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Acute Management Overview
Nerve agents (NAs) are the most toxic of the known chemical warfare agents. They are chemically similar to organophosphate pesticides (OPs) and exert their biological effects by inhibiting acetylcholinesterase enzymes.
- Nerve agents can cause loss of consciousness and convulsions within seconds and death from respiratory failure within minutes of exposure.
Volatile Nerve Agents (vapor)
- Nerve agent vapor is readily absorbed by inhalation and ocular contact and produces rapid local and systemic effects.
- G-type agents are clear, colorless and tasteless liquids that are soluble in water and most organic solvents.
- GB is odorless and is the most volatile nerve agent; however, it evaporates at about the same rate as water. GA has a slightly fruity odor and GD has a slight camphor-like odor (not reliable signs).
Low Volatility Nerve Agents (liquid)
- Liquid nerve agent is readily absorbed through the skin; however, effects may be delayed for several minutes to up to 18 hours.
- VX is a clear, amber-colored, odorless, oily liquid. It is soluble in water as well as in all other solvents. It is the least volatile nerve agent.
- Responders should obtain assistance in identifying the chemical(s) from container shapes, placards, labels, shipping papers, and analytical tests. General information on these identification technicques is located in Emergency Response Guidebook.
- Identification Tools - CHEMM-IST, WISER, Nerve Agents Chemical Properties
- Devices - M8, M9 chemical agent detector paper (liquid agents), M18A3 chemical agent detectors (vapor), M256A1 chemical agent detector kit (liquid and vapor), Draeger CDS Kit (vapor and aerosol), Hazmat Smart Strips (qualitative), Chemical Agent Detector C2 Kit (liquid and vapor), Chemical Agent Monitor (CAM) (vapor)
- A comprehensive source for the selection of chemical identification equipment is the Guide for the Selection of Chemical Detection Equipment for Emergency First Responders, Guide 100-06, January 2007, 3rd Edition published by the Department of Homeland Security to assist with this process.
Nerve Agent Specific Triage
Triage for Nerve Agent Casualties |
Immediate (1) |
Effects - Unconscious, talking but not walking, moderate to severe effects in two or systems more systems (e.g., respiratory, GI, cardiac arrest. muscular, CNS) |
Clinical Signs - seizing or postictal, severe respiratory distress, recent cardiac arrest |
Delayed (2) |
Effects - recovering from agent exposure or antidote |
Clinical Signs - diminished secretions, improving respiration. |
Minimal (3) |
Effects - walking and talking |
Clinical Signs - pinpoint pupils, runny nose, and mild to moderate difficulty breathing. |
Expectant (4) (limited resources) |
Effects - Unconscious |
Clinical Signs - Cardiac/respiratory arrest of long duration. |
- Victims whose skin or clothing is contaminated with liquid nerve agent can contaminate rescuers by direct contact or through off-gassing vapor.
- Persons whose skin is exposed only to nerve agent vapor pose no risk of secondary contamination; however, clothing and hair can trap vapor.
- Link to prehospital management section
- Inhalation - nerve agents are readily absorbed from the respiratory tract. Runny nose and tightness in the throat or chest begin within seconds to minutes after exposure. Nerve agent vapors are heavier than air. Odor does not provide adequate warning of detection.
- Skin/Eye Contact - nerve agent liquids are readily absorbed from the skin and eyes. Vapors are not absorbed through the skin except at very high concentrations. Ocular effects may result from both direct contact and systemic absorption. The nature and timing of symptoms following dermal contact with liquid nerve agents depend on exposure dose; effects may be delayed for several hours.
- Ingestion - ingestion of nerve agents is expected to be relatively rare compared to inhalation exposure or skin contact; however, they are readily absorbed from the GI tract and are highly toxic.
Clinical Signs and Symptoms
Nerve agents are potent acetylcholinesterase inhibitors causing the same signs and symptoms regardless of the exposure route. However, the initial effects depend on the dose and route of exposure.
- Children are much more vulnerable than adults to nerve agent toxicity.
- Manifestations of nerve agent exposure include:
- Neuromuscular - pinpoint pupils (highly indicative of nerve agent exposure in a mass casualty situation), muscle twitching, confusion, seizures, flaccid paralysis, and coma.
