Managing Hazardous Materials Incidents Volume II, Hospital
Emergency Departments
U.S. Department of Human Services, Public Health Service, Agency for Toxic Substance and Disease Registry
Publication date: 01/01/1992
Table of Contents
Introduction
Emergency Department Response to Hazardous Materials Incidents
Hazard Recognition
Principles of toxicology for emergency department personnel
Personnel Protection and Safety Principles
Respiratory
Protection
Emergency Department Personnel Decontamination
Communications
Selected Bibliography
Patient Management
Emergency Department Preparation
Patient Arrival
Decontamination of Patient
Considerations for Patient Treatment
Critique
Patient Management Under Mass Casualty Conditions Involving
Hazardous
Selected Bibliography
Systems Approach To Planning
The Role of the Hospital in a Systems Approach to Planning
The Spectrum of Hazardous Materials Incidents
Joint Commission on Accreditation of Healthcare Organizations (JCAHO
SARA Title 111
The State Emergency Medical Services (EMS) Agency
Federal Emergency Response Activities
Hazard Analysis
Selected Bibliography
Appendix A; Hazardous Materials Classification Systems
System Notes; HEALTH (BLUE)
Flammability (RED)
Reactivity (STABILITY) (YELLOW)
U.S. Department of Transportation Research and Special Programs Administration Hazardous Materials Marking, Labeling & Placarding
Material Safety Data Sheets
Appendix B; Types of Respiratory Protection
Appendix C; Levels of Protection
Additional Information
POINT OF CONTACT FOR THIS DOCUMENT:
Tables
Telephone Information And Technical Support References
Local Telephone Information And Technical Support Resource Worksheet
Computerized Data Sources Of Information And Technical Support
Examples Of Adverse Health Effects From Exposure To Toxic Chemicals
Classification Of factors Influencing Toxicity
Dose-Response Relationship For Humans Inhaling Tetrachlorthylene
Acute LD (50) Values For Representative Chemicals When Administered
Occupational Exposure Limits
Types Of Respiratory Protection
Levels Of Protection
Figures
Levels Of Protection
Levels Of Protection (Continued)
A Chemical Cartridge Air-Purifying Respirator
A Self-Contained Breathing Apparatus/Supplied-Air Respirator
Nine-Step Personnel Decontamination Plan
Eight-Step Dry Decontamination Plan For Personnel
Material Safety Data Sheet
Material Safety Data Sheet (Continued)
Introduction
The presence of hazardous materials or toxic chemicals at an incident
location or other emergency situation adds a new dimension of risk to those
handling and treating casualties. The fundamental difference between a
hazardous materials incident and other emergencies is the potential for
acute risk from contamination to both patient and responder. In some
cases, traditional practices must be altered to avoid compounding a
critical situation.
Hospital emergency departments must protect their personnel and other
people within the hospital, while providing the best care for the
chemically contaminated patient. This guide is intended to help hospital
emergency departments plan for incidents that involve hazardous materials
and improve their ability to respond to these incidents appropriately.
To ensure appropriate and timely patient care, as well as optimal worker
protection, emergency personnel must have an understanding of
decontamination procedures and personal protective equipment that they do
not generally receive in the course of their routine professional training.
They should also be aware of community resources that could be called upon
to assist in emergency response.
Current training curricula for emergency physicians, nurses, and emergency
medical technicians (EMTs) often do not adequately prepare these
professionals to either manage the contaminated individual or decontaminate
patients exposed to toxic substances. High-quality, specific, and concise
guidance is needed to describe appropriate procedures to be followed by
emergency medical personnel to safely care for a patient, as well as to
protect equipment, hospital personnel, and others from risk of exposure.
In response to this need, the Agency for Toxic Substances and Disease
Registry (ATSDR) has contracted for the production of two documents: (I)
Emergency Medical Services: A Planning Guide for the Management of
Contaminated Patients and (II) Hospital Emergency Departments: A Planning
Guide for Management of Contaminated Patients. The first document is
designed for use by emergency medical technicians and other prehospital
care providers to minimize their risks of exposure during the prehospital
treatment and to provide for the safe and effective treatment of chemically
contaminated patients.
This guide for emergency department personnel is designed to familiarize
readers with the concepts, terminology, and key considerations that affect
the management of incidents of chemical contamination. It has been
developed not only to present uniform guidance for emergency care of
chemically contaminated patients, but also to provide basic information
critical to advance planning and implementation of emergency medical
services' (EMS) strategies. It is intended to illustrate the
characteristics of hazardous materials incidents that mandate modifications
to traditional emergency response and the preparatory actions that should
be taken to respond effectively to hazardous materials incidents.
All hospital and community emergency response systems may not be prepared
to respond to a hazardous chemical incident to the same degree. This
document may be used to assess capabilities with respect to potential
community hazards and to develop response plans using national and
community specific resources. Worker safety and training are also key
factors in effective management of medical emergencies. This document is
intended to provide source material for developing local training and
safety protocols.
Emergency Department Response to Hazardous Materials Incidents, outlines
general principles for hazard recognition, chemical exposure, and personal
protective equipment. In addition, the hazard recognition section presents
generalized guidance for determining whether a given situation constitutes
a hazardous materials incident and details various hazardous materials
classification systems. Basic toxicological and chemical terminology that
emergency personnel need to understand to effectively conduct patient
assessments is presented, as well as an outline of personal protective
equipment such as respiratory devices and protective clothing.
Patient Management, includes guidelines for emergency department
preparation and response to a potential hazardous materials incident. In
addition, this chapter discusses patient assessment and decontamination
guidelines.
Systems Approach to Planning, details the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) guidelinesfor emergency preparedness
and hazardous materials and waste programs. Government and private planning
activities are also outlined, such as those established under the Superfund
Amendments and Reauthorization Act (SARA) Title III, the National Response
Team, the Community Awareness Emergency Response (CAER) program, and the
Chemical Emergency Preparedness Program (CEPP). This chapter discusses the
need for hazard identification and risk analysis pertaining to hazardous
materials located in the community or transported through the community.
Although this guidance document has been developed to provide for the
safety of responders, as well as the needs of patients, it is not all-
encompassing. Supplemental material that is vital to successful response
to hazardous materials contamination is cited within the document. These
supplementary materials should be reviewed before preparing any strategic
plans or before conducting training exercises on this topic. This document
cannot be regarded as a substitute for comprehensive instruction and
training for hazardous materials incidents.
Emergency Department Response to Hazardous Materials Incidents
Hazard Recognition
When dispatched to the scene of an incident, emergency response
personnel may not be aware that the incident involves hazardous materials.
As a result, emergency department personnel should always be alert to the
possibility that they may be dealing with a chemically contaminated
individual, and should ask incident victims and dispatch personnel about
the nature of the incident. Emergency departments should also be prepared
for exposed patients that arrive unannounced by privately owned vehicles
miles away from an incident site. Although an injury at a hazardous
materials incident need not invariably involve a chemical exposure (it
could have resulted from a purely physical occurrence, such as slipping off
a ladder), as a routine precaution, the involvement of hazardous materials
should be considered a possibility in such situations. As outlined in the
National Fire Academy/National Emergency Training Center Manual,
Recognizing and Identifying Hazardous Materials, there are six clues that
may confirm the presence of hazardous materials. These clues are included
in this guidance document to facilitate and expedite prompt identification
of any hazardous materials at the scene of the incident. Hospital
emergency department personnel, familiar with these clues, will
subsequently find the communication with field personnel enhanced. For
example, patient symptoms reported from the field--such as nausea,
dizziness, itching/burning eyes or skin, or cyanosis could suggest to the
hospital staff the presence of hazardous materials. Knowledgeable hospital
staff could then request field personnel to examine the site for these six
clues:
-
Occupancy and Location. Community preplanning should identify the
specific sites that contain hazardous materials. In addition,
emergency personnel should be alert to the obvious locations in
their communities that use hazardous materials -- for example
laboratories, factories, farm and paint supply outlets, and
construction sites.
- Container Shape. Department of Transportation (DOT) regulations
specify container specifications for transport of hazardous
materials. There are three categories of packaging: stationary
bulk storage containers at fixed facilities that come in a variety
of sizes and shapes; bulk transport vehicles, such as rail and
truck tank cars, that can vary in shape depending upon the cargo;
and smaller quantities of hazardous materials that may be packaged
in fiberboard boxes, drums, or cylinders with labeling. Often the
shape and configuration of the container can be a useful clue to
the presence of hazardous materials.
- Markings/Colors. Transportation vehicles must use DOT markings,
including identification (]D) numbers. Identification numbers,
located on both ends and both sides, are required on all cargo
tanks, portable tanks, rail tank cars, and other packages that
carry hazardous materials. A marking system designed by the
National Fire Protection Association (NFPA) identifies hazardous
materials at terminals and industrial sites but does not provide
product-specific information. This system uses a diamond divided
into four quadrants. Each quadrant represents a different
consideration: the left, blue section refers to health; the top,
red quarter pertains to flammability; the right, yellow area is for
reactivity; and the bottom, white quadrant highlights special
information. In addition, a number from zero through four
indicates the relative risk of the hazard with zero being the
minimum risk.
- Placards/Labels. These convey information by use of colors,
symbols, Hazard Communication Standard, American National Standard
Institute (ANSI) Standards for Precautionary Labeling of Hazardous
Industrial Chemicals, United Nations Hazard class numbers, and
either hazard class wording or four-digit identification numbers.
Placards are used when hazardous materials are in bulk, such as in
cargo tanks; labels designate hazardous materials on small
packages.
- Shipping Papers. These can clarify what is labeled "dangerous" on
placards. They should provide the shipping name, hazard class, ID
number, and quantity and may indicate "waste" or "poison".
(Shipping papers must accompany all hazardous material shipments.)
- Senses. Odor, vapor clouds, dead animals or dead fish, fire, and
irritation to skin or eyes can signal the presence of hazardous
materials. Generally, if one detects the odor of hazardous
materials, one should assume that exposure has occurred. Some
chemicals, however, can impair an individual's sense of smell
(i.e., hydrogen sulfide), and others have no odor at all (i.e.,
carbon monoxide).
Appendix A provides illustrations and greater detail on the National Fire
Protection Association 704M system, the Department of Transportation
hazardous materials marking, labeling, and placarding guide, and the
Department of Labor Material Safety Data Sheet (MSDS). It is important
that any and all available clues are used in the process of substance
identification, especially the most obvious, such as the information
provided on a label or in shipping papers (NOTE: shipping papers should
remain at the incident scene for use by other response personnel). The aim
of the health provider should be to make a product-specific identification.
Every effort should be taken to prevent exposure to chemicals. Identifying
the hazardous material and obtaining information on its physical
characteristics and toxicity are steps that are vital to the effective
management of the hazardous materials incident. Since each compound has
its own unique set of physical and toxicological properties, early and
accurate identification of the hazardous material involved in the incident
allows the emergency responders and emergency department staff to initiate
appropriate scene management steps.
Many printed resources are available to provide information concerning
response and planning for hazardous materials incidents. A selected
bibliography is included at the end of each section; however, this is not a
complete list of the materials available. Printed reference materials
provide several advantages: they are readily available, can be transported
in the response vehicle, are not dependent on a power source or subject to
malfunction, and are relatively inexpensive. Disadvantages include the
difficulty in determining a correct identity for an unknown chemical,
materials are often out of date and cannot be easily updated, and no single
volume is capable of providing all the information that may be needed
There is also a vast array of telephone and computer-based information
sources concerning hazardous materials. They can help you by describing
the toxic effects of the chemical, its relative potency, and the potential
for secondary contamination and by recommending decontamination procedures.
They may also provide advice on the adequacy of specific types of
protective gear. (Table 1) is a partial listing of the many
information resources available by telephone. (Table 2) is a list
of suggested telephone numbers that should be filled in for your community.
Planning is an essential part of every response, and these resources will
also provide guidance that can be used in forming an effective response
plan. (Table 3) provides a partial listing of the available
computerized and on-line information sources. It should be noted that not
all on-line databases are peer reviewed. Therefore, some medical
management information may be based only on DOT or MSDS data. Care and
planning should be used when selecting information sources.
