Hazardous Materials Medicine Treating the Chemically Injured Patient
, by Stilp, Richard; Bevelacqua, Armando- ISBN: 9781119663928 | 111966392X
- Cover: Hardcover
- Copyright: 5/9/2023
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.
Richard H. Stilp MA, RN started his career in the fire service in 1976 and has worked in many positions in the fire service including firefighter/paramedic, engineer, lieutenant, district chief, and fire chief. During his career he served as a paramedic program chair for a local college, emergency department registered nurse, executive director of the fire academy, worked in administration for a large hospital system.
Armando S. Bevelacqua is a 38 year veteran of the fire service, writes free-lance, publishing articles, instructional materials and educational textbooks in the field of hazmat response. Has served during the course of his career as a firefighter-paramedic, HazMat technician, High Angle rescue, below grade rescue, Dive rescue, chief officer and flight medic.
Author Bios and Acknowledgements 15
Richard’s Biographical Information 15
Acknowledgements: 15
Armando’s Biographical Information 17
Acknowledgements: 18
Preface 22
Forward 25
Chapter 1 – HazMat Medicine and the HazMat Medic 27
Introduction 27
Case Study – Sarin Attack in the Tokyo Subway 31
History 33
Events 38
Confidence Cycle (Situational Assessment Continuum) 39
Patient Presentation 41
Event Conditions (Scene evaluation and size-up) 41
Scene Assessment 41
Summary 42
Chapter 2 – Exposures 44
Introduction 44
Case Study – Derailment in South Carolina, A No-Notice Evacuation Event 45
Patient Presentation 46
The Toxidrome Exam 48
Respiratory System 50
Overview 50
Respiratory System Anatomy and Physiology 51
External Respiratory System 51
Internal Respiratory System 55
Chemical and Physical Form of Respiratory Exposure 59
Gases, Vapors, and Fumes 59
Solid Particles 60
Aerosols/Mists 61
Concentration and Duration 61
Types of Injuries Resulting from Chemical Exposure 62
Chemically Induced Bronchiole Constriction 62
Atelectasis and Disruption of Surfactant 63
Chemically Induced Pulmonary Edema (Noncardiogenic Pulmonary Edema) 64
Chemical Sensitivity 65
Types of Chemicals That Injure the Respiratory System 66
Asphyxiants 66
Simple Asphyxiants 66
Chemical Asphyxiants 67
Irritants (corrosives) 67
Respiratory System Injury Recognition (Assessment) and Diagnostics 68
Pulse Oximetry 68
Specific Oximetry Considerations When Assessing HazMat Exposures 70
Capnography 71
Masimo/Rainbow Technology 75
Cardiovascular Abnormalities Related to Exposure 76
Description 76
Vasogenic Shock 77
Hypovolemic Shock 77
Heart Failure 78
Neurological Abnormalities Related to Exposure 80
Central Nervous System (CNS) Exposure 80
CNS Depression 80
CNS Stimulation 81
Parasympathetic Nervous System 82
Parasympathetic Stimulation 82
Parasympathetic Depression 82
Integumentary System (Skin) 83
Skin Anatomy and Physiology 83
Structure 84
Function 86
Types of Chemical Injuries to the Skin 86
Chemical Related Irritation 86
Chemical Skin Burns 87
Ocular Exposure and Injury 92
Eye Anatomy and Physiology 93
The Globe 93
The Ocular Surface 93
Assessment of Eye Injury After Exposure 96
Normal Eye Assessment 96
Chemical Eye Burns 98
Surface Toxins 99
Treatment of Eye Exposure 104
Specialized Eye Equipment 105
The Morgan Lens 105
Nasal Cannula for Eye Irrigation 107
Gastrointestinal Exposure to Toxic Materials 108
Absorbing Chemicals and Nutrients 108
Liver 109
Phase I and II Detoxification 110
Environmental Exposures 112
The Hot Environment – Hydration and Hyperthermia 112
Physiology 113
Absorption of Water 115
Acclimation 119
