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Safety & Treatment in Disaster Response Basic Biodefense Curriculum Module 3 2005 Modules were developed as part of a grant from the HRSA BTCDP initiative Purpose of Module: B-NICE / CBRNE response procedures Caregiver safety and protective equipment Decontamination Isolation and quarantine Mass casualty care Vulnerable Populations Psychological consequences of disasters Learning Objectives List key safety questions for health care providers Describe principles of disease or exposure containment including decontamination and community-level actions Describe and identify vulnerable populations Describe appropriate personal protective equipment for a given type of exposure Describe the importance of psychological as well as physical care Key Safety Questions Where is it (What is the setting)? • Risks at the scene - safety of rescuers and victims • Risks at off-site treatment centers - safety of caregivers & patients What type of agent(s) are involved? • Use CBRNE or B-NICE What are the routes of exposure? • Can I become contaminated by touching or inhaling? Am I safe? How do I remain safe while I work? • Where are the safety zones • Should Personal Protective Equipment (PPE) be used • What are the protective (prevention) procedures Answers Will Guide Safety Decisions Some methods used to protect and prevent more exposures: Quarantine Isolation Immunization Prophylaxis with medications Decontamination Evacuation or sheltering-in-place Routes of Exposure Injection Inhalation Almost as direct as injection plus affects large crowds Expect large number of casualties at same time Ingested Most direct, but usually affects only one person Exception: infectious disease that spreads over time May affect fewer people, but easier to administer Topical If agent easily absorbed through skin, like inhalation Can affect large crowds May see secondary wave of victims due to contamination Factors Impacting Exposure Length of Time Exposed Longer time agent is in contact; the more that is absorbed Decrease effects by decontaminating (cleaning) skin and moving victims to area where air is clean Quantity of Agent Released Higher quantities of agent increase overall effects. Affected by: • Amount of agent released • proximity to point of origin Preventive Measures To decrease amount of exposure to an agent: • Avoid areas where agent was released • May leave area ahead of release (evacuate) or to stay put during release (shelter-in-place) Scenario: “C” Nerve Agent Scene: Hospital Emergency Department Over 500 begin to swarm Symptoms: uncontrollable secrections Diagnosis: severe organophosphate poisoning Plan: Immediate care is needed, but… …STOP... ASK YOUR SAFETY QUESTIONS… Is the hospital away from the disaster site? YES Which type of exposure? CHEMICAL NERVE AGENT How were they exposed? assume TOPICAL AND INHALED What safety measures are needed? • NEED TO KEEP CLEAN AREAS CLEAN --- DECONTAMINATE BEFORE TREATING • Solution: Set up decontamination area before allowing into hospital Chemical Accident / Injury Event CLEAN FIRST; THEN TREAT For Chemical Exposures Chemical Accident/Injury Event Algorithm Patient is moved to safe area upwind and away from the hazard by Emergency Personnel wearing the appropriate PPE Are Life Saving Procedures Required? YES Are there Unknown or Potentially Life Threatening Contaminants? YES Simultaneously Grossly Decontaminate (i.e. remove clothing and big chunks), cover or wrap contaminated areas to prevent spread to unaffected areas, initiate stabilization / ABC’s No Perform Life-Saving Procedures No Environmental or Patient Condidtions Prevent Further Decontamination YES Cover or wrap patient to prevent spread of contamination to others No Decontaminate by making patient as clean as possible (ACAP - Contamination reduced to a level that is no longer a threat to patient or responder) Further Medical Attention or Surveillance Required No Report to superiors for instructions YES Advise Receiving Medical Facility of Patient Status and Deliver/ Transport as Instructed Undress and Bag Work Uniform Shower - Change into clean clothes Decontaminate Transport Vehicle Crowd Control Line Staging Area Drainage Command Post Access Control Points Decontamination Line Exclusion (Hot) Zone Access Control Points W ind Contamination Reduction (Warm) Zone Support (Cold) Zone Hot Line When the disaster victims come to the hospital: DECONTAMINATION ALGORITHM – AT THE HOSPITAL OR TREATMENT CENTER DECONTAMINATION AREA CLEAN AREA NONAMBULATORY Airway and antidote administration and clothing removal Gurney decontamination Initial Triage: Contaminated? Airway Compromise? Amublatory? Requires decontamination Male Ambulatory decontamination AMBULATORY Female Antidote administration and clothing removal Not exposed, requires no decontamination EXIT Clean area: clean clothing. Triage again Hospital treatment area assigned based upon nature and acuity of signs and symptoms Contaminated Patient Video Scenario: Patient exposed to Copper Sulfate arrives at emergency department Watch how personnel handle the situation And NOTE five (5) things they do to safely care for the patient Chemical Exposure Pearl Treatment of victims of a chemical exposure begins with provider self