Computerized information sources are basically two types: (a) call-up
systems that are addressed via telephone lines and (b) database systems
that are housed on a local computer disc. Each system contains large
amounts of information on many hazardous materials and can be searched to
help identify the material involved. They are updated frequently at no
extra cost to the subscriber and are extremely portable with today's
computer systems. Computer databases can be expensive, as can the initial
cost of the equipment. Most systems will require the operator to have some
knowledge of computer terms and search protocols. Also, mechanical
equipment may fall and should not be counted on asa sole source of
information.
Principles of toxicology for emergency department personnel
Exposure to hazardous chemicals may produce a wide range of adverse
health effects. The likelihood an adverse health effect occurring, and the
severity of the effect, are dependent on the toxicity of the chemical,
route of exposure, and the nature and extent of exposure to that substance.
In order to better traderstand potential health effects, emergency
department personnel should have an understanding of the basic principles
and terminology of toxicology.
Toxicology is the study of the nature, effects, and detection of poisons in
living organisms. Some examples of these adverse effects, sometimes called
toxic end points, include carcinogenicity (development of cancer),
hepatotoxicity (liver damage), neurotoxicity (nervous system damage), and
nephrotoxicity (kidney damage). This is by no means a complete list of
toxic end points, but rather a selection of effects that might be
encountered (Table 4).
Toxic chemicals often produce injuries at the site at which they come into
contact with the body. A chemical injury at the site of contact with the
body, typically the skin and the mucous membranes of the eyes, nose, mouth,
or respiratory tract, is termed a local toxic effect. For example,
irritant gases, such as chlorine and ammonia, can produce a localized toxic
effect in the respiratory tract; corrosive acids and bases can produce a
local damage to the skin. In addition, a toxic chemical may be absorbed
into the blood stream and distributed to other parts of the body. These
compounds may then produce systemic effects. For example, many pesticides
are absorbed by the skin, distributed to other sites in the body, and
produce adverse effects such as seizures or other neurological problems.
It is important for medical providers to recognize that exposure to
chemical compounds can result not only in the development of a single
systemic effect but also in the development of multiple systemic effects or
a combination of systemic and local effects.
Routes and Extent of Exposure--
There are three main routes of chemical exposure: inhalation, skin contact,
and ingestion. Inhalation results in the introduction of toxic compounds
into the respiratory system. Most of the compounds that are commonly
inhaled are gases or vapors of volatile liquids; however, solids and
liquids can be inhaled as dusts or aerosols. Inhalation of toxic agents
generally results in a rapid and effective absorption of the compound into
the blood stream because of the large surface area of the lung tissue and
number of blood vessels in the lungs. Skin contact exposure does not
typically result in as rapid systemic dosage as inhalation, although some
chemicals are readily absorbed through the skin. Many organic compounds
are lipid (fat) soluble and can therefore be rapidly absorbed through the
skin. Some materials that come in contact with the eyes can also be
absorbed. Ingestion is a less common route of exposure for emergency
response personnel at hazardous materials incidents. However, incidental
hand-to-mouth contact, smoking, and swallowing of saliva and mucus
containing trapped airborne contaminants can cause exposure by this route.
In addition, emergency medical personnel in both hospital or prehospital
settings will see chemical exposures in patients who have ingested toxic
substances as a result of accidental poisonings or suicide attempts.
Compounds can also be introduced into the body by injection; however,
injection exposure is an unlikely scenario involving spills or discharges
of hazardous materials.
The route by which personnel are exposed to a compound plays a role in
determining the total amount of the compound taken up by the body because a
compound may be absorbed following exposure by one route more readily than
by another. In addition to the route of exposure, the amount of the
compound absorbed by the body depends on the duration of exposure to the
compound and the concentration of the compound to which one is exposed.
Therefore, a complex relationship exists between the total amount of the
compound absorbed by the body (dose) and the concentration of that compound
in the environment. This relationship is important for emergency medical
personnel to understand because the adverse effects produced by a toxic
compound are often related to the dose of that compound received by a
patient.
However, because we usually only monitor the concentration of the toxic
substance in the environment (e.g., parts per million (ppm) of a compound
in air), the actual dose of the compound received by the patient is seldom
known. Factors specific to the exposed patient, such as size of the skin
surface area exposed, presence of open wounds or breaks in the skin, and
rate and depth of respiration, are important in estimating the dose of the
compound received by the patient.
Dose-Response Relationship--
The effect produced by a toxic compound is a function of the dose of the
compound received by the organism. This principle, termed the dose-
response relationship, is a key concept in toxicology. Many factors affect
the normal dose-response relationship and should be considered when
attempting to extrapolate toxicity data to a specific situation
(Table 5).
Typically, as the dose increases, the severity of the toxic response
increases. For example, humans exposed to 100 ppm of tetrachloroethylene,
a solvent that is commonly used for dry-cleaning fabrics, may experience
relatively mild symptoms, such as headache and drowsiness. However,
exposure to 200 ppm tetrachloroethylene can result in a loss of motor
coordination in some individuals. Exposure to 1,500 ppm
tetrachloroethylene for 30 minutes may result in a loss of consciousness
(Table 6). As shown in Table 6, the severity of the toxic effect
is also dependent on the duration of exposure, a factor that influences the
dose of the compound in the body.
Toxicity information is often expressed as the dose of the compound that
causes an effect in a percentage of the exposed subjects, which are mostly
experimental animals. These dose-response terms are often found in
Material Safety Data Sheets (MSDS) and other sources of health information.
One dose-response term that is commonly used is the lethal dose 50 (LD50),
the dose which is lethal to 50% of an animal population from exposure by
any route other than inhalation when given all in one dose. Another
similar term is the lethal concentration 50 (LC50), which is the
concentration of a material in air that on the basis of respiratory
exposure in laboratory tests is expected to kill 50% of a group of test
animals when administered as a single exposure (usually 1 hour).
(Table 7) lists a number of chemicals that may be encountered in
dealing with hazardous materials incidents, and the reported acute LD50
values of these compounds when they are administered orally to rats.
From (Table 7), it can be seen that a dose of 3,000-3,800 mg/kg
tetrachloroethylene is lethal to 50% of rats that received the compound
orally; however, only 6.4 to 10 mg/kg of sodium cyanide is required to
produce the same effect. Therefore, compounds with low LD50 values are
more acutely toxic than substances with larger LD50 values.
The LD50 values that appear in an MSDS or in the literature must be used
with caution by emergency medical personnel. These values are an index of
only one type of response and give no indication of the ability of the
compound to cause nonlethal, adverse or chronic effects. Furthermore, LD50
values typically come from experimental animal studies. Because of the
anatomical and physiological differences between animals and humans, it is
difficult to compare the effects seen in experimental animal studies to the
effects expected in humans exposed to hazardous materials in the field.
Therefore, emergency medical personnel should remember that the LD50 and
LC50 values are only useful for comparing the relative toxicity of
compounds and should only be used to determine if one chemical is more
toxic than another.
Responses to toxic chemicals may differ among individuals because of the
physiological variability that is present in the human population. For
example, an individual may be more likely to experience an adverse health
effect after exposure to a toxic chemical because of a reduced ability to
metabolize that compound. The presence of preexisting medical conditions
can also increase one's susceptibility to toxic chemicals. Respiratory
distress in patients orworkers with asthma may be triggered by exposure to
toxic chemicals at lower concentrations than might be expected to produce
the same effect in individuals without respiratory disease. Factors such
as age, personal habits (i.e., smoking, diet), previous exposure to toxic
chemicals, and medications may also increase one's sensitivity to toxic
chemicals. Therefore, exposure to concentrations of toxic compounds that
would not be expected to result in the development of a toxic response in
most individuals may cause an effect in susceptible individuals. Not all
chemicals, however, have a threshold level. Some chemicals that produce
cancer (carcinogens) may produce a response (tumors) at any dose level.
Any exposure to these compounds may be associated with some risk of
developing cancer. Thus, literature values for levels which are not likely
to produce an effect do not guarantee that an effect will not occur.
Exposure Limits--
The various occupational exposure limits found in the literature or in an
MSDS are based primarily on time-weighted average limits, ceiling values,
or ceiling concentration limits to which the worker can be exposed to
without adverse effects. Examples of these are listed in (Table 8).
The values listed in (Table 8) were established to provide worker
protection in occupational settings. Because the settings in which these
values are appropriate are quite different than an uncontrolled spill site,
it is difficult to interpret how these values should be used by emergency
medical personnel dealing with a hazardous materials incident. At best, TLV,
PEL, IDLH, and REL values can be used as a benchmark for determining
relative toxicity, and perhaps assist in selecting appropriate levels of
Personal Protective Equipment (PPE). Furthermore, these occupational
exposure limits are only useful if the appropriate instrumentation is
available for measuring the levels of toxic chemicals in the air at the
chemical spill site. Of the above occupational exposure limit values, only
the OSHA values are regulatory limits. The ACGIH values are for guidance
only and are not regulatory limits. In addition, the ACGIH limits have
certain caveats that may or may not affect the usefulness of the values.
Some of these conditions are individual susceptibility or aggravation of a
preexisting condition. Nevertheless, all emergency medical personnel
responsible for the management of chemically contaminated patients should
be familiar with these concepts because they will be encountered in various
documents dealing with patient care or the selection of PPE.
This brief discussion highlights some fundamental concepts of toxicology.
Emergency medical personnel responsible for managing chemically
contaminated patients are encouraged to obtain further training in
recognizing and treating health effects related to chemical exposures.
Also, a list of general references in toxicology is provided at the end of
this section that will allow emergency medical personnel to undertake a
more in-depth examination of the principles of toxicology.
Personnel Protection and Safety Principles
This section is designed to provide those emergency medical personnel
who may be required to provide care to chemically contaminated patients,
because of their proximity to a chemical industrial area or transport
corridor, with information on protective equipment and safety principles.
However, in the vast majority of cases, hospital staff will not experience
a large enough number of cases to keep them optimally trained or their
equipment properly maintained. For example, respirators and their
cartridges must be properly fitted, tested, and stored. Staff must be
initially trained in the proficient use of PPE, specifically respiratory
equipment, and must maintain that proficiency. Equipment must be
maintained according to OSHA standards. Many hospitals, given their
workload mix, may not be able to expend the funds and time necessary to
accomplish this task. In these cases, these hospitals should make
arrangements with the local fire department or hazardous materials (hazmat)
team to be ready, if the situation warrants, to decontaminate patients,
including those who are transported to a hospital before they are
decontaminated. Considerations in determining what a hospital's
capabilities should be include the number of incidents occurring locally
(several per week versus only a few per year) and proximity to industries
or transportation routes that have a potential for a hazardous materials
incident (see SARA Title III).
Federal Regulations Pertaining to Use of Personal Protective Equipment (PPE)-- The term Personal Protective Equipment
(PPE) is used in this
document to refer to both personal protective clothing and equipment. The
purpose of PPE is to shield or isolate individuals from the chemical,
physical, and biological hazards that may be encountered at a hazardous
materials incident.
Recent new OSHA standards mandate specific training requirements (8 hours
of initial training or sufficient experience to demonstrate competency) for
employees engaged in emergency response to hazardous substances incidents
at the first responder operations level. Additionally, each employer must
develop a safety and health program and provide for emergency response.
These standards also are intended to provide additional protection for
those who respond to hazardous materials incidents, such as firefighters,
police officers, and EMS personnel. OSHA's March 6, 1989, 29 CFR
(1910.120) final rule as it applies to emergency medical personnel states
that: "Training shall be based on the duties and functions to be performed
by each responder of an emergency response organization" (p. 9329).
Training Is Essential Before Any Individual Attempts To Use PPE.
No single combination of protective equipment and clothing is capable of
protecting against all hazards. Thus, PPE should be used in conjunction
with other protective methods. The use of PPE can itself create
significant worker hazards, such as heat stress, physical and psychological
stress, and impaired vision, mobility, and communication. In general, the
greater the level of PPE protection, the greater are the associated risks.
