Emergency Chemical Response Decontamination Principles and Patient Management

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Kitipong Banomyong MD.,GP, MHSc (OHS), PM ( Occ. Med.)
Occupational and Environmental Medicine Center
Nopparat Rajathanee Hospital

Published in: Health & Medicine

Emergency Chemical Response Decontamination Principles and Patient Management

  1. 1. Emergency Chemical Response Decontamination Principles and Patient Management Kitipong Banomyong MD.,GP, MHSc (OHS), PM ( Occ. Med.) Occupational and Environmental Medicine Center Nopparat Rajathanee Hospital
  2. 2. Reasonable ≠ Adequate Best possible care for victims while not compromising the safety hospital staff and current patients
  3. 3. Lessons Learned From Mass Casualty Incidents
  4. 4. Emergency Management Consequence Timelines
  5. 5. Timeline For Medical Intervention of Terrorist / Warfare Agents 10 min 20 min 40 min 1 hr 2 hr 4 hr 8 hr 1 day 2 days 4 days 8 days 16 days Saxitoxin Tetrodotoxin Conotoxin Batrachotoxin Tricothecene Aflatoxin Ricin Perfringens Verotoxin Botulism SEB Toxins Elapsed Time From: Greenwood, D. P., A Relative Assessment of Putative Biological-Warfare Agents: Technical Report 1040 , (Lexington, Massachusetts: Lincoln Laboratory, Massachusetts Institute of Technology, 17 July 1997). Chemical Agents T=0 threat first reaches victims Overt Encephalitis (various) Hantaan Congo-Crimean Chikungunya Rift Valley Dengue Yellow Ebola/Marburg Lassa Smallpox Viruses Cryptococcosis Coccidioidomycosis Histoplasmosis Fungi Anthrax Plague Shigellosis Cholera Salmonella Tularemia Legionnaire’s Glanders Melioidosis Brucellosis Typhoid Nocardiosis Bacteria RMSF Typhus Psittacosis Q fever Rickettsiae, Chlamydiae Covert 1 st Responders Arrive (1) 2 nd Responders Arrive (1) Civil Support Teams Arrive (1) Follow-up Federal Resources & Supplies Arrive (1) (1) After Notification
  6. 6. Summary Comparison SUMMARY CHARACTERISTICS Low Local to Global CHEM RAD BIO AGENTS Days to Weeks City Blocks City to Region Potential Impact High Medium Availability Seconds to Hours Minutes to Hours Time To Effects
  7. 7. Chem-Agent Dose Note: A barrel holds 44 gallons; tanker trucks carry 1,000 to 12,000 gallons; rail cars carry in excess of 20,000 gallons. Lethal doses vary among different Chem-agents 100% Lethal Air Dose Quantity 5.3 Quarts 21 Gallons 1820 Gallons Riot-Control 1.5 Quarts 6 Gallons 520 Gallons Blood 2.3 Quarts 9 Gallons 780 Gallons Choking 1 Quart 4 Gallons 338 Gallons Blister 1.3 ounces 2 ½ Cups 13 Gallons Nerve Boeing 747-400 Movie Theater Domed Stadium Chemical Agent
  8. 8. Bhopal Disaster 3 Dec.1984 8,000 died 300,000 injured
  9. 9. Tokyo March 20, 1995 <ul><li>5,500 People Exposed </li></ul><ul><li>3,227 Went to Hospital </li></ul><ul><li>550 Transported Via EMS </li></ul><ul><li>Essentially no Decontamination of Patients </li></ul>
  10. 10. Tokyo – Sarin Symptoms <ul><li>Dim Vision 73% (11-15) </li></ul><ul><li>Miosis in 73% of these (8/11) </li></ul><ul><li>Rhinorrhea 53% </li></ul><ul><li>Dyspnea or Chest Tightness 27% </li></ul><ul><li>Cough 13% </li></ul><ul><li>Six Treated With Atropine </li></ul><ul><li>One Treated With Pralidoxime </li></ul>
  11. 12. Lessons Learned From Chemical Mass Casualty Incidents <ul><li>Most Victims are Exposed to Vapor </li></ul><ul><li>Hospitals, EMS, Fire, Public Safety Overwhelmed </li></ul><ul><li>Dry Decontamination Suitable for Most </li></ul>
  12. 13. Lessons Learned Continued <ul><li>Victims Will Not Wait In Line to Shower </li></ul><ul><li>Most Decontamination Needs to be Done at the Hospital Not the Scene </li></ul><ul><li>Mass Disaster Response Occurs With Local Resources </li></ul><ul><li>Decontamination initiated at medical facilities 3 hours after exposure </li></ul>
  13. 14. Lessons Learned Continued <ul><li>Ambulatory Patients Present Earliest and Overwhelm the Resources </li></ul><ul><li>Only 10%-15% of Patients Via EMS </li></ul><ul><li>Emergency Department Resources Limited </li></ul><ul><li>Use of Secondary “Treatment Facilities” </li></ul>
  14. 15. Current State of Preparedness <ul><li>Data from 30 hospitals FEMA Region III </li></ul><ul><li>100% of sites not fully prepared for biologic incident </li></ul><ul><li>73% not prepared for chemical incident </li></ul><ul><li>73% not prepared for nuclear incident </li></ul>Treat K.N. Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Annals of Emergency Medicine Nov. 2001
  15. 16. Current State of Preparedness <ul><li>73% would set up a “single room” decontamination process. </li></ul><ul><li>13% had no decontamination process. </li></ul><ul><li>3% (1 hospital) had chemical antidote stockpile </li></ul><ul><li>0% had prepared media statements </li></ul><ul><li>25% had “some” training in WMD incidents </li></ul>Treat K.N. Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Annals of Emergency Medicine Nov. 2001
  16. 17. Current State of Preparedness <ul><li>77% had facility security plan in place </li></ul><ul><li>50% able to “lock down” the facility </li></ul><ul><li>4% aware of “secondary device” threat </li></ul><ul><li>Conclusion: “Hospitals in this sample do not appear to be prepared to handle WMD events” </li></ul>Treat K.N. Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Annals of Emergency Medicine Nov. 2001
  17. 18. The World Of Chemical Agents <ul><li>The vast majority of HazMat incidents resulting in the contamination of people involve common industrial chemical agents. </li></ul><ul><li>The study of all potential sources of contamination are best supported by looking at these chemicals in a categorical system. </li></ul>
  18. 19. Agents Categories <ul><li>1. Industrial Chemicals. </li></ul><ul><li>2. Chemical Warfare Agents. </li></ul><ul><li>3. Biological Warfare Agents. </li></ul><ul><li>4. Radiological Materials. </li></ul>
  19. 20. Vapor Pressure(VP) VP = 3877 mm VCM Chlorine VP = 7600 mm X VP = 60 mm
  20. 21. Boiling point(BP) VCM BP = -13.88 C H2O BP = 100 C BP = 50.55 C Chlorine BP = -34.6 C HCl
  21. 22. Vapor Density(VD) VD of dry air = 1
  22. 23. Specific gravity (SG) SG of Water = 1
  23. 24. The process of removing or neutralizing surface contaminants that have accumulated on personnel and equipment. What is Decontamination?
