Medical Management Of Chemical Casualties

Emergency Response in Chemical Casualties: System Approach to Effective Hospital Preparedness

Objectives • Lessons Learned & Event Characteristics• Antidote and chemical stockpile • Incident Response Requirements • Chemical protective clothing • Scene Safety • Hazmat traing trends • Medical Management of Hazmat Victims • Summary – Primary Survey & Resuscitation – Decontamination – Hazmat Patient Assessment – Poisoning Treatment Paradigm

Lessons Learned From Coaminated Casualties Incidents

Emergency Management Consequence Timelines EMERGENCY INCIDENT TIMELINES INCIDENTS POTENTIAL CASUALTIES RESPONSES Super Terrorism Warfare Type Ops - Chemical - Evacuation - Biological - Containment - Nuclear - Biological - Decontamination - Radiological - Quarantine - Vaccination Tens of (contagious) - Antidotes Millions - Detoxification Natural Disasters State-Fed Escalation Millions - Nuclear - Radio- - Flood logical - Search & Rescue - Earthquake - Sustainment - Hurricane Thousands - Medical Triage - Chemical - Temp Morgue - Tornado -Earthquake Criminal Terrorism (non- Escalation Hundreds -Hurricane contagious) - Explosives -Tornado - Bomb Squad Tens -Explosives - Flood Everyday Life First Response Seconds Days Weeks - First Aid - Accidents Minutes - Rescue Months Hours - Fire <991130v30> - Police

Bhopal Disaster 3 Dec.1984 8,000 died 300,000 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

What kind of gas was released? … •50 Chechen rebels, storm Moscow’s House of Culture Theatre during a performance of Nord-Ost, taking 700 hostages. The rebels demand Russian withdrawal from Chechnya, and threaten to kill the hostages if demands are not met. •After three days of fruitless negotiations an unknown gas, meant to incapacitate the rebels, is released in the theatre. Most of the rebels and 116 hostages die. October 26, 2002

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 victims while not compromising the safety hospital staff and current patients”

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

Scene Safety Hot, Warm and Cold zones You will be here. Public Health does not usually decontaminate or function in the hot zone Hot Zone Warm Zone Cold Zone Contaminated area Contamination Normal function Need PPE reduction

Zone rules Very limited treatment Isolate cadavers before decontamination Control access to zones Temporary Morgue Decontamination direction No back flow!! Hot Zone Warm Zone Cold Zone Contaminated area Contamination Normal function Need PPE reduction

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

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

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 High risk for secondary secondary contamination contamination Critically ill Critically ill Focus on Simultaneous Treatment decontamination and treatment Low risk for High risk for secondary secondary contamination contamination Mild or no illness Mild or no illness Decontamination Decontamination not needed 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 role At least one person should be medically trained May be quicker than non-ambulatory process, should utilize about the same amount of solution Focus on non-clothed/exposed areas Decon 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 in eyes • Encourage careful scrubbing of warm, moist regions – axilla, groin, etc. • Rinse thoroughly, copious water

Wet Ambulatory Decontamination • Once decontaminated, patient moves to cold zone staging area • Re-clothed • Status monitored until transport available

Do not need to decon if it can 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

CORRIDOR DECONTAMINATION • 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 HEAD DECONTAMINATION • 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 when identifying means for rapid decontamination methods. • 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.

Other Field-Expedient Water Decontamination Methods • wade and wash in water sources such as public fountains, chlorinated swimming pools, swimming areas, etc., provides an effective, high-volume decon technique. • 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.

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 all ages 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

Decon Shower- Infants & nonambulatory kids Pediatric Disaster Toolkit: Hospital Guidelines for Pediatrics in Disasters http://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml

Decon Shower- Child Pediatric Disaster Toolkit: Hospital Guidelines for Pediatrics in Disasters http://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml

From a Child’s Perspective?

Operations Set-up • Arrival Point – Staffed by Animal Control Staff and one veterinary tech in appropriate PPE – Personnel arriving for decontamination with pets will be relieved of the animal – Animals will be evaluated for injuries and extent of contamination – Animal will be tranquilized (if necessary) for handling and decontamination, or will be euthanized if injuries are too severe – Disposable leash will be placed on animal and moved to the gross decontamination area

Operations Set-up • Gross Decontamination Area – Staffed by Animal Control personnel in appropriate PPE – 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

Operations Set-up • 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 appropriate container at site • Container will be left in hot zone for mitigation contractor

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 urgent decontamination 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 for hazardous properties and make treatment or disposal decisions

Problem Summary • Theoretical hazard – nature and magnitude of downstream risks uncertain • Hazard-specific assessment not be possible during incident • Decisions must be made rapidly based on limited, if any, information about contaminants

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 • Disability – Overbite – Epilepsy – Small jaw • Elimination – Big tongue – Renal failure • Breathing – Liver failure – Asthma – COPD • Cardiovascular – Coronary Artery Disease (CAD) – Anemia

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 treatment No Antidotes for following • Ammonia • Chlorine • Hydrogen sulphide • Phosgene • Carbon monoxide • Nitrogen Oxides • Formalin • Acids

Chemical Protective Clothing

Levels of Protection Greater Hazard Level Level Level Level A B C D Higher Burden