protection and victim decontamination. Treatment Approaches for Chemical Exposure Decontaminate first, then manage the symptoms Some chemical agents have antidotes Soap and water for blister agents and irritants/corrosives Clean air or oxygen for inhaled agents (e.g., choking) Nerve Agents: atropine, protopam, diazepam Blood Agent (cyanide): amyl nitrite plus sodium thiopental Vesicant (Lewisite): BAL (dimercapral) for severe cases only Supportive care may be only option Suction or supplemental oxygen for breathing Maintain blood pressure Keep comfortable Protection from Exposure Personal Protective Equipment (PPE) Used to protect against biological, chemical, and radiological contamination Includes a range of equipment • May be as simple as wearing gloves to avoid touching • May be as complex as wearing full suits with SelfContained Breathing Apparatus (SCBA) to avoid inhaling The Four Levels of PPE Level Skin Eyes Lungs SCBA Highest A B C Lowest D +++ ++ ++ + +++ ++ ++ + +++ +++ + --- Description YES Self-contained suit that is water and vapor proof, boots, gloves, hardhat YES Splash-resistant clothing with hood, gloves, boots --- Air purifying respirator with goggles and gloves --- Face shield, gloves, glasses, cover clothing PPE: Level D Protection includes: Normal work attire plus Standard Precautions Gloves Goggles, glasses or face shield Face mask (if appropriate) Does not protect from corrosives or vapors PPE: Level C Replace normal attire with a chemical-resistant suit and boots Wear two (2) layers of gloves Add a full hood with mask Add an air-purifying respirator Does not protect from toxic gases PPE: Level B Chemical splash suit with hood Inner and outer chemicalresistant gloves Chemical-resistant boots and covers Add a hard hat Add an external selfcontained breathing apparatus (SCBA) with positive pressure full face piece PPE: Level A Totally encapsulating chemical protective suit that is also vapor proof Inner and outer chemical resistant gloves Chemical resistant boots Hard hat SCBA with positive pressure, full face piece inside suit Scenario: “B” Infectious Agent Meningococcal meningitis case in the dormitory Nature of the disease: Contagious for close contacts Generally treatable with antibiotics Vaccine available Post-exposure prophylaxis option General Approaches for Biological Agents What is the agent? Category A Biological Agents (Treatment): BACTERIA (antibiotics) • Anthrax, Plague, Tularemia VIRUS Smallpox (vaccine, supportive care) Hemorrhagic Fever (supportive care) TOXIN Botulism (antitoxin) Ricin (supportive care) Caregiver Precautions for Infectious Diseases Four Types of Precautions Standard Contact Airborne Droplet Precautions used will vary by mode of transmission of pathogen Standard Precautions Standard Precautions used in routine practice Assumes all bodily fluids are contaminated Standard Precautions involve: Hand washing between patients or after handling specimen Protective physical barriers (gloves, masks, eye protection, face shield, gown over clothes) Appropriate disposal of infectious wastes or specimen Sterilization or disinfection of re-usable equipment Elements of Standard Precautions Contact Precautions Contact may be direct or indirect Examples of contact-borne pathogens Direct: person-to-person Indirect: person-to-fomite-to-person Methicillin-resistant Staphyloccus aureus (MRSA) Clostridium difficile Enterovirus Ebola virus Contact precautions involve Standard Precautions PLUS • Disinfect inanimate objects (e.g., door knobs, telephone receivers) • May opt to restrict movement of infected patients (i.e., isolation) Airborne Precautions Limits spread of infection by small pathogen-laden particles that remain suspended in air for long time and are easily inhaled Examples of airborne pathogens: • Measles virus • Smallpox virus Airborne Precautions involve Standard Precautions PLUS • • • • Negative air pressure room with vent to outside Isolation ward or private room Put mask on patient Wear an N95 respirator instead of face mask Droplet Precautions Use for infections spread by droplets coming into contact with mucus membranes Examples of droplet-borne pathogens: tuberculosis, pertussis (whooping cough) and mumps Droplet Precautions involve: Standard precautions PLUS Isolation ward or private room Limit movement outside of room Maintain at least 3 feet between patient and caregiver Patient wears mask or covers up when coughing or sneezing Community-level Precautions Restrict movement of infected residents Quarantine: • Restricts movement of exposed but asymptomatic (i.e., not ill) people to a room or building • Also keeps people who are not yet exposed out of the area Isolation: • Restricts movement and separation of symptomatic (ill) folks from healthy folks Proper disposal of infected wastes and specimens Mass Clinic for Immunization or Post Exposure Prophylaxis (PEP) Mass Immunization or PEP Clinic • Temporary public health clinic • Immunization - Provides vaccinations for a large number of residents before they are exposed • PEP - Dispenses medications to residents who were most likely exposed to an agent Clinic may offer one or both services To activate a mass clinic, you must have: Confirmation of etiologic (causative) agent Potential for further