  24. 25. General Principles <ul><li>Decontaminate victims as soon as possible. </li></ul><ul><li>Disrobing is decontamination; head to toe, more removal is better. </li></ul><ul><li>Water flushing generally is the best mass decontamination method. </li></ul><ul><li>After a known exposure to a liquid chemical agent, emergency responders should be decontaminated as soon as possible to avoid serious effects. </li></ul>
  25. 26. For gases <ul><li>Remove from the gas </li></ul><ul><li>to undress or further decontaminate </li></ul>
  26. 27. For vapors, mists, liquids <ul><li>Remove clothes </li></ul><ul><li>Irrigate skin with soap and water </li></ul><ul><li>• Gentle- Do not scrub </li></ul><ul><li>• No bleach </li></ul><ul><li>• Do not neutralize </li></ul><ul><li>• Address contaminated areas </li></ul><ul><li>If only arm do not wash hair </li></ul>
  27. 28. Exposed, Symptomatic Eyes <ul><li>• Should be irrigated immediately and continuously </li></ul><ul><li>– Use Tepid water or saline only </li></ul><ul><li>– Water is best </li></ul><ul><li>• Readily available in copious quantities at scene </li></ul><ul><li>ocular topical anesthetic </li></ul><ul><li>• Remember to check for patient contact lenses </li></ul><ul><li>and remove them </li></ul>
  28. 29. Industrial Chemical Victim Triage <ul><li>High Priority for Decontamination: </li></ul><ul><li>• Victims closest to point of release and reporting exposure. </li></ul><ul><li>• Victims showing some evidence of contamination on clothing or skin. </li></ul><ul><li>• Victims demonstrating serious symptoms. </li></ul><ul><li>Medium Priority for Decontamination: </li></ul><ul><li>• Victims not as close to point of release, and who have minimal evidence of contamination on clothing or skin. </li></ul><ul><li>• Victims who are mildly symptomatic. </li></ul><ul><li>Low Priority for Decontamination: </li></ul><ul><li>• Victims who are far away from point of release. </li></ul><ul><li>• Victims who have no verified contamination. </li></ul><ul><li>• Victims who are asymptomatic. </li></ul>
  29. 30. Urgency for decontamination Triage High risk for secondary contamination Mild or no illness Decontamination before treatment Low risk for secondary contamination Mild or no illness Decontamination not needed High risk for secondary contamination Critically ill Simultaneous decontamination and treatment Low risk for secondary contamination Critically ill Focus on Treatment Urgency for Medical Care
  30. 31. Decontamination Site Selection <ul><li>Outside! </li></ul><ul><li>Level impermeable surfaced area </li></ul><ul><li>Up wind </li></ul><ul><li>Water supply/collection </li></ul><ul><li>Illuminated </li></ul><ul><li>Ingress and Egress routes </li></ul>
  31. 32. Layout of Hospital Decontamination Zone
  32. 33. Decontamination Station 2 lines
  33. 34. Decontamination Station 3 lines
  34. 35. Control Zones <ul><li>Control Zones should be established for: </li></ul><ul><ul><li>Entrance and exit </li></ul></ul><ul><ul><li>Operations inside the ETA </li></ul></ul><ul><li>The ETA has three distinct zones </li></ul><ul><li>Zones are separated to: </li></ul><ul><ul><li>Control access </li></ul></ul><ul><ul><li>Provide security </li></ul></ul><ul><ul><li>Minimize transfer of contamination </li></ul></ul><ul><li>Enables scene control of bystanders </li></ul><ul><li>Established by barricades and isolation areas </li></ul>
  35. 36. Isolation Zones WARM INCIDENT SITE HOT **SAFE REFUGE AREA DECONTAMINATION CORRIDOR ACCESS CORRIDOR COLD COMMAND POST WIND DIRECTION **
  36. 37. <ul><ul><ul><li>เครื่องอ่านค่าโดยตรง </li></ul></ul></ul><ul><li>(Direct Reading Instruments) </li></ul>
  37. 39. Hospital Decontamination Zones (OSHA) <ul><li>Hospital Pre-decontamination Zone </li></ul><ul><ul><li>Assessment, triage, and treatment </li></ul></ul><ul><ul><li>Similar to OSHA’s “Hot Zone” </li></ul></ul><ul><li>Hospital Decontamination Zone </li></ul><ul><ul><li>Decontamination of patients </li></ul></ul><ul><ul><li>Similar to OSHA’s “Warm Zone” </li></ul></ul><ul><li>Hospital Post-decontamination Zone </li></ul><ul><ul><li>Advance patient care and treatment </li></ul></ul><ul><ul><li>Similar to OSHA’s “Cold Zone” </li></ul></ul><ul><li>OSHA Best Practices for Hospital-based First Receivers of Victims…, dated 9/2/2004 </li></ul>
  38. 40. Arrival Point <ul><li>Purpose </li></ul><ul><ul><li>Initial reception for potentially contaminated patients </li></ul></ul><ul><ul><li>Patient checked for contamination </li></ul></ul><ul><li>Location </li></ul><ul><ul><li>Close to triage area </li></ul></ul><ul><li>Staffing </li></ul><ul><ul><li>Personnel in Level C? </li></ul></ul>