- In many instances children present with only neurological signs and symptoms.
- Pulmonary - chest tightness, wheezing, shortness of breath, respiratory failure.
- Gastrointestinal - nausea, vomiting, abdominal cramps, involuntary defecation.
- Other - runny nose, excessive salivation and sweating, and urination.
- Link to Toxic Syndromes
- Link to Primary and Secondary Survey
- The diagnosis in a severely intoxicated individual is straightforward. The combination of miosis, copious secretions, bronchospasm, generalized muscle fasciculations, and seizures is characteristic.
- Look carefully for miosis (if present will be helpful). Miosis may not be present initially following a low volatility nerve agent exposure.
- A mild vapor exposure may mimic a child having allergic rhinitis/conjunctivitis.
- A mild vapor exposure may present with only visual complaints such as narrowing of the visual field or a sense that everything is going dark.
- GI symptoms by themselves could be confusing and they could be the only presenting signs.
- Opioid abuse can include miosis, apnea, seizures, etc.
- Link to Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST)
Hot Zone
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Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained in its use, call for assistance in accordance with local Emergency Operational Guides (EOG). Sources of such assistance should be obtained from a local HAZMAT teams, mutual aid partners, the closest metropolitan strike system (MMRS) and the U. S. Soldier and Biological Chemical Command (SBCCOM)-Edgewood Research Development and Engineering Center. SBCCOM may be contacted (from 7:00 AM - 4:30 PM EST call 410-671-4411 and from 4:30PM - 7:00AM EST call 410-278-5201), ask for the Staff Duty Officer.
Hot Zone
Nerve agents are the most toxic of the known chemical warfare agents. They are chemically similar to organophosphate pesticides and exert their biological effects by inhibiting acetylcholinesterase enzymes.
- Nerve agents can cause loss of consciousness and convulsions within seconds and death from respiratory failure within minutes of exposure.
Volatile Nerve Agents (vapor)
- Nerve agent vapor is readily absorbed by inhalation and ocular contact and produces rapid local and systemic effects.
- G-type agents are clear colorless and tasteless liquids that are miscible in water and most organic solvents.
- GB is odorless and is the most volatile nerve agent; however, it evaporates at about the same rate as water. GA has a slightly fruity odor and GD has a slight camphor-like odor.
Low Volatility Nerve Agents (liquid)
- Liquid nerve agent is readily absorbed through the skin; however, effects may be delayed for several minutes to up to18 hours.
- VX is a clear, amber-colored, odorless, oily liquid. It is miscible with water and soluble in all solvents. It is the least volatile nerve agent.
- Responders should obtain assistance in identifying the chemical(s) from container shapes, placards, labels, shipping papers, and analytical tests. General information on these identification technicques is located in Emergency Response Guidebook.
- Identification Tools - CHEMM-IST, WISER, Nerve Agents Chemical Properties
- Devices - M8, M9 chemical agent detector paper (liquid agents), M18A3 chemical agent detectors (vapor), M256A1 chemical agent detector kit (liquid and vapor), Draeger CDS Kit (vapor and aerosol), Hazmat Smart Strips (qualitative), Chemical Agent Detector C2 Kit (liquid and vapor), Chemical Agent Monitor (CAM) (vapor)
- A comprehensive source for the selection of chemical identification equipment is the Guide for the Selection of Chemical Detection Equipment for Emergency First Responders, Guide 100-06, January 2007, 3rd Edition published by the Department of Homeland Security to assist with this process.
Nerve Agent is a highly toxic systemic poison that is absorbed well by inhalation and through the skin. Victims exposed only to nerve agent vapor do not pose secondary contamination risks to rescuers, but do not attempt resuscitation without a barrier. Victims whose clothing or skin is contaminated with liquid nerve agent can secondarily contaminate response personnel by direct contact or through off-gassing vapor. Avoid dermal contact with nerve agent contaminated victims or with gastric contents of victims who may have ingested nerve agent-containing materials.
