1
Q
Triage Priority 1
A
RED = Immediate
- Sucking chest wound
- Airway obstruction secondary to mechanical cause
- Asphyxia
- Shock (a quick fix shock, they need fluids or blood)
- Hemothorax
- Tension pneumothorax
- Unstable chest and abdominal wounds
- Incomplete amputations (tourniquet)
- Open fractures of long bones
- 2nd and 3rd degree burns of 15-40% of total body surface area
2
Q
Characteristics of Priority 1 Triage
A
Injuries are life threatening, but survival is possible with minimal intervention
** Patient in this category progress to expectant or black tagged if treatment is delayed
3
Q
Characteristics of Priority 2 Triage
A
Injuries are significant and require medical care, but treatment can be delayed for hours without threat to life or limb
** Individuals in this category receive treatment only after immediate casualties have been treated
4
Q
Triage Priority 2
A
YELLOW = Delayed
- Stable abdominal wounds without massive hemorrhage
- Soft tissue injuries
- Maxillofacial wounds without airway compromise
- Vascular injuries with adequate collateral circulation
- Genitourinary tract disruption
- Fractures requiring open reduction
- Debridement
- External fixation
- Most eye and CNS injuries
5
Q
Characteristics of Priority 3 Triage
A
Injuries are minor and treatment can be delayed hours or days
** Individuals in this category should be moved away from the main triage area
6
Q
Priority 3 Triage
A
GREEN = Minimal
- Upper extremity fractures
- Minor burns
- Sprains
- Small lacerations without significant bleeding
- Behavioral disorders
- Psychological disturbances (hallucinations)
7
Q
Characteristics of Priority 4 Triage
A
Injuries are extensive and chances of survival are unlikely, even with definitive care
- Persons in this group should be separated from other casualties, but not abandoned
- Comfort measures only
8
Q
Priority 4 Triage
A
BLACK = Expectant or black tagged
- Unresponsive patients with penetrating head wounds
- High spinal cord injuries
- Wounds involving multiple anatomical sites and organs
- 2nd and 3rd degree burns in excess or 60% of body surface area
- Seizures or vomiting within 24 hours after radiation exposure
- Profound shock with multiple injuries
- Agonal respirations, no pulse, no BP, pupils fixed and dilated
9
Q
Components of the Emergency Preparedness Operations Plan
A
- Activation response
- An internal/external communication plan (one spokesperson)
- Implement a plan for coordinated patient care
- Implement security plans
- Identification of external resources
10
Q
Trends that may suggest deliberate dispersal of toxins or infectious agents
A
- Unusual increase in the number of people seeking care for fever, respiratory, or GI symptoms
- Clusters of patients who present with the same unusual illness from a single location
- A large number of rapidly fatal cases, especially when death occurs within 72 hours after hospital admission
- Any increase in disease incidence in a normally healthy population
11
Q
Level A PPE
A
Protection is worn when the highest level respiratory, skin, eye, and mucous membrane is required
- Self-contained breathing apparatus (SCBA)
- Fully encapsulating, vapor tight chemically resistant suit
- Chemical-resistant gloves and boots
12
Q
Level B PPE
A
Protection requires the highest level of respiratory protection, but a lesser level of skin and eye protection
- SCBA
- Chemical-resistant suit, suit is not vapor tight
13
Q
Level C PPE
A
Protection requires air-purified respirator, which filters harmful substance from the air
- Chemical resistant coverall with splash hood
- Chemical resistant gloves
- Boots
14
Q
Level D PPE
A
Typical work uniform
15
Q
TB Masks are which PPE Level
A
Level C
16
Q
Decontamination
A