Metabolic Thermoregulation 120
Determining Severity of Heat 122
Effects of Heat in an Encapsulated Suit 124
Factors Contributing to Heat Emergencies/Injuries 126
Treatment 129
The Cold Environment 132
Exposure to Liquefied Gas and Cryogenics 132
Frostbite Injuries 133
Assessment 135
Treatment 136
Summary 136
Chapter 3 – Toxidromes 138
Introduction 138
Case Study – Silvery Cyanide Exposure 139
Assessment Capabilities 140
Blood Pressure 140
Pulse 142
Toxidromes 143
Corrosives and Irritants Toxidromes 143
Chlorine (Cl2) 143
Agent Identification 143
History 144
Pathophysiology 145
Signs and Symptoms 145
Where is Chlorine found 146
Decontamination 147
Emergency Field Treatment 147
Ammonia (NH3) 148
Agent Identification 148
History 148
Physiology 149
Signs and Symptoms 149
Where is Ammonia found 150
Decontamination 150
Emergency Field Treatment 150
Hydrofluoric Acid and Fluorine Based Chemicals 154
History 155
Experience; Hydrofluoric Acid Spill 155
Pathophysiology 155
Signs and Symptoms of Exposure 157
Where Hydrofluoric Acid is Commonly Found 159
Decontamination and Significant Danger to Rescuers 159
Treatment 159
Eye Injury Treatment (hydrofluoric acid) 160
Skin Burn Treatment (hydrofluoric acid) 161
Respiratory Injury Treatment (hydrofluoric acid) 162
Systemic Injury from hydrofluoric acid (hypocalcemia) 162
Phenol (Carbolic Acid) 164
History 164
Pathophysiology, Signs, and Symptoms 165
Where Phenol is Commonly Found 166
Field Treatment and Decontamination 166
Assessment/Treatment or Phenol: 167
Pediatric Considerations (Phenol) 167
Lacrimatory Agent Exposure 167
Chemical Currently Being Used: 168
Effect 168
Treatment 169
Asphyxiant Toxidromes 171
Effects of Hypoxia 171
Simple Asphyxiants 174
Experience; Death at McDonald's: "Five Lousy Feet" 174
Assessment/Treatment for Simple Asphyxiants: 174
Chemical Asphyxiants 175
Carbon Monoxide Poisoning 176
History 176
Pathophysiology 177
Concerns 181
Signs and Symptoms 181
Where Carbon Monoxide is Typically Found 183
Decontamination and Danger to Responders 184
Field Treatment 184
Cyanide Poisoning - Hydrogen Cyanide, Cyanide Salts, and Cyanide Containing Gases 186
History 187
Pathophysiology 188
Signs and Symptoms 190
Definitive Diagnosis 191
Where Cyanide is Commonly Found 192
Decontamination of Patients 194
Emergency Medical Field Treatment 194
Hydrogen Sulfide Poisoning 198
History 198
Pathophysiology 199
Signs and Symptoms 200
Where Hydrogen Sulfide is Commonly Found 201
Decontamination and Significant Danger to Rescuers 201
Field Treatment 202
Definitive Treatment and Follow-up Care 203
Nitrites, Nitrates, Nitrobenzene Poisoning 203
History 203
Pathophysiology 204
Signs and Symptoms 206
Where are Nitrogen Compounds Found 207
Field Treatment 208
Cholinergic Toxidrome 210
Organophosphate Insecticide Poisoning 210
Experience: Novichok Nerve Agent Used Against Russian Dissident has Dark History 212
Experience; Tokyo Subway, site of an attack using Sarin Nerve Agent 213
Pathophysiology 214
Signs and Symptoms 216
Location of Organophosphate Insecticides 217
Decontamination and Significant Danger to Rescuers 217
Treatment 219
Experience: Malathion Overdose Treated without Protopam 221
Treatment 221
Carbamate Poisoning 224
Treatment 225
Hydrocarbons and Derivatives Toxidrome 227
Hydrocarbon Toxicity 227
Pathophysiology 228
Cardiac Effects 229
CNS Effects 229
Emergency Medical Care 230
Signs and Symptoms 230
Treatment 231
Toxic Alcohols 234
Treatment 235
Etilogical Toxidrome 236
Overview 236
Vancomycin-resistant enterococci (VRE) 239
Symptoms 239
Diagnosis 239
Treatment 240
Methicillin-resistant Staphylococcus aureus (MRSA) 240
Pathophysiology 240
