cbrne - an introduction

The Role of

Emergency Physician

in Response to

CBRNE Attack

Dr. Chew Keng Sheng

Emergency Medicine

Universiti Sains Malaysia

Objectives

Definitions

Key criteria for determining a terrorist attack

Overview on selected terrorists’ attacks and WMDs

Major Lessons Learnt from Previous Disasters

Syndromic Surveillance

Defining roles of EPs in response to CRBNE Terrorist

Attacks – ―7Ds in Disasters‖

Q & A

Definitions of Disaster, Mass

Casualty Incidents and

Terrorism

Definitions

Disaster – defined as a sudden ecologic

phenomenon of sufficient magnitude to

require external assistance

In the Emergency Department, disaster exists

when the number of patients presenting in any

given space of time are such that even

minimal care cannot be offered without

external assistance.

Definitions

Disasters occur when normal, basic services of

a society become disrupted to such extent that

widespread human and environmental losses

exceed the community‟s management

capacity (SAEM Disaster Medicine White Paper

Subcommittee)

Disasters characterized by large numbers of

deaths and injuries are also referred to “Mass

Casualty Incidents”

Definitions

However, disasters are not defined only by a

given number of victims

Example: The arrival of one VIP guest with

severe medical or trauma emergency conditions

can completely disrupt normal operations of

even the most efficient emergency departments.

In short, the essence of the concept of disaster

is it has a “massive disruptive impact”

Definitions

Mass Casualty Incidents (MCI) – events resulting in a numbers of victims large enough to disrupt normal course of emergency and health care services of the affected community

Disasters result in MCIs, but encompass a broad range of calamities beyond just the high numbers of casualties

―All MCIs are disastrous, but not all disasters are due to MCIs‖

Definitions

Disasters can be divided into two:

Natural Disasters OR Man-made Disasters

External Disasters (events occurring outside the

hospital) OR Internal Disasters (events involving

the physical structures of hospital itself - e.g. fire,

lab accident involving radioactive materials)

Terrorism – man made, external disasters

Directive 20, National Security

Council

A Disaster is

1. an event that occurs suddenly.

2. complex in nature.

3. loss of lives.

4. destruction of property and/or environment.

5. disruption of the community daily activities

Three Levels According to Directive

20, NSC

Level 1

Localized, well-controlled, manageable by local authorities

Level 2

Well-controlled, management at state or national level

Level 3

Complete destruction, disruption of routine activities,

Directive 20, NSC

Disaster can be divided into 3 level

LEVEL 1

1. Localized major incident

2. Under controlled

3. Not complex

4. Small no. of casualties and property loss

5. Minor disruption of daily community activities

6. Manageable by the local authorities requiring

7. Multisectoral involvement.

Example: bus accident, train derailment, landslide.

Directive 20, NSC

LEVEL 2 Disaster

1. Widespread over a large area but under controlled

2. Complicated and complex

3. Large no. of casualties and property loss.

4. Affecting daily community activities

5. Not manageable by the local authorities requiring

6. Assistance from other states or National Authorities

7. Support required, Regional or National Support

Examples: Highland Towers Collapse, Greg Storm Sabah, Bright Sparklers.

Directive 20, NSC

LEVEL 3 Disaster

1. Involves a very large area.

2. Loss of many lives.

3. Total Destruction of infrastructure and public facility.

4. Complicated and complex.

5. High risk to rescue workers.

6. Complete disruption of daily community activities.

7. Major destruction of resources.

8. All local resources destroyed and assistance from external resources required.

e.g. Earthquake, typhoons, volcanoes, war.

Disasters Vs Emergencies

Routine Emergencies Disasters

Interaction with familiar

parties

Interaction with unfamiliar

parties

Familiar tasks/procedures Unfamiliar

tasks/procedures

Intra-organization

coordination

Intra- and inter-

organization coordination

Intact communications,

roads, etc.

Disrupted

communications, blocked

roads, etc

Disasters Vs Emergencies

Routine Emergencies Disasters

Familiar terminology Unfamiliar, organization-

specific terminology

Local press attention National/international

media attention

Resources adequate for

management

Resources overwhelmed for

management capacity

PRE-HOSPITAL MANAGEMENT ORGANIZATION

Hospital Director

INCIDENT SITE MEDICAL MANAGER

Red Team Leader

Medical Triage Officer

NGO ADVANCED MEDICAL POST

Yellow Team Leader

Evacuation Officer

Admin.

