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Introduction |
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Threat of NBC Terrorism |
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Chemical Casualty Care |
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Biological Casualty Care |
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Radiological Casualty Care |
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Special Hospital Considerations in NBC Terrorist
Incidents |
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Additional Information for Independent Reading |
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Train healthcare providers to initiate the
correct medical response and treatment actions in a Nuclear, Biological, or
Chemical (NBC) terrorist incident, including: |
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Identifying various threat agents, and the signs
and symptoms of exposure to them |
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Selecting the proper treatment for resulting
conditions |
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Identifying special threats to healthcare
providers, such as secondary contamination |
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Nuclear Materials |
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Biological Agents |
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Chemical Agents |
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HMI NBCTI |
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Deliberate attack D |
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Greater agent toxicity D |
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Early hazard identification x |
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Potential for mass casualties D |
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Need for mass decontamination D |
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Unusual risk to D |
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healthcare providers |
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To familiarize you with |
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Recent NBC events |
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The potential for terrorist use of NBC agents |
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Sources and hazards of NBC agents |
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Targets and indicators of NBC attacks |
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Outcomes of NBC terrorist events |
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So that you can recognize an NBC attack and
understand the potential impacts |
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Lone individual |
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Identified local or non-aligned terrorist groups |
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Internationally sponsored |
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Doomsday cults |
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Insurgents |
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Agents are available & relatively easy to
manufacture |
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Large amount not needed in enclosed space |
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NBC incident difficult to recognize |
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Easily spread over large areas |
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Psychological impact |
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Can overwhelm existing resources |
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B’nai B’rith, Washington, D.C. |
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April 1997 |
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30 persons decontaminated |
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Effective dissemination difficult |
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Delayed effects can detract from impact |
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Counterproductive to terrorists’ support |
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Potentially hazardous to the terrorist |
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Development and use require skill |
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Home production |
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Laboratory / commercial production |
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Industrial facilities |
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Foreign military sources |
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Medical / university research facilities |
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Enclosed spaces |
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Large crowds (high profile events) |
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Critical facilities and infrastructure |
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Accessible facilities with significant hazard / damage
potential (materials in transit) |
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Facilities of interest to terrorists’ cause |
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It can’t happen to us |
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NBC agents are so deadly the victims will all
die anyway |
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There is nothing we can do |
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Use FBI video OR additional slides; not both |
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Update module with recent local incidents |
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Points to emphasize |
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Terrorist groups have means, motive, opportunity |
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NBC agents have far-reaching effects |
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Advantages and limitations of NBC agents |
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Identify potential targets in your community |
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Describe types of chemical warfare agents |
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Recognize signs and symptoms of exposure |
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Describe management of chemical agent attack
victims |
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Chemicals used in military operations to
kill, injure, or incapacitate |
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Battlefield use |
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World War I and Middle East conflicts |
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Terrorist use |
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Matsumoto and Tokyo, Japan |
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Matsumoto: |
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Approximately 280 injured |
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7 dead |
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Tokyo |
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12 dead |
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Approximately 1,000 hospitalized |
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5,500 sought medical care |
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10% of first responders
injured |