  39. 41. Immediate Treatment <ul><li>Life Saving Procedures </li></ul><ul><li>A </li></ul><ul><li>B </li></ul><ul><li>C </li></ul><ul><li>D </li></ul>
  40. 42. Hospital Decontamination Immediate Treatment Triage Arrival Point Hospital & Secondary Treatment Facility Dry Decon litter Wet Decon (Non-Ambulatory) Wet Ambulatory Decon
  41. 43. Dry Decontamination <ul><li>Vapor or no exposure </li></ul><ul><li>Removal of clothing </li></ul><ul><li>Modesty concerns </li></ul><ul><li>Tracking of Valuables </li></ul><ul><li>Requires large amounts of disposable clothing </li></ul><ul><li>Clothing disposition </li></ul>
  42. 44. Suggested Cut-Out Procedures (Non-ambulatory Patient’s Clothing)
  43. 45. Ideal Decontaminants <ul><li>Neutralize all Agents </li></ul><ul><li>Safe </li></ul><ul><li>Easy to use </li></ul><ul><li>Available </li></ul><ul><li>Rapid acting </li></ul><ul><li>No toxic end products </li></ul><ul><li>Affordable </li></ul><ul><li>No irritability </li></ul>
  44. 46. Other Field-Expedient Water Decontamination Methods <ul><li>should not overlook existing facilities when identifying means for rapid decontamination methods. </li></ul><ul><li>although water damage to a facility might occur, the necessity of saving lives would justify the activation of overhead fire sprinklers for use as showers. </li></ul>
  45. 47. Other Field-Expedient Water Decontamination Methods <ul><li>wade and wash in water sources such as public fountains, chlorinated swimming pools, swimming areas, etc., provides an effective, high-volume decon technique. </li></ul><ul><li>Car washes with hand-held wands should also be considered. Water used for decontamination in lifesaving operations should be properly handled and disposed of in compliance with environmental and health regulations, whenever possible. </li></ul>
  46. 48. Wet Ambulatory Decontamination <ul><li>Clothing removal </li></ul><ul><li>Shower with warm water and soap </li></ul><ul><li>Modesty concerns </li></ul><ul><li>Requires large amounts of water, towels, and disposable clothing </li></ul>
  47. 49. Do not need to decon if it can be confirmed that patien t: <ul><li>Never in contaminated area </li></ul><ul><li>Without signs and symptoms of exposure </li></ul>
  48. 50. Litter Wet Decontamination <ul><li>Requires minimum of 2-4 persons per patient </li></ul><ul><li>10 to 20 minutes per patient </li></ul><ul><li>Decontamination solutions: </li></ul><ul><ul><li>Water and Detergent </li></ul></ul><ul><ul><li>Hypochlorite 0.5% and 5% (do not use in eye, open head or abd wounds, must be made daily) </li></ul></ul><ul><li>Scrape off visible contamination </li></ul>
  49. 51. Litter Wet Decontamination <ul><li>Decontaminate with copious </li></ul><ul><li>decontaminating fluid </li></ul><ul><li>Transfer to clean stretcher </li></ul><ul><li>Monitor patient and move to clean area </li></ul>
  50. 52. Litter Wet Decontamination <ul><li>Non-ambulatory patients displaying serious signs and symptoms </li></ul><ul><li>Rapid decontamination </li></ul><ul><li>5-10 minutes per patient </li></ul>
  51. 53. Self-Decontamination <ul><li>Because time is a critical factor when decontaminating victims, allowing the victims to self-decontaminate can speed up the decontamination process. </li></ul><ul><li>This will contribute to the possible reduction of staffing needs </li></ul><ul><li>Further, victims who are able and allowed to self-decontaminate will often be more thorough and more efficient. </li></ul><ul><li>finally, allowing self-decontamination will reduce issues and concerns of modesty. </li></ul>
  52. 54. Mass Decon Fire Department / Haz Mat Team
  53. 55. CORRIDOR DECONTAMINATION <ul><li>The simplest solution </li></ul><ul><li>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. </li></ul>
  54. 56. SPRINKLER HEAD DECONTAMINATION <ul><li>water delivered at 500 gallons a minute </li></ul><ul><li>If the victim remains in the shower for 3 seconds on average, and assuming the person is exposed to 50% of the water </li></ul><ul><li>500 gals./minute = 8 gals/second </li></ul><ul><li>8 gals./second × 3 seconds = 24 gals. </li></ul><ul><li>24 gals. × 50% = 12 gals. </li></ul>
  55. 60. Mass Decon Hospital Based
  56. 67. VICTIM DECONTAMINATION FACILITY
  57. 68. Entrance to Emergency Department Site of Decon Unit
  58. 69. Site of Decon Unit Circular Drive at Front of Med Ctr
  59. 70. Routinely used as break area. During emergency, site of decon unit.
