Disaster Nursing and Bioterrorism

1
Disaster Nursing and Bioterrorism

• Tony Keith, RN
• Emergency Management and Disaster Preparedness
  Coordinator
• Presbyterian Hospital Matthews

2
Disaster Nursing and Bioterrorism

• History of US Terrorism
• Weapons of Mass Destruction
• Hospital Preparedness
• PPE
• Disaster Nursing Opportunities

3
US Terrorism History

• 1984 Dalles, Oregon 751 confirmed cases of
  Salmonella Typhimurium- 1st use of germ warfare
  on US soil
• 1993 - World Trade Center bombing kills 6,
  injures 1,000
• 1995 - Oklahoma City Bombing kills 168, 759
  injuries
• 1996 - Khobar Towers bomb kills 19
• 1996 - Centennial Park bomb
• 1997 - Clinic, night club first use of
  secondary devices

4
US Terrorism History

• 1999 Columbine High School- 14 deaths
• 2001 World Trade Center Towers and Pentagon
  death toll 3000 casualties
• 2001- Anthrax- Began 7 days after 9/11, killing 5
  and infected 17
• 2002- Beltway Sniper- Killed 10 and critically
  injuring 3 others

5
WTC 1993

• This explosion resulted in six deaths
• Over 1,000 victims were treated on scene
• There were 384 victims treated in area hospitals
• There were 105 firefighters injured five
  admitted to hospitals
• There were multiple responder disciplines present
  at the incident

6
Oklahoma City

• April 19th 1995
• 13 55 gallon barrels of ANFO (5000 lbs)
• 168 casualties (19 children)
• Over 800 injuries
• Blast felt 55 miles away
• Measured a 3.0 on the Richter Scale

7
Remember 9/11?

• 2974 Fatalities
• 246 on four planes
• 2603 in NYC in Twin Towers and on ground
• 125 at Pentagon
• Over 90 countries lost citizens in World Trade
  Center attack

8
Hurricaine Katrina

• August 2005
• Category 5 Storm
• 175 mph winds
• Flooded 80 of New Orleans for weeks
• 1836 people died
• Most expensive storm in US history

9
Midwest Floods

• June-July 2008
• Flooded Wisconsin, Iowa, Indiana, Illinois,
  Michigan, Minnisota, and Missouri
• 13 deaths
• Over 6 Billions in damages

10
New Beginnings

• 9/11 was the catalyst to begin preparedness in
  United States
• Department of Homeland Security November 2002
• Nation recognized that it was not truly prepared
• TJC creates a new CHAPTER for Emergency
  Management - 2009

11
The NBC Threat
Nuclear Biological Chemical Explosive and
Incendiary Devices
12
Biological Agents

• Define bacteria, virus, and toxins
• Describe Bacteria as used as WMD along with
  signs/symptoms and treatment.
• Describe Virus as used as WMD along with
  signs/symptoms and treatment.
• Describe Toxins as used as WMD along with
  signs/symptoms and treatment.

13
Biological Agents

• Bacteria a single celled organism that causes
  different diseases in plants, animals, and
  humans.
• Virus- smaller than bacteria, and uses the
  reproductive mechanism of host cells to create
  many more viruss.
• Toxins The byproduct produced by almost all
  living creatures, usually potent poisons.

14
Anthrax

• Bacillus Anthracis
• Gram spore forming bacteria
• Known as Woolsorters disease.
• Naturally occurring disease
• Solid fine particle dust
• Inhalation, absorption, ingestion, and injection
  hazard.
• Not transmitted through human contact, with the
  exception of cutaneous Anthrax.
• Can survive heat up to 318 degrees Fahrenheit.
• Can live in soil or water for decades.

15
Anthrax

• Cutaneous Anthrax
• Incubation period from 1-10 days
• Lesions usually present on forearms, chest neck
  and fingers.
• Usually from direct contact of contaminated
  hides, wools, or tissue.
• Painless, but can have tingling and/or itching
  sensation.
• Diagnosis is made by culture or biopsy.
• Untreated mortality rate 20. Only 1 with
  antibiotic treatment.

