Weapons of Mass Destruction

CHAPTER 40 Weapons of Mass Destruction

Bettina M. Stopford, RN, FAEN, PMP Wendy L. Colón, RN, BSN

General Strategy

National Preparedness

Regional and Local Preparedness

Specific Weapons of Mass Destruction

Biologic Agents

Bacillus anthracis (Anthrax)

Clostridium botulinum (Botulism)

Yersinia pestis (Bubonic, Septicemic, and Pneumonic Plague)

Francisella tularensis (Tularemia)

Filovirus, Arenavirus (Hemorrhagic Fevers)

Nuclear and Radiologic Weapons

Chemical Weapons

Pulmonary Agents: Phosgene, Chlorine, Anhydrous Ammonia

I. GENERAL STRATEGY

Because of the ongoing, credible threat of weapons of mass destruction (WMD) attacks, emergency nurses must be able to care for victims of weapons of mass destruction. Emergency personnel will have a direct, front-line role in the detection and treatment of this threat and therefore must be prepared to deal with possible patient contamination, infection, or injures from terrorist activities. Preparation for an all-hazards disaster event, such as an industrial accident or a natural hazard such as a hurricane, will assist emergency personnel in preparing for a WMD event, but a WMD event has certain characteristics that require special preparation. Preparedness includes an understanding of the location’s credible threat, the facility’s disaster plan, emergency personnel’s role, the plan of care of the contaminated patient and the infectious patient, methods of screening for a suspicious event, forensic evidence awareness and preservation, and specific knowledge of chemical, biologic, nuclear, radiologic and explosive event injury patterns and treatments. Additionally, a WMD event immediately elevates the local event to one of national significance, and emergency personnel must become familiar with their role in recognizing and reporting a suspicious event. First “receivers,” or facility-based medical personnel, may be the initial detectors of a suspicious event such as a rapidly emerging infectious disease from a bioterrorist release. Emergency personnel need to plan, train, and exercise frequently with their colleagues and with those from other agencies such as public safety, emergency medical services, public health, hazardous materials, public information, and emergency management. An integrated, practiced response is key to a community’s ability to be resilient in the face of a WMD event.

A. National Preparedness

1. The National Response Plan

In the case of an event of national significance, such as a WMD event, the National Response Plan (NRP) will be activated to provide support to local and state response agencies (see Chapter 39)

a. National pharmaceutical stockpile

1) Developed by Centers for Disease Control and Prevention (CDC)

2) One asset in the NRP

3) Strategically located around the United States

4) Provides large supplies of antibiotics, chemical antidotes, and medical supplies

5) Published timeline arrival to state-receiving location is less than 12 hours

6) Access through local to state emergency management or public health agencies

7) States and high-risk jurisdictions often have additional local or state stockpiles

8) Prior to requesting stockpile assets

a) Identify immediately available supplies

b) Calculate number of patients needing medications and treatment

c) Estimate projected needs, overtime requirements

d) Integrate preplanning with local public health

9) Facility must be prepared for autonomous services for up to 5 days

10) Facility recommendations include stockpiling prophylactic medications or treatment for personnel and immediate family members

2. Surveillance and notification programs

a. Global Outbreak Alert and Response Network (GOARN), World Health Organization (WHO) and many other health intelligence networks, which collect and communicate medical surveillance data

b. The United States has multiple, integrated surveillance systems that include public health epidemiologists, medical practitioners, electronic records, ambulance call volumes, pharmaceutical sales patterns, presenting diagnoses and illness patterns, school surveillance, and laboratory culture reports

c. Emergency nursing role in surveillance

1) Recognize and report suspicious symptoms

2) Know where to find the correct treatment and diagnostic protocols

d. Health care facilities have a role in active surveillance to detect a WMD event

1) Ensuring educated personnel in WMD awarenss and syndromic surveillance

2) Promptly reporting suspicious illnesses to public health authorities

3) Rapidly identifying and initiating appropriate medical screening, diagnostic tools, and agent-specific medical interventions

3. Contact resources

a. CDC: www.cdc.gov

b. WHO: www.who.com

c. Agency for Health Research and Quality Bioterrorism Initiative: www.ahrq.gov

d. Local public health and/or emergency management offices serve as request and education conduits in some states

