Safety & Treatment in Disaster Response

Modules were developed as part of a grant from the HRSA BTCDP initiative

Basic Biodefense Curriculum Module 32005

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

Most direct, but usually affects only one person Exception: infectious disease that spreads over time

Inhalation Almost as direct as injection plus affects large crowds Expect large number of casualties at same time

Ingested 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…

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

…STOP... ASK YOUR SAFETY QUESTIONS…

Chemical Accident/Injury Event Algorithm

Chemical Accident / Injury Event

Patient is moved to safe area upwind and away from the hazard by Emergency Personnel wearing the appropriate PPE

Are Life Saving Procedures Required?

Are there Unknown or Potentially Life Threatening Contaminants?

Environmental or Patient Condidtions Prevent Further Decontamination

Further Medical Attention or Surveillance Required

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

Perform Life-Saving Procedures

Decontaminate by making patient as clean as possible (ACAP - Contamination reduced to a level that is no longer a threat to patient or responder)

Report to superiors for instructions

Advise Receiving Medical Facility of Patient Status and Deliver/

Transport as Instructed

Cover or wrap patient to prevent spread of contamination to others

Undress and Bag Work Uniform - Shower - Change into clean clothes

Decontaminate Transport Vehicle

No

YES

YES

YES

YES

No

No

No

CLEAN FIRST; THEN TREAT For Chemical Exposures

Staging Area

CrowdControlLine

DecontaminationLine

HotLine

CommandPost

Exclusion(Hot)Zone

ContaminationReduction

(Warm) Zone

Support(Cold) Zone

Wind

Drainage

AccessControlPoints

AccessControlPoints

When the disaster victims come to the hospital:

Initial Triage:

Contaminated?Airway

Compromise?Amublatory?

Requires decontamination

NON-AMBULATORY

Airway and antidote administration and clothing

removal

AMBULATORYAntidote administration and

clothing removal

Gurney decontamination

Male

Ambulatory decontamination

Female

Clean area:clean clothing.Triage again

Not exposed, requires no decontamination

EXIT

Hospital treatment area assigned

based upon nature and acuity of signs

and symptoms

DECONTAMINATION AREA CLEAN AREA

DECONTAMINATION ALGORITHM – AT THE HOSPITAL OR TREATMENT CENTER

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 Soap and water for blister agents and irritants/corrosives Clean air or oxygen for inhaled agents (e.g., choking)

Some chemical agents have antidotes 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 Self-

Contained Breathing Apparatus (SCBA) to avoid inhaling

The Four Levels of PPE

Level Skin Eyes Lungs SCBA Description

A +++ +++ +++ YESSelf-contained suit that is

water and vapor proof,boots, gloves, hardhat

B ++ ++ +++ YESSplash-resistant clothing

with hood, gloves, boots

C ++ ++ + ---Air purifying respirator with

goggles and gloves

D + + --- ---Face shield, gloves, glasses, cover clothing

Highest

Lowest

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 chemical-resistant gloves

Chemical-resistant boots and covers

Add a hard hat Add an external self-

contained 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 Direct: person-to-person Indirect: person-to-fomite-to-person

Examples of contact-borne pathogens 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) Treat injuries first, then radiation exposure

For patients exposed to particles, 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? People or animals who are at increased risk of

injury or death

Why are they vulnerable? 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

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 Basic BioBio--DefenseDefense

ProjectProject

Emergency Preparedness Curriculum

Authors

Jean Carter Sandra Kuntz Earl Hall Steven Fehrer Steven Glow

Basic Basic BioBio--DefenseDefense

ProjectProject

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

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 jean.carter@umontana.edu

Basic Basic BioBio--DefenseDefense

ProjectProject

Emergency Preparedness Curriculum

Modules prepared as part of the Montana Basic BioDefense Curriculum For Pharmacy, Nursing, and Allied Health

Funded by the HRSA CFDA 93.996 initiative