NCLEX-RN: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Acute Radiation Syndrome

Focus topic: Disaster Nursing: Bioterrorism

 

Disaster Nursing: Bioterrorism: Characteristics

Focus topic: Disaster Nursing: Bioterrorism
A. An acute illness characterized by manifestations of cellular deficiencies caused by the body’s reaction to ionizing radiation.

  • Prodromal period: loss of appetite, nausea, vomiting, fatigue, diarrhea.
  • Latent period: Symptoms disappear for a period of time.
  • Overt illness follows the latent period: infection, electrolyte imbalance, diarrhea, bleeding.
  • The final phase is a period of recovery or death.

B. The higher the radiation dose, the greater the severity of early effects and possibility of late effects.

Disaster Nursing: Bioterrorism: Assessment

Focus topic: Disaster Nursing: Bioterrorism
A. Attempt to identify dose exposure of client. (Treatment is according to dose exposure.)

  • Dose less than 2 Gy (200 rads) is usually not severe; nausea and vomiting seldom experienced at 0.75 to 1 Gy (75–100 rads) of penetrating gamma rays.
    a. Hospitalization unnecessary at less than 2 Gy, thus outpatient care indicated.
  • Dose greater than 2 Gy (200 rads). Signs and symptoms become increasingly severe with increased dose.

B. Identify if radiation dose includes radioactive iodine—uptake of this isotope could destroy thyroid tissue.

C. Identify acute radiation syndromes.

  • Hematopoietic syndrome.
    a. Characterized by deficiencies of RBC, lymphocytes, and platelets, with immunodeficiency.
    b. Increased infectious complications, including bleeding, anemia, and impaired wound healing.
  • Gastrointestinal syndrome.
    a. Characterized by loss of cells lining intestine and alterations in intestinal motility.
    b. Fluid and electrolyte loss with vomiting and diarrhea.
    c. Loss of normal intestinal bacteria, sepsis, and damage to the intestinal microcirculation, along with the hematopoietic syndrome.
  • Cerebrovascular–central nervous system.
    a. Primarily associated with effects on the vasculature and resultant fluid shifts.
    b. Signs and symptoms include vomiting and diarrhea within minutes of exposure, confusion, disorientation, cerebral edema, hypotension, and hyperpyrexia.
    c. Fatal in short time.
  • Skin syndrome.
    a. Can occur with other syndrome.
    b. Characterized by loss of epidermis (and possibly dermis) with “radiation burns.”

Disaster Nursing: Bioterrorism: Implementation

Focus topic: Disaster Nursing: Bioterrorism
A. Give supportive care: Treat gastric distress with H2 receptor antagonists (Tagamet, Pepcid, etc.).
B. Prevent and treat infections: Monitor viral prophylaxis.
C. Consult with hematologist and radiation experts.
D. Observe for erythema, hair loss, skin injury, mucositis, weight loss, and fever.
E. Administer potassium iodide before exposure, if possible, or as soon as available (within 4 hours).

  • Blocks uptake of specific damaging isotope.
  • rotects thyroid tissue.

Disaster Nursing: Bioterrorism: Personal Protection Equipment

Focus topic: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Assessment

Focus topic: Disaster Nursing: Bioterrorism
A. Identify clients who present risk to healthcare professionals.
B. Assess need for special equipment (biohazard bags, specimen bags, etc.).
C. Determine type of protection equipment required according to biohazard that is identified (biological, chemical, or radiological).
D. Assess need for decontaminating victims prior to triage.
E. Assess strategy for decontamination at site of incident.
F. Assess need for mass casualty decontamination.

Disaster Nursing: Bioterrorism: Implementation

Focus topic: Disaster Nursing: Bioterrorism
A. Protective equipment for biological exposure.

  • Respirators—type selected according to hazard identified and its airborne concentration.
    a. High level of protection: self-contained breathing apparatus (SCBA) with full face piece. Provides highest level of protection against airborne hazards when used correctly—reduces exposure to hazard by a factor of 10,000.
    b. Minimal level of protection: half-mask or full face piece air-purifying respirator with particulate filters like N95 (used for TB) or P100 (used for hantavirus).
  • Protective clothing includes gloves and shoe covers—necessary for full protection.
    a. Level A protective suit used when a suspected biological incident occurs and type, dissemination method, and concentration is unknown.
    b. Level B protective suit used when biological aerosol is no longer present.
    c. Full face piece respirator (P100 or HEPA filters) used if agent was not aerosoled or dissemination was by letter or package that could be bagged.

