Pharmacology: Connections to Nursing Practice

Emergency Preparedness: Bioterrorism and Management of Poisoning 78 Learning Outcomes Discuss the role of professional nursing in emergency preparedness and the management of poisoning. Discuss the purpose, function, and components of the Strategic National Stockpile. Identify the types of agents that might be used for a bioterrorist attack. Learning Outcomes Compare and contrast the various chemical agents that can be used as poisons. Explain the risks associated with ionizing radiation emitted from a nuclear terrorist attack. Describe the five general principles of treating acute poisoning. Learning Outcomes Identify the drugs important in emergency preparedness and management of poisoning. Compare the pharmacologic management of biologic, chemical, radiologic, nuclear, and explosive agents in emergency preparedness. Learning Outcomes Discuss the management of poisoning by the poison control center, including minimizing poison absorption and enhancing poison removal. Apply the nursing process to the care of patients who are receiving pharmacotherapy for poisoning or overdose. PharmFact 78.1 Emergency preparedness has become an essential competency for all health care professionals. Emergency Preparedness, Bioterrorism, and Nursing Emergency Preparedness, Bioterrorism, and Nursing Readiness to respond Mass casualty incidents, potential disasters, or epidemics Anthrax, avian flu, SARS Biological Chemical Radiological Nuclear Explosive Emergency Preparedness, Bioterrorism, and Nursing Standard triage may be reversed 78.2 Bioterrorism is the intentional release of a virus or microorganism to cause human harm. Emergency Preparedness, Bioterrorism, and Nursing Bioterrorism: Greatest Concerns Highly infectious diseases Anthrax Smallpox Hemorrhagic viruses Plague Bioterrorism: Greatest Concerns Toxic agents Nerve gas Cyanide Chlorinated agents Nuclear threats Radiation threats 78.3 Nurses may have the first opportunity to recognize and initiate a response to bioterrorism. Emergency Preparedness, Bioterrorism, and Nursing Nursing Response to Bioterrorism Essential areas for nurses Critical thinking Communication Knowledge of pharmacology Technical skills Safe administration Medications and immunizations Interventions Adverse medical events Nursing Response to Bioterrorism Key roles Education Resources and referrals Diagnosis and treatment Planning Shift in focus from disaster planning to emergency management 78.4 The Strategic National Stockpile has large quantities of medicine to protect the public if there is a health emergency. Emergency Preparedness, Bioterrorism, and Nursing Strategic National Stockpile (SNS) SNS repository Antibiotics Chemical antidotes Antitoxin Antiviral agents Life support medications Strategic National Stockpile (SNS) SNS repository Intravenous (IV) administration equipment Airway maintenance supplies Surgical material Strategic National Stockpile (SNS) Two SNS components Push Packages Preassembled drugs, antidotes, medical supplies Deployed within 12 hours Vendor-managed inventory (VMI) packages Event-specific supplies Shipped in 24 to 36 hours 78.5 Highly infectious bacteria or viruses could be used as bioterrorist threats. Biological Agents Biological Agents: Highly Infectious Bacteria or Viruses Anthrax Botulism toxin Pneumonic plague Tularemia Smallpox Viral hemorrhagic fevers Biological Agents Anthrax Potential for inhalation infection Ciprofloxacin (primary antibiotic) Oral prophylaxis dose IV treatment for exposure Vaccination for select population Safety at issue Biological Agents Botulism Transmitted in air, food, water Treatment Immediate antitoxin Availability State Departments of Health CDC Assisted ventilation for weeks or months Biological Agents Pneumonic plague Treatment Antibiotics within 24 hours, for at least 7 days Doxycycline 100 mg twice a day or Ciprofloxacin (Cipro) 500 mg twice a day for 7 days Biological Agents Tularemia IV therapy with streptomycin – drug of choice Mass casualty – preferred for adults and children Oral doxycycline 14 to 21 days, and Ciprofloxacin for 10 days Biological Agents Smallpox Vaccination is only treatment, effective Prior to exposure Up to 3 days postexposure Hemorrhagic fever No cure or vaccine Connection Checkpoint 78.6 There are 13 categories of toxic chemicals that could cause mass casualties if released in the environment. Chemical and Physical Agents Chemical and Physical Agents Toxic chemicals Biotoxins Vesicants and blister agents Blood agents Acids and caustics Pulmonary and choking agents Incapacitating agents Long-acting anticoagulants Chemical and Physical Agents Toxic chemicals Metals Nerve agents Organic solvents Tear gas or mace Toxic alcohols Vomiting agents 78.7 Ionizing radiation produces immediate and long-term effects on human tissue. Chemical and Physical Agents Chemical and Physical Agents Ionizing radiation Treatment Potassium iodide (KI) before or immediately after exposure Effective even 3 to 4 hours after radiation A single 130-mg dose Only protects thyroid gland Connection Checkpoint 78.8 The general management of poisoning includes contacting the poison control center or emergency medical services as soon as possible. Management of Poisoning Management of Poisoning: Strategy for Treatment Five general principles: Topical decontamination Prevention of absorption Neutralization Increase in the rate of excretion Antidotes and symptomatic therapy 78.9 Activated charcoal is effective at adsorbing (binding) most poisons if administered within 60 minutes of ingestion. Management of Poisoning Prototype Drug: Activated Charcoal (CharcoAid) Therapeutic classification Antidote Pharmacologic