PPE required level A
Respiratory Protection: Positive-pressure, self-contained breathing apparatus (SCBA) is recommended in response situations that involve exposure to potentially unsafe levels of nerve agent.
Skin Protection: Chemical-protective clothing is recommended because both nerve agent vapor (high exposure doses) and liquid can be absorbed through the skin to produce systemic toxicity.
- Level A - protective clothing is the highest level of protection. Level A includes a Self Contained Breathing Apparatus(SCBA) with a fully encapsulating vapor tight suit with gloves and booties attached to the suit (tanks last from 1/2 hour to 1 hour).
- Link to reference section for acute event PPE related safety information
Chemical casualty triage is based on walking feasibility, respiratory status, age, and additional conventional injuries. The triage officer must know the natural course of a given injury, the medical resources immediately available, the current and likely casualty flow, and the medical evacuation capabilities.
For the victim esposed to nerve agent who presents with severe multisystem symptoms, antidotes and supportive care can be lifesaving if initiated immediately.
Mass Casualty Triage Standards
General Principles of Triage for Chemical Exposures
- Check triage tag/card for any previous treatment or triage.
- Survey for evidence of associated traumatic/blast injuries.
- Observe for sweating, labored breathing, coughing/vomiting, secretions.
- Severe casualty triaged as immediate if assisted breathing is required.
- Blast injuries or other trauma, where there is question whether there is chemical exposure, victims must be tagged as immediate in most cases. Blast victim's evidence delayed effects such as ARDS, etc.
- Mild/moderate casualty: self/buddy aid, triaged as delayed or minimal and release is based on strict follow up and instructions.
- If there are chemical exposure situations which may cause delayed but serious signs and symptoms, then over-triage is considered appropriate to the proper facilities that can observe and manage any delayed onset symptoms.
- Expectant categories in multi-casualty events are those victims who have experienced a cardiac arrest, respiratory arrest, or continued seizures immediately. Resources should not be expended on these casualties if there are large numbers of casualties requiring care and transport with minimal or scant resources available.
- In a given category prioritize a child, pregnant woman over a non-pregnant adult.
Nerve Agent Specific Triage
Triage for Nerve Agent Casualties |
Immediate (1) |
Effects - Unconscious, talking but not walking, moderate to severe effects in two or systems more systems (e.g., respiratory, GI, cardiac arrest. muscular, CNS) |
Clinical Signs - seizing or postictal, severe respiratory distress, recent cardiac arrest |
Delayed (2) |
Effects - recovering from agent exposure or antidote |
Clinical Signs - diminished secretions, improving respiration. |
Minimal (3) |
Effects - walking and talking |
Clinical Signs - pinpoint pupils, runny nose, and mild to moderate difficulty breathing. |
Expectant (4) (limited resources) |
Effects - Unconscious |
Clinical Signs - Cardiac/respiratory arrest of long duration. |
Quickly access for a patent airway, ensure adequate respiration and pulse (document pulse ox if possible). If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Apply direct pressure to stop arterial bleeding (if present).
- Inhalation - nerve agents are readily absorbed from the respiratory tract. Runny nose and tightness in the throat or chest begin within seconds to minutes after exposure. Nerve agent vapors are heavier than air. Odor does not provide adequate warning of detection.
- Skin/Eye Contact - nerve agent liquids are readily absorbed from the skin and eyes. Vapors are not absorbed through the skin except at very high concentrations. Ocular effects may result from both direct contact and systemic absorption. The nature and timing of symptoms following dermal contact with liquid nerve agents depend on exposure dose; effects may be delayed for several hours.
- Ingestion - ingestion of nerve agents is expected to be relatively rare compared to inhalation exposure or skin contact; however, they are readily absorbed from the GI tract and are highly toxic.
Clinical Signs and Symptoms
Nerve agent's primary means of inducing toxicity is through inhalation and skin/eye contact. Occasionally ingestion can occur.
The onset of action with inhaled vapor can be almost instantaneous causing local and systemic effects. Liquid which is readily absorbed thru the skin can cause system effects in minutes and up to 18 hours later.
- Respiratory: Inhalation of nerve agent vapor causes respiratory tract effects within seconds to minutes. Symptoms include increased, rhinorrhea, and bronchial secretions, chest tightness secondary to bronchial muscle contraction.