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Tabun, Sarin, Soman, VX |
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Mustard, Lewisite |
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Phosgene, Chlorine, Ammonia, Cyanide |
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Mace®, Pepper Spray |
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Nerve Agents |
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Vesicants |
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Industrial Chemicals |
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Riot Control Agents |
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Tabun (GA), Sarin (GB), Soman (GD), VX |
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Most toxic of the chemical agents |
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Penetrate skin, eyes, lungs |
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Loss of consciousness, seizures, apnea, death after large amount |
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Diagnosis made clinically; confirmed in
laboratory (cholinesterase) |
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Organs with cholinergic receptors |
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Muscarinic |
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Smooth
muscles |
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Glands |
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Nicotinic |
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Skeletal
muscles |
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Ganglia |
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Increased secretions |
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Saliva |
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Tears |
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Runny nose |
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Secretions in airways |
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Secretions in gastrointestinal tract |
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Sweating |
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Smooth muscle contraction |
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Eyes:
miosis |
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Airways:
bronchoconstriction (shortness of breath) |
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Gastrointestinal: hyperactivity (nausea, vomiting, and diarrhea) |
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Skeletal muscles |
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Fasciculations |
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Twitching |
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Weakness |
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Flaccid paralysis |
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Other (ganglionic) |
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Tachycardia |
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Hypertension |
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Cardiovascular |
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Tachycardia, bradycardia |
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Heart block, ventricular arrhythmias |
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Central Nervous System |
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Acute |
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Loss of consciousness |
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Seizures |
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Apnea |
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Prolonged (4-6 weeks) |
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Psychological effects |
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Mild exposure |
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Miosis (dim vision, eye pain), rhinorrhea,
dyspnea |
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Moderate exposure |
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Pronounced dyspnea, nausea, vomiting, diarrhea,
weakness |
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Severe exposure |
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Immediate loss of consciousness, seizures,
apnea, and flaccid paralysis |
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Vapor effects occur within seconds, peak within
minutes; no late onset |
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Mild exposure (to 18 hours) |
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Localized sweating |
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Fasciculations |
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No miosis |
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Moderate exposure (<LD50) (to 18
hours) |
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Gastrointestinal effects |
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Miosis uncommon |
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Severe exposure (LD50) (<30
minutes) |
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Sudden loss of consciousness |
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Seizures |
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Apnea |
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Flaccid paralysis |
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Death |
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Symptomatic |
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May be systemic or organ-specific |
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Combination of symptoms is more definitive |
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Situational |
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Multiple casualties with similar symptoms |
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Time or location factors in common |
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Airway/ventilation |
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High resistance |
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Antidotes |
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Atropine |
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2-PAMCl |
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Diazepam |
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Atropine |
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Antagonizes muscarinic effects |
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Dries secretions; relaxes smooth muscles |
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Given IV, IM, ET |
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No effect on pupils |
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No effect on skeletal muscles |
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IV in hypoxic patient Ù ventricular fibrillation |
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Starting dose - 2 mg |
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Maximum cumulative dose - 20 mg |
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Total dose calculated over time; but enough must
be administered to abate severe symptoms if casualty is to survive |
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Insecticide poisoning requires much more |
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Side effects in normal people |
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Mydriasis |
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Blurred vision |
