NSG210 Hinkle Ch. 68: Disaster Nursing

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 68, pp. 2218-2241 (textbooks/HINKLE_MS_CH68.pdf, also in textbooks/exam04/). Listed twice: in the Week 09 protection topics (October 21) and as the Week 14 online module (November 25). It is Exam 4 content. Numbering note: the syllabus lists “Ch. 69,” which is the 16th edition number; in the 15th edition disaster nursing is Ch. 68 (see nsg210-textbook-chapter-crosswalk). Extraction note: the local PDF starts partway through the learning outcomes (the chapter title page is missing), and several tables are partly garbled; table content below was rebuilt from context.

Learning Outcomes

1. Describe the types of disasters a nurse may encounter.
2. Identify essential components of an emergency operations plan and disaster preparedness, including personal protection and decontamination.
3. Discuss how disaster triage differs from emergency department triage.
4. Explain manifestations and treatment of injuries and illnesses from natural disasters, outbreaks, epidemics, pandemics, and weapons of terror (blast, biologic, chemical, radiologic).

Key Terms

• Disaster: sudden event that disrupts the functioning of a community
• Disaster nursing: adapting nursing knowledge and skills to meet health needs during a crisis
• Mass casualty incident (MCI): casualties exceed available resources
• Natural disaster: tornado, hurricane, flood, earthquake and similar events causing major damage and loss of life
• Outbreak: disease occurrence that exceeds normal expectations
• Epidemic: widespread outbreak of a specific infectious disease from a single source that exceeds anticipated levels
• Pandemic: epidemic that spreads across multiple countries or continents (WHO declared COVID-19 a pandemic in March 2020)
• Terrorism: unlawful, systematic use of violence or threats to coerce or intimidate
• Weapons of mass destruction (WMD): weapons causing widespread death and destruction
• Biologic weapon: agent used to spread disease. Chemical weapon: agent used to cause disability and death. Radiologic weapon: radiation byproducts used to cause harm
• Decontamination: removing contaminants from people and equipment or rendering them harmless
• Personal protective equipment (PPE): equipment beyond standard precautions, in levels matched to the agent
• Material safety data sheet (MSDS): chemical name, physical data, ingredients, fire and explosion hazards, health and reactivity data, spill procedures, protection and precautions (“Workers’ Right to Know”)

I. Disaster Planning and Response Agencies

• Plans follow the National Incident Management System (NIMS), directed by FEMA under the Department of Homeland Security; used for terrorism, natural disasters, outbreaks, epidemics and pandemics
• In an MCI, the operating principle becomes the greatest good for the greatest number
• Sustainability planning: local communities must be able to act alone and provide care for up to 5 DAYS before state or federal help arrives
• Hazard vulnerability assessments identify threats; mutual aid agreements between communities
• States request federal help through government channels when local resources are or will be depleted

Federal agencies (Table 68-1):

• CDC: disease prevention; backs up state and local health departments
• HHS: coordinates health, medical and health-related social services in the federal response plan
• Department of Defense: armed services, National Guard
• Department of Homeland Security: national counterterrorism strategy; National Terrorism Advisory System (NTAS) issues bulletins (trends) and alerts (credible threat; “elevated” or “imminent”)
• FDA: safety of drugs, biologics, devices, food; during COVID-19 used Emergency Use Authorization to speed testing
• National Disaster Medical System (NDMS): Disaster Medical Assistance Teams (DMATs, volunteer teams that can staff a field hospital and are self-sufficient for 72 HOURS), Disaster Mortuary Operational Response Teams (DMORTs), Veterinary Medical Assistance Teams, National Medical Response Teams for WMD
• US Public Health Service
• American Red Cross: nongovernment nonprofit; shelters and volunteers

State and local: Office of Emergency Management or Emergency Services (OEM/OES) coordinates state and local relief; Metropolitan Medical Response Teams; poison control centers. State and local governments lead public health emergencies until they request federal help.

