Emergency Response in Chemical Casualties:System Approach to Effective Hospital

Preparedness

Objectives• Lessons Learned & Event Characteristics

• Incident Response Requirements

• Scene Safety

• Medical Management of Hazmat Victims

– Primary Survey & Resuscitation

– Decontamination

– Hazmat Patient Assessment

– Poisoning Treatment Paradigm

• Antidote and chemical stockpile

• Chemical protective clothing

• Hazmat traing trends

• Summary

Lessons Learned From Coaminated Casualties Incidents

INCIDENTS

EMERGENCY INCIDENT TIMELINES

RESPONSESPOTENTIAL CASUALTIES

- Flood

- Chemical

-Tornado

-Earthquake

-Hurricane

-Explosives

Tens ofMillions

Thousands

Hundreds

Tens

HoursMinutes

Seconds Days

MonthsWeeks

- NuclearMillions

(contagious)

(non-contagious)

- Biological

- Radio-logical

Everyday Life

- Accidents- First Aid- Rescue- Fire- Police

First Response

- Explosives

Criminal Terrorism

- Bomb Squad

- Flood- Earthquake- Hurricane- Tornado

Natural Disasters

- Search & Rescue- Sustainment- Medical Triage- Temp Morgue

State-Fed Escalation

- Chemical- Biological- Nuclear- Radiological

Super Terrorism

- Evacuation- Containment- Decontamination- Quarantine- Vaccination- Antidotes- Detoxification

Warfare Type Ops

Escalation

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Emergency Management Consequence Timelines

Bhopal Disaster3 Dec.1984

8,000 died300,000 injured

Tokyo March 20, 1995• 5,500 People Exposed• 3,227 Went to Hospital• 550 Transported Via

EMS• Essentially no

Decontamination of Patients

SARIN Clip

October 26, 2002

•50 Chechen rebels, storm Moscow’sHouse of Culture Theatre during aperformance of Nord-Ost, taking 700hostages. The rebels demand Russianwithdrawal from Chechnya, and threatento kill the hostages if demands are not met.

•After three days of fruitless negotiationsan unknown gas, meant to incapacitate therebels, is released in the theatre. Most ofthe rebels and 116 hostages die.

What kind of gas was released? …

Event Characteristics

• Most Victims are Exposed to Vapor• No warning• Victims Will Not Wait In Line to Decon.• Most Decontamination Needs to be Done

at the Hospital Not the Scene • Mass Disaster Response Occurs With

Local Resources

Event Characteristics

• Agent will likely be unknown• Dry Decontamination Suitable for Most• Only 10%-15% of Patients Via EMS• Emergency Department Resources Limited

Most Common Fatal Injuries

– Trauma (65%)

– Thermal burns (16%)

– Respiratory irritation with airway obstruction

&/or respiratory failure (10%)

– Chemical burns (6%)

– Other causes (3%)

Hazardous Substances Emergency Events Surveillance (HSEES)

What is wrong with the patient

• Physical Trauma• Exposure to Chemical HAZMAT

– Inhalation• Most common

– Skin & mucous membranes• Common

– Ingestion & Injection• Unlikely

• Toxicity – Local– Systemic

The World Of Chemical Agents

• The vast majority of HazMat incidents resulting in the contamination of people involve common industrial chemical agents.

• The study of all potential sources of contamination are best supported by looking at these chemicals in a categorical system.

Agents Categories

1. Industrial Chemicals. 2. Chemical Warfare Agents. 3. Biological Warfare Agents. 4. Radiological Materials.

Incident Response Requirements

• Protect patients, staff, and facility• Rapid decon• Expert informations• Surge capacity• Some specialized expertise

Hospital Preparedness

•Medicare

•Manage care

Reasonable ≠ Adequate

“Best possible care for victimswhile not compromising the safetyhospital staff and current patients”

Hospital Plan

• Cost effective• Simple as possible• Minimized manpower• Immediate availability• Rapid patient processing

Scene SafetyHot, Warm and Cold zones

Hot ZoneContaminated area

Need PPE

Warm ZoneContamination

reduction

Cold ZoneNormal function

You will be here. Public Health does not usually

decontaminate or function in the hot zone

Zone rules

Hot ZoneContaminated area

Need PPE

Warm ZoneContamination

reduction

Cold ZoneNormal function

Control access to zones

Temporary

Morgue

Very limited treatment before decontamination

Isolate cadavers

Decontamination direction No back flow!!

