any extraordinary event that requires a rapid and skilled response and can be managed by a community’s existing resources • Mass casualty incident (MCI) • Manmade or natural event or disaster that overwhelms community’s ability to respond with existing resources

  5. Emergency and Mass Casualty Incident Preparedness • Total number of casualties a hospital can expect is estimated by doubling number of casualties that arrive in first hour • 30% admission to hospital • half will need surgery within 8 hours

  6. Emergency and Mass Casualty Incident Preparedness • All health care providers have a role in emergency and MCI preparedness • Know hospital’s emergency response plan • Participation in emergency/MCI preparedness drills is required

  7. Emergency and Mass Casualty Incident Preparedness • Response to MCIs often requires the aid of a federal agency such as the National Disaster Medical System (NDMS) • U.S. Department of Homeland Security • responsible for the coordination of the federal medical response to MCIs

  8. Bioterrorism • Anthrax • Botulism • Plague • Tularemia • Smallpox • Typhoid fever • Hemorrhagic fever

  9. Anthrax • Bacillus anthracis • Infected animals • Skin, ingestion, inhalation • Pulmonary • Cutaneous • GI • Antibiotics • Oral Fluoroquinolones • Prevention • Vaccination limited

  10. Botulism • Clostridium botulinum • Ingestion (12-36), inhalation (24-72) • Neuropathies • Blurred vision • Weakness • Respiratory dysfunction • Vaccine investigational

  11. Plague • Yersiniapestis • Infected fleas (2-8d), aerosol (1-3) • Lymphatic (bubonic) • Blood (septicemia) • Airborne • Pulmonary variant • Fever • Cough • Hemoptysis • Antibiotics • Doxycycline • Vaccine • Bubonic

  12. Smallpox • Variola virus • Airborne • 7-17d incubation • Flu-like symptoms • Rash • Vaccine

  13. Chemical Exposure • A-Z • Biotoxins • Blood agents • Caustics (acids) • Incapacitating agents • Metals • Nerve agents • Pulmonary agents • Riot control agents • Toxic alcohols • Vesicants

  14. Chemical Exposure • Categorized by target organ or effect • Sarin: • Neurotoxin • Death within minutes of exposure • Enters body through eyes and skin • Paralyzes respiratory muscles • Antidotes • Atropine • Pralidoxime chloride (2-PAM, Protopam given IV)

  15. Chemical Exposure • Phosgene • Colorless gas normally used in chemical manufacturing • Severe respiratory distress, pulmonary edema, and death • Mustard gas • Yellow to brown in color with garlic-like odor • Eyes • Skin burns/blisters

  16. Radiation Exposure • Ionizing radiation • Nuclear bomb • Radioactive material • Serious threat to safety of casualties and environment • MASS CASUALTY • Decontamination procedures • Acute radiation syndrome • Substantial exposure • Predictable pattern

  17. Acute Radiation Syndrome

  18. Management Radiation Exposure • Exposure dependent • 10-12 Gy fatal • Vomiting • Lymphopenia • Cerebrovascular changes • Fluid replacement • Cytokines • G-CSF, GM-CSF, filgrastim • Antiobiotics • Burns, wounds • Abdominal trauma • Thyroid protection • KI • OR • Within 36hr or after 6wks

  19. Explosion • Radiologic dispersal devices (RDDs) • Mix of explosives and radioactive material • Scatters radioactive dust, smoke, and other material into environment • Main danger from RDDs: Explosion

  20. Explosive Devices as Agents of Terrorism • Blast, crush, or penetrating • Blast injuries • Supersonic overpressurization shock wave that results from explosion • Lungs • Ear • GI • Fracture, lacerations, burns, blindness

  21. Other Emergencies/Disasters • Earthquakes • Floods • Hurricanes • Landslide/mudslide • Tornadoes • Tsunamis • Volcanoes • Wildfires • Winter weather

  22. Emergency and Mass Casualty Incident Preparedness • Level-1 DMAT - disaster medical assistance teams • Deployed within 8 hours • Self-sufficient for 72 hours with enough food, water, shelter, and medical supplies to treat about 250 patients per day • Level-2 DMAT • Replaces a Level-1 team • Supplements the equipment left on site

  23. Emergency and Mass Casualty Incident Preparedness • HAZMAT • NRP • First responders • Police • Emergency Medical Personnel • Triageof casualties differs from usual ED triage and is conducted in <15 seconds

  24. Emergency and Mass Casualty Incident Preparedness • Colored tags • Green • minor injury • walking wounded • Yellow • non-critical injury • RPM • *R-resp. P-pulse M- mental status/response/commands • Red • life-threatening injury • immediate intervention • Black • dead or expected to die • catastrophically injured

  25. RPM assessment • Step 1. Respiration (breathing)A. None, open airway, still no breathing, tag deceased - blackB. Respiration’s greater than 30/min. or less than 10/min. tag Red.C. Respiration between 10-30 per minute. Go on to Step 2.Step 2. Perfusion check (radial pulse) or use a capillary blanch testA. Squeeze nail bed, palm of hand or pad of finger.B. If color regains in greater than two seconds, tag Red.C. If the color returns in less than two seconds go onto Step 3 – Mental status.D. In poor lighting, attempt to find the radial pulse. If radial pulse is present proceed to Step 3.Step 3. Mental statusA. Altered mental status is the inability to follow simple commands, tag Red.B. Able to follow simple commands, tag Yellow.C. Example of simple commands: “can you squeeze my hands?” “Can you open and close your eyes?” D. All steps have been passed for patient to be tagged Yellow.

