Complete background on chemical exposures that create illnesses, including assessment, diagnosis, and treatment protocols
Written on a level that can be understood by field practitioners and/or first responders, Hazardous Materials Medicine: Treating the Chemically Injured Patient provides an in-depth understanding of how to diagnose and treat toxic chemical exposures in a prehospital or emergency department setting.
The protocols used in this book conform to the guidelines set forth in the NFPA 470 standard, and the medical guidance developed by FEMA for Type I, II & III Deployable Hazmat Response Teams. The hazardous materials medical protocols in this book have been fully vetted by three poison control toxicologists, multiple emergency physicians, and paramedics.
Hazardous Materials Medicine: Treating the Chemically Injured Patient covers sample topics such as: - Scene assessment, to help determine the cause of the exposure, and exposure assessment, to determine what physiologic systems are affected - Toxic syndromes/toxidromes to appropriately treat the exposed patient, including corrosive and irritant, asphyxiant, cholinergic, and hydrocarbon and derivative toxidromes - Science behind a chemical exposure, to allow for a complete understanding of both the chemistry and physiology of what is occurring because of the exposure - Interfacing between the on-scene response team and the hospital, to ensure consistency and continuity of care from the field into the hospital
Enabling public safety and health professionals to administer effective care while retaining their own personal safety, Hazardous Materials Medicine: Treating the Chemically Injured Patient is a must-have resource for emergency medical technicians, paramedics, hazmat technicians, and emergency physicians and nurses working in high-risk field situations with chemically injured patients.
Table of Contents
Author Biographies and Acknowledgments xvii
Foreword xxi
Preface xxiii
1 HazMat Medicine and the HazMat Medic 1
Introduction 1
Case Study - Sarin Attack in the Tokyo Subway 3
History 4
Events 7
Situational Assessment Continuum 8
Patient Presentation 9
Event Conditions (Scene Evaluation and Size- up) 9
Scene Assessment (Hazard Identification) 9
Summary 10
2 Exposures 11
Introduction 11
Case Study - Derailment in South Carolina, a No- Notice Evacuation Event 11
Patient Presentation 12
The Toxidrome Exam 14
Respiratory System 14
Overview 14
Respiratory System Anatomy and Physiology 16
External Respiratory System 16
Internal Respiratory System 19
Chemical and Physical Form of Respiratory Exposure 22
Gases, Vapors, and Fumes 22
Solid Particles 22
Aerosols/Mists 23
Concentration and Duration 23
Types of Injuries Resulting from Chemical Exposure 23
Chemically Induced Bronchiole Constriction 23
Atelectasis and Disruption of Surfactant 24
Chemically Induced Pulmonary Edema (Noncardiogenic Pulmonary Edema) 25
Chemical Sensitivity 26
Types of Chemicals that Injure the Respiratory System 26
Asphyxiants 26
Simple Asphyxiants 26
Chemical Asphyxiants 27
Irritants (Corrosives) 27
Respiratory System Injury Recognition (Assessment) and Diagnostics 27
Pulse Oximetry 27
Specific Oximetry Considerations When Assessing HazMat Exposures 28
Capnography 29
Masimo™/Rainbow Technology 32
Cardiovascular Abnormalities Related to Exposure 33
Description 33
Vasogenic Shock 33
Hypovolemic Shock 33
Heart Failure 34
Neurological Abnormalities Related to Exposure 34
Central Nervous System (CNS) Exposure 34
CNS Depression 34
CNS Stimulation 35
Parasympathetic Nervous System 35
Parasympathetic Stimulation 35
Parasympathetic Depression 36
Integumentary System (Skin) 36
Skin Anatomy and Physiology 36
Structure 37
Function 38
Types of Chemical Injuries to the Skin 38
Chemical- Related Irritation 38
Chemical Skin Burns 39
Ocular Exposure and Injury 41
Eye Anatomy and Physiology 42
The Globe 42
The Ocular Surface 42
Assessment of Eye Injury After Exposure 43
Normal Eye Assessment 44
Chemical Eye Burns 45
Surface Toxins 46
Treatment of Eye Exposure 48
Specialized Eye Equipment 49
The Morgan Lens 49
Nasal Cannula for Eye Irrigation 51
Gastrointestinal Exposure to Toxic Materials 51
