2015 National Disaster Life Support Foundation, Inc. All

 2015 National Disaster Life Support Foundation, Inc. All

2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Session 2 Lesson Four Chemical Disasters 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Learning Objectives Identify clinical and epidemiologic clues that may suggest occurrence of chemical disaster Identify illnesses and injuries seen in chemical disasters

Describe actions to protect health, safety, and security of responders and affected populations in a chemical disaster Discuss diagnostic and treatment considerations for individuals exposed to blister/vesicant agents, choking/ pulmonary agents, asphyxiant agents, and nerve agents 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Background Chemical agents can be released by a variety of intentional or unintentional means, such as: Industrial accidents Transportation

Terrorism Senior Airman Darlene Seltmann/US Air Force 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Detection of Chemical Exposure Nature of agent or method of exposure may be unknown Each class of agent has a specific set of signs and symptoms, called a toxidrome Signs and symptoms can help determine:

Onset Present within minutes to hours of event Possible Signs/Symptoms Nausea, vomiting, diarrhea, loss of consciousness, seizures, respiratory difficulty, pupil changes, fasciculation, weakness, etc. 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Detection Situational Awareness Information gathering

Multiple 911 calls from same area Known hazards, substance leaking or spilling Time of symptom onset Foul or unusual odors present Dead animals Ensure responder safety; prevent secondary contamination 2015 National Disaster Life Support Foundation, Inc. All rights reserved.

BDLS v.3.2 Detection Detection devices may be used by HAZMAT: Multi-gas meters Oxygen sensors Chemical agent monitors When detectors are not available, responders must begin treatment based on clinical presentation 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Safety and Security Responders must utilize PPE to reduce the risk of exposure

Consider recommendation to shelter in place in contaminated areas vs evacuation Notify receiving hospitals early For the ill or injured: Remove individual from toxic area Perform decontamination

Prevent further exposure 2015 National Disaster Life Support Foundation, Inc. All rights reserved. David Valdez/FEMA BDLS v.3.2 Casualty Management: General Considerations Ingestion Injection Toxins may enter the body through one of four ways

Have high suspicion if multiple patients from same location present with same onset symptoms Different agents have different probability of secondary exposure Inhalation Absorption 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Casualty Management: Triage Considerations

Triage - often required when multiple casualties present Contamination Decontaminate prior to medical care but do not delay lifesaving intervention Triage pre and post decontamination 2015 National Disaster Life Support Foundation, Inc. All rights reserved. n o ti a n

i m a t n Injection Absorption Co Ingestion Inhalation BDLS v.3.2 Casualty Management: Assessment Cardiovascular Fast/slow heartbeat, low/high blood pressure, decreased blood flow

Skin Blistering, redness, pallor, sweating Gastrointestinal Nausea, vomiting, diarrhea Neurologic Seizures, loss of consciousness Respiratory Difficulty breathing, wheezing 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Casualty Management: Pediatric Considerations Children exposed faster and inhale more agent due to faster

breathing rate and metabolic rate Increased skin absorption due to thin skin Agents that are heavier than air more accessible due to childs size Limited ability to recognize and flee from danger 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Casualty Management: Injuries and Illnesses Agent Types Central Nervous

System Nerve, incapacitating, asphyxiant, or any agent Respiratory System Nerve, choking, blister, asphyxiant Nerve, incapacitating, asphyxiant, Circulatory System or any agent GI System Skin 2015 National Disaster Life Support Foundation, Inc. All rights reserved. Nerve, any agent Nerve, incapacitating, blister BDLS v.3.2 Casualty Management: Treatment Principles May include, in accordance with protocols, resources:

Oxygen therapy Placement of intravenous (IV) lines Anticholinergic medications/nerve agent antidotes Administration of bronchodilators Airway control - intubation if needed

Bleeding control 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Selected Chemical Agents Blister (Vesicant) Agents Choking (Pulmonary) Agents Asphyxiant (Cyanide) Agents Nerve (Organophosphate) Agents 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Selected Chemical Agents Blister (Vesicant) Chemicals that cause blisters to form on skin

Skin primary route of absorption, pulmonary and GI tract secondary route Persistent in the environment, heavier than air Types are: Lewisite: colorless, oily, smells like geraniums Mustard: oily, smells like horseradish or garlic 2015 National Disaster Life Support Foundation, Inc. All rights reserved.