II. Incident Command

• Incident Command System (ICS): federally mandated structure that coordinates personnel, facilities, equipment and communication; identifies hazardous substances and distributes PPE; decides when the MCI has ended
• Hospital Incident Command System (HICS): incident commander is the hospital emergency preparedness coordinator; team includes safety officer, public information officer, liaison officer, and operations, logistics, planning and finance chiefs, all reporting to the incident commander

III. Hospital Emergency Preparedness

• The Joint Commission requires a plan practiced with all employees at least TWICE a year
• Hazard vulnerability analysis: likely disasters based on local traffic, weather patterns, nearby chemical plants, nuclear facilities, military bases, government buildings, schools, gathering places
• Hospitals should be self-sufficient for at least 96 HOURS, ideally 7 days
• Plan how to triage scarce resources (for example, ventilators)
• COVID-19 lessons: social distancing to flatten the curve; shortages of ventilators and PPE (N95s, face shields, gowns) led to health care worker infections and deaths; Defense Production Act; FEMA supply chain task force (preservation, acceleration, expansion, allocation)

Components of the emergency operations plan (EOP):

• Activation response (where, how, when the plan starts)
• Internal and external communication plan
• Coordinated patient care into, within and out of the facility
• Security plan
• Identification of external resources
• People management and traffic flow (patients, public, media, personnel)
• Data management with a backup if the EHR fails
• Demobilization response (who decides normal operations resume)
• After-action report: critique and debriefing right away and later; volumes may stay high for 3 months or more
• Practice drills: full-scale regional drills with hospitals and EMS work best because they expose communication breakdowns
• Anticipated resources (food and water for an extended period)
• MCI planning, including mass fatality and morgue readiness
• Education plan for all personnel

Initiating the EOP: notification usually comes from outside (field incident command gives approximate numbers); self-referring patients are not counted.

Patient identification: numbered disaster tags with triage priority, name, address, age, injuries and treatments; tag stays on the patient; tag number recorded in a disaster log used for tracking, bed assignment and family information.

IV. Triage

• Everyday ED triage: the sickest get the most resources
• Disaster triage: do the greatest good for the greatest number; decisions based on likelihood of survival and resource use. A patient with a high chance of dying (for example, a young adult in cardiac arrest from a chest injury) gets LOW priority even if conscious, because spending scarce resources on low-survival patients denies them to treatable patients
• One person triages in the field while others do lifesaving interventions and transport; secondary and continuous triage at every level of care
• An experienced ED provider triages at the hospital entrance; traffic control is one of the most important parts of disaster management; field-triaged patients may be reclassified

Table 68-2, MCI triage categories:

SALT triage (Sort, Assess, Lifesaving interventions, Treatment/Transport): sort by ability to follow commands, assess individually, give lifesaving interventions, assign priority for treatment or transport; works for any age and any event.

V. Managing Internal Problems, Media and Families

• Supplies: each facility does its own needs assessment; identify the top 10 critical daily medications and anticipated disaster drugs (antidote stockpiles such as cyanide kits; antibiotics for biologic agents)
• Media: designated spokesperson (public information officer), a site away from patient care areas, a regular update schedule; focus initial statements on current efforts; do NOT release casualty information; keep media out of patient care areas. Media can help with quarantine, shelter and dispensing-site announcements
• Families: designated area away from triage and treatment, staffed by social workers, counselors or clergy, with controlled access; give updates early and regularly; families help identify the injured and dead
• Visitor restrictions in outbreaks (COVID-19): one support person for obstetric patients; exceptions for imminent death and patients with developmental or cognitive disabilities; use video calls, and plan for families without technology

Chart 68-1, cultural considerations: family roles, language barriers, privacy, rituals for handling the dead, religious practices about treatment, hygiene and diet, prayer times, funeral timing, travel and visa restrictions. Integrate religious communities’ emergency plans.

VI. The Nurse’s Role

• Nurses are the largest part of the health care workforce
• May work outside usual expertise (intubation, chest tubes, debridement, suturing, serving as triage officer); maximize safety and know state practice regulations
• Know who is in charge of each area and which procedures each nurse may perform
• Delegate to students, outside staff and volunteers after rapidly assessing their skills
• Disaster care focuses on essential care for the good of all patients; tension between patient-centered care and public-focused fair allocation (public health ethics)
• Know the hospital plan, take part in drills, build disaster competencies
• New roles: shelter care, bereavement support, identification of the dead, crisis intervention, critical incident stress management
• Nurse leaders plan for security, surge capacity, water, supplies, drugs, generator power, evacuation routes and destinations, and shortages of staff and supplies

Chart 68-3, people with disability: personal support network to check on them, backup systems and an evacuation plan; service animals go to shelters; rescuers need to know where equipment is (communication aids, medications, oxygen); bring mobility devices, oxygen, suction and medications to shelters; keep people with vision or hearing loss informed; sign language interpreters.

