emergency chemical response decontamination principles and patient management

Emergency Chemical Response Emergency Chemical Response

Decontamination PrinciplesDecontamination Principlesand Patient Management and Patient Management

Kitipong Banomyong MD.,GP, MHSc (OHS), PM ( Occ. Med.)

Occupational and Environmental Medicine CenterNopparat Rajathanee Hospital

Reasonable ≠ Reasonable ≠ AdequateAdequate

Best possible care for victims Best possible care for victims while not compromising the while not compromising the

safety hospital staff and safety hospital staff and current patients current patients

Lessons Learned Lessons Learned From Mass Casualty From Mass Casualty

IncidentsIncidents

INCIDENTS

EMERGENCY INCIDENT TIMELINES

RESPONSESPOTENTIAL CASUALTIES

- Flood

- Chemical

-Tornado

-Earthquake

-Hurricane

-Explosives

Tens ofMillions

Thousands

Hundreds

Tens

HoursMinutes

Seconds Days

MonthsWeeks

- NuclearMillions

(contagious)

(non-contagious)

- Biological

- Radio-logical

Everyday Life

- Accidents - First Aid- Rescue- Fire- Police

First Response

- Explosives

Criminal Terrorism

- Bomb Squad

- Flood- Earthquake- Hurricane- Tornado

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

State-Fed Escalation

- Chemical- Biological- Nuclear- Radiological

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

Warfare Type Ops

Escalation

<991130v30>

Emergency Management Consequence Timelines

Encephalitis (various)Hantaan

Congo-CrimeanChikungunya

Rift ValleyDengueYellow

Ebola/MarburgLassa

Smallpox

Viruses

CryptococcosisCoccidioidomycosisHistoplasmosis

Fungi

AnthraxPlague

ShigellosisCholera

Salmonella

TularemiaLegionnaire’s

GlandersMelioidosis

BrucellosisTyphoid

Nocardiosis

Bacteria

RMSFTyphus

PsittacosisQ fever

Rickettsiae, Chlamydiae

Covert

Timeline For Medical InterventionTimeline For Medical Intervention of Terrorist / Warfare Agents of Terrorist / Warfare Agents

10min

20min

40min

1hr

2hr

4hr

8hr

1day

2days

4days

8days

16days

SaxitoxinTetrodotoxin

ConotoxinBatrachotoxin Tricothecene

Aflatoxin

RicinPerfringensVerotoxin

BotulismSEBToxins

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 firstreaches victims

1st Responders

Arrive (1)

2nd Responders

Arrive (1)

Civil SupportTeams

Arrive (1)

Follow-up FederalResources & SuppliesArrive (1)

(1) After Notification

Overt

AGENTSAGENTS

SUMMARY CHARACTERISTICSSUMMARY CHARACTERISTICS

Time To Time To EffectsEffects

Potential Potential ImpactImpact

AvailabilityAvailability

BIOBIODays to Days to WeeksWeeks

Local toLocal toGlobalGlobal Low Low

RADRAD Minutes to Minutes to HoursHours

City to City to RegionRegion MediumMedium

CHEMCHEM Seconds to Seconds to HoursHours

City City BlocksBlocks HighHigh

Summary Comparison

Chem-Agent DoseChem-Agent Dose

Chemical Chemical AgentAgent

100% Lethal Air Dose Quantity100% Lethal Air Dose Quantity

Domed StadiumDomed Stadium Movie TheaterMovie Theater Boeing 747-400Boeing 747-400

NerveNerve 13 Gallons13 Gallons 2 ½ Cups2 ½ Cups 1.3 ounces1.3 ounces

BlisterBlister 338 Gallons338 Gallons 4 Gallons4 Gallons 1 Quart1 Quart

ChokingChoking 780 Gallons780 Gallons 9 Gallons9 Gallons 2.3 Quarts2.3 Quarts

BloodBlood 520 Gallons520 Gallons 6 Gallons6 Gallons 1.5 Quarts1.5 Quarts

Riot-ControlRiot-Control 1820 Gallons1820 Gallons 21 Gallons21 Gallons 5.3 Quarts5.3 QuartsNote: 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

Bhopal Disaster3 Dec.1984

8,000 died300,000 injured

Tokyo March 20, 1995Tokyo March 20, 1995 5,500 People Exposed5,500 People Exposed 3,227 Went to Hospital3,227 Went to Hospital 550 Transported Via EMS550 Transported Via EMS Essentially no Essentially no

Decontamination of Decontamination of PatientsPatients

Tokyo – Sarin SymptomsTokyo – Sarin Symptoms

Dim Vision 73% (11-15)Dim Vision 73% (11-15) Miosis in 73% of these (8/11)Miosis in 73% of these (8/11) Rhinorrhea 53%Rhinorrhea 53% Dyspnea or Chest Tightness 27%Dyspnea or Chest Tightness 27% Cough 13%Cough 13% Six Treated With AtropineSix Treated With Atropine One Treated With PralidoximeOne Treated With Pralidoxime

Lessons Learned From Lessons Learned From Chemical Mass Casualty Chemical Mass Casualty

IncidentsIncidents Most Victims are Exposed to VaporMost Victims are Exposed to Vapor Hospitals, EMS, Fire, Public Safety Hospitals, EMS, Fire, Public Safety

OverwhelmedOverwhelmed Dry Decontamination Suitable for MostDry Decontamination Suitable for Most

Lessons Learned Lessons Learned ContinuedContinued

Victims Will Not Wait In Line to ShowerVictims Will Not Wait In Line to Shower Most Decontamination Needs to be Most Decontamination Needs to be

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

Local ResourcesLocal Resources Decontamination initiated at medical Decontamination initiated at medical

facilities 3 hours after exposurefacilities 3 hours after exposure

Lessons Learned Lessons Learned ContinuedContinued

Ambulatory Patients Present Earliest and Ambulatory Patients Present Earliest and Overwhelm the ResourcesOverwhelm the Resources

Only 10%-15% of Patients Via EMSOnly 10%-15% of Patients Via EMS Emergency Department Resources LimitedEmergency Department Resources Limited

Use of Secondary “Treatment Facilities” Use of Secondary “Treatment Facilities”

Current State of PreparednessCurrent State of Preparedness

• Data from 30 hospitals FEMA Region III

• 100% of sites not fully prepared for biologic incident

• 73% not prepared for chemical incident

• 73% not prepared for nuclear incident

Treat K.N. Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Annals of Emergency Medicine Nov. 2001


73% would set up a “single room” 73% would set up a “single room” decontamination process.decontamination process.