  60. 71. Deploying the shower curtains
  61. 72. Curtain separates male/female ambulatory decon lines
  62. 73. Drop down sprayers help with final rinse of ambulatory and decon of non-ambulatory victims.
  63. 75. Off/on box and mixing unit for shower
  64. 76. Deluge shower head – five on each line
  65. 77. Fully deployed shower Entrance for ambulatory victims Shower lines for ambulatory victims Disrobing area for ambulatory victims
  66. 79. Looking down the ambulatory men’s shower line
  67. 80. Assisting an ambulatory victim (drill)
  68. 81. Decon’ing a non-ambulatory victim
  69. 82. Planning for Decontamination Washwater <ul><li>Decon washwater is an issue that has gained prominence in the last couple of years </li></ul><ul><li>Hospital washwater only one possible source </li></ul>
  70. 83. History, briefly <ul><li>Hospitals required to plan for rapid influx of victims in mass-contamination incident </li></ul><ul><ul><li>Increased numbers, may not be deconned prior to arrival, contaminant unknown or unusual </li></ul></ul><ul><li>May need to rapidly perform emergency mass decontamination </li></ul><ul><ul><li>life saving, personnel/facility protection </li></ul></ul>
  71. 84. History, continued <ul><li>Capacity for mass decon limited in most hospitals (a few victims) </li></ul><ul><li>Proper on-site washwater management identified as barrier </li></ul><ul><ul><li>containment ~ 90% of cost </li></ul></ul><ul><ul><li>may not solve problem anyway </li></ul></ul>
  72. 85. What is the Problem? <ul><li>Is there a problem if decon washwater enters the sanitary sewer system? </li></ul><ul><ul><li>Yes </li></ul></ul><ul><ul><li>No </li></ul></ul><ul><ul><li>Maybe, not enough information….depends on contaminant type/amount/concentration, exposure potential, impacts to wastewater system or environment, legal concerns </li></ul></ul>
  73. 86. Plausible Scenario <ul><li>Hospital needs to provide urgent decontamination for large number victims </li></ul><ul><li>Contaminant(s) uncertain or unknown </li></ul><ul><li>Decon by disrobing and showering or flushing with copious amounts of water </li></ul><ul><li>Large volume of washwater generated </li></ul><ul><li>Capacity to collect and test washwater on-site overwhelmed </li></ul>
  74. 87. Quantitative Solution <ul><li>Attempted calculation based on plausible “worst-case” scenario </li></ul><ul><li>2.5 mg VX / victim -- 25% of LD50 </li></ul><ul><li>VX selected -- low vapor pressure and relative persistence </li></ul><ul><li>90% removal by disrobing </li></ul><ul><li>10:1 ratio uncontaminated to contaminated victims </li></ul>
  75. 88. Quantitative Solution <ul><li>1000 victims x 10 gal/person = 37854 liters </li></ul><ul><li>100 contaminated with 2.5 mg VX = 250 mg </li></ul><ul><li>90% removed with disrobing = 25 mg </li></ul><ul><li>25 mg/37854 L = 0.00066 ppm = 0.66 ppb at most concentrated point </li></ul>
  76. 89. Quantitative Solution <ul><li>is this (0.66 ppb VX) a problem? </li></ul><ul><li>Is this the worst case? </li></ul><ul><li>have we considered all down stream issues? </li></ul><ul><li>could other contaminants be worse? </li></ul>
  77. 90. Key Uncertainties <ul><li>Scenario Uncertainties – </li></ul><ul><ul><li>how many victims total? </li></ul></ul><ul><ul><li>at what rate? </li></ul></ul><ul><ul><li>how much contamination? </li></ul></ul><ul><ul><li>how much water used? </li></ul></ul><ul><ul><li>amount of dilution in system? </li></ul></ul><ul><ul><li>effects of treatment processes (e.g., retention time for short-lived radionuclides) </li></ul></ul>
  78. 91. Key Uncertainties <ul><li>Contaminant(s) unknown </li></ul><ul><ul><li>Amount (total and concentration) </li></ul></ul><ul><ul><li>Behavior/fate </li></ul></ul><ul><ul><li>Exposure potential </li></ul></ul><ul><ul><li>Toxicity </li></ul></ul><ul><ul><li>Treatability </li></ul></ul><ul><ul><li>Impacts on people, system, environment </li></ul></ul><ul><li>May not have opportunity to test waste stream for hazardous properties and make treatment or disposal decisions </li></ul>
  79. 92. Emergency Response Plan Guidance for Wastewater Systems <ul><li>Prepared by the Water Environment Research Foundation (WERF) www.werf.org/pdf/03CTS4S.pdf </li></ul><ul><li>Includes information related to managing patient decon wastewater </li></ul><ul><li>Advises developing action plans for significant events </li></ul>
  80. 93. Planning for Decontamination Wastewater <ul><li>Guidance from National Association of Clean Water Agencies (www.nacwa.org) </li></ul><ul><li>Describes potential contaminants, sources for entry to sewer, managing risks through planning, coordination and communication </li></ul><ul><li>Includes information about hospital washwater and recommends local planning and coordination </li></ul>
  81. 94. Medical Management Medical Treatment Protocol available from US Dept. of Health and Human Services Agency for Toxic Substances and Disease Registry http://www.atsdr.cdc.gov/mmg.html
