CHEMICAL DISASTERS: NURSING MANAGEMENT

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CHEMICAL DISASTERS NURSING MANAGEMENT

• Nerve Agents Part I

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OBJECTIVES

• Identify common nerve agents
• Discuss signs and symptoms
• Discuss nursing management and treatment
• Discuss the nurse roles and responsibilities
• Discuss personal safety risk exposure

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Emergency Support Function (ESF) 8 OVERVIEW

• DHH has the role of providing leadership for
  planning, directing and coordinating the overall
  State efforts to provide public health and
  medical assistance.
• The Secretary of Health and Human Services
  through the Office of Public Health Emergency
  Preparedness is responsible for the federal
  coordination.
• The command and control of operations are
  consistent with the National Response Framework
  and compliant with National Incident Management
  System requirements.

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Command Chain/ICS
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Unified Command

• Enables all agencies with responsibility to
  manage an incident together by establishing a
  common set of incident objectives and
  strategies.
• Allows Incident Commanders to make joint
  decisions by establishing a single command
  structure.
• Maintains unity of command. Each employee only
  reports to one supervisor.

Agency 2 Incident Commander
Agency 1 Incident Commander
Agency 3 Incident Commander
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Disaster Management Continuum
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Chemical Disasters

• May result from industrial accidents, accidental
  exposure, or terrorist acts
• Chemical Agents of Concern
• Nerve agents
• Blister agents/vesicants
• Blood agents
• Choking/lung/
• pulmonary agents

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Agencies/Partners Involved

• Federal Bureau of Investigation (FBI)
• Military
• US Department of Health and Human Services
  (HHS)-Centers for Disease Control and Prevention
  (CDC)
• Other Federal partners
• Governors Office of Homeland Security and
  Emergency Preparedness
• Fire/Hazmat

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Agencies/Partners Involved

• Department of Environmental Quality
• Department of Health and Hospitals
• Law Enforcement Louisiana State Police
• Louisiana State National Guard
• Department of Public Works
• Department of Wildlife and Fisheries
• Department of Agriculture and Forestry
• Other state agencies

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Agencies/Partners Involved

• Local Parish Office of Homeland Security and
  Emergency Preparedness Office
• Louisiana Poison Center
• Healthcare facilities
• Medical Examiners/Coroners
• Animal Control
• Local Partners
• LAVA Volunteers agencies/volunteers

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Nerve Agents

• Most toxic of chemical warfare agents and inhibit
  the bodys normal functions
• Dangerous to humans and can be utilized as
  potential weapons by terrorist
• Act as acetylcholinesterase inhibitors which
  produce the same signs and symptoms of
  organophosphate poisioning

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Nerve Agents

• Sarin
• Soman
• Tabun
• VX

• Odorless
• Slight camphor odor
• Faint fruity odor
• Odorless

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Nerve Agents Exposure

• Inhalation
• Can be dispersed as aerosols, vapors, or liquids
• Vapors absorbed by inhalation and vapor contact
• Immediate onset of symptoms

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Nerve Agents Exposure

• Ingestion
• Readily absorbed

• Skin/eye
• Onset depends on concentration can be delayed
  for several hours

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Safety Risk

• First responders are trained individuals who will
  respond to the event
• Nurses should not be first responders unless you
  have been trained on hazardous materials or part
  of a fire response team

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Signs and Symptoms
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Signs and Symptoms

• Mild
• Miosis
• Nausea
• Diarrhea

• Severe
• Muscle weakness
• Fasciculations
• Respiratory failure
• Coma
• Seizures
• Permanent damage to the CNS after high toxic
  exposure

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Real Life Incidents

• Sarin incident in Tokyo-1995
• Carbamate insecticide methomyl was added to salt
  at a restaurant in Fresno, California-1999

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Exposure to Healthcare Workers

• Tokyo incident several people were exposed.
  Contaminated individuals may self present to a
  facility.
• Healthcare workers must wear PPE and use it
  correctly
• Contaminated individuals must be decontaminated

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Exposure to Healthcare Workers

• Sudden and severe symptoms may occur hours after
  treatment/contamination (through skin)
• You must have appropriate PPE to approach any
  contaminated victim

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Precautions

• Standard
• Airborne
• Droplet
• Contact

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PPE Equipment

• Determined by the type and level of exposure and
  duration of exposure
• Nerve agents are absorbed through intact skin and
  even through the clinical examination gloves

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Treatment/Exposure
Exposure Treatment
Skin Decontaminate using soap/water
Inhalation If severe symptomatic, consider antidote use.
If signs/symptoms progressing continue antidote administration.
If breathing has stopped or is difficult use artificial respiration
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Treatment/Exposure
Exposure Treatment
Eyes Immediately flush eyes with water for 10-15 minutes

