1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 15: Disaster Management: Implications for the Critical Care Nurse

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Mass Casualty Incident (MCI) Massive amount of population needs medical treatment at same time Exceeds capacity of local emergency services and hospitals Requires field disaster triage –Triage priority is to sort victims according to likelihood of surviving –Provides greatest good to the greatest number

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Role of the Critical Care Nurse During MCI First responders perform field triage in the community –Primary and secondary survey of trauma patients –Provide care with limited medical supplies in field hospital In the hospital setting –Provide care using scarce resources –Determine patients to discharge or move to other units, other areas of hospital, or other facilities to free up beds

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Process of Triage (North Atlantic Treaty Organization Triage System) Priority 1 (Immediate): patient has life-threatening but survivable injuries requiring minimal interventions Priority 2 (Delayed): patient can wait hours without threat to life or limb Priority 3 (Minimal): patient has minor injuries and treatment may be delayed for days Priority 4 (Expectant death): patient has severe injuries; chance of survival is slim even with emergent intensive care

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A disaster victim has a small laceration on the head and a closed fracture of the right arm. Which of the triage categories should this victim be placed in? A. Priority 1 (Red) B. Priority 2 (Yellow) C. Priority 3 (Green) D. Priority 4 (Black)

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Priority 3 (Green) Rationale: The victim has minor injuries and treatment may be delayed for days. In a MCI there are many people needing care, and priority 1 victims must be seen first. Priority 1 victims have life-threatening but survivable injuries requiring minimal interventions. An example would be a victim with an open pneumothorax. Priority 2 victims can wait hours without threat to life or limb. An example is a victim with soft tissue injuries; this group receives treatment after group 1. Priority 4 victims have severe injuries and their chances of survival are slim even with emergent intensive care.

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Radiological/Nuclear Attacks Type of Radiological/ Nuclear Attack Time/ Level of Radiation DistanceShielding Simple radiological device Quick and various levels of radiation Spreads over broad area Sound buildings behind multiple walls Radiological dispersal device Quick: low levels of radiation Less than a city block to several miles radius Wind can carry radioactive dust Nuclear reactor sabotage Quick: high levels of radiation Large areaSound buildings away from site Improvised nuclear device Quick: high levels of radiation Small contained area Sound buildings away from site Nuclear weaponMay have warningLarge areaSound buildings away from site

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Comparison of Radiation Effects Internal Radiation Contamination incident –Absorption or ingestion –Critical not to spread to other parts of skin –Treat serious medical needs before radiological assessment/ decontamination Victim is radioactive External Radiation Types –Local exposure –Whole body exposure Victim is not radioactive

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of Effects of Radiation Exposure See Table 15-1.

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Caring for Patients Exposed to Radiation Treat and stabilize life-threatening traumatic wounds first. Assess with radiation exposure meter and collect nose, throat swabs, CBC. If internal radiation exposure is suspected, treat with chelating agents, or potassium iodide, if contaminated with radioiodine. Provide decontamination in special decontamination unit. –Decontaminate infants and children first. Counsel on long-term risks of radiation exposure.

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A patient presents to the disaster triage after being exposed to radiation 48 hours ago. He has nausea, vomiting, diarrhea, fatigue, temp 101 degrees F, and dyspnea. The radiation exposure meter reading is >800 rads. Which of the following is true? A. The patient is in the latent phase of acute radiation syndrome. B. The patient may survive. C. The patient is in the prodromal phase of acute radiation syndrome. D. The patient is in the recovery phase of acute radiation syndrome.

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. The patient is in the prodromal phase of acute radiation syndrome. Rationale: The client is in the prodromal phase because he was exposed 48 to 72 hours ago. With this dose of radiation (>800 rads), the patient is not likely to survive. The latent phase occurs after the prodromal phase, and the victim with a high dose of radiation has a short latent period. The recovery phase is much later for victims who are likely to survive (100 to 400 rads) or who may survive (400 to 800 rads).

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Differences Among Chemical Agents Nerve agents –Most toxic of all chemicals –Affect nervous system Vesicants –Cause blistering of skin and mucosal surfaces –Can cause damage to lungs –Can last in an area for 1 week

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Differences Among Chemical Agents (cont.) Cyanide –Stops the ability of cells to receive oxygen –If antidote is not administered immediately, victim will die Pulmonary intoxicants –Prevent gas exchange in the lungs Riot control agents –Incapacitate victims because of skin/eye irritation

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chemical Decontamination Process Use special decontamination shelters. –Use appropriate personal protective equipment. Decontaminate children first. –Provide interventions to minimize hypothermia. –Keep children with parents, if possible.

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Bioterrorism Terrorists grow the microorganisms in a lab. Various routes can be used to spread the microbes into the targeted population: –Anthrax: send spores in mail for most deadly route: inhalation exposure –Smallpox: infect victims in crowded cities to cause pandemic –Plague: infect fleas, which will infest rodents, exposing victims walking in grass where rodents have been

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Bioterrorism (cont.) Tularemia: infect vectors (fleas, ticks) for transmission from animals to human victims Botulism: contaminate food supply Ebola virus: infect vectors (flea) for transmission from animals to human victims

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessing For Bioterrorism-Related Diseases Take a through history of the victim’s recent activities and locations. Search for vectors or bites from vectors, or animal bites. Inquire about dietary intake and where food was obtained. Look for a pattern of other similar cases in the area. Involve the CDC in suspicious cases.

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A nurse should use which of the following precautions with a patient diagnosed with inhalational anthrax? A.Standard-base precautions B.Contact isolation C.Airborne isolation D.Droplet isolation

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Standard-base precautions Rationale: The victim who inhales the spores of anthrax becomes ill but is not contagious. The nurse would use standard-base precautions as with any patient. If the anthrax was ingested by eating contaminated beef, then the nurse would need to use contact precautions when handling the patient’s feces. If the anthrax was in a cutaneous lesion, contact precautions would also be necessary.