- CNS: High dose - seizures, loss of consciousness, apnea. Other signs and symptoms include; irritability, memory loss, fatigue, memory loss, behavioral and psychological changes.
- Cardiovascular: Potentially up to three phases in variable length - transient tachycardia/with or without hypertension (minutes) followed by bradycardia and hypotension. The final phase starts hours to days after exposure with QT prolongation and a tendency toward malignant dysrhythmias. In one Organophosphate toxicity study 42 % had cardiac arrhythmias with torsades de pointe occurring in 37 % of the cases.
- Gastrointestinal: Abdominal pain, N&V, diarrhea are common manifestations of any exposure. It may be the first systemic effects of skin exposure. If GI symptoms occur within one hour of dermal contamination severe intoxication is present.
- Skeletal Muscles; Nerve agents stimulate skeletal muscles producing twitching and fasciculations. This leads to fatigue and flaccid paralysis.
- Metabolic: Sweating.
- Ocular: Symptoms may occur from local effects secondary to vapor exposure or as a manifestation of systemic absorption. Pinpoint pupils, eye pain, conjunctivitis, and increased tearing are common (with systemic absorption pinpoint pupils may not occur immediately).
- Link to Toxic Syndromes
- Link to Primary and Secondary Survey
- The diagnosis in a severely intoxicated individual is straight forward. The combination of miosis, copious secretions, bronchospasm, generalized muscle fasciculations, and seizures is characteristic.
- Look carefully for miosis (if present will be helpful). Miosis may not be present initially following a low volatility nerve agent exposure.
- A mild vapor exposure may mimic a child having allergic rhinitis/conjunctivitis in combination with an asthmatic episode.
- GI symptoms by themselves could be confusing and they could be the only presenting signs.
- Opiod abuse can include miosis, apnea, seizures, etc.
- Link to Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST)
Pediatric/Obstetric/Geriatric Vulnerabilities
- Nerve Agents may penetrate the blood brain barrier more easily in children than adults. Children may only exhibit CNS effects.
- Children under four years of age with status epilepticus have the highest risk of death.
- A child's smaller mass alone reduces the dose of nerve agent required for toxic/lethal effects. Animal studies have shown that the lethal dose of nerve agent in an immature vs. adult animal is 10 %.
- With higher respiratory rates and minute volumes than adults a child will inhale a greater dose of nerve agent.
- The smaller airway diameter, anatomic subglottic narrowing, omega shaped epiglottic structure, relatively large tongue size, less rigid ribs and trachea make them more vulnerable to nerve agent induces pathology i.e. bronchospasm, copious secretions.
- There are few case reports regarding fetal toxicity from nerve agent/organophosphate exposure.
- There is a high incidence of premature labor following organophosphate exposure in which maternal treatment has been delayed.
- Link to Primary and Secondary Survey
Mild effects:
- Miosis alone (no respiratory symptoms)- No antidotes. However, if eye/head pain or N&V (in the absence of other systemic signs suggesting a liquid exposure) are severe use atropine ophthalmic drops
- Miosis and severe rhinorrhea - Atropine
| Atropine Autoinjector/IM† * |
Infant (0-2 yrs) | 0.05 mg/kg autoinjector/IM |
Child (3-7 yrs) | 1 mg autoinjector/IM |
Child (8-14 yrs) | 2 mg autoinjector/IM |
Adolescent/Adult | 2 mg autoinjector/IM |
Pregnant women | 2 mg autoinjector/IM |
Senior | 1 mg autoinjector/IM |
Mild/Moderate effects:
- These include localized swelling, muscle fasciculations, nausea and vomiting, weakness, shortness of breath. Utilize auto-injectors if available. May use a 600 mg 2PAM Cl auto-injector in an infant as small as 12 kg. Autoinjector containing 2 mg of atropine and 600 mg of pralidoxime is available (DuoDote).
