The Citadel Chemical Contamination Questions

DISASTER MEDICINE/CONCEPTS Emergency Department Hazardous Materials Protocol for Contaminated Patients From the Occupational and Environmental Health Unit, University of Arizona Prevention Center,* Tucson, AZ; the Indiana Poison Center,‡ Indianapolis, IN; the Medical and Toxicological Intensive Care Unit, Hôpital Larioboisière, Paris, France, and the International Toxicology Consultants LLC, Washington DC§; and the Department of Emergency Medicine, Medical College of Virginia,II Richmond, VA. Jefferey L Burgess, MD, MPH* Mark Kirk, MD‡ Stephen W Borron, MD, MS§ James Cisek, MDII Received for publication August 29, 1997. Revisions received May 27, 1998, and February 22, 1999. Accepted for publication March 2, 1999. Address for reprints: Jefferey L Burgess, MD, MS, MPH, Occupational and Environmental Health Unit, University of Arizona Prevention Center, 1435 North Fremont, Box 210468, Tucson, AZ 85719-4197. Copyright © 1999 by the American College of Emergency Physicians. 0196-0644/99/$8.00 + 0 47/1/98455 See editorial, p. 223. Emergency department handling and treatment of chemically contaminated patients can have potentially serious consequences. Medical staff can be exposed to hazardous chemicals through dermal contact or inhalation of volatile compounds or particulate matter. Exposure can result in symptomatic illness from either a direct chemical toxic effect or an odor-mediated psychologic response. Either situation can severely affect ED function and lead to facility evacuation. The Joint Commission on Accreditation of Healthcare Organizations standards and the Occupational Safety and Health Administration regulations for participation in community hazardous materials incident emergency response plans require hospital EDs to prepare for hazardous materials incidents. This study provides a template protocol for ED preparation for and treatment of patients exposed to hazardous materials. [Burgess JL, Kirk M, Borron SW, Cisek J: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med August 1999;34:205-212.] BACKGROUND Hazardous materials incidents and chemically contaminated patients pose potentially serious problems for hospital EDs. Secondary contamination from treatment of patients exposed to hazardous materials can potentially result in significant injury or illness in emergency care providers.1-5 Exposure can occur from dermal contact with chemicals remaining on the patient or through inhalation of volatile contaminants or particulates. Acute chemical exposures are not infrequent. A survey of hospital safety officers revealed that 47% of responding hospitals had received an average of 2.4 chemically contaminated patients during 1994.6 In Washington State alone, more than 2,360 individuals had acute exposure to haz- AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE 2 0 5 HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS Burgess et al ardous materials from 1993 to 1996; of these, 1,762 (75%) were transported to a health care facility.7 The degree of decontamination performed in the prehospital environment varies with the team providing hazardous materials response and the patient’s medical condition. Ideally, decontamination should be performed before hospital transport, but in some cases, particularly when the patient’s condition appears to be unstable, prehospital decontamination may be deferred to hospital personnel. In addition, exposed patients can transport themselves to the hospital without previous prehospital evaluation or decontamination, which can lead to hospital evacuation without adequate preparation. Conversely, excessively rigorous interpretation and implementation of hazardous materials spill protocols can delay definitive treatment of chemically exposed patients and lead to prolonged ED closure. Strong or unpleasant odors from chemically contaminated patients can also result in hospital staff illness, even if the chemical concentrations in the air are below levels normally considered injurious. The Occupational Safety and Health Administration (OSHA) requires hospitals participating as an integral unit of a community-wide emergency response to a release of a hazardous substance to comply with the Hazardous Waste Operations Emergency Response (HAZWOPER) standards.8 These standards require staff training, as well as an emergency response plan that includes procedures for decontaminating patients and appropriate personal protective equipment for hospital staff. Accredited institutions under the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are required to have emergency procedures that describe the specific precautions, procedures, and protective equipment used during hazardous materials and waste spills or exposures.9 Specifically, any institution with an ED should have plans for treatment of a contaminated patient. However, a study of Washington State hospitalbased emergency care facilities found only 52 (55%) had protocols for handling medical facility contamination and potential evacuation arising during the management of contaminated patients.10 A similar lack of preparation would be expected in other states and countries. Information is currently available to help guide hospitals in the treatment of hazardous materials exposures. Guidance materials have been published for managing hazardous materials incidents, including those published by the Agency for Toxic Substances and Disease Registry.11,12 Protocols are also available for treatment of exposure to radioactive materials.13 However, to our knowledge, the peer-reviewed literature currently does 2 0 6 not contain a general protocol for treatment of contaminated patients. To prevent secondary injury, while maintaining ED function when possible, EDs must devise contaminated patient protocols that correspond to their capabilities and limitations, provide employees with appropriate training, practice these protocols during simulations, and carefully review both training sessions and actual incidents to improve future performance. 