Ethical conflicts: assisted suicide, confidentiality, consent, duty, futile therapy, rationing, resuscitation; withholding information to avoid panic; self-protection versus duty. Plan an ethical framework in advance using autonomy, nonmaleficence, beneficence and distributive justice.

• Ethical Dilemma (Chart 68-2): with two equally eligible patients and one ventilator, a predetermined randomization protocol is used; allocation protocols may not discriminate by ethnicity, race, socioeconomic status, sexual orientation, gender or age
• COVID-19 moral distress: limited visitation, patients dying without family, rationed therapies
• ANA: reasons nurses may choose not to respond include belonging to a vulnerable group, unsafe conditions (lack of PPE or testing), inadequate support for personal or family needs, and legal protection concerns. Nurses also have an obligation to self-care; organizations must support them

VII. Behavioral Issues

• Common responses: anxiety, compassion fatigue, depression, impaired performance, interpersonal conflict, PTSD, somatization (fatigue, malaise, headache, GI upset, rashes), substance use disorder
• Influences: degree of exposure; loss of people, pets, home and possessions; coping skills; resources and support; personal meaning of the event; prolonged danger; toxic exposure
• Higher risk: those exposed to the dead and injured or endangered, older adults, children, first responders, health care workers
• Nursing: active listening, emotional support, information, referral to therapists or social workers (few victims seek help on their own; early intervention reduces harm); discourage repeated media exposure; encourage return to normal roles

Critical incident stress management (CISM): team-based prevention and treatment of emotional trauma in responders and others (about 350 US teams). Before: education on stress and coping. During: field support (rest, food, fluids, rotating assignments). After: defusing, debriefing, demobilization, family support, follow-up.

VIII. Preparedness: Recognition, PPE, Decontamination

Signs that suggest deliberate release or an outbreak:

• Unusual increase in people with fever, respiratory or GI symptoms
• Clusters with the same unusual illness from one location or event (city, sports event, wedding, funeral)
• Large number of deaths, especially within 72 HOURS of admission
• Increased disease in a normally healthy population (report to the state health department and CDC)
• If seen: take a targeted exposure history (current and past exposures, typical day, all jobs including military, home locations, water supply, hobbies, recent and international travel, sick or dead contacts); report to infection control, state health department, CDC, poison control; use MSDS
• Novel pathogens change patterns (COVID-19: children infected at adult rates but milder; later multisystem inflammatory syndrome in children, MIS-C)

PPE (EPA levels):

• Levels C and D are used most in hospitals. Level D (standard precautions) is NOT adequate for chemically, biologically or radiologically contaminated patients; Level C is adequate for the average exposure
• Don PPE BEFORE contact with a contaminated patient
• No single PPE protects against everything; never wear PPE without training, practice and respirator fit testing
• N95 respirator: filters at least 95% of airborne particles; must be fit-tested; ideally discard after each patient or aerosol-generating procedure, or when damaged, no longer sealing, wet, dirty, hard to breathe through, or contaminated with blood or secretions
• Surgical mask: protects against large droplets and splashes and protects the patient from the nurse; no seal; NOT respiratory protection
• Nursing Research Profile: about three-quarters of health care workers failed a PPE pretest; simulation-based training raised pass rates to 100%; N95s and coveralls were hardest

Decontamination:

• Protects providers from secondary contamination; plan procedures, equipment and disposal
• Minimum two steps: (1) remove clothing and jewelry and rinse with water (removes much of the contamination); (2) thorough soap-and-water wash and rinse
• Hospitals must be ready to decontaminate before entry, including “walking wounded” who skipped field decontamination
• Quality and Safety Alert: do NOT assume patients arriving from prehospital care were fully decontaminated

IX. Natural Disasters (Table 68-3)

• Loss of communications, potable water and electricity is usually the biggest obstacle; wireless may fail
• Most immediate casualties are trauma; most patients arrive within an hour, but walking wounded may come 5 days to 2 weeks later or with cleanup injuries
• Three waves: (1) minimally injured who come on their own; (2) severely injured; (3) injured found later by rescuers (earthquake deaths mainly head and chest)
• Hazards: heat, cold, contaminated food and water; dangerous animals (snakes, alligators, spiders); chain saw and building collapse injuries in rescuers; hypothermia in water at 75 F (23.9 C) or below; need for mental health workers, shelters and veterinary help
• Pulmonary problems peak after earthquakes and volcanic eruptions (particulates)
• Later morbidity: no water purification, waste removal, removal of remains, vector control