| Atropine Autoinjector/IM† * | 2-PAM Cl - 600 mg Autoinjector/IM† * |
Infant (0-2 yrs) | 0.05 mg/kg IM | 15 mg/kg‡ |
Child (3-7 yrs) 13-25 kg | 1 mg autoinjector/IM | 15 mg/kg May use 1 autoinjector (600 mg)‡ |
Child (8-14 yrs) 26-50 kg | 2 mg autoinjector/IM | 15 mg/kg May use 1 autoinjector (600 mg)‡ |
Adolescent/Adult | 2-4 mg autoinjector/IM | 1 autoinjector (600 mg) |
Pregnant Women | 2-4 mg autoinjector/IM | 1 autoinjector (600 mg) |
Seniors, frail | 1 mg autoinjector/IM | 10 mg/kg IM 1 autoinjector (600 mg) |
- Repeat atropine every 5-10 minutes (similar dosing) until dyspnea, resistance to ventilation, and secretions are minimized. Treat vomiting and diarrhea from a liquid exposure in a similar way. Regular IM atropine dosing may take 20-25 minutes to have a therapeutic effect (vs. 8 minutes with an autoinjector).
- May repeat pralidoxime - up to a total of 45 mg/kg during the first hour
- May repeat pralidoxime - up to 45 mg/kg 1 hour after initial treatment
Severe Effects - Initial Dosing:
- These include unconsciousness, convulsions, apnea, and flaccid paralysis. Atropine should not be given IV, if at all possible, in a hypoxic patient exposed to nerve agent or organophosphates. IV Atropine has regularly produced ventricular fibrillation in test animals in these clinical situations. Give at least the initial dose IM via autoinjector. Regular IM dosing may take 20-25 minutes to have a therapeutic effect.
| Atropine Autoinjector/IM† * | 2-PAM Cl Autoinjector/IM† * |
Infant (0-3 yrs) | 0.1 mg/kg IM | 45 mg/kg IM‡ |
Child (3-7 yrs) 13-25 kg | 0.1 mg/kg IM 1 (2 mg) autoinjector | 45 mg/kg Use 1 autoinjector (600 mg)‡ |
Child (8-14 yrs) 26-50 kg | 4 mg 2 (2 mg) autoinjector | 45 mg/kg IM Use 2 autoinjector (1200 mg)‡ |
Adolescent (>14 yrs) | 6 mg 3 (2 mg) autoinjectors | Use 3 autoinjectors (1800 mg) |
Adult | 6 mg 3 (2mg) autoinjectors | Use 3 autoinjectors (1800 mg) |
Pregnant Women | 6 mg 3 (2 mg) autoinjectors | Use 3 autoinjectors (1800 mg) |
Seniors, frail | 2-4 mg 1-2 (2 mg) autoinjectors | 25 mg/kg IM Use 2-3 autoinjectors (1200-1800 mg) |
- Repeat atropine 2 mg IM or 1 mg IM (infants) at 5-10 minute intervals until secretions have diminished, breathing is comfortable, and airway resistance has returned to normal.
- Repeat 2PAM Cl dose hourly X 2, if possible start 2 PAM Cl via continuous infusion 10-20 mg/kg/hr (max 500 mg/hr)
Treatment of seizures:
If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. Victims who are unable to walk may be removed on backboards or gurneys; if these are not available, carefully carry or drag victims to safety. Should there be a large number of casualties, and if decontamination resources permit, separate decontamination corridors should be established for ambulatory and non-ambulatory victims.
Consider appropriate management of chemically contaminated children, such as measures to reduce separation anxiety if a child is separated from a parent or other adult.
Decontamination Zone
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Rapid decontamination is critical to prevent further absorption by the patient and to prevent exposure to others.
Decontamination Zone
Personnel should continue to wear the same level of protection as required in the Hot Zone.
Link to Hot Zone - Rescuer Protection
If exposure levels are determined to be safe, decontamination may be conducted by personnel wearing a lower level of protection than that worn in the Hot Zone. However, do not attempt resuscitation without a barrier.