Clerk

Transport Officer

Ambulance Drivers

Acute Treatment Manager

Admin.

Clerk Doctors & Paramedics

•JPA 3

•MRCS.

•SJAM

Medical/Health Officer

COMMAND POST Temporary

Morgue

Green Team Leader

Know Your Role!

Key Criteria Defining a Terrorist

Attack

Violence "the only general characteristic [of terrorism] generally agreed

upon is that terrorism involves violence and the threat of violence" -Walter Laqueur of the Center for Strategic and International Studies

Psychological Impact and Fear attack was carried out in such a way as to maximize the

severity and length of the psychological impact.

Perpetrated for a Political Goal This is often the key difference between an act of terrorism

and a hate crime or lone-wolf "madman" attack

The political change is desired so badly that failure is seen as a worse outcome than the deaths of civilians.

Key Criteria Defining a Terrorist

Attack

Targeting of non-combatants

It is commonly held that the distinctive nature of terrorism lies in its deliberate and specific selection of civilians as direct targets.

Much of the time, the victims of terrorism are targeted not because they are threats, but because they are specific "symbols, tools, or corrupt beings" that tie into a specific view of the world that the terrorist possess.

Their suffering accomplishes the terrorists' goals of instilling fear, getting a message out to an audience, or otherwise accomplishing their political end.

(en.wikipedia.org)

Overview of Selected Terrorist

Incidents

Bombing of WTC New York City 1993

Sarin Gas Attack by Aum Shinrikyo in Matsumoto, Japan, 1994

Truck Bomb explosion of Alfred P. Murrah Building in Oklahoma, 1995

Sarin Gas Attack by Aum Shinrikyo in five subway train stations simultaneously in Tokyo, 1995

WTC Bombing, New York, September 11, 2001

US Anthrax Incident, 2001

Bombing in Bali, Indonesia 2002

Major Lessons Learnt

Incident Confirmation

At time of incident (whether biological, chemical or even

high explosive incidents), most people at the scene and even

the initial responders did not recognize the event as a terrorist

attack

E.g. during the Sarin Gas Attack in Matsumoto, Japan,

emergency responders initially thought that the first victims

were ill from food poisoning, contaminated water, or natural

gas

To improve early detection, a process called Syndromic

Surveillance is employed


A method to aid the early detection of bioterrorism events

This is to respond to bioterrorism attack – time is essential

This type of surveillance involves collecting and analyzing statistical data on health trends – such as symptoms reported by people seeking care in emergency rooms or other health care setting – or even sales of flu medicines.


Because bioterrorist agents such as anthrax, plague, and smallpox initially present ―flu-like‖ symptoms, a sudden increase of individuals with fever, headache, or muscle pain could be evidence of a bioterrorist attack.

By focusing on symptoms rather than confirmed diagnoses, syndromic surveillance aims to detect bioterror events earlier than would be possible with traditional disease surveillance systems.


In other words, the term syndromic surveillance

refers to methods relying on detection of clinical

case features that are discernable before

confirmed diagnoses are made

Recommended Website

Centers for Disease Control and Prevention –

Emergency Preparedness & Response (http://www.bt.cdc.gov/)


Command and Control

Unlike smaller emergencies where one single Incident Commander in charge, in a terrorist attack, numerous agencies and organizations involved

The need to speedily establish a secure perimter around the incident. Failure to do so during the Oklahoma bombing

Communications

Communications failure

Overloaded land lines and cell phones with calls from public trying to obtain info about their loved ones


Initial Responders

Traditionally initial responders are defined as the local police, firefighters, EMDs, paramedics. Well trained, part of daily routine

In overwhelming terrorist attacks, other professionals were needed at the scene – NGOs, volunteers, mental health workers

These individuals thrust into new roles – without proper training.

Safety of these responders – 1993 WTC bombing, 124 emergency responders injured; in Oklahoma bombing, one nurse killed from falling debris.