- Removal of patient clothing and jewelry and rinsing patient with water
- Depending on the type of exposure, this can remove a large amount of contaminant - Thorough soap and water wash and rinse
- Each patient who arrives after pre-hospital treatment should go through this procedure
17
Q
Three Waves of Casualties
A
- First wave consists of minimally injured people who arrive on their own
- Second wave consists of severely injured people
- Third wave consists of injured patients whoa re discovered by rescuers
* * The walking wounded may not seek treatment for 5 days to 2 weeks after the event
18
Q
Types of Explosive Devices
A
- Pipe bombs (most commonly used; may contain nails and other things that cause damage when ignited)
- Molotov cocktail (uses a flammable liquid such as gasoline in a glass bottle as an ignition)
- Fertilizer bombs
- Dirty bombs (spread radiation)
19
Q
Blast Injuries: Lung Damage
A
Results in hemorrhage and tearing of the lung
- Dyspnea
- Hypoxia
- Tachypnea
- Apnea
- Cough
- Chest pain
- Hemodynamic instability
- Hemo/pneumothorax
- Air embolus
20
Q
Complications to the lungs from blast injuries
A
- ARDS
2. Respiratory failure
21
Q
Blast Injuries: Tympanic Membrane
A
Most frequent injury after blast in an enclosed building due to pressure wave
- Majority only suffer high frequency hearing loss
1. Hearing loss (5% require hearing aids post blast)
2. Tinnitus
3. Abdomen and head trauma
4. Pain
5. Dizziness
6. Otorrhea
7. Tympanic membrane rupture
- Majority only suffer high frequency hearing loss
22
Q
Blast Injuries: Head
A
- Typically minor, but those that are severe result in majority of post-blast deaths
- Concussions are the most common
23
Q
Blast Injuries: Abdomen
A
Evidenced by abdominal hemorrhage and internal organ injury
- Increase in pulse rate (internal hemorrhage)
- Pain
- Guarding
- Rebound tenderness
- Rectal bleeding
- N/V
24
Q
Anthrax
A
- Caused by bacteria bacillus anthracis
- Replicates and releases a toxin that causes hemorrhage, edema, and necrosis
- Is odorless and invisible and can travel a great distance before disseminating
25
Anthrax Infection only results from:
1. Skin contact
2. Ingestion of infective animal products (usually raw meat)
3. Inhalation of spores
26
S/Sx of Skin Contact Anthrax
1. Edema
2. Pruritus
3. Macule/papule formation
- Results in ulceration
- 1-3 mm vesicles
- Painless eschar (fall off in 1-2 weeks)
* * Most Common
27
S/Sx of Inhalation Anthrax
1. Symptoms mimic the flu
2. Treatment usually sought when stage 2 of respiratory distress occurs
3. Current antibiotic therapy does not halt progression of the disease
4. Inhaled anthrax incubates for up to 60 days
28
Anthrax Initial Symptoms
1. Cough
2. HA
3. Fever
4. Vomiting
5. Chills
6. Weakness
7. Mild chest discomfort
8. Dyspnea
9. Syncope
29
2nd Stage of Anthrax
1. Fever
2. Severe respiratory distress
3. Stridor
4. Hypoxia
5. Cyanosis
6. Diaphoresis
7. Hypotension
8. Shock
9. IMPORTANT for VS q 15-30 min because respiratory distress can lead to circulatory collapse
30
GI Ingestion Anthrax Symptoms
1. Fever
2. N/V
3. Abdominal pain
4. Bloody diarrhea
5. Occasionally ascites
* * If severe diarrhea develops, decreased intravascular volume is the primary concern
31
Anthrax Treatment
1. Penicillin V
2. Erythromycin
3. Gentamicin
4. Doxycycline
* * If treatment begins within 24 hours of exposure, death may be prevented
* * Treatment continues for 60 days
* * Vaccine is used by military
* * Cremate the infected corpses
32
What medications are used for mass casualty anthrax exposure?
1. Ciprofloxacin
| 2. Doxycycline
33
Smallpox
- Virus (variola)
- Incubation is approximately 12 days
- Large portion of the population has no immunity to the virus
- 30% fatality rate
34
How is smallpox spread?