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Tachycardia |
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Decreased secretions and sweating |
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Atropine - How much to give? |
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Until secretions are drying or dry |
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Until ventilation is “easy” |
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If conscious or casualty is comfortable |
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Do not rely on heart rate/pupil size |
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Pralidoxime Chloride (2PAM-Cl) |
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Remove nerve agent from AChE in absence of aging |
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1 gram slowly (20-30 minutes) in IV infusion |
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Hypertension with rapid
infusion |
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No effects at muscarinic
sites |
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Helps at nicotinic sites |
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Diazepam |
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Decreases seizure activity |
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Reduces seizure-induced brain injury |
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Give to severely-intoxicated casualties whether
convulsing or not |
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Treatment regimen |
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No signs/symptoms |
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Reassure |
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Observe |
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Vapor: 1
hour |
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Liquid:
Up to 18 hours |
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Mild vapor exposure |
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Miosis, rhinorrhea - observation only |
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Increasing SOB - treat |
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Mild liquid exposure |
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Localized fasiculations & sweating - treat |
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One MARK I kit (2 mg atropine/ 600 mg 2 -PAMCl) |
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OR |
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1 gram 2-PAMCl IV |
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2 mg atropine, IM or IV |
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Parenteral atropine will not reverse miosis |
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Moderate vapor or liquid exposure |
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One or two MARK I kits |
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Or give IV: |
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2 to 4 mg atropine |
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1gm 2-PAMCl (infusion) |
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Severe - vapor or liquid |
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Give 3 MARK I kits or 6 mg atropine and 1 gram
of 2-PAMCl as soon as possible |
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Airway |
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Ventilation/O2 |
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Consider diazepam 10 mg IM (2 to 5 mg IV) |
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Repeat atropine every 5 to10 minutes as needed |
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Repeat 2-PAMCl in one hour |
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Atropine |
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Infant (0 to 2) 0.5 mg IM |
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IV for infants and children 0.02 mg/kg |
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Child (2 to 10) 1.0 mg IM |
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Adolescent (> 10) 2.0 mg |
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Elderly 1.0 mg IM |
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2-PAMCl |
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< 20 kg 15 mg/kg IV |
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> 20 kg 600-mg IM autoinjector |
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Elderly 1/2 adult dose (7.5 mg/kg IV) |
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2 PAMCl-induced hypertension |
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Phentolamine Adult 5 mg IV |
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Child 1 mg IV |
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Vapor exposure |
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Symptoms develop suddenly |
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Most ambulatory victims require minimal
intervention |
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Risk of secondary contamination, which is
minimized by removing the victim’s clothing |
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Requires immediate access to antidotes |
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Quickly cyclizes in tissue |
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Alkylates cell components, including DNA |
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DNA damage, cell death |
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Mild conjunctivitis |
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Moderate/severe conjunctivitis, lid inflammation
and edema, blepharospasm, and corneal roughening |
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Corneal opacification, ulceration, and/or
perforation |
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Well over 95% had only mild to moderate
conjunctivitis |
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Under 1% had permanent damage to cornea |
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Erythema |
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Small vesicles; later coalesce |
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Blisters/bulla |
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Possible coagulation necrosis with liquid |
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Upper:
nose sinuses, pharynx |
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(epistaxis, sore throat, hacking cough) |
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Mid:
Larynx (hoarseness) |
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Lower:
Bronchioles (dyspnea, productive cough) |
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Pulmonary edema is rare |
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Gastrointestinal |
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Within 24 hours |
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Nausea and vomiting |
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Cholinergic effects |
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After 3 to 5 days |
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Tissue destruction |
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Damages stem cells |
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Decreased WBC, RBC, platelets after 3 - 5 days |
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Survival rare if WBC < 200 |