  82. 95. ตัวอย่างไอระเหย / ก๊าซพิษที่เกิดจากการเผาไหม้พลาสติก
  83. 96. Chemicals Can Often Be Recognized by the Clusters of Symptoms That They Cause (Toxidromes)
  84. 97. Recognize Toxic Syndromes: 5 Hazmat Toxidromes <ul><li>1. Irritant gases </li></ul><ul><li>2. Asphyxiants </li></ul><ul><li>3. Hydrocarbon and halogenated hydrocarbons </li></ul><ul><li>4. Cholinergic </li></ul><ul><li>5. Corrosive </li></ul>
  85. 98. 1. Irritant Gases Toxidrome <ul><li>Impaired Breathing due to effects from a gas on the upper airway and/or alveolar-capillary membrane </li></ul>
  86. 99. <ul><li>Site of injury to body determined primarily by: </li></ul><ul><li>– Water solubility </li></ul><ul><li>• Nose and upper airways filter water soluble gases </li></ul><ul><li>– Duration of exposure </li></ul><ul><li>– Concentration </li></ul><ul><li>Effects: </li></ul><ul><li>– Eye, nose, throat irritation, cough, stridor, </li></ul><ul><li>shortness of breath, pulmonary edema </li></ul><ul><li>– Symptoms within minutes to hours </li></ul>
  87. 100. <ul><li>Highly water-soluble </li></ul><ul><li>– Ammonia </li></ul><ul><li>– Sulfur Dioxide </li></ul><ul><li>– Hydrogen Chloride </li></ul><ul><li>– Formaldehyde </li></ul><ul><li>• Moderately water-soluble </li></ul><ul><li>– Chlorine </li></ul><ul><li>• Slightly water-soluble </li></ul><ul><li>– Phosgene </li></ul><ul><li>– Nitrogen dioxide </li></ul>
  88. 101. Irritant Gas Highly Water Soluble <ul><li>Low dose exposure </li></ul><ul><li>– Eye, nose, throat irritation, tearing </li></ul><ul><li>Moderate exposure- </li></ul><ul><li>– Hoarseness, cough, tracheobronchitis </li></ul><ul><li>• Concentrations decreased by time it reaches </li></ul><ul><li>trachea </li></ul><ul><li>• Greater exposure by duration or concentration </li></ul><ul><li>results in deeper injury </li></ul>
  89. 102. <ul><li>Acute Upper Airway </li></ul><ul><li>– Burning sensation </li></ul><ul><li>– Coughing </li></ul><ul><li>– Excess mucus production </li></ul><ul><li>– Upper airway edema </li></ul><ul><li>– Dysphonia </li></ul><ul><li>– Stridor </li></ul><ul><li>– Difficulty breathing </li></ul>
  90. 103. <ul><li>• Ammonia, Sulfur Dioxide, Hydrogen </li></ul><ul><li>Chloride, Formaldehyde, HF </li></ul><ul><li>• HF- large exposure may cause bronchial and pulmonary destruction, death usually due to systemic toxicity </li></ul>
  91. 104. Ammonia <ul><li>• Colorless, water-soluble, </li></ul><ul><li>alkaline gas </li></ul><ul><li>• Pungent odor </li></ul><ul><li>Uses: </li></ul><ul><li>• To make fertilizer, explosives, </li></ul><ul><li>dyes, and plastics </li></ul><ul><li>• In the manufacture of nitric </li></ul><ul><li>acid, hydrazine hydrate, </li></ul><ul><li>hydrogen cyanide, </li></ul><ul><li>nitrocellulose, </li></ul><ul><li>ureaformaldehyde, and others </li></ul>
  92. 105. <ul><li>Household ammonia </li></ul><ul><li>– pH < 12 - limited damage </li></ul><ul><li>Anhydrous ammonia </li></ul><ul><li>– pH > 12 - severe damage </li></ul><ul><li>• Rapidly absorbed by mucosal surfaces </li></ul><ul><li>– Eyes, and Throat </li></ul><ul><li>• Corrosive when combined with water </li></ul><ul><li>– Liquefaction necrosis </li></ul>
  93. 106. Irritant Gas Moderately Water Soluble
  94. 107. Moderately water soluble <ul><li>Chlorine gas </li></ul><ul><li>Affects upper and lower airway but to a lesser extent the highly or slightly water soluble irritants </li></ul>
  95. 108. Chlorine (Cl ) 2 CAS 7782-50-5; UN 1017 <ul><li>• Persons exposed only to chlorine gas pose little risk of secondary contamination to others. However, clothing or skin soaked with industrial-strength chlorine bleach or similar solutions may be corrosive to rescuers and may release harmful chlorine gas. </li></ul><ul><li>• Chlorine is a yellow-green, noncombustible gas with a pungent, irritating odor. It is a strong oxidizing agent and can react explosively or form explosive compounds with many common substances. Chlorine is heavier than air and may collect in low-lying areas. </li></ul><ul><li>• Chlorine gas is highly corrosive when it contacts moist tissues such as the eyes, skin, and upper respiratory tract. Significant dermal absorption or ingestion is unlikely. </li></ul>
  96. 109. Vapor Density(VD) VD of dry air = 1
  97. 110. Prehospital Management <ul><li>• Rescue personnel are at low risk of secondary contamination from victims who have been exposed only to chlorine gas. However, clothing or skin soaked with industrialstrength bleach or similar solutions may be corrosive to rescuers and may release harmful chlorine gas. </li></ul><ul><li>• Acute exposure to chlorine gas initially causes coughing, eye and nose irritation, lacrimation, and a burning sensation in the chest. Airway constriction and noncardiogenic pulmonary edema may occur. Chlorine irritates the skin and can cause burning pain, inflammation, and blisters. Exposure to liquefied chlorine can result in frostbite. </li></ul><ul><li>• There is no specific antidote for chlorine poisoning. Treatment is supportive. </li></ul>