13% had no decontamination process.13% had no decontamination process. 3% (1 hospital) had chemical antidote 3% (1 hospital) had chemical antidote

stockpilestockpile 0% had prepared media statements0% had prepared media statements 25% had “some” training in WMD 25% had “some” training in WMD

incidentsincidents



77% had facility security plan in place77% had facility security plan in place 50% able to “lock down” the facility50% able to “lock down” the facility 4% aware of “secondary device” threat4% aware of “secondary device” threat

Conclusion: Conclusion: “Hospitals in this sample “Hospitals in this sample do not appear to be prepared to handle do not appear to be prepared to handle WMD events”WMD events”


The World Of ChemicalAgents

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 syste

m.

Agents Categories

1. Industrial Chemicals.

2. Chemical Warfare Agents.

3. Biological Warfare Agents.

4. Radiological Materials.

Vapor Pressure(VP)

VP = 3877 mm

VCMChlorine

VP = 7600 mm

X

VP = 60 mm

Boiling point(BP)

VCMVCM

BP = -13.88 C

H2O

BP = 100 CBP = 50.55 C

Chlorine

BP = -34.6 C

HCl

Vapor Density(VD)

VD of dry air = 1

Specific gravity (SG)

SG of Water = 1

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

What is What is Decontamination?Decontamination?

General PrinciplesGeneral Principles

Decontaminate victims as soon as Decontaminate victims as soon as possible.possible.

Disrobing is decontamination; head to Disrobing is decontamination; head to toe, more removal is better.toe, more removal is better.

Water flushing generally is the best mass Water flushing generally is the best mass decontamination method.decontamination method.

After a known exposure to a liquid After a known exposure to a liquid chemical agent, emergency responders chemical agent, emergency responders should be decontaminated as soon as should be decontaminated as soon as possible to avoid serious effects.possible to avoid serious effects.

For gases

Remove from the gas

to undress or further decontaminate

For vapors, mists, liquids

Remove clothes Irrigate skin with soap and water • - Gentle Do not scrub • No bleach • Do not neutralize • Address contaminated areas If only arm do not wash hair

Exposed, Symptomatic Eyes

• Should be irrigated immediately andcontinuously

– Use Tepid water or saline only – Water is best • Readily available in copious quantities atscene

ocular topical anesthetic • Remember to check for patient contact lenses

and remove them

Industrial Chemical Victim Triage

High Priority for Decontamination: • Victims closest to point of release and reporting exposure.

• Victims showing some evidence of contamination on clothin g or skin.

• Victims demonstrating serious symptoms.

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

mal 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 Urgency for Medical CareMedical Care

Low risk for Low risk for secondary secondary contaminationcontamination

Critically illCritically ill

Focus on Focus on TreatmentTreatment

High risk for High risk for secondary secondary contaminationcontamination

Critically illCritically illSimultaneous Simultaneous decontamination decontamination and treatmentand treatment

Low risk for Low risk for secondary secondary contaminationcontamination

Mild or no Mild or no illnessillness

DecontaminatioDecontamination not neededn not needed

High risk for High risk for secondary secondary contaminationcontamination

Mild or no Mild or no illnessillness

DecontaminatioDecontamination before n before treatmenttreatment

TriagTriagee

Urgency for Urgency for decontaminatiodecontaminationn

Decontamination Site Decontamination Site SelectionSelection

Outside!Outside! Level impermeable surfaced Level impermeable surfaced

areaarea Up windUp wind Water supply/collectionWater supply/collection IlluminatedIlluminated Ingress and Egress routesIngress and Egress routes

Layout of Layout of Hospital Decontamination Zone

Decontamination Station 2 Decontamination Station 2 lines lines

Decontamination Station 3 lines Decontamination Station 3 lines

Control ZonesControl Zones Control Zones should be established for:Control Zones should be established for:

– Entrance and exitEntrance and exit– Operations inside the ETAOperations inside the ETA

The ETA has three distinct zonesThe ETA has three distinct zones Zones are separated to:Zones are separated to:

– Control accessControl access– Provide securityProvide security– Minimize transfer of contaminationMinimize transfer of contamination

Enables scene control of bystandersEnables scene control of bystanders Established by barricades and isolation Established by barricades and isolation

areasareas

Isolation ZonesIsolation Zones

WARM

INCIDENTSITE

HOT

**SAFE REFUGE **SAFE REFUGE AREAAREA

DECONTAMINATION DECONTAMINATION CORRIDORCORRIDOR

ACCESS CORRIDORACCESS CORRIDOR

COLD

COMMAND POSTCOMMAND POST

WIND DIRECTIONWIND DIRECTION

**

เคร��องอานคาโดยตรงเคร��องอานคาโดยตรง(Direct Reading (Direct Reading Instruments)Instruments)

Hospital Decontamination Zones Hospital Decontamination Zones (OSHA)(OSHA)

Hospital Pre-decontamination ZoneHospital Pre-decontamination Zone– Assessment, triage, and treatmentAssessment, triage, and treatment– Similar to OSHA’s “Hot Zone”Similar to OSHA’s “Hot Zone”

Hospital Decontamination ZoneHospital Decontamination Zone– Decontamination of patientsDecontamination of patients– Similar to OSHA’s “Warm Zone”Similar to OSHA’s “Warm Zone”

Hospital Post-decontamination ZoneHospital Post-decontamination Zone– Advance patient care and treatmentAdvance patient care and treatment– Similar to OSHA’s “Cold Zone”Similar to OSHA’s “Cold Zone”

OSHA Best Practices for Hospital-based First OSHA Best Practices for Hospital-based First Receivers of Victims…, dated 9/2/2004Receivers of Victims…, dated 9/2/2004

Immediate Treatment

Life Saving Procedures A B C D

Dry DecontaminationDry Decontamination

Vapor or no exposureVapor or no exposure Removal of clothingRemoval of clothing Modesty concernsModesty concerns Tracking of ValuablesTracking of Valuables Requires large amounts of disposable Requires large amounts of disposable

clothingclothing Clothing dispositionClothing disposition

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

Clothing)Clothing)

Ideal DecontaminantsIdeal Decontaminants

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

Other Field-Expedient Water Other Field-Expedient Water Decontamination MethodsDecontamination Methods

should not overlook existing facilities when should not overlook existing facilities when identifying means for rapid decontamination identifying means for rapid decontamination methods. methods.

although water damage to a facility might although water damage to a facility might occur, the necessity of saving lives would occur, the necessity of saving lives would justify the activation of overhead fire justify the activation of overhead fire sprinklers for use as showers.sprinklers for use as showers.