The Volunteers

Volunteers, though well intentioned, often created problems

Most not familiar with the emergency command and control system

The Victims

At most disasters, victims left the scene and sought medical help on their own

Need for rapid establishment of a centralized database containing identification victims from all responding medical sites. E.g. in Bali Bombing – internet database used extensively


Psychological Effects

PTSD – Example 11 months after 9/11 incident, 1277 stress related illnesses reported

Need for debriefing and de-stressing; short briefings prior to change of shift for responders

Tokyo Sarin Attack and Anthrax threat – created unique psychological fear – the healthy but anxious lots taxed the health services at a time when others needed care.

Need for proper public education


Mortuary Affairs

Temporary morgues, body bags

Body decay

Rapid identification of victims – for family members, law, insurance companies, etc; the need for DNA analysis

Example – Oklahoma bombing – unavoidable delays in official death notifications added emotional trauma to the already bereaved families

The need for religious sensitivity in handling bodies


Duration of event

Prolonged duration – strained the human and material

resources; depletion of stocks

Need for regular work shifts

Criminal Investigations

One of the main difference between natural disaster and

man-made disaster

The concern to preserve the evidence

Medical emergency responders help protect the evidence by

only touching and removing items when necessary


Media

Mixed blessings

Disseminate information

Yet, in an effort to provide information ASAP, sometimes

media give false and confusing information

VIP Visits

Politicians, celebrities, etc

Timing of these visits sometimes interfered with ongoing

recovery efforts

Overview

Chemical Weapons Nerve Agents – G series (GA,

GB, GD), V series

Blood Agents - cyanides

Blistering Agents

Biological Weapons Biological Agents – viruses (e.g

Ebola), bacteria (Yersenia pestis, anthrax)

Biological Toxins – botulism, ricin, Staphylococcal Enterotoxin B

Radiation α radiation

β radiation

γ radiation

Nuclear A bomb (Atomic)

H bomb (Hydrogen)

Explosives Large scale - Incendiary

bombs, Napalm-B, Mark 77

Smaller scale - Molotov Cocktail (Poor man’s hand grenades)

Explosives

(Reference: en.wikipedia.org) Molotov Cocktail

The use of Napalm-B in

Vietnam in 1966

How Prepared are the ED?

In 1997, Burgess et al. reported that only 44.2% of

hospital EDs had the ability to handle any chemically

contaminated patients from HAZMAT

41.1% - no designated decontamination facilities

Greenberg et al. in June 2000, conducted a survey to

assess the level of preparedness of hospital EDs in a

large metropolitan area to evaluate and treat victims of

a terrorist biological or chemical agent release

44 out of 62 ED directors responded to the questionnaire

How Prepared Are the EDs?

(Figures given in percentage) Yes No DK

Decon facilities 90.7 9.3 0

Ability to decon:

a. < 10/Hr 83.3 - -

b. 10-19/Hr 7.4 - -

c. 20-50/Hr 5.6 - -

d. >50/Hr 3.7 - -

Written plan for handling post-decon waste water 63 18.5 18.5

Written plan for handling contaminated clothings 42.6 29.6 27.8

Presence of detection equipment in ED 14.9 68.5 16.7

Personal Protective Clothing 87 13 0

(Greenberg et al., 2000)

Suggested Criteria for Minimum Preparedness of

EDs to Evaluate and Treat Victims of Biological or

Chemical Agent Release

1. At least one EP who has completed formal training regarding biological and chemical WMD

2. Ability to decon ≥10 patients/Hr

3. Written policies addressing the evaluation and treatment of biological and chemical casualties

4. Written cooperative agreements with local agencies addressing issues of biological and chemical terrorism

5. Participation in a disaster exercise involving biological or chemical agents within the past 12 months

6. Self characterized adequate supplies of appropriate antidotes

Antidotes

Atropine and oxide

(2 PAM CI)

injection auto-

injector

Roles of Emergency Physician in

DISASTERS –EIGHT „D‟s Detection and Diagnosis

Rapid Recognition

Declaration and Activation Activate contingency plans

Establish intra-hospital, inter-hospital, inter-agencies, inter-states, international communications

Defense Self-protection

Decontamination

Delegations

Drugs

Disposition Delivering right patients to right place and right time

Debriefing and De-stressing

The Main Problem with Biological

Weapon

Biological weapons can be divided into two categories

Overt (Announced)

First responders (fire fighters or law enforcement) are most likely to

respond to the announced release, or more likely the hoax

Covert (Unannounced)

First responders would probably be the GPs, family doctors, EPs, etc.