B. Regional and Local Preparedness

1. Minimize risk of contamination

2. Recognize signs and symptoms of agent

a. Suspicion of possible initial exposure

1) Increased death rate in hospitalized patients within 72 hours of admission

2) Small or large outbreak of disease

3) Clusters of patients from a single location

4) Single case of highly unusual disease

5) Atypical presentation of an endemic disease

6) Rapidly increasing incidence of illness

7) Unusual increase of patients with complaints of fever, gastrointestinal (GI) symptoms, or respiratory complaints

8) Childhood disease in adults

9) Appearance of a disease off season (e.g., flulike signs and symptoms during nonflu season)

10) Unexpected mortality rates of flulike illnesses

11) Multiple epidemics of differing illnesses

12) Unexplained blood disorders

13) Patients from a suspicious explosive event; consider contamination

14) Clusters of patients with rapidly progressing respiratory distress

15) Signs of chemical exposure

16) Commonalities of patients (e.g., in a similar area during a similar time frame)

17) Patients with presenting signs and symptoms from a CDC Health Alert Network (HAN) alert

b. Second wave of infectious illnesses corresponding to incubation periods

3. Provide personnel protection

a. Use personal protective equipment (PPE)

b. Provide antidotes, prophylaxis, and vaccination when indicated

c. Provide available alternate personnel to assume duties at end of individual rotations

d. Effective equipment maintenance program

e. Differentiate between contaminated and infected patients

1) Contaminated patients have had a hazardous materials exposure, and wearing decontamination-specific PPE is indicated.

a) U.S. regulatory agencies mandate the use of appropriate levels of PPE (Table 40-1)

b) PPE for receiving a contaminated patient is a minimum of level C

c) If the contaminant is not immediately known, the facility must follow the broadest PPE standards required by their annual hazards vulnerability analysis (HVA) data

2) Infected patients usually do not require decontamination, and standard precautions should be followed

a) Airborne risk requires a fitted mask (e.g., N-95 respiratory mask or higher level of respiratory protection, gloves, and impervious gown)

b) Droplet precautions include face shield, gloves, and gown

c) Contact precautions include gloves and gown

e) Highly infectious diseases may require

(1) Additional PPE (e.g., powered air-purifying respirator [PAPR])

(2) Evaluation by infection control professionals and/or by facility policy, with recommendations available from the CDC

f. Until identification of the substance is made and it is deemed nontoxic, responders should wear their PPE

g. Levels of PPE (seeTable 40-1)

4. Patient decontamination

a. Physical process of removing contaminants from persons, equipment, and the environment

b. Residual contaminants from exposed persons are a source of ongoing exposure and pose a risk of secondary exposure to first responders and emergency care personnel

c. Immediate decontamination is a major treatment priority for those with exposure

1) Initial field decontamination, gross or hasty, involves removal of patients from the contaminated environment followed by copious irrigation of the patient with water

2) Patient decontamination is a medical procedure

3) Hospitals receiving contaminated persons with or without initial field decontamination should consider the person contaminated and should provide definitive/detailed decontamination prior to entry into the facility

4) Lifesaving interventions (e.g., assessment, airway establishment, respiratory support, bleeding stabilization, circulatory support, and fracture stabilization) should not be delayed for decontamination

5) Definitive/detailed decontamination is complete and thorough patient decontamination, not the “hasty” initial gross field decontamination where only gross contaminants may be removed

6) Hospitals receiving contaminated persons should

a) Establish an area outside the emergency department in which to perform decontamination before people and equipment are allowed to enter

b) Minimally provide portable decontamination equipment with showers and runoff water collection systems

c) Consider construction of external fixed “turnkey” decontamination facilities

d. Decontamination preplanning

1) The Joint Commission Guidelines state that all hospitals should have the capacity to safely decontaminate at least one person, but the Health Resources and Services Administration (HRSA) list higher benchmark numbers

2) The Department of Homeland Security’s (DHS) State Homeland Security Assessment Strategies (SHSAS) suggest that much higher numbers of presenting patients will appear commensurate with the local credible threat (e.g., mass gatherings, public event venues, and public transportation sites)