Other Field-Expedient Water Other Field-Expedient Water Decontamination MethodsDecontamination Methods

wade and wash in water sources such as wade and wash in water sources such as public fountains, chlorinated swimming public fountains, chlorinated swimming pools, swimming areas, etc., provides an pools, swimming areas, etc., provides an effective, high-volume decon technique.effective, high-volume decon technique.

Car washes with hand-held wands should Car washes with hand-held wands should also be considered. Water used for also be considered. Water used for decontamination in lifesaving operations decontamination in lifesaving operations should be properly handled and disposed of should be properly handled and disposed of in compliance with environmental and in compliance with environmental and health regulations, whenever possible. health regulations, whenever possible.

Wet Ambulatory Decontamination

Clothing removal Shower with warm water and soap Modesty concerns Requires large amounts of water, towels,

and disposable clothing

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

Never in contaminated area Without signs and symptoms of exposure

Litter Wet Decontamination

Requires minimum of 2-4 persons per patient 10 to 20 minutes per patient 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


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


Non-ambulatory patients displaying serious signs and symptoms

Rapid decontamination 5-10 minutes per patient

Self-Decontamination Because time is a critical factor when

decontaminating victims, allowing the victims to self-decontaminate can speed up the decontamination process.

This will contribute to the possible reduction of staffing needs

Further, victims who are able and allowed to self-decontaminate will often be more thorough and more efficient.

finally, allowing self-decontamination will reduce issues and concerns of modesty.

Mass DeconMass Decon

Fire Department / Haz Mat Fire Department / Haz Mat TeamTeam

CORRIDORDECONTAMINATION

The simplest solution The nozzles are set at low pressure and

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

SPRINKLER HEADDECONTAMINATION

500water delivered at gallons a minute ttt tttttt ttt tttt tt ttt tttt tt ttt t ttttt3

tt tttttttt ttt ttttt ttt ttt tttttt tt tt, 50posed to % of the water

500 8gals./minute = /

8 3 24gals./second × seconds =.

2 4 . × 5 0 % = 1 2 .

Mass DeconMass Decon

Hospital BasedHospital Based

VICTIM DECONTAMINATION

FACILITY

Entrance to Emergency Department

Site of Decon UnitSite of Decon Unit

Site of Decon UnitSite of Decon Unit

Circular Drive at Front of Med Ctr

Routinely used as break area.

During emergency, site of decon unit.

Deploying the shower curtains

Curtain separates male/female ambulatory decon lines

Drop down sprayers help with final rinse of ambulatory and decon of non-ambulatory victims.

Off/on box and mixing unit for shower

Deluge shower head – five on each line

Fully deployed shower

Entrance for Entrance for ambulatory victimsambulatory victims

Shower lines for Shower lines for ambulatory victimsambulatory victims

Disrobing area for Disrobing area for ambulatory victimsambulatory victims

Looking down the ambulatory men’s shower line

Assisting an ambulatory victim (drill)

Decon’ing a non-ambulatory victim

Planning for Planning for Decontamination Decontamination

WashwaterWashwater Decon washwater is an issue that has Decon washwater is an issue that has

gained prominence in the last couple gained prominence in the last couple of years of years

Hospital washwater only one possible Hospital washwater only one possible sourcesource

History, brieflyHistory, briefly

Hospitals required to plan for rapid Hospitals required to plan for rapid influx of victims in mass-influx of victims in mass-contamination incidentcontamination incident– Increased numbers, may not be Increased numbers, may not be

deconned prior to arrival, contaminant deconned prior to arrival, contaminant unknown or unusualunknown or unusual

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

History, continuedHistory, continued

Capacity for mass decon limited in Capacity for mass decon limited in most hospitals (a few victims) most hospitals (a few victims)

Proper on-site washwater Proper on-site washwater management identified as barriermanagement identified as barrier– containment ~ 90% of cost containment ~ 90% of cost – may not solve problem anywaymay not solve problem anyway

What is the Problem?What is the Problem?

Is there a problem if decon washwater Is there a problem if decon washwater enters the sanitary sewer system?enters the sanitary sewer system?– YesYes– No No – Maybe, not enough Maybe, not enough

information….depends on contaminant information….depends on contaminant type/amount/concentration, exposure type/amount/concentration, exposure potential, impacts to wastewater system potential, impacts to wastewater system or environment, legal concernsor environment, legal concerns

Plausible ScenarioPlausible Scenario

Hospital needs to provide urgent Hospital needs to provide urgent decontamination for large number decontamination for large number victimsvictims

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

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

on-site overwhelmedon-site overwhelmed

Quantitative SolutionQuantitative Solution

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

2.5 mg VX / victim -- 25% of LD502.5 mg VX / victim -- 25% of LD50 VX selected -- low vapor pressure VX selected -- low vapor pressure

and relative persistence and relative persistence 90% removal by disrobing90% removal by disrobing 10:1 ratio uncontaminated to 10:1 ratio uncontaminated to

contaminated victimscontaminated victims


1000 victims x 10 gal/person = 1000 victims x 10 gal/person = 37854 liters37854 liters

100 contaminated with 2.5 mg VX = 100 contaminated with 2.5 mg VX = 250 mg250 mg

90% removed with disrobing = 25 90% removed with disrobing = 25 mgmg

25 mg/37854 L = 0.00066 ppm = 25 mg/37854 L = 0.00066 ppm = 0.66 ppb at most concentrated point 0.66 ppb at most concentrated point


is this (0.66 ppb VX) a problem?is this (0.66 ppb VX) a problem? Is this the worst case?Is this the worst case? have we considered all down stream have we considered all down stream

issues?issues? could other contaminants be worse?could other contaminants be worse?

