SECTION V. DISASTER PREPAREDNESS AND RESPONSE
Natural and man-made disasters occur around the world on a frequent basis. The Department of Homeland Security (2016) and the Centers for Disease Control and Prevention (CDC; 2016a) provide current and valuable resources for a wide variety of diseases, emergencies, and disasters that impact patient care, including outbreaks, incidents, natural disasters and severe weather, chemical and radiation emergencies, and bioterrorism. Although beyond the scope of this text to address all aspects of both natural and man-made disasters, this section focuses on content that is more challenging to locate, such as pediatric preparedness for mass casualty incidents (MCIs) and specific information on terrorism, including violent incidents, nuclear or radiologic attacks, chemical attacks, biological attacks, and the psychological impact. More information regarding patient management of pediatric victims of multiple trauma is located in the “Multiple Trauma” section in this chapter.
In the past 15 years, terrorism has unfortunately become an increasingly real threat to the citizens of the United States. During 2016, numerous terrorist acts in various states impacted several hospitals because of the number of victims brought to these hospitals. Terrorism by definition is the unlawful use of force or violence against persons or property to intimidate civilians or to coerce a government or a civilian population in the furtherance of political and social objectives and to effect the conduct of a government by mass destruction, assassination, or kidnapping (Federal Bureau of Investigation [FBI], 1992). Because the scale of a terrorist attack can be often widespread, this type of disaster can be overwhelming to a nation’s healthcare system.
A report to the Congressional Committee from the U.S. General Accounting Office (GAO) regarding hospital preparedness for a bioterrorist incident was published in August 2003. This report stated that although most urban hospitals nationwide reported participating in basic planning and coordination of activities for bioterrorism response, they did not have the medical equipment, especially ventilators, needed to handle the number of patients who would likely require medical attention as the result of a bioterrorism incident. Four of five hospitals reported having a written emergency response plan that addresses bioterrorism; however, many hospitals lacked key resources, such as laboratories. Many reported being involved in state or local planning and had conducted some training of staff members; however, few had actually conducted drills to prepare for a bioterrorist attack. Most hospitals admitted a lack of preparedness, particularly in terms of having adequate resources to handle a large influx of patients (GAO, 2003). A similar governmental study has not been done to address the overall hospital preparedness since then, but in 2002 the Hospital Preparedness Program (HPP) was established through the Office of Assistant Secretary for Preparedness and Response (ASPR), which has given funding to 62 awardees, including all states and several major cities and counties to strengthen hospital preparedness (ASPR, 2016). This program took a few years to develop fully and some of this funding still exists. The goal of this program was to improve patient outcomes, minimize the need for supplemental state and federal resources, and enable rapid disaster response recovery. The hospitals that receive funding have several deliverables to sustain their operation in a real disaster, including supplies, equipment, education, pharmaceuticals, and personnel to address whatever disaster they may have. Numerous groups have looked at the needs of pediatric patients and make suggestions to identify their needs specifically, including the report by the National Advisory Committee on Children and Disasters (NACCD; 2015) and the Pediatric Mass Critical Care Task Force (Kissoon, 2011). In addition, numerous resources have been published specific to pediatric response (Foltin, Schonfeld, & Shannon, 2006; Bradley et al., 2014; Hamele, Poss, & Sweeney, 2014). The following website has an archived list of many of the studies and reports regarding pediatric disaster preparedness: ncdp.columbia.edu/library/publications.
A. Besides being generally unprepared to deal with a large-scale attack, most hospitals are specifically unprepared to care for pediatric patients. State and federal plans historically have not included provisions for pediatric patients, although that is changing. Children have unique needs for which adult models cannot be adapted easily, because these models were based around military models that did not include 828children. In February 2003, a National Consensus Conference was convened to address pediatric preparedness for disasters and terrorism. The conference was funded by grants from the Agency for Healthcare Research and Quality (AHRQ) and the Emergency Medical Services for Children (EMSC) program of the Maternal and Child Health Bureau and sponsored by the Program for Pediatric Preparedness of the National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, the Children’s Health Fund, and the Children’s Hospital at Montefiore (Markenson & Redlener, 2003). Since that time, several other groups have been convened and resources have been developed specifically for pediatric patients.
B. Several special pediatric considerations in terrorism and disaster preparedness have been identified:
1. Children are more vulnerable to chemical agents that are absorbed through the skin or inhaled.
2. Children are especially susceptible to dehydration and shock from a biological attack.
3. Children cannot be decontaminated in adult decontamination units because of their unique needs.
4. Children require different dosages, antibiotics, and antidotes to many agents.
5. Children are more susceptible to the effects of radiation exposure and require responses that are different from those required by adults.