For any given situation, equipment and clothing should be selected that
provide an adequate level of protection. Over-protection can be as
hazardous as under-protection and should be avoided. Personnel should not
be expected to use PPE without adequate training. The two basic objectives
of any PPE program should be to protect the wearer from safety and health
hazard and to prevent injury to the wearer from incorrect use and/or
malfunction of the PPE. To accomplish these goals, a comprehensive PPE
program should include: hazard identification; medical monitoring;
environmental surveillance; selection, use, maintenance, and
decontamination of PPE; and training.
Levels of Protection--
The Environmental Protection Agency (EPA) has assigned four levels of
protection to assist in determining which combinations of respiratory
protection and protective clothing should be employed:
- Level A protection should be worn when the highest level of respiratory,
skin, eye, and mucous membrane protection is needed. It consists of a
fully-encapsulating chemical-resistant suit and self-contained breathing
apparatus (SCBA).
- Level B protection should be selected when the highest level of
respiratory protection is needed but a lesser level of skin and eye
protection is sufficient. It differs from Level A only in that it
provides splash protection by use of chemical-resistant clothing
(overalls, long sleeves, jacket, and SCBA).
- Level C protection should be selected when the type of airborne
substances is known, concentration is measured, criteria for using air-
purifying respirators are met, and skin and eye exposures are unlikely.
This involves a full-facepiece, air-purifying, canister-equipped
respirator and chemical-resistant clothing. It provides the same level
of skin protection as Level B, but a lower level of respiratory
protection.
- Level D is primarily a work uniform. It should not be worn on any site
where respiratory or skin hazards exist. It provides no respiratory
protection and minimal skin protection.
(Figure 1) and (Figure 2) illustrates these four levels of
protection. For more information on this area, Appendix C outlines the
protective equipment recommended for each level of protection.
Factors to be considered in selecting the proper level of protection
include the routes of entry for the chemical, degree of contact, and the
specific task assigned to the user. Activities can also be used to
determine which level of protection should be chosen. The EPA and NIOSH
recommend that initial entry into unknown environments and into a confined
space that has not been chemically characterized be conducted in at least
"Level B" protection.
Routes of Entry--
PPE is designed to provide emergency medical personnel with protection from
hazardous materials that can affect the body by one of three primary routes
of entry: inhalation, ingestion, and direct contact. Inhalation occurs
when emergency personnel breathe in chemical fumes or vapors. Respirators
are designed to protect the wearer from contamination by inhalation and
must wear properly and be fit tested frequently to ensure continued
protection. Ingestion usually is the result of a health care provider
transferring hazardous materials from his hand or clothing to his mouth.
This can occur unwittingly when an individual wipes his mouth with his hand
or sleeve. Direct contact refers to chemical contact with the skin or eye.
Skin is protected by garments, and full-face respirators protect against
ingestion and direct contact. Mucous membranes in the mouth, nose, throat,
inner ear, and respiratory system are affected by one or more of the three
primary routes of entry. Many hazardous materials adhere to and assimilate
with the moist environment provided by these membranes, become trapped or
lodged in the mucus, and, subsequently, absorbed or ingested.
Chemical Protective Clothing (CPC)--
Protective clothing is designed to prevent direct contact of a chemical
contaminant with the skin or body of the user. However, there is not one
single material that will afford protection against all substances. Thus,
multilayered garments are often employed, which may reduce dexterity and
agility. CPC is designed to afford the wearer a known degree of protection
from a known type, a known concentration, and a known length of exposure to
a hazardous material, but only if it is properly fitted and worn correctly.
Improperly worn equipment can expose and endanger the wearer. One factor
to keep in mind during the selection process is that most protective
clothing is designed to be impermeable to moisture, thus limiting the
transfer of heat from the body through natural evaporation. This is a
particularly important factor in hot environments or for strenuous tasks
since such garments can increase the likelihood of heat injury.
The effectiveness of protective clothing can be reduced by three actions:
degradation, permeation, and penetration. Chemical degradation occurs when
the characteristics of the material in use are altered through contact with
chemical substances. Examples of degradation include cracking and
brittleness, and other changes in the structural characteristics of the
garment. Degradation can also result in an increased permeation rate
through the garment, that is, the molecular absorption by or passage
through the protective material of a chemical substance.
Permeation is the process in which chemical compounds cross the protective
barrier of CPC because of passive diffusion. The rate at which a compound
permeates CPC is dependent on factors such as the chemical properties of
the compound, the nature of the protective barrier in the CPC, and the
concentration of the chemical on the surface of the CPC. Most
manufacturers of CPC provide charts on the breakthrough time, or the time
it takes for the chemical to permeate the material of a protective suit,
for a wide range of chemical compounds.
Penetration occurs when there is an opening or a puncture in the protective
material. These openings can include unsealed seams, button holes, and
zippers. Often such openings are the result of faulty manufacture or
problems with the inherent design of the suit. Protective clothing is
available in a wide assortment of forms, ranging from fully-encapsulating
body suits to gloves, hard hats, earplugs, and boot covers. CPC comes in a
variety of materials, offering a range of protection against a number of
chemicals. Emergency medical personnel must evaluate the properties of the
chemical versus the properties of the material. Selection of which kinds
of CPC to use will depend on the specific chemical, and on the specific
tasks to be performed.
Respiratory Protection
Substantial information is available for the correct selection,
training, and use of respirators. The correct respirator must be selected
for the specific hazard in question. Material safety data sheets (if
available) often specify the type of respirator that will protect users
from risks. The manufacturers suggest the types of hazards their
respirators are capable of protecting against. There are two basic types
of respirators: atmosphere-supplying and air-purifying. Atmosphere-
supplying respirators include self-contained breathing apparatus (SCBA) and
supplied-air respirators (SAR). The OSHA has requirements under 29 CFR
1910. 134 which specify certain aspects of a respiratory protection
standard, and these are mandatory legal minimums for a program to be
operated. In addition, NIOSH has established comprehensive requirements
for the certification of respiratory protection equipment.
Air-Purifying Respirators (APRs)--
An air-purifying respirator depends on ambient air purified through a
filtering element before inhalation. Three basic types of APRs are used by
emergency personnel: chemical caxtfidges or canisters, disposables, and
powered-air. The major advantage of the APR system is the increased
mobility it affords the wearer. However, the respirator can only be used
where there is sufficient oxygen (19.5%) since it depends on ambient air to
function. In addition, the APR should not be used when substances with
poor warning properties are known to be involved.
The most commonly used APR depends on cartridges (Figure 3) or
canisters to purify the air by chemical reaction, filtration, adsorption,
or absorption. Cartridges and canisters are designed for specific
materials at specific concentrations. To aid the user, manufacturers have
color-coded the cartridges/canisters to indicate the chemical or class of
chemicals the device is effective against. NIOSH recommends that use of a
carmdge not exceed one work shift. However, if "breakthrough" of the
contaminant occurs first, then the cartridge or canister must be
immediately replaced. After use, cartridges and canisters should be
considered contaminated and disposed of accordingly.
Disposable APRs are usually designed for use with particulates, such as
asbestos. However, some are approved for use with other contaminants.
These respirators are customarily half-masks that cover the face from nose
to chin, but do not provide eye protection. Once used, the entire
respirator is usually discarded. This type of APR depends on a filter to
trap particulates. Filters may also be used in combination with cartridges
and canisters to provide an individual with increased protection from
particulates. The use of half-mask APRs is not generally recommended by
emergency response organizations.
Atmosphere-Supplying Respirators--
Atmosphere-supplying respirators consist of two basic types: the self-
contained breathing apparatus (SCBA), which contains its own air supply,
and the supplied-air respirator (SAR), which depends on an air supply
provided through a line linked to a distant air source. (Figure 4)
illustrates an example of each.
Self-Contained Breathing Apparatus (SCBA)--
A self-contained breathing apparatus respirator is composed of a facepiece
connected by a hose to a compressed air source. There are three varieties
of SCBAs: closed-circuit, open-circuit, and escape. Open-circuit SCBAs,
most often used in emergency response, provide clean air from a cylinder to
the wearer, who exhales into the atmosphere. Closed-circuit SCBAs, also
known as "rebreathers," recycle exhaled gases and contain a small cylinder
of oxygen to supplement the exhaled air of the wearer. Escape SCBAs
provide air for a limited amount of time and should only be used for
emergency escapes from a dangerous situation.
The most common SCBA is the open-circuit, positive-pressure type. In this
type, air is supplied to the wearer from a cylinder and supplied to the
facepiece under positive pressure. In contrast to the negative-pressure
units, a higher airpressure is maintained inside the facepiece than
outside. This affords the SCBA wearer the highest level of protection
against airborne contaminants since any leakage may force the contaminant
out. There is a potential danger, when wearing a negative-pressure-type
apparatus, that contaminants may enter the facemask if it is not properly
sealed. The use of a negative-pressure SCBA is prohibited by OSHA under 29
CFR 1910.120(q)(iv) in incidents where personnel are exposed to hazardous
materials. However, one disadvantage of SCBAs is that they are bulky and
heavy, and can be used for only the period of time allowed by air in the
tank.
Personnel must be fit-tested for use of all respirators.
A tiny space between the respirator and you could permit exposure to a
hazard by allowing contaminated air in. Anyone attempting to wear any type
of respirator should be trained and drilled in its proper use.
Furthermore, equipment must be inspected and checked for serviceability on
a routine basis.
Supplied-Air Respirators (SARs)--
Supplied-airrespirators differ from SCBAs in that the air is supplied
through a line that is connected to a source away from the contaminated
area. SARs are available in both positive- and negative-pressure models.
However, only positive-pressure SARs are recommended for use at hazardous
materials incidents. One major advantage the SAR has over the SCBA device
is that the SAR allows an individual to work for a longer period. In
addition, the SAR is less bulky than the SCBA. However, by necessity, a
worker must retrace his steps to stay connected to the SAR, and therefore
cannot leave the contaminated work area by a different exit.
Emergency Department Personnel Decontamination
Decontamination is the process of removing or neutralizing harmful
materials that have gathered on personnel and/or equipment during the
response to a chemical incident. Many stories are told of seemingly
successful rescue, transport, and treatment of chemically contaminated
individuals by unsuspecting emergency personnel who in the process
contaminate themselves, the equipment, and the facilities they encounter
along the way. Decontamination is of the utmost importance because it:
- Protects all hospital personnel by sharply limiting the transfer of
hazardous materials from the contaminated area into clean zones;
- Protects the community by preventing transportation of hazardous
materials from the hospital to other sites in the community by secondary
contamination; and
- Protects workers by reducing the contamination and resultant permeation
of, or degradation to, their protective clothing and equipment.
This section will only address the steps necessary for dealing with worker
decontamination. Patient decontamination will be addressed in Patient
Management. It should be stressed that in order to carry out proper
decontamination, personnel must have received at least the same degree of
training as required for workers who respond to hazardous materials
incidents. The design of the decontamination process should take into
account the degree of hazard and should be appropriate for the situation.
For example, a nine-station decontamination process, as presented in
(Figure 5), need not be set up if only a bootwash station would
suffice.
Avoiding contact is the easiest method of decontamination -- that is, not
to get the material on the worker or his protective equipment in the first
place. However, if contamination is unavoidable, then proper
decontamination or disposal of the worker's outer gear is recommended.
Segregation and proper disposal of the outer gear in a polyethylene bag or
steel drum is recommended. With extremely hazardous materials, it may be
necessary to dispose of equipment as well.
Physical decontamination of protective clothing and equipment can be
achieved in some cases by several different means. These all include the
systematic removal of contaminants by washing, usually with soap and water,
and then rinsing. In rare cases, the use of solvents may be necessary.
There is a trend toward dry decontamination, which involves using
disposable clothing (e.g., suits, boots, and gloves) and systematically
removing these garments in a manner that precludes contact with the
contaminant. The appropriate procedure will depend on the contaminant and
its physical properties. A thorough work-up of the chemical involved and
its properties or expert consultation is necessary to make these kinds of
decisions.
Care must be taken to ensure that decontamination methods, because of their
physical properties, do not introduce fresh hazards into the situation.