Ingestion Do not induce vomiting Consider Mark I kit use
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Treatment

• Adults
• Atropine 2mg (antimuscarinic)
• Pralidoxime (2 Pam) 600mg
• Children
• Pediatric atropine autoinjector is now available
• Supportive therapy and assisted ventilation as
  need
• Benzos for prevention of seizures

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• STRATEGIC NATIONAL STOCKPILE

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Strategic National Stockpile

• CHEMPACK
• Managed Inventory
• Antivirals
• Vaccines
• Federal Medical Stations

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• Pharmacys Role

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CHEMPACK

• Hospital/EMS Containers (contents are different)
• Mark 1 Kits
• Atropine Sulfate 0.4mg/mL
• Pralidoxime 1gram vials
• Atropen 0.5mg auto-injectors
• Atropen 1mg auto-injectors
• Diazepam 10mg/2mL auto-injectors
• Diazepam 5mg/mL 10mL
• Sterile Water for Injection 20mL single use vials

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CHEMPACK

• Prepositioned across the state. Locations are
  confidential.
• Louisiana Poison Control
• 1-800-222-1222
• Will provide consultation on symptoms of nerve
  agents and organophosphate poisoning to first
  responders and health care professionals.
• Will provide assistance regarding dosing
  questions.

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Labeled Containers with Buffers
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Treatment

• Duodote eventually will replace Mark I Kits

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• PREHOSPITAL MANAGEMENT

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Scene Safety Management

• Minimize casualties
• Decontamination
• Triage
• Antidote therapy
• Crisis scene
• management

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Emergency Medical Service's (EMS) Role

• EMS has 2 Mark I Kits available on the ambulance
• State Police will pick up EMS container if
  CHEMPACK is needed
• Administer Mark 1 Kit per protocol
• Airway support and ventilation. Perform
  endotracheal intubation if needed.
• Circulatory support IV therapy and pulse
  oximetry monitoring
• Consultation with Louisiana Poison Control

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Field Treatment
Exposure Symptoms Initial Dosing (EMS/Field) Repeat Dosing (Transport/Hospital)
Mild DUMBBELS Agitation Observe or MARK 1 Observe
Moderate DUMBBELS Agitation Respiratory distress 2 Mark 1 Atropine 5-10 min 2-PAM q 30-60 min
Severe DUMBBELS Respiratory distress Seizures 3 MARK 1 Diazepam Atropine 5-10 min 2-PAM q 30-60 min Diazepam q 2-5 min
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Transport
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• HOSPITAL MANAGEMENT

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Hospitals Role

• Ventilatory support patients with respiratory
  failure and compromised airways will require
  immediate endotracheal intubation and positive
  pressure ventilation.
• Oxygen supplement
• Decontamination before entering the emergency
  department
• Suctioning for removal of bronchial secretions
• Gastric decontamination-activated charcoal

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Hospitals Role

• Observation
• Treatment-Atropine and Pralidoxime
• Monitoring for seizure activity (administering
  anticonvulsants for prevention)
• Recovery may take several months
• Risk of permanent damage to the Central Nervous
  System (high dose exposure)
• Consult with the Louisiana Poison Center