3) Hospitals are required by The Joint Commission to conduct an annual HVA to assist in determining the likely number of patients requiring detailed/technical decontamination and the hourly throughput needed for the facility

5) Community planning for a mass casualty event

6) Rapid access to detection monitors, with trained users for radiologic, biologic, and chemical agents is recommended

7) Hospitals should consider retrofitting or constructing the facility as a defensible facility because hospitals, as critical infrastructures in the community, may be primary and secondary terrorist targets. This involves

a) Excluding direct line of vision access to critical areas (e.g., the emergency department and the operating room)

b) Ability to compartmentalize the facility to offset security and contaminated patient breeches

c) Ability to minimize damage from a direct attack (e.g., barriers for unscreened access areas to the facility by vehicles or persons)

5. Quarantine and isolation

a. With the threat of rapidly emerging, highly infectious diseases, whether naturally occurring or from deliberate release, hospitals must have a plan to address large numbers of infected and exposed persons

b. The plan should be integrated with local, regional, and state public health and emergency management plans because a mass casualty event is a public health emergency, not just a hospital emergency

c. Health care facilities must be prepared to function autonomously with supplies and limited personnel for at least 5 to 7 days in an incident of national significance (e.g., a pandemic event)

d. Health care facilities must be aware of state laws governing quarantine, because these laws affect their patients, visitors, and personnel

e. Quarantine declarations are usually the domain of the lead public health official and are intended to limit spread of infectious disease; quarantine on a large scale may be voluntary, may require health care facilities to provide epidemiologic data, and may affect staffing, travel, and supplies

f. Isolation is the medical procedure to remove an infected, contagious person from the general population

g. Medical isolation focuses on the containment of the disease

h. Health care facilities must have plans to

1) Rapidly increase isolation capability (e.g., by cohorting patients)

2) Use portable isolation/filtration machines and procedures

3) Dedicate equipment, and personnel with the appropriate PPE

4) Decontaminate patients without delaying lifesaving assessment and medical treatment

i. Community plans for a large-scale infectious disease event may include use of alternate facilities for infected patients; health care facilities should be aware of their role in the community isolation plan (e.g., staffing, supplies, referrals, transportation, and/or space)

6. Antidotes, mass prophylaxis, and vaccination

a. Several chemical and radiologic agents have available specialized antidotes

b. Facility responsibilities

1) Have rapid access to the antidotes for agents posing a credible threat to their community

2) Have an amount immediately available to minimally treat affected personnel and a first wave of presenting patients before requiring resupply from local or regional specialized pharmaceutical caches

3) Have rapid access to pharmaceuticals for personnel, families, and a first wave of presenting patients, and have plans for community-based resupply

4) Have a dispensing plan for personnel and families, and know their role in the local, regional, and state mass-dispensing plan

5) Preserve the critical medical infrastructure for ill patients

6) Have autonomous plans for supplies, medications, and staffing for at least 7 days, for an event of national significance

7) Immunization plan

7. Facility evacuation

a. Evacuation plans are mandatory

b. In the event of a WMD event such as contamination, structural damage, or a natural disaster, plans should include autonomous offsite evacuation

c. Evacuation plans should be integrated with local emergency management, with additional resources such as private company transportation contracts, for redundancy in the event these resources are contracted to other facilities