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Decontamination must be done within minutes to
reduce damage |
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Delays in decontamination will not prevent
illness, but will prevent cross-contamination |
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Supportive care - soothing lotions, frequent
irrigation, topical antibiotics, pain medication |
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Do NOT overhydrate; not a thermal burn |
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Topical mydriatics |
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Topical antibiotics |
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Vaseline on lid edges |
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Topical steroids (only in the first 24 hrs) |
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Cool mist, cough suppressants for mild symptoms |
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Oxygen |
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Assisted ventilation |
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Early intubation |
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Bronchodilators (steroids) |
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Antibiotics AFTER organism identified |
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Causes severe irritation to eyes, skin, and
airways IMMEDIATELY on exposure (no delay) |
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Tissue necrosis,
pseudomembranes |
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Increased capillary
permeability |
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No bone marrow
effects |
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Immediate decontamination |
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British anti-Lewisite (BAL) for systemic effects |
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Supportive Care |
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Oxygen |
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Agents damage eyes, skin, respiratory system;
cause additional systemic effects |
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Mustard |
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Fast acting; symptoms delayed, no specific
antidote |
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Lewisite |
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Fast acting, symptoms immediate, BAL antidote
available |
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Decontamination is best initial treatment |
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At high concentrations: |
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Irritates eyes, nose, upper airways; possible
laryngospasm |
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Toxic to lungs by inhalation |
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Carbonyl group damages alveolar-capillary
membrane |
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Non-cardiac pulmonary edema: onset 2 to 12 hours |
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Dyspnea, cough with sputum |
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Management of non-cardiac pulmonary edema |
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Hypoxia, fluid loss; requires pulmonary care,
careful fluid replacement |
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ABSOLUTE REST POST-EXPOSURE |
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High concentration or prolonged exposure |
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Pulmonary edema, sudden death |
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Eye irritation, cough, dyspnea |
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More severe airway and lung |
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damage with high concentration |
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Management |
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Remove from exposure; manage airway |
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Oxygen, ventilation, PEEP |
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Intubation, bronchodilators |
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Anhydrous Ammonia |
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pH>12; (household ammonia pH < 12) |
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Wide industrial use |
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Plastics, fertilizer, explosives |
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Irritating, corrosive; causes necrosis, severe
pain |
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Serious injury to eyes, lungs, skin, GI tract |
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Management |
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Remove from exposure, decontaminate |
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Symptomatic; maintain airway |
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Irritating agents, lacrimators, “tear gas” |
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Cause reaction in |
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Eyes:
burning, tearing, eyelid spasm, redness |
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Airways:
burning, coughing, dyspnea |
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Skin:
burning, erythema |
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Eye irrigation and supportive care |
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Vapor exposure |
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Nerve agent symptoms develop suddenly, mustard
and phosgene symptoms are delayed |
|
Most ambulatory victims require minimal
intervention |
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Risk of secondary contamination |
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Requires airway management; antidotes for nerve
agents and Lewisite |
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Liquid exposure |
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Symptoms delayed minutes to hours |
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Greater
need for decontamination |
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Risk of secondary contamination, victims require
clothing removal & decontamination |
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Requires immediate access to antidotes |
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Be able to describe the various types of
biological warfare agents and recognize the signs and symptoms of
exposure. |
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Be able to describe how to properly manage and
treat infectious victims |
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Know which agents are a risk for secondary
transmission and how to protect against this spread using personal
protective equipment (PPE) and isolation measures. |
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Oldest of the NBC triad of agents |
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Used for > 2,000 years |
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Sieges of middle ages |
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Smallpox blankets given to Native Americans |
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Germany in World War I |
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Japan in World War II |
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Large epidemic with high illness and death rate |