Additionally, the residues of the decontamination process must be treated
as hazardous wastes. The decontamination stations and process should be
confined to the Contamination Reduction Zone. Steps for dry
decontamination (not using water) are
outlined in (Figure 6).
- Decontamination of Personnel
---Personnel should remove protective clothing in the following sequence.
- Remove tape securing gloves to suit.
- Remove outer gloves turning them inside out as they are removed.
- Remove suit turning it inside out and avoid shaking.
- Remove plastic shoe cover from one foot and step over "clean line."
Remove other shoe cover and put that foot over the line.
- Remove mask. The last staff member removing his/her mask may want to
wash all masks with soapy water before removing suit and gloves.
Place masks in plastic bag and hand over the clean line, and place in
second bag held by another member of the staff. Send for
decontamination.
- Remove inner gloves and discard in drum inside dirty area.
- Close off dirty area until level of contamination is established and
the area is properly cleaned.
- Personnel should then move to a shower area, remove scrub suit and
place it in a plastic bag.
- Shower and redress in normal working attire.
Note: Double bag clothing and label appropriately.
Communications
Effective communications are essential to maintaining incident
control. These include a dedicated radio frequency and a sufficient number
of radios for distribution to all participating agencies. Another network
links the on-scene command post to support groups. Other networks that may
have to be activated include one linking the hospital emergency room to
EMTs and one dedicated for use by the teams in the Exclusion Zone. Often
when an Incident Command System is activated, one person is assigned to
manage communications.
Selected Bibliography
American Conference of Governmental Industnal Hygienists. Guidelines for
the Selection of Chemical Protective Clothing. Cincinnati, Ohio, 1983.
Arena, J.M. Poisoning: Toxicology, Symptoms, Treatments. Fifth Edition.
Charles C. Thomas, Springfield, Illinois, 1986.
Browning, E. Toxicity and Metabolism of Industrial Solvents. Elsevier,
Amsterdam, 1965.
Klaassen, C.D., Amdur, M.O., Doull, J., eds. Casarett and Doull's
Toxicology: The Basic Science of Poisons. Third Edition. Macmillan
Publishing Company, New York, 1986.
Clayton, G.D., Clayton, F.E. Patty's Industrial Hygiene and Toxicology.
Revised Edition. John Wiley and Sons, New York, 1985.
Chemical Manufacturers Association (CMA), and the Association of American
Railroads. Terms for Personal Protective Equipment. CMA, Washington, DC,
October 1987.
Dreisbach, R.H., Robertson, W.O. Handbook of Poisoning: Prevention,
Diagnosis, and Treatment. Twelfth Edition. Lange Medical, Los Altos,
California, 1986.
Ellenhorn, M.J., B arceloux, D .G. Medical Toxicology: Diagnosis and
Treatment of Human Poisoning. Elsevier, New York, 1988.
EPA Region VII. Chemical Response Planning and Operations. EPA Region VII,
EPA, Washington, DC, January 1989.
Goldfrank, L.R. Goldfrank's Toxicological Emergencies, A Comprehensive
Handbook in Problem Solving. Third Edition. Appleton Century Crofts, New
York, 1986.
Gosselin, R.E., Smith, R.P., Hodge, H.C. Clinical Toxicology of Commercial
Products. Fifth Edition. Williams and Wilkins Publishers, Baltimore,
Maryland, 1984.
Hayes, A.W., ed. Principles and Methods of Toxicology. Raven, New York,
1989.
Hodgson, E., Levi, P.E. A Textbook of Modern Toxicology. Elsevier, New
York, 1987.
Levine, S .P., Martin, W.F. Protecting Personnel at Hazardous Waste Sites.
Butterworth Publishers, Boston, Massachusetts, 1985.
Lu, F.C. Basic Toxicology: Fundamentals, Target Organs, and Risk
Assessment. Hemisphere, Washington, DC, 1985.
National Fire Academy/National Emergency Training Center. Recognizing and
Identifying Hazardous Materials. National Audio-Visual Center, Capitol
Heights, Maryland, 1985.
Sax, N.I. Dangerous Properties of Industrial Materials. Seventh Edition.
Van Nostrand Reinhold Publishing Corp., New York, New York, 1988.
Schwope, A.D., Costas, P.P., Jackson, J.O., Weitzman, D.J. Guidelines for
the Selection of Chemical Protective Clothing. Third Edition. American
Conference of Governmental Industrial Hygienists, Cincinnati, Ohio, 1987.
Windholz, M., ed. The Merck Index. Tenth Edition. Merck and Co., Rahway,
New Jersey, 1983.
Patient Management
Growing concern about the proper treatment of chemically contaminated
patients has outpaced adequate guidance on the subject. However,
definitive work has been done on cases that bear similar characteristics
(e.g., radioactive exposure), and many of the same principles apply. Many
of these principles can be found in the article "Emergency Department
Radiation Accident Protocol" by R.B. Leonard, Ph.D., M.D., and R.C. Ricks,
Ph.D., published in the September 1980 issue of Annals of Emergency
Medicine. Further information on radiation response procedures is
contained in Hospital Emergency Department Management of Radiation
Accidents by Robert C. Ricks, Ph.D., prepared for the Federal Emergency
Management Agency.
When a hospital receives a call that a patient exposed to hazardous
materials is to be received, a planned course of action should be
implemented. Steps in a protocol must be practiced before a hazardous
materials emergency occurs. All staff members of an emergency department
should know their responsibilities and how to perform them. All required
equipment should be immediately available or readily accessed.
Individuals receiving a potential hazardous materials call should obtain as
much information as possible. A checklist should be developed and made
available for all telephone or radio communication centers. Information
that will aid in initiating appropriate actions includes:
- Type and nature of incident
- Caller's telephone number
- Number of patients
- Signs/symptoms being experienced by the patients
- Nature of injuries
- Name of chemical(s) involved
- Extent of patient decontamination in the field
- Estimated time of arrival
After the above information is received, a predesignated resource center
(e.g., regional poison control center, ATSDR) should be contacted for
information regarding definitive care procedures, which should include
decontamination methods that need to be performed. Communications should
be kept open with on-site response personnel to obtain as much advance
information as possible.
If incident notification comes from other than usual emergency
communication channels, the call should be verified before a hazardous
materials response plan is initiated. Ambulance personnel should be
notified of any special approach or entrance to the emergency department
and also advised not to bring the patient into the emergency department
until the patient has been assessed and accepted by the emergency
department.
Often patients contaminated by hazardous materials may be brought into the
emergency department unannounced or not through regular EMS channels. This
could be an ambulatory patient or a patient transported by private vehicle.
The ideal response to this is to call a fire department which is properly
trained and equipped or a hazmat team to come to the hospital and set up a
decontamination area outside the ambulance entrance. In any event, these
patients should be isolated from other patients and assessed and
decontaminated as soon as possible.
Emergency Department Preparation
Every member of the emergency department should be familiar with the
hospital's hazardous materials response plan and be required to participate
in scheduled drills. Preparation for arrival of a contaminated patient
should include: notification of all services involved, preparation of a
Decontamination Area, and suiting up of the Decontamination Team.
Emergency Department Mobilization--
The person receiving a call of incoming victims should notify the Nursing
Supervisor who will in turn notify appropriate personnel according to the
hospital's response plan. The hospital operator should be instructed to
notify security and maintenance, and the nurse on duty should contact the
predesignated resource center.
Decontamination Area Preparation--
Any victim of a hazardous materials incident must be considered to be
contaminated until demonstrated otherwise. Therefore, the route from the
emergency entrance to the decontamination area may also become contaminated
and all persons along that route should be removed by security personnel.
Ideally, this area should be protected with plastic or paper sheeting.
This barrier should be taped securely to the floor, and care should be
taken while walking on it because plastic can be very slippery when wet.
Security personnel should be stationed at the main entrance of the
emergency department close to the decontamination area to prevent
unauthorized entry, to control the entrance of the contaminated
patient into the department, and to direct the vehicle transporting the
patient to the appropriate area. A reception area should be set up just
outside the emergency department entrance, where arriving contaminated
patients can be screened for adequate decontamination before entering the
department.
A decontamination area should be large enough to facilitate decontamination
of more than one patient and accommodate the many personnel involved in
patient treatment and contamination reduction. The ventilation system
should either be separate from the rest of the hospital or turned off in
order to prevent spread of airborne contaminants throughout the facility.
If the ventilation system is shut off during the handling of a contaminated
victim in an enclosed area, the emergency department medical team could be
endangered. Therefore, OSHA regulations (i.e., 29 CFR 1910.120(q)(3)(iv)
on monitoring the atmosphere should be adhered to, especially if APRs are
used. The best place (weather permitting) to evaluate and initially treat
contaminated patients is outside where ambient ventilation will keep cross-
exposure low. Some hospitals have radiation decontamination facilities
that can be used with minor changes. An outside or portable
decontamination system is a viable substitute and would aid in preventing
contamination of the emergency department and other patients. A practical
alternative for facilities with limited resources is to have a warm shower
nozzle, soap, a wading pool, and plastic garbage bags in a predesignated
area outside the emergency department back door. The patient may be able
to remove his or her own contaminated clothing, place it in a double bag,
and do his or her own soap and water decontamination. A partial tent or
curtain can provide privacy for the patients. In most circumstances,
ordinary hospital gowns, plastic goggles, and plain latex gloves will
adequately protect hospital staff in case they have to assist the patient
in removing soaked clothing, wash exposed skin and hair, or perform eye
irrigation. With large amounts of concentrated corrosives or very oily
materials, such as pesticides, disposable CPC and unmilled nitrile gloves
will offer additional protection. If it is anticipated that your facility
is likely to receive heavily contaminated patients who have not received
prior decontamination, then it may be appropriate to purchase appropriate
protective gear and to fit and train emergency department staff in its use.
However, no person should wear and use specialized PPE, especially
respiratory protective gear, without prior training.
To prevent unnecessary contamination, all nonessential and nondisposable
equipment should be removed from the decontamination area. All door knobs,
cabinet handles, light switches, and other areas that have contact with
hands should be taped, and the floors should be covered with plastic or
paper sheeting to prevent contamination. The floor coverings should be
securely taped to prevent slippage, and the entrance to the room marked
with a wide strip of colored tape to indicate a contaminated area.
Personnel should not enter the area unless properly protected, and no
personnel or equipment should leave the area until properly decontaminated.
A "clean" member of the staff should stand on the clean side of the
entrance to hand in supplies and receive medical specimens. The essential
requirements for any decontamination task are:
- A safe area to place a patient while undergoing decontamination
- A method for washing contaminants off a patient
- A means of containing the rinsate
- Adequate protection for personnel handling the patient
- Disposable or cleanable medical equipment to treat the patient
Decontamination Team Preparation--
A decontamination team should be predesignated and trained in appropriate
personal protection equipment and procedures. The team should consist of:
- Emergency physician
- Emergency department nurses and aides
- Support personnel
- Nursing Supervisor
- Occupational Health and Safety Officer
- Security
- Maintenance
- Recorder
The decontamination team should be equipped with personal protective
clothing (as discussed in Section I) for whatever level described as
appropriate for the substance(s) involved. This may be determined by
consulting reference guidebooks, database networks, or telephone hotlines.
Appropriate dress for the decontamination team should include:
- A scrub suit
- Plastic shoe covers
- Disposable CPC with hood and booties built in; tape hood at neck
- Poly Vinyl Chloride (PVC) gloves taped to sleeves
- Respiratory protection as appropriate
- Multiple layers of surgical gloves, neoprene or disposable nitrile
gloves; change whenever torn; tape bottom layer
- Protective eyewear
A 2-inch-wide piece of masking tape with the team member's name placed on
the back of the protective suits will often assist employee in
communicating.
Patient Arrival
The emergency physician-in-charge or an emergency department nurse
should meet the ambulance upon arrival and assess the condition of the
patients as well as the degree of contamination. Personnel should keep in
mind that the actual contamination may be (or become) a life-threatening
condition. Triage procedures should also be initiated at this point, if
necessary. During initial patient survey and stabilization, contamination
reduction should simultaneously be performed. This consists of cutting
away or otherwise removing all suspected contaminated clothing, including
jewelry and watches, and brushing or wiping off any contamination. Care
should be taken to protect any open wounds from contamination. Emergency
department personnel should make every effort to avoid contact with any
potentially hazardous substance.