16
Anthrax
17
Anthrax

• Inhalation Anthrax
• Incubation period of 6 days.
• Fever, body aches, fatigue, and cough.
• Patients may show brief signs of improvement
  followed by acute onset of respiratory distress
  leading to death in 24-36hrs.
• Chest X-Ray shows widened mediastinum.
• Untreated mortality rate 95, and 75 with
  antibiotic treatment.

18
Anthrax - Treatment

• ABCs
• Usually a combination of the following
• Ciprofloxacin
• Tetracycline
• Penicillin
• Antibiotic treatment last for at least 60 days
• Prophylaxis treatment also last for 60 days for
  uninfected, but exposed population.
• Vaccination is available

19
Plague

• Yersenia Pestis
• Gram - Rod
• Known as the Black Death.
• Naturally occurring.
• Aerosol
• Inhalation, ingestion, and injection hazard.
• Easily destroyed by sunlight and drying, living
  only 1 hour depending on the environment.
• Responsible for killing 1/3 of Europes
  population in the 14th century.
• No vaccine available.

20
Plague

• Bubonic Plague
• Is transmitted from bites from rodent fleas that
  are carrying bacteria, or handling an infected
  animal.
• Travels through lymphatic system.
• Incubation period of 2-10 days.
• Symptoms include tender lymph nodes called
  buboes, malaise, and fever.
• Not contagious in person to person contact.
• May progress to septicemia and progress to
  pneumonic plague.

21
Plague

• Pneumonic Plague
• Can be transmitted from inhalation of the
  organism, or from septicemic form of disease.
• Incubation is 1-6 days.
• Symptoms include fever, chills, vomiting blood,
  and difficulty breathing, hemorrhagic pneumonia,
  toxemia, circulatory collapse, and death.
• Is highly contagious in person to person contact.
  
• Mortality rate of untreated pneumonic plague is
  90-100.

22
Plague - Treatment

• ABCs
• Self protection (PPE)
• Mortality decreases when antibiotics are given
  within the first 24 hours.
• Antibiotics of choice are
• Streptomycin
• Gentamycin
• Chloramphenicol
• Tetracycline
• 7 day antibiotic prophylaxis post exposure.

23
Smallpox

• Variola major
• Aerosol dissemination
• No longer naturally occurring, due to vaccination
  programs.
• Inhalation hazard.
• Very contagious with person to person contact.
• Usually prolonged direct face to face contact
  needed for transmission.
• Spread through infected bodily fluids or
  contaminated clothing, or bedding.
• Incubation period 7-17 days.
• Vaccine is available.

24
Smallpox

• Incubation Period
• Pre-eruptive Stage
• Macules
• Papules
• Vesicles
• Pustules
• Scabs
• Scars

25
Smallpox

• Incubation Period
• Average incubation period is 10-14 days
• This is the time between the exposure until the
  onset of symptoms.

26
Smallpox

• Pre-eruptive Period
• Fever
• Chills
• Headache
• Back Pain
• Sore Throat
• Vomiting
• Diarrhea
• Pts are infectious during this stage

27
Smallpox

• Macules
• Small red spots
• Lesions form on face and forehead, known as
  Herald Spots.
• Spreads to extremities
• Last 1-2 days

28
Smallpox

• Papules
• Rash is raised above skin
• Fluid begins to accumulate in rash.

29
Smallpox

• Vesicles
• Fluid continues to accumulate.
• Fluid changes from clear to cloudy in about 2
  days.

30
Smallpox

• Pustules
• Become filled with pus
• Takes about 4 days to reach its maximum size
• Feels like hard peas under skin
• When fluid starts to absorb, pustule becomes
  flat.

31
Smallpox

• Scab
• Scabs for when fluid is absorbed.
• Pt is infectious until last scab falls off.
• May take 2-3 weeks for process to occur.

32
Smallpox

• Recovery is typical with a mortality rate of
  usually 30.
• No approved treatment.
• After recovery a person is left with permanent
  scars.
• Some are left blind.

33
Smallpox - Treatment

• Vaccination prior to outbreak
• IV fluids
• Supportive treament
• Antibiotics for secondary infections.
• Post-exposure quarantine for at least 17 days.
• Research is being done on anti-viral agents to
  fight the virus.