Medical Management of Hazmat Victims

• Primary Survey & Resuscitation

• Decontamination

• Hazmat Patient Assessment

• Poisoning Treatment Paradigm

Primary Survey & Resuscitation: The Basics

• Airway with cervical spine control

• Breathing

• Circulation

• Disability (nervous system)

• Exposure with environmental control

“The process of removing or neutralizing surface contaminants thathave accumulated on personnel and equipment.”

Decontamination

Chemical Victim Triage

High Priority for Decontamination: • Victims closest to point of release and reporting exposure. • Victims showing some evidence of contamination on clothing or skin. • Victims demonstrating serious symptoms.

Medium Priority for Decontamination: • Victims not as close to point of release, and who have minimal

evidence of contamination on clothing or skin. • Victims who are mildly symptomatic.

Low Priority for Decontamination: • Victims who are far away from point of release. • Victims who have no verified contamination. • Victims who are asymptomatic.

Urgency for Medical Care

Low risk for secondary contaminationCritically illFocus on Treatment

High risk for secondary contaminationCritically illSimultaneous decontamination and treatment

Low risk for secondary contaminationMild or no illnessDecontamination not needed

High risk for secondary contaminationMild or no illnessDecontamination before treatment

Triage Urgency for decontamination

General Principles

• Decontaminate victims as soon as possible.• Disrobing is decontamination; head to toe, more

removal is better.• Water flushing generally is the best mass

decontamination method.• After a known exposure to a liquid chemical

agent, emergency responders should be decontaminated as soon as possible to avoid serious effects.

Decontamination Site Selection

• Outside!• Level impermeable surfaced area• Up wind• Water supply/collection• Illuminated• Ingress and Egress routes

Layout of Hospital Decontamination Zone

Decontamination Station 2 lines

Decontamination Station 3 lines

Suggested Cut-Out Procedures (Non-ambulatory Patient’s Clothing)

Ideal Decontaminants

• Neutralize all Agents• Safe• Easy to use• Available• Rapid acting• No toxic end products• Affordable• No irritability

Dry Decontamination• Remove clothing/personal effects –

85% decon performed by this step• Vapor or no exposure• Removal of clothing• Modesty concerns• Requires large amounts of

disposable clothing• Clothing disposition

Wet Ambulatory Decontamination

Requires only one or two personnel to perform, primarily supervisory roleAt least one person should be medically trainedMay be quicker than non-ambulatory process, should utilize about the same amount of solutionFocus on non-clothed/exposed areasDecon wounds and bandage before entering shower (occlusive dressing)

Wound Decontamination

Wet Ambulatory Decontamination

• Remove clothing/personal effects• Decontaminate from head down

– Lean head back to avoid runoff ineyes

• Encourage careful scrubbing of warm,moist regions – axilla, groin, etc.

• Rinse thoroughly, copious water

Wet Ambulatory Decontamination

• Once decontaminated, patientmoves to cold zone staging area

• Re-clothed• Status monitored until

transport available

Do not need to decon if itcan be confirmed that patient:

• Never in contaminated area• Without signs and symptoms of exposure

Litter Wet Decontamination

• Requires minimum of 2-4 persons per patient• 10 to 20 minutes per patient• Average resources per patient: 35 – 50 gallons• Decontamination solutions:

– Water and Detergent– Hypochlorite 0.5% and 5% (do not use in eye,

open head or abd wounds, must be made daily)• Scrape off visible contamination

Litter Wet Decontamination

• Decontaminate with copious decontaminating fluid• Transfer to clean stretcher• Monitor patient and move to clean area

Litter Wet Decontamination

• Non-ambulatory patients displaying serious signs and symptoms

• Rapid decontamination• 5-10 minutes per patient

Skin Decon: Special Areas

• Commonly ignored during decon• Including

– Scalp– Body hair– Genitalia– Skin creases & folds– Hands– Feet– Nails

CORRIDORDECONTAMINATION

• The simplest solution• The nozzles are set at low pressure and high

volume so as not to inflict damage but which maximize the amount of water each victim is exposed to.