1,3,11,14-17 We propose a hazardous materials template protocol for dealing with contaminated patients, which can be modified according to local needs. C O N TA M I N AT E D PAT I E N T P R O T O C O L The first steps in handling contaminated patients in the ED are to recognize the presence of chemical contamination, and if possible, to identify the hazardous substance and determine its level of toxicity and risk for secondary contamination (Appendix). Triage personnel, in particular, should be trained to recognize high-risk situations for chemical contamination of patients. In our experience, nearly all ED evacuations/closures have been related to lack of early recognition and high levels of concern about the potential for secondary contamination, and not from lack of a written protocol or dedicated decontamination equipment. Prompt recognition of chemical exposure usually occurs through history or observation. Accidents at industrial or agricultural sites and accidents involving chemical transport should be considered high risks for chemical contamination as should suspected terrorism and mass casualty incidents. Patients should be considered at risk for chemical contamination if they exhibit a cholinergic syndrome, irritant mucous membrane symptoms, chemical burns, soiling of skin or clothing with unidentified liquids or powders, or if they have intentionally overdosed with industrial, cleaning, or agricultural chemicals. Strong or caustic odors suggest chemical exposure, although their presence does not prove the existence of a toxic concentration of chemicals, and their absence does not rule out contamination. In general, toxic liquids and solids pose a dermal contact hazard to ED staff, and only volatile liquid or solid contamination poses a risk of significant exposure through inhalation. The process of hazardous substance identification and the determination of the toxicity level and risk for secondary contamination may benefit from external consultation. EDs should have direct telephone access to the hazardous materials team responding to the incident, so ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999 HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS Burgess et al they can gather information about the incident and chemicals involved. Medical toxicologists experienced in chemical exposures may be available with local poison control centers, or through other local, state, or federal agencies. It is important that consultants are trained and experienced in hazardous materials exposures, or the information provided could be inappropriate or even dangerous. Chemical incidents provoke extreme fear among the public and can result in large numbers of “casualties” who suffer only from collective hysteria.18-20 Knowledge of the toxicologic profile of the involved chemical(s) may allow emergency care providers to rapidly rule out contamination in these patients. When in doubt, however, symptomatic patients should initially be treated as if exposed. Once any potential exposure has been discounted, this should be explained to the patient to address continued health concerns. This protocol assumes the patient(s) is still contaminated at the time of hospital arrival. If adequate previous decontamination has taken place, then it obviates this protocol. Ideally, either a portable outside decontamination unit or a dedicated decontamination facility with appropriate ventilation and water containment is available. External decontamination units should be supplied with warm running water, particularly in cold weather conditions. Portable curtains of adequate strength can provide both protection from wind and personal privacy during decontamination. This protocol also assumes there is either a separate waste water containment system or the sewer system for the hospital (municipal or otherwise) has the capacity to treat the low concentrations of chemical contaminants that decontamination of exposed patients would produce, as contrasted with larger-volume primary spills. If necessary, plastic pools or commercially available specialized decontamination stretchers can be used for decontamination, and the waste water kept in sealed containers for later disposal. The ED staff has 3 primary goals in managing a patient who has been exposed to a hazardous material and may be contaminated or who has not undergone adequate decontamination before arrival at the hospital: 1. To isolate the chemical contamination 2. To appropriately decontaminate and treat the patient(s), while protecting hospital staff, other patients, and visitors 3. To reestablish normal service as quickly as possible. These goals should be accomplished concurrently. It may be necessary to initiate medical care before complete isolation of the chemical contamination, although rapid AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE institution of personal protection of health care providers should precede intervention. Facility evacuation is rarely necessary and can generally be avoided by recognizing chemical contamination and adequately decontaminating the patient outside the ED, or by using an appropriately designed room within the ED. DISCUSSION The keys to effective hazardous materials management are common sense, preplanning, and training on that plan. The equipment, training, and preparedness required for decontamination of chemically exposed patients will differ from hospital to hospital, depending on the hospital’s capability to treat seriously poisoned patients, and its proximity to major industrial sites, agricultural activities, and transportation routes. Major trauma centers and hospitals designated by local emergency planning committees (LEPCs) for care of chemically contaminated patients should have a higher level of preparedness. Any plan must include contingencies for contamination sources within the hospital and for ED evacuation. The determination of a workable hazardous materials plan requires careful thought and often professional input from medical toxicologists, hazardous materials teams, and industrial hygiene and safety officers. Use of a patient decontamination plan implemented without specific adaptation to the hospital and without practice can result in undesirable outcomes. Medically necessary care, such as stabilization of a traumatized victim of a motor vehicle accident, should not be delayed because of contamination with relatively low toxicity substances such as diesel fuel. At the same time, a patient who is critically ill or in cardiac arrest assumed to be caused by chemical exposure demands caregiver protection before treatment intervention if risk of secondary contamination remains. In such an instance, basic life support may be provided during initial protected decontamination and followed up immediately thereafter with advanced life support. In general, the amount of contamination on a patient is much less than what would be present at the actual site of chemical release. Unless significant solid and liquid chemical contamination of the ED has occurred, it is unlikely that volatilization of chemicals from a contaminated patient would injure hospital staff. Most hazardous material exposure victims are exposed by inhalation only and are unlikely to have enough residual chemical on their skin to present a risk to hospital personnel, although strong odors can be present. 