exposure or spread Available supply of medications or vaccines “N” or “R” Nuclear or Radiological Exposures What is the agent? Nuclear or Radiological What are your local risks? Most radiological exposures are accidental Sources of radiation (may see both in one person) Waves (especially gamma) Particles that are touched, inhaled, or ingested Decontamination Needs Vary by Type of Exposure Irradiation caused by physical contact with radioactive particles: Need to decontaminate skin before treating injuries • • • • Remove clothing to eliminate 70-90% of radiation source Wash skin and exposed areas Removing particles ends radiation exposure Care givers are at risk of radiation exposure if patients NOT decontaminated Irradiation caused by exposure to gamma rays: Nothing to decontaminate – treat injuries • Move away from source of gamma radiation to end exposure • Irradiated patients cannot contaminate healthcare providers General Treatment Approaches for Radiation Exposures For patients exposed only to irradiating waves (no solid particles) For patients exposed to particles, Treat injuries first, then radiation exposure Decontaminate skin, then treat injuries followed by internal decontamination methods Treatments for radiation poisoning Chelating agents to bind radioactive particles inhaled or ingested • Prussian Blue or DTPA Protect thyroid gland • Potassium Iodide Treat bone marrow suppression “E” and “I” Scenario Scene: At a busy metropolitan hospital in the heart of the city Event: A muffled sound similar to a distant sonic boom. Bottles of medication on the shelves rattle momentarily. The ambulance medic says that there is smoke billowing out of the nearby underground metro station. A bomb has exploded. Key Questions: What are your personal safety considerations? What kind of injuries might you expect of those affected by the blast? What will be your initial actions? Will you have enough resources and how long will they last? “E” and “I” Explosive and Incendiary Exposures Injuries may be caused directly by initial blast Or indirectly due to: • • • • Collapse of structures Flying debris Secondary explosions Fire Injuries due to Explosion Some may be internal or delayed and not readily apparent Types of injuries associated with explosions: • • • • • Penetrating and blunt trauma Blast lung or ear drum rupture Traumatic brain Injury Amputations Eye Injuries “E” and “I” Explosive and Incendiary Exposures Fire-related injuries Most deaths related to inhalation of smoke or fumes, not burns • Respiratory symptoms occur most quickly • Other symptoms may be delayed Vulnerable Populations What is a Vulnerable Population? Why are they vulnerable? People or animals who are at increased risk of injury or death Very young or very old Physical or mental limitations Language or cultural barriers Pre-existing medical conditions Domestic and wild animals Who are the vulnerable populations in your community? Where are they located? Issues to Consider Plans and Responses need to consider people who: Confined to home Not able to communicate Cannot understand information Require assistance to travel Need adjustments to treatments Cannot advocate for themselves Psychological Consequences of Disasters Not everyone experiences physical effects during a disaster but most will have some psychological reaction during or after an event Need to have plan for mitigating psychological effects: Example: Critical Incident Stress Debriefings (CISD) • Minimizes post-traumatic stress disorders in first responders Need to include health care workers Community recovery will depend on psychological and physical health Common Symptoms of Excessive Stress: If you or another responder displays some or all of these symptoms, it may mean excessive stress: Easily distracted or inability to concentrate Quick to anger Depressed with or without anxiety Substance abuse Change in weight Change in sleep patterns Summary Basic BioBio-Defense Project Emergency Preparedness Curriculum Safety First Take steps to ensure your own safety as well as that of your patients Care Components for B-NICE / CBRNE agents Use current information for controlling contamination and treating patients exposed to these agents Your plan should include procedures for decontamination, quarantine, iIsolation, and mass clinic-treatment options Determine who the vulnerable populations are in your community Plan to attend to psychological as well as physical injuries during and after a disaster Basic BioBio-Defense Project Authors Jean Carter Sandra Kuntz Earl Hall Steven Fehrer Steven Glow Emergency Preparedness Curriculum Jacqueline Elam Michele Sare Lisa Wrobel Michael Minnick Modules prepared as part of the Montana Basic BioDefense Curriculum For Pharmacy, Nursing, and Allied Health Funded by the HRSA CFDA 93.996 initiative Photo Credits Basic BioBio-Defense Project Emergency Preparedness Curriculum Do not reproduce individual photos or videoclips without permission from original source. A list of photo credits was included in the instructor’s packet. To request a copy of the photo credits, send an email to [email protected] Modules prepared as part of the Montana Basic BioDefense Curriculum For Pharmacy, Nursing, and Allied Health Funded by the HRSA CFDA 93.996 initiative