SPRINKLER HEADDECONTAMINATION

• water delivered at 500 gallons a minute• If the victim remains in the shower for 3

seconds on average, and assuming the person is exposed to 50% of the water

• 500 gals./minute = 8 gals/second• 8 gals./second × 3 seconds = 24 gals.• 24 gals. × 50% = 12 gals.

Other Field-Expedient Water Decontamination Methods

• should not overlook existing facilities whenidentifying means for rapid decontaminationmethods.

• although water damage to a facility might occur,the necessity of saving lives would justify theactivation of overhead fire sprinklers for use asshowers.

Other Field-Expedient Water Decontamination Methods

• wade and wash in water sources such as publicfountains, chlorinated swimming pools, swimmingareas, etc., provides an effective, high-volume decontechnique.

• Car washes with hand-held wands should also beconsidered. Water used for decontamination inlifesaving operations should be properly handledand disposed of in compliance with environmentaland health regulations, whenever possible.

Hazmat & Children

Children: Not “Small Adults”

• Anatomical/ physiological differences• Vital signs vary with age• Smaller, shorter stature

– lower “breathing zones”

• Higher minute volume• Less intravascular volume reserve

Uniquely Vulnerable

• Greater body surface area to weight ratio• Increased skin permeability• More pliable skeleton• Weight is critical in determination of:

– drug dosages– fluid requirements– equipment sizes

Example:Decontamination of Children

• Must be done with high-volume, low-pressure,heated water systems

• Must be designed for decontamination of allages and types of children

• All protocols and guidance must address:– Water temperature and pressure– Nonambulatory children– Children with special health care needs– Clothing for after decontamination

Pediatric Disaster Toolkit: Hospital Guidelines for Pediatrics in Disastershttp://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml

Decon Shower- Infants & nonambulatory kids

Pediatric Disaster Toolkit: Hospital Guidelines for Pediatrics in Disastershttp://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml

Decon Shower- Child

From a Child’s Perspective?

Operations Set-up• Arrival Point

– Staffed by Animal Control Staff and oneveterinary tech in appropriate PPE

– Personnel arriving for decontamination with pets willbe relieved of the animal

– Animals will be evaluated for injuries and extent ofcontamination

– Animal will be tranquilized (if necessary) for handlingand decontamination, or will be euthanized if injuriesare too severe

– Disposable leash will be placed on animal and movedto the gross decontamination area

Operations Set-up• Gross Decontamination Area

– Staffed by Animal Control personnel in appropriatePPE

– All collars and tags removed and discarded– Animal washed with soap and water solution and rinsed– Leash is again removed after the gross decon and

discarded– Animal wrapped in large blanket or towel to prevent

environmental exposure– Clean leash will be placed on animal prior to transfer to

second decontamination area

Operations Set-up• Second Decontamination Area

– Staffed with two Animal Control staff– Leash and blanket or towel removed, discarded– Animal sprayed with soap and water solution– Clean leash and blanket placed on animal for transport to

third decontamination area

Operations Set-up

• Third Decontamination Area– Staffed with two Animal Control staff– Leash and blanket removed, discarded– Animal rinsed with clean water, wrapped in new blanket– New leash will be placed on the animal

• Clean Area– Decontamination identification tags placed on animal– Animal evaluated by veterinarian and Animal Control staff– Wounds will be treated or animal will be transported to veterinary

clinic for further treatment– Animals reunited with owners if possible– Unclaimed animals transported to Animal Shelter or other

shelter facilities• Photo of animal displayed at scene

– Contaminated deceased animals will be placed in appropriatecontainer at site

• Container will be left in hot zone for mitigation contractor

Operations Set-up

Planning for Decontamination Washwater

• Decon washwater is an issue that has gained prominence in the last couple of years

• Hospital washwater only one possible source

In the real world• Hospitals required to plan for rapid influx of

victims in mass-contamination incident– Increased numbers, may not be deconned prior

to arrival, contaminant unknown or unusual

• May need to rapidly perform emergency mass decontamination – life saving, personnel/facility protection

In the real world• Capacity for mass decon limited in most

hospitals (a few victims) • Proper on-site washwater management

identified as barrier– containment ~ 90% of cost – may not solve problem anyway

What is the Problem?

