Terrorism, Mass Casualty, and Disaster Nursing

Prepared by:

Kristina Angela Carbon

Cindy Jane Q. Paba

Chemical Weapon

• May be used an agents in warfare or for terrorist purposes; they are overt agents in that the effects are more apparent and occur more quickly than those caused by biological weapons.

• Typical exposures in these instances include Industrial chemicals, gasoline, turpentine, kerosene, and insecticides.

Characteristics of Chemicals

Votality – is the tendency for a chemical to become a vapor.

- The most common volatile agents are phosgene and cyanide.

Persistence – means that the chemical is less likely to vaporize and disperse.

Toxicity – is the potential of an agent to cause injury to the body.

- The median lethal dose (LD50

Latency – is the time from absorption to the appearance of signs and symptoms.

Limiting Exposure – Evacuation is essential, as is removal of the person’s clothing and decontamination as close to the scene as possible and before transport of the exposed person.

Types of Chemicals

Vesicants – are chemicals that cause blistering and result in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death.

Clinical Manifestation Similar to that of a large superficial to partial-thickness burn in the warm

Moist areas of the body

Stinging and erythema for approximately 24 hours

Pruritus

Painful burning

Small Vesicles formation after 2 to 18 hours.

Photophobia

Lacrimination

Decreased vision

Treatment Appropriate decontamination includes soap and water. Scrubbing and use of hypochlorite solutions should be

avoided because they increase penetrating. Once the substance has penetrated, it cannot be removed. Eye exposure requires copious irrigation.

Nerve Agents – the most toxic agents in existence are the nerve agents such as sarin, soman , tabun. They are inexpensive, effective in small quantities, and easily dispersed.

Clinical Manfestations Bilateral miosis Visual disturbances Increased gastrointestinal motility Nausea and vomiting Diarrhea Substernal spasm Indigestion Bradycardia Atrioventicular block Bronchoconstriction Laryngeal spasm

TreatmentDecontamination with copious amounts

of soap and water or saline solution for 8 to 20 minutes is essential

Fresh 0.5% hypochlorite solutionAtropine 2 to 4 mg is administered by

IV, followed by 2 mg every 3 to 8 minutes for up to 24 hours of treatment.

Pralolidoxime

Blood Agents – such as hydrogen cyanide and cyanogens chloride have a direct effect on cellular metabolism, resulting in asphyxiation through alterations in hemoglobin.

Clinical ManifestationRespiratory muscle failure Respiratory arrest Cardiac arrestFlushingTachypnea Tachycardiac Stupor Coma

TreatmentAmyl nitrateSodium thiosulfateSodium nitrate

Pulmonary Agent – such as phosgene and chlorine destroy the pulmonary membrane that separates the alveoles from the capillary bed, distrupting alveolar-capillary oxygen transport mechanisms.

Signs and symptoms include pulmonary edema with shortness of breath, especially during exertion, initial hacking cough, frothy sputum production.

Nuclear Radiation Exposure The threat of nuclear warfare or exposure to a

radiologic weapon is very real with the availability of nuclear material and easily concealed simple devices, such as the so called dirty bomb, for dispersal. Types of Radiation

Alpha – particles cannot penetrate the skin. A thin layer of paper or clothing is all that is necessary to protect the skin from alpha radiation.

Beta – particles have the ability to moderately penetrate the skin to the layer in which skin cells and being produced.

Gamma radiation id s dhort-wavelength electromagnetic energy that is emitted when there is excess core nucleus energy.

Exposure

Exposure is affected by time, distance, and shielding. The longer a person is within the radiation area, the higher the exposure.

The larger the amount of radioactive material in the area, the greater the exposure.

Three types of radiation-induced injury can occur: external irradiation, contamination with radioactive materials, and incorporation of radioactive material into body cells, tissues or organs

External radiation exposure occurs when all or part of the body is exposed to radiation that penetrates or passes completely through the body.

Contamination occurs when the body is exposed to radioactive gases, liquids, or solids either externally or internally.