1. Direct contact
2. Clothing/linens
3. Droplets (after fever has decreased and rash phase has begun)
* * Contagious only after the rash begins
35
Smallpox: First Symptoms
1. High fever
2. Malaise
3. HA
4. Backache
36
Smallpox Symptoms after 1-2 days
1. Maculopapular rash evolving at the same rate
2. Begins on face, mouth, pharynx, and forearms
3. Progresses to trunk and becomes vesicular to pustular
4. Large amount of virus in the saliva/pustules
37
Smallpox Treatment
1. Supportive care with antibiotics for secondary infections
2. Laundry and biologic wastes must be autoclaved before they are washed
3. All persons in contact with infected should be vaccinated within 4 days
4. A patient with temperature > 38 C (101 F) within 17 days must be isolated
5. Cremation for all deaths is preferred (virus can live in scabs for 13 years)
38
Characteristics of Chemicals
1. Volatility
2. Persistence
3. Toxicity
4. Latency
39
Volatility
- Tendency for a chemical o become a vapor
- Most common volatile agents are cyanide and phosgene
- Most chemicals are heavier than air, except for cyanide
- In the presence of most chemicals, STAND UP to avoid heavy exposure
40
Persistence
- Chemical is less likely to vaporize or disperse
- More volatile chemicals do not evaporate very quickly
- Most industrial chemicals are not persistent (cyanide)
- Most weaponized chemicals are likely to penetrate skin and mucous membranes (mustard gas)
41
Toxicity
- Potential of an agent to cause injury to the body
| - Median lethal dose is the amount of chemical that will cause death in 50% of those who are exposed
42
Latency
- The time from absorption to the appearance of signs/symptoms
- Sulfur mustards and pulmonary agents have the longest latency periods
- Other vesicants, nerve agents, cyanide produce signs/symptoms within seconds
43
Limiting Exposure to Chemicals
1. Evacuation is essential
2. Remove patient's clothing and decontamination closest to the scene as possible
3. Soap and water are an effective means of decontamination in most cases
4. Staff must wear PPE
5. Dispose of run-off after decontamination procedures
6. Decontamination should be done away from the initial triage area
44
Vesicants
Chemicals that cause blistering and result in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death
45
Examples of Vesicants
1. Lewisite
2. Phosgene
3. Nitrogen mustard
4. Sulfur mustard
* * Liquid sulfur mustard was the most frequently used vesicant in these conflicts
46
Symptoms of Vesicant Exposure
1. Initial presentation is similar to superficial to partial thickness burns in the warm and moist areas of the body
2. Stinging and erythema for approximately 24 hours followed by:
- Pruritus
- Painful burning
- Small vesicle formation after 2-18 hours then become bullae
3. Tissue damage can occur within minutes
47
Eye Symptoms of Vesicant Exposure
1. Photophobia
2. Pain
3. Lacrimation
4. Decreased vision which progresses to
- Conjunctivitis
- Corneal ulcerations
- Corneal edema
48
Respiratory Symptoms of Vesicant Exposure
Purulent fibrinous pseudomembrane discharge
| - Airway obstruction
49
GI Symptoms of Vesicant Exposure
1. N/V
2. Leukopenia
3. Upper GI bleeding
50
Treatment for Vesicant Exposure
1. Soap and water
2. NO scrubbing!! Because it can increase penetration of the vesicant
3. Once the substance has penetrated, it cannot be removed
4. Eyes: copious irrigation
5. Respiratory: intubation and bronchoscopy
51
Nerve Agents
1. In liquid form they evaporate into odorless, colorless vapor
2. Organophosphates (fertilizers) are similar in nature to nerve agents
3. These agents bond with acetylcholinesterase so that acetylcholine is not inactivated causing hyperstimulation to the nerve endings
4. Effects can be from 30 minutes to 18 hours
5. Can cause a cholinergic crisis
52
S/Sx of Cholinergic Crisis
1. Bilateral miosis
2. Increased GI motility
3. N/V
4. Diarrhea
5. Substernal spasm
6. Indigestion
7. Bradycardia and AV block
8. Bronchoconstriction
9. Laryngeal spasm
10. Weakness
11. Fasciculation
12. Incontinence
53
S/Sx of Lethal Dose of Nerve Agent (Severe Cholinergic Crisis)
1. Loss of consciousness
2. Seizures
3. Copious secretions
4. Flaccid muscles
5. Apnea
54