Key UncertaintiesKey Uncertainties

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

retention time for short-lived retention time for short-lived radionuclides)radionuclides)

Key UncertaintiesKey Uncertainties

Contaminant(s) unknownContaminant(s) unknown – Amount (total and concentration)Amount (total and concentration)– Behavior/fateBehavior/fate– Exposure potentialExposure potential– ToxicityToxicity– TreatabilityTreatability– Impacts on people, system, environmentImpacts on people, system, environment

May not have opportunity to test waste May not have opportunity to test waste stream for hazardous properties and make stream for hazardous properties and make treatment or disposal decisionstreatment or disposal decisions

Emergency Response Plan Emergency Response Plan Guidance for Wastewater Guidance for Wastewater

SystemsSystems Prepared by the Water Environment Prepared by the Water Environment

Research Foundation (WERF) Research Foundation (WERF) www.werf.org/pdf/03CTS4S.pdfwww.werf.org/pdf/03CTS4S.pdf

Includes information related to Includes information related to managing patient decon wastewatermanaging patient decon wastewater

Advises developing action plans for Advises developing action plans for significant eventssignificant events

Planning for Decontamination Planning for Decontamination WastewaterWastewater

Guidance from National Association of Guidance from National Association of Clean Water Agencies (www.nacwa.org)Clean Water Agencies (www.nacwa.org)

Describes potential contaminants, Describes potential contaminants, sources for entry to sewer, managing sources for entry to sewer, managing risks through planning, coordination risks through planning, coordination and communicationand communication

Includes information about hospital Includes information about hospital washwater and recommends local washwater and recommends local planning and coordinationplanning and coordination

Medical Medical ManagementManagement

Medical Treatment Protocol available from US Dept. of Health and Human Services Agency for Toxic Substances and Disease Registr

yhttp://www.atsdr.cdc.gov/mmg.html

ก�าซพ�ษ PE,PP PVC ABS EPOXY PC Halons PS FoamFormicaยางรถยนต�เมลาม�นCO X X X X X X X X X X

SO2 - - - - - - - - X -

NO2 - - - X - - - - X X

HCl - X - X X - - - - -HCN - - X - - - - - - X

COCl2 - - - - X - - - - -

HF - - - - - X - - - -HBr - - - - - X - - - -

NH3 - - - X - - - - - X

CH2O - - - - - - - X - -

C6H5OH - - - X X - - X - -

ต�วอยางไอระเหย/ก�าซพ�ษท��เก�ดจากการเผาไหม#พลาสต�ก

Chemicals Can Often Chemicals Can OftenBeBe

Recognized by the Recognized by the Clusters of Clusters of

Symptoms That They Symptoms That TheyCauseCause

(Toxidromes)(Toxidromes)

Recognize Toxic Syndromes: Recognize Toxic Syndromes: 5 Hazmat Toxidromes 5 Hazmat Toxidromes

1. Irritant gases 1. Irritant gases

2 . Asphyxiants 2 . Asphyxiants

3. Hydrocarbon and halogenated 3. Hydrocarbon and halogenatedtttttttttttttttttttttttt 4 . Cholinergic 4 . Cholinergic

5. Corrosive 5. Corrosive

1. Irritant Gases 1. Irritant GasesToxidromeToxidrome

Impaired Breathing due to effects Impaired Breathing due to effects from a gas on the upper airway an from a gas on the upper airway an

- d/or alveolar capillary membrane - d/or alveolar capillary membrane

Site of injury to body determined primarily by: Site of injury to body determined primarily by: – – Water solubility Water solubility • • Nose and upper airways filter water soluble Nose and upper airways filter water solublegasesgases

– – Duration of exposure Duration of exposure – – ConcentrationConcentration

Effects:Effects: – – Eye, nose, throat irritation, cough, stridor, Eye, nose, throat irritation, cough, stridor,

shortness of breath, pulmonary edema shortness of breath, pulmonary edema – – Symptoms within minutes to hours Symptoms within minutes to hours

tttttt ttttt-ttttttttttttt ttttt-ttttttt – – AmmoniaAmmonia – – Sulfur Dioxide Sulfur Dioxide – – Hydrogen Chloride Hydrogen Chloride – – FormaldehydeFormaldehyde • • t ttttttttt t tttt-tttttttt ttttttttt t tttt-ttttttt – – ChlorineChlorine • • tttttttt t tttt-ttttttttttttttt t tttt-ttttttt – – PhosgenePhosgene – – Nitrogen dioxide Nitrogen dioxide

Irritant Gas Irritant Gas Highly Water Soluble Highly Water Soluble

Low dose exposure Low dose exposure

– – Eye, nose, throat irritation, tearing Eye, nose, throat irritation, tearing

-Moderate exposure -Moderate exposure

– – Hoarseness, cough, tracheobronchitis Hoarseness, cough, tracheobronchitis

• • Concentrations decreased by time it reaches Concentrations decreased by time it reaches

tracheatrachea

• • Greater exposure by duration or Greater exposure by duration orconcentrationconcentration

results in deeper injury results in deeper injury

ttttt t tttt tttt ttttttt t tttt tttt tt

– – ttttttt tttttttttttttttt ttttttttt – – tttttttttttttttt – – tttttt t tttt tttttttttttttttt t tttt tttttttttt – – Upper airway edema Upper airway edema – – t ttttttttt tttttttt – – StridorStridor – – Difficulty breathing Difficulty breathing

• • Ammonia, Sulfur Dioxide, Hydrogen Ammonia, Sulfur Dioxide, Hydrogen

Chloride, Formaldehyde, HF Chloride, Formaldehyde, HF

• • - HF large exposure may cause- HF large exposure may cause bronchial and pulmonary destruction, bronchial and pulmonary destruction,

death usually due to systemic toxicity death usually due to systemic toxicity

AmmoniaAmmonia

• • -Colorless, water soluble, -Colorless, water soluble, alkaline gas alkaline gas

• • Pungent odor Pungent odorUses:Uses:

