Nursing in Disasters

4-25-08 Kathy Batton
Nursing in Disasters
• Disasters and Nursing
o A sudden and massive disruption in health care service because of hostile elements of any
kind (natural and man-made) requiring survival resources be brought into action in the
shortest possible time using the fewest resources
o Does not necessarily mean numerous injured or dead. It may be 5 critically injured MVA
clients taken to a small community hospital.
• Disaster Types
o Natural
 Tornadoes
 Hurricanes
 Earthquakes
 Blizzards
 Epidemics
o Man-Made
 Fires
 Explosions
 Nuclear accidents
 Bombings
 Biological
 Chemical
 Radiation
 War
• Nurses Role in Disaster Triage
o Triage will be based on utilization of resources to treat the MOST people
o Good of the “whole” becomes more important than good of the individual
o Potential outcomes/ survivability and available resources is the issue-not degree of injury
o Nurses will still be involved with assessment and basic treatment
• Disaster Triage Categories
o Immediate/ Priority 1/ Red Tagged
 Life threatening injuries that are survivable with minimal interventions
 Examples: airway obstruction, sucking chest wounds, tension pneumothorax,

hemothorax, open fractures of long bones, burns (2nd and 3rd degree as long as it
is 15%-40% of the TBSA)
 This group can rapidly deteriorate without treatment and become black tagged
o Delayed/ Priority 2/ Yellow Tagged
 Significant injuries that are survivable with medical care, but aren’t going to die
immediately without care
 Examples: stable abdominal injuries, fractures that need reducing, eye injuries,
soft tissue injuries, facial injuries without airway difficulties
 Can go from yellow to red as they get sicker
o Minimal/ Priority 3/ Green Tagged
 Minor injuries, treatment can be delayed for hours or days without death
 Examples: sprains, cuts, fractures that don’t have to be reduced surgically, psych
people
o Expectant/ Priority 4/ Black Tagged
 Significant injuries, chances of survival are minimal even with immediate care or
walking wounded
 Examples: nursing home patients who are DNR, unresponsive people with
penetrating head wounds, major burns over 60% of body, fixed and dilated
pupils, brain matter coming out of ears, this is also the walking wounded
 People that will be fine even if they don’t get medically treated. Usually the
walking wounded are trying to care of the dying.
o After triage category decided the person is tagged and treated and / or transported, triage
continues at each point of care.
• Disaster Levels
o Level I-local emergency response personnel and organizations can contain and
effectively manage the disaster and its aftermath
o Level II-regional efforts and aide from surrounding communities are sufficient to manage
the effects of the disaster
o Level III- local and regional assets are overwhelmed; state wide or federal assistance is
required
• Terrorism Recognition and Awareness
o Be aware of an unusual increase in the number of people with fever of GI problems
o Unusual illness for time of year
o Cluster of client from a specific location
o Large number of rapidly fatal cases with death in 72 hours
o Increase in disease in otherwise healthy population
• Levels of protection for health care workers
o Level A- highest level of respiratory, skin, eye, mucus membrane protection
 Covered from head to toe, breathing apparatus, chemical resistant
o Level B-same respiratory but less skin and eye protection, still wear chemical resistant
suit
o Level C-air purified respirator, with filters that remove harmful substances and a
chemical resistant coverall, gloves, boots, and splash hood
o Level D- what you would normally wear plus universal precautions
• Weapons of Terror
o Biological Weapons
 Easily obtained
 Easily disseminated
 Significant morbidity and mortality
 Signs and symptoms similar to common diseases
 May be liquid, dry, applied to foods or water or vaporized

 Vector may be animal, insect, or human or direct contact with agent itself.
 Types
• Anthrax/Bacillus Anthracis
o Most likely weapon to be used (has been used before)
o Naturally occurring in soil
o As an aerosol it is odorless and invisible and can travel for miles
o Causes hemorrhage, edema and necrosis
o Incubation period is 1-6 days
o Use standard precautions
o Skin contact
 Signs and symptoms
• edema with pruritis
• macule, papule formation resulting in ulceration

with 1-3mm vesicles
• eschar (painless) develops and falls off in 1-2

weeks
 Nursing care
• Treat symptoms
• Maybe antibiotics
o Ingestion
• Fever
• Nausea and vomiting
• Abdominal pain
• Bloody diarrhea (occ. Ascites)
• Massive diarrhea can result in volume depletion