Speed is critical. If the victim is symptomatic, immediately institute emergency life support measures including the use nerve agent specific antidotes. Treatment should be given simultaneously with decontamination procedures. Quickly ensure that the victim has a patent airway and is ventilating well. Assist ventilation with a bag-valve-mask device equipped with a canister or air filter if necessary Maintain adequate circulation. Atropine administration will very likely will be required to enable ventilation. Stabilize the cervical spine with a decontaminable collar and a backboard if trauma is suspected. Direct pressure should be applied to control heavy bleeding, if present.
Antidotes/Seizure Medications
If clinically indicated, administer initial or repeat dosing of atropine, pralidoxime and seizure medications. If possible, a system should be employed to track antidotes administered.
Link to Treatment in the Hot Zone
Set up Considerations
- Use pictorial and written posted instructions for victims to self decon when able, use locale-appropriate multilingual signage.
- Double bag contaminated clothing etc. (place hearing aids, valuables in small bag). Place bag in container by showers.
- Victims who are able may assist with their own decontamination.
- Children and the elderly are at increased risk for hypothermia - provide warm showers, blankets.
- Privacy must be considered, if possible.
- The decontamination system should be designed for use in children of all ages, by parentless children, the non-ambulatory child, the child with special needs, and also allow families to stay together.
- Use step-by-step child friendly instructions that explain to the children and parents what they need to do, why they are doing it, and what to expect.
- Take into consideration that infants when wet are slippery and will need a way to get them through the decontamination process - i.e. plastic buckets, car seats, stretchers...
- Designate a holding area and provide staff to support and supervise the children.
- Recommended age appropriate staffing ratios for untended children:
- 1 adult to 4 infants
- 1 adult to 10 preschool children
- 1 adult to 20 school-age children
Washing Instructions
- If there will be significant delay to decontamination, have the victims rinse off with water exposed skin surfaces and disrobe (disposable clothing kits should be available).
- Remove all clothing (at least down to their undergarments) and place the clothing in a labeled durable 6-mil polyethylene bag (removal of clothing, at least to the undergarment level will reduce victim's contamination by 85 %).
- If exposure to liquid agent is suspected, cut and remove all clothing and wash skin immediately with soap and water.
- If exposure to vapor only is certain, remove outer clothing and wash exposed skin with soap and water.
- The eyes must be decontaminated within minutes of exposure to liquid nerve agent to limit injury. Flush the eyes immediately with water for about 5 to 10 minutes by tilting the head to the side, pulling eyelids apart with fingers, and pouring water slowly into eyes. There is no need to flush the eyes following exposure to nerve agent vapor. Remove contact lenses if easily removable without additional trauma to the eye.
- If clothes have been exposed to contamination, then extreme care must be taken when undressing to avoid transferring chemical agents to the skin - i.e. any clothing that has to be pulled over your head should be cut off instead of being pulled over your head.
- Scraping with a wooden stick, i.e. a tongue depressor or popsicle stick, can remove bulk agent.
- Cover all open wounds with plastic wrap prior to performing head to toe decontamination (particular attention should be made to open wounds because cyanide is readily absorbed through abraded skin).
- Flush the exposed skin and hair with plain water for 2 to 3 minutes then wash twice with mild soap. Rinse thoroughly with water. Be careful not to break the patient/victim's skin during the decontamination process.
- Caution - many people shower as they do it at home rather than conducting a rapid decontamination of their bodies. Too aggressive scrubbing can lead to further damage to skin and open wounds.
- Irrigate exposed or irritated eyes with plain water or saline for 5 minutes. Continue eye irrigation during other basic care or transport. Remove contact lenses if easily removable without additional trauma to the eye.
- Utilizing large amounts of water by itself is very effective (limit pressure in infants).
- If water supplies are limited, and showers are not available an alternative form of decontamination is to use 0.5 % sodium hypochlorite solution, or absorbent powders such as flour, talcum powder, or Fuller's earth.
- Sodium hypochlorite is not recommended for use in infants and young children.
- Certification of decontamination is accomplished by any of the following: processing through the decontamination facility; M8, M9 tape; M256A1 ticket; or by the Chemical Agent Monitor (CAM).
- If still contaminated repeat shower procedure.