Absorbing Chemicals and Nutrients 51
Liver 51
Phase I and II Detoxification 52
Environmental Exposures 53
The Hot Environment - Hydration and Hyperthermia 53
Physiology 54
Absorption of Water 55
Acclimation 57
Metabolic Thermoregulation 58
Determining Severity of Heat 60
Effects of Heat in an Encapsulated Suit 60
Factors Contributing to Heat Emergencies/Injuries 62
Treatment 63
The Cold Environment 64
Exposure to Liquefied Gas and Cryogenics 64
Frostbite Injuries 65
Assessment 66
Treatment 67
Summary 67
3 Toxidromes 69
Introduction 69
Case Study - Silver Cyanide Exposure 69
Assessment Capabilities 70
Blood Pressure 70
Increase in Blood Pressure 71
Decrease in Blood Pressure 71
Pulse 72
Toxidromes 72
Corrosives and Irritants Toxidromes 72
Chlorine (Cl 2) 72
Agent Identification 72
History 73
Pathophysiology 73
Signs and Symptoms 73
Where Is Chlorine Found 74
Decontamination 75
Emergency Field Treatment 75
Basic Life Support 75
Advanced Life Support 75
Ammonia (NH 3) 76
Agent Identification 76
History 76
Physiology 76
Signs and Symptoms 76
Where Is Ammonia Found 77
Decontamination 77
Emergency Field Treatment 77
Assessment/Treatment 77
Basic Life Support 77
Advanced Life Support 77
Phosgene, aka. Carbonyl Chloride 78
Agent Identification 78
History 78
Physiology, Signs, and Symptoms 78
Where Phosgene Is Found 78
Decontamination 79
Emergency Field Treatment (Chloramine, Ammonia, and Phosgene) 79
Basic Life Support 79
Advanced Life Support 79
Pediatric Considerations (Chlorine, Chloramine, Ammonia, Phosgene) 80
Hydrofluoric Acid and Fluorine- Based Chemicals 80
History 80
Pathophysiology 80
Signs and Symptoms of Exposure 82
Where Hydrofluoric Acid Is Commonly Found 82
Decontamination and Significant Danger to Rescuers 83
Treatment 83
Eye Injury Treatment (Hydrofluoric Acid) 83
Skin Burn Treatment (Hydrofluoric Acid) 84
Respiratory Injury Treatment (Hydrofluoric Acid) 84
Systemic Injury from Hydrofluoric Acid (Hypocalcemia) 85
Phenol (Carbolic Acid) 85
History 85
Pathophysiology, Signs, and Symptoms 86
Where Phenol Is Commonly Found 86
Field Treatment and Decontamination 87
Assessment/Treatment or Phenol 87
Lacrimatory Agent Exposure 87
Chemical Currently Being Used 88
Effect 88
Treatment 88
Asphyxiant Toxidromes 89
Effects of Hypoxia 90
Simple Asphyxiants 92
Experience; Death at McDonald’s: “Five Lousy Feet” 93
Assessment/Treatment for Simple Asphyxiants 93
Chemical Asphyxiants 93
Carbon Monoxide Poisoning 93
History 94
Pathophysiology 94
Concerns 96
Signs and Symptoms 97
Where Carbon Monoxide Is Typically Found 98
Decontamination and Danger to Responders 98
Field Treatment 98
Cyanide Poisoning - Hydrogen Cyanide, Cyanide Salts, and Cyanide Containing Gases 99
History 100
Pathophysiology 101
Signs and Symptoms 102
Definitive Diagnosis 103
Where Cyanide Is Commonly Found 103
Decontamination of Patients 104
Emergency Medical Field Treatment 104
CyanoKit - Hydroxocobalamin (Preferred Treatment for Cyanide Poisoning) 105
(Lily or Pasadena) Nitrite- Based Cyanide Antidote Kit (Used for hydrogen sulfide or (Cyanide if the CyanoKit Is Not Available) 106
Hydrogen Sulfide Poisoning 106
History 107
Pathophysiology 107
Signs and Symptoms 108
Where Hydrogen Sulfide Is Commonly Found 108
Decontamination and Significant Danger to Rescuers 108
Field Treatment 108
Definitive Treatment and Follow- up Care 109
Nitrites, Nitrates, Nitrobenzene Poisoning 109
History 109
Pathophysiology 110
Signs and Symptoms 111
Where Are Nitrogen Compounds Found 111
Field Treatment 112
Cholinergic Toxidrome 113
Organophosphate Insecticide Poisoning 113
Experience: Novichok Nerve Agent Used Against Russian Dissident Has Dark History 114
Experience: Tokyo Subway, Site of an Attack Using Sarin Nerve Agent 115
Pathophysiology 115
Signs and Symptoms 116
Location of Organophosphate Insecticides 117
Decontamination and Significant Danger to Rescuers 117
Treatment 118
Experience: Malathion Overdose Treated Without Protopam 119
Treatment 119
Carbamate Poisoning 121
Treatment 121
Hydrocarbons and Derivatives Toxidrome 122
Hydrocarbon Toxicity 122
Pathophysiology 123
Cardiac Effects 124
CNS Effects 124
Emergency Medical Care 124
Signs and Symptoms 124
Treatment 125
Toxic Alcohols 127
