Introduction to Hazardous Area Response Team (HART) project Why HART is needed What can and should be done for casualties from chemical release Problems in providing care Basis and development of the HART clinical standard operating procedures (SOP) Provision of pre - hospital emergency care – the case for a combined paramedical – medical response in HART and USAR.

1. Hazardous Area Response Teams:
the clinical aspects
David Baker DM FRCA
Chemical Hazards and Poisons Division (London)
Health Protection Agency (UK)

2. Objectives
Introduction to Hazardous Area Response Team (HART)
project
Why HART is needed
What can and should be done for casualties from chemical
release
Problems in providing care
Basis and development of the HART clinical standard
operating procedures (SOP)
Provision of pre - hospital emergency care – the case for a
combined paramedical – medical response in HART and
USAR

3. Toxic hazards and threats in civil life
Deliberate or accidental release of toxic chemical agents is
an established hazard
Hazards may be established agents of chemical warfare
(CW) or toxic industrial chemicals (TIC)
Some TIC are also CW agents
CW agents classed as part of Chemical, Biological,
Radiological and Nuclear (CBRN) releases
Not an appropriate classification in terms of emergency medical responses

4. Properties of toxic agents
Toxicity
Latency of onset of signs and symptoms
Persistency
Transmissibility
In chemical releases toxicity and latency determine the
management of the patient but persistency and
transmissibility determine the management of the incident
and the health risks to others

5. Specific Chemical Hazards
Nerve agents (eg sarin)
High toxicity, short latency, variable persistency, high transmissibility
Cyanide agents (eg hydrogen cyanide
High toxicity, short latency, limited persistency and transmissibility
Lung damaging agents (eg phosgene, methyl isocyanate)
Toxic after a variable latency period
Vesicant agents (eg mustard gas)
Relatively long latency period to clinical manifestation but early lung
damage occurs in high temperatures

6. Somatic systemic attack by chemical agents
CNS
PNS
Autonomic
voluntary
Epithelial and cellular
Gastrointestinal
Urinary
Circulatory
Haemopoeitic
Respiratory
Control, mechanics, airways (large and small), alveoli

7. Decon
Shower
Decon
Shower
I
n
n
e
r
C
o
r
d
o
n
HOT
ZONE
WIND
Triage
Sieve
Casualties
Triage
Sort
A&E
Loading
Point
O
u
t
e
r
C
o
r
d
o
n
WARM
ZONE
COLD
ZONE
Chemical incidents: the civil Hazmat
response

8. Chemical agent medical response realities
HAZMAT protocols confine victims to the warm zone prior to
decontamination
Requirement in certain cases for early and continuing
medical care before decontamination
Antidotes alone may not enough for patient support
Life support required in a contaminated zone by trained and
protected personnel

9. Problems of working in a contaminated
zone
Need for personal protection
Loss of contact with patient
Difficulties in physical
examination
Normal emergency medical
procedures for airway,
ventilation and vascular
access are all made more
difficult

10. What care must be given in the
contaminated zone?
Triage (P1 – P4)
Airway management
Artificial ventilation
Vascular access
Control of haemorrhage from associated physical injury

11. What primary care is feasible in the
contaminated zone?
Application of skills used in normal emergency practice
Triage: primary triage sieve
Recognition of key signs and symptoms
Airway management: position, suction, airway insertion
Ventilation: use of specially designed equipment
Vascular access: intraosseous approach
Early administration of antidotes

12. Contaminated zone care – a Cold War view

13. TOXALS
Protocol (1996) for advanced life support
in a contaminated zone or decontamination area
Assessment (patient and site)
Airway
Breathing
Artificial ventilation
Circulatory
- control of haemorrhage and cardiac abnormalities
Disability (AVPU scale)
Drugs and antidotes
Decontamination
Evacuation

14. Department of Health
Emergency Preparedness
Division project
Two-year investigation into
Hot Zone Working
Final report submitted in Jan 05
Ministerial approval in Aug 05
Hazardous Area Response Teams
(HART) origins

15. HART: Development of
Standard Operating
Procedures
SOP define the following and provide
the bibliography for the project
Tactical Role and Responsibilities
Health and Safety & Risk Assessment
Team Structures, Concept of
Operations, Objectives and Roles
Vehicles & Areas of Operation
PPE, Deployment Criteria
Communications
Clinical procedures

16. HART - clinical objectives
Provision of essential immediate care for chemical casualties before and
during decontamination
Provision of continued care from point of chemical release to A and E
and beyond – treatment protocols, decontamination, life support
equipment and antidote stockpiles
To train and equip paramedical personnel to operate safely in a
contaminated zone
Integration with other dangerous environment responses – urban search
and rescue (USAR)

17. HART: the paramedic challenge
Extension of current clinical skills
Special training to operate safely inside a contaminated
zone
To provide essential early life support before and during
decontamination and to deliver the patient quickly to
definitive hospital treatment

18. HART clinical sub – group
Input from specialists in:
Accident and emergency medicine
Anesthesiology
Medical Toxicology
Paramedic Training

19. Clinical Rationale
Triage
Advanced clinical life support with early intervention
Airway and ventilation management.
Infusion control of major haemorrhage
Antidotes
Support drug administration

20. Hart Clinical Subgroup: basis for warm
zone treatment protocols
Findings of the DH Expert Group on the Management of
Chemical Casualties Caused by Terrorist Activity (Blain
Committee) report 2003
Existing JRCALC paramedic training protocols
Medical and paramedical experience