  98. 111. Multi-Casualty Triage <ul><li>Patients with evidence of significant exposure (e.g., severe or persistent cough, dyspnea or chemical burns) should be transported to a medical facility for evaluation. </li></ul><ul><li>Patients who have minor or transient irritation of the eyes or throat may be discharged from the scene after their names, addresses, and telephone numbers are recorded. </li></ul><ul><li>They should be advised to seekmedical care promptly if symptoms develop or recur </li></ul>
  99. 112. Emergency Department Management <ul><li>• Hospital personnel are at minimal risk of secondary contamination from patients who have been exposed only to chlorine gas. However, clothing or skin soaked with industrial-strength bleach or similar solutions may be corrosive to personnel and may release harmful chlorine gas. </li></ul><ul><li>• Acute exposure to chlorine gas initially causes coughing, eye and nose irritation, lacrimation, and a burning sensation in the chest. Airway constriction, noncardiogenic pulmonary edema, hemoptysis, and bronchopneumonia may occur. </li></ul><ul><li>• Chlorine irritates the skin and can cause burning pain, inflammation, and blisters. Exposure to liquefied chlorine can result in frostbite. </li></ul><ul><li>• There is no specific antidote for chlorine poisoning. Treatment requires supportive care. </li></ul>
  100. 113. Disposition and Follow-up <ul><li>Consider hospitalizing patients who have a suspected significant exposure or have eye burns or serious skin burns. </li></ul><ul><li>Symptomatic patients complaining of persistent shortness of breath, severe cough, or chest tightness should be admitted tothe hospital and observed until symptom-free. </li></ul><ul><li>Pulmonary injury may progress for several hours. </li></ul>
  101. 114. Patient Release <ul><li>Asymptomatic patients and those who experienced only minor sensations of burning of the nose, throat, eyes, and respiratory tract (with perhaps a slight cough) may be released. </li></ul><ul><li>In most cases, these patients will be free of symptoms in an hour or less. </li></ul><ul><li>They should be advised to seek medical care promptly if symptoms develop or recur </li></ul>
  102. 115. Follow-up <ul><li>Follow up is recommended for all hospitalized patients because long-term respiratory problems can result. </li></ul><ul><li>Respiratory monitoring is recommended until the patient is symptom-free. </li></ul><ul><li>Chlorine-induced reactive airways dysfunction syndrome (RADS) has been reported to persist from 2 to 12 years. </li></ul>
  103. 116. Irritant Gas Slightly Water Soluble <ul><li>Some irritation acutely </li></ul><ul><li>Delayed Pneumonia </li></ul><ul><li>– Wheezing </li></ul><ul><li>– Bronchospasm </li></ul><ul><li>– Noncardiogenic </li></ul><ul><li>pulmonary edema </li></ul><ul><li>– Hypoxemia </li></ul><ul><li>– CNS agitation </li></ul><ul><li>– CNS depression </li></ul>
  104. 117. <ul><li>Nitrogen Dioxide </li></ul><ul><li>Heavier than air, reddish brown gas </li></ul><ul><li>• Criteria air pollutant </li></ul><ul><li>• Uses commercially </li></ul><ul><li>– Chemical intermediate, catalyst, nitrating agent, oxidizing </li></ul><ul><li>agent, polymerization inhibitor, oxidizer for rocket fuels, </li></ul><ul><li>and in bleaching flour </li></ul>
  105. 118. Asphyxiant <ul><li>Asphyxiants are chemicals that interfere with the body’s ability to use oxygen while not affecting the airway or alveolar-capillary membranes </li></ul>
  106. 119. Asphyxiant <ul><li>1.Simple Asphyxiants </li></ul><ul><li>Displace ambient air </li></ul><ul><li>2.Systemic Asphyxiants </li></ul><ul><li>Inhibit oxygen utilization by </li></ul><ul><li>cells </li></ul>
  107. 120. Signs & Symptoms <ul><li>Respiratory </li></ul><ul><li>• Decreased oxygen supply causes </li></ul><ul><li>– Tachypnea </li></ul><ul><li>• If hypoxia is not corrected </li></ul><ul><li>– Eventual respiratory arrest </li></ul><ul><li>• Patients may experience significant “air </li></ul><ul><li>hunger” </li></ul>
  108. 121. Signs & Symptoms <ul><li>Cardiovascular </li></ul><ul><li>• Decreased oxygen supply can cause </li></ul><ul><li>– Tachycardia </li></ul><ul><li>– Myocardial ischemia </li></ul><ul><li>– Dysrhythmias , Cardiac arrest </li></ul><ul><li>• Nitrites, nitrates, and azides cause </li></ul><ul><li>– Direct vasodilation </li></ul><ul><li>– Hypotension </li></ul>
  109. 122. Signs & Symptoms <ul><li>Neurological </li></ul><ul><li>CNS excitation can lead to CNS depression </li></ul><ul><li>Hypoxia can cause </li></ul><ul><li>– Headache </li></ul><ul><li>– Dizziness </li></ul><ul><li>– Weakness </li></ul><ul><li>– Confusion </li></ul><ul><li>– Agitation </li></ul><ul><li>– Seizures </li></ul><ul><li>– Coma </li></ul>