Signs and symptoms 241
Treatment 241
Clostridium difficle (C. Diff) 241
Overview 241
Symptoms 242
Other risk factors 243
Complications from C. difficile include 243
Prevention 243
Necrotizing Fasciitis 243
Overview 243
Symptoms 244
Cause 244
Treatment 244
Means of Entry 245
Virulence 246
Exposure 246
Radiological Toxidrome 248
Overview 248
Types of Radiation 249
Alpha Particles 249
Beta Particles 249
Gamma Rays 250
Neutrons 250
X-Rays 251
Measuring Radioactivity 251
Principles of Protection 252
Location of Radiation and Common Sites for Accidents 254
Types of Injuries 255
Rescue and Emergency Treatment 258
Treatment 260
Associated Toxic Conditions 261
Closed Space Fires 261
History 261
Fire Toxicology 263
Danger to Firefighters 266
Treatment 267
Wheezing Secondary to Toxic Inhalation 270
Overview 270
Tachycardia Secondary to Chemical Exposure 272
Hypotension Caused by Exposure 273
Seizures Post Exposure 274
Opioids Overdose/Exposure 275
History 276
Opium Alkaloids 276
Synthetic Opioids 277
Semisynthetic Opioids 278
Today’s Fentanyl and Carfentanil 278
Signs and Symptoms 280
Summary 281
Chapter 4 – Event Conditions 283
Introduction 283
Case Study – Fertilizer Explosion in West Texas 285
Operational Hazards 287
Dispatch Information 287
Scene Safety 289
Upon Arrival – Stop, Look, and Listen 293
Weather Conditions 293
Witnesses Accounts 295
Risk Awareness 296
Containers, Shape, and sizes 296
Placards and Label 297
NFPA 704 Placard 304
Hazardous Materials Identification System (HMIS) 305
Shipping Papers and Facility Documents 305
Reference Materials 307
The North American Emergency Response Guidebook (ERG) 307
NIOSH Pocket Guide 311
CAMEO 312
MARPLOT 313
ALOHA 314
WISER 314
ToxNet and the Hazardous Substance Database 315
Resources 316
Summary 317
Chapter 5 – Hazard Identification 318
Introduction 318
Case Study - Phosgene Exposure 319
States of Matter 321
Solid 322
Fumes 323
Liquids 323
Vapors and Gases 324
Mists and Aerosols 324
Gases 324
Compressed gas 324
Liquified gas 324
Cryogenic gas 325
Chemical and Physical Properties 325
Chemical properties 326
pH (Corrosivity) 326
Flammable range 327
Ignition temperature (IT) 328
Flashpoint (FP) 328
Heat transfer 328
Physical Properties 329
Appearance 329
Viscosity 329
Melting point (MP) 330
Freezing point (FrPt) 330
Boiling point (BP) 330
Density 331
Specific gravity (SG) 331
Vapor density (VD) 332
Vapor pressure (VP) 335
Expansion ratios 336
Properties and their medical implications 336
Vapor Pressure, medical implications 337
Vapor Density, medical implications 339
Specific Gravity, medical implications 339
Solubility, medical implications 340
History of Toxicology 341
Exposure vs. Contamination 343
Toxin vs. Poison 344
Toxicity of a Poison or Toxin 344
Standards, Guidelines, and Acts Regulating Hazardous Materials 348
NFPA and OSHA 348
Environmental Protection Agency (EPA) 348
Basic Toxicology Definitions 356
Acute Exposure 358
Sub-chronic/Sub-acute 362
Chronic Exposure 363
NOEL, NOAEL, LOAEL 365
Levels of Concern 366
Dose Response and Exposure 367
Detoxification 386
Phase I and Phase II Reactions 386
Detoxification by the Lungs 390
Chemical Toxic Qualities 391
Chemical Excretion 393
Nanotoxicology 394
Determining the Level of Medical Surveillance 395
Risk Assessment and Detection 396
Identification of Hazards 396
Assess Hazards to Determine the Risks 397
Develop Controls to Manage the Risks 397
Supervise and Evaluate the Process 398
Summary 401
Chapter 6 – Team Capabilities 403
Introduction 403
Case Study – Sodium Nitrate Overdose 403
Technician Operational Considerations 405
Personnel Protective Equipment (PPE) 405
Rehabilitation 411
Decontamination 411
