Advanced Trauma Life Support ATLS Student Course Manual 2018
297 APPENDIX D n Disaster Preparedness and Response Nerve agents disrupt the normal mechanisms by which nerves communicate with muscles, glands and other nerves. Symptoms of nerve agent exposure following large liquid or vapor exposure include loss of consciousness, convulsions, apnea, and flaccid paralysis. Asphyxiants are chemicals that interfere with the body’s ability to perform aerobic metabolism. An example is hydrogen cyanide, a deadly poison that causes death within minutes. Symptoms of a large exposure to an asphyxiant include loss of consciousness, convulsions, apnea, and cardiac arrest. Pulmonary agents are substances that cause pulmonary edema, such as phosgene and chlorine. Vesicant agents are substances that cause erythema (redness) and vesicles (blisters) on the skin as well as injury to the eyes, airways and other organs. Sulfur mustard and Lewisite are examples of vesicant agents. Symptoms of exposure to vesicant agents include erythema and vesicles, conjunctivitis, pain, and upper respiratory distress. Riot control agents, such as chloroacetophenone (CN) and chlorobenzalmalononitrile (CS), are tear gases or lacrimators. Symptoms of exposure include burning eyes and skin, respiratory discomfort, and bronchospasm. Special considerations in the care of chemical injuries are outlined in n BOXES D-3 AND D-4. Radioactive Injuries and Illnesses There are two major types of ionizing radiation: 1. Electromagnetic radiation (external radiation: gamma rays and x-rays)—Passes through box d-3 special considerations in the care of chemical injuries Nerve Agents • Ventilation with oxygen • Suction of copious secretions from airways • Atropine (antidote)—affects muscarinic system symptoms • Pralidoxime (2-PAM) (antidote)—affects nicotinic system symptoms. Timing of 2-PAM administration is critical because the binding of the nerve agents to cholinesterase (enzyme responsible for breaking down the neurotransmitter acetylcholine) can become irreversible with time. • Diazepam—auto-injector for convulsions • DuoDote—single auto injector (atropine+ pralidoxime) • Mark 1 Kit—atropine + pralidoxime chloride auto-injectors Asphyxiant Agents • Ventilation with oxygen • Cyanide antidote kit or hydroxocobalamin IV (preferred) Pulmonary Agents • Termination of exposure • Oxygen/ventilation as needed • No physical activity! Vesicant Agents • Decontamination • Symptomatic management of lesions Riot Control Agents (tear gasses/lacrimators) • Generally not life-threatening • Symptomatic management of lesions • Normal saline irrigation to eyes or cool water and liquid skin detergent to affected areas of body. • CN (Chloroacetophenone) and CS (chlorobenzyliden malononitrile) most common. box d-4 classic toxidromes Exposure to Nerve Agents (Muscarinic System) Exposure to Nerve Agent Symptoms (Nicotinic System) SLUDGE* DUMBELS* MTW(t)HF^ Salivation , Lacrimation Urination Defecation Gastroenteritis Emesis Diarrhea, Urination Miosis Bradycardia, Bronchorrhea, Bronchospasm Emesis Lacrimation Salivation, Secretions, Sweating • Mydriasis • Tachycardia • Weakness (muscle) • (t)Hypertension, hyperglycemia • Fasciculations ^ Nicotinic effects * Muscarinic effects treated with atropine n BACK TO TABLE OF CONTENTS
298 APPENDIX D n Disaster Preparedness and Response tissue, irradiating casualties but leaving no radioactivity behind. 2. Particle radiation (alpha and beta particles)— Does not easily penetrate tissue. (The amount of radiation absorbed by cells is measured in Grays (Gy) or new international standard of radiation dose the rad 1 Gy = 100 rad.) Radiation exposure can consist of external contamination, localized or whole body, or internal contamination. With external contamination, radioactive debris is deposited on the body and clothing. With internal contamination, radioactive debris is inhaled, ingested or absorbed. Assume both external and internal contamination when responding to disasters involving radioactive agents. Emergency Management of Radiation Victims The medical effects of radiation include focal tissue damage and necrosis, acute radiation syndrome (ARS, n BOX D-5), and long-term effects that can persist for box d-5 acute radiation syndrome (ars) • Group of clinical sub-syndromes that develop acutely (within several seconds to several days) after exposure to penetrating ionizing radiation above whole-body doses of 1 Gy (100 rads). • ARS affects different systems, depending on the total dose of radiation received. • Lower doses predominantly damage the hematopoietic system. • Increasing doses damage the gastrointestinal system, the cardiovascular system, and the central nervous system, in that order. • The higher the exposure, the earlier symptoms will appear and the worse the prognosis. Prodromal Phase • Symptoms—nausea, vomiting, diarrhea, fatigue Latent Phase • Length of phase variable depending on the exposure level • Symptoms and signs—relatively asymptomatic, fatigue, bone marrow depression • A reduced lymphocyte count can occur within 48 hours and is a clinical indicator of the radiation severity. Manifest Illness • Symptoms—Clinical symptoms associated with major organ system injury (marrow, intestinal, neurovascular) Death or Recovery weeks to decades, such as thyroid cancer, leukemia, and cataracts. Principles of the emergency management of radiation victims include: •• Adhere to conventional trauma triage principles, because radiation effects are