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Patient Mild/Moderate Effects1 Severe Effects2 Other Treatment
Child Atropine 0.05mg/kg IM or IV (minimum 0.1mg Maximum 5mg) AND 2-PAM 25mg/kg IM or IV (maximum 2Gm IM or 1Gm IV) Atropine 0.1mg/kg IM or IV (minimum 0.1mg, maximum 5mg) AND 2-PAM 50mg/kg IM or IV (maximum 2Gm IM or 1Gm IV) Assisted ventilation for severe exposure. Repeat atropine at 2-5 minute intervals untilsecretions have diminished and airway resistance has decreased. Repeat 2-PAM chloride once at 30-60 minutes, then at one-hour intervals for 1-2 doses, as necessary. Diazepam for seizures Child - 0.05 to 0.3 mg/kg IV(maximum 10 mg)Adult - 5 mg IV Other benzodiazepines (e.g. lorazepam) may provide relief. Phentolamine for 2-PAM chloride-inducedhypertension 1 mg IV for children 5 mg IV for adults.
Adult Atropine 2 to 4 mg IM or IV AND 2-PAM3 600mg IM, or Atropine 6mg IM AND 2-PAM3 1800 mg IM, or 50mg/Kg IV slowly Assisted ventilation for severe exposure. Repeat atropine at 2-5 minute intervals untilsecretions have diminished and airway resistance has decreased. Repeat 2-PAM chloride once at 30-60 minutes, then at one-hour intervals for 1-2 doses, as necessary. Diazepam for seizures Child - 0.05 to 0.3 mg/kg IV(maximum 10 mg)Adult - 5 mg IV Other benzodiazepines (e.g. lorazepam) may provide relief. Phentolamine for 2-PAM chloride-inducedhypertension 1 mg IV for children 5 mg IV for adults.
Mild/Moderate effects of nerve agents include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea. Severe effects of nerve agents include unconsciousness, seizures, apnea, flaccid paralysis. Dose selection of 2-PAM chloride for elderly patients should be cautious (usually starting at 600 mg IM, or 25 mg/kg IV slowly) to account for the generally decreased organ functions in this population. NOTE 2-PAM chloride (2-PAM) is pralidoxime chloride, trade name Protopam. CHEMPACK CHEMPACK is a federal program to provide nerve agent antidotes (Atropine, 2-PAM, Diazepam) to during an emergency. Additional Assistance Contact the at 800-222-1222 or 318-813-3317 for additional information regarding dosing. Mild/Moderate effects of nerve agents include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea. Severe effects of nerve agents include unconsciousness, seizures, apnea, flaccid paralysis. Dose selection of 2-PAM chloride for elderly patients should be cautious (usually starting at 600 mg IM, or 25 mg/kg IV slowly) to account for the generally decreased organ functions in this population. NOTE 2-PAM chloride (2-PAM) is pralidoxime chloride, trade name Protopam. CHEMPACK CHEMPACK is a federal program to provide nerve agent antidotes (Atropine, 2-PAM, Diazepam) to during an emergency. Additional Assistance Contact the at 800-222-1222 or 318-813-3317 for additional information regarding dosing. Mild/Moderate effects of nerve agents include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea. Severe effects of nerve agents include unconsciousness, seizures, apnea, flaccid paralysis. Dose selection of 2-PAM chloride for elderly patients should be cautious (usually starting at 600 mg IM, or 25 mg/kg IV slowly) to account for the generally decreased organ functions in this population. NOTE 2-PAM chloride (2-PAM) is pralidoxime chloride, trade name Protopam. CHEMPACK CHEMPACK is a federal program to provide nerve agent antidotes (Atropine, 2-PAM, Diazepam) to during an emergency. Additional Assistance Contact the at 800-222-1222 or 318-813-3317 for additional information regarding dosing. Mild/Moderate effects of nerve agents include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea. Severe effects of nerve agents include unconsciousness, seizures, apnea, flaccid paralysis. Dose selection of 2-PAM chloride for elderly patients should be cautious (usually starting at 600 mg IM, or 25 mg/kg IV slowly) to account for the generally decreased organ functions in this population. NOTE 2-PAM chloride (2-PAM) is pralidoxime chloride, trade name Protopam. CHEMPACK CHEMPACK is a federal program to provide nerve agent antidotes (Atropine, 2-PAM, Diazepam) to during an emergency. Additional Assistance Contact the at 800-222-1222 or 318-813-3317 for additional information regarding dosing.
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Hospitals Role

• Employee training
• Hospitals are going to be reserved for your
  critically ill individuals
• Medical Surge
• Decontamination
• Treatment/Supportive Measures/Assisted Ventilation

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• PUBLIC HEALTH

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Public Health Preparedness

• Strategic National Stockpile
• Exercises, drills, trainings
• State and local planning efforts
• Paradigm shift to all hazards approach

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Public Healths Role

• Promote life safety through education,
  information and planning
• Goal is to prevent illness by minimizing exposure
  and rapid, effective response
• Provide medical intelligence such as knowledge of
  antidotes and symptoms of exposure
• Procure resources available to the State with
  forward placement whenever possible

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Public Healths Role

• Provide guidance for use of assets under the
  direction of the State Health Officer
• Participate as ESF 8 in Incident Command and/or
  Unified Command
• Assist in the development of factual
  communication for multiple audiences during
  response
• Promote behavioral health

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Public Healths Role

• Conduct epidemiological investigations
• Coordinate laboratory services
• Participate assessments and actions to minimize
  the health and environmental impacts

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Office of Public Health Nurses Role

• Planning, preparedness, and response
• Assessment
• Triage
• Treatment/Education
• Sheltering

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Personal Safety

• Having a family emergency plan
• Decontamination of self
• PPE
• Emergency Communication Devices

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Vulnerable Populations

• Communication
• Establish safe shelter
• Food and water
• Shelter in place versus Medical Special Needs
  Shelters, General Population Shelters, Critical
  Transportation Needs Shelters
• Rely on existing agencies
• Will need assistance if decontamination is needed
• Time of day when incident happens

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Education

• If exposed, remove all clothing immediately and
  wash with copious amounts of soap and water.
• Shelter in place Go indoors, close all windows,
  doors, and close up the building. Turn off fans,
  air conditioners, and heaters. Move to a lower,
  inner room vs. higher room for floods
• Listen to the local news and radio for further
  instructions

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Education

• Contaminated clothing should be double bagged.
• Food and water

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CHEMPACK Response Operation Overview

• Step 1 Event- a suspected chemical or biological
  incident occurs. 911 is notified of the
  situation and the need for security
  considerations or medical attention for/by the
  public. At this time, 911 operators also notify
  the parish Office of Homeland Security and
  Emergency Preparedness of the event.
• Step 2 Isolation- security and medical
  responders will follow local parish protocol for
  isolation and triage for treatment.