Science Behind Decontamination 412
Types of Decontamination 416
Gross Decontamination 416
Secondary Decontamination 416
Tertiary Decontamination 417
Emergency Decontamination 417
Techniques 417
Physical Decontamination 418
Factors to Consider During Decontamination 418
Equipment uses 421
Choosing a Decontamination Site Location 421
Detection and Monitoring 421
The Approach 424
The System of Detection 427
Radiation 427
pH 428
Petroleum/Hydrocarbons 429
Oxygen 429
Organic Compounds 430
Additional Monitoring schemes for chained nonpolar organic chemicals 432
Biologicals 432
Detection and Monitoring 432
Current Detection Technologies 435
Radiation Detectors 435
pH Paper and Impregnated Papers 437
KI Paper or Oxidizer Paper 437
Wet Chemistry 438
Electrochemical Sensors 438
Catalytic Bead 439
Colorimetric Tubes 440
Photoionization Detection (PID) 441
Flame Ionization Detection (FID) 442
Ion Mobility Spectroscopy (IMS) 443
Infrared Spectroscopy (FT-IR) 444
Raman Spectroscopy 445
Positive Protein 445
Handheld Immunoassay (HHA) 446
Polymerase Chain Reaction (PCR) 447
Mass Causality Incidents 448
Triage Considerations (Non-START Triage) 448
Bevelacqua & Stilp Exposure Score 449
Cardiovascular 451
Breathing (Respiratory) 451
Rx – Immediate Basic Treatment 452
Neurological 452
Mass Decontamination 452
Initial Operations 452
HazMat Alert 454
Hospital Interface 455
Casualty Collection Points 459
Temporary Medical Care Units (Alternate Care Facilities) 459
The Medical Reserve Corp 460
Hospital Decontamination Considerations 460
PPE in the Hospital Environment 462
Hospital Isolation Rooms 463
Notification and Preparation 464
Hospital Scenario Possibilities 465
Hospital Decontamination Corridor 466
Hospital Decontamination Sequence Model 467
Summary 471
Chapter 7 – HazMat Safety Officer 473
Introduction 473
Case Study – Lieutenant Dan 474
Medical Assessment 475
Medical Surveillance 478
Initial Baseline Physical and Annual Physical 479
Pre-Entry Physical 482
Considerations of the Entrance Physical 484
Post Entry Physicals 489
Use of Findings 491
Preventive Health Screening 493
Post Exposure Physicals 494
Biological Monitoring 495
Team Exit and Retirement Physicals 496
Program Review 497
ADA, civil rights, and Health Insurance Portability and Accountability Act (HIPPA) 497
Critical Incident Stress Debriefing 498
Developing a Medical Surveillance Program 502
Summary 505
Chapter 8 – Terrorism 507
Introduction 507
Case Study – Salmonella Salad Bar 508
Terrorism using Chemical Warfare Agents 510
Nerve Agents (Cholinergic Toxidrome) 510
Military Nerve Agents 511
Blood Agents – Asphyxiants Toxidrome 513
Military Blood Agents 514
Choking Agents – Irritant Gas Toxidrome 516
Military Choking Agents 517
Vesicants – Corrosive Toxidrome (Military Blister Agents) 520
Military Blister Agents (Vesicants) 520
Lacrimators (Riot Control Agents) 523
Terrorism using Biological Agents 525
Bacteria 526
Viruses 526
Biological Toxins 527
Bacterial Agents 527
Anthrax (Bacillus anthracis) 527
Cholera (Vibrio cholerae) 528
Pneumonic/Bubonic Plague (Yersinia pestis) 529
Tularemia (Francisella tularensis) 529
Q Fever (Coxiella burnetii rickettsia) 530
Salmonellae (Salmonella typhimurium) 531
Viral Agents 531
Smallpox (Variola virus) 531
Venezuelan Equine Encephalitis (VEE) 532
Viral Hemorrhagic Fevers (VHFs) 533
Biological Toxins 534
Botulinum Toxin 534
Staphylococcal Enterotoxin B (SEB) 536
Ricin 537
Trichothecene Mycotoxins (T2) 538
Explosives and Incendiary Devices 539
Bomb Incidents 539
Anatomy of Explosives 539
Expected Effects from Explosions 541
Summary 543
Epilogue 546
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