6. Because they have unique psychosocial vulnerabilities, children require special management plans in the event of mass casualties and evacuation.
7. Emergency responders, medical professionals, and children’s healthcare institutions require special expertise and training to ensure optimal care of those exposed to chemical, biological, or nuclear agents.
8. Children’s developmental ability and cognitive levels may impede their ability to escape danger.
9. EMS and medical and hospital staff may not have pediatric training, equipment, or facilities (Markenson & Redlener, 2003).
C. Since that conference, several groups have developed resources, but the one most relevant to the pediatric critical care nurses is the Pediatric Mass Critical Care Task Force project that implemented recommendations that were specific to pediatric patients:
1. Treatment and triage recommendations
2. Supplies and equipment
3. Neonatal and pediatric regionalized recommendations
5. The role of community preparedness in conserving critical care resources
6. Legal considerations
7. Focus on family-centered care
8. Ethical issues (Kissoon, 2011)
D. The following recommendations were made by the National Advisory Committee on Children and Terrorism:
1. All planning and training mechanisms must specifically include elements that focus on the needs of infants, children, and adolescents.
2. Direct attention will be addressed to settings where children normally gather.
3. Coordination and integration response efforts must be made at all levels of government.
4. In the event of an incident, priority will be given to returning children to their normal routine (National Advisory Committee on Children and Terrorism, 2003).
E. In 2006, a group was convened to address pediatric terrorism and disaster preparedness that was sponsored by the AAP and the AHRQ. The resource that was developed by this workgroup is very extensive and addresses not only the physical differences between children and adults, but also addresses all of the recommendations for treating nuclear, biological, and chemical terrorism (Foltin et al., 2006).
TYPES OF TERRORISM
Terrorism exists in a variety of forms:
• Violence, explosions, and hijackings
• Nuclear or radiologic attacks
829• Chemical attacks
• Biological attacks
A. Violence (Including Active Shooters), Explosions, and Hijackings
1. The United States has an organized trauma system to deal with small-scale violence or explosions, but is not prepared for large-scale attacks. It is important that we become better prepared to deal with large-scale emergencies. In the past, attacks within the United States, including the Oklahoma City bombing, the Columbine High School shootings, and the shootings at the Jewish Community Center in Granada Hills, California, have overwhelmed EDs and pediatric critical care centers. The Sandy Hook Elementary School shooting could have also overwhelmed the system, but unfortunately there were few survivors.
2. MCIs require that patients be assessed and triaged quickly but comprehensively. An MCI is characterized by an influx of large numbers of casualties that exceed the capabilities of local emergency and medical personnel. Nurses perform the primary and secondary survey, as with any other trauma patient. Tables 9.32 and 9.33 list the assessment components of the pediatric trauma patient.
Assess for patency; look for loose teeth, vomitus, or other obstruction; note position of head.
Suspect cervical spine injury with multiple trauma; maintain neutral alignment during assessment; evaluate effectiveness of cervical collar, cervical immobilization device, or other equipment used to immobilize the spine.
Open cervical collar to evaluate neck for jugular vein distention and tracheal deviation.
Auscultate breath sounds in the axillae for presence and equality.
Assess chest for contusions, penetrating wounds, abrasions, or paradoxic movement.
Assess apical pulse for rate, rhythm, and quality; compare apical and peripheral pulses for quality and equality.
Evaluate capillary refill; normal is less than 2 seconds.
Check skin color and temperature.
Assess level of consciousness; check for orientation to person, place, and time in the older child.
In a younger child, assess alertness, ability to interact with environment, and ability to follow commands. Is the child easily consoled and interested in the environment? Does the child recognize a familiar object and respond when you speak to him or her?
Check pupils for size, shape, reactivity, and equality.
Note open wounds or uncontrolled bleeding.
Remove clothing to allow visual inspection of entire body.
Head, eye, ear, nose
Assess scalp for lacerations or open wounds; palpate for step-off defects, depressions, hematomas, and pain.
Reassess pupils for size, reactivity, equality, and extraocular movements; ask the child whether he or she can see.
Assess ears and nose for rhinorrhea or otorrhea.
Observe for raccoon eyes (bruising around the eyes) or Battle’s sign (bruising over the mastoid process).
Palpate forehead, orbits, maxilla, and mandible for crepitus, deformities, step-off defect, pain, and stability; evaluate malocclusion by asking child to open and close mouth; note open wounds.
Inspect for loose, broken, or chipped teeth as well as oral lacerations.