classification Adsorbent agent Pregnancy category C Prototype Drug: Activated Charcoal (CharcoAid) Mechanism of action Binds toxic substances, inhibiting their gastric absorption, enterohepatic circulation, and bioavailability Prototype Drug: Activated Charcoal (CharcoAid) Indications General-purpose antidote in treatment of poisoning Not effective for poisoning by cyanide, mineral acids, caustic alkalis, organic solvents, iron, ethanol, or methanol ingestion Prototype Drug: Activated Charcoal (CharcoAid) Contraindications Decreased level of consciousness or diminished gag reflex Central nervous system depression Coma GI obstruction Prototype Drug: Activated Charcoal (CharcoAid) Drug interactions Will decrease absorption of all oral medications Milk and dairy products Prototype Drug: Activated Charcoal (CharcoAid) Adverse effects Vomiting Constipation Diarrhea Prototype Drug: Activated Charcoal (CharcoAid) Nursing responsibilities Administer as soon as possible after poisoning May be swallowed or given through nasogastric tube Administer slowly Prototype Drug: Activated Charcoal (CharcoAid) Nursing responsibilities Improve palatability by adding a small amount of fruit juice or chocolate powder May be stirred into tap water to make a slurry Prototype Drug: Activated Charcoal (CharcoAid) Patient/family teaching Can cause stools to appear black Report excessive nausea, vomiting, abdominal discomfort, diarrhea, or constipation Drugs Similar to Activated Charcoal Activated charcoal is the only agent in this class 78.10 Ion trapping with forced diuresis may be helpful for some poisonings. Management of Poisoning Management of Poisoning Ion trapping with forced diuresis Forced alkaline diuresis Increases excretion of acidic drugs like salicylates and phenobarbital Diuretic such as furosemide, along with IV sodium bicarbonate, makes urine more alkaline Recommended when rhabdomyolysis occurs Management of Poisoning Forced acid diuresis Ascorbic acid used to increase excretion of such drugs as: Amphetamines Quinine Strychnine 78.11 Chelating agents are capable of forming bonds with heavy metals. Management of Poisoning Management of Poisoning Chelating agents Form bonds with heavy metals Mercury, arsenic, lead Make chemically inert Easy excretion Administration IV or IM Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Therapeutic classification Agent for heavy metal poisoning Pharmacologic classification Chelating agent Pregnancy category C Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Mechanism of action Combines with metals to form stable, nonionizing soluble complexes that can be excreted by kidneys Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Indications Heavy metal poisoning (but not effective against arsenic, gold, or mercury poisoning) Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Contraindications Severe kidney disease Anuria Oliguria Lead encephalopathy (IV administration) Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Drug interactions None known Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Adverse effects Febrile reaction Histamine-like reactions Serious adverse effects Renal damage Nephrotoxicity Cardiac rhythm irregularities Hypotension Thrombophlebitis Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Nursing responsibilities Assess adequacy of urinary output prior to therapy Increase fluid intake to enhance urinary excretion Monitor urine intake and output ratio Obtain serum creatinine, calcium, and phosphorous before and during each course of therapy Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Nursing responsibilities Monitor baseline blood urea nitrogen levels and ECG during therapy Monitor for febrile reaction 4 to 8 hours after infusion Use separate injection sites if calcium EDTA and BAL are given at same time Prototype Drug: Edetate Calcium Disodium (Calcium EDTA) Patient/family teaching Report signs of lead toxicity Eat foods rich in zinc, calcium, magnesium, and iron to prevent storage of lead in the body Prototype Drug: Dimercaprol (BAL in Oil) Therapeutic classification Antidote Pharmacologic classification Chelating agent Pregnancy category C Prototype Drug: Dimercaprol (BAL in Oil) Mechanism of action Forms ring complexes with heavy metals, such as arsenic, gold, and mercury, which prevents or reverses binding of metallic cations to body proteins Prototype Drug: Dimercaprol (BAL in Oil) Indications Heavy metal poisoning Used as an adjunct to edetate calcium disodium (EDTA) in the treatment of lead encephalopathy Off-label: chromium dermatitis, ocular and dermatologic manifestations of arsenic poisoning Prototype Drug: Dimercaprol (BAL in Oil) Contraindications Hepatic insufficiency Severe renal insufficiency Poisoning by cadmium, iron, selenium, or uranium Hypersensitivity to peanut products Prototype Drug: Dimercaprol (BAL in Oil) Precautions Hypertension Oliguria G6PD deficiency Preexisting renal disease Prototype Drug: Dimercaprol (BAL in Oil) Drug interactions Iron Cadmium Selenium Uranium Prototype Drug: Dimercaprol (BAL in Oil) Adverse effects Nausea/vomiting Fatigue Restlessness Headache Burning sensation of mouth, throat, and eyes Serious adverse effects Hypertension Tachycardia Prototype Drug: Dimercaprol (BAL in Oil) Nursing responsibilities Obtain allergy history Initiate therapy as soon as possible Administer by deep IM injection only Monitor vital signs and body temperature Monitor intake and output ratio Assess urine daily for albumin, blood, casts, and pH Prototype Drug: Dimercaprol (BAL in Oil) Patient/family teaching Drink as much fluid as health care provider will allow (to prevent nephrotoxicity) Do not take iron supplements during therapy