34
Smallpox vs. Chickenpox
35
Smallpox vs. Chickenpox

• During the first day or two of rash it may be
  impossible, from the rash alone, to differentiate
  smallpox from chickenpox.
• Was there prior fever?
• Vaccination? (If so, when?)

36
Smallpox vs. Chickenpox

• Day 5
• Smallpox lesions
• Same stage of development.
• Uniformly larger (5-10 mm.)
• Pustules firm and deeply
• embedded.
• Chickenpox lesions
• Several different stages of rash.
• Small (1 - 5 mm)
• Superficial.

37
Smallpox vs. Chickenpox

• Day 7
• Smallpox scabs have not yet formed.
• Chickenpox lesions have already formed scabs and
  some have already separated.

38
Smallpox vs. Chickenpox
39
Smallpox vs. Chickenpox

• The relative density of rash on different parts
  of the body should be carefully observed.
• Left slide Smallpox
• Right slide Chickenpox

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Smallpox vs. Chickenpox

• Palms
• Chickenpox
• Smallpox

41
Smallpox vs. Chickenpox

• Soles
• Smallpox
• Chickenpox

42
Soviet Smallpox Storage Facility
43
Botulism

• Neurotoxin produced by Clostridium botulinum -
  Botulism
• Most lethal compound per weight (15,000 times
  more toxic than the nerve agent VX)
• Similar effects whether inhaled or ingested
• Descending paralysis
• Blocks the release of acetylcholine at 3 places
  in the presynaptic terminal of the neuromuscular
  junction and autonomic nervous system
• Bulbar palsies and skeletal muscle weakness

44
Botulism

• Bulbar palsies
• blurred vision
• mydriasis
• diplopia
• ptosis
• photophobia
• dysphagia
• dysarthria

Floppy Baby Flaccid Paralysis
45
Botulism

• Routes of entry ingestion, inhalations, and
  injection
• Found in improperly canned vegetables
• During Persian Gulf War, Iraq filled bombs with
  Botulism toxin (19,000 liters)
• Would have killed the current world population 3
  times

46
Botulism - Treatment

• Supportive - long-term mechanical ventilation
• Several antitoxins are available and effective if
  administered early (but associated with numerous
  adverse effects)
• CDC vaccine good only for A and B

47
Ricin

• In 1978, a Bulgarian exile was shot with the end
  of a device, disguised as an umbrella, which was
  packed with ricin (few hundred millionths of a
  gram). He died 4 days later.

48
Ricin

• Ricinus Communis
• Potent cytotoxin - a by-product of castor oil
  production
• Over a million tons of castor beans are processed
  yearly into castor oil
• 200 times more toxic per weight than VX
• Blocks protein synthesis within the cell and
  causes airway necrosis and edema when inhaled

49
Ricin

• Toxic by multiple routes of exposure
• Can be dispersed as an aerosol
• Effective orally and by injection
• Ricin poisoning is not contagious. It cannot be
  spread from person to person through casual
  contact

50
Ricin

• Fever, chest tightness, cough, SOB, nausea, and
  joint pain 4 to 8 hours after inhalation
• Airway necrosis and edema leads to death in 36 to
  72 hours
• Ingestion causes N,V, severe diarrhea, GI
  hemorrhage, and necrosis of the liver, spleen,
  and kidneys - shock and death within 3 days
• Injection causes marked necrosis of muscles and
  lymph nodes with multiple organ failure leading
  to death

51
Ricin - Treatment

• ABCs
• Early Intubation
• Supportive - oxygenation and hydration
• No antitoxin or vaccine available

52
Ricin

• Mammalian lungs exposed to aerosolized ricin
• Lungs are edematous with accompanying hemorrhage
  and necrosis

53
Chemical Agents
54
Cyanide

• 2 types Hydrogen cyanide (AC) and Cyanogen
  Chloride (CK)
• Used in metallurgy, photography, electroplating,
  and is a byproduct of burning plastics
• Transported in 30,000 gallon tanks by rail car
• Can be liquid or gas
• Can range from lighter than air (AC) to
  significantly heavier than air (CK)
• Inhalation hazard
• Bitter almond or peach pits

55
Cyanide

• Cyanide blocks the oxygen transfer in body
  causing cell death.
• Blood remains fully oxygenated. This causes
  Cherry Red Skin.
• Oxymetry will not work with these patients, due
  to oxygen rich blood.
• Similar to carbon monoxide poisoning