B. Protective equipment for chemical exposure.

  • Cover all skin surfaces with protective clothing impervious to chemicals—necessary for protection until exact chemical agent is identified.
    a. Use Mission Oriented Protective Posture (MOPP) suit (chemical protection suit), if available.
    b. Use fire department chemical suits as alternative.
  • Don masks with filtered respirator (HEPA filter respirator—N100 with full face piece—and fit-tested N95 meet CDC performance criteria for chemical exposure).
  • Wear boots or boot covers to prevent tracking contaminant.
  • Initiate decontamination procedures with trained personnel.
    a. Decontaminate at site, if possible.
    b. Otherwise, decontaminate outside of facility.
  • Use chemical detection devices, if available, to validate presence or absence of agent.
    a. M8 paper (sheet of chemically treated paper): If colored spots appear within 20 seconds, chemical agent is present.
    b. M9 tape: Affix adhesive-backed paper to equipment or protective clothing—color changes when exposed to chemical agent.
    c. M2S6A1 chemical agent detector kit: Can detect nerve, blister, or blood agent vapors; a glass ampoule contains substance that, when placed on test spot, changes color.
    d. Chemical agent monitors (CAMs): Contain a microprocessor chip that identifies presence of certain nerve and blister agents.

C. Protective equipment for a radiological attack.

  • Don protective clothing: Basic gear will stop alpha and some beta particles, not gamma rays.
    a. Scrub suit.
    b. Gown and cap.
    c. Mask.
    d. Eye shield.
    e. Double gloves—one pair under cuff of gown and taped to close all entry; second pair can be removed and/or replaced.
    f. Masking tape, 2” wide.
    g. Shoe cover with all seams taped.
    h. Radiation detection device: Able to detect energy emitted from a radiation source. Several detectors available: Geiger counters, dosimeters, etc.
    i. Film badge.
  • If radiation incident is suspected, self-contained breathing apparatus (SCBA) and flash suits are indicated to reduce potential exposure of healthcare providers.
  • If SCBA suits not available:
    a. Use surgical attire or disposable garments (such as those made of Tyvek).
    b. Use eye protection and double gloves.
    c. Use masks with respirators.
  • Triage client’s medical condition first, regardless of radiation exposure—first priority is delivery of emergency medical services, including transport.
    a. Administer emergency medical treatment to radiation-exposed clients.
    b. Decontaminate clients who have been contaminated on the scene before transport.
  • Complete decontamination of victims.
    a. Remove client’s clothing and have client do a total body wash, scrubbing skin with soap and soft brush.
    b. Place contaminated clothing in bins or biohazard bag labeled “Radioactive.”
    c. Capture runoff of water; contain and label “Radioactive.”
    d. Wash area down between washing victims to prevent transfer of contaminated material.
    e. Capture material with vacuum cleaner with HEPA filter, if appropriate, to prevent release of radioactive material into the air.
    f. Open wounds or nonintact skin: Irrigate with sterile water or normal saline (NS); cover with dry, sterile dressing.
    g. Eyes: Irrigate with sterile water or NS as directed.
    h. Intact skin: Wash skin with soap and warm water. Bleach, 0.5%, may also be used.
    i. Radiation burns: Treat as other burns are treated.
  • Implement isolation techniques for contaminated victims to confine contamination and protect personnel.
  • Recheck radiation levels at each stage of treatment until reduced to background levels.
  • Dispose of used protective gear appropriately.

Disaster Nursing: Bioterrorism: Decontamination: General Protocol

Focus topic: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Implementation

Focus topic: Disaster Nursing: Bioterrorism
A. Utilize standard precautions for all clients admitted to or arriving at the hospital.
B. Follow routing client placement for normal number of admissions.

  • Isolate suspicious cases.
  • Group similar cases.

C. Utilize alternative placement for large numbers of clients.

  • Co-group clients with similar syndromes in a designated area.
  • Establish designated unit, floor, or area in advance.
  • Place clients based on pattern of airflow and ventilation with respiratory problems, smallpox, or plague.
  • Place clients after consultation with engineering staff.

D. Control entry to client-designated areas.
E. Transport bioterrorism clients as little as possible—limit to essential movement.
F. Clean, disinfect, and sterilize equipment according to principles of standard precautions.

  • Use procedures facility has in place for routine cleaning and disinfection.
  • Have available approved germicidal cleaning solutions.
  • Contaminated waste should be sorted and disposed of in accordance with biohazard waste regulations.
  • For clients with bioterrorism-related infections, use standard precautions for cleaning unless infecting organism indicated special cleaning.

Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Decontamination Procedures

Focus topic: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Implementation

Focus topic: Disaster Nursing: Bioterrorism
A. Decontaminate at scene of incident (hot zone) to prevent hospital system from absorbing contaminated victims and protect healthcare providers and uncontaminated casualties.
B. Familiarize emergency personnel with stages of decontamination.