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HIV(+) individuals may have first susceptibility |
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Respiratory symptoms predominate |
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Infection non-endemic for region |
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Multiple, simultaneous outbreaks |
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Multi-drug-resistant pathogens |
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Sick or dead animals |
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Delivery vehicle or intelligence information |
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Travel history |
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Infectious contacts |
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Employment history |
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Activities over the preceding 3 to 5 days |
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Bacteria |
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Single celled microorganism |
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Invade tissue; cause inflammatory reaction or
produce toxins |
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May form spores |
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Anthrax |
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Plague |
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Tularemia |
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Q Fever |
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Bacillus anthracis - gram +, spore-forming
bacillus |
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Endemic infection in animals |
|
Humans develop infection naturally from handling
contaminated fluids or hides (“Woolsorters Disease”) |
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Inoculation, ingestion, or inhalation of spores
which may travel to the regional lymph nodes |
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Vegetative bacteria produce edema factor and
lethal factor (toxins) |
|
Inhalation route has highest mortality and is
most likely route to be used by terrorists |
|
Inhaled anthrax causes a mediastinitis rather
than a pneumonia |
|
Untreated skin infection - 21% mortality if
septicemia develops (treated 1%) |
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2 to 6-day incubation period followed by fever,
myalgias, cough, and fatigue |
|
Initial improvement followed by abrupt onset of
respiratory distress, shock, and death in 24 to 36 hours |
|
Physical findings are nonspecific, pneumonia is
rare |
|
Chest x-ray - may show widened mediastinum with
or without a bloody pleural effusion |
|
50 % of cases have associated hemorrhagic
meningitis |
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No documented cases of person-to-person
transmission of inhalational anthrax has ever occurred |
|
Cutaneous transmissions are possible |
|
Universal precautions required |
|
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An accident at a Soviet military compound in
Sverdlovsk (microbiology facility) in 1979 resulted in an estimated 66
deaths downwind. |
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Clinical picture of sudden onset of respiratory
distress with mediastinal widening on x-ray |
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A small number of patients may present with GI
or cutaneous anthrax |
|
Gram stain of blood and blood cultures - but
these may be late findings in the course of the illness |
|
ELISA and immunohistology testing may confirm
diagnosis but samples must go to reference laboratory |
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Acute Treatment |
|
Usually futile in severe mediastinitis patients
who inhaled or ingested spores |
|
Ciprofloxacin - 400 mg IV q 8 to 12 hr |
|
Doxycycline - 100 mg IV q 12 hr X 4 wks |
|
Vaccination begins at the start of drug therapy |
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Prophylaxis |
|
Penicillin |
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Doxycycline |
|
IV Therapy |
|
Penicillin |
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Doxycycline |
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|
Yersinia pestis - gram(-), non-motile, non-spore
forming bacillus |
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|
Fleas living on infected rodents spread
infection to humans |
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Recovery offers temporary immunity |
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Produces disease by being consumed by
macrophages and transported to regional lymph nodes, causing regional
adenitis |
|
Bacteremia - spread to other organs (lungs,
spleen, liver, and brain) |
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Secondary transmission is possible and likely |
|
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2 to 3 day incubation period followed by high
fever, myalgias, chills, HA, and cough with bloody sputum |
|
In contrast to anthrax, pneumonia and sepsis
develop acutely and may be fulminant with patients developing dyspnea,
stridor, cyanosis, and circulatory collapse |
|
Patchy infiltrates or consolidation seen on
chest x-ray |
|
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|
|
Erythema, fever, rigors |
|
Bubo formation in regional lymph nodes |
|
Bubo aspiration and gram stain is diagnostic |
|
Differentiate from |
|
Tularemia |
|
Cat-scratch fever |
|
Staph-strep lymphadenitis |
|
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|
|
Gram stain and culture of lymph node aspirates,
sputum, or CSF samples |
|
Bipolar staining “Safety Pin” may be present |
|
Immunoassays are also available |
|
|
|
|
Care is otherwise supportive |
|
Vaccine effective only for bubonic plague |
|
Prophylaxis - tetracycline or doxycycline |
|
|
|
Antibiotics must be started within 24 hours of
symptoms to impact survival |
|
Streptomycin (30 mg/kg/day IM divided BID for 10
days) |
|
Doxycycline (100 mg IV BID for 10 days) |
|
Chloramphenicol for plague meningitis |
|
|
|
|
Prophylaxis |
|
Doxycycline |
|
Trimethoprim/Sulfamethoxazole |
|
IV Therapy |
|
Streptomycin (over 1 year of age) |
|
Gentamicin |
|
Chloramphenicol |
|
|
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|
Smallpox |
|
Viral Hemorrhagic Fevers (VHF) |
|
Venezuelan Equine Encephalitis (VEE) |
|
|
|
|
RNA or DNA within a protein coat |
|
Require a host to function and survive |
|
Many viruses attack a specific type of cell
causing disease or cancer |
|
|
|
|
May cause disease through direct cytopathic
effect, immune complex deposition and other effects |
|
May result in end-organ system failure, vascular
damage |
|
|
|
Few antiviral medications available |
|
|
|
Vaccination is the most effective means of
preventing infection |
|
|
|
|
Variola (Var-ï-óla) virus, an Orthopox virus,
both minor and major forms of smallpox exist |
|
Structure is a large DNA virus |
|
Declared eradicated in 1980 and the U.S. stopped
its civilian vaccination in 1981, U.S. military stopped in 1985 |
|
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|
In 1963, en route by air from Australia to
Sweden, a seaman stops in Djakarta, Singapore, Rangoon, Calcutta, Karachi,
Teheran, Damascus, and Zurich |
|
Fifteen days later he develops a fever and rash |
|
Diagnosed with smallpox; 19 cases identified |
|
More than 300,000 vaccinated worldwide |
|
|
|
|
DIAGNOSIS |
|
Clinical presentation |
|