• • To make fertilizer, explosives, To make fertilizer, explosives, dyes, and plastics dyes, and plastics

• • In the manufacture of nitric In the manufacture of nitric acid, hydrazine hydrate, acid, hydrazine hydrate,

hydrogen cyanide, hydrogen cyanide,nitrocellulose,nitrocellulose,

ureaformaldehyde, and others ureaformaldehyde, and others

Household ammonia Household ammonia – – - pH < 12 limited damage - pH < 12 limited damage Anhydrous ammonia Anhydrous ammonia – – - 12pH > severe damage - 12pH > severe damage • • Rapidly absorbed by mucosal Rapidly absorbed by mucosal

surfacessurfaces – – Eyes, and Throat Eyes, and Throat • • Corrosive when combined with water Corrosive when combined with water – – Liquefaction necrosis Liquefaction necrosis

Irritant Gas Irritant Gas Moderately Water Soluble Moderately Water Soluble

Moderately water solubleModerately water soluble

Chlorine gasChlorine gas Affects upper and lower airway but to Affects upper and lower airway but to

a lesser extent the highly or slightly a lesser extent the highly or slightly water soluble irritantswater soluble irritants

2Chlorine (Cl ) 2Chlorine (Cl ) - - 7782505CAS ; UN - - 7782505CAS ; UN10171017

• • Persons exposed only to chlorine gas pose little risk Persons exposed only to chlorine gas pose little risk of secondary contamination to others. However, clo of secondary contamination to others. However, clo

- thing or skin soaked with industrial strength chlorin - thing or skin soaked with industrial strength chlorin e bleach or similar solutions may be corrosive to res e bleach or similar solutions may be corrosive to res

cuers and may release harmful chlorine gas. cuers and may release harmful chlorine gas.

• • - Chlorine is a yellow green, noncombustible gas with - Chlorine is a yellow green, noncombustible gas with a pungent, irritating odor. It is a strong oxidizing ag a pungent, irritating odor. It is a strong oxidizing ag

ent and can react explosively or form explosive com ent and can react explosively or form explosive com pounds with many common substances. Chlorine is pounds with many common substances. Chlorine is - heavier than air and may collect in low lying areas. - heavier than air and may collect in low lying areas.

• • Chlorine gas is highly corrosive when it contacts moi Chlorine gas is highly corrosive when it contacts moi

st tissues such as the eyes, skin, and upper respirat st tissues such as the eyes, skin, and upper respirat ory tract. Significant dermal absorption or ingestion ory tract. Significant dermal absorption or ingestion

is unlikely. is unlikely.

Vapor Density(VD)

VD of dry air = 1

Prehospital Management Prehospital Management • • Rescue personnel are at low risk of secondary con Rescue personnel are at low risk of secondary con

tamination from victims who have been exposed o tamination from victims who have been exposed o nly to chlorine gas. However, clothing or skin soak nly to chlorine gas. However, clothing or skin soak ed with industrialstrength bleach or similar solutio ed with industrialstrength bleach or similar solutio ns may be corrosive to rescuers and may release h ns may be corrosive to rescuers and may release h

armful chlorine gas. armful chlorine gas.

• • Acute exposure to chlorine gas initially causes cou Acute exposure to chlorine gas initially causes cou ghing, eye and nose irritation, lacrimation, and a b ghing, eye and nose irritation, lacrimation, and a b urning sensation in the chest. Airway constriction urning sensation in the chest. Airway constriction

and noncardiogenic pulmonary edema may occur. and noncardiogenic pulmonary edema may occur. Chlorine irritates the skin and can cause burning p Chlorine irritates the skin and can cause burning p

ain, inflammation, and blisters. Exposure to liquefi ain, inflammation, and blisters. Exposure to liquefi ed chlorine can result in frostbite. ed chlorine can result in frostbite.

• • There is no specific antidote for chlorine poisoning. There is no specific antidote for chlorine poisoning. Treatment is supportive. Treatment is supportive.

- Multi Casualty Triage- Multi Casualty Triage Patients with evidence of significant exposur Patients with evidence of significant exposur

e (e.g., severe or persistent cough, dyspnea e (e.g., severe or persistent cough, dyspnea or chemical burns) should be transported to or chemical burns) should be transported to

a medical facility for evaluation. a medical facility for evaluation.

Patients who have minor or transient Patients who have minor or transient irritation of the eyes or throat may be discha irritation of the eyes or throat may be discha

rged from the scene after their names, addr rged from the scene after their names, addr esses, and telephone numbers are recorded. esses, and telephone numbers are recorded.

They should be advised to seekmedical care They should be advised to seekmedical care promptly if symptoms develop or recur promptly if symptoms develop or recur

Emergency Department Management Emergency Department Management

• • Hospital personnel are at minimal risk of secondary cont Hospital personnel are at minimal risk of secondary cont amination from patients who have been exposed only t amination from patients who have been exposed only t

o chlorine gas. However, clothing or skin soaked with in o chlorine gas. However, clothing or skin soaked with industrial strength bleach or similar solutions may be cor- dustrial strength bleach or similar solutions may be cor

rosive to personnel and may release harmful chlorine g rosive to personnel and may release harmful chlorine gas.as.

• • Acute exposure to chlorine gas initially causes coughin Acute exposure to chlorine gas initially causes coughin g, eye and nose irritation, lacrimation, and a burning se g, eye and nose irritation, lacrimation, and a burning se

nsation in the chest. Airway constriction, noncardiogeni nsation in the chest. Airway constriction, noncardiogeni c pulmonary edema, hemoptysis, and bronchopneumo c pulmonary edema, hemoptysis, and bronchopneumo

nia may occur. nia may occur.

• • Chlorine irritates the skin and can cause burning pain, in Chlorine irritates the skin and can cause burning pain, in flammation, and blisters. Exposure to liquefied chlorine flammation, and blisters. Exposure to liquefied chlorine

can result in frostbite. can result in frostbite.

• • There is no specific antidote for chlorine poisoning. Tre There is no specific antidote for chlorine poisoning. Tre atment requires supportive care. atment requires supportive care.

- Disposition and Follow up - Disposition and Follow up

Consider hospitalizing patients who have a suspec Consider hospitalizing patients who have a suspec ted significant exposure or have eye burns or serio ted significant exposure or have eye burns or serio

us skin burns. us skin burns.

