Disaster Nursing Flashcards
Triage Priority 1
RED = Immediate
- Sucking chest wound
- Airway obstruction secondary to mechanical cause
- Asphyxia
- Shock (a quick fix shock, they need fluids or blood)
- Hemothorax
- Tension pneumothorax
- Unstable chest and abdominal wounds
- Incomplete amputations (tourniquet)
- Open fractures of long bones
- 2nd and 3rd degree burns of 15-40% of total body surface area
Characteristics of Priority 1 Triage
Injuries are life threatening, but survival is possible with minimal intervention
** Patient in this category progress to expectant or black tagged if treatment is delayed
Characteristics of Priority 2 Triage
Injuries are significant and require medical care, but treatment can be delayed for hours without threat to life or limb
** Individuals in this category receive treatment only after immediate casualties have been treated
Triage Priority 2
YELLOW = Delayed
- Stable abdominal wounds without massive hemorrhage
- Soft tissue injuries
- Maxillofacial wounds without airway compromise
- Vascular injuries with adequate collateral circulation
- Genitourinary tract disruption
- Fractures requiring open reduction
- Debridement
- External fixation
- Most eye and CNS injuries
Characteristics of Priority 3 Triage
Injuries are minor and treatment can be delayed hours or days
** Individuals in this category should be moved away from the main triage area
Priority 3 Triage
GREEN = Minimal
- Upper extremity fractures
- Minor burns
- Sprains
- Small lacerations without significant bleeding
- Behavioral disorders
- Psychological disturbances (hallucinations)
Characteristics of Priority 4 Triage
Injuries are extensive and chances of survival are unlikely, even with definitive care
- Persons in this group should be separated from other casualties, but not abandoned
- Comfort measures only
Priority 4 Triage
BLACK = Expectant or black tagged
- Unresponsive patients with penetrating head wounds
- High spinal cord injuries
- Wounds involving multiple anatomical sites and organs
- 2nd and 3rd degree burns in excess or 60% of body surface area
- Seizures or vomiting within 24 hours after radiation exposure
- Profound shock with multiple injuries
- Agonal respirations, no pulse, no BP, pupils fixed and dilated
Components of the Emergency Preparedness Operations Plan
- Activation response
- An internal/external communication plan (one spokesperson)
- Implement a plan for coordinated patient care
- Implement security plans
- Identification of external resources
Trends that may suggest deliberate dispersal of toxins or infectious agents
- Unusual increase in the number of people seeking care for fever, respiratory, or GI symptoms
- Clusters of patients who present with the same unusual illness from a single location
- A large number of rapidly fatal cases, especially when death occurs within 72 hours after hospital admission
- Any increase in disease incidence in a normally healthy population
Level A PPE
Protection is worn when the highest level respiratory, skin, eye, and mucous membrane is required
- Self-contained breathing apparatus (SCBA)
- Fully encapsulating, vapor tight chemically resistant suit
- Chemical-resistant gloves and boots
Level B PPE
Protection requires the highest level of respiratory protection, but a lesser level of skin and eye protection
- SCBA
- Chemical-resistant suit, suit is not vapor tight
Level C PPE
Protection requires air-purified respirator, which filters harmful substance from the air
- Chemical resistant coverall with splash hood
- Chemical resistant gloves
- Boots
Level D PPE
Typical work uniform
TB Masks are which PPE Level
Level C
Decontamination
- Removal of patient clothing and jewelry and rinsing patient with water
- Depending on the type of exposure, this can remove a large amount of contaminant - Thorough soap and water wash and rinse
- Each patient who arrives after pre-hospital treatment should go through this procedure
Three Waves of Casualties
- First wave consists of minimally injured people who arrive on their own
- Second wave consists of severely injured people
- Third wave consists of injured patients whoa re discovered by rescuers
* * The walking wounded may not seek treatment for 5 days to 2 weeks after the event
Types of Explosive Devices
- Pipe bombs (most commonly used; may contain nails and other things that cause damage when ignited)
- Molotov cocktail (uses a flammable liquid such as gasoline in a glass bottle as an ignition)
- Fertilizer bombs
- Dirty bombs (spread radiation)
Blast Injuries: Lung Damage
Results in hemorrhage and tearing of the lung
- Dyspnea
- Hypoxia
- Tachypnea
- Apnea
- Cough
- Chest pain
- Hemodynamic instability
- Hemo/pneumothorax
- Air embolus
Complications to the lungs from blast injuries
- ARDS
2. Respiratory failure
Blast Injuries: Tympanic Membrane
Most frequent injury after blast in an enclosed building due to pressure wave
- Majority only suffer high frequency hearing loss
1. Hearing loss (5% require hearing aids post blast)
2. Tinnitus
3. Abdomen and head trauma
4. Pain
5. Dizziness
6. Otorrhea
7. Tympanic membrane rupture