Demonstrate virus from vesicular sampling via
electron microscopy |
|
Confirmation by tissue culture |
|
|
|
|
Contagious |
|
All contacts are quarantined for at least 17
days |
|
Infectious until all scabs are healed over |
|
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|
|
|
|
RNA viruses causing high fevers and generalized
vascular damage |
|
Human infections by insect bites or by contact
with blood and body fluids |
|
|
|
|
Fever, myalgias, prostration |
|
Cases evolve into shock and generalized
mucous membrane hemorrhage |
|
Conjunctival injection, petechial hemorrhage,
and hypotension |
|
Abnormal renal and LFT - poor prognosis |
|
Mortality varies; 50 - 80% Ebola Zaire |
|
Disease severity and survival depends on various
host factors; target organ is the vascular bed. |
|
|
|
|
|
Hemodynamic resuscitation and monitoring |
|
Invasive Swan Gantz catheter as feasible |
|
Careful fluid management |
|
use of colloid |
|
Vasopressors and cardiotonic drugs |
|
Cautious sedation and analgesia |
|
No anti-platelet drugs or IM injections |
|
Coagulation studies and replacement of clotting
factors / platelet transfusions |
|
|
|
|
|
No vaccine is available at this time |
|
Single room w/ adjoining anteroom as only
entrance |
|
handwashing facility with decontamination
solution |
|
Negative air pressure if possible |
|
Strict barrier precautions |
|
gloves, gown, mask. shoe covers, protective
eyeware/faceshield |
|
consider HEPA respirator for prominent
hemorrhage, vomiting, diarrhea, cough |
|
|
|
|
Chemical toilet |
|
All body fluids disinfected |
|
Disposable equipment/sharps into rigid
containers and autoclaved/incinerated |
|
Double-bag refuse-outside bag disinfected |
|
Electronic/mechanical equipment can be
paraformaldehyde disinfected |
|
|
|
|
|
|
Wash / irrigate wound site immediately |
|
Mucous membranes (eye, mouth, nose) |
|
Continuous irrigation with rapidly flowing water
or sterile saline for >15 minutes |
|
Skin |
|
Scrub for >15 minutes while copiously soaking
the wound with detergent solution |
|
Germicidal solution |
|
(Dilute 1 part laundry bleach with 9 parts tap
water) |
|
|
|
|
|
|
April 5, 1995 -
Zaire laboratory worker - fever and bloody diarrhea |
|
May 17 - 93 cases - 92% fatality - most cases
were in health care providers |
|
June 25 - 296 cases |
|
|
|
|
Botulinum |
|
Ricin |
|
Staphylococcal Enterotoxin B (SEB) |
|
|
|
|
Naturally produced poisons |
|
More toxic per weight than manmade chemical
agents |
|
Non-volatile |
|
Minimal absorption in intact skin |
|
Not prone to person-to-person transmission |
|
|
|
|
Neurotoxin produced by Clostridium botulinum -
Botulism |
|
Most lethal compound per weight (15,000 times
more toxic than the nerve agent VX) |
|
Different toxicity if inhaled or ingested |
|
|
|
|
Blocks the release of ACh at 3 places in the
presynaptic terminal of the neuromuscular junction and autonomic nervous
system |
|
Bulbar palsies and skeletal muscle weakness |
|
|
|
|
|
Descending paralysis |
|
Bulbar palsies |
|
blurred vision |
|
mydriasis |
|
diplopia |
|
ptosis |
|
photophobia |
|
dysphagia |
|
dysarthria |
|
|
|
|
|
Clinical diagnosis - bulbar palsy with
descending paralysis |
|
Mouse neutralization assay can confirm diagnosis |
|
Treatment is supportive |
|
Long-term mechanical ventilation |
|
Antitoxins are available; must be administered
early |
|
CDC vaccine protective for A and B toxins |
|
|
|
|
Toxic by multiple routes of exposure |
|
Can be dispersed as an aerosol |
|
Effective orally, by injection, or inhalation |
|
|
|
|
|
|
Fever, chest tightness, cough, SOB, nausea, and
joint pain 4 to 8 hours after inhalation |
|
Airway necrosis and edema leads to death in 36
to 72 hours |
|
Ingestion causes N,V, severe diarrhea, GI
hemorrhage, and necrosis of the liver, spleen, and kidneys - shock and
death within 3 days |
|
Injection causes marked necrosis of muscles and
lymph nodes with multiple organ failure leading to death |
|
|
|
|
DIAGNOSIS |
|
Difficult |
|
Routine labs are nonspecific |
|
ELISA of blood |
|
Immunohistochemical tests may confirm |
|
|
|
|
|
BW EXPOSURE: WET OR DRY AGENT AEROSOLS |
|
BACTERIAL AGENTS |
|
LETHAL: Anthrax,
Tularemia, Plague |
|
NON-LETHAL:
Q Fever |
|
|
|
VIRAL AGENTS |
|
LETHAL: Smallpox
/ Monkeypox, Viral Hemorrhagic Fevers |
|
NON-LETHAL: Venezuelan Equine Encephalitis |
|
|
|
TOXINS |
|
LETHAL: Ricin,
Botulinum Toxin A |
|
NON-LETHAL:
Staphyloccal Enterotoxin B |
|
|
|
SECONDARY INFECTION IS POSSIBLE WITH |
|
Plague, Smallpox/Monkeypox, and VHF |
|
|
|
|
Case Study |
|
|
|
Emergency departments always seem busier during
a full moon despite evidence to the contrary. Tonight was no exception.
Over a 6-hour period, it seemed that almost half of the patients
presented with similar complaints of high fever, cough, shortness of
breath, and generalized ill feeling.
Five young, previously healthy individuals required intubation and
mechanical ventilation for severe respiratory distress. Strangely, most of the patients knew
each other from work and none of their family members were suffering
similar symptoms. At 11 p.m., the
only other community hospital in the area went on diversion because all of
their intensive care unit (ICU) beds were full and their need for
mechanical ventilators was at a critical level. The public health officer on call was not aware of any recent
infectious outbreak. |
|
|
|
|
What might the causative agent be? |
|
How could you identify common factors which
might relate the patients to each other? |
|
How long ago might the attack have occurred? |
|
If you are suspicious that patient illnesses
could be the result of a biological attack, whom should you notify? |
|
What precautions should you and other healthcare
providers take? |
|
|
|
|
|
|
Be able to describe the various types of
radiological hazards. |
|
Become familiar with the acute health effects
from radiation contamination and exposure. |
|
Become familiar with the principles of
diagnosis, treatment and management of radiation casualties. |
|
|
|
|
Simple radiological device |
|
Radiological dispersal device |
|
Reactor |
|
Improvised nuclear device |
|
Nuclear weapon |
|
|
|
|
Ionizing radiation is electromagnetic energy or
energetic particles emitted from a source. |
|
|
|
Ionizing radiation is able to strip electrons
from atoms causing chemical changes in molecules. |
|
|
|
|
|
|
2 neutrons and 2 protons |
|
Highly ionizing |
|
Travels several centimeters in air and a few
microns in tissue |
|
Component of nuclear fallout |
|
Stopped by a thin paper or clothing |
|
Threat is inhalation or absorption of alpha
emitter in wounds |
|
|
|
|
|
High energy “electron” emitted from nucleus |
|
Can have wide range of energies depending upon
the particular radionuclide |
|
Moderately penetrating |
|
Up to a few meters in air |
|
Millimeters in tissue |
|
|
|
|
High energy rays |
|
Very penetrating |
|
Difficult to shield |
|
Can be produced from radioactive decay and a
nuclear weapon explosion or reactor accident |
|
|
|
|
Neutral particle emitted from the nucleus |
|
Can be very penetrating |
|
Requires special consideration for shielding |
|
|
|
|
|
|
Time required for a radioactive substance to
lose half of its radioactivity |
|
Each radionuclide has a unique half-life |
|
Half-lives range from extremely short (fraction
of a second) to millions of years |
|
|
|
Examples: |
|
Tc-99m 6.0 hrs |
|
I-131 8.05 days |
|
Co-60 5.26 yrs |
|
Sr-90 28.1 yrs |
|
Pu-239 24,400 yrs |
|
U-238 4,150,000,000 yrs |
|
|
|
|
rad - basic unit for measuring radiation |
|