Symptomatic patients complaining of persistent sh Symptomatic patients complaining of persistent sh ortness of breath, severe cough, or chest tightness ortness of breath, severe cough, or chest tightness

should be admitted tothe hospital and observed u should be admitted tothe hospital and observed u - ntil symptom free. - ntil symptom free.

Pulmonary injury may progress for several hours. Pulmonary injury may progress for several hours.

Patient Release Patient Release Asymptomatic patients and those who Asymptomatic patients and those who

experienced only minor sensations of burning of th experienced only minor sensations of burning of th e nose, throat, eyes, and respiratory tract (with pe e nose, throat, eyes, and respiratory tract (with pe

rhaps a slight cough) may be released. rhaps a slight cough) may be released.

In most cases, these patients will be free of sympt In most cases, these patients will be free of sympt oms in an hour or less. oms in an hour or less.

They should be advised to seek medical care prom They should be advised to seek medical care prom ptly if symptoms develop or recur ptly if symptoms develop or recur

-Follow up-Follow up tttttt tt tt ttttttttttt ttt ttt tttttttttttt tttttt tt tt ttttttttttt ttt ttt tttttttttttt

tttttttt ttttttt tttt-tttt ttttttttttt ttttttttttt ttttttt tttt-tttt ttttttttttt ttt ttt ttttttt . ttt ttttttt .

ttttttttttt tttttttttt tt ttttttttttt ttttt ttt ttttttttttttt tttttttttt tt ttttttttttt ttttt ttt tt tt ttt tttt -ttttt. tt ttt tttt -ttttt.

- Chlorine induced reactive airways- Chlorine induced reactive airways tttt tt ttt tttt ttt( ) tttt tt ttt tttt ttt( )

2 12orted to persist from to years. 2 12orted to persist from to years.

Irritant Gas Irritant Gas Slightly Water Soluble Slightly Water Soluble

Some irritation acutely Some irritation acutely Delayed Pneumonia Delayed Pneumonia – – t tttttttt ttttttt – – BronchospasmBronchospasm – – t tttttttttttttt ttttttttttttt tttt ttttt tttt ttttt ttttt tttt t – – t tttttt ttt tttttt tt – – CNS agitation CNS agitation – – CNS depression CNS depression

Ni t r ogen Di oxi de Ni t r ogen Di oxi de tttt tttt ttttttt tttt t ttt, tttt tttt ttttttt tttt t ttt, • • tttttttt ttt ttttttttttttttttt ttt ttttttttt • • Uses commercially Uses commercially – – Chemical intermediate, catalyst, nitrating Chemical intermediate, catalyst, nitrating

agent, oxidizing agent, oxidizing agent, polymerization inhibitor, oxidizer for agent, polymerization inhibitor, oxidizer for

rocket fuels, rocket fuels, ttt tt ttttttttt tttttttt tt ttttttttt ttttt

AsphyxiantAsphyxiant

Asphyxiants are chemicals that Asphyxiants are chemicals that interfere with the body’s ability t interfere with the body’s ability t

o use oxygen while not affecting t o use oxygen while not affecting t - he airway or alveolar capillary me - he airway or alveolar capillary me

mbranesmbranes

AsphyxiantAsphyxiant

1.Simple Asphyxiants 1.Simple Asphyxiants

Displace ambient air Displace ambient air

2.Systemic Asphyxiants 2.Systemic Asphyxiants

Inhibit oxygen utilization by Inhibit oxygen utilization by

cellscells

Signs & Symptoms Signs & Symptoms

RespiratoryRespiratory

• • Decreased oxygen supply causes Decreased oxygen supply causes

– – TachypneaTachypnea

• • If hypoxia is not corrected If hypoxia is not corrected

– – Eventual respiratory arrest Eventual respiratory arrest

• • Patients may experience significant “ Patients may experience significant “airair

hunger”hunger”


CardiovascularCardiovascular • • Decreased oxygen supply can cause Decreased oxygen supply can cause – – TachycardiaTachycardia – – Myocardial ischemia Myocardial ischemia – – Dysrhythmias , Cardiac arrest Dysrhythmias , Cardiac arrest • • Nitrites, nitrates, and azides cause Nitrites, nitrates, and azides cause – – Direct vasodilation Direct vasodilation – – HypotensionHypotension


NeurologicalNeurological CNS excitation can lead to CNS depression CNS excitation can lead to CNS depression

t tttttt ttt tttttt tttttt ttt ttttt – – t tttttttt ttttttt – – DizzinessDizziness – – WeaknessWeakness – – tttttttttttttttttt – – tttttttttttttttttt – – SeizuresSeizures – – ttt tttt t

Skin and Mucous Membranes Skin and Mucous Membranes

• • Simple asphyxiants & Simple asphyxiants &methemoglobinformingmethemoglobinforming

compounds produce compounds produce

– – Peripheral and central cyanosis Peripheral and central cyanosis

• • This may not be seen with systemic This may not be seen with systemic

asphyxiantsasphyxiants

Simple Asphyxiants Simple Asphyxiants

• • Biologically inert gases Biologically inert gases

• • Displaces ambient air so there is less oxygen Displaces ambient air so there is less oxygen

inhaled into the lungs inhaled into the lungs

• • Examples: Carbon dioxide, Nitrogen, Helium, Examples: Carbon dioxide, Nitrogen, Helium,

Methane, Ethane, Butane, Propane, Acetylene Methane, Ethane, Butane, Propane, Acetylene

– – Methane in mines, canaries Methane in mines, canaries

• • - Treatment remove from exposure, oxygen- Treatment remove from exposure, oxygen

Hydrocarbon Gases Hydrocarbon Gases

Methane, Ethane, Butane, Propane, Methane, Ethane, Butane, Propane,AcetyleneAcetylene

Natural Gas (M 85%, E 9%, P 3%, B Natural Gas (M 85%, E 9%, P 3%, B 1 2% Nitrogen %) 1 2% Nitrogen %)

• • Heavier than air Heavier than air • • Explosive !!! Explosive !!!