Furthermore, patients exposed to biologic agents

usually present with vague symptoms associated with

flulike illnesses (latency period).

Overt Attack

First responders (trained fire fighters or law enforcement) are most likely to respond to the announced release, or more likely the hoax

In recent anthrax attack, an example would be the letter received and opened in a Senator’s office in the Hart Senate Office Building.

The envelope contain a letter stating that it contained anthrax spores and the opener was going to die.

First responders called, the presence of spores of Bacillus anthracis confirmed.

Exposed individuals given prophylaxis. To date, none in the Senate Building has developed anthrax

Covert Attack

Current NO REAL TIME environmental monitoring for a covert release of biological weapon

A covert attack would probably go unnoticed, with those exposed leaving the area long before the act of terrorism became evident

Furthermore, because of the incubation period, the first signs of the biological agent released not be recognized until days or weeks later.

Thus those first responders would probably be the family doctors, GPs, EPs, etc

Factors indicative of a Potential

Bioterrorism Event Multiple simultaneous patients with similar clinical syndrome

Severe illnesses, especially among the young and otherwise healthy

Predominantly respiratory symptoms

Unusual (non-endemic) organisms

Unusual antibiotics resistance

Atypical clinical presentation of disease

Unusual patterns of disease such as geographic co-location of victims

Intelligent information – tips from law enforcement, discovery of delivery devices, etc

Reports of sick or dead animals or plants (Richards et al., 1999)

ON SITE MANAGEMENT

YELLOW ZONE

OSC

(POLICE )

COMMAND POST

F.F.C. - BOMBA

SAR TEAM

RED ZONE

WORK MATRIX

P.K.T.K.

O.M.C. BOMBA

MEDICAL BASE

CRTICAL

S.CRITICAL

N.CRITICAL

DEAD

RESCUERS

FORENSIC M.E.L.O.

QUARTER

MASTER

M.E.S.A.R.O. SAR

SAR

SPECIALISTS SJAM MRCS JPA 3 BOMBA S.B.

ON SITE MANAGEMENT – TRIAGE SYSTEM

TO NEAREST APPROPRIATE HOSPITAL

GREEN

Victims Collecting Point

COLLECTING POINT

Working Area

Impact Zone

Advance Medical Post

Simple Triage and Rapid Treatment

* Victims who can

walk are first identified

and be diverted to one

designated area

START Triage System

Disaster Operation and the SAVE

Concept

Basic/Simple Advanced Medical Post

RED YELLOW

GREEN WHITE TRIAGE AREA

EVACUATION

Standard Advanced Medical Post

RED YELLOW

GREEN WHITE

TRIAGE AREA

EVACUATION

NON-ACUTE

ACUTE

NON-ACUTE

ACUTE

Disaster Zoning

VICTIM FLOW

―Conveyor Belt‖ Management

Transport Resource Flow Victim Flow

TRANSFER ADVANCE

MEDICAL POST

Triage

Impact

Zone

Collecting

Point

Triage

Treatment Treatment

HOSPITAL

Evacuation

Initiating Isolation

Ideally be decontaminated outside the hospital Approach from upwind direction

Isolate at least 100 m radius (initial isolation) for hot zone

If large spill, 500 m; and if on fire (flammable substances), 800 m

Establish three zones Hot zone

where the spill/contamination occurred

Only trained personnel with proper attire to enter

Only the most immediate life threats addressed here – like opening up airway, cervical spine immobilization, bleeding control

Warm zone

area for thorough decontamination

Theoretically no risk of primary contamination but secondary contamination still possible


Initial Isolation

Protective

Action Zone

Principles of Decontamination

Removal of clothings most important step

(accomplishes 80-90% of decon)

From top to bottom

The more the better

Privacy is an issue

Water flushing the best Typically shower 3 – 5min

Decon ASAP

Expect a 5:1 of unaffected: affected casualties ratio

First responders must self-decon too

Decontamination

Emergency Decontamination

Summary

Terrorist Attacks are disastrous – but that does

not mean that there is nothing we can do.