  110. 123. <ul><li>Skin and Mucous Membranes </li></ul><ul><li>• Simple asphyxiants & methemoglobinforming </li></ul><ul><li>compounds produce </li></ul><ul><li>– Peripheral and central cyanosis </li></ul><ul><li>• This may not be seen with systemic </li></ul><ul><li>asphyxiants </li></ul>
  111. 124. Simple Asphyxiants <ul><li>• Biologically inert gases </li></ul><ul><li>• Displaces ambient air so there is less oxygen </li></ul><ul><li>inhaled into the lungs </li></ul><ul><li>• Examples: Carbon dioxide, Nitrogen, Helium, </li></ul><ul><li>Methane, Ethane, Butane, Propane, Acetylene </li></ul><ul><li>– Methane in mines, canaries </li></ul><ul><li>• Treatment- remove from exposure, oxygen </li></ul>
  112. 125. Hydrocarbon Gases <ul><li>Methane, Ethane, Butane, Propane, Acetylene </li></ul><ul><li>Natural Gas (M 85%, E 9%, P 3%, B 1% Nitrogen 2%) </li></ul><ul><li>• Heavier than air </li></ul><ul><li>• Explosive !!! </li></ul>
  113. 126. Simple Asphyxiants: Decontamination <ul><li>• Remove the patient from exposure </li></ul><ul><li>• No need to undress or decontaminate </li></ul><ul><li>• Tx </li></ul><ul><li>– Ensure adequate ventilation with 100% </li></ul><ul><li>oxygen for symptomatic patients </li></ul><ul><li>– CPR/ Intubation as necessary </li></ul><ul><li>– Cardiac Monitoring </li></ul>
  114. 127. Systemic Asphyxiants 3 types <ul><li>1. Interfere with oxygen transportation via hemoglobin </li></ul><ul><li>– Methemoglobin-forming compounds </li></ul><ul><li>• Primarily nitrites (Isobutyl nitrite) and other nitro </li></ul><ul><li>compounds </li></ul><ul><li>2. Interfere with oxygen utilization by inhibiting </li></ul><ul><li>mitochondrial cytochrome oxidase (cyt a,a3) </li></ul><ul><li>– Cyanides & cyanogenic compounds </li></ul><ul><li>– Sulfides </li></ul><ul><li>– Azides </li></ul><ul><li>3. Does both </li></ul><ul><li>– Carbon monoxide </li></ul>
  115. 128. Systemic Asphyxiants <ul><li>Interfere with oxygen transportation via hemoglobin </li></ul><ul><li>Nitrites </li></ul><ul><li>Methemoglobin forming compounds </li></ul>
  116. 129. Impaired oxygen delivery Methemoglobin forming compounds <ul><li>• Hemoglobin's ferrous </li></ul><ul><li>iron (Fe+2) is oxidized to </li></ul><ul><li>ferric iron (Fe+3) by </li></ul><ul><li>nitrites </li></ul><ul><li>• Oxygen (O2) cannot bind </li></ul><ul><li>to methemoglobin's Fe+3. </li></ul><ul><li>Water (H2O) binds in </li></ul><ul><li>oxygen's place. </li></ul><ul><li>• Methemoglobin cannot </li></ul><ul><li>transport O </li></ul>
  117. 130. <ul><li>Cardiovascular </li></ul><ul><li>– Methemoglobinemia </li></ul><ul><li>– Chocolate-brown blood </li></ul><ul><li>– Peripheral cyanosis </li></ul>
  118. 131. <ul><li>Treatment </li></ul><ul><li>• Oxygen </li></ul><ul><li>• Supportive Care </li></ul><ul><li>• Monitor for shock and treat accordingly </li></ul><ul><li>– Nitrates and nitrites are potent vasodilators </li></ul><ul><li>– Large quantities of isotonic IV fluids may be required </li></ul><ul><li>• Antidote Administration </li></ul><ul><li>– Methylene blue, if indicated </li></ul>
  119. 132. <ul><li>Systemic Asphyxiants </li></ul><ul><li>Interfere with oxygen utilization by inhibiting </li></ul><ul><li>mitochondrial cytochrome oxidase (cyt a,a3) </li></ul><ul><li>Cyanides </li></ul><ul><li>& cyanogenic compounds </li></ul><ul><li>Sulfides </li></ul><ul><li>Azides </li></ul>
  120. 135. Cyanide Blocks oxygen utilization through cytochrome oxidase pathway <ul><li>• Metal plating industry </li></ul><ul><li>• Bitter almonds smell </li></ul><ul><li>– only a small % of the population can smell it </li></ul><ul><li>HA, nausea, dizziness, LOC, anoxia </li></ul>
  121. 136. Cyanide Treatment <ul><li>• Remove from area </li></ul><ul><li>• If conscious and breathing: </li></ul><ul><li>– Oxygen </li></ul><ul><li>– IV fluids </li></ul><ul><li>– Observe; no antidotes </li></ul><ul><li>• If unconscious: </li></ul><ul><li>– Oxygen and bag-mask ventilate </li></ul><ul><li>– Amyl Nitrite - give until IV started </li></ul>
  122. 137. Treatment - Nitrites <ul><li>Amyl Nitrite (Inhalation) </li></ul><ul><li>– 1 amp inhaled for 30 seconds out of each minute </li></ul><ul><li>– Change ampoules every 3 minutes </li></ul><ul><li>– Discontinue use when sodium nitrite is </li></ul><ul><li>administered </li></ul>
  123. 138. <ul><li>Sodium Nitrite (IV) Preferred </li></ul><ul><li>– 1 ampule, over no less than 5 minutes </li></ul><ul><li>– 1/2 the initial dose may be repeated at 30min if no </li></ul><ul><li>significant response </li></ul><ul><li>– Dosage is not titrated </li></ul><ul><li>– Peds 0.12 to 0.33 ml/kg (up to 10ml), over > 5 minutes </li></ul>
  124. 139. <ul><li>Sodium Thiosulfate (IV) </li></ul><ul><li>– 1 amp over 10-20 minutes </li></ul><ul><li>– Peds: 1.6 ml/kg over 10-20 minutes </li></ul><ul><li>Converts cyanide to the </li></ul><ul><li>much less toxic thiocyanate </li></ul><ul><li>But not very effective </li></ul>