Treatment for Nerve Agent Exposure
1. Decontamination with soap and water or saline solution for 8-20 minutes
2. Fresh bleach can also be used
3. Airway support with intubation and suctioning
4. Atropine 2-4 mg IV, followed by 2 mg every 3-8 minutes for up to 24 hours of treatment
5. IV Atropine 1-2 mg/hr until signs of anticholinergic activity has returned
- Decreased secretions
- Tachycardia
- Decreased GI motility
55
Examples of Nerve Agents
1. Saran
2. Soman
3. Tabun
56
Blood Agents
- Cyanide and cyanogen chloride have a direct effect on cellular metabolism
- A cyanide release smells like bitter almond
- In house fires cyanide is released in combustible plastics, rugs, silks, furniture, and other construction materials
57
Symptoms of Blood Agent Exposure
1. Inhalation results in flushing, tachypnea, tachycardia, nonspecific neuro symptoms, stupor, coma, and seizures preceding respiratory arrest
2. Respiratory muscle failure
3. Respiratory distress
4. Cardiac arrest
5. Death
58
Treatment of Blood Agent Exposure
Rapid administration of amyl nitrate, sodium nitrate, and sodium thiosulfate
1. Amyl nitrate given to induce methemoglobinemia
2. Sodium nitrate given IV to induce the rapid formation of methemoglobin
3. Sodium thiosulfate given IV stimulates the conversion of cyanide to sodium thiosulfate which is secreted by the kidneys
* * Alternative treatment for cyanide poisoning is Vitamin B12 in large doses
59
Pulmonary Agents
- Phosgene and chlorine destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting oxygen transport mechanisms
- Capillary leakage results in fluid-filled alveoli
- Phosgene smells like fresh-mown hay
60
Symptoms of Pulmonary Agent Exposure
1. Pulmonary edema
2. Hacking cough followed by frothy sputum production
3. Particulate air mask is the only protection
* * Phosgene does not harm the eyes
61
Priorities in Treating Radiation Exposure
1. Life-threatening
2. Measures to limit exposure
3. Contamination control
4. Decontamination
62
Radiation Decontamination
1. Triage outside the hospital is the most effective means of preventing contamination of the facility itself
2. All air vents/ducts are sealed
3. Floors are covered to protect from contamination
4. Strict isolation precautions are initiated
5. Double-bagged waste
6. Dosimetry device worn by staff and patients
63
PPE for Radiation Patients
1. Water-resistant gowns
2. Double gloves
3. Masks
4. Caps
5. Goggles
6. Booties
64
Acute Radiation Syndrome (ARS)
- The development of ARS is determined by the dose, rather than the source
- Four phases
65
ARS Prodromal Phase
48-72 hours after exposure
1. N/V
2. Loss of appetite
3. Diarrhea
4. Fatigue
5. High dose exposure: Fever, respiratory distress, increased excitability
66
ARS Latent Phase
Can last up to 3 weeks after resolution of prodromal phase
* * Symptom free period
* * Decreased lymphocytes, leukocytes, thrombocytes, and RBCs
67
ARS Illness Phase
1. Infection
2. Fluid/electrolyte imbalance
3. Bleeding
4. Diarrhea
5. Shock
6. Altered LOC
68
ARS Recovery or Death Phase
Can take weeks or months for full recovery
| - Increased ICP is a sign of impending death, cardiac collapse
69
Three Categories of Predicted Radiation Survival
1. Probable
2. Possible
3. Improbable
70
Probable Radiation Survival
Survivors have no initial symptoms or minimal
1. N/V with symptom resolution within a few hours **
2. Discharge home with instructions
71
Possible Radiation Survival
1. Survivors present with N/V that persists for 24-48 hours **
2. Latent period, in which lab work is altered
3. Barrier precautions and protective isolation if lymphocyte count < 1200
72
Improbable Radiation Survival
1. Acute onset N/V, bloody diarrhea, shock **
2. Survivors receive more than 800 rad of total body penetrating irradiation
3. ANY neuro symptoms suggest a lethal dose
4. Require decontamination to prevent further damage
5. Survival time is variable, but usually swift due to shock
6. A patient may have extensive burns, instead of neuro symptoms
7. Triage into the black category and provide comfort measures
8. If no mass casualty situation - aggressive fluid/electrolyte therapy
Sophomore 2 Test 4
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