Simple Asphyxiants: Simple Asphyxiants:DecontaminationDecontamination

• • Remove the patient from exposure Remove the patient from exposure

• • No need to undress or decontaminate No need to undress or decontaminate

• • TxTx

– – Ensure adequate ventilation with Ensure adequate ventilation with100%100%

oxygen for symptomatic patients oxygen for symptomatic patients

– – CPR/ Intubation as necessary CPR/ Intubation as necessary

– – Cardiac Monitoring Cardiac Monitoring

Systemic Asphyxiants Systemic Asphyxiants 3 types 3 types

1. Interfere with oxygen transportation via hemoglob 1. Interfere with oxygen transportation via hemoglobtttt

– – t ttttt ttttttt-tttt ttt ttt ttttttt ttttt ttttttt-tttt ttt ttt tttttt • • ttttttttt tttttttt ttt ttttt ttttt( ) ttttttttt tttttttt ttt ttttt ttttt( )

tttttttttttttttttt 2. Interfere with oxygen utilization by inhibiting 2. Interfere with oxygen utilization by inhibiting ttttt( , 3 ) ttttt( , 3 )

– – t tttttttttt ttt tttttt& t tttttttttt ttt tttttt& – – tttttttttttttttt – – tttttttttttt t ttt tttt3. t ttt tttt3. – – Carbon monoxide Carbon monoxide

Systemic Asphyxiants Systemic Asphyxiants

Interfere with oxygen transportation Interfere with oxygen transportation via hemoglobin via hemoglobin

NitritesNitrites

Methemoglobin forming compounds Methemoglobin forming compounds

tttttttt tttttt tttttttttttttttt tttttt ttttttttttttttttttttt ttttttt ttttttttttttttttttttt ttttttt tttttttt

ss

• • Hemoglobin's ferrous Hemoglobin's ferrous iron(Fe+2) i s oxi di zed t o iron(Fe+2) i s oxi di zed t o ferriciron(Fe+3) by ferriciron(Fe+3) byni t r i t esni t r i t es

• • Oxygen (O2) cannot bind Oxygen (O2) cannot bind to methemoglobin's Fe+3 . to methemoglobin's Fe+3 .

2Water(HO) bi nds i n 2Water(HO) bi nds i n oxygen's place. oxygen's place.

• • t ttttt ttttttt ttttttt ttttt ttttttt ttttttttttttttt tttttttttt t

CardiovascularCardiovascular

– – MethemoglobinemiaMethemoglobinemia

– – - Chocolate brown blood- Chocolate brown blood

– – Peripheral cyanosis Peripheral cyanosis

tttttt ttttttttt ttt • • t tttttt ttttt • • Supportive Care Supportive Care • • Monitor for shock and treat accordingly Monitor for shock and treat accordingly – – Nitrates and nitrites are potent vasodilators Nitrates and nitrites are potent vasodilators – – ttttt tttttttttt tt tttttttt tt tttttt t tt tt ttttt tttttttttt tt tttttttt tt tttttt t tt tt tttttttttttttttt

• • tttttttt ttt ttttttttttttttttttt ttt ttttttttttt – – Methylene blue, if indicated Methylene blue, if indicated

Systemic Asphyxiants Systemic Asphyxiants

Interfere with oxygen utilization by Interfere with oxygen utilization byinhibitinginhibiting

mitochondrial cytochrome oxidase (cyt a,a mitochondrial cytochrome oxidase (cyt a,a3)3)

CyanidesCyanides

& cyanogenic compounds & cyanogenic compounds

SulfidesSulfides

AzidesAzides

CyanideCyanidetttttt tttttt ttttttttttt tttttt tttttt ttttttttttt

through cytochrome oxidase path through cytochrome oxidase patht ttt tt

• • Metal plating industry Metal plating industry

• • Bitter almonds smell Bitter almonds smell

– – only a small % of the population can s only a small % of the population can s mell it mell it

HA, nausea, dizziness, LOC, anoxia HA, nausea, dizziness, LOC, anoxia

CyanideCyanideTreatmentTreatment

• • Remove from area Remove from area • • If conscious and breathing: If conscious and breathing: – – OxygenOxygen – – IV fluids IV fluids – – Observe; no antidotes Observe; no antidotes • • If unconscious: If unconscious: – – - Oxygen and bag mask ventilate - Oxygen and bag mask ventilate – – - Amyl Nitrite give until IV started - Amyl Nitrite give until IV started

- Treatment Nitrites - Treatment Nitrites

Amyl Nitrite (Inhalation) Amyl Nitrite (Inhalation)

– – 1 30amp inhaled for seconds out of e 1 30amp inhaled for seconds out of e ach minute ach minute

– – Change ampoules every 3 minutes Change ampoules every 3 minutes

– – Discontinue use when sodium nitrite i Discontinue use when sodium nitrite iss

administeredadministered

Sodium Nitrite (IV) Sodium Nitrite (IV) PreferredPreferred

– – 1 5ampule, over no less than minutes 1 5ampule, over no less than minutes

– – 12/ the initial dose may be repeated a 12/ the initial dose may be repeated a 30t min if no 30t min if no

ttttttttttt ttttttttttttttttttt tttttttt – – Dosage is not titrated Dosage is not titrated

– – Peds 0.12 to 0.33 ml/kg (up to 10ml), Peds 0.12 to 0.33 ml/kg (up to 10ml), over > 5 minutes over > 5 minutes

Sodium Thiosulfate (IV) Sodium Thiosulfate (IV) – – - 1 1020amp over minutes - 1 1020amp over minutes – – - Peds: 1.6 ml/kg over 10 20 minutes - Peds: 1.6 ml/kg over 10 20 minutes Converts cyanide to the Converts cyanide to the much less toxic thiocyanate much less toxic thiocyanate But not very effective But not very effective

Hydrogen Sulfide Hydrogen Sulfide

Blocks oxygen utilization through Blocks oxygen utilization through cytochrome oxidase pathway cytochrome oxidase pathway