X. Outbreaks, Epidemics and Pandemics

• Outbreak types: communicable disease, chemical or toxin exposure, unknown source; spread by persons, animals or the environment
• An epidemic requires a vulnerable population, a disease agent, and a mechanism for large-scale transmission. Drivers: baseline disease levels, environmental change, population density and displacement, utility disruption, interrupted health services, sanitation
• An epidemic is an emergency when: many cases are projected; disease causes serious disability or death; it threatens social or economic disruption; officials cannot manage resources (staff, supplies, vaccines, drugs, tests); there is risk of international spread
• Investigation: surveillance, cluster monitoring, interviews, questionnaires, home visits; identify the source and contain
• An outbreak is over when new cases fall below the normally expected number

XI. Blast Injuries

• Explosive devices: pipe bomb (most common terrorist bomb; low-velocity explosive, may contain nails), Molotov cocktail (flammable liquid in a glass bottle with a rag wick), fertilizer bombs, dirty bombs (radioactive material spread by the blast)
• Scene hazards: secondary devices timed for rescuers’ arrival, building collapse, biologic, chemical or radiologic contamination, perpetrators among victims. The whole scene is a crime scene
• Triage as for any disaster, remembering that serious internal blast injuries may not be evident at first
• Most injuries come from the primary blast wave; enclosed spaces reflect and amplify it. Wave effects: spalling (the pressure wave itself), implosion (organ rupture from trapped gas), shearing (tissues of different density), irreversible work (forces beyond tissue strength)

Table 68-4, phases of blast injury:

• Blast lung: hemorrhage and tearing of lung tissue, V/Q mismatch, possible air emboli. Signs: dyspnea, hypoxia, tachypnea or apnea, cough, chest pain, hemodynamic instability. Treatment: oxygen by nonrebreather, intubation and ventilation if needed, chest tube for hemothorax or pneumothorax. AIR EMBOLUS: place PRONE, LEFT LATERAL immediately and arrange emergent hyperbaric therapy. Complications: respiratory failure, ARDS
• Tympanic membrane rupture: the MOST FREQUENT blast injury (TM is the organ most sensitive to pressure); more likely when close to the blast or in an enclosed space. Signs: hearing loss, tinnitus, pain, dizziness, otorrhea. Most heal on their own; about 5% need hearing aids; most have mild high-frequency hearing loss
• Blast abdomen: hemorrhage and organ injury; pain, guarding, rebound tenderness, rectal bleeding, nausea, vomiting
• Head injuries: usually minor, but severe ones cause most post-blast deaths; can occur without a direct blow; concussion common (follow up for postconcussive syndrome); about 30% involve vascular structures (AV fistula, pseudoaneurysm, dissection)
• Special populations: older adults (fractures from low bone density, more comorbidities); pregnant women (placental shear forces, abruptio placentae); people with mobility disability (difficulty escaping)

XII. Biologic Weapons

• Easily obtained and spread; delivered as liquid or dry agents in food or water, aerosolized, or by direct contact; vectors include insects, animals and people; travel can carry disease far from the release site
• Many mimic common illnesses, so surveillance and suspicion matter
• Management: rapid recognition, proper PPE, decontamination, isolation or quarantine as appropriate, vaccines, antidotes and medications for those at risk

Table 68-5, CDC categories:

• Category A (high mortality): anthrax (Bacillus anthracis), botulism (Clostridium botulinum), tularemia (Francisella tularensis), viral hemorrhagic fevers (Ebola, dengue), smallpox (variola), plague (Yersinia pestis)
• Category B (low mortality, moderate morbidity): Staphylococcus aureus and Vibrio food poisoning, typhus (Rickettsia typhi), arboviral encephalitis, brucellosis, Q fever (Coxiella burnetii), cryptosporidiosis
• Category C (low mortality, low morbidity): hantavirus