Check orthodontic appliances for stability.
Evaluate facial symmetry by asking child to smile, grimace, and open and close mouth.
Do not remove impaled objects or foreign objects.
Open cervical collar and reassess anterior neck for jugular vein distention and tracheal deviation; note bruising, edema, open wounds, pain, and crepitus.
Check for hoarseness or changes in voice by asking child to speak.
Obtain respiratory rate; reassess breath sounds in anterior lobes for equality.
Palpate chest wall and sternum for pain, tenderness, and crepitus.
Observe inspiration and expiration for symmetry or paradoxic movement; note use of accessory muscles.
Reassess apical heart rate for rate, rhythm, and clarity.
Observe abdomen for bruising and distention; auscultate bowel sounds briefly in all four quadrants; palpate abdomen gently for tenderness; assess pelvis for tenderness and stability.
Palpate bladder for distention and tenderness; check urinary meatus for signs of injury or bleeding; note priapism and genital trauma such as lacerations or foreign body.
Have rectal sphincter tone assessed, usually by physician.
Assess extremities for deformities, swelling, lacerations, or other injuries.
Palpate distal pulses for equality, rate, and rhythm; compare to central pulses.
Ask child to wiggle toes and fingers; evaluate strength through hand grips and foot flexion/extension.
Logroll as a unit to inspect back; maintain spinal alignment during examination; observe for bruising and open wounds; palpate each vertebral body for tenderness, pain, deformity, and stability; assess flank area for bruising and tenderness.
3. As patients go through triage, they are sent to the appropriate level of care. The JumpSTART triage model is a model that can be used to triage pediatric patients during mass casualty events. (More information about this triage model can be obtained by visiting www.jumpstarttriage.com.) This differs from the START model, which is adult based, that is traditionally used in an MCI event.
4. In preparing for MCIs, it is important to have the appropriate size and amount of emergency medication, supplies, and equipment. Many new documents related to MCIs in pediatrics have been published, but much more work needs to be done to handle large-scale disasters involving pediatric patients. One crucial step is to ensure that pediatric patients can be placed in a PICU that can take care of pediatric trauma patients as quickly as possible and that the PICU nurses know how to treat victims of weapons of mass destruction. The Pediatric Mass Critical Care Task Force recommended that hospitals prepare to care for patients for at least 10 days and have equipment such as ventilators and ventilation equipment; intravenous fluids; and equipment, sedation, and items to reduce cold stress (Bohn, Kanter, Burns, Barfield, & Kissoon, 2011).
5. Trauma injuries would result from some type of blast injury, given that explosions and bombings are often the weapons of choice for terrorists. Such injuries can result from either primary, secondary, and tertiary blasts. These were the types of injuries seen in the children during the Boston marathon bombing (Biddinger et al., 2013).
a. Primary blast injuries are the result of sudden changes in atmospheric pressure caused by an explosion. The following are examples of primary blast injuries:
i. Ear injuries (e.g., perforated eardrums)
ii. Pulmonary injuries, including hemorrhagic contusion and hemopneumothorax
iii. Gastrointestinal hemorrhage, bowel perforation, or rupture
b. Secondary blast injury occurs when victims are struck by flying objects and debris.
c. Tertiary blast injuries occur when the body is hurled through the air and struck by another object.
B. Nuclear/Radiologic Attacks
1. The threat of nuclear attack was more of an issue before the end of the Cold War. Radiation accidents/attacks can arise from problems with nuclear reactors, industrial sources, and medical sources. 831It is important that clinicians understand how such an attack can occur and how to treat patients affected by it. Medical consequences depend on the type of device used. A radiologic or nuclear attack occurs in one of five ways:
a. Simple radiological device (SRD). Use of an SRD is a deliberate act of spreading radioactive material without the use of an explosive device, such as putting a high-activity radioactive isotope in a public place, exposing numerous individuals to various levels of radiation.
b. Radiologic dispersal device (RDD). This type of device is formed by combining an explosive agent with radioactive materials that might have been stolen. The initial explosion kills or injures those closest to the bomb, and radioactive substances remain to expose and contaminate survivors and possibly emergency responders. This is also known as a dirty bomb. This material is common to labs, medical centers, and used in industry. This is the most common type of exposure (CDC, 2014).
c. Nuclear reactor sabotage. This type of incident is uncommon because of sophisticated shielding but could occur with an attack on a nuclear reactor. In addition, no one is known to survive whole-body doses of radiation exceeding about 8 Gy. Acute radiation system results from this type of exposure and care is general supportive care. Because the body retains radioactive materials after death, cremation should be avoided in these patients to avoid vaporizing the radioactive material (CDC, 2014). These patients may receive a bone marrow transplant that may prolong their life for a few months.
d. Improvised nuclear device (IND). An IND is a device designed to cause a nuclear detonation; it is an RDD. Because it is difficult to detonate such a weapon correctly, this type of incident is uncommon; a high level of sophistication is required to engineer it, but a stolen device would generate high levels of radiation.