  • Gross decontamination.
    a. Decontaminate those who require assistance.
    b. Remove and dispose of exposed victim’s clothing. (This will remove 70–80% of contaminant.)
    c. Perform a thorough head-to-toe tepid water rinse. (Cold water can cause hypothermia and hot water can result in vasodilation, speeding distribution of the contaminants.)
  • Secondary decontamination.
    a. Perform a full-body rinse with clean tepid water. (Water is an effective decontaminant because of rapidity of application.)
    b. Wash rapidly from head to toe with cleaning solution (HTH chlorine is effective) and rinse with water. (HTH chlorine can decontaminate both chemical and biological contaminants.) Note: Undiluted household bleach is 5.0% sodium hypochlorite.
  • Definitive decontamination.
    a. Perform thorough head-to-toe wash and rinse.
    b. Dry victim and don clean clothes.

C. Initial decontamination may be accomplished by the fire department with hoses spraying water at reduced pressure. (This will remove a high percentage of contaminant at an early stage.)
D. Decontaminate salvageable clients first as they are the first priority. (This allows those in need of medical intervention to be treated.)

  • Nonsymptomatic and ambulatory victims are the second priority for decontamination as they have been exposed, yet are salvageable.
  • Clients who are dead or unsalvageable are third priority for decontamination.

E. Reduce extent of contamination in facility by decontaminating clients prior to receiving in healthcare facility to ensure safety of clients and staff.

  • Establish decontamination site outside facility using a decontamination tent prior to needing it.
  • Set up procedures for decontamination, depending on infectious agent.

F. Implement procedure for decontaminating client.

  • Don appropriate personal protective gear before assisting clients to decontaminate.
  • Remove decontaminated clothing and place in appropriate double biohazard bags.
  • Instruct or assist client to shower with soap and water.
  • Use clean water, normal saline, or ophthalmic solution for rinsing eyes.

Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Specific Decontamination Steps

Focus topic: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Implementation

Focus topic: Disaster Nursing: Bioterrorism
A. Following a biological terrorist event.

  • Identify dermal exposure, if possible.
  • Remove victim’s clothing as soon as possible and place in biohazard bags.
  • Cleanse exposed areas using soap and tepid water (large amounts) or diluted sodium hypochlorite (0.5%).
  • Adhere strictly to standard precautions for emergency personnel to prevent secondary contamination of personnel.
  • Send victims home, if possible, to continue decontamination procedure.
    a. Instruct to wash thoroughly with soap and water.
    b. Instruct victims to monitor for signs and symptoms of agent.

B. Following a chemical terrorist event.

  • Know general principles to guide actions following a chemical agent incident.
    a. Expect a 5:1 ratio of unaffected to affected casualties.
    b. Decontaminate immediately (ASAP).
    c. Disrobing is decontamination, head-to-toe; the more removal, the better.
    d. Large volume water flush is best decontamination method.
    e. Following exposure, first responders must decontaminate immediately to avoid serious effects.
  • Practice triage guidelines for mass casualty decontamination. (Chemical exposure can be deadly, so early decontamination is critical.) Prioritize casualties by identifying those:
    a. Closest to point of release.
    b. Reporting exposure to vapor or aerosol.
    c. With liquid deposits on clothing or skin.
    d. With serious medical conditions.
    e. With conventional injuries.
  • Decontaminate victims as early as possible. (Requirements differ according to type of chemical agent used: Sarin dissipates quickly in the air; VX remains lethal for hours.)
    a. Nerve agents may be absorbed on all body surfaces—must be removed quickly to be effective.
    b. Vesicant (blister) agents are not always identified due to latent effects.
  • Treat eyes and mucous membranes with special protocol.
    a. Flush with copious amounts of water.
    b. If available, isotonic bicarbonate (1.26%) or saline (0.9%) may be used as a flushing agent.
  • Monitor victim for remains of agent or contaminate using chemical agent monitor (CAM) or M8 paper for chemical agents.

C. Following radiation exposure.

  • Determine cause of incident to identify radiation exposure or contamination. (Exposure does not necessarily indicate need for decontamination.)
    a. First responders may be told by those requesting assistance that there has been a radiation-exposure event.
    b. First responders may recognize radiation exposure from observation at incident site.
  • Understand difference between exposure and contamination.
    a. Exposed victim: Presents no hazard, requires no special handling, and presents no radiological threat to personnel.
    b. Externally contaminated victim: May mean individual has come in contact with unconfined radioactive material.
  • Decontaminate all victims; remove all clothing and complete a full body wash.
  • Institute isolation techniques to confine contamination and protect others.
  • Decontaminate equipment touched by client.
    a. Gurney used to transfer client.
    b. Equipment used in client care, e.g., BP cuff, stethoscope, etc.
    c. Ambulance.
  • Decontaminate care providers who touched or moved client (protective clothing may be contaminated).
  • Examine surrounding area (walls, floor that client may have touched).
  • Control victims’ entry and exit to/from area. (Radioactive particles adhere to dust, may become airborne, and can contaminate other clients and personnel.)