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CHEMPACK Response Operation Overview

• Step 3 CHEMPACK Standby/Alert- the Louisiana
  Poison Center will be notified by either the
  field Incident Commander or the 911 Operations
  Center that there is a suspected nerve or
  organophosphate incident. Triaging assistance is
  provided to the Incident Commander an on-scene
  first responders. Since positive identification
  of the substance involved is nearly impossible in
  the initial response, symptoms consistent with a
  nerve agent or organophosphate exposure will be
  sufficient for recommending appropriate treatment
  and release of the assets.
• Louisiana Poison Center 1-800-222-1222

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CHEMPACK Response Operation Overview

• Step 4 CHEMPACK Activation- If the Tier I
  assets are insufficient to meet the need, then
  the Louisiana Poison Center activates this
  CHEMPACK plan. The Louisiana Poison Center will
  notify appropriate Host Sites with a request for
  Tier II countermeasures via the CHEMPACK assets.
  The Louisiana Poison Center considers such
  factors as wind trajectory, volume of patients,
  and treatment needs when selecting Host Site(s)
  and Receiving Site (s) for CHEMPACK supplies.
  Louisiana Poison Center will notify Host Sites to
  open containers and prepare appropriate
  allocations for

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CHEMPACK Response Operation Overview

• distribution. Further, Louisiana Poison Center
  coordinates transportation with Louisiana State
  Police.
• Step 5 Countermeasures- Tier II CHEMPACK assets
  will be dispensed as per the plan and appropriate
  Regional plan(s).
• Step 6 Collection/Transportation of a Specimen-
  A request may be made to transport a sample of
  the substance/agent to the State Lab for
  analysis.

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Scenario
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(No Transcript)
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Scenario Facts

• XYZ Plant located in Somewhere, Louisiana in
  Region 10
• Has a population of approximately 300 employees
  on duty

• Its Friday, January 14 something has been
  dispersed into the ventilation system at the XYZ
  Plant and no one is aware.

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Labeled Containers with Buffers
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Decontamination on Scene

• Decontamination of Vehicle

• Decontamination Tent

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Treatment
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Transport
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Mass Casualty Incident
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Phone Calls

• You are the nurse working in the triage line.

• What symptoms should the PHN tell her to watch
  for?

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(No Transcript)
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Summary

• Contact the Louisiana Poison Control Center
• 1-800-222-1222 for questions/concerns
• Nerve agents exposure serious medical emergency
• For life saving measures rapid administration of
  antidotes
• Remember DUMBBELS
• Always wear appropriate PPE before taking care of
  any victim

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Summary

• Most toxic of chemical agents
• Triage
• Treatment Decontamination, Rapid antidote
  therapy, supportive therapy, and ventilator
  assistance, Anticonvulsants for prevention of
  seizures

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Future Topics

• Chemicals Agents
• Blistering agents/vesicants
• Tissue/Blood agents
• choking/lung/pulmonary agents
• Biological Agents
• Radiological Agents

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Future Topics

• Disaster triage
• Decontamination
• PPE
• JUMPSTART/START

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References

• Centers for Disease Control and Prevention
  www.bt.cdc.gov
• Veenema, Tener Goodwin., Ready RN Handbook for
  Disaster Nursing and Emergency Preparedness,
  2009.
• Agency for Toxic Substances and Disease Registry
• American Academy of Pediatrics
• Louisiana Emergency Operations Plan
• State/Regional CHEMPACK Response Plan

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Password for SurveyMonkey Participant Evaluation

• NERVE
• (all uppercase)

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• QUESTIONS

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Contact Us

• Louisiana Department of Health and Hospitals
• Office of Public Health
• Center for Community Preparedness
• 8919 World Ministry, Ste. B
• Baton Rouge, LA 70810
• 225-763-3503
• http//www.dhh.louisiana.gov

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CONTACT INFORMATION

• Sherhonda Harper, RN, MHA
• Statewide Nurse Consultant, Nursing Services
• Emergency Preparedness
• DHH/OPH
• [phone]-OFFICE
• [phone]-FAX