A. Anthrax

• The most likely weaponized biologic agent; gram-positive encapsulated rod that lives in soil as spores; infective ONLY in spore form; odorless and invisible as an aerosol and can travel far
• Toxin causes hemorrhage, edema and necrosis
• Incubation: cutaneous 5 to 7 days; GI 1 to 6 days; inhalation 1 to 43 days (can incubate up to 60 days)
• Cutaneous (most common): itchy edema, macule or papule, ulcer with 1 to 3 mm vesicles, then a PAINLESS black eschar that falls off in 1 to 2 weeks
• GI: fever, nausea, vomiting, abdominal pain, bloody diarrhea, sometimes ascites; targets the terminal ileum and cecum; volume loss and sepsis
• Inhalation: flulike first stage (cough, headache, fever, vomiting, chills, weakness, mild chest discomfort, dyspnea, syncope) WITHOUT rhinorrhea or nasal congestion; brief recovery; second stage within 1 to 3 days with fever, severe respiratory distress, stridor, hypoxia, cyanosis, diaphoresis, hypotension, shock; over 50% have hemorrhagic MEDIASTINITIS (widened mediastinum) on chest x-ray (hallmark); may cause meningitis with subarachnoid hemorrhage; death 24 to 36 hours after severe distress; mortality approaches 100%. Antibiotics do not halt progression once symptomatic
• Treatment: penicillin, ciprofloxacin, levofloxacin, doxycycline; antibiotics within 24 hours of exposure can prevent death; in mass casualties use oral ciprofloxacin or doxycycline (stockpiled); treat for 60 DAYS. Exposed but asymptomatic: ciprofloxacin or doxycycline prophylaxis for 60 days
• NOT contagious person to person: standard precautions; clean with standard disinfectant; cremation recommended after death (spores survive for decades). Vaccine (six doses) available to the Department of Defense

B. Smallpox (variola)

• DNA virus; incubation 7 to 17 days; extremely contagious by direct contact, clothing or linens, or droplets, but person-to-person spread begins only after the fever falls and the rash appears
• Eradicated (WHO 1977); vaccination stopped worldwide in 1980 (last US child vaccinated in 1972), so most people are not immune. Only people at high exposure risk are now encouraged to be vaccinated
• Signs: high fever, malaise, headache, backache, prostration; in 1 to 2 days a maculopapular rash appears, all lesions evolving at the SAME rate, starting on the face, mouth, pharynx and forearms, then the trunk, becoming vesicular then pustular. Contagious until scabs crust and fall off
• Variola major (more common): higher fever, more extensive rash, 30% case fatality. Hemorrhagic smallpox: dusky erythema, petechiae, frank skin and mucosal hemorrhage, death by day 5 or 6
• Management: supportive care, antibiotics for secondary infection, possibly antivirals and immune globulin; vaccination is the best prevention
• Negative-pressure room with strict AIRBORNE and CONTACT precautions; autoclave laundry and waste before washing in hot water and bleach
• Vaccinate household and face-to-face contacts within 4 DAYS; isolate any exposed person with temperature 38 C (101 F) or higher within 17 days of exposure
• Cremation preferred (virus survives in scabs up to 13 years)

C. Other agents (Table 68-6)

XIII. Chemical Weapons

• Overt agents: effects appear faster and more obviously than with biologic agents. Everyday chemicals (industrial chemicals, gasoline, turpentine, kerosene, insecticides) follow the same principles
• Volatility: tendency to vaporize (phosgene, cyanide most common volatile agents). Most chemicals are HEAVIER than air (except hydrogen cyanide), so people should STAND UP to avoid heavy exposure
• Persistence: less likely to vaporize; weaponized agents (mustard) penetrate skin more and cause secondary exposure; industrial chemicals like cyanide are not very persistent
• Toxicity: LD50 kills 50% of those exposed (cyanogen chloride has the highest, twice hydrogen cyanide and eight times sulfur mustard); ED50 causes symptoms in 50%; concentration time (CT) = concentration released times time exposed (1,000 mg for 10 minutes = 10,000 mg/min)
• Latency: sulfur mustard and pulmonary agents have the longest; other vesicants, nerve agents and cyanide act within seconds
• Limiting exposure: evacuate; remove clothing; decontaminate near the scene BEFORE transport; soap and water work in most cases; staff wear PPE and contain runoff

Table 68-7, common chemical agents:

A. Vesicants

• Cause blistering, burning, conjunctivitis, bronchitis, pneumonia, bone marrow suppression, death; used in WWI and the Iran-Iraq war; incapacitating with low mortality (under 5%); liquid sulfur mustard most used
• Skin: like a large superficial to partial-thickness burn in warm, moist areas (perineum, axillae, antecubital spaces); stinging and erythema for about 24 hours, then itching, burning and small vesicles after 2 to 18 hours that coalesce into bullae. Lewisite and phosgene cause IMMEDIATE pain
• Eyes: pain, photophobia, tearing, decreased vision, then conjunctivitis, blepharospasm, corneal ulcer and edema
• Respiratory effects are most serious and the usual cause of death: dyspnea, airway mucosal necrosis and sloughing, chemical pneumonitis, pulmonary edema, ARDS
• GI: nausea, vomiting, leukopenia, upper GI bleeding
• Management: soap and water; AVOID scrubbing and hypochlorite (increase penetration); once absorbed it cannot be removed; copious eye irrigation; intubation and bronchoscopy to remove necrotic tissue; lewisite: dimercaprol IV (systemic) and topically (skin); monitor all sulfur mustard exposures for 24 hours for delayed effects