• • Rotten egg odor Rotten egg odor • • Olfactory fatigue Olfactory fatigue • • Manure pit, sewage worker, farmer Manure pit, sewage worker, farmer • • ttt t tttttttt tttttttt ttttttt ttttt t tttttttt tttttttt ttttttt tt ttttt tttt ttttttt" " ttttt tttt ttttttt" "

gas wells. gas wells. Mucous membrane and respiratory Mucous membrane and respiratory

irritation, LOC, anoxia irritation, LOC, anoxia

TreatmentTreatment

• • t tttttt ttttttt ttttt tttttt ttttttt tttt • • t tttttt ttttt • • t ttttttttt ttttttt ttttttttt tttttt – – ttttttt tt ttttttttt tttt tttttttttttttt tt ttttttttt tttt ttttttt • • ttttttt t tttttt ttttttt& ttttttt t tttttt ttttttt& – – tttttt ttt tttttttttttt tt tttttttt tttt ttttttttt ttt tttttttttttt tt tttttttt tttt ttt

achrome a,a3 to achrome a,a3 tot ttttt ttttttt tt tttttt ttttttt t ttttt ttttttt tt tttttt ttttttt

t tttttttttt ttttttttt

Carbon Monoxide Carbon Monoxide “The Silent Killer” “The Silent Killer”

• • From Incomplete combustion of From Incomplete combustion of carbon based fuels carbon based fuels

• • No warning properties No warning properties

• • Colorless, odorless, tasteless, Colorless, odorless, tasteless,nonirritatingnonirritating

• • Density 0.97 of air Density 0.97 of air

• • High concentrations give a lavender o High concentrations give a lavender otttttt

Impaired oxygen Impaired oxygen

deliverydelivery

Also causes Hb to hold Also causes Hb to hold

-onto O2 more tightly -onto O2 more tightly

Due the leftward shift Due the leftward shift

of the oxygen of the oxygen

dissociation curve dissociation curve

CO toxicity CO toxicity Signs and Symptoms Signs and Symptoms

• • CNS and the CV systems, which have the highest CNS and the CV systems, which have the highest requirementsf or oxygen, ar e most sensi t i ve t o t he requirementsf or oxygen, ar e most sensi t i ve t o t he

effects of CO effects of CO • • CO sxs are exacerbated by increased O2 demands CO sxs are exacerbated by increased O2 demands – – exertion, trauma, burns, drug ingestions, MI, CVA, s exertion, trauma, burns, drug ingestions, MI, CVA, smokemoke

inhalationinhalation • • Cardiovascular:Cardiovascular: – – MI, palpitations (dysrhythmias), mottled skin, poor MI, palpitations (dysrhythmias), mottled skin, poorcapcap

refill, hypotension, cardiac arrest refill, hypotension, cardiac arrest

Minimal: Minimal: Mild headache, mild nausea Mild headache, mild nausea Mild: Mild: Moderate to severe headache, moderate to seve Moderate to severe headache, moderate to seve

rere nausea, dizziness nausea, dizziness

CO toxicity CO toxicity TreatmentTreatment Initiated for any symptomatic patient Initiated for any symptomatic patient • • -Administer 100% oxygen by tight fitting, -Administer 100% oxygen by tight fitting, - non rebreather face mask to any patient as- non rebreather face mask to any patient as soon as the diagnosis is suspected soon as the diagnosis is suspected • • Obtain a history; physical exam should Obtain a history; physical exam should focus on neurologic and cardiac evaluation focus on neurologic and cardiac evaluation

CNS Effects CNS Effects

• • Most sensitive area to CO Most sensitive area to CO

poisoningpoisoning

• • - -Acute HA, dizzy, ataxia (15 20%)- -Acute HA, dizzy, ataxia (15 20%)

• • Syncope, Sz, coma (longer Syncope, Sz, coma (longer

exposures)exposures)

Moderate:Moderate: • • LOC or Seizures at the scene LOC or Seizures at the scene • • Confusion, pronounced Lethargy or Weakness, Confusion, pronounced Lethargy or Weakness, • • VomitingVomiting • • Tachypnea, Shortness of breath Tachypnea, Shortness of breath • • Chest pain,Tachycardia Chest pain,Tachycardia

Severe:Severe: • • Syncope, Disorientation, Seizures, Obtundation or LOC in the Syncope, Disorientation, Seizures, Obtundation or LOC in the

ERER • • Focal neurological deficits, Focal neurological deficits, • • EKG changes, Cardiac dysrhythmias/arrest (Primary cause of EKG changes, Cardiac dysrhythmias/arrest (Primary cause of

death) , death) ,HypoTN,HypoTN,

• • Respiratory distress, Cyanosis Respiratory distress, Cyanosis Cardiac injury more common than previously thought Cardiac injury more common than previously thought

There is a poor correlation between There is a poor correlation betweenseverityseverity

of symptoms and the COHb levels. of symptoms and the COHb levels.

Highly variable, the mild symptoms often Highly variable, the mild symptoms often

being mistaken for other etiologies e.g: being mistaken for other etiologies e.g:

viral illness (“the flu”), gastroenteritis or viral illness (“the flu”), gastroenteritis or

food poisoning food poisoning

AntidotesAntidotes

There is no There is no

for 99% of for 99% of ChemicalsChemicals

There is only supportive treatment for There is only supportive treatment for 99% of Chemicals99% of Chemicals

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

Only Supportive treatmentOnly Supportive treatmentNo Antidotes for followingNo Antidotes for following

AmmoniaAmmonia ChlorineChlorine Hydrogen sulphideHydrogen sulphide PhosgenePhosgene Carbon monoxideCarbon monoxide Nitrogen OxidesNitrogen Oxides FormalinFormalin AcidsAcids

SummarySummary Physical removal is BEST deconPhysical removal is BEST decon Must plan for patient decon at all aspects of Must plan for patient decon at all aspects of

carecare Decon process is resource intensive and Decon process is resource intensive and

must be planned and practiced in advancedmust be planned and practiced in advanced Identify and train personnel earlyIdentify and train personnel early Learn benefits of coordination with medical Learn benefits of coordination with medical

assets in your hospital and regionassets in your hospital and region

Prior Planning Prevents Poor Prior Planning Prevents Poor PerformancePerformance

Explosives…

Decon???

Madrid, 11 March 2004

Anthrax 2001-2002Anthrax 2001-2002

Decon? Or Prophylaxis? Decon? Or Prophylaxis?

emergency chemical response decontamination principles and patient management

Health & Medicine