• Can result in sepsis
• Frequently fatal due to sepsis
 Nursing care
• Assess for and maintain adequate fluid status
• Treat symptoms
• Assess for sepsis
 Medications
• Fluoroquinolones
• Tetracycline
• Penicillin
o Inhalation
• Mimics flu-in first stage
o Headache, syncope
o Cough, dyspnea (no rhinorrhea or nasal

congestion)
o Fever, chills
o Vomiting, weakness
• After initial s/s brief recover period then 1-3

days
o Fever
o Severe respiratory distress, strider,

hypoxia, cyanosis
o 50% have hemorrhagic mediastinitis on

x-ray
o Diaphoresis
o Hypotension
o Shock
o May progress to meningitis with SA

hemorrhage
o Death 24-35 hours
o Mortality rate near 100%
 Nursing Care
• Use standard precautions
• If antibiotics started within 24 hours after

exposure death can usually be prevented
• Nurses must be vigilant in surveillance
• Penicillin, chloramphenicol, gentamicin or

doxycycline
• For mass exposure and persons exposed but

without s/s-doxycycline or ciprofloxacin for 60
days
• Cremation for the dead
• Smallpox/ Variola Major
o DNA virus
o Highly contagious
o Lives 24 hours in cool temperatures
o 30% Mortality rate, morbidity rate extremely high
o Spread by direct contact and contact with clothing, linens, or by

droplet
o Contact precautions and droplet precautions
o Incubation period
 7-17 days
 Not contagious during this time

 Feel fine
 Contagious after patient develops fever
o Prodrome Phase
 Sometimes contagious
 Lasts 2-4 days
 Fever (high 101-104F) highest when rash starts
 Malaise, head and body aches
 Feel too sick to carry
o Rash phase
 4 days
 Most contagious during rash phase
 Starts as small red spots on tongue and in mouth, these

rupture and spreads virus into mouth and throat, rash
then starts of face and spreads to arms and legs and then
hands and feet
 Rash is everywhere in 24 hours
 As rash appears fever decreases they feel better
 3rd day of rash is raised bumps
 4th day bumps fill with thick opaque fluid and have
depression in center (looks like a belly button and a
major characteristic)
 Fever will rise again and stay high until scabs form over
the bumps
o Pustular Rash Phase
 Duration -5 days
 Bumps become pustules-raised, usually round and firm
 Crust and scabs form (duration about 5 days,) by end of

the second week of the rash most of the sores have
formed scabs
 Once scabs are gone, patient is no longer contagious
• Hemorrhagic smallpox
o Same s/s as variola major except dusky erythema and petechiae

to frank hemorrhage of the skin and mucus membranes
o Death usually within 5-6 days
o Nursing Care for both types of Smallpox
 Protect yourself (contact and airborne precautions)
 Symptomatic care
 Assess for additional infection-if present administer

antibiotics
 Vaccine administered up to 4 days after exposure-before

the rash appears will help prevent and or decrease
disease symptoms
 Chemotherapeutic agent-Cidofovir is being used

experimentally in the lab
 Bodies should be cremated
o Infection control
 Wear gloves, caps, gowns, and surgical masks
• Tularemia
o Also known as deerfly or rabbit fever
o Naturally found in small mammals and the insects that bite them
o Can survive for weeks at low temps in water, moist soil, hay,
straw, or decaying animal carcasses
o Can be aerosolized for biological weapon use
o Mortality rate not high
o Can’t be spread from person to person
o S/S
 Develop 3-5 days

 May be mild illness or acute sepsis and rapid death
 Sudden fever, chills, headache, diarrhea, generalized

aching, dry cough sore throat without adenopathy, then
progressive weakness, pneumonia to chest pain, blood
sputum and dyspnea
 If inhaled death due to pneumonitis, sepsis and shock
o Nursing care
 For inhaled, treatment within 48 hours
 Treat symptomatically
 Streptomycin or gentamicin for 10-14 days
 For mass casualty, doxycline or cipro for 14 days
• Botulism
o Produces a neurotoxin
o Exposure results in flaccid paralysis
o May be ingested or inhaled
o Spread via direct contact
o Not contagious via human to human
o Use standard precautions
o If skin contact use soap and water or bleach solution to clean
o S/S
 GI-abdominal cramps, N&V, diarrhea
 Inhaled (manmade)
• Symmetric descending paralysis
• Diploplia
• Dysphagia, dry mouth, altered mental status
• death from airway obstruction and decreased

tidal volume
• may or may not have fever
• usually responsive initially
 Nursing care
• Supportive care
o Mechanical ventilation
o Fluids and nutrition
o Do not give aminoglycosides or

clindamycin
o No isolation required
• Antitoxin
o Equine antitoxin given to decrease nerve

damage-check allergies
• Plague
o Necrosis and destroys the lymph nodes
o Pneumonic plague type most likely to be used in terrorism
o Will likely be aerosolized
o Pneumonic is contagious through human to human contact
o Transmitted via respiratory droplet contact
o s/s
 severe bronchospasms
 chest pain
 dyspnea, cough
 hemoptysis
 100% mortality if not treated within first 24 hours after