- Majority only suffer high frequency hearing loss
Blast Injuries: Head
- Typically minor, but those that are severe result in majority of post-blast deaths
- Concussions are the most common
Blast Injuries: Abdomen
Evidenced by abdominal hemorrhage and internal organ injury
- Increase in pulse rate (internal hemorrhage)
- Pain
- Guarding
- Rebound tenderness
- Rectal bleeding
- N/V
Anthrax
- Caused by bacteria bacillus anthracis
- Replicates and releases a toxin that causes hemorrhage, edema, and necrosis
- Is odorless and invisible and can travel a great distance before disseminating
Anthrax Infection only results from:
- Skin contact
- Ingestion of infective animal products (usually raw meat)
- Inhalation of spores
S/Sx of Skin Contact Anthrax
- Edema
- Pruritus
- Macule/papule formation
- Results in ulceration
- 1-3 mm vesicles
- Painless eschar (fall off in 1-2 weeks)
* * Most Common
S/Sx of Inhalation Anthrax
- Symptoms mimic the flu
- Treatment usually sought when stage 2 of respiratory distress occurs
- Current antibiotic therapy does not halt progression of the disease
- Inhaled anthrax incubates for up to 60 days
Anthrax Initial Symptoms
- Cough
- HA
- Fever
- Vomiting
- Chills
- Weakness
- Mild chest discomfort
- Dyspnea
- Syncope
2nd Stage of Anthrax
- Fever
- Severe respiratory distress
- Stridor
- Hypoxia
- Cyanosis
- Diaphoresis
- Hypotension
- Shock
- IMPORTANT for VS q 15-30 min because respiratory distress can lead to circulatory collapse
GI Ingestion Anthrax Symptoms
- Fever
- N/V
- Abdominal pain
- Bloody diarrhea
- Occasionally ascites
* * If severe diarrhea develops, decreased intravascular volume is the primary concern
Anthrax Treatment
- Penicillin V
- Erythromycin
- Gentamicin
- Doxycycline
* * If treatment begins within 24 hours of exposure, death may be prevented
* * Treatment continues for 60 days
* * Vaccine is used by military
* * Cremate the infected corpses
What medications are used for mass casualty anthrax exposure?
- Ciprofloxacin
2. Doxycycline
Smallpox
- Virus (variola)
- Incubation is approximately 12 days
- Large portion of the population has no immunity to the virus
- 30% fatality rate
How is smallpox spread?
- Direct contact
- Clothing/linens
- Droplets (after fever has decreased and rash phase has begun)
* * Contagious only after the rash begins
Smallpox: First Symptoms
- High fever
- Malaise
- HA
- Backache
Smallpox Symptoms after 1-2 days
- Maculopapular rash evolving at the same rate
- Begins on face, mouth, pharynx, and forearms
- Progresses to trunk and becomes vesicular to pustular
- Large amount of virus in the saliva/pustules
Smallpox Treatment
- Supportive care with antibiotics for secondary infections
- Laundry and biologic wastes must be autoclaved before they are washed
- All persons in contact with infected should be vaccinated within 4 days
- A patient with temperature > 38 C (101 F) within 17 days must be isolated
- Cremation for all deaths is preferred (virus can live in scabs for 13 years)
Characteristics of Chemicals
- Volatility
- Persistence
- Toxicity
- Latency
Volatility
- Tendency for a chemical o become a vapor
- Most common volatile agents are cyanide and phosgene
- Most chemicals are heavier than air, except for cyanide
- In the presence of most chemicals, STAND UP to avoid heavy exposure
Persistence
- Chemical is less likely to vaporize or disperse
- More volatile chemicals do not evaporate very quickly
- Most industrial chemicals are not persistent (cyanide)
- Most weaponized chemicals are likely to penetrate skin and mucous membranes (mustard gas)
Toxicity
- Potential of an agent to cause injury to the body
- Median lethal dose is the amount of chemical that will cause death in 50% of those who are exposed
Latency
- The time from absorption to the appearance of signs/symptoms
- Sulfur mustards and pulmonary agents have the longest latency periods
- Other vesicants, nerve agents, cyanide produce signs/symptoms within seconds
Limiting Exposure to Chemicals
- Evacuation is essential
- Remove patient’s clothing and decontamination closest to the scene as possible
- Soap and water are an effective means of decontamination in most cases
- Staff must wear PPE
- Dispose of run-off after decontamination procedures
- Decontamination should be done away from the initial triage area
Vesicants
Chemicals that cause blistering and result in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death
Examples of Vesicants
- Lewisite
- Phosgene
- Nitrogen mustard
- Sulfur mustard
* * Liquid sulfur mustard was the most frequently used vesicant in these conflicts
Symptoms of Vesicant Exposure
- Initial presentation is similar to superficial to partial thickness burns in the warm and moist areas of the body
- Stinging and erythema for approximately 24 hours followed by:
- Pruritus
- Painful burning
- Small vesicle formation after 2-18 hours then become bullae
- Tissue damage can occur within minutes
Eye Symptoms of Vesicant Exposure
- Photophobia
- Pain
- Lacrimation
- Decreased vision which progresses to
- Conjunctivitis
- Corneal ulcerations
- Corneal edema
Respiratory Symptoms of Vesicant Exposure