Though we are probably helpless in preventing

them from coming, yet our preparedness would

hopefully be able to lessen the magnitude of

severity of the attack

Sarin Gas Attack on Tokyo Subway

Attack on 20th March 1995 was the second attack – 12 people died. First attack 1994 – 7 died.

How many perpetrators were involved and how many train stations were contaminated?

How did they do it?

Shoko Asahara –

Founder of AUM

Shinrikyo

Ikuo Hayashi

– one of the

perpetrators

The Attack

Attack at approximately 7:55 AM on March 20, 1995.

8:16 AM - the St Luke's ED was alerted

520-bed tertiary care

located near the affected subway stations (within 3 km)

received the largest number of victims from the subway attack.

services comparable to those of any medical center within the United States.

Within hours of the terrorist incident, St Luke's emergency department received 640 patients.

The Attack

8:28 AM - the first subway victim arrived at the St Luke's ED. This patient was ambulatory and arrived without assistance from ambulance personnel. The patient's only complaints were of eye pain and dim vision.

8:43 AM – arrival of first ambulance arrived

During the next hour, approximately 500 additional subway victims, including 3 patients who were in cardiopulmonary arrest on arrival, presented to the ED

Five of the female patients were pregnant.

The Attack

9:20 AM - hospital directors activated the hospital's disaster plan.

This resulted in the cancellation of all routine surgeries and outpatient activity.

More than 100 doctors and 300 nurses and volunteers were immediately called to care for victims

Victims into three clinical groups - mild, moderate and severe

The Attack

Mild cases (528, or 82.5%) - only eye signs or symptoms (eg, miosis, eye pain, dim vision, decreased visual acuity) on presentation

released after a maximum of 12 hours of ED observation

Moderate cases (107, or 16.7%) - systemic signs and symptoms (eg, weakness, difficult breathing, fasciculations, convulsions) BUT not require mechanical ventilation

Severe cases (5, 0.78%) - emergency respiratory support (eg, intubation and ventilation support)

Outcomes of Patients Admitted to St.

Luke‟s Hospital ED, Tokyo

Lessons Learnt

Delay in confirming the nature of the toxin

Delay in organizing an effective mass casualty strategy

Poor ventilation in patient reception area

Secondary exposure by medical staffs treating the patients

Inadequate provision of privacy to remove contaminted clothings

Inadequate shower facilities

Treatment

Three drugs are the mainstay treatment Atropine

Counteract primarily the muscarinic effect

Administer doses of 2 mg every 5 – 10 min to minimize dyspnea, airway resistance or respiratory secretions

Pralidoxime To reactivate acetylcholinesterase and counteract the nicotinic effect

Over time, OP-acetylcholinesterase bond becomes irreversibly covalent and resistant to reactivation by pralidoxime (―aging‖ process)

But still, Pralidoxime should never be withheld.

Diazepam The only effective anticonvulsant drugs for nerve gas poisoning

patients with seizure

Nerve Gas Agents

Are organophosphates Inhibits acetylcholinesterase, block degradation of Ach at postsynaptic

membrane.

Two main classes G series

―G‖ because accidentally first discovered by German scientist, Dr. Gerhard Schrader

GA (Tabun), GB (Sarin), GD (Soman) and GF (cyclosarin). Why no GC?

SARIN (most toxic of the four in G series) named in honor of its discoverers: Gerhard Schrader, Ambros, Rüdiger and Van der LINde.

V series V stands for ―venomous‖. Examples: VX, VR

All G series – watery, high volatility, serious vapor hazard; VX – oily, less vapor hazard, but poses a greater environmental hazard over time.