  26. Nursing concerns • Triage • Assessment • Interventions • Drug therapy • Diet therapy • Hypermetabolic states • Surgical/medical interventions

  27. Triage Emergency Severity Index • Short term hospital resource and staffing needs • Illness severity • Hospital resources • 5 level • ESI-1 highest priority • Triage algorithm

  28. ESI Triage Algorithm

  29. ESI-1 • Cardiac arrest. • Respiratory arrest. • Severe respiratory distress. • SpO2 < 90. • Critically injured trauma patient who presents unresponsive. • Overdose with a respiratory rate of 6. • Severe respiratory distress with agonal or gasping-type respirations. • Severe bradycardia or tachycardia with signs of hypoperfusion. • Hypotension with signs of hypoperfusion. • Trauma patient who requires immediate crystalloid and colloid resuscitation. • Chest pain, pale, diaphoretic, blood pressure 70/palp. • Weak and dizzy, heart rate = 30. • Anaphylactic reaction. • Baby that is flaccid. • Unresponsive with strong odor of ETOH. • Hypoglycemia with a change in mental status.

  30. Triage • ISOLATION PRECAUTIONS • Basic triage principles • 1. life threatening injuries • 2. decontaminate • 3. decongest area

  31. Triage the following (ESI) • A 6 yo w T 103.2 • A 22 yo w asthma in acute resp distress • An infant who has been vomiting for 2 days • A 50 yo man w LBP/spasms • A 32 yo woman unconcious following an MVA • A 40 yo woman w rhinitis and cough • A 58 yo man w midsternal chest pain • A teenager w an angulated FA from sports

  32. Primary Survey • Maintain airway • Suction and/or remove foreign body • Insert nasopharyngeal/oropharyngeal airway • Endotracheal intubation • Cricothyroidotomy or tracheostomy

  33. Primary Survey • Stabilize/immobilize cervical spine • Collar • Spinal precautions • Flat bedrest • Log roll

  34. Primary Survey • Breathing • Assessment • Administer high-flow O2 via a nonrebreather mask • Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions • Monitor patient response

  35. Primary Survey • Circulation • Check central pulse • Assess skin for color, temperature, moisture • Assess mental status and capillary refill • Aggressive fluid resuscitation • Insert two large-bore IV catheters • NS or LR

  36. Primary Survey • Disability • LOC • AVPU • A = alert • V = responsive to voice • P = responsive to pain • U = unresponsive • GCS • Pupils

  37. Secondary Survey • Exposure/Environmental control • Remove clothing • Provide temperature control—avoid hypothermia

  38. HPI • Obtain history • Location • Duration • Activity • Occupation • # affected

  39. Secondary Survey • VS • BP • HR • RR • Temperature

  40. Secondary Survey • Head-to-toe assessment • Headand spine • Chest • Listen to abdomen first • Pelvis • Perineum • Limbs – reduce fractures

  41. Assessment • S/S nonspecific • VS • LOC • Neuro • GI • Skin

  42. Secondary Survey • Five interventions • ECG • Pulse oximetry • Catheterize • NGT • Labs

  43. Labs • Serial CBC • Blood cultures • Chromosomal aberration • 24 hr urine/stool

  44. Drug therapy • Volume expanders • Inotropes • Vasopressors • Opiods • Vasocnstrictors • Immunizations, vaccines, immune globulin • Antibiotics and antivirals • Antidotes such as atropine

  45. Nursing Diagnosis • Ineffective airway • Ineffective tissue perfusion • Risk for infection • Impaired physical mobility • Spiritual distress • Risk for post-trauma syndrome

  46. Emergency and Mass Casualty Incident Preparedness • Many hospitals and DMATs have a Critical Incident Stress Management unit • Group discussions • Facilitates psychologic recovery

  47. Question • The nurse performing a primary survey in the ED is assessing • a. the acuity of the patient’s condition to determine priority of care • b. the status of airway, breathing, circulation, or presence of deformity. • c. whether the patient is responsive enough to provide needed information • d. whether the resources of the ED are adequate to treat the patient.

  48. Question • A homeless man is brought to the ED in profound hypothermia with a temperature of 85 degrees F. On initial assessment, the nurse would expect to find • a. shivering and lethargy • b. fixed and dilated pupils • c. respirations of 6-8 per minute • d. BP obtainable only by doppler

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