Purulent fibrinous pseudomembrane discharge
- Airway obstruction
GI Symptoms of Vesicant Exposure
- N/V
- Leukopenia
- Upper GI bleeding
Treatment for Vesicant Exposure
- Soap and water
- NO scrubbing!! Because it can increase penetration of the vesicant
- Once the substance has penetrated, it cannot be removed
- Eyes: copious irrigation
- Respiratory: intubation and bronchoscopy
Nerve Agents
- In liquid form they evaporate into odorless, colorless vapor
- Organophosphates (fertilizers) are similar in nature to nerve agents
- These agents bond with acetylcholinesterase so that acetylcholine is not inactivated causing hyperstimulation to the nerve endings
- Effects can be from 30 minutes to 18 hours
- Can cause a cholinergic crisis
S/Sx of Cholinergic Crisis
- Bilateral miosis
- Increased GI motility
- N/V
- Diarrhea
- Substernal spasm
- Indigestion
- Bradycardia and AV block
- Bronchoconstriction
- Laryngeal spasm
- Weakness
- Fasciculation
- Incontinence
S/Sx of Lethal Dose of Nerve Agent (Severe Cholinergic Crisis)
- Loss of consciousness
- Seizures
- Copious secretions
- Flaccid muscles
- Apnea
Treatment for Nerve Agent Exposure
- Decontamination with soap and water or saline solution for 8-20 minutes
- Fresh bleach can also be used
- Airway support with intubation and suctioning
- Atropine 2-4 mg IV, followed by 2 mg every 3-8 minutes for up to 24 hours of treatment
- IV Atropine 1-2 mg/hr until signs of anticholinergic activity has returned
- Decreased secretions
- Tachycardia
- Decreased GI motility
Examples of Nerve Agents
- Saran
- Soman
- Tabun
Blood Agents
- Cyanide and cyanogen chloride have a direct effect on cellular metabolism
- A cyanide release smells like bitter almond
- In house fires cyanide is released in combustible plastics, rugs, silks, furniture, and other construction materials
Symptoms of Blood Agent Exposure
- Inhalation results in flushing, tachypnea, tachycardia, nonspecific neuro symptoms, stupor, coma, and seizures preceding respiratory arrest
- Respiratory muscle failure
- Respiratory distress
- Cardiac arrest
- Death
Treatment of Blood Agent Exposure
Rapid administration of amyl nitrate, sodium nitrate, and sodium thiosulfate
- Amyl nitrate given to induce methemoglobinemia
- Sodium nitrate given IV to induce the rapid formation of methemoglobin
- Sodium thiosulfate given IV stimulates the conversion of cyanide to sodium thiosulfate which is secreted by the kidneys
* * Alternative treatment for cyanide poisoning is Vitamin B12 in large doses
Pulmonary Agents
- Phosgene and chlorine destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting oxygen transport mechanisms
- Capillary leakage results in fluid-filled alveoli
- Phosgene smells like fresh-mown hay
Symptoms of Pulmonary Agent Exposure
- Pulmonary edema
- Hacking cough followed by frothy sputum production
- Particulate air mask is the only protection
* * Phosgene does not harm the eyes
Priorities in Treating Radiation Exposure
- Life-threatening
- Measures to limit exposure
- Contamination control
- Decontamination
Radiation Decontamination
- Triage outside the hospital is the most effective means of preventing contamination of the facility itself
- All air vents/ducts are sealed
- Floors are covered to protect from contamination
- Strict isolation precautions are initiated
- Double-bagged waste
- Dosimetry device worn by staff and patients
PPE for Radiation Patients
- Water-resistant gowns
- Double gloves
- Masks
- Caps
- Goggles
- Booties
Acute Radiation Syndrome (ARS)
- The development of ARS is determined by the dose, rather than the source
- Four phases
ARS Prodromal Phase
48-72 hours after exposure
- N/V
- Loss of appetite
- Diarrhea
- Fatigue
- High dose exposure: Fever, respiratory distress, increased excitability
ARS Latent Phase
Can last up to 3 weeks after resolution of prodromal phase
- Symptom free period
- Decreased lymphocytes, leukocytes, thrombocytes, and RBCs
ARS Illness Phase
- Infection
- Fluid/electrolyte imbalance
- Bleeding
- Diarrhea
- Shock
- Altered LOC
ARS Recovery or Death Phase
Can take weeks or months for full recovery
- Increased ICP is a sign of impending death, cardiac collapse
Three Categories of Predicted Radiation Survival
- Probable
- Possible
- Improbable
Probable Radiation Survival
Survivors have no initial symptoms or minimal
- N/V with symptom resolution within a few hours **
- Discharge home with instructions
Possible Radiation Survival
- Survivors present with N/V that persists for 24-48 hours **
- Latent period, in which lab work is altered
- Barrier precautions and protective isolation if lymphocyte count < 1200
Improbable Radiation Survival
- Acute onset N/V, bloody diarrhea, shock **
- Survivors receive more than 800 rad of total body penetrating irradiation
- ANY neuro symptoms suggest a lethal dose
- Require decontamination to prevent further damage
- Survival time is variable, but usually swift due to shock
- A patient may have extensive burns, instead of neuro symptoms
- Triage into the black category and provide comfort measures
- If no mass casualty situation - aggressive fluid/electrolyte therapy