rem - quantifies the amount of damage that is
suspected from a particular type of radiation dose |
|
|
|
|
Natural background and manmade radiation
360 mrem / yr |
|
Diagnostic chest x-ray 10 mrem |
|
Flight from LA to Paris 4.8 mrem |
|
Barium enema 800 mrem |
|
Smoking 1.5 ppd
16,000 mrem / yr |
|
Heart catheterization 45,000 mrem |
|
Mild acute radiation sickness 200,000 mrem |
|
LD50 for irradiation 450,000 mrem |
|
|
|
|
External irradiation - whole-body or
partial-body |
|
Contamination by radioactive materials -
external (deposited on the skin) or internal (inhaled, swallowed, absorbed
through skin, or introduced through wounds) |
|
Incorporation of radioactive materials - uptake
by body cells, tissues, or organs (bone, liver, kidney, etc) |
|
Combined radiation injury - combination of the
above complicated by trauma. |
|
|
|
|
|
|
|
|
|
|
|
We know what radiations are produced |
|
We know how to measure them |
|
But the body senses cannot detect
radiation. Therefore, how can we
measure the biological damage? |
|
LD50/30 Animals |
|
LD50/60 Human |
|
|
|
|
Species Dose (rads) |
|
Guinea Pigs 250 LD 50/30 |
|
Goat 350
LD 50/30 |
|
Man 250-450 (LD 50/60) |
|
Mouse 570 LD 50/30 |
|
Rat 550-800 LD 50/30 |
|
Frog 700
LD 50/30 |
|
Snail 8,000-20,000 LD 50/30 |
|
|
|
|
The higher the dose, the more severe the early
effects and the greater the possibility of delayed effects |
|
|
|
|
|
Group of symptoms that develop after total body
irradiation (> 100 rads) |
|
May occur from either internal or external
radiation |
|
Four important factors are: |
|
High Dose |
|
High Dose Rate |
|
Whole Body Exposure |
|
Penetrating Radiation |
|
|
|
|
Prodromal Phase - occurs in the first 48 to 72
fours post-exposure and is characterized by nausea, vomiting, and
anorexia. At doses below about 500
rads last 2 to 4 days. |
|
Latent Phase - follows the prodromal phase and
lasts for approximately 2 to 2 1/2 weeks.
During this time, critical cell populations (leukocytes, platelets)
are decreasing as a result of bone marrow insult. The time interval decreases as the dose increases. |
|
Illness Phase - period when overt illness
develops |
|
Recovery or Death Phase - may take weeks or
months |
|
|
|
|
|
|
|
|
Radiation > 600 rads |
|
Damages intestinal lining |
|
Nausea and vomiting within the first 2 - 4 hours |
|
May develop diarrhea |
|
Associated with sepsis and opportunistic
infections |
|
At 10 days could develop bloody diarrhea
resulting in death |
|
|
|
|
Seen with radiation dose > 1,000 rads |
|
Microvascular leaks Õ edema |
|
Elevated intracranial pressure |
|
Death within hours |
|
|
|
|
|
|
Radiation and Trauma = á Mortality |
|
|
|
Trauma is the first priority |
|
|
|
|
Wound and burn care, surgery, and orthopedic
repair should be done in the first 48 hours or delayed for 2 to 3 months |
|
|
|
|
|
|
|
Patients are classified in three categories
based on signs and symptoms: |
|
Survival probable < 100 rads |
|
Survival possible 200 - 800 rads |
|
Survival improbable > 800 rads |
|
|
|
|
Various medications can be used to limit uptake
or facilitate removal of radioactive material |
|
Numerous medications are approved by the
FDA. Certain drugs are
investigational and can be used in an emergency (i.e. Radiogardase
[Prussian Blue] and DTPA) |
|
NCRP 65 |
|
|
|
|
|
|
No antidote for radiation exposure - treatment
is primarily supportive |
|
Minimal risk to responding personnel from
radiation contaminated patients |
|
Early symptoms are an indication of the severity
of the radiation dose |
|
Consult with specialists for “survivable groups” |
|
Treat life-threatening injuries first |
|
|
|
|
|
|
Describe the unique principles of triage, agent
detection and decontamination in an NBC mass casualty incident (MCI) |
|
|
|
List factors to be considered in planning
emergency response to a terrorist attack involving weapons of mass
destruction |
|
|
|
|
|
A medical disaster occurs when the destructive
effects of natural or manmade forces overwhelm a community’s ability to
properly allocate existing resources |
|
Terrorism’s impact on the medical infrastructure |
|
World Trade Center Bombing - 6 dead; 1000
injured |
|
Oklahoma City Bombing - 168 dead; 759 injured |
|
Tokyo Subway Attack - 12 dead; 5500 injured |
|
|
|
|
Hospitals provide most of the initial care |
|
High risk of secondary contamination |
|
Personal protective equipment is required |
|
Disaster planning must address NBC |
|
Maximize use of existing resources |
|
|
|
|
Preparedness for an MCI |
|
Training |
|
Command, control, communication |
|
PPE |
|
Decontamination |
|
Detection |
|
|
|
Triage |
|
Staff preparedness |
|
Logistics / supplies |
|
Hospital space utilization |
|
Evidence preservation |
|
Exercising “ the plan” |
|
|
|
|
Planning similar to other disasters |
|
Unique characteristics of an NBC terrorist
attack must be considered |
|
Pro-active and integrated planning,
coordination, and training is essential |
|
Must be familiar with local incident management
system |
|
“All hazards approach” to disaster planning |
|
|
|
|
|
Must improve state of readiness |
|
Training and equipment lacking |
|
Agent recognition |
|
Patient management |
|
Patient decontamination |
|
Patient transport |
|
Supplies and equipment |
|
Antidote |
|
PPE |
|
Decontamination |
|
|
|
|
Take a genuine inventory of current capabilities
and rectify
any deficiencies |
|
Instruct personnel about the disaster plan using
realistic scenarios |
|
Ensure plan addresses triage, decontamination,
and treatment |
|
|
|
|
|
|
Develop strategies to overcome resistance to
preparedness |
|
Incorporate responsible people in the planning
process |
|
Keep the plan cost effective |
|
Plan for problems that may occur |
|
Communication and sharing of information |
|
Security, traffic control, hospital access |
|
Staff identification, triage, decontamination,
information management |
|
|
|
|
|
Participate in joint planning |
|
Work together with EMS, law enforcement, fire,
LEPC |
|
Integrate plan into community-
wide disaster plan |
|
Develop mutual aid agreements |
|
Develop policies and procedures |
|
|
|
|
|
Acquire necessary equipment |
|
Purchase PPE and decontamination equipment and
provide training |
|
Stockpile antidotes & other medications |
|
Make sure facility remains open and viable |
|
|
|
|
Focus shifts from acute injury and illness to
the everyday needs of the population |
|
May have increased need for medications,
shelter, food, water, clothing, and emotional support |
|
Hospital staff emotional needs and fatigue |
|
|
|
|
Hospitals must first prepare to treat the
everyday HAZMAT contaminated patient |
|
Once established, HAZMAT training should be supplemented to include NBC |
|
Training must be facility-wide and tailored to
the needs of the hospital staff |
|
Train using realistic scenarios |
|
Equipment training available from commercial
sources |
|
Public education should also be considered |
|
|
|
|
|
Community orchestrated and coordinated response
based on the incident command model |
|
|
|
At the incident scene |
|
|
|
At the healthcare facility |
|
|
|
|
|
Accurate, timely notifications |
|
Disaster scene to hospital |
|
Hospital to disaster scene |
|
Communications |
|
Community to disaster scene |
|
Disaster scene to hospital |
|
Hospital to disaster scene |
|
Within the hospital |
|
|
|
|
|
|
Media Coordination |
|
Accurate communications |
|
At the disaster scene |
|
At the hospital |
|
Provide the media |
|
Dedicated space |
|
Timely and accurate updates |
|
Public relations |
|
|
|
|
|