exposure, even with treatment mortality is 50%
o Treatment
 Symptomatic
 Utilize barrier precautions with full face respirators
 Have client wear mask
 Streptomycin or gentamicin for 10-14 days
 After close contact give doxycycline for 7 days
o Chemical Weapons
 Nerve Agents
• Sarin Gas-heavier than area, settles in low areas
o Evaporates into a colorless, odorless, vapor
o Can be inhaled or absorbed
o Results in continuous stimulation of the nerve endings
o S/S start in ½ hour to 18 hours
 Bilateral miosis
 Visual disturbances
 GI motility
 N&V, and diarrhea
 Substernal spasm
 Bradycardia
 AV block
 Bronchoconstriction
 Laryngeal spasm
 Seizures
 Death –really bad death
o Nursing Care
 Decontamination at site with copious amounts of water

or NS for 8-20 minutes
 Blot to dry
 Maintain airway
 Suction PRN
 Decontamination at hospital
 IV atropine 2-4 mg, Then 2 mg every 3-8 minutes for up

to 24 hours or atropine 1-2 mg every hour until
resolution
 Pralidoxime 1-2mg in NS IVPB over 15-30 minutes
 Diazepam (valium) or benzodiazepines for seizures
• Cyanide
o Affect cellular metabolism resulting in alterations of hemoglobin

that leads to asphyxiation
o Has a bitter almond odor
o Can be ingested inhaled or absorbed through skin and mucus

membranes
o Inhalation symptoms
 Flushing
 Tachycardia
 Nonspecific neurologic symptoms
 Seizure
 Respiratory arrest
o Nursing Care
 Intubate
 Ventilate
 Nitrate pearls-put in reservoir of ventilator
 Sodium nitrate-given IV 300mg over 2-4 minutes
 Sodium thiosulfate-given IV 12.5mg over 5 minutes
 Alternative treatment-vitamin B12

• Chemical Vesicants (mustards, phosgene, lewisite-contains arsenic)
o Cause blistering and burning
o Minimal mortality but large morbidity
o Sulfa mustard smells like garlic
o Signs and Symptoms
 Initially presents like a large superficial partial thickness

burn in warm, moist areas
 Then pruritus painful burning and vesicle formation
 Possibly a purulent fibrinous discharge that may obstruct

airway
o Nursing Care
 Treated as a burn
 Decontaminate with soap and water
 Do not rub skin
 Irrigate eyes if exposed
 If respiratory exposure-intubate, ventilate, and prepare

for bronchoscopy
 Observe all mustard exposures for 24 hours due to

possible latent effects
• Chemical Pulmonary Agents (phosgene, chlorine)
o Destroy pulmonary membrane that separates alveolus from the

capillary bed
o Capillary leaks result in fluid filled alveoli
o Phosgene smell like fresh-mown hay
o S/S
 Pulmonary edema with SOB
 Hacking cough that progresses to frothy sputum

o Nursing Care
 Supportive
 Airway management
 Intubate
 ventilate
o Radiation Weapons
 Types
• Alpha
o Low level
o Localized damage only
• Beta
o Moderately penetrates the skin
o Skin damage if prolonged exposure
• Gamma
o Penetrates
o Difficult to shield from
o Often accompanies alpha and beta emissions
• Measurement and Detection
o Rad-basic unit of measurement
o Rem-type of radiation and potential for damage
o Half life-time it takes to lose half of radioactivity
o Geiger counter-detects gamma and some beta radiation
o Personal dosimeters-worn by radiology personnel to detect

exposure
o It is the dose rather than the source that determines if ARS will
develop
• Radiation Exposure/ injury
o Time-how long they were exposed
o Distance-how close they were to the source
o Shielding-decreasing exposure by stopping at shield
o External Irradiation-when body itself exposed, all the way

through the body, but the patient doesn’t become radioactive
o Contamination-body has been exposed to source of radiation,

don’t touch someone who is contaminated-need to be
decontaminated-need medical attention very quickly to prevent
incorporation
o Incorporation – patient will have radiation that goes into the cells
of their body-will kill off liver, kidneys, bone, and thyroid
o Nursing care should begin at the scene
 Decontaminate without contamination of rescuers
 Assess presenting symptoms to determine triage
 Triage based on predicted survival
• Probable-minimal or no initial s/s
o CBC, discharge with possible

instructions to return for certain s/s
• Possible-N/V for 24-48 hrs
o Start supportive measures
o Probably go ahead and isolate them