• Is there a problem if decon washwater enters the sanitary sewer system?– Yes– No – Maybe, not enough information….depends on

contaminant type/amount/concentration, exposure potential, impacts to wastewater system or environment, legal concerns

Plausible Scenario

• Hospital needs to provide urgentdecontamination for large number victims

• Contaminant(s) uncertain or unknown• Decon by disrobing and showering or

flushing with copious amounts of water• Large volume of washwater generated• Capacity to collect and test washwater on-

site overwhelmed

Quantitative Solution

• Attempted calculation based on plausible“worst-case” scenario

• 2.5 mg VX / victim -- 25% of LD50• VX selected -- low vapor pressure and

relative persistence• 90% removal by disrobing• 10:1 ratio uncontaminated to contaminated

victims

Quantitative Solution

• 1000 victims x 10 gal/person = 37854 liters• 100 contaminated with 2.5 mg VX = 250 mg• 90% removed with disrobing = 25 mg• 25 mg/37854 L = 0.00066 ppm = 0.66 ppb

at most concentrated point

Quantitative Solution

• is this (0.66 ppb VX) a problem?• Is this the worst case?• have we considered all down stream issues?• could other contaminants be worse?

Key Uncertainties

• Scenario Uncertainties –– how many victims total? – at what rate? – how much contamination?– how much water used?– amount of dilution in system?– effects of treatment processes (e.g., retention

time for short-lived radionuclides)

Key Uncertainties

• Contaminant(s) unknown– Amount (total and concentration)– Behavior/fate– Exposure potential– Toxicity– Treatability– Impacts on people, system, environment

• May not have opportunity to test waste stream forhazardous properties and make treatment ordisposal decisions

Problem Summary

• Theoretical hazard – nature and magnitudeof downstream risks uncertain

• Hazard-specific assessment not be possibleduring incident

• Decisions must be made rapidly based onlimited, if any, information aboutcontaminants

Nopparat capacity• 12 Non ambuatory victims per hour• 48 Ambulatory victims per hour• Ability to CPR 6 Pts. at Red Zone• Information services (MSDS)• Chemical (antidote) stockpile in term

of Network ( local, regional )• Level C and PPE• Health surveillance for Decon team

and Hazmat team

Hazmat Patient Assessment

• Occurs concurrently

• Only once Resuscitated and Stable

• Patient history

• Secondary survey

Secondary Survey

• Identify poisoning complications

• Recognize preexistent problems

• Assess for trauma & burns

• Recognize toxic syndromes (toxidromes)

Identify Poisoning Complications• Airway Insufficiency

– Ammonia etc.

• Breathing Insufficiency– Aspiration pneumonitis, Noncardiogenic pulmonary edema– Sarin, Phosgene etc.

• Cardiovascular– Bradydysrythmias, Tachydysrythmias, Hypotension, Hypertension

• Disability (nervous system)– Confusion, Agitated delirium, Combativeness, Seizures, Coma

– Weakness, Paralysis, Sarin, etc.• Elimination (liver & kidneys)

Preexistent Problems• Airway

– Overbite– Small jaw– Big tongue

• Breathing– Asthma– COPD

• Cardiovascular– Coronary Artery

Disease (CAD)– Anemia

• Disability– Epilepsy

• Elimination– Renal failure– Liver failure

Recognize Toxic Syndromes

• Toxic + syndrome = Toxidrome• 5 fundamental hazmat toxidromes

– Irritant gas– Asphyxiant – Cholinergic– Corrosive– Hydrocarbon & halogenated

hydrocarbon

Antidotes

• There is no for 99% of Chemicals

• There is only supportive treatment for 99% of Chemicals

• There are standard WHO guidelines for antidotes in an industrial setting, where chemicals enter through lungs or skin

Only Supportive treatmentNo Antidotes for following

• Ammonia• Chlorine• Hydrogen sulphide• Phosgene• Carbon monoxide• Nitrogen Oxides• Formalin• Acids

Chemical Protective Clothing

Levels of Protection

Greater Hazard

Higher Burden

Level

A

Level

B

Level

C

Level

D

Hazmat PPE

• Levels of PPE– A: big suit, big tank– B: little suit, big tank– C: little suit, little mask– D: no suit, no mask

• Level A for entry• Level C for known hazard• Level B or C for unknown?