56
Cyanide

• Remove from source
• Cyanide Antidote Kit (Sodium Thiosulfate, Amyl
  Nitrite, Sodium Nitrite)
• O2
• Hyperventilate
• IV Fluids

57
Mustard
58
Mustard

• 2 types Sulfur Mustard(HD), Nitrogen
  Mustard(HN).
• Nitrogen mustard was one of the first
  chemotherapy agents
• Not commercially available. It has to be made
• Liquid or Vapor
• Heavier than air
• Persistent with an oil consistency
• Inhalation, ingestion, and absorption hazard
• Onion, garlic, and/or horseradish odor
• Will penetrate leather, wood, rubber, and plants

59
Mustard

• Does not cause immediate symptoms
• Destroys DNA by binding with proteins
• Chemical damage in 1-2 minutes
• Observable damage from 2-48 hrs
• Symptoms include cough, sore throat, nausea,
  vomiting, severe itching, erythema to skin,
  blisters/bulla, corneal opacification,
  ulceration, and/or perforation.

60
Mustard
61
Mustard - Treatment

• Early skin decontamination
• Removal of clothes
• Flush skin
• Frequent skin irrigation
• Antibiotics (skin and eye)
• Mydriatics
• Steroids (eye)
• DO NOT OVER-HYDRATE! (Not a thermal burn)
• Intubation if needed

62
Nerve Agents

• Saddam Hussein authorized a release of a
  cocktail of Mustard, Nerve, and Blood agents on
  60,000 evacuating Kurds.
• 5000 casualties
• Mostly women and children

63
Nerve Agents

• Tabun(GA), Sarin(GB), Soman(GD), and VX
• Not commercially available
• Liquid or vapor
• Heavier than air
• Can range from non-persistent (Sarin) to very
  persistent (VX).
• Inhalation and absorption hazard
• Fruity (Tabun), Sweet (Sarin), Camphor (Soman),
  and Odorless (VX).

64
Nerve Agent

• Similar to pesticides in how they work
• Act at the nerve receptor junction or synapse.
• Nerve agent blocks the uptake of ACh at receptor
• Causes over stimulation of nerves at receptor
  site
• Acts on nicotinic and muscarinic receptors.
• Blocks AChE from ending the nerve transmission

65
Nerve Agent

• Muscarinic Symptoms
• Salivation
• Lacrimation
• Urination
• Defecation
• Gastric Distress
• Emesis
• Miosis (Most Reliable)
• Killer Bs Bradycardia, Bronchorrhea,
  Bronchospasms

• Nicotinic Symptoms
• Mydriasis
• Tachycardia
• Weakness
• Hypertension, Hyperglycemia
• Fasciculation's

66
Nerve Agent

• CNS Symptoms
• Confusion
• Convulsions
• Coma

67
Nerve Agent Treatment

• Self Protection
• Removal of clothes
• Decontamination
• Airway management
• 2- Pam Nicotinic Symptoms
• Atropine Muscarinic Symptoms
• Diazepam - Seizures

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Hospital Preparedness

• Emergency Management Committees at PHC/POH, PHM,
  PHH
• Emergency Management Coordinators at PHC/POH,
  PHM, and position posted at PHH for 2009
• Disaster Trailer
• Mass Casualty cabinet
• Hospital Incident Command System
• Departmental Emergency Planning

69
Hospital Preparedness

• Hazard Vulnerability Analysis
• Emergency Operations Plan (EOP)
• Alternate Care Facilities
• Redundant Communications
• Decontamination Team
• Decontamination Tent/Supplies
• Chempack

70
Hospital Preparedness

• Coordination with Police, Fire, EMS, and County
  Emergency Management
• Yearly Disaster Drills

71
PPE

• Level C Tyvex/Tychem suits
• 3M Breatheasy PAPR
• Butyl Rubber Boots
• Butyl Rubber Outer Gloves
• Nitrile Inner Gloves

72
Disaster Nursing

• SORT
• SMAT
• American Red Cross
• Hospital Disaster Team
• NDMS
• MMRS
• CERT
• Volunteer for Disaster Drills as Nursing
  Students!!!!!!!