Nerve Gas

Different from organophosphate insecticides

Much more toxic

VX – most toxic substance synthesized de novo

(botulinism toxin – biological)

Unlike typical OP, no association with urination

Bradycardia is rare

Its miosis effect does not respond to systemic

therapy

Actions of Cholineseterase Inhibitors

Muscarinic Effects

SLUDGE

Salivation, Lacrimation,

Urination, Diarrhea, GI

pain, Emesis

DUMBELS

Diarrhea, Urination,

Miosis, Bronchorrhea,

Emesis, Lacrimations,

Salivation

Clinical Features

There is no delay effects

Symptoms of sarin gas occur within seconds of inhalation and peak at 5 minutes.

If patients remaining asymptomatic 1 hour after possible exposure, have not been contaminated.

In vapor exposed – miosis first appeared but in liquid exposed – miosis usually last sign

Unlike botulinism toxin, flaccid paralysis never on initial presentation.

Differences between Nerve Agents

and Cyanide

Characteristics Nerve Agent Cyanide

Odor None Bitter Almond

Eyes Miosis (unresponsive

to nalaxone), dim

vision, pain and

lacrimation

Pupils normal or

dilated

Oral, nasal and

respiratory system

Copious secretions Relatively few

secretions

Skin Profuse sweating,

cyanosis likely

Profuse sweating,

sometimes also

cyanosis

Differences between Nerve Agents

and Cyanide

Characteristics Nerve Agent Cyanide

Initial CVS response HPT, tachycardia Often hypotension

Muscle Weakness,

generalized

fasciculations,

eventually paralysis

Twitching of body

parts (but not

fasciculation)

Arterial Blood Gas

and Acid Base

Balance

Resp alkalosis or

hypoxemia with

respiratory acidosis

High AG, above

normal venous

oxygenation

Vesicants

Cause blistering and irritations to eyes, skin and airway (example – Mustard)

Ophthalmic effect – conjunctivitis, corneal damage, temporal or permanent visual loss

Skin effect – blistering like 2nd degree burn

Systemic toxicity – BM suppression, leukopenia

Indicators of fatal exposure

Airway burn within 6 hours

Burn >25%

Absolute WBC <200/mm3

Blood Agents

Blood agents such as cyanide Bind to cytochromes within mitochondria and inhibit cellular oxygen use

Low-dose exposures result in tachypnea, headache, dizziness, vomiting, and anxiety.

Symptoms subside when the patient is removed from the source

In higher doses the symptoms progress to seizures, respiratory arrest, and asystole within minutes of exposure.

Victims should be removed from the area, should have their clothing discarded, and should receive oxygen (100%).

If no improvement occurs, the cyanide antidote is given (amyl nitrate, sodium nitrite, sodium thiosulfate)

Anthrax

Current assessment suggests that three biologic agents—anthrax, plague, and smallpox—represent the greatest threat

Bacillus anthracis a gram-positive spore-forming bacterium, is the causative agent of

anthrax

the spores are extremely hardy

survive for years in the environment

the disease is caused by exposure to the spores

normally a disease of sheep, cattle, and horses and is rarely seen in developed countries because of animal and human vaccination programs

disease in humans can occur when spores are inhaled, ingested, or inoculated into the skin

spores germinate into bacilli inside macrophages

bacteria then produce disease by releasing toxins that cause edema and cell death.

Nuclear and Radiation Attack

Terrorists selecting radiation as a means to inflict

casualties are unlikely to employ nuclear weapons

are heavily guarded

difficult to move due to their size and weight

easy to detect

Sabotage at nuclear power stations is possible, but

given tight security, multiple safety systems, and thick

concrete housings surrounding the reactors, the threat

is probably low

Nuclear and Radiation Attack

Instead, simple radiologic devices, such as those used by hospitals for radiation therapy, are thought to be the source of choice.

These sources are plentiful and usually unguarded

The only wartime use of atomic and nuclear energy was the detonation of atomic bombs over Hiroshima and Nagasaki in 1945.

However, with the dissemination of technical information and raw materials, many nations now have nuclear weapons in their arsenals. The real possibility of terrorist groups obtaining and using such weapons also exists.

Bombings of Hiroshima and

Nagasaki The first event occurred on

the morning of August 6, 1945, when the US dropped a uranium gun-type device code-named "Little Boy" on the Japanese city of Hiroshima.

The second event occurred three days later when a plutonium implosion-type device code-named "Fat Man" was dropped on the city of Nagasaki.