delayed. •• Perform decontamination before, during, or after initial stabilization, depending on the severity of injury. •• Recognize that radiation detectors have specific limitations, and many detectors measure only beta and gamma radiation. •• Emergency surgery and closure of surgical wounds should be performed early in victims of radiation exposure. •• Nuclear reactors contain a specific mixture of radioactive elements. Iodine tablets are effective only against the effects of radioactive iodine on the thyroid. n BOX D-6 outlines key features of several radiation threat scenarios. box d-6 radiation threat scenarios Nuclear Detonations Three types of injuries result from nuclear detonations: • Blast injuries—overpressure waves • Thermal injuries—flash and flame burns • Radiation injuries—irradiation by gamma waves and neutrons and radioactive debris (fallout) Meltdown of a Nuclear Reactor • Core must overheat, causing nuclear fuel to melt • Containment failure must occur, releasing radioactive materials into environment Radiation Dispersal Device (dirty bomb) • Conventional explosive designed to spread radioactive material • No nuclear explosion Simple Radiological Dispersion • Simple radioactive device that emits radioactivity without an explosion Pitfalls The four common pitfalls in disaster medical response are always the same—security, communications, triage n BACK TO TABLE OF CONTENTS
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- Page 310 and 311: Appendix A OCULAR TRAUMA OBJECTIVES
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- Page 318 and 319: Appendix B HYPOTHERMIA AND HEAT INJ
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297<br />
APPENDIX D n Disaster Preparedness and Response<br />
Nerve agents disrupt the normal mechanisms by<br />
which nerves communicate with muscles, glands and<br />
other nerves.<br />
Symptoms of nerve agent exposure following large<br />
liquid or vapor exposure include loss of consciousness,<br />
convulsions, apnea, and flaccid paralysis.<br />
Asphyxiants are chemicals that interfere with the<br />
body’s ability to perform aerobic metabolism. An<br />
example is hydrogen cyanide, a deadly poison that<br />
causes death within minutes. Symptoms of a large<br />
exposure to an asphyxiant include loss of consciousness,<br />
convulsions, apnea, and cardiac arrest.<br />
Pulmonary agents are substances that cause pulmonary<br />
edema, such as phosgene and chlorine.<br />
Vesicant agents are substances that cause erythema<br />
(redness) and vesicles (blisters) on the skin as well as<br />
injury to the eyes, airways and other organs. Sulfur<br />
mustard and Lewisite are examples of vesicant agents.<br />
Symptoms of exposure to vesicant agents include<br />
erythema and vesicles, conjunctivitis, pain, and upper<br />
respiratory distress.<br />
Riot control agents, such as chloroacetophenone<br />
(CN) and chlorobenzalmalononitrile (CS), are tear<br />
gases or lacrimators. Symptoms of exposure include<br />
burning eyes and skin, respiratory discomfort,<br />
and bronchospasm.<br />
Special considerations in the care of chemical injuries<br />
are outlined in n BOXES D-3 AND D-4.<br />
Radioactive Injuries and Illnesses<br />
There are two major types of ionizing radiation:<br />
1. Electromagnetic radiation (external radiation:<br />
gamma rays and x-rays)—Passes through<br />
box d-3 special considerations in the care of chemical injuries<br />
Nerve Agents<br />
• Ventilation with oxygen<br />
• Suction of copious secretions from airways<br />
• Atropine (antidote)—affects muscarinic system symptoms<br />
• Pralidoxime (2-PAM) (antidote)—affects nicotinic system<br />
symptoms. Timing of 2-PAM administration is critical<br />
because the binding of the nerve agents to cholinesterase<br />
(enzyme responsible for breaking down the neurotransmitter<br />
acetylcholine) can become irreversible with time.<br />
• Diazepam—auto-injector for convulsions<br />
• DuoDote—single auto injector (atropine+ pralidoxime)<br />
• Mark 1 Kit—atropine + pralidoxime chloride auto-injectors<br />
Asphyxiant Agents<br />
• Ventilation with oxygen<br />
• Cyanide antidote kit or hydroxocobalamin IV (preferred)<br />
Pulmonary Agents<br />
• Termination of exposure<br />
• Oxygen/ventilation as needed<br />
• No physical activity!<br />
Vesicant Agents<br />
• Decontamination<br />
• Symptomatic management of lesions<br />
Riot Control Agents (tear gasses/lacrimators)<br />
• Generally not life-threatening<br />
• Symptomatic management of lesions<br />
• Normal saline irrigation to eyes or cool water and liquid<br />
skin detergent to affected areas of body.<br />
• CN (Chloroacetophenone) and CS (chlorobenzyliden<br />
malononitrile) most common.<br />
box d-4 classic toxidromes<br />
Exposure to Nerve Agents (Muscarinic System)<br />
Exposure to Nerve Agent Symptoms (Nicotinic System)<br />
SLUDGE*<br />
DUMBELS*<br />
MTW(t)HF^<br />
Salivation ,<br />
Lacrimation<br />
Urination<br />
Defecation<br />
Gastroenteritis<br />
Emesis<br />
Diarrhea,<br />
Urination<br />
Miosis<br />
Bradycardia, Bronchorrhea, Bronchospasm<br />
Emesis<br />
Lacrimation<br />
Salivation, Secretions, Sweating<br />
• Mydriasis<br />
• Tachycardia<br />
• Weakness (muscle)<br />
• (t)Hypertension, hyperglycemia<br />
• Fasciculations<br />
^ Nicotinic effects<br />
* Muscarinic effects treated with atropine<br />
n BACK TO TABLE OF CONTENTS
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