B. Nerve agents

• The most toxic agents in existence; cheap, effective in tiny amounts, colorless and odorless vapor; organophosphate pesticides are similar
• Inhaled or absorbed through skin; bind acetylcholinesterase so acetylcholine is not broken down, causing continuous nerve stimulation. Carbamates release the enzyme spontaneously after several hours; organophosphates require new enzyme to be made
• A tiny drop causes sweating and twitching at the site; larger amounts cause systemic signs within 30 minutes to 18 hours
• Signs (cholinergic crisis): bilateral MIOSIS (check in a dark area), visual disturbance, increased GI motility, nausea, vomiting, diarrhea, substernal spasm, indigestion, BRADYCARDIA and AV block, bronchoconstriction, laryngeal spasm, weakness, fasciculations, incontinence; insomnia, forgetfulness, poor judgment, depression, irritability. Lethal dose: loss of consciousness, seizures, copious secretions, fasciculations, flaccid muscles, apnea
• Decontamination: copious soap and water or saline for 8 to 20 minutes; BLOT, do not wipe (wiping rubs agent in); fresh 0.5% hypochlorite also works
• Airway: frequent suctioning; do NOT use plastic airway equipment (absorbs sarin and prolongs exposure)
• Atropine 2 to 4 mg IV, then 2 mg every 3 to 8 minutes for up to 24 hours, or 1 to 2 mg/hr IV until anticholinergic signs return (drying of secretions, tachycardia, decreased GI motility)
• Pralidoxime 1 to 2 g in 100 to 150 mL NS over 15 to 30 minutes: reactivates cholinesterase; no effect on secretions; side effects hypertension, tachycardia, weakness, dizziness, blurred vision, diplopia
• Diazepam or other benzodiazepines for seizures, fasciculations and agitation

C. Blood agents (cyanide)

• Hydrogen cyanide and cyanogen chloride cause asphyxiation at the cellular level; used in gold and silver mining, plastics and dyes
• Odor of BITTER ALMONDS; released in house fires from burning plastics, rugs, silk and furniture (fire victims may die of cyanide; blood cyanide correlates with carbon monoxide)
• Ingested, inhaled or absorbed; inhibits aerobic metabolism leading to respiratory muscle failure, respiratory and cardiac arrest
• Inhalation: flushing, tachypnea, tachycardia, nonspecific neuro symptoms, stupor, coma, seizures before respiratory arrest
• Treatment: intubate and ventilate; amyl nitrite pearls (printed as “amyl nitrate” in the text) crushed into the ventilator reservoir to induce methemoglobinemia (cyanide binds methemoglobin, which is detoxified in the liver by rhodanese); then IV sodium nitrite (more methemoglobin); then IV sodium thiosulfate (converts cyanide to thiocyanate excreted by the kidneys)
• Side effects: sodium nitrite causes severe hypotension; thiocyanate causes vomiting, psychosis, arthralgia, myalgia
• Inducing methemoglobin is CONTRAINDICATED with smoke inhalation (carboxyhemoglobin already lowers oxygen carrying); hyperbaric oxygen if available
• Alternative: hydroxocobalamin (vitamin B12a) IV in large doses binds cyanide to form cyanocobalamin (vitamin B12); causes transient pink or red skin, mucous membranes and urine; high doses can cause tachycardia and hypertension that resolve within 48 hours

D. Pulmonary agents (phosgene, chlorine)

• Destroy the alveolar-capillary membrane; capillary leak fills alveoli; both vaporize rapidly
• Phosgene smells like freshly mown hay; does not injure the eyes
• Signs: pulmonary edema with dyspnea, especially on exertion; hacking cough followed by frothy sputum
• A particulate air filter mask is the only protection staff need
• Pulse oximetry was the most useful tool for detecting worsening in a chlorine spill; routine triage did not predict severity