Ideally, decontamination should be performed before patient transport;
however, field decontamination facilities are limited and emergency
department personnel should consider that all hazardous materials patients
need decontamination. If a patient's clothing was not removed at the
incident site, it should be removed outside the ambulance but before entry
into the emergency department. This will reduce further exposure to the
patient and lessen the extent of contamination introduced to the emergency
department. Contaminated clothing should be double bagged in plastic bags,
sealed, and labeled. The decontamination team should bring the prepared
stretcher to the ambulance, transfer the patient, and take him or her
directly to the decontamination area along the predesignated route.
Priority should be given to the ABC (Airway, Breathing, and Circulation)
and simultaneous contamination reduction. Once life-threatening matters
have been addressed, emergency department personnel can then direct
attention to thorough decontamination and secondary patient assessment.
Identification of hazardous materials involved can be simultaneously
performed by other personnel. It is important to remember that appropriate
personal protective clothing must be worn until personnel are no longer in
danger. Therefore, the sooner the patient becomes decontaminated the
sooner personnel may reduce protective measures.
Effective decontamination consists of making the patient As Clean As
Possible (ACAP). This means that the contamination has been reduced to a
level that is no longer a threat to the patient or the responder. The
recorder notes on a diagram of the body the areas found by the physician to
be contaminated.
Decontamination of Patient
The basic purpose of decontamination is to reduce external
contamination, contain the contamination present, and prevent the further
spread of potentially dangerous substances. In other words, remove what
you can and contain what you can't. With a few exceptions, intact skin is
more resistant to hazardous materials than injured flesh, mucous membranes,
or eyes. Therefore, decontamination should begin at the head of the
patient and proceed downward with initial attention to contaminated eyes
and open wounds. Once wounds have been cleaned, care should be exercised
so that the wounds are not recontaminated. This can be aided by covering
the wounds with a waterproof dressing. For some chemicals, such as strong
alkali, it may be necessary to flush exposed skin and eyes with water or
normal saline for an extended period of time.
External decontamination should be performed using the least aggressive
layer methods. Mechanical or chemical irritation to the skin should be
limited to prevent damage to the epidermal layer, which would result in
increased permeability. Contaminated areas should be gently washed under a
spray of water, with a sponge and a mild soap. Warm, never hot, tap water
should be used. Care should be taken so that contaminants are not
introduced into open wounds. All run-off from decontamination procedures
should be collected for proper disposal.
The first priority in the process of decontamination should be contaminated
open wounds. These areas allow for rapid absorption of hazardous
materials. Wounds should be irrigated with copious amounts of normal
saline, and deep debridement and excision should be performed only when
particles or pieces of material have been embedded in the tissues.
Decontamination of eyes should also have high priority. Gentle irrigation
of the eyes should be performed with the stream of normal saline diverted
away from the medial canthus so that it does not force material into the
lacrimal duct. Contaminated nares and ear canals should also be gently
irrigated with frequent suction to prevent any material being forced deeper
into those cavities. Washing with soap and tepid water is usually all that
is needed to remove contamination. Hot water, stiff brushes, or vigorous
scrubbing should never be used because they cause vasodilation and
abrasion. This increases the chances for absorption of hazardous materials
through the skin.
Considerations for Patient Treatment
Primary goals for emergency department personnel in handling a
contaminated patient include termination of exposure to the patient,
patient stabilization, and patient treatment -- while not jeopardizing the
safety of emergency department personnel. Termination of exposure can best
be accomplished by removing the patient from the area of exposure and by
removing contaminants from the patient. Basically, a contaminated patient
is like any other and may be treated as such except that staff must protect
themselves and others from dangers due to contamination.
Personnel must first address life-threatening issues and then
decontamination and supportive measures. Priority should be given to the
ABC with simultaneous contamination reduction. Once life-threatening
matters have been addressed, emergency department personnel can then direct
attention to thorough decontamination, secondary patient assessment, and
identification of materials involved. It is important to remember that
appropriate personal protective clothing must be worn until personnel are
no longer in danger. Therefore, the sooner the patient becomes
decontaminated the sooner personnel may reduce protective measures or
downgrade the level of protection. Primary and secondary surveys should be
completed as conditions allow. In treating patients, personnel should
consider the chemical-specific information received from the hazardous
materials response resources. In multiple patient situations, proper
triage procedures should be implemented. Presenting signs and symptoms
should be treated as appropriate and when conditions allow. The sooner a
patient has been decontaminated the sooner he or she can be treated like a
"normal" patient. Orders of the designated poison control center and
attending physician should be administered. Invasive procedures, such as
IVs or intubation, should be performed only for life-threatening
conditions, until decontamination is performed. These procedures may
create a direct route for introducing the hazardous material into the
patient. The patient should be frequently re-assessed because many
hazardous materials have latent physiological effects.
Information on Materials Involved--
Identification of materials involved should also be determined early in a
hazardous material incident. Using resources outlined in this section, and
in Section I under Hazard Recognition, personnel should identify and obtain
detailed information involving treatment, decontamination procedures, and
possible adverse health effects of the specific chemical(s) involved.
Information that may be needed will include:
- Chemical name of substance involved
- Form of material (solid, liquid, gas)
- Length of exposure
- Routes of exposure
- Possible adverse health effects
- Treatment/antidote therapy
- PPE required
- Decontamination procedures
The importance of finding out as much as possible, as soon as possible,
about an unknown substance cannot be emphasized enough; however, based on
experience, NIOSH and EPA recommend that "Level B" protection is the
minimum level to be worn when entering an area containing unknown
substances. However, if the substance in question is suspected to involve
the skin as a route of exposure or is otherwise noted to be dangerous by
absorption, corrosion, and the like, "Level A" protection should be worn
because it provides additional skin protection.
Removal of Patient from Decontamination Room--
After the patient has been decontaminated, he or she should be discharged
home or admitted to the hospital, depending on the patient's clinical
condition. Place a clean piece of plastic on the floor for the patient and
staff to use when exiting the clean area. If the patient is not ambulatory
a clean stretcher or wheelchair should be brought to the doorway by an
individual who has not been exposed. After the patient is transferred to
the clean area, the physician can perform the physical examination and
initiate routine patient management.
Note: The attending staff must remember that since exposure to some
substances can result in serious delayed effects, sustained observation and
monitoring are required.
Critique
As soon as possible after each incident, all participating units
should send knowledgeable representatives to review the measures that were
taken by each unit or agency. The purpose of this review is to examine
which activities succeeded and which did not, and to evaluate the overall
coordination effort.
Patient Management Under Mass Casualty Conditions Involving Hazardou
Chemicals
Basic medical procedures in a large-scale hazardous materials incident
are not substantially different from life-saving measures in other mass
casualty disasters. Primary attention to the ABC continues to have first
priority with decontamination performed at the same time. A chemical
disaster may overwhelm any one hospital, particularly if it occurs along
with another disaster such as an earthquake. Hospitals need to preplan
what they will do if they are overwhelmed with hazmat patients.
There are, however, several important differences in disasters involving
hazardous materials. Such differences include the need for the effective
decontamination of exposed patients and response personnel, and the need
for effective safety measures to protect response personnel. Training in
the appropriate procedures to be followed is essential for potential
responders to a hazardous materials incident involving mass casualties.
Standard principles of tnage apply in chemical disasters, except in
exposures to very toxic substances. The patient, injured or not, must be
decontaminated before being transported to the emergency department to
protect EMS and emergency department staff.
Selected Bibliography
Cashman, J.R. Hazardous Materials Emergencies, Response and Control.
Revised, second edition. Technomic Publishing Co., Lancaster, Pennsylvania,
1988.
Currance, P.L., Bronstein, A.C. Emergency Care for Hazardous Materials
Exposure. C.V. Mosby, St. Louis, Missouri, 1988.
Department of Transportation (DOT). Emergency Response Guidebook.
Washington, DC, 1987; DOTP-5800.5
Federal Emergency Management Agency (FEMA). Disaster Planning Guidelines
for Fire Chiefs. Prepared by International Association of Fire Chiefs, Inc:
February 1981. FEMA, Washington, DC. Federal Emergency Management Agency
(FEMA). Guidance for Developing State and Local Radiological Emergency
Response Plans and Preparedness for Transportation-Accidents. FEMA,
Washington, DC, 1985.
Federal Emergency Management Agency (FEMA). Hazardous Materials Management
System. A Guide for Local Emergency Managers. Prepared by the Multnomah
County Office of Emergency Management: July 1981. FEMA, Washington, DC.
Federal Emergency Management Agency (FEMA). Hospital Emergency Department
Management of Radiation Accidents. FEMA, Washington, DC, 1984.
Goldfrank, L.R. Goldfrank's Toxicological Emergencies, A Comprehensive
Handbook in Problem Solving. Appleton Century Crofts, New York, New York,
1986.
Haddad, L.M., Winchester, J.F. Clinical Management of Poisoning and
Overdose. WB Saunders Co., Philadelphia, Pennsylvania, 1983.
Leonard, R.B., Ricks, R. Emergency Department Radiation Accident Protocol,
Annals of Emergency Medicine, September, 1980.
Noji, E.K., Kelen, G.D. Manual of Toxicologic Emergencies. Year Book
Medical Publishers, Chicago, Illinois, 1989.
Noll, G., Hildebrand, M.S., Yvorra, J.G. Hazardous Materials, Managing the
Incident. Fire Protection Publications, Oklahoma State University,
Stillwater, Oklahoma, 1988.
Ricks, R.C. Hospital Emergency Department Management of Radiation
Accidents. Oak Ridge Associated Universities, Oak Ridge, Tennessee, 1984.
Stutz, D.R., Ricks, R., Olsen, M. Hazardous Materials Injuries, a Handbook
of Prehospital Care. Bradford Communications Corporation, Greenbelt,
Maryland, 1982.
Systems Approach To Planning
The Role of the Hospital in a Systems Approach to Planning
The potential for hazardous materials incidents exists almost
everywhere. While occurring infrequently, chemical incidents are capable
of endangering the health of individuals and the emergency personnel
directed to assist them. People who have been seriously injured by a
hazardous material have a greater chance of recovery without complications
when appropriate emergency treatment is provided by trained prehospital EMS
personnel at the scene, and the patient is transported to a facility having
the most appropriate personnel and technical resources to manage his or her
care. This requires an integrated emergency medical response. However,
many local governments, private businesses, and hospitals do not have a
tested integrated hazardous materials response plan in place that involves
all of the responders. This has resulted in several problems including:
- On-site incidents have been poorly managed by first responders.
- Communication channels between the private sector and the public
sector or among public responders have not been clearly identified
and formalized.
- The medical community has not been firmly integrated into many
response systems and may not be prepared to treat multiple
casualties resulting from a serious hazardous materials incident.
Hospitals are a crucial link in the community response system for emergency
preparedness planning. Not only are hospitals asked to treat patients who
have been chemically contaminated at remote sites, but as repositories of
hazardous materials themselves, are potential sites of hazardous materials
incidents. Coordination and communication between hospitals and other
elements of an Emergency Medical Services plan can best be achieved by
hospital staff and physicians fully participating at local meetings for
hazmat planning and protocol review.
Hospitals must acknowledge their role as a component of the community-wide
emergency response system. Hospital administrators must familiarize
themselves with the contingency planning of other components, such as fire,
police, and health departments, and understand what services are expected
from hospitals. Optimally, hospital staff should be represented on
planning committees that develop and periodically review these contingency
plans.
A common characteristic of the successful management of chemical incidents
is adequate contingency planning. Planning requires the involvement of an
array of community institutions -- fire and police departments and
community hospitals. Not every hospital in an area needs to have an
emergency department capable of handling hazardous materials patients. In
fact many communities have centralized such services into one major area
hospital or shock trauma center. However, all hospitals should be capable
of performing decontamination and basic care since some patients may come
in on their own -- not through the Emergency Medical Services (EMS)
Systems. In addition, emergency department personnel must be knowledgeable
about where to send patients for further specialized care.