Treatment 127
Etiological Toxidrome 127
Overview 127
Vancomycin- Resistant Enterococci (VRE) 130
Symptoms 130
Diagnosis 130
Treatment 130
Methicillin- Resistant Staphylococcus aureus (MRSA) 130
Pathophysiology 131
Signs and symptoms 131
Treatment 131
Clostridium Difficile (C. Difficile) 131
Overview 131
Symptoms 132
Other Risk Factors 132
Complications from C. Difficile Include 132
Prevention 132
Necrotizing Fasciitis 133
Overview 133
Symptoms 133
Cause 133
Treatment 133
Means of Entry 133
Virulence 134
Exposure 134
Radiological Toxidrome 135
Overview 135
Types of Radiation 136
Alpha Particles 136
Beta Particles 136
Gamma Rays 137
Neutrons 137
X- Rays 137
Measuring Radioactivity 137
Principles of Protection 139
Location of Radiation and Common Sites for Accidents 140
Types of Injuries 140
Rescue and Emergency Treatment 142
Treatment 143
Associated Toxic Conditions 144
Closed Space Fires 144
History 144
Fire Toxicology 145
Danger to Firefighters 147
Treatment 147
Wheezing Secondary to Toxic Inhalation 149
Overview 149
Tachycardia Secondary to Chemical Exposure 150
Hypotension Caused by Exposure 151
Seizures Post- Exposure 151
Opioids Overdose/Exposure 152
History 152
Opium Alkaloids 152
Synthetic Opioids 153
Semisynthetic Opioids 153
Today’s Fentanyl and Carfentanil 154
Signs and Symptoms 154
Summary 155
Reference 156
4 Event Conditions 157
Introduction 157
Case Study - Fertilizer Explosion in West Texas 158
Operational Hazards 159
Dispatch Information 159
Scene Safety 160
Upon Arrival - Stop, Look, and Listen 162
Weather Conditions 162
Witnesses Accounts 163
Risk Awareness 163
The North American Emergency Response Guidebook (ERG) 173
NIOSH Pocket Guide 175
Cameo 176
Marplot 177
Aloha 177
Wiser 177
ToxNet and the Hazardous Substance Database 177
Resources 178
Summary 178
5 Hazard Identification 181
Introduction 181
Case Study - Phosgene Exposure 182
States of Matter 182
Solid 184
Liquids 186
Vapors and Gases 186
Mists and Aerosols 186
Gases 186
Compressed Gas 186
Liquified Gas 186
Cryogenic Gas 187
Chemical and Physical Properties 187
Chemical Properties 188
pH (Corrosivity) 188
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Ignition Temperature (IT) 188
Flashpoint (FP) 188
Heat Transfer 188
Physical Properties 188
Appearance 189
Viscosity 189
Melting Point (MP) 189
Freezing Point (FrPt) 189
Boiling Point (BP) 189
Flammable Range 190
Density 190
Specific Gravity (SG) 190
Vapor Density (VD) 191
Vapor Pressure (VP) 192
Expansion Ratios 193
Properties and Their Medical Implications 193
Vapor Pressure, Medical Implications 194
Vapor Density, Medical Implications 195
Specific Gravity, Medical Implications 195
Solubility, Medical Implications 195
History of Toxicology 196
Exposure vs. Contamination 197
Toxin vs. Poison 198
Toxicity of a Poison or Toxin 198
Standards, Guidelines, and Acts Regulating Hazardous Materials 200
NFPA and OSHA 200
Environmental Protection Agency (EPA) 200
Time Weighted Average 201
Short- Term Exposure Limits (STELs) 201
Immediately Dangerous to Life and Health (IDLH) 201
Control Banding 203
Basic Toxicology Definitions 205
Acute Exposure 206
Sub- Chronic/Sub- Acute 208
Chronic Exposure 209
Noel, Noael, Loael 209
Levels of Concern 210
Dose Response and Exposure 210
Graded Response 211
Quantal Response 211
Response Curve 212
Lethal Concentrations and Lethal Doses 213
Chemical Time lines 214
Additional Toxic Effects 216
Toxic Influences 217
General Health 217
Diet 217
Previous Exposure 218
Age 218
Gender 219
Genetics 220
Sleep 220
Biochemistry 221
Detoxification 221
Phase I and Phase II Reactions 221
Detoxification by the Lungs 224
Chemical Toxic Qualities 224
Chemical Excretion 225
Nanotoxicology 225
Determining the Level of Medical Surveillance 226
Risk Assessment and Detection 226
Identification of Hazards 227
Assess Hazards to Determine the Risks 227
Develop Controls to Manage the Risks 227
Implementing Controls 227
Supervise and Evaluate the Process 228
Summary 230
6 Team Capabilities 231
Introduction 231
Case Study - Sodium Nitrate Overdose 231
Technician Operational Considerations 232
Personnel Protective Equipment (PPE) 232
Rehabilitation 235
Decontamination 236
Occupational Safety and Health Administration 237