Selecting the Correct Glove

MATERIAL of CPC GOOD FOR POOR FOR

MATERIAL GOOD FOR POOR FOR

MATERIAL GOOD FOR POOR FOR

Results of Alternate Protective Clothing Performance Test

ClassificationPossible alternate

material

Defense capability Remarks

Method 204(Blister resistance)

Method 206(Gas resistance)

Military standard (butyl coated texture for

protective clothing)

100 min 200 min Defense ministry standard

Military use Officer’s raincoat 2 min 2 min

Sapper’s raincoat, poncho 7 min 7 min

Disposable protective suit 14 min 14 minTyvek

Civilian useDisposable raincoat 2 min 2 min

Sae-ma-eul raincoat 5 min 5 min

Transparent raincoat 6 min 6 min

Raincoat 11 min 11 min

Gentlemen’s raincoat 10 min 10 min

Sportswear raincoat 17 min 17 min

Results of Alternate Protective hood/ Overboots/ Protective gloves Performance Test

Classification Possible alternate material

Defense capabilityRemarks

Method 204

(Blister

resistance)

Method 206

(Gas

resistance)

Protective

hood

Military Standard(butyl coated texture for protective

clothing)

30 min 30 min MilitaryStandard

Black plastic bag 2 min 4 min

Supermarket plastic bag 2 min 5 min

Standard garbage bag 6 min 10min

Protective

Gloves

Military Standard 360 min 450 min

Taewha rubber gloves 25 min 50 min

Goeunson rubber gloves 25 min 42 min

Overboots

Military standard 360 min 450 min

Farmer’s boots 100~120 min 210 min

Regular boots 220 min 230 min

Results of Covers/ Adhesive Tapes Performance Test

Classification

Possible

alternate

material

Defense capability

Remarks

Method 204

(Blister resistance)

Method 206

(Gas resistance)

Covers

Military vehicle

cover1 min Less than 1 min

Agricultural

Vinyl

plastic cover

10 min 12 min

Industrial Vinyl

plastic cover2 min 3 min

Adhesive

Tapes

Transparent

tape100 min Over 240 min

Blue tape 25 min 50 min

Effect of Overlapping Vinyl Plastic Covers

Classification One layer Double layers Triple layers

Agricultural Vinyl

plastic cover

(thickness: 0.1 mm)

Method 204

(Blister Resistance)10 min 26 min 40 min

Method 206

(Gas Resistance) 12 min 50 min104 min

Industrial Vinyl

plastic cover

(thickness: 0.05 mm)

Method 204

(Blister Resistance)2 min 7 min 14 min

Method 206

(Gas Resistance)