Equipment and training mandated |
|
OSHA (29 CFR 1910.120 and
1910.134) |
|
NIOSH |
|
EPA |
|
JCAHO |
|
|
|
|
|
|
Level A - IDLH environments, fully encapsulated,
requires SCBA |
|
Level B - Chemicals or substances with
inhalation hazard, requires SCBA or SAR |
|
Level C - Known contaminants, requires
air-purifying respirator |
|
|
|
|
PPE for decontamination personnel |
|
PPE for healthcare providers |
|
Limitations of PPE |
|
Staff rotation |
|
|
|
|
Treat every patient with respiratory complaints
and open wounds as an “infectious source” |
|
Normal standard universal precautions for most
BW agents |
|
HEPA filter mask upgrade for pneumonic plague / smallpox / VHF |
|
Special protective garments usually not
necessary |
|
Precaution upgrades in areas of the hospital
where aerosols could be generated:
lab centrifuges, autopsy facilities, etc. |
|
|
|
|
Respiratory - Particulate mask (level C minimum) |
|
Shielding |
|
Dosimeter |
|
|
|
|
|
Decontamination removes harmful substances |
|
Hospital preparedness for decontamination |
|
Decon of casualties arriving at
the healthcare
facility |
|
Vapor exposure |
|
Liquid exposure |
|
Mass casualty incident |
|
|
|
|
|
Vapor verses liquid exposure |
|
Mass casualty incidents |
|
Ambulatory vs. non-ambulatory |
|
Decon methods |
|
Water vs. bleach |
|
Location of decon area |
|
|
|
|
|
Decon of casualties arriving at the hospital |
|
Already decontaminated |
|
Not decontaminated |
|
Decon of healthcare providers |
|
Decon Team Members |
|
Treating personnel |
|
|
|
|
|
|
Many biological agents can be identified by
standard hospital laboratory techniques |
|
Standard laboratory procedures may require 12 to
48 hours to yield results |
|
Treatment should be based on index of suspicion;
should not await test results |
|
|
|
|
|
Instrumentation |
|
G.M. Survey Meter |
|
Dose Rate Meter - Ionization Chamber |
|
Alpha Meter |
|
Neutron Meter |
|
Personal Dosimeters |
|
Film Badge |
|
Thermoluminescent Dosimeter |
|
Quartz Fiber Dosimeter |
|
Electronic Instantaneous Read Out Dosimeter |
|
|
|
|
|
Use a triage system in an MCI that parallels
normal routine |
|
Practice regularly to ensure familiarity |
|
Triage is a continual process |
|
Re-triage all victims
transported by EMS |
|
Set up triage area near the
ED entrance |
|
Shielded and secure |
|
Readily accessible |
|
|
|
|
|
“Greatest good for the greatest number of
casualties” |
|
Psychological impact |
|
Classification: |
|
Red Yellow Green Black |
|
Limitations: |
|
Time consuming |
|
User variability |
|
Lack of familiarity |
|
|
|
|
TRIAGE CRITERIA: |
|
Respiratory status |
|
Perfusion and pulse |
|
Neurological status |
|
TRIAGE CATEGORIES: |
|
Walking wounded - “Green” or minimal (relocate when told) |
|
Normal findings - “Yellow” or delayed (unable to relocated) |
|
Abnormal - “Red” or immediate |
|
Non-salvageable - “Black” or expectant |
|
|
|
|
|
|
|
|
|
|
Unconsciousness or convulsions |
|
|
|
Two or more body systems involved |
|
|
|
|
Initial symptoms are improving (miosis still
present) |
|
Recovering well from pre-hospital antidote
therapy |
|
|
|
|
Minimal |
|
Walking and talking which indicates intact
breathing and circulation |
|
|
|
|
Delayed |
|
2 to 50% BSA burns by liquid |
|
Eye involvement |
|
|
|
Minimal |
|
< 2% BSA burns by liquid in non-critical
areas |
|
|
|
|
|
Triage of biological agent casualties is
different |
|
Symptoms are delayed |
|
Initial cases may go unrecognized |
|
More difficult to detect |
|
Epidemiological information becomes critical |
|
|
|
|
|
Triage: |
|
Stabilize the patient first and only when this
is done does one consider irradiation and contamination. |
|
Ensure ABCs |
|
|
|
|
Disasters produce tremendous emotional and
psychological stress, with large numbers of psychogenic casualties |
|
Presenting signs could be confused with organic
disease |
|
Use of START triage system maintains focus on
objective signs of disease & minimizes impact of subjective complaints
on the triage process |
|
Psychological casualties are usually triaged as
“minimal” |
|
|
|
|
Casualty arrival is uncoordinated |
|
Arrival times vary |
|
Closest hospital is typically overwhelmed |
|
Medical needs of unaffected community continue |
|
|
|
|
|
Problems are agent-specific |
|
Decontamination |
|
Containment |
|
Refrigeration until definitive disposal |
|
Follow local coroner and medical examiner
protocols |
|
Establish cooperative agreements for fatality
management |
|
Secure personal effects |
|
Not all can be decontaminated |
|
|
|
|
Plan for the needs of the unaffected population |
|
Prepare to receive large numbers of casualties |
|
Prepare to receive large numbers of dead |
|
Rotate staff to avoid congestion and fatigue, especially personnel in PPE |
|
|
|
|
|
Highest priority: getting the right resources to the right place at the right
time |
|
Personal protective equipment and dosimetry |
|
Medications / antidotes / vaccines |
|
Mechanical ventilators |
|
Isolation rooms remote from other patients |
|
Identify current inventory and augment as
necessary |
|
Develop a procedure to access external assets |
|
|
|
|
|
Identify alternative medical
treatment areas |
|
Planning for use of available
space |
|
Open areas |
|
Isolated areas |
|
Temporary morgue |
|
|
|
|
|
Maintaining evidence is critical for an
investigation |
|
Clothing |
|
Embedded foreign bodies |
|
Decontamination runoff |
|
Chain of Evidence must be maintained |
|
|
|
|
Start small - few casualties |
|
Be realistic |
|
Coordinate with other agencies / hospitals |
|
Exercise frequently |
|
|
|
DON’T WAIT FOR A DISASTER TO HAPPEN |
|
|
|
|
Hospitals must expand their emergency planning
and scope of services to include NBC care |
|
Concentrate on the disaster planning process |
|
Develop policies & procedures |
|
Train frequently using realistic scenarios |
|
|
|
|
A national basketball championship was what the
city needed to boost its national reputation, and tonight was the
night. Every hotel within 30 miles
was booked with fans eagerly awaiting the game. |
|
After the national anthem was played the crowd
began to loudly chant their team’s respective fight song. The sounds within the stadium were
deafening. |
|
|
|
|
Just as the game was ready to begin fans from
section “A” started to run from their seats. Total chaos ensues.
In a rampage fans were pushing and shoving trying to get out through
the exit doors. Many were being
trampled upon during the exodus.
Most were coughing, rubbing their eyes, and many appeared to be
choking. |
|
911 was called and the closest hospital, two
blocks away, was also notified. |
|
|
|
|
Assume you are working in the emergency
department, please answer the following: |
|
After notification, what would you do? |
|
Where would you set up triage? |
|
Who would function as the triage officer? |
|
Where would you set up & perform decon? |
|
|
|
|
Within 15 minutes of the incident 100
victims arrive at your hospital without the assistance of EMS |
|
How will you control access into your hospital? |
|
What level of protective gear should be worn? |
|
Should these victims be decontaminated? |
|
How will you decontaminate these victims? |
|
Where will you treat the first wave of victims? |
|
|
|
|
Victims are complaining of shortness of
breath, cough, eye & throat irritation, and burning skin. |
|
What chemical were they exposed to? |
|
What clues would you look for to help you
identify the agent? |
|
Lacking positive agent identification, how would
you begin treatment? |
|
What medications/antidotes are necessary? |
|