  125. 140. Hydrogen Sulfide <ul><li>Blocks oxygen utilization through cytochrome oxidase pathway </li></ul><ul><li>• Rotten egg odor </li></ul><ul><li>• Olfactory fatigue </li></ul><ul><li>• Manure pit, sewage worker, farmer </li></ul><ul><li>• Commercially hydrogen sulfide is </li></ul><ul><li>obtained from &quot;sour gas&quot; natural </li></ul><ul><li>gas wells. </li></ul><ul><li>Mucous membrane and respiratory </li></ul><ul><li>irritation, LOC, anoxia </li></ul>
  126. 141. Treatment <ul><li>• General Support Care </li></ul><ul><li>• Oxygen </li></ul><ul><li>• Hyperbaric oxygen </li></ul><ul><li>– helpful in anecdotal case reports </li></ul><ul><li>• Amyl nitrite & sodium nitrite </li></ul><ul><li>– Change the distribution of sulfides from cytachrome a,a3 to </li></ul><ul><li>methemoglobin to enable aerobic metabolism </li></ul>
  127. 142. Carbon Monoxide “The Silent Killer”
  128. 143. <ul><li>• From Incomplete combustion of carbon based fuels </li></ul><ul><li>• No warning properties </li></ul><ul><li>• Colorless, odorless, tasteless, nonirritating </li></ul><ul><li>• Density 0.97 of air </li></ul><ul><li>• High concentrations give a lavender odor </li></ul>
  129. 144. <ul><li>Impaired oxygen </li></ul><ul><li>delivery </li></ul>
  130. 145. <ul><li>Also causes Hb to hold </li></ul><ul><li>onto O2 more tightly- </li></ul><ul><li>Due the leftward shift </li></ul><ul><li>of the oxygen </li></ul><ul><li>dissociation curve </li></ul>
  131. 146. CO toxicity Signs and Symptoms <ul><li>• CNS and the CV systems, which have the highest </li></ul><ul><li>requirements for oxygen, are most sensitive to the </li></ul><ul><li>effects of CO </li></ul><ul><li>• CO sxs are exacerbated by increased O2 demands </li></ul><ul><li>– exertion, trauma, burns, drug ingestions, MI, CVA, smoke </li></ul><ul><li>inhalation </li></ul><ul><li>• Cardiovascular: </li></ul><ul><li>– MI, palpitations (dysrhythmias), mottled skin, poor cap </li></ul><ul><li>refill, hypotension, cardiac arrest </li></ul>
  132. 147. <ul><li>Minimal: Mild headache, mild nausea </li></ul><ul><li>Mild: Moderate to severe headache, moderate to severe </li></ul><ul><li>nausea, dizziness </li></ul><ul><li>CO toxicity </li></ul><ul><li>Treatment </li></ul><ul><li>Initiated for any symptomatic patient </li></ul><ul><li>• Administer 100% oxygen by tight-fitting, </li></ul><ul><li>non-rebreather face mask to any patient as </li></ul><ul><li>soon as the diagnosis is suspected </li></ul><ul><li>• Obtain a history; physical exam should </li></ul><ul><li>focus on neurologic and cardiac evaluation </li></ul>
  133. 148. <ul><li>CNS Effects </li></ul><ul><li>• Most sensitive area to CO </li></ul><ul><li>poisoning </li></ul><ul><li>• Acute- HA, dizzy, ataxia (15-20%) </li></ul><ul><li>• Syncope, Sz, coma (longer </li></ul><ul><li>exposures) </li></ul>
  134. 149. <ul><li>Moderate: </li></ul><ul><li>• LOC or Seizures at the scene </li></ul><ul><li>• Confusion, pronounced Lethargy or Weakness, </li></ul><ul><li>• Vomiting </li></ul><ul><li>• Tachypnea, Shortness of breath </li></ul><ul><li>• Chest pain,Tachycardia </li></ul><ul><li>Severe: </li></ul><ul><li>• Syncope, Disorientation, Seizures, Obtundation or LOC in the ER </li></ul><ul><li>• Focal neurological deficits, </li></ul><ul><li>• EKG changes, Cardiac dysrhythmias/arrest (Primary cause of death) , </li></ul><ul><li>HypoTN, </li></ul><ul><li>• Respiratory distress, Cyanosis </li></ul><ul><li>Cardiac injury more common than previously thought </li></ul>
  135. 150. <ul><li>There is a poor correlation between severity </li></ul><ul><li>of symptoms and the COHb levels. </li></ul><ul><li>Highly variable, the mild symptoms often </li></ul><ul><li>being mistaken for other etiologies e.g: </li></ul><ul><li>viral illness (“the flu”), gastroenteritis or </li></ul><ul><li>food poisoning </li></ul>
  136. 182. Antidotes <ul><li>There is no </li></ul><ul><li>for 99% of Chemicals </li></ul><ul><li>There is only supportive treatment for 99% of Chemicals </li></ul><ul><li>There are standard WHO guidelines for antidotes in an industrial setting, where chemicals enter through lungs or skin </li></ul>No Magic Bullet
  137. 183. Only Supportive treatment No Antidotes for following <ul><li>Ammonia </li></ul><ul><li>Chlorine </li></ul><ul><li>Hydrogen sulphide </li></ul><ul><li>Phosgene </li></ul><ul><li>Carbon monoxide </li></ul><ul><li>Nitrogen Oxides </li></ul><ul><li>Formalin </li></ul><ul><li>Acids </li></ul>
  138. 189. Summary <ul><li>Physical removal is BEST decon </li></ul><ul><li>Must plan for patient decon at all aspects of care </li></ul><ul><li>Decon process is resource intensive and must be planned and practiced in advanced </li></ul><ul><li>Identify and train personnel early </li></ul><ul><li>Learn benefits of coordination with medical assets in your hospital and region </li></ul><ul><li>Prior Planning Prevents Poor Performance </li></ul>
  139. 190. Explosives… Decon??? Madrid, 11 March 2004
  140. 191. Anthrax 2001-2002 <ul><li>Decon? Or Prophylaxis? </li></ul>

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