In cases of ingestion, do not induce emesis. If the victim is alert, asymptomatic, and has a gag reflex, administer slurry of activated charcoal (administer at 1 gm/kg, usual adult dose 60-90 g, child dose 25-50 g). A soda can and a straw may be of assistance when offering charcoal to a child (consider naso-gastric tube - if possible contact ED prior to use of NG tube in infants and children [risk vs. benefit of inducing emesis with NG tube placement]).
Decontamination of First Responder
- Begin washing PPE of the first responder using soap and water solution and a soft brush. Always move in a downward motion (from head to toe). Make sure to get into all areas, especially folds in the clothing. Wash and rinse (using cold or warm water) until the contaminant is thoroughly removed.
- Reactive Skin Decontamination Lotion (RSDL) - designed to be carried by First Responders and warfighters, this lotion was found to be highly effective in removing and or neutralizing groups of chemical warfare agents. RSDL performed significantly better than the predicate device against the agents tested. The foam applicator immediately removes the CW agent off the skin and the CW Agent is chemically changed to a non-toxic form. Once the CW Agent is decontaminated, RSDL leaves a non-toxic residue that can be rinsed off when operational conditions allow.
- Avoid combining bleach (hypochlorite) with RSDL - the combination is combustible
- Links - RSDL background information
- Remove PPE by rolling downward (from head to toe) and avoid pulling PPE off over the head. Remove the SCBA after other PPE has been removed.
- Place all PPE in labeled durable 6-mil polyethylene bags.
Decontamination of Infants and Children
- Video: Decontamination of Infants and Children (HHS/AHRQ, Children's Hospital Boston) (Watch video)
- Decontamination of Children (HHS/AHRQ) provides a step-by-step decontamination demonstration in real time, and trains clinicians about the nuances of treating infants and children, who require special attention during decontamination.
Wound Management
References
- Medical Management of Chemical Casualties Handbook, 2nd edition, September, 1995
- Braue EH, Boardman CH. Decontamination of Chemical Casualties
- Jagminas L. CBRNE - Chemical Decontamination (eMedicine)
Support Zone
Following decontamination the patient should be reassessed; noting changes in triage category (if any), the need for or the modification of supportive therapy as well as the initiation or continuation of nerve agent specific antidotes (See ABC reminders/Advanced Treatment) .
Quickly access airway patency. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Ensure adequate respiration and pulse. Document oxygen saturation. Place on a cardiac monitor.
Link to Primary and Secondary Survey
If the patient is symptomatic, immediately institute emergency life support measures, including the use of nerve agent specific antidotes.
Advanced Treatment
In cases of respiratory compromise, secure airway and respiration via endotracheal intubation or laryngeal mask airway (LMA) (use Bag Valve Mask (BVM) if unable to secure airway). If clinically indicated, perform cricothyroidotomy or place 14 gauge intracath in the cricothryroid membrane (if equipped and trained to do so).
Link to 14 gauge intracath placement instructions.
Patients who are in cardiorespiratory failure or have seizures should be treated according to advanced life support (ALS) protocols.
Link to Basic and Advanced Life Support
Antidotes
If clinically indicated, initiate/repeat dosing of atropine and pralidoxime.
Link to Antidote Treatment in the Hot Zone
Transfer to Medical Facility
Only decontaminated patients or patients not requiring decontamination should be transported to a medical facility. "Body bags" are not recommended.
If a nerve agent containing solution has been ingested, prepare the ambulance in case the victim vomits toxic material. Have ready several towels and open plastic bags to quickly clean up and isolate.
Patients exposed to vapor who have miosis and rhinorrhea will need no care unless:
(a) They have eye or head pain or nausea and vomiting; under these circumstances topical atropine or homatropine in the eye should relieve the symptoms and the patient can be discharged within an hour or so.
(b) The rhinorrhea is very severe; under these circumstances, atropine IM (2 mg in adults and 0.05 mg/kg in children) should relieve this and the patient can be discharged in an hour or so.
Topical atropine and homatropine should not be used routinely for miosis because they cause visual impairment for about 24 hours. The patient's names, addresses, and telephone numbers should be recorded. They should be advised to seek medical care promptly if symptoms develop or recur (see Patient Information Sheet ).
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Acute Patient Care Guidelines References
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