XIV. Radiation Exposure

• Sources: nuclear weapons, reactors, weapons-grade plutonium or uranium, spent fuel, medical sources (radium, cesium). A radioactive sample hidden in a public place can expose thousands
• Dirty bomb: conventional explosive packed with radioactive material; a radiologic weapon, NOT a nuclear weapon (fission, thousands of times more destructive)

Types of radiation:

• Alpha: cannot penetrate skin (paper or clothing protects); harmful if inhaled, ingested or entering a wound; localized damage
• Beta: moderately penetrates to the germinal skin layer; skin damage with prolonged exposure
• Gamma: highly penetrating short-wavelength energy (x-rays are an example); hard to shield; often accompanies alpha and beta

Measurement: rad is the basic unit (0.01 J/kg); rem reflects damage potential (1 rem = 1,000 mrem); 200,000 mrem (200 rem) causes mild radiation sickness; natural yearly exposure about 360 mrem. Half-life: time to lose half the radioactivity. Detection only by devices: Geiger counter (gamma and some beta; may underestimate high levels), ionization chamber survey meter, alpha monitors, dose rate meters; personal dosimeters.

Exposure is reduced by limiting TIME, increasing DISTANCE, and SHIELDING.

Three types of injury:

• External irradiation: radiation passes through the body; the person is NOT radioactive and needs no isolation or decontamination; not necessarily an emergency
• Contamination: radioactive gas, liquid or solid on or in the body; needs immediate management to prevent incorporation
• Incorporation: uptake into cells and organs (kidneys, bones, liver, thyroid); effects days to years later. POTASSIUM IODIDE before or promptly after radioactive iodine intake protects the thyroid

Treatment priorities, always in this order: (1) life-threatening injuries and illness, (2) limit exposure, (3) contamination control, (4) decontamination.

Radiation decontamination:

• Activate disaster plans; restrict access; triage OUTSIDE the hospital (most effective way to keep the facility clean); cover floors; strict isolation; seal air ducts and vents; double-bag waste in plastic-lined containers outside; yellow and magenta radioactive waste containers
• Staff: water-resistant gowns, TWO pairs of gloves, masks, caps, goggles, booties; dosimeters for all direct care staff; notify the radiation safety officer immediately for surveys and dosimeters. Risk to staff is minimal with proper survey and decontamination
• Survey each patient with a radiation survey meter, then decontaminate outside the ED (shower, collection pool, tarp, belongings containers, soap, towels, paper gowns; contain runoff). Uninjured patients can self-decontaminate with handheld showers. Resurvey and repeat until clean; wash hair so runoff does not recontaminate clean areas
• Irrigate wounds and cover with a water-resistant dressing BEFORE whole-body decontamination
• Internal contamination: catharsis, gastric lavage with chelating agents; survey urine, feces and vomitus; nasal and throat swabs; CBC with differential

Acute radiation syndrome (ARS)

• Determined by DOSE, not source: high dose (at least 100 rad), high rate, whole-body, penetrating radiation; age, history and genetics also matter
• Rapidly dividing cells are most affected

Table 68-8, phases:

• Prodromal: 48 to 72 hours after exposure; nausea, vomiting, anorexia, diarrhea, fatigue; high doses add fever, respiratory distress, excitability
• Latent: symptom-free, up to 3 weeks (shorter with higher doses); falling lymphocytes, leukocytes, platelets and RBCs
• Manifest illness: infection, fluid and electrolyte imbalance, bleeding, diarrhea, shock, altered consciousness
• Recovery (weeks to months) or death; increased ICP signals impending death

Systems:

• Hematopoietic: FIRST affected and the indicator of severity; absolute lymphocyte count at 48 hours predicts outcome; 300 to 1,200/mm3 indicates significant exposure. Neutrophils fall within 1 week, platelets within 2 weeks, RBCs within 3 weeks; hemorrhage, fever, sepsis; use barrier precautions
• GI: about 600 rad or more; nausea and vomiting within 2 hours; sepsis, fluid and electrolyte imbalance, opportunistic infection; HIGH FEVER with BLOODY DIARRHEA around day 10 is ominous
• CNS: over 1,000 rad; cerebral edema, nausea, vomiting, headache, increased ICP; irreversible; appears BEFORE hematopoietic or GI signs; cardiovascular collapse
• Skin: 600 to 1,000 rad causes erythema that may fade and return (check hourly); over 1,000 rad desquamation; over 5,000 rad necrosis within days to months

Survival categories (triage after decontamination):

