Emergency Management: Bioterrorism and Emergency Care

• Emergency management addresses bioterrorism and emergency care.

Issues in Emergency Nursing

• Documentation of consent and privacy is crucial.
• Limiting exposure to health risks for both patients and staff.
• Addressing violence within the Emergency Department (ED).
• Discharge planning involves community, transitional services, and specific considerations for gerontologic and obese patients.

Principles of Emergency Care

• Triage to prioritize patients based on severity.
• Assessment and intervention are continuous processes.

Hospital Incident Command System (HICS)

• The system is federally mandated to ensure:
  • Equipment compatibility.
  • Effective communication.
  • Resource distribution.
  • Clear roles and responsibilities.
  • Personal Protective Equipment (PPE) distribution.
  • Management of hazardous substances.
• Debriefing after Mass Casualty Incidents (MCI).
• Key roles: emergency preparedness coordinator, safety officer, public information officer, liaison officer, operations chief, logistic chief, planning chief, and finance chief.
• The Joint Commission (TJC) has standards for emergency preparedness.
• Disaster triage aims for the "greatest good for the greatest number".

Ethical Issues

• Ethical considerations include:
  • Assisted suicide.
  • Resuscitation decisions.
  • Rationing of care.
  • Futile therapy.
  • Consent and confidentiality.
  • Duty, nonmaleficence, beneficence, and distributive justice.

Critical Incident Stress Management (CISM)

• Provides support for healthcare providers dealing with traumatic stress.
• Offers mental health support.
• Field support includes resources, rest, fluids, food, and work rotation.
• Defusing and debriefing sessions are essential.

Identifying Toxic/Infectious Agent Contamination

• Look for:
  • An increase in people seeking care for unusual symptoms.
  • Clusters of patients from the same location.
  • Large numbers of fatalities.
  • Increased disease incidence in a healthy population.
• PPE use is vital.

Decontamination

• Determine containment.
• Steps: removal of clothing and jewelry, followed by washing with soap and water, and rinsing.

Mass Casualties

• Natural disasters include:
  • Storms, floods, fires, earthquakes.
  • Exposure to elements and animal attacks.
  • Lack of food and water.
• Disaster Victim Waves:
  • Wave 1: initial walk-ins from the disaster site.
  • Wave 2: victims brought by EMS.
  • Wave 3: victims who waited and came later.
• Plans, trains, and automobile crashes can cause mass casualties.
• Terrorism events:
  • World Trade Center, Boston Marathon, Paris, Brussels, and active shooter incidents.

Weapons of Terror

• Bombs can cause:
  • Blast lung.
  • Blast tympanic membrane rupture.
  • Tissue tearing and hemorrhage.
• Air emboli symptoms: dyspnea, hypoxia, tachypnea, apnea, cough, chest pain, hemodynamic instability, hearing loss, tinnitus, pain, dizziness, and otorrhea.
• Head injuries are the majority of post-blast deaths, including TBI such as arteriovenous fistulas, pseudoaneurysm, and dissection. Geriatric patients are at high risk of bone fracture.
• Abdominal injuries: internal organ injury, hemorrhage, pain, guarding, rebound tenderness, rectal bleeding, nausea/vomiting; pregnancy consideration: abruptio placentae.

Bioterrorism: Anthrax

• Pathophysiology: destruction of the immune system and vascular collapse.
• Diagnosis: antibodies in blood, skin lesion samples, respiratory secretions, or spinal fluid.
• Clinical manifestations: skin, GI, respiratory, CNS.
• Symptoms: macule papule, ulcerations, edema, pruritus, painless eschar, fever, N/V, abdominal pain, bloody diarrhea, ascites, and decreased intravascular volume.
• Can incubate up to 60 days.
• Other symptoms: cough, headache, fever, vomiting, chills, weakness, chest pain, dyspnea, syncope.
• Treatment: penicillin, macrolides (erythromycin), aminoglycosides (gentamycin), tetracycline (doxycycline), or fluoroquinolones (ciprofloxacin) for 60 days; vaccine only for military use.

Ebola-Viral Hemorrhagic Fever

• Pathophysiology: contact with infected animals (bats), semen, blood, urine, saliva (via broken skin/mucous membranes), leading to decreased immune response and clotting.
• Diagnosis: ELISA, antibodies, viral isolation in blood/body fluids.
• Symptoms: incubation 2-21 days, day 3-5 (fever, diarrhea, vomiting, abdominal pain, >5 L stool/day), severe hemodynamic shock, CNS symptoms (encephalitis, confusion, agitation, delirium), 5% developed hemorrhage, multiorgan failure/shock, death.
• Those who survive the first 2 weeks are likely to live.
• Treatment: ventilator, dialysis, fluid/electrolyte replacement, BP management; no FDA-approved vaccine or antiviral drug available; broad-spectrum antibiotics for septic shock, psychological support.
• Precautions: complete coverage of clothing, skin, mucous membranes; use PPE and a "buddy" system.

Botulism (Clostridium botulinum)

• Pathophysiology: attacks motor and autonomic nerves with neurological symptoms appearing after 12-36 hours (foodborne) or 24-72 hours (aerosol).
• Causes: contaminated food, traumatic injury, IV drug use.
• Diagnosis: rule out Guillain-Barré, myasthenia gravis, CVA; stool, blood, wound, or food cultures.
• Symptoms: neuro, paralysis, dysphasia, dry mouth, drooping eyelids, blurred/double vision, vomiting, constipation/diarrhea initially, symmetric flaccid paralysis, bilateral cranial nerve impairment, fatality up to 10%, recovery takes months.
• Treatment: antitoxin immediately, mechanical ventilation, penicillin (pen G), nitroimidazole (metronidazole); antibiotics not recommended for infants; interdisciplinary planning for long-term recovery; standard precautions.

Smallpox

• Pathophysiology: inhalation and/or direct contact with variola major or minor.
• Diagnosis: pustular lesions, antibodies in blood, virus in blood or lesions.
• Symptoms: vesicles, pitted scars, maculopapular rash begins on face, mouth, pharynx, forearms, progressing to trunk, erythema, petechiae, skin death.
• Maculopapular rash appears after 1-2 days of exposure, beginning on face, mouth, pharynx, forearms, progressing to trunk becoming vascular to pustular.
• Contagious only after rash appearance.

Hemorrhagic Smallpox

• Subtype of variola major.
• All previous symptoms, dusky erythema, petechiae leading to frank hemorrhage of skin and mucous membrane.
• Death usually by day 5-6.
• Treatment: vaccine only for high likelihood of exposure; if exposure, vaccinate within 4 days; smallpox vaccine, cidofovir; secondary skin infections treated with penicillin or first-generation cephalosporins or penicillin-beta-lactamase inhibitor (amoxicillin/clavulanate).
• Cremation recommended as the virus can survive in scabs for 13 years.
• Precautions: droplet and contact.