Incorporation is the actual uptake of radioactive material into the cells, tissues, and susceptible organs. The organs involved are usually the kidneys, bones, liver and thyroid.

Sequelae of contamination and incorporation can occur days to years later. The thyroid gland can be largely protected from radiation exposure by administration of stable iodine before or promptly after the intake of radioactive iodine.

Priorities in the treatment of any type of radiation exposure are always treatment for life-threatening injuries and illnesses first, followed by measures to limit exposure, contamination control, and finally decontamination.

Decontamination Hospital and community disaster plans should be in effect when managing radiation

disaster. Access restriction is essential to prevent contamination of other areas of the hospital.

Floors are covered to prevent tracking of contaminants throughout the treatment areas.

Strict isolation precautions should be in effect. All air ducts and vents must be sealed to prevent spread. Waste is controlled through double-bagging and the use of plastic lined containers

outside of the facility. All radiation-contaminated waste must be disposed in appropriate color-coded yellow

and magenta canisters. Staff are required to wear protective clothing (water resistant gowns, two pairs of

gloves, masks, caps, goggles, and booties) Dosimetry devices should be worn by all staff members participating in patient care. Radiation safety officer

Decontamination (cont)

Each patient arriving at the hospital should be first surveyed with the radiation survey meter. The majority of patients can be safely decontaminated with soap and water. After the patient has showered, a resurvey is conducted to determine whether the radioactive

contaminants have been removed. Wounds are irrigated and then covered with a water-resistant dressing prior to total body

decontamination Internal contamination or incorporation requires decontamination, through catharis, gastric

lavage with chelating agents (agents that bind with radioactive substances and are then excreted), or both.

Samples of urine, feces, and vomitus are surveyed to determine internal contamination levels. Biologic samples are taken through nasal and throat swabs, and a complete blood count with

differential is obtained.

Acute Radiation Syndrome

Acute Radiation Syndrome Can occur after the exposure to radiation. It is the dose, rather than the source, that

determines whether ARS develops. Factors that determine whether the patient’s response to exposure will result in ARS include a high dose(minimum 100rad) and rate of radiation with total body exposure and penetrating-type radiation.

Phases of effects of Radiation ExposurePhase Time of Occurrence Signs and SymptomsProdromal phase (presenting symptoms)

48-72 hours after exposure Nausea, vomiting, loss of appetite, diarrhea, fatigue

Latent phase (a symptom free period)

After resolution of prodromal phase; can last up to 3 weeks

Decreasing lymphocytes, leukocytes, thrombocytes, red blood cells

Illness phase After latent period phase Infection, fluid and electrolyte imbalance, bleeding, diarrhea

Recovery phase After illness phase Can take weeks to months for full recovery

Death After illness phase Increased intracranial pressure

Each body system is affected differently in ARS. Systems with cells that rapidly reproduce are most commonly affected.

The hematopoietic system is the first system affected and serves as an indicator of the severity of radiation exposure.

A predictor of outcome is the absolute lymphocyte count at 48 hours after exposure. A significant exposure would be indicated by blood lymphocyte counts of 300 to 1,200/mm. Barrier precautions should be implemented to protect the patient from infection. Neutrophils decrease within 1 week, platelets decrease within 2 weeks, and red blood cells decrease within 3 weeks.

The gastrointestinal system, with its rapidly reproducing cells, is also readily affected by radiation. Doses of radiation required to produce symptoms are approximately 600rad or higher.

The central nervous system is affected when the dose exceeds 1,000 rad. Skin effects can also indicate the dose of radiation exposure. Secondary injury can occur when the radiation exposure occurs during a traumatic

event such as a blast or burn

Survival

Presenting signs and symptoms determine the potential for survival and therefore the category of predicted survival during triage.

Probable survivors have either no initial symptoms or only minimal symptoms (nausea and vomiting), or these symptoms resolve within few hours.

Possible survivors present with nausea and vomiting that persist for 24-48 hours. They experience a latent period, during which leukopenia, thrombocytopenia and lymphocytopenia occur.

Improbable survivors have received more than 800rad of total-body penetrating irradiation.