• Probable: no or minimal symptoms (nausea, vomiting) that resolve within hours; draw a CBC and discharge with return instructions
• Possible: nausea and vomiting for 24 to 48 hours; latent period with leukopenia, thrombocytopenia, lymphopenia; protective isolation if lymphocytes under 1,200/mm3; blood products, infection prevention, nutrition
• Improbable: more than 800 rad whole-body penetrating; acute vomiting, bloody diarrhea, shock; ANY neurologic symptom suggests a lethal dose. Still decontaminate (protect others); may be alert at first; in an MCI triage BLACK (comfort and emotional support); otherwise aggressive fluids and electrolytes

Combined trauma and radiation raises mortality: primary trauma survey first; do all definitive treatment within the first 48 hours; then delay surgery 2 to 3 months (poor wound healing, opportunistic infection).

High-Yield Numbers

• Communities self-sufficient up to 5 days; hospitals at least 96 hours (ideally 7 days); DMATs self-sufficient 72 hours
• Joint Commission: drills at least twice a year
• Deaths within 72 hours of admission in a cluster suggest a deliberate release or outbreak
• N95 filters at least 95% of particles
• Red: burns 15% to 40% TBSA; Black: burns over 60% TBSA
• Hypothermia in water at 75 F (23.9 C) or below
• Walking wounded may present 5 days to 2 weeks later
• TM rupture: most frequent blast injury; 5% need hearing aids
• Head injuries: about 30% vascular
• Anthrax incubation: cutaneous 5 to 7 days, GI 1 to 6, inhalation 1 to 43 (up to 60); treat or prophylax 60 days; antibiotics within 24 hours of exposure
• Smallpox: incubation 7 to 17 days; vaccinate contacts within 4 days; isolate if 101 F within 17 days; variola major 30% fatal
• Botulism antitoxin: 2% anaphylaxis; mortality 5%
• Plague: treat within 12 to 24 hours; pneumonic 100% fatal if untreated in 24 hours; contacts within 2 m get doxycycline 7 days
• Tularemia: inhalation treated within 48 hours; exposed get 14 days
• Nerve agent decontamination 8 to 20 minutes; atropine 2 to 4 mg IV then 2 mg every 3 to 8 minutes; pralidoxime 1 to 2 g over 15 to 30 minutes
• Vesicants: vesicles 2 to 18 hours; monitor sulfur mustard 24 hours
• Radiation: 1 rem = 1,000 mrem; natural 360 mrem/year; ARS at least 100 rad; GI at 600 rad; CNS over 1,000 rad; improbable survival over 800 rad
• Lymphocytes 300 to 1,200 at 48 hours = significant exposure; isolate under 1,200
• Neutrophils fall in 1 week, platelets 2 weeks, RBCs 3 weeks
• Trauma plus radiation: definitive care within 48 hours, then delay surgery 2 to 3 months

Priority Nursing Actions and Red Flags

• Disaster triage: greatest good for the greatest number; expectant (black) patients are separated and comforted, not abandoned
• Don PPE before contact; Level D is not enough for contaminated patients; never assume field decontamination was complete
• Decontaminate before entry: remove clothing (removes most contamination), rinse, then soap-and-water wash
• Radiation: treat life threats FIRST, then limit exposure, control contamination, decontaminate; time, distance, shielding
• Externally irradiated patients are not radioactive
• Chemical exposure: stand up and move to fresh air (most agents are heavier than air)
• Nerve agent: miosis, secretions, bradycardia, fasciculations; atropine until secretions dry; blot, do not wipe; no plastic airways
• Cyanide: bitter almonds, bright red skin; do not induce methemoglobin after smoke inhalation; hydroxocobalamin turns skin and urine red
• Vesicants: soap and water, blot; no scrubbing or bleach
• Botulism: descending flaccid paralysis in an alert, afebrile patient; watch airway; no aminoglycosides
• Inhalation anthrax: flulike illness without runny nose, then widened mediastinum; not contagious
• Smallpox: negative pressure, airborne plus contact; synchronous rash starting on the face and arms
• Pneumonic plague: droplet transmission, mask the patient
• Blast: suspect hidden internal injuries; air embolus means prone, left lateral and hyperbaric oxygen
• Any neurologic symptoms after radiation suggest a lethal dose
• Media: no casualty information; families in a separate supported area
• Watch staff and victims for stress reactions; CISM

Medications

Related

• nsg210-hinkle-ch19-chest-lower-respiratory-disorders (ARDS, chest trauma, chest tubes)
• nsg210-hinkle-ch12-oncologic-management (radiation safety)
• INDEX