21. Patients in hot and warm zones: levels of care
Level 1: ambulant and asymptomatic
Level 2: ambulant and symptomatic
Level 3: non – ambulant, conscious
Level 4: Unconscious
Level 5: physically – trapped
Level 4 and 5 patients are vulnerable but salvageable and in need of
expert clinical care. TOXALS essential to avoid fatality from toxic
respiratory failure

22. Is patient able to walk? YES = P3
NO Is patient conscious? (able to obey commands)
YES = P2 NO
Signs of Life? (open airway & respiratory effort)
YES = P1* NO = P4
HART: primary toxic triage
* Unconscious patients and those with obvious signs of respiratory distress must be
prioritised for immediate assessment and emergency treatment (P1)

23. Point of injury/poisoning (Hot Zone)
The Casualty Collection Point (Warm Zone)
,
Casualty Decontamination Area
The Casualty Clearing Station
HART: provision of TOXALS and antidotes

24. Cold Zone
(AMP)
Medical
Recce:
Toxic Triage
Combopen(s)
Evacuation to
warm zone
Hot Zone
Decontamination
Continued Medical care
ABC’s
with antidotes
Continued
Medical care
Re - triage
Advanced
Medical
Management
And
Transfer to
definitive care
Warm Zone
(Casualty
collection point)
Warm Zone
(decontamina
tion)
Oxygen,
LMA
Portable gas –
powered
ventilators
Combo-pens,
IO access
Atropine,
Diazepam,
Salbutamol,
Dexamethasone,
Dicolbalt Edetate)
Spectrum of HART Clinical Care at toxic primary Incident site

25. HART airway and ventilation management
Hot zone: simple positioning – lateral
Airway clearance: suction
Warm zone:
Laryngeal mask airway as desired option
ETT as alternative option
Ventilation using VR1 portable gas – powered CBRN ventilator
Oxygen from multi – outlet supply

26. HART: ventilation capability in a contaminated
zone

27. Multiple outlet oxygen provision

28. HART: Life support logistics

29. HART Logistic Unit

30. Treatment protocols
Simple and straightforward to allow for difficulties of working
in PPE in a contaminated zone.
Based upon previous DH consensus for primary treatment
of chemical victims
(EXPERT GROUP ON THE MANAGEMENT OF CHEMICAL CASUALTIES CAUSED BY
TERRORIST ACTIVITY, 2003)

31. Patient group directions (PGDs)
Patient Group Directions (PGDs) are documents which allow medicines
to be given to groups of patients - for example in a mass casualty
situation - without individual prescriptions having to be written for each
patient.
They empower staff other than doctors (for example paramedics and
nurses) to give the medicine in question legally

33. UK National Reserve Stocks: 2002
POD 1
- Modesty Clothing
POD 2
- Nerve Agent antidote
POD 3
- Equipment; Ventilators
etc.
POD 4
- Ciprofloxacin
POD 5
- Doxycycline
POD 4
POD 1
POD 3

34. Replacement of original PODS and transfer of control to
ambulance services - ongoing
Strategic supplies to be placed on underground and national
main line stations
Upgrading of equipment and drug scales
Drug & Equipment Pods
revision 2007

35. 2006 REVISED PODS/HART response drugs
Combopens (P2S, Atropine, Avisophone)
Atropine (2mgs/ml) – 50 mls
Diazemuls (1mg/ml) – 10 mls
(Amyl Nitrite ampoules)
Dicobolt Edetate 300mgs ampoules
50% glucose - 50mls
Salbutamol Inhalers 100ugs
Beclomethasone inhalers 100ugs
Salbutamol 5mgs (for nebuliser)
Dexamethasone 8mgs
Naloxone 400ugs
Flumazanil 500ugs

36. Urban Search And Rescue
Emergency medical teams working alongside the Fire Service
to deliver clinical support to trapped injured persons
New skills must be learned ranging from working
underground, in confined spaces and working at height
Wide range of incidents in abnormal environments

37. USAR Clinical SOP
USAR SOP requirements different from HART
No SOP have yet been drafted
USAR clinical sub – committee not yet formed
Early consultations with clinical expertise taking place
Training to JRCALC standards before USAR training
Issues
Consensus on early management of crush syndrome
Division of crushed tissues for release
Use of chest drains
Airway management in confined spaces
Training and governance for use of ketamine and midazolam

38. 2006 REVISED PODS/USAR response drugs
Etomidate
Suxamethonium
Ketamine
Midazolam
Morphine
Propafol
Cyclizine
Lignocaine 1%
50% glucose

39. The requirement for a joint paramedical
medical entry team in HART and USAR
Difficult triage decisions can be taken by medical personnel
on site (the question of P4 triage)
Antidotes and life support drugs can be given without the
need to use patient group directions and dose protocols
Difficult airway – ventilation cases can be managed with a
team approach
General anaesthesia can be given for extraction

40. Joint paramedical – medical emergency care
Proven value in conventional attacks
HEMS and BASICS are integrated
already into EMS response in UK
Problems
No official recognition or funding
of existing arrangements
Lack of co – ordinated policy and
structure

41. HART commissioning: London, December 2006

42. HART clinical policy – problems identified
Training issues regarding new procedures – regional
variations eg LMA
Administration of essential antidotes and support drugs
(PGD)
Clinical SOP still being adjusted with user feedback
USAR clinical SOP have yet to be determined but raise
questions about medical presence

43. Conclusions
HART project now active in London
Expansion of project to other cities projected for 2007 -8
Special skills have been taught to paramedics and
technicians to enable provision of essential life support in a
contaminated zone
USAR has been linked in with HART by DH EP Division
Both initiatives increase the ability of the ambulance
services to respond to circumstances outside the remit of
usual practice.