21 In an 2 0 7 HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS Burgess et al ED study of 72 patients exposed to hazardous materials during a 6-year period, positive pre-decontamination swabs analyzed by a certified analytical chemistry laboratory using gas chromatography/mass spectrometry were seen for pesticides and PCBs only.11 Studies of chemical concentrations in the breathing zone of hospital staff while decontaminating mannequins soaked with volatile solvents demonstrated levels well within acceptable occupational exposure limits.22 Simply removing clothing will substantially decrease the amount of chemical contamination and risk of secondary contamination. However, individual sensitivity to chemicals varies, and it is not unusual for chemicals with strong odors to elicit a symptomatic response in hospital staff even at concentrations far below commonly accepted “toxic” levels. Symptomatic staff will not be able to function optimally, regardless of the toxicity of the chemical contaminant. No medical consensus exists for the minimum level of personal protection required for hospital decontamination. This is especially true regarding respiratory protection, which is only necessary when toxic vapors are at concentrations high enough to cause potentially harmful effects to staff. After clothing removal, a contaminated patient poses minimal inhalation risk when decontamination is performed outside the ED. However, if a patient is placed in a poorly ventilated treatment room (enclosed space), personnel without respiratory protection could have symptoms from inhalation of off-gassing vapors from clothing, skin, or vomitus. Selecting the appropriate protective equipment depends on the specific hazardous substance identified. Surgical masks never provide adequate protection from toxic vapors. Legal requirements do apply to hospital-based decontamination. All EDs incorporated in an emergency response plan for hazardous materials incidents through LEPCs, an agreement with a facility or hazardous waste site, or other means, must meet OSHA requirements (29 CFR 1910.120(q)) for both training and response to hazardous materials, because it is likely they will be faced with a chemically exposed patient without previous decontamination at some time. Under these regulations, emergency medical personnel who would decontaminate victims exposed to a hazardous substance should be trained at a minimum to the first-responder operations level. Additional guidance on OSHA regulations concerning hospitals and emergency response to hazardous substances is available in an informational booklet.23 For response to an unknown hazard, OSHA regulations require level B protection, which includes a positive-pressure self-contained breathing apparatus and 2 0 8 splash-protective chemical resistant clothing. However, these regulations should not interpreted to require the use of this equipment for treatment of contaminated patients in all hospitals. Use of self-contained breathing apparatus can itself pose significant problems to ED staff. These hazards include increased weight, improper use of the equipment, problems with donning and doffing, and decreased dexterity. Other options include having the patients decontaminate themselves if they are capable, designating a local fire department hazardous materials team to assist in or perform the decontamination, or proceeding with decontamination with less than level B protection if assistance is not available within a suitable time interval based on the patient’s condition. Hospitals frequently receiving contaminated casualties or in high-risk areas may need to consider additional training and equipment, such as specialized chemical-resistant clothing and respirators. Evacuation of an ED because of contamination from a chemically exposed patient is rarely indicated. Moving a patient outside or to a designated room with separate ventilation and establishing proper ventilation, such as with large fans, is usually sufficient to prevent exposure to other patients. Care should be taken to avoid spreading volatile contaminants throughout the hospital, by ventilating to an appropriate outside location and closing other doors as necessary. Similarly, the facility can be reoccupied rapidly if evacuation has already occurred given these conditions. Primary spills of hazardous volatile liquids or solids that cannot be quickly controlled may require facility evacuation. The final decision to reopen the facility may officially lie with the fire chief; thus a close working relationship between the fire chief, ED personnel, and toxicology consultants is essential. The need for rapid, effective, and consistent postincident debriefing cannot be overemphasized. Appropriate specialists should review the chemicals involved for potential toxicity, so hospital staff, patients, and their families can receive appropriate treatment and follow-up when necessary, or reassurance in other cases that further problems are not anticipated. The perception of exposure to hazardous materials can have profound consequences on hospital staff and patients. Failure to allay unnecessary concerns can result in lingering effects. At the same time, it is important to be sensitive during the delivery of debriefing information. Staff members who have experienced very real symptoms (such as irritation, nausea and vomiting, headache) from a presumed exposure are not likely to appreciate information that fear or “hysteria” induced their symptoms. It is preferable to state, when ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999 HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS Burgess et al true, that no lasting effects are anticipated in spite of the symptoms experienced. When specific identification of involved compounds is not possible, it is imperative that staff be invited to seek follow-up for symptoms in the employee health clinic, with occupational medicine, toxicology consultation, or both. Unnecessary laboratory studies should be avoided, because these may serve to reinforce the impression that a serious exposure has occurred. There should be a good reason for each test ordered and the results should be carefully explained. Preplanning and preparedness are essential in hazardous materials incidents. JCAHO standards require semiannual drills of emergency preparedness,9 and including scenarios requiring treatment of contaminated patients is advisable. Although …

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