3 min 14min 38 min

Agricultural Vinyl plastic cover (one layer) addedCover/Raincoats

Classification

One layerDouble layers

Triple layers

Original

material

Vinyl plastic

cover addedOriginal

material

Vinyl Plastic

cover added

Military vehicle

cover1 min 50 min 1 min 20 min

Officer’s raincoat 2 min 33 min 2 min 50 min

Sapper’s

raincoat/ poncho7 min 55 min 14 min 180 min

Gentlemen’s

raincoat4 min 45 min 5 min

68 min

Evatox™ NBC hoods for civiliansBaby Safe Pro Infant Protective Wrap

โรงพยาบาลนพรัตนราชธานกีับเครอืข่ายศูนย์พิษแห่งชาติ

โรงพยาบาลนพรัตนราชธานี

โรงพยาบาลล าปาง

โรงพยาบาลขอนแก่น

โรงพยาบาลหาดใหญ่

โรงพยาบาลระยอง

รูปภาพแสดงเครือข่ายศูนย์พิษแห่งชาติ

ศูนย์พิษวิทยา โรงพยาบาลนพรตันราชธานี

ข้อมูลข่าวสาร

การรักษาพยาบาล

ศูนย์ข้อมูลด้านพิษส าหรับประชาชน

บุคลากรทางการแพทย์

เครือข่าย

การให้ความช่วยเหลือในที่เกิดเหตุ

การรับส่งต่อในกรณีทางวิชาการ

เฝ้าระวังและควบคุม จัดท าข้อมูล GIS น าสถิติภัยหรือโรคจากสารพิษมาวางแผนงาน

ศูนย์พิษวิทยา โรงพยาบาลนพรตันราชธานี

การฝึกอบรมการซ้อมแผน

การประชุมวิชาการ

การประสานเครือข่ายการจัดประชุมเครือข่ายระดับภูมิภาค

การจัดประชุมเครือข่ายระดับประเทศ

ห้องปฏิบัติการ การประสานเครือข่าย สร้างมาตรฐาน ใช้ทรัพยากรร่วมกัน

ผลของการจัดประชมุเครือขา่ยระดับภูมภิาค

• อยากให้มีการแบ่งระดับศูนย์พิษ• อยากให้มีนโยบายที่ชัดเจน และ มีการถ่ายทอดให้กบัผู้บริหาร• อยากให้มีการสนับสนุนเรื่องงบประมาณ• ต้องการให้มีการซ้อมแผน• ให้ศูนย์พิษขึ้นกับอาชีวก่อนในชั้นแรก• ผู้ปฏิบัติควรเป็น แพทย์และเจ้าหน้าที่ห้องฉุกเฉิน อาชีวจะให้ข้อมูลด้าน

พิษ

ห้องปฏิบัติการ

• มีการประสานเครือข่ายห้องปฏิบัติการ• มีการจัดท ามาตรฐานห้องปฏิบัติการ• มีระบบส่งต่อตัวอย่างเพื่อการตรวจ• ห้องปฏิบัติการควรไปเป็นกลุ่มกับระดับของศูนย์พิษแม่ข่ายของตนเอง

เพื่อง่ายต่อการบริหารจัดการ• ในการประชุมเครือข่ายควรน าเรื่องห้องปฏิบัติการเข้าประชุมด้วย

Common pitfalls in Hazmat Drill

In a drill , hospital personnel treatedpatients without wearing PPE

Common pitfalls in Hazmat Drill

In a drill, contaminated patients would be sentto a designated hospital, but in reality……

Overlook the timerequired for actions

Before a drill, responderswear PPE and waited forthe signal.

Photo credit: Mike Vance, MD

Man dropped bucket of silver paint that splattered onto areas ofbody commonly ignored or forgotten during decon.

Photo credit: Mike Vance, MD

Can of mace went off in pants pocket & pants not removed in timelymanner.

Photo credit: Mike Vance, MD

What can happen if genitals are forgotten during decontamination.

Photo credit: Mike Vance, MD

What can happen if skin folds are forgotten during decon.

Photo credit: Mike Vance, MD

Close-up of what can happen if skin folds are forgotten during decon.

Photo credit: Mike Vance, MDWhat can happen if feet are forgotten during decon.

Eye Decon

• Irrigate exposed, symptomatic eyes immediately & continuously

– Use water or saline •Water is best

–Readily available in large quantity

–Efficient

• Check for & remove contact lenses

Mild corneal chemical burn Fluorescein indicates corneal burn site Adjacent chemical conjunctivitis

Photo credit: Mike Vance, MD

Severe corneal chemical burn Opaque cornea Blind eye

Requires cadaver corneal transplantPhoto credit: Mike Vance, MD

HAZMAT Training Trends

Summary

• Physical removal is BEST decon• Must plan for patient decon at all aspects of care• Decon process is resource intensive and must be

planned and practiced in advanced• Identify and train personnel early• Learn benefits of coordination with medical assets

in your hospital and region

Prior Planning Prevents Poor Performance