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

Results of Alternate Protective Clothing Performance Test Possible alternate Defense capability Remarks Classification material Method 204 Method 206 (Blister resistance) (Gas resistance) Military standard (butyl coated texture for 100 min 200 min Defense ministry protective clothing) standard Military use Officer’s raincoat 2 min 2 min Sapper’s raincoat, poncho 7 min 7 min Disposable protective suit 14 min 14 min Tyvek Disposable raincoat 2 min 2 min Civilian use 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 Defense capability Remarks Classification Possible alternate material Method 204 Method 206 (Blister (Gas resistance) resistance) Military Standard (butyl coated texture for protective 30 min 30 min Military Standard clothing) Protective Black plastic bag 2 min 4 min hood Supermarket plastic bag 2 min 5 min Standard garbage bag 6 min 10min Military Standard 360 min 450 min Protective Gloves Taewha rubber gloves 25 min 50 min Goeunson rubber gloves 25 min 42 min Military standard 360 min 450 min Overboots Farmer’s boots 100~120 min 210 min Regular boots 220 min 230 min

Results of Covers/ Adhesive Tapes Performance Test Defense capability Possible Classification alternate Remarks material Method 204 Method 206 (Blister resistance) (Gas resistance) Military vehicle 1 min Less than 1 min cover Agricultural Covers Vinyl 10 min 12 min plastic cover Industrial Vinyl 2 min 3 min plastic cover Transparent 100 min Over 240 min Adhesive tape Tapes Blue tape 25 min 50 min

Effect of Overlapping Vinyl Plastic Covers Classification One layer Double layers Triple layers Method 204 10 min 26 min 40 min (Blister Resistance) Agricultural Vinyl plastic cover (thickness: 0.1 mm) Method 206 104 min (Gas Resistance) 12 min 50 min Method 204 2 min 7 min 14 min (Blister Resistance) Industrial Vinyl plastic cover (thickness: 0.05 mm) Method 206 3 min 14min 38 min (Gas Resistance)

Agricultural Vinyl plastic cover (one layer) added Cover/Raincoats Double layers One layer Triple layers Classification Original Vinyl plastic Original Vinyl Plastic material cover added material cover added Military vehicle 1 min 50 min 1 min 20 min cover Officer’s raincoat 2 min 33 min 2 min 50 min Sapper’s 7 min 55 min 14 min 180 min raincoat/ poncho Gentlemen’s 68 min 4 min 45 min 5 min raincoat

Evatox™ NBC hoods for civiliansBaby Safe Pro Infant Protective Wrap

โรงพยาบาลนพรัตนราชธานีกับเครือข่ายศูนย์พิษแห่งชาติ

โรงพยาบาลลาปาง โรงพยาบาลขอนแก่น โรงพยาบาลนพรัตนราชธานี โรงพยาบาลระยอง โรงพยาบาลหาดใหญ่ รูปภาพแสดงเครือข่ายศูนย์พิษแห่งชาติ

ศูนย์พิษวิทยา โรงพยาบาลนพรัตนราชธานี ข้อมูลข่าวสาร ศูนย์ข้อมูลด้านพิษสาหรับประชาชน บุคลากรทางการแพทย์ เครือข่าย การรักษาพยาบาล การให้ความช่วยเหลือในที่เกิดเหตุ การรับส่งต่อในกรณีทางวิชาการ เฝ้าระวังและควบคุม จัดทาข้อมูล GIS นาสถิติภัยหรือ โรคจากสารพิษมาวางแผนงาน

ศูนย์พิษวิทยา โรงพยาบาลนพรัตนราชธานี การซ้อมแผน การฝึกอบรม การประชุมวิชาการ การจัดประชุมเครือข่าย การประสานเครือข่าย ระดับภูมิภาค การจัดประชุมเครือข่าย ระดับประเทศ ห้องปฏิบัติการ การประสานเครือข่าย สร้าง มาตรฐาน ใช้ทรัพยากรร่วมกัน

ผลของการจัดประชุมเครือข่ายระดับภูมภาค ิ • อยากให้มีการแบ่งระดับศูนย์พิษ • อยากให้มีนโยบายที่ชัดเจน และ มีการถ่ายทอดให้กบผู้บริหาร ั • อยากให้มีการสนับสนุนเรื่องงบประมาณ • ต้องการให้มีการซ้อมแผน • ให้ศูนย์พิษขึ้นกับอาชีวก่อนในชั้นแรก • ผู้ปฏิบัติควรเป็น แพทย์และเจ้าหน้าที่ห้องฉุกเฉิน อาชีวจะให้ข้อมูลด้าน พิษ

ห้องปฏิบัติการ • มีการประสานเครือข่ายห้องปฏิบัติการ • มีการจัดทามาตรฐานห้องปฏิบัติการ • มีระบบส่งต่อตัวอย่างเพื่อการตรวจ • ห้องปฏิบัติการควรไปเป็นกลุ่มกับระดับของศูนย์พิษแม่ข่ายของตนเอง เพื่อง่ายต่อการบริหารจัดการ • ในการประชุมเครือข่ายควรนาเรื่องห้องปฏิบัติการเข้าประชุมด้วย

Common pitfalls in Hazmat Drill In a drill , hospital personnel treated patients without wearing PPE

Common pitfalls in Hazmat Drill In a drill, contaminated patients would be sent to a designated hospital, but in reality……

Overlook the time required for actions Before a drill, responders wear PPE and waited for the signal.

Man dropped bucket of silver paint that splattered onto areas of body commonly ignored or forgotten during decon. Photo credit: Mike Vance, MD

Can of mace went off in pants pocket & pants not removed in timely manner. 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, MD

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

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 Photo credit: Mike Vance, MD  Requires cadaver corneal transplant

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

Medical Management Of Chemical Casualties

by Society of Thai Emergency Physicians

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Medical Management Of Chemical Casualties Presentation Transcript