2. There are two categories of radiation incidents:
a. External exposure, which is irradiation from a source that is either distant or close to the body. External irradiation can be divided into whole-body exposure or local exposure.
b. Contamination, which is defined as unwanted radioactive material in or on the body (ACR, 2002).
3. Response is based on the type of incident. Most external exposures result in irradiation of the victim. A person exposed to external radiation does not become radioactive and poses no hazard to nearby individuals. Once the victim is removed from the source of radiation, the irradiation ceases.
4. Contamination incidents require a different approach. Caregivers and support personnel must be careful not to spread the contamination to uncontaminated parts of the victim’s body, to themselves, or to the surrounding area. Internal contamination can result from inhalation, ingestion, direct absorption through the skin, or penetration of radioactive materials through open wounds (Yu, 2003). Treatment of serious or significant medical conditions should always take precedence over radiologic assessment or decontamination of the patient.
5. Treatment of patients of a radiologic attack involves the following priorities:
a. Treat and stabilize life-threatening injuries. A radiologic assessment should be performed by an individual with radiologic health training. Radiologic measurements can be done using a Geiger counter and swabs containing blood fluid can be sent to the lab for measurement.
b. Prevent and minimize internal contamination. Time is critical to prevent radioactive uptake. Potassium iodide (KI) is administered to prevent radioiodine from accumulating in the thyroid gland. The pediatric dose of KI is listed in Table 9.34. KI should be given within 2 hours of contamination.
c. Assess internal contamination and decontamination. Patients who are contaminated but not seriously injured should be decontaminated before they are treated.
d. Contain contamination and decontamination.
e. Minimize external contamination to medical personnel. Staff should wear personal protective clothing and, if the area is highly contaminated, respirators should be worn.
f. Assess internal contamination (concurrent with the preceding).
g. Assess local radiation injuries and burns and flush if they are contaminated.
h. Follow up on patients with significant whole-body irradiation or internal contamination.
Exposure, Gy (rad)
KI Dosea (mg)
1 month–3 years
Pregnant or lactating women
KI, potassium iodide.
aChildren/adolescents weighing more than 70 kg should receive the adult dose (130 mg).
Note: This table was created from recommendations developed at the Consensus Conference and in part is based on reviewed reference materials from the American Academy of Pediatrics, Centers for Disease Control, and U.S. Food and Drug Administration.
Source: American Academy of Pediatrics. (2003). AAP policy statement: Radiation disasters and children. Pediatrics, 111(6), 1455–1466. Retrieved from pediatrics.aappublications.org/content/pediatrics/111/6/1455.full.pdf
C. Chemical Attacks
1. Chemical warfare agents are hazardous chemicals that have been designed for use by the military to irritate, incapacitate, injure, or kill during wartime (Foltin et al., 2006; Los Angeles County EMSA and Public Health, 2012). The sarin gas attacks in Japan in the mid-1990 resulted in few deaths, but the influx of contaminated patients to medical facilities was overwhelming to the medical system. Chemical attacks may be combined with explosions and blast attacks to make dirty bombs. To have chemical contamination associated with explosions, victims will be in close proximity to the explosion or blast attack. In these situations, casualties occur almost immediately and the attack is recognized right away. First responders need to be cautious as to not expose themselves (Foltin et al., 2006). Children are more vulnerable in these types of attacks because of their physiologic, developmental, and psychological differences.
2. Many nerve agents are transported on a daily basis by truck or rail cars in the United States. Potentially, tear gas, which is sold in stores, could be used in an attack. Chemicals can be absorbed through the eyes, skin, airways, or a combination of these routes.
