FIGURE 132.3 Approach to the recognition and diagnosis of an attack with an unknown chemical agent FIGURE 132.4 A fixed, indoor decontamination facility, contiguous with, but structurally separate from, the main ED A : The external entrance from the ambulance bay B : Three parallel lanes to provide capacity for both ambulatory and nonambulatory victims (Courtesy of Tony Van Dyke and Michael Goldberg, Department of Environmental Health and Safety, Children’s Hospital of Philadelphia, Philadelphia, PA.) Decontamination of casualties contaminated with chemical agents should occur as soon as possible Chemical agents, particularly liquid nerve agents and vesicants as either liquids or vapors, can be absorbed through intact skin within a few minutes Although the effects of percutaneously absorbed chemical agents may not appear for minutes to hours, tissue damage from vesicants occurs within a few minutes, and agent that penetrates the skin is far less amenable to decontamination than the agent that has not yet been absorbed Patient decontamination has two important purposes: prevention or minimization of continuing absorption of agent into the patient and prevention of secondary exposure of healthcare workers By preventing absorption of a lethal dose of agent, immediate decontamination can be the most important lifesaving action available for a chemical casualty This process would ideally occur at the scene; however, in a large-scale terrorist incident, it is far more likely that some victims will self-transport to the ED A special decontamination and treatment area in the decontamination corridor outside or adjacent to the ED markedly facilitates casualty processing and management, and accreditation agencies have mandated that all hospitals provide such decontamination capacity FIGURE 132.5 A rapidly deployable outdoor decontamination facility Capability for thorough decontamination must be available quickly with little setup time Many models have been proposed, but most authorities recommend an outdoor facility with multiple patient stations, arranged so that parallel lines of ambulatory and nonambulatory patients may be processed simultaneously ( Fig 132.5 ) An outdoor facility is more capable of handling multiple patients and may make the use of copious water irrigation easier; however, it may be challenging to protect victims from inclement weather in temperate climate zones, an issue especially important in the management of young children Thus, an outdoor facility must provide adequate water, temperature control, and curtains separating shower lines for males and females An alternative might be the use of a facility that is enclosed, and adjacent to, but separate structurally from, the main ED, with a separate and high-volume ventilation system vented directly outdoors ( Fig 132.4 ) Optimally, the surface of the decontamination facility would allow drainage, minimizing risk of patients slipping and falling and risk of further exposure to contaminated rinse water Young children requiring assistance may be accompanied by parents if they are contaminated, as well Older ambulatory patients can be instructed in self-decontamination Decontamination efforts should stress physical and mechanical removal over chemical decontamination For vapor-exposed patients, decontamination is effected primarily by clothing removal and hair washing with soap and water In contrast, those patients with liquid dermal exposure require disrobing and thorough skin decontamination Agent on their skin or in their clothing poses a serious threat to ED personnel Clothing must be carefully removed and double bagged Patients with ocular exposure require copious eye irrigation with saline or water Skin and hair should be washed thoroughly with soap and tepid water Previously, some authorities have recommended 0.5% sodium hypochlorite (dilute bleach) for skin decontamination of nerve agents and vesicants However, even dilute bleach may be a skin irritant, thus increasing permeability to agent, and application is time-consuming and not proven superior to copious soap and water washing A decontaminant that is now the standard for U.S military field use is reactive skin decontamination lotion (RSDL), which is packaged as a lotion-impregnated sponge and acts by both physical removal and also neutralization of chemical agents RSDL is orders of magnitude superior to standard decontamination methods and is particularly useful for immediate (local, or “spot”) skin decontamination; the FDA has not yet approved it for whole-body decontamination or use in eyes or wounds FIGURE 132.6 The pediatric emergency care provider is garbed in appropriate level C personal protective equipment OSHA provides a list of suggested PPE for healthcare workers to use in the warm zone Most authorities believe that adequate protection for ED staff is afforded by Level C PPE, which consists of a nonencapsulated chemically resistant body suit, gloves, and boots, with a full-face air-purifying mask containing a cartridge with both an organic-vapor filter for chemical gases and vapors and a HEPA filter to trap aerosols of biologic and chemical agents ( Fig 132.6 ) Such PPE is much less cumbersome to work in than level A or B outfits (which use self-contained breathing apparatus) and is much less expensive Finally, current guidelines from the Environmental Protection Agency (EPA) and from The Joint Commission stress that a plan for disposal of contaminated waste needs to be put into place by hospitals as part of their preparation for an event CLINICAL ASSESSMENT AND MANAGEMENT Specific Agents Nerve Agents CLINICAL PEARLS AND PITFALLS ... yet approved it for whole-body decontamination or use in eyes or wounds FIGURE 132.6 The pediatric emergency care provider is garbed in appropriate level C personal protective equipment OSHA