The Spectrum of Hazardous Materials Incidents
Local and state EMS agencies should be able to participate in the
response to a range of hazmat incidents from the individual level, to the
multi-casualty, to the disaster level. The hospital and emergency medical
responders are key components of the local response system. Planning
should integrate hospital personnel, equipment, and supply needs into the
state and local hazmat plans. In turn, the hospital must be familiar with
these plans and know how to use them if it is involved in a incident that
overwhelms its capabilities.
- Individual patient -- a single individual is contaminated and must be
transported to an emergency department:
- Can be an occupational or accidental exposure.
- May pose a problem in rural areas with small hospitals, or where
there are low levels of hazmat skills and experience for EMTs.
- Multi-casualty -- this situation is usually limited to a single
location:
- Involves normal systems of transportation.
- Patients are usually treated at the same level facility as a single
emergency response, but the demand on all systems is much greater.
- Disaster -- disrupts a large segment of the community:
- Involves several locations.
- Involves additional units to the normal responders; such units are
not part of the local EMS system, and these units may not know how
it works.
- Involves long-range mutual aid; normal systems of transportation
(ambulances) are inadequate or disrupted.
- Patients may be treated locally at different facilities providing
various levels of care, or even outside of the area altogether.
While transportation incidents attract larger media attention, statistics
show that almost 75% of all acute hazardous materials events, excluding
fuel spills, occur in the fixed locations where they are used or stored.
In addition, events resulting in death and injury occur almost 1.5 times as
often in plants as in transit.
Hazardous material incidents range from small releases at a factory site to
rapidly expanding events that endanger a community. Regardless of its
size, an incident's successful management depends on preplanning. This
preplanning often requires coordination between local, state, and federal
agencies, and industries, as well as those in the community who use and
maintain stocks of potentially hazardous materials. Contributions to
hazardous materials planning come from a variety of sources: regulations
from the Joint Commission on Accreditation of Healthcare Organizations,
state and local planning committees established by SARA Title III, state
EMS agencies, and federal agencies.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO
In drawing up contingency plans, administrators of hospitals have
significant guidance available from the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO). The JCAHO establishes standards that
must be met before a hospital can receive accreditation. A comprehensive
accreditation survey occurs once every three years with intermittent
evaluation if a specific area of weakness is identified at the time of full
review.
The Key Indicator Probe (KIP) system in the Plant Technology and Safety
Management Standards is a valuable addition to the accreditation process.
Before the JCAHO survey is conducted, KIPs define what the accreditation
survey expects a hospital to have completed in order to comply with a
specific standard. For example, JCAHO standard PL.1.11.1 describes the
hospital's role in community-wide emergency preparedness plans. The
description of the hospital's role in community-wide emergency preparedness
plans is the key indicator. The probe for this key indicator presents the
question "Is the role of this facility and other health care organizations
and community civil services addressed in the program?"
Additionally, JCAHO standard PL.1.11.2 discusses procedures in response to
environmental or man-made events. For the key indicator item "information
about how the hospital plans to implement specific procedures in response
to environmental or man-made events," there are five probes. These
include:
- Has the organization identified alternate sources of essential
utilities?
- Is there an emergency communication system?
- Is there a procedure for identifying an alternate care site?
- Are facilities available for radioactive or chemical isolation and
decontamination?
- Is there a workable plan for total facility evacuation?
JCAHO Accreditation Standards for Hospitals outlines the JCAHO standards
and indicator probes that there relevant for treating chemically
contaminated patients.
JCAHO Accreditation Standards for Hospitals, 1989
ER.5.2 Current toxicologic reference materials and antidote information
are readily available in the emergency department/service, along with the
telephone number of the regional poison control information center.
ER.5.3 A list of referral and consultation services is prominently
displayed and includes, as appropriate, the regional coordinating office
for radiologic emergency assistance, antivenin service, county coroner or
medical examiner, police department, state and local health departments,
ambulance transport and rescue services, tissue donation centers, and
special care services not provided by the hospital.
ER.6.8.3 Standard drugs, antivenin (in geographic areas as indicated),
common poison antidotes, syringes and needles, parenteral fluids and
infusion sets, plasma substitutes and blood administration sets, and
surgical supplies are available for immediate use.
PL.I.10 There is a hazardous materials and wastes program, designed
and operated in accordance with applicable law and regulation, to identify
and control hazardous materials and wastes; the program includes:
PL.1.10.1 policies and procedures for identifying, handling,
storing, using, and disposing of hazardous materials
from receipt through use and hazardous wastes from
generation to final disposal;
PL.1.10.2 training for and, as appropriate, monitoring of
personnel who manage and/or regularly come into
contact with hazardous materials and/or wastes;
PL.1.10.3 monitoring of compliance with the program's
requirements; and
PL.1.10.4 evaluation of the effectiveness of the program, with
reports to the safety committee and to those
responsible for other appropriate monitoring
activities.
PL.1.11 There is an emergency preparedness program designed to manage the
consequences of natural disasters or other emergencies that
disrupt the hospital's ability to provide care and treatment; the
program includes:
PL.1.11.1 a description of the hospital's role in community
wide emergency preparedness plans;
PL.1.11.2 information about how the hospital plans to implement
specific procedures in response to environmental or
man-made events;
PL.1.11.3 provisions for the management of space, supplies,
communications, and security;
PL.1.11.4 provisions for the management of staff, including
distribution and assignment of responsibilities and
functions;
PL.1.11.5 provisions for the management of patients, including
scheduling of services, control of patient
information, and admission, transfer, and discharge;
PL.1.11.6 staff training in their roles during emergencies;
PL.1.11.7 semiannual implementations of the plan, either in
response to an emergency or in a planned drill.
PL.I.11.7.1 The hospital's performance during
implementation of the plan is evaluated,
documented, and reported to the safety
committee through the hospital-wide
information collection and evaluation
system.
Key Items
PL.1.10.3 monitoring of compliance with the program's requirements; and
Probes
a. Are reports of hazardous materials and waste monitoring programs
presented to the safety committee?
b. Are all hazardous materials and waste incident reports reviewed by
the safety committee?
PL.1.10.4 evaluation of the effectiveness of the program, with reports to
the safety committee and to those responsible for other appropriate
monitoring activities.
a. Does the safety officer or other responsible individual(s) compare the
results of the program with standards established by law, regulation, or
the organization to evaluate the effectiveness of the program?
b. Is the analysis reported to the safety committee and others as
appropriate?
PL.1.11 There is an emergency preparedness program designed to manage
the consequences of natural disasters or other emergency situations that
disrupt the hospital's ability to provide care and treatment; the program
includes:
Is there a current written program at the facility that addresses the
responsibilities of the medical staff, the nursing staff, and support
services during a variety of applicable emergencies, both within the
organization and in the surrounding community?
PL.1.11.1 a description of the hospital's role in community-wide emergency
preparedness plans;
Is the role of this facility and other health care organizations and
community civil services addressed in the program?
PL.1.11.2 information about how the hospital plans to implement specific
procedures in response to environmental or man-made events;
a. Has the organization identified alternate sources of essential
utilities?
b. Is there an emergency communication system?
c. Is there a procedure for identifying an alternate care site?
d. Are facilities available for radioactive or chemical isolation and
decontamination?
e. Is there a workable plan for total facility evacuation?
PL.1.11.3 provisions for the management of space, supplies,
communications, and security;Does the facility's plan address the use of
space, replenishment of supplies, and the loss of communication, security,
and utilities?
PL.1.11.4 provisions for the management of staff, including distribution
and assignment of responsibilities and functions;
a. Does the program list staff roles and responsibilities during
emergencies?
b. Is there a reliable method for notifying staff of an emergency?
c. Is there a procedure for assigning available staff that reflects
staffing changes on various shifts and days?
d. Was the plan tested during drills or actual implementation?
e. Are staff lists current?
PL.1.11.5 provisions for the management of patients, including scheduling
of services, control of patient information, and admission, transfer, and
discharge;
Does the plan include procedures for:
a. modification or discontinuation of less than essential services?
b. moving of patients within the facility?
c. relocating patients outside the facility in the event of an emergency?
d. provision of appropriate medical staff services and physical facilities
to implement the plan?
PL.1.11.6 staff training in their roles during emergencies; and
a. Is there documentation of the training and education of all personnel
who have an assigned role in the emergency preparedness program?
b. Can a random sample of staff adequately describe training they have
received in the emergency preparedness program and in the fire plan?
PL.I.11.7 semiannual implementation of the plan, either in response to an
actual emergency or in a planned drill.
Is there evidence of semiannual implementation, either in response to an
emergency, or in a planned drill?
NOTE: Drills separated by at least four months are acceptable.
NOTE: Organizations that offer emergency services and/or are designated as
disaster receiving stations must have at least one implementation per year
that includes an influx of patients.
PL.1.11.7.1 The hospital's performance during implementation of the plan
is evaluated, documented, and reported to the safety committee through the
hospital-wide information collection and evaluation system.
Is there evidence:
a. of evaluation of the emergency preparedness plan gathered from previous
drills, changes in the mission or capability of hospitals, and changes in
the community?
b. in the community of a review of the effectiveness of the program, and
changes made where appropriate?
c. of critiques of each implementation addressing elements of hospital
preparedness, staff preparedness, and patient management?
d. for each critique, evidence of identification of problems, corrective
actions taken, and recommendations for modification of the program?
e. of a random sample of staff being asked about the drill?
NOTE: Some organizations may not participate in a community-wide emergency
plan. In these cases, item (b) is not applicable, and compliance with
PL.1.11.7.1 will be scored:
- a,c,d,e
- 3 of 4
- 2 of 4
- 1 of 4
- none in place
The emergency department standards include: 1) current toxicologic
reference materials and antidote information (ER.5.2), 2) a list of
referral and consultation services (ER.5.3), and 3) equipment for chemical
incidents (ER.6.8.3). In addition, JCAHO standards and key indicator
probes for a hazardous materials and wastes program (PL.1.10) and an
emergency preparedness program (PL.1.11 ) are provided. A hospital can
more readily comply with some JCAHO standards by using community response
and public information systems mandated by SARA Title III.
SARA Title 111
Title III of the Superfund Amendments and Reauthorization Act (SARA),
passed by Congress in 1986, provides for an infrastructure in states and
local communities to plan for effective response to hazardous material
emergencies. In addition, the legislation also provides for public access
to information on the presence and releases of specified hazardous
chemicals in communities.
Title III, "The Emergency Planning and Community Right-to-Know Act of
1986," required that each state establish a State Emergency Response
Commission (SERC), which consists of members with technical expertise in
emergency response, environmental and natural resources, public health,
occupational safety, media, and transportation. The SERC is responsible
for establishing local emergency planning districts (usually on a county
level), appointing and overseeing local emergency planning committees
(LEPC), establishing procedures for handling public requests for
information, and reviewing LEPC emergency plans.
SARA Title III requires that the local committees must include, at a
minimum, representatives from the following groups: State and local
officials, law enforcement, civil defense, firefighting, environmental,
hospital, media, first aid, health, transportation, and facility owners or
operators subject to the emergency planning requirements. The LEPC was
primarily responsible for preparing a comprehensive emergency response plan
for its district by October 1988, and for making information on hazardous
chemicals, which is submitted under Title III, available to the public.
Using information about the presence of potentially hazardous chemicals
reported by businesses and other facilities under Title III, the LEPC was
to have developed its plan.
As part of the planning process, the LEPC must evaluate available resources
for developing, implementing, and exercising the plan. The plan must
include the following:
- identification of facilities subject to planning provisions under
Title III
- identification of transportation routes for extremely hazardous
substances
- identification of risk-related facilities
- methods and procedures for response
- designated community and facility coordinators
- procedures for public notification
- methods for determining release occurrence and area affected
- description of emergency equipment and facilities and those
responsible
- evacuation plans and training programs
Under Title III's planning provisions, EPA was mandated by Congress to
establish a list of chemicals to help focus local emergency planning
activities. In April 1987, EPA listed 406 Extremely Hazardous Substances
(EHS) and established a Threshold Planning Quantity (TPQ) for each. If any
business or facility contains one of these EHS, in an amount equal to or
greater than its respective TPQ, the facility owner or operator is required
to notify the SERC and LEPC. These facilities must name a facility
coordinator to work with the LEPC for specific inclusion of that facility
in the local plan.