3. The following are types of chemical agents:
a. Nerve agents are the most toxic of all weaponized military agents. They can cause sudden loss of consciousness, seizures, apnea, and death. The diagnosis is usually made on clinical signs and symptoms. Nerve agents inhibit cholinesterase. Examples of these agents are tabun, sarin, saman, and VX, a man-made chemical warfare agent that is very fast acting and very serious.
b. Vesicants cause blistering. The most common vesicants are sulfur, mustard, and lewisite. Mustard and lewisite cause injury to the eyes, skin, airways, and some internal organs.
c. Cyanide is a chemical agent that is widely used in the United States. Terrorists may use it in confined spaces such as subway cars, shopping centers, convention centers, and small buildings. Shortly after inhalation, victims often become anxious and start to hyperventilate. Convulsions, asystole, and death also can occur. Antidotes should be administered immediately.
d. Pulmonary intoxicants can cause severe life-threatening lung injury after inhalation. The effects are generally delayed for several hours. Examples are phosgene and chlorine. An example of this type of accident occurred at the Union Carbide plant in 1984 in Bhopal, India, which was due to an industrial accident (not to a terrorist attack). These intoxicants are irritating to the eyes and respiratory tract and can cause severe pulmonary edema of a noncardiac nature.
833e. Riot-control agents stimulate the lacrimal glands to produce tears and cause irritation to eyes, nose, mouth, skin, and respiratory tract. These are routinely used by police to control an out-of-control crowd or individual. The effect is immediate and lasts about 30 minutes. Examples of these agents are chloroacetophenone (Mace 7), OC (oleoresin capsicum or pepper spray), and adamsite or chlorobenzylidene malinonitrile (tear gas; Los Angeles County EMSA and Public Health, 2012; CDC, 2016a).
f. Antidotes for the aforementioned agents are listed in Table 9.35.
4. Decontamination Standards
a. Staff needs to be trained to decontaminate patients appropriately and the staff should have the appropriate personal protective equipment (PPE). Hospitals should have the equipment required to decontaminate victims.
834b. Decontamination shelters should have the following:
i. A water connection compatible with the facility’s water lines
ii. The ability to collect and contain large quantities of water
iii. Something to mix with the water to remove the chemicals
iv. Adequate lighting
v. Connection to electricity, whether plugged into the hospital or into a generator
vi. A conveyor system for nonambulatory patients
vii. Allowance for patient privacy
viii. Room for two or three personnel, preferably nonhealthcare providers
ix. Room for families in pediatric facilities. Parents may also require decontamination. Parents can also help with decontaminating their children (Hudson, Reilly, & Dulagh, 2003).
c. Special considerations must be made when decontaminating children. Because children might not be at a developmental level to understand what is going on, they may be uncooperative, even combative. Children are lower to the ground and so might be exposed to more of the contaminant; in addition, their large surface-to-volume ratio places them at higher risk of absorption and exposure to the contaminant. Removing clothing will help with decreasing exposure. Because of their size, a smaller dose may be lethal, so it is important to get them decontaminated as quickly as possible. Children are at a higher risk of thermoregulation and must be placed in a neutral thermal environment and out of the extreme heat or cold. It is important to keep the family unit together if possible so that parents can keep smaller children safe. If parents are not available, appropriate arrangements for supervision must be made.
d. A diagram of a decontamination trailer with all the preceding requirements is illustrated in Figure 9.13.
D. Biological Attacks
Biological warfare is a very real threat. In 1999, the Association of Professionals in Infection Control developed a template for hospitals to adopt when dealing with bioterrorism; this template is entitled the “Bioterrorism Readiness Plan: A Template for Healthcare Facilities” (Association for Professionals in Infection Control [APIC], 1999). A biological attack is called bioterrorism. Since this document was developed, there has been a strong focus on preparedness for this type of attack. In 2002, the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 was signed into law. This required facilities to register if they had selected agents. The most recent guidance on this Act can be found at www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/FoodDefense/ucm331957.htm.
Bioterrorism is defined as the deliberate release of microorganisms (bacteria, viruses, fungi, or toxins) into a community to produce death or disease or to poison humans, animals, or plants (Los Angeles County EMSA and Public Health, 2012). Biological weapons are often called the poor man’s bomb because they are relatively inexpensive to produce and disseminate. A bioterrorist attack is a real threat, as evidenced by the anthrax attacks in 2001, which resulted in 22 cases of anthrax exposure, five deaths, and a nation on high alert.
i. An acute infectious disease caused by Bacillus anthracis
ii. Some spores viable and infectious in soil for up to 50 years
iii. Found most frequently in sheep, goats, and cattle, but has been used as a biological weapon with serious consequences; considered a national security threat by the U.S. government and guidelines have been developed for pediatric clinical management (Bradley et al., 2014)
iv. Three types. Cutaneous, gastrointestinal, and pulmonary (usually based on the route of exposure); another new concern is injection anthrax, which has been described for drug abusers, but it is not something that is a real threat at this time; if left untreated, any form of anthrax can lead to serious complications, including hemorrhage, edema, necrosis, or even meningoencephalitis (Bradley et al., 2014)