National Fire Protection Association 237
Environmental Protection Agency 237
Science Behind Decontamination 237
Types of Decontamination 239
Gross Decontamination 239
Secondary Decontamination 240
Tertiary Decontamination 240
Emergency Decontamination 240
Techniques 240
Physical Decontamination 241
Factors to Consider During Decontamination 241
Equipment Uses 242
Choosing a Decontamination Site Location 243
Detection and Monitoring 243
The Approach 244
The System of Detection 245
Radiation 246
pH 247
Oxygen 247
Organic Compounds 247
Biologicals 249
Detection and Monitoring Responses 249
Current Detection Technologies 250
Radiation Detectors 250
pH Paper and Impregnated Papers 252
KI Paper or Oxidizer Paper 252
Wet Chemistry 252
Electrochemical Sensors 253
Catalytic Bead 253
Colorimetric Tubes 254
Photoionization Detection (PID) 254
Flame Ionization Detection (FID) 255
Ion Mobility Spectroscopy (IMS) 255
Infrared Spectroscopy (FT- IR) 256
Raman Spectroscopy 256
Positive Protein 257
Handheld Immunoassay (HHA) 257
Polymerase Chain Reaction (PCR) 258
Mass Causality Incidents 259
Triage Considerations (Non- START Triage) 259
Stilp and Bevelacqua Exposure Score 259
Cardiovascular 260
Breathing (Respiratory) 261
Rx - Immediate Basic Treatment 261
Neurological 261
Mass Decontamination 261
Initial Operations 261
HazMat Alert 262
Hospital Interface 263
Casualty Collection Points (Field Treatment Site) 266
Temporary Medical Care Units (Alternate Care Facilities) 266
The Medical Reserve Corp 266
Hospital Decontamination Considerations 268
PPE in the Hospital Environment 268
Hospital Isolation Rooms 269
Notification and Preparation 269
Hospital Scenario Possibilities 270
Hospital Decontamination Corridor 271
Hospital Decontamination Sequence Model 272
Summary 274
7 HazMat Safety Officer 275
Introduction 275
Case Study - Lieutenant Dan 275
Medical Assessment 276
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Medical Surveillance 278
Initial Baseline Physical and Annual Physical 279
Pre- Entry Physical 281
Considerations of the Entrance Physical 283
Post- Entry Physicals 285
Use of Findings 286
Preventive Health Screening 288
Post- Exposure Physicals 288
Biological Monitoring 289
Team Exit and Retirement Physicals 290
Program Review 290
ADA, Civil Rights, and Health Insurance Portability and Accountability Act (hipaa) 290
Critical Incident Stress Debriefing 291
Developing a Medical Surveillance Program 293
Summary 294
8 Terrorism 297
Introduction 297
Case Study - Salmonella Salad Bar 298
Terrorism Using Chemical Warfare Agents 299
Nerve Agents (Cholinergic Toxidrome) 299
Military Nerve Agents 299
Physical Properties and Routes of Entry 300
Decontamination 301
Treatment 301
Blood Agents - Asphyxiants Toxidrome 301
Military Blood Agents 301
Physiology 302
Physical Properties and Routes of Entry of Cyanide Agents 302
Decontamination 302
Treatment 302
Choking Agents - Irritant Gas Toxidrome 302
Military Choking Agents 303
Physiology of Respiratory Irritant Injury 304
Physical Properties and Routes of Entry 304
Decontamination 304
Treatment 304
Vesicants - Corrosive Toxidrome (Military Blister Agents) 305
Military Blister Agents (Vesicants) 305
Physiology of Blister Agent Exposure 306
Physical Properties and Routes of Entry 306
Decontamination 306
Treatment 306
Lacrimators (Riot Control Agents) 306
CN and CS 307
Oc 307
Decontamination 307
Treatment 308
Terrorism Using Biological Agents 308
Bacteria 308
Viruses 309
Biological Toxins 309
Bacterial Agents 309
Anthrax (B. anthracis) 309
Cholera (Vibrio cholerae) 310
Pneumonic/Bubonic Plague (Y. pestis) 310
Tularemia (F. tularensis) 311
Q Fever (Coxiella burnetii rickettsia) 311
Salmonellae (Salmonella typhimurium) 311
Viral Agents 312
Smallpox (Variola virus) 312
Venezuelan Equine Encephalitis (VEE) 312
Viral Hemorrhagic Fevers (VHFs) 313
Biological Toxins 313
Botulinum Toxin 313
Staphylococcal Enterotoxin B (SEB) 314
Ricin 315
Trichothecene Mycotoxins (T2) 315
Explosives and Incendiary Devices 316
Bomb Incidents 316
Anatomy of Explosives 316
Expected Effects from Explosions 317
Physiology of Blast Effects 318
Blast Effects 318
Summary 320
Epilogue 323
Index 325