Representative facilities covered under the planning provisions include not
only major chemical manufacturing facilities, but also a wide variety of
chemical users, such as farmers, dry cleaners, and other service-related
businesses. Exemptions under this provision apply only to vessels
(ship/boat), federal facilities, and transportation. Storage incidental to
transportation is exempt provided that the EHS are still moving under
active shipping papers and have not reached the final consignee.
Accidental releases of EHSs and other hazardous substances identified in
the Comprehensive Environmental Response, Compensation, and Liability Act
of 1980 (CERCLA) must be reported to the LEPC and SERC. This requirement
ensures immediate notification to local response personnel. Other
provisions of Title III provide further information on the presence,
storage, and emissions of hazardous and toxic chemicals. These data
further assist the LEPC in obtaining a fuller picture of chemical risk in
the local district.
Hospitals can be better prepared for response to incidents that involve
contaminated patients by actively participating in the LEPC planning
process. Title III provides for the submission of information on hazardous
and toxic chemicals as presented above. In addition, Title III contains a
specific provision for the disclosure of chemical identity by facility
owners or operators on chemicals for which facilities have made trade
secret claims. Access to chemical identity assists health professionals,
physicians, and nurses in obtaining further information for diagnostic
purposes during emergencies and for prevention and treatment measures
during nonemergencies.
The State Emergency Medical Services (EMS) Agency
Planning for hazardous materials incidents should include the
appropriate linkage to the state EMS agency. The state agencies are
responsible for overseeing a network of local EMS units, and thus are an
essential part of the planning process. Often this body is part of the
SERC.
Duties of the agencies vary from state to state. However, EMS agencies
usually are responsible for medical management and medical control of first
responders. EMS agencies develop medical mutual aid agreements between
counties, and establish procedures for distribution of casualties between
hospitals. In addition, these agencies maintain an inventory of disaster
medical supplies. Further, EMS agencies develop and maintain
communications protocols for on-site activities: between receiving
hospitals and the base hospital, between base hospitals and ambulances, and
between all hospitals and the Regional Poison Control Center. The EMS
agencies also work with counties in designating field casualty
decontamination and collection points for a major disaster.
Suggested planning activities may include:
Medical Direction -- the local EMS agency should be contacted for
information on how medical control is provided for the EMS system.
Patient Destination -- hospital emergency departments are able to
provide supportive care. However, in some cases it may be more
appropriate to take the patient to a hospital that has expertise in
handling certain kinds of poison exposures. The plan should include
directions for obtaining this information. One option is to go through the
Regional Poison Control Center via the base hospital. The poison center
will often know which hospitals are best prepared for which substances.
Decontamination and Medical Management Protocols -- the literature on
the clinical management of hazardous materials exposures is sometimes
inconsistent in its recommendations. Provision should be made in the plan
for obtaining field and hospital medical management information from
experienced physicians. For example, the Regional Poison Control Center
can provide decontamination and medical management protocols via facsimile
transmission or telephone to all receiving hospitals, and through the base
hospital or via cellular telephone to EMTs in the field. They also have
rapid access to experts.
Coordination with Burn Centers, Hyperbaric Chamber Facilities, and
Other Specialty Centers -- provision should be made to alert and coordinate
patient destination with various specialty care centers.
Federal Emergency Response Activities
Contingency planning is essential to the successful implementation of
any system designed to manage chemically contaminated patients and to
promptly contain the hazard itself. Contingency plans require a
coordinated community response that may also involve state and federal
agencies. Pre-planning and coordination of services are equally critical
at the national level. A National Contingency Plan (NCP) has been
established by the federal govemment to promote coordination of resources
and services of federal and state response systems. To oversee this plan,
a National Response Team (NRT) and National Response Center, a network of
Regional Response Teams (RRTs), and a group of On-Scene Coordinators (OSCs)
have been established.
The Hazardous Materials Emergency Planning Guide, referred to as NRT-1,
provides guidance to help local communities prepare for potential hazardous
materials incidents. The NRT-1 can be used by local communities developing
their own plan, as well as by LEPCs formed in accordance with the
"Emergency Planning and Community Right-to-Know Act" (SARA Title III) of
1986.
The objectives of the Hazardous Materials Emergency Planning Guide are to:
- Focus communities on emergency preparedness and response.
- Provide communities with information that can be used to organize
the emergency planning task.
- Furnish criteria for risk and hazard assessments, and assist
communities in determining whether a hazardous materials incidents
plan is needed, in addition to the district-wide plan developed by
the LEPC.
- Help LEPCs and individual communities prepare a plan that is
appropriate for their needs and consistent with their capabilities.
- Provide a method for revising, testing, and maintaining community
emergency plans.
The NRT-1 is published by the National Response Team, and was developed
cooperatively by its 14 federal member agencies, including the Department
of Defense, Department of the Interior, Department of Transportation
(Research and Special Programs Administration and U.S. Coast Guard),
Environmental Protection Agency (EPA), Department of Commerce (National
Oceanic and Atmospheric Administration [NOAA]), Federal Emergency
Management Agency (FEMA), Department of State, Department of Agriculture,
Department of Health and Human Services (Agency for Toxic Substances and
Disease Registry), Department of Justice, Department of Labor (Occupational
Safety and Health Administration), Nuclear Regulatory Commission, and the
Department of Energy. The NRT-1 represents a concerted effort by federal
agencies to consolidate their general hazardous material planning guidance
into an integrated federal document.
NRT-1 states that an emergency plan must include response procedures of
facilities and local emergency and medical personnel, as well as a
description of emergency equipment and facilities in the community. It
also recommends that hospital, emergency medical service, and health
department personnel be included as members of an emergency planning team.
As previously mentioned, SARA Title III requires medical, hospital, and
first aid personnel to be members of the local emergency planning
committee. The NRT-1 describes relevant publications that provide specific
operational guidance to emergency responders, such as the DOT's Emergency
Response Guidebook for first responders, which provides guidance for
firefighters, police, and other emergency services personnel to help them
protect themselves and the public during the initial minutes immediately
following a hazardous materials incident.
In addition, the document provides information on the Chemical
Manufacturers Association's (CMA) Community Awareness Emergency Response
(CAER) and Chemical Transportation Emergency Center (CHEMTREC) programs.
The CAER program encourages local facilities to inform local residents,
public officials, and emergency response organizations about industry
operations and to integrate their on-site emergency response plans with the
planning efforts of the local community. In some areas of the country, the
chemical industry has established physician networks. The purpose of the
networks is to develop a better dialogue between company physicians and
local health authorities. CAER has outlined that the following specific
steps be taken: review the plant emergency plan, improve employee
awareness and training, prepare a community relations plan, inventory the
status of local emergency planning, develop a briefing paper, prepare a
list of initial contacts, meet with initial contacts and identify key
officials, establish a coordinating group, and begin implementation steps.
On the federal level, EPA and FEMA provide technical assistance and
guidance to local and state planners through the SARA Title III program.
The NRT-I document also recommends that contingency plans include:
standard operating procedures for entering and leaving sites,
accountability for personnel entering and leaving sites, decontamination
procedures, recommended safety and health equipment, and personal safety
precautions. The document suggests that emergency plans include a list of
emergency response equipment appropriate to various degrees of hazard using
the EPA levels of protection (A, B, C, and D). Further, it recommends that
the list include the type of respirator (e.g., self-contained breathing
apparatus, supplied-air respirator, or air-purifying respirator), the type
of clothing that must be worn, and the equipment needed to protect the
head, eyes, face, ears, hands, arms, and feet.
In addition, the NRT- 1 recommends that medical personnel be made aware of
significant chemical hazards in the community in order to train properly
and prepare for possible hazardous materials incidents. It also states
that emergency medical teams and hospital personnel must be trained in the
proper methods for decontaminating and treating persons exposed to
hazardous chemicals.
Hazard Ananlysis
Hazard analysis is a necessary step in comprehensive emergency
planning for a community. It is a three-step decision-making process
comprised of: hazard identification, vulnerability analysis, and risk
analysis. The first task in conducting analysis is to complete an
inventory of the hazardous materials present in the community and describe
the nature of the hazard. This is a key step because it permits planners
to describe and evaluate risks and, to allocate resources accordingly.
However, the task of analyzing all relevant hazards may not prove cost
effective to many communities. The planning committee therefore should
assign priorities to the hazards found in its community,and establish
affordable limits for analysis. It should be noted that several federal
agencies (e.g., DOT, FEMA, and EPA) report that frequently encountered
substances often pose the most prevalent dangers. These materials include
fuels and chemicals, such as chlorine, ammonia, and hydrochloric and
sulfuric acids. Such materials should be given special attention by the
LEPC in the planning process.
In this context, a hazard is any situation that is capable of causing
injury or impairing an individual's health. During the process of
identifying hazards, facilities or transportation routes will be pinpointed
that contain materials that are potentially dangerous to humans. The
identification of hazards also should provide the following information:
- The types, quantities, and location of hazardous materials in the
community, or transported through a community
- The nature of the hazard that would accompany incidents, such as
explosions, spills, fires, and venting to the atmosphere
Hazards should be identified at as many facilities in the community as
possible. These include the obvious ones such as chemical plants,
refineries, petroleum plants, and storage facilities and warehouses. In
requesting information directly from facilities, remember that SARA Title
III planning provisions require certain facilities to provide the LEPC with
any information on the facility that the committee needs to develop and
implement its plan. The LEPCs may provide assistance here, particularly if
the LEPC has industry representatives on it. It is essential that these
industries or businesses understand the role these data play in ensuring a
sound emergency response plan. As previously stated, placing business or
industrial representatives on the community-wide planning committee as
required under SARA Title III may assist in gaining their cooperation. The
cooperation and assistance of a facility that regularly deals with
hazardous materials presents the local planning unit with a wide array of
services. For example, such a facility can provide technical experts,
11spill prevention control and countermeasure (SPCC) plans, training and
safe handling instructions, and cleanup capabilities.
In addition, hospitals and educational and governmental facilities should
not be overlooked since they all contain a variety of chemicals. Major
transportation routes and transfer points, such as airports, vessels in
port, railroad yards, and trucking terminals, should be included in the
overall hazards identification plan. SARA Title III planning provisions,
for example, address many of these potential risk areas by requiring the
following: facility cooperation in plan preparation, a wide range of
chemical handlers (manufacturers to service-related businesses), and
specific risk areas to be addressed in the plan (i.e., transportation).
Risk analysis includes the probable damage that may occur if a chemical
incident occurs. Information that is necessary for a risk analysis
includes:
- The type of risk to humans, such as an acute, chronic, or delayed
reaction
- The groups that are at highest risk
- The type of risk to the environment, such as permanent damage or
recoverable condition
Many documents can be of assistance in conducting a risk analysis. Risk
analysis in transportation settings has been outlined in the DOT's
"Community Teamwork: Working Together To Promote Hazardous Materials
Safety, A Guide for Local Officials". In conjunction with FEMA and DOT,
EPA published a supplement to NRT-1 in December 1987. This document,
entitled Technical Guidance for Hazardous Analysis and often referred to as
the "Green Book," provides technical assistance to LEPCs in assessing the
lethal hazards associated with potential airborne releases of extremely
hazardous substances.
Selected Bibliography
Department of Transportation. Community Teamwork: Working Together To
Promote Hazardous Materials Safety, A Guide for Local Officials.
Washington, DC, May 1983.
Environmental Protection Agency and Federal Emergency Management Agency.
Technical Guidance for Hazardous Anaysis: Emergency Planning for Extremely
Hazardous Substances. Environmental Protection Agency, Washington, DC,
December 1987.
Federal Emergency Management Agency. Guide for Development of State and
Local Emergency Operations Plan. Washington, DC, October 1985; CPG 1-8.