BDLS v.3.2 Diagnosis of Blister Agents Eyes Itching, burning, blindness Gastrointestinal Vomiting, diarrhea Skin Blistering and erythema Respiratory Edema and sloughing of respiratory tract 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2

Treatment of Blister Agents Immediate decontamination of all exposed symptomatic AND asymptomatic Those with secondary exposure need decontamination Remove clothing, wash with soap and water or hypochlorite solution, wash exposed eyes British anti-lewisite (BAL) chelating agent used to reduce lewisite effects Overall treatment is supportive 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2

Selected Chemical Agents Choking or Pulmonary Symptoms related to water solubility Highly water soluble agents cause upper airway damage and have strong warning properties e.g., Anhydrous Ammonia Intermediate water soluble agents cause upper and lower airway damage and have moderate warning properties e.g., Chlorine Poorly water soluble agents cause lower airway damage and have poor warning properties e.g., Phosgene 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Chlorine

No specific diagnostic test Chlorine agents: Reacts with water in airways to form hydrochloric acid Bleach-like smell, irritation of nose, throat Lungs: wheezing, pulmonary edema Eyes: burning, corneal abrasions 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Phosgene No specific diagnostic test Phosgene smells like newly mown hay Initial exposure may cause mild tearing and cough or

patients may be asymptomatic Early symptoms may not indicate level of exposure Asymptomatic patients should be observed for the development of delayed pulmonary edema (up to 24 hours) 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Treatment of Choking/Pulmonary Agents No specific therapy Supportive care and remove to fresh air Patients with mucus membrane irritation should be wet decontaminated Pain

Analgesics Respiratory complaints Oxygen, Bronchodilators, Intubation PRN Eye exposure Irrigate and check pH (goal: pH 7) 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Selected Chemical Agents Asphyxiant Sources Natural occurring (e.g., peach pit) Mass produced for industrial uses Produced by combustion - wool, silk, plastics, synthetics

Prevents bodys cells from utilizing oxygen Can be ingested, inhaled, or absorbed through skin 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Selected Chemical Agents Cyanide Odor is unreliable (may be no odor) Many people cannot detect the odor (genetic) Low level: Nonspecific signs and symptoms: headache, excitement, dizziness, weakness High level: Cardiac arrhythmias, hypotension, seizures,

death 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Treatment Cyanide Agents Remove victim to fresh air quickly, use proper PPE Medications Cyanokit Hydroxocobalamin, 5 g IV Older treatments (Lilly/Pasadena kit) may still be used and consists of three drugs two given IV Amyl nitrite (inhaled) Sodium nitrite (IV) Sodium thiosulfate (IV)

Supportive treatment Oxygen 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Selected Chemical Agents Nerve Interfere with bodys ability to break down acetylcholine Major cause of death is hypoxia

Found in pesticides: diazinon and parathion Warfare agents: sarin (GB), tabun (GA), soman (GD), VX 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Detection of Nerve Agents Nerve agent detection kit Shannon Arledge/FEMA 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2

Diagnosis of Nerve Agents Detection based on toxidrome D U M B E L S iarrhea rination iosis pinpoint pupils ronchorrhea/bronchospasm mesis acrimation tearing

alivation/sweating Large inhalational dose lethal immediately Small dermal doses may have delayed effects 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Treatment of Nerve Agents Rapid control of airway intubation as needed Medications: Atropine

Pralidoxime chloride Benzodiazepines 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Lesson Summary Chemical agents Released intentionally or unintentionally

Varied time of onset Effect on children different then adults Have a high suspicion for chemical incidents 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Lesson Summary Use proper PPE Decontaminate any contaminated patient prior to medical treatment (except LSI)

Treatment plans may be guided by clinical presentations rather than identification of agent 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2 Questions? 2015 National Disaster Life Support Foundation, Inc. All rights reserved. BDLS v.3.2

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