d. Exercises and personnel training of the evacuation plan must occur

Table 40-1 PERSONAL PROTECTIVE EQUIPMENT

Level A PPE: Not Indicated for Use in a Health Care Facility Receiving Patients	Level B PPE: Not Indicated for Use in a Health Care Facility Receiving Patients	Level C PPE: OSHA Recommended Level of Protection for First Receivers in a Health Care Facility
1. Required for hot zone entry or hazardous environments with unknown contaminants, confined space entry, or an environment requiring the highest level of protection for skin, eyes, and the respiratory system 2. Ensembles include fully encapsulated, liquid and vapor protective ensemble, positive pressure, full face piece, SCBA or positive pressure supplied air respirator with escape SCBA, gas tight, NIOSH-approved totally encapsulated chemical-protective suit with the highest level of permeation resistance, chemical-resistant double gloves and boots 3. Difficult to wear longer than 30 minutes; hot and cumbersome, dependent on the air supply and user level of activity	1. Worn when the highest level of respiratory protection is required, but less skin protection is needed, as determined by the identified contaminant or absence of aerosol or an oxygen percentage of less than 19.5, which is less than breathable air contains 2. Ensembles include liquid splash-resistant ensemble with the highest level of respiratory protection, positive pressure, full face piece, SCBA or positive pressure supplied air respirator with escape SCBA, gas tight, NIOSH-approved hooded, chemical- resistant clothing, chemical-resistant double gloves and boots 3. Difficult to wear; dependent on the air supply and user level of activity 4. Required for hospital-based personnel, only if a risk is indicated in the facility that would require the highest level of respiratory protection	1. Recommended by OSHA as the minimum standard PPE for first receivers; used when a hazard is present that may be absorbed through exposed skin and where the filters would remove the contaminant 2. Ensemble includes liquid splash-resistant ensemble with the same level of skin protection as level B, hooded, chemical- resistant clothing, full face mask, positive air-purifying respirator with filters appropriate to the contaminant, chemical- resistant double gloves and boots 3. Requires medical monitoring and safety program, competency-based training, equipment maintenance 4. PAPR batteries may run for 8 or more hours, but personnel would require monitored rotations and rehabilitation

NIOSH, National Institute for Occupational Safety and Health; OSHA, Occupational Safety and Health Administration; PAPR, powered air-purifying respirator; PPE, personal protective equipment; SCBA, self-contained breathing apparatus.

II. SPECIFIC WEAPONS OF MASS DESTRUCTION

A. Biologic Agents

Bacillus anthracis (Anthrax)

Anthrax is a gram-positive, spore-forming bacterium that affects both humans and animals. The spores are hardy and can survive for decades in soil. Because of the virulence of this pathogen as a spore, many experts in biologic warfare consider anthrax to be the perfect biologic weapon. In humans, anthrax can present in three forms: inhalation, cutaneous, and GI. Anthrax is not transmissible from human to human. Inhaled anthrax is the most lethal form and results from inhaling spores. It is extremely rare. A prodromal stage of GI symptoms lasts from hours to days. Then there may be a period in which improvement occurs, followed by the fulminant stage. Death may occur within 24 to 36 hours. Cutaneous anthrax is the most common form and is responsible for 95% of all cases. It is a local infection, usually resulting from direct contact with livestock. The incubation period is approximately 2 weeks after exposure. GI anthrax occurs from eating contaminated meat products, and the onset of symptoms is usually within 2 to 5 days of ingestion. It is difficult to diagnose.

1. Assessment

a. Subjective data collection

2) Past medical history

a) Current or preexisting diseases/illness

d) Immunization status

b. Objective data collection

2. Analysis: differential nursing diagnoses/collaborative problems

a. Ineffective breathing pattern

b. Deficient fluid volume

c. Anxiety/fear

d. Deficient knowledge

f. Risk for ineffective airway patency

g. Risk for impaired skin integrity

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

1) Rapid-sequence intubations (RSI) and ventilatory support in patients with respiratory compromise: inhaled anthrax

c. Establish intravenous (IV) access for administration of crystalloid fluids/blood products/medications as needed

d. Prepare for/assist with medical interventions

1) Patient decontamination and personnel protection

2) Advanced airway management: inhaled anthrax

a) Nasal or oral intubation

b) Laryngeal mask airway

d) Surgical airway (e.g., cricothyrotomy)

3) Institute cardiac and pulse oximetry monitoring

4) Insert gastric tube and attach to suction as indicated

5) Insert indwelling urinary catheter as indicated

6) Assist with hospital admission (inhaled anthrax)

7) Notification of CDC

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Antibiotic treatment as soon as diagnosis is suspected

a) Ciprofloxacin (Cipro)

b) Doxycycline (Dynapen), or antibiotic based on laboratory confirmed susceptibility

f. Educate patient and significant others

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Tags: Emergency Nursing Core Curriculum

Nov 8, 2016 | Posted by admin in NURSING | Comments Off

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