(en.wikipedia.org)

Being Exposed or Being

Contaminated? Being exposed to heat; or being

burned (external and internal

burn)?

The first step of recognizing contamination is to understand the difference between exposure to and contamination by radiologic agents.

Exposure is defined by an individual's proximity to material emitting ionizing radiation.

Actual touching, inhaling, or swallowing that material is contamination.

Personal Protection Equipment

(PPE)

PPEs are respiratory equipment, garments, and barrier materials used to protect rescuers and medical personnel from exposure to biological, chemical, and radioactive hazards.

The goal of PPE is to prevent the transfer of hazardous material from patients or the environment to health care workers.

Different types of PPE may be used depending on the hazard present

PPE can be divided into Civilian PPE – especially those working in hot zone (IDLH)

Military PPE

(www.emedicine.com)

SCBA

SCBA: Self Containing Breathing Apparatus

Vs SCUBA: Self Containing Underwater Breathing

consists of a full face piece connected by a hose to a portable source of compressed air.

the open-circuit, positive-pressure SCBA is the most common type

this SCBA provides clean air under positive pressure from a cylinder; the air then is exhaled into the environment.

(www.emedicine.com)

Civilian PPE

Self-contained breathing apparatus

Supplied-air respirator

Air-purifying respirator

High-efficiency particulate air filter

HEPA filters 0.3-15 micron

efficiency of 98-100%

exclude aerosolized BWA particles in the highly infectious 1- to 5-mm range

Surgical mask

Protective Clothing (www.emedicine.com)

Levels of Civilian PPE

Level A

SCBA and a totally encapsulating chemical-protective (TECP) suit

highest level of respiratory, eye, mucous membrane, skin protection

Level B

positive-pressure respirator (SCBA or SAR)

nonencapsulated chemical-resistant garments, gloves, and boots, which guard against chemical splash exposures.

highest level of respiratory protection with a lower level of dermal protection.

(www.emedicine.com)

Levels of Civilian PPE

Level C

APR and nonencapsulated chemical-resistant clothing, gloves, and boots.

same level of skin protection as Level B, with a lower level of respiratory protection.

used when the type of airborne exposure is known to be guarded against adequately by an APR.

Level D

standard work clothes without a respirator.

In hospitals, it consists of surgical gown, mask, & latex gloves (universal precautions).

no respiratory protection and only minimal skin protection

(www.emedicine.com)

Decontamination

Extenal Decontamination

Gross Decontamination Removal of clothings; done before reaching hospital

Secondary Decontamination Designated site at ED; with advice from Radiation Safety Officer;

head to toe survey

Internal Decontamination

Blockade of enteral absorption Gastric lavage

Use emetic agents – Barium sulphate

Blockade of end organ uptake Potassium Iodide

References

Kales, S. N. & Christisni, D. C. (2004) Acute Chemical

Emergencies. NEJM, 350, 800-8.

Greenberg, M. I., Sherri, M. J. & Gracely, E. J. (2002)

Emergency Department Preparedness For The

Evaluation And Treatment of Victims of Biological or

Chemical Terrorist Attack. Journal of Emergency Medicine,

22, 273-78.

Roy, M. J. (Ed.) (2004) Physician's Guide to Terrorist

Attack, Totowa, New Jersey, Humana Press.

References

Schultz, C. H., Koenig, K. L. & Noji, E. K. (1996) Current Concepts - A Medical Disaster Response To Reduce Immediate Mortality After An Earthquake. NEJM, 334, 438-44.

Richards, C. F., Burnstein, J. L., Waeckerie, J. F. & Hutson., H. R. (1999) Emergency Physician and Biological Terrorism. Annals of Emergency Medicine, 34, 183-190.

Mandl, K. D., Overhage, J. M., Wagner, M. M., Lober, W. B., Sebastiani, P., Mostashari, F., Pavlin, J. A., Gesteland, P., Treadwell, T., Koski, E., Hutwagner, L., Buckeridge, D. L., Raymond, D. A. & Grannis, S. (2004) Implementing Syndromic Surveillance: A Practical Guide Informed by the Early Experience. Journal of the American Medical Informatics Association, 11, 141-150

cbrne - an introduction

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