(reverse isolation)
• Improbable-greater than 800 rad of total body

penetrating irradiation-death
o Shock, neurological symptoms
 Decontamination
• First decontamination then triage, should occur

at the scene
• Disaster plan should be in effect
• Immediately notify hospital radiation safety

officer
• Survey for exposure
• Triage outside the hospital if possible to prevent

facility contamination
• Cover floors
• Strict isolation
• Control waste
• Staff should wear dosimeter badges, and

protective covering
• Decontamination should occur outside the

hospital (shower, collection pool, tarp collection
containers for belongings). Provide soap, towels,
disposable paper gowns
• Then survey-decontaminate until free of

contamination
• After survey indicates no external contamination

victim can be sent into hospital
• Biologic samples should be taken
• If client has internal contamination or

incorporation then catharsis and/ or gastric
lavage with chelating agents
• Sample of urine feces, and vomitus may be

surveyed to determine internal effects
o Acute Radiation Syndrome (ARS)
 Severity determined by dose,, rate, total body exposure

and penetrating type radiation
 Age, medical history, and genetics
 Cells that multiply rapidly are most affected

 Hematopoietic system affected first
o Outcome indicators
 Lymphocyte count 48 hours after exposure-300-

1200=significant exposure
 600 rad or more=GI symptoms=NV in 2 hours post

exposure
 1000 rad or more = CNS symptoms
 600-1000 rad effects skin
 5000 rad or more= necrosis in a few days to months
 Secondary injury may be present if exposure due to blast

or burn-trauma increases mortality
o Phases of ARS
 Prodromal phase
• s/s 48-72 hours post exposure
o NV, decreased appetite, fatigue, high

dose=fever, resp distress, excitability
• Monitor lymphocyte count, provide fluids and

electrolytes, if significant exposure isolate to
prevent infection, bleeding precautions
 Latent phase
• Symptom free period
• Lasts up to 3 wks-less if significant exposure
• Decreasing lymphocytes, platelets, leukocytes,

thrombocytes, and RBC’s
• Isolation as needed
• Frequent rest periods
• O2 PRN
• Bleeding precautions
• Supportive measures
 Illness phase
• Infections
• Fluid and electrolyte imbalances
• S/S =bleeding, shock, change in LOC
• Treat symptomatically
• Isolation precautions
 Recovery phase or death
• Can take weeks or months to recover or die
• S/S=increasing ICP is ominous sign of

impending death
• Supportive care
• ABC’s
• www.thepodgame.com
o Can become a disaster worker to see how well you manage your disasters

Nursing in Disasters

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4-25-08 Kathy Batton

• Nurses Role in Disaster Triage

o Triage will be based on utilization of resources to treat the MOST people

o Nurses will still be involved with assessment and basic treatment

• Disaster Triage Categories

o Immediate/ Priority 1/ Red Tagged

 Life threatening injuries that are survivable with minimal interventions

 Examples: airway obstruction, sucking chest wounds, tension pneumothorax,

o Delayed/ Priority 2/ Yellow Tagged

 Can go from yellow to red as they get sicker

o Minimal/ Priority 3/ Green Tagged

o Expectant/ Priority 4/ Black Tagged

• Terrorism Recognition and Awareness

o Be aware of an unusual increase in the number of people with fever of GI problems

o Unusual illness for time of year

o Cluster of client from a specific location

o Large number of rapidly fatal cases with death in 72 hours

o Increase in disease in otherwise healthy population

• Levels of protection for health care workers

o Level A- highest level of respiratory, skin, eye, mucus membrane protection

 Covered from head to toe, breathing apparatus, chemical resistant

o Level D- what you would normally wear plus universal precautions

 Significant morbidity and mortality

 Signs and symptoms similar to common diseases

 May be liquid, dry, applied to foods or water or vaporized

o Most likely weapon to be used (has been used before)

o Naturally occurring in soil

o As an aerosol it is odorless and invisible and can travel for miles

o Causes hemorrhage, edema and necrosis

o Incubation period is 1-6 days

o Use standard precautions

 Signs and symptoms

• edema with pruritis

• macule, papule formation resulting in ulceration

• eschar (painless) develops and falls off in 1-2

 Signs and symptoms

• Nausea and vomiting

• Bloody diarrhea (occ. Ascites)

• Massive diarrhea can result in volume depletion

• Can result in sepsis

• Frequently fatal due to sepsis

• Assess for and maintain adequate fluid status

• Assess for sepsis

 Signs and symptoms

• Mimics flu-in first stage

o Cough, dyspnea (no rhinorrhea or nasal

• After initial s/s brief recover period then 1-3

o Severe respiratory distress, strider,

o 50% have hemorrhagic mediastinitis on

o May progress to meningitis with SA

o Death 24-35 hours

o Mortality rate near 100%

• Use standard precautions

• If antibiotics started within 24 hours after

• Nurses must be vigilant in surveillance

• Penicillin, chloramphenicol, gentamicin or

• For mass exposure and persons exposed but

• Cremation for the dead

• Smallpox/ Variola Major

o Lives 24 hours in cool temperatures

o 30% Mortality rate, morbidity rate extremely high

o Spread by direct contact and contact with clothing, linens, or by

o Contact precautions and droplet precautions