Hazardous Materials Medicine Treating the Chemically Injured Patient

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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