Disaster Nursing: Bioterrorism: Triage

Focus topic: Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism: Characteristics

Focus topic: Disaster Nursing: Bioterrorism
A. Triage, a French word (trier) meaning “to sort,” is a medical process of prioritizing treatment urgency.

  • The triage system can quickly assess large numbers of people with multiple problems.
  • Rapid identification determines which clients require immediate treatment and which can safely wait.

B. The goal of triage is to do the greatest good for the greatest number.
C. From triage, victims are taken to a designated medical treatment area (immediate care, delayed care, or morgue), and from there, transported out of the disaster area.
D. Three-level triage has been used for years to differentiate levels of emergency cases.
E. Now, a five-level system is preferred because it reduces ambiguity of middle-level emergency care.

Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism

Disaster Nursing: Bioterrorism

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Disaster Nursing: Bioterrorism: Assessment

Focus topic: Disaster Nursing: Bioterrorism
A. Assess need to establish triage treatment areas.
B. Validate that public health parameters are established.
C. Observe that steps of triage are followed.
D. Assess that victim is not in immediate danger, or conversely, requires immediate intervention.
E. Assess vital signs of victims.
F. Assess the treatment steps necessary to treat life-threatening conditions.

  • Observe for signs of respiratory distress.
  • Assess need for establishing an airway.
  • Observe for amount and source of bleeding and need for intervention.
  • Recognize shock state and need for intervention.

G. Assess victims post-triage and observe for any signs or symptoms that indicate major injury.
H. Identify victims having a severe psychological reaction to bio-terrorism event.
I. Assess possibility of post-traumatic stress syndrome developing.

Disaster Nursing: Bioterrorism: Implementation

Focus topic: Disaster Nursing: Bioterrorism
A. Assign roles to personnel in treatment areas.
B. Select a site as soon as possible—advance planning is essential.

  • Select safe area, free of hazards and debris.
  • Position site upwind of hazard zone.
  • Determine site is accessible to transportation vehicles (ambulances, trucks, helicopters).
  • Be sure site is able to expand.
  • Survey entire scene, including area above you, for threats to your safety before beginning triage or teamwork.

C. Protect treatment area and delineate area using tarps, covers, etc.
D. Set up signs to identify subdivisions of area.
I = Immediate care.
D = Delayed care.
Dead = Dead for morgue.

  • Establish I and D areas close together in order to facilitate verbal communication between workers; this also allows them to share medical supplies and transfer victims quickly when status changes.
  • Position victims in head-to-toe configuration, with 2 to 3 feet between victims, facilitating effective use of space and personnel.
  • Establish a secure morgue site that is away (and not visible) from medical treatment areas.

E. Establish public health parameters.

  • Assign personnel to monitor public health concerns where disaster victims are sheltered.
  • Have available search and rescue safety equipment.
  • Maintain proper hygiene by washing hands and using gloves.
    a. Wash hands with soap and water if dirty or antibacterial gel between victims.
    b. Wear gloves at all times.
    c. Change gloves between victims if possible.
    If not, clean them between victims in a bleach and water solution (1 part bleach to 10 parts water).
  • Wear a mask and goggles.
  • Avoid direct contact with body fluids.
  • Maintain sanitation.
    a. Mark and have available specific biohazard waste disposal containers where bacterial sources (gloves, dressings, etc.) are discarded.
    b. Place waste products in plastic bags and bury them in designated area.
    c. Bury human waste.
  • Purify water for drinking, cooking, medical use, if potable water is not available.
    a. Boil water at rolling boil for 10 minutes.
    b. Use water purification tablets.
    c. Use unscented liquid bleach (16 drops per gallon of water or 1 teaspoon per 5 gallons; mix and let stand for 30 minutes).

F. Steps of trauma assessment applied to triage.

  • Perform a rapid systematic assessment. (Trauma is a multisystem condition so all systems must be assessed.)
  • Complete a primary trauma assessment. (To identify victim’s primary and critical problem.)
    a. Airway.
    b. Breathing capability.
    c. Shock—circulation and bleeding.
    d. Neurological—level of consciousness, mental status.
    e. Exposure to contaminant.
    f. Disability.
    g. Evacuation necessity.
  • Complete a secondary assessment (post-triage) that includes a focus assessment.
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