Federal Emergency Management Agency. Planning Guide and Checklist for
Hazardous Materials. U.S. Government Printing Office, Washington, DC, July
1981; FEMA-10.
National Institute for Occupational Safety and Health/Occupational Safety
and Health Administration. Pocket Guide to Chemical Hazards. U.S.
Government Printing Office, Washington, DC, 1985.
National Response Team. Hazardous Materials Emergency Planning Guide. U.S.
Government Printing Office, Washington, DC, 1987; NRT 2100.
SARA Title 111 Compliance Guidebook, Government Institutes, Inc., 1988;
ISBN: 0-86587-749-1.
Appendix A; Hazardous Materials Classification Systems
- National Fire Protection Association, 704M System
- Department of Transportation DOT Chart 9
- Example of Department of Labor Material Safety Data Sheet NFPA 704M
System Notes; HEALTH (BLUE)
In general, health hazard in firefighting is that of a single exposure
which may vary from a few seconds up to an hour. The physical exertion
demanded in firefighting or other emergency conditions may be expected to
intensify the effects of any exposure. Only hazards arising out of an
inherent property of the material are considered. The following
explanation is based upon protective equipment normally used by
firefighters.
4 Materials too dangerous to health to expose firefighters. A few
whiffs of the vapor could cause death or the vapor or liquid could
be fatal on penetrating the firefighter's normal full protective
clothing. The normal full protective clothing and breathing
apparatus available to the average fire department will not provide
adequate protection against inhalation or skin contact with these
materials.
3 Materials extremely hazardous to health but areas may be entered
with extreme care. Full protective clothing -- including self-
contained breathing apparatus, coat, pants, gloves, boots, and
bands around legs, arms, and waist -- should be provided. No skin
surface should be exposed.
2 Material hazardous to health, but areas may be entered freely with
full-faced mask self-contained breathing apparatus which provides
eye protection.
1 Materials only slightly hazardous to health. It may be desirable
to wear self-contained breathing apparatus.
0 Materials which on exposure under fire conditions would offer no
hazard beyond that of ordinary combustible material.
Flammability (RED)
Susceptibility to burning is the basis for assigning degrees within
this category. The method of attacking the fire is influenced by this
susceptibility factor.
4 Very flammable gases or very volatile flammable liquids. Shut off
flow and keep cooling water streams on exposed tanks or containers.
3 Materials which can be ignited under almost all normal temperature
conditions. Water may be ineffective because of the low flash
point.
2 Materials which must be moderately heated before ignition will
occur. Water spray may be used to extinguish the fire because the
material can be cooled below its flash point.
1 Material that must be preheated before ignition will occur. Water
may cause frothing if it gets below the surface of the liquid and
turns to steam. However, water fog gently applied to the surface
will cause a frothing which will extinguish the fire.
0 Materials that will not burn.
Reactivity (STABILITY) (YELLOW)
The assignment of degrees in the reactivity category is based upon the
susceptibility of materials to release energy either by themselves or in
combination with water. Fire exposure was one of the factors considered
along with conditions of shock and pressure.
4 Materials which (in themselves) are readily capable of detonation
or of explosive decomposition or explosive reaction at normal
temperatures and pressures. Includes materials which are sensitive
to mechanical or localized thermal shock. If a chemical with this
hazard rating is in an advanced or massive fire, the area should be
evacuated.
3 Materials which (in themselves) are capable of detonation or of
explosive decomposition or of explosive reaction which require a
strong initiating source which must be heated under confinement
before initiation. Includes materials which are sensitive to
thermal or mechanical shock at elevated temperatures andpressures
or which react explosively with water without requiting heat or
confinement. Fire fighting should be done from an explosive-
resistant location.
2 Materials which (in themselves) are normally unstable and readily
undergo violent chemical change but do not detonate. Includes
materials which can undergo chemical change with rapid release of
energy at normal temperatures and pressures or which can undergo
violent chemical change at elevated temperatures and pressures.
Also includes those materials which may react violently with water
or which may form potentially explosive mixtures with water. In
advanced or massive fires, firefighting should be done from a safe
distance or from a protected location.
1 Materials which (in themselves) are normally stable but which may
become unstable at elevated temperatures and pressures or which may
react with water with some release of energy but not violently.
Caution must be used in approaching the fire and applying water.
0 Materials which (in themselves) are normally stable even under fire
exposure conditions and which are not reactive with water. Normal
firefighting procedures may be used.
U.S. Department of Transportation Research and Special ProgramsAdministration Hazardous Materials Marking, Labeling & Placarding
June 15, 19931 Guide
This Marking, Labeling and Placarding Guide will assist shippers,
carriers, fire departments, police, emergency response personnel, and
others in complying with, and enforcing the regulations governing the safe
transport of hazardous materials by highway, rail, water and air.
The information and illustrations presented in this Guide are intended to
serve as an introduction to regulations governing hazardous materials
transportation. The Guide should be read in conjunction with the Hazardous
Materials Regulations (HMR; 49 CFR 100-199). Published annually, and
amended periodically, the HMR are the key to compliance and contain the
information needed to comply with the requirements for the safe transport
of hazardous materials.
** The DOT Chart 9 and the Guidelines for Hazardous Materials Warning
Labels can be ordered from the Publication Warehouse 404-639-6360.
Material Safety Data Sheets
The Material Safety Data Sheet (MSDS) has become a major source of
chemical information. It is the key document used to provide hazard
information to employees and can become an invaluable tool for emergency
personnel when used in a chemical emergency.
Occupational Safety and Health (OSHA) Hazard Communication Standard (29 CFR
1910.1200) requires all manufacturers of pure chemicals and/or mixtures to
evaluate their products and relate, via MSDS, any hazards that may be
encountered while handling these materials. This standard is intended for
all workplaces, manufacturing and non-manufacturing alike. The
Environmental Protection Agency's (EPA) Emergency Response and Community
Right-to-Know Act of 1986 ensures the availability of MSDS to emergency
response personnel such as fire departments, first aid crews, and hospital
emergency room staff.
MSDS contain a wealth of information which may be understood with a minimum
of training. It is the purpose of this document to briefly explain the
format and information found in properly prepared MSDS.
SECTION 1--Figure 7
This section identifies the material by product or trade name and chemical
name. It is the product or trade name that is usually found on the
container labels although the chemical name is also required by some
states. Section I will also contain the manufacturer's name, address, and
telephone number.
SECTION 2--Figure 7
This section lists the chemical ingredients of the material if they are
known or suspected to be hazardous. Hazardous materials which are not
carcinogens must be reported if they represent 1 percent or more of the
product. Carcinogens must be reported and identified as such if their
levels are O.1 percent or higher. Also included in this section are
Threshold Limit Values (TLV) and OSHA Permissible Exposure Limit (PEL).
SECTION 3--Figure 7
Section 3 provides physical data about the product that can be utilized for
proper identification. Included are specifics such as color, odor,
specific gravity (weight), vapor pressure, and boiling point.
SECTION 4--Figure 7
Section 4 includes fire and explosion hazard data. This information is
especially useful when devising both in-house and community contingency
plans. Plant first responders, local fire deparunents, and HAZMAT teams
need unlimited access to this information.
SECTION 5--Figure 8
This section contains information on the reactivity of the product. It
will list other chemicals which, when mixed with the product, will result
in a chemical reaction. If a product is water reactive it will be noted in
this section.
Also, hazardous decomposition products such as carbon monoxide and other
hazardous gases formed and emitted during chemical reactions or during
fires are listed. It is imperative that this section be carefully noted by
firefighters, both in-house and local.
SECTION 6--Figure 8
Section 6 contains health hazard data. It will describe any acute (short-
term exposure) and/or chronic (long-term exposure) effects on the body.
These will include routes (inhalation, skin, ingestion) of overexposure and
the bodily organs affected as well as the signs and symptoms of
overexposure. First aid procedures will also be found in this section.
SECTION 7--Figure 8
Section 7 lists the procedures that should be used if the product spills or
leaks, including waste disposal methods.
SECTION 8--Figure 8
Section 8 contains information regarding the proper personal protective
equipment (PPE) necessary to handle the product in a manner which will
minimize exposure. Ventilation practices are also listed in this section.
Summary --
A Material Safety Data Sheet can aid in making the right decisions on
health and safety issues in a plant or in a community. Yet, it must be
noted that it is but one of many references that should be used to make
final determinations. MSDS are offered by manufacturers for identification
and verification and are not the last word on safety and health practices.
Appendix B; Types of Respiratory Protection
(Table 9)
Appendix C; Levels of Protection
(Table 10)
Additional Information
The Agency for Toxic Substances and Disease Registry would greatly
appreciate your comments and suggestions for improving future editions of
this guidance material. They may be addressed to:
ATSDR
Attention: Scott V. Wright
Hazardous Materials Response Committee
Emergency Response and Consultation Branch (MS E57)
1600 Clifton Road, N.E.
Atlanta, GA 30333
Acknowledgements
To facilitate the usefulness of this guidance document, the Agency for
Toxic Substances and Disease Registry (ATSDR) convened a panel of experts
to guide the project in identifying and ranking the important actions and
requirements involved in the safe management of chemically contaminated
patients. The panel members brought to the project their different
emergency medical perspectives, as well as their life experiences, to
ensure that their colleagues would find this guidance document both
realistic and useful.
ATSDR thanks the panel members for their contributions:
- Phillip L. Currance, EMT-P
Emedia, Inc.
3300 East First Avenue Suite 330
Denver, Colorado 80206
(303) 377-9100
-
Ralph B. "Monty" Leonard, Ph.D., M.D., F.A.C.E.P.
Department of Emergency Medicine
Bowman Gray School of Medicine
Medical Center Boulevard
Winston-Salem, North Carolina
(919) 748-4625
-
Chief Mary Beth Michos, R.N.
-
Training Officer, Montgomery County,
Maryland Department of Fire-Rescue Services
- EMS Specialist, Montgomery County,
Maryland Hazardous Incidents Response Team
Department of Fire and Rescue Services
101 Monroe Street, 12th Floor
Rockville, Maryland 20850
(301) 217-2099
- Eric K. Noji, M.D., M.P.H, F.A.C.E.P.
Assistant to the Branch Chief for Emergency Response
Health Studies Branch (Mail Stop F28)
Division of Environmental Hazards and Health Effects
National Center for Environmental Health and Injury Control
Centers for Disease Control
Atlanta, Georgia 30333
(404) 639-4682
-
Martin J. O'Neill, Industrial Hygienist
Roy F. Weston, Inc.
Raritan Plaza One
4th Floor Raritan Center
Edison, New Jersey 08837
(908) 225-3990
-
Paul R. Seidlitz, R.N.
Seidlitz and Associates
457 Altgeld
Glendale Heights, Illinois 60139
(708) 469-9552
The project was directed by Scott V. Wright, Environmental Health
Scientist, Program Operations Section, Emergency Response and Consultation
Branch (ERCB), Division of Health Assessment and Consultation (DHAC),
ATSDR. Contributors were Frank Mitchell, D.O. Chief Medical Officer,
ATSDR; Michael Straight, M.D., Division of Health Studies, ATSDR; and Edwin
Kent Gray, Chief, Emergency Response Coordination Group, National Center
for Environmental Health and Injury Control, CDC. Consultants to the
project were Rosalind Brannigan, Gary Turner, Shelli Rossman, Ron Brown,
Eugenia Davis, and B.J. Boyd of Technical Resources, Inc.
This document is the result of an intensive process of comment and review
by the panel members, the aforementioned project directors and consultants,
and other appropriate federal, state, and private agencies. These include:
-
Ben Blankeshire, NREMT-A, NAEMT, Secretary,
Board of Directors, Board of Governors
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Kenneth Bouvier, NREMT-I, Chairman
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
MacNeil Cross,
NREMT-P, Co-Chairman,
Mass Casualty Incidents
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Robert Daughdril,
NREMT-P, NAEMT Board of Governors
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Craig Deatley,
EMT-P, PA-C, Advisory Committee Member
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
- Eileen Fanes,
NREMT-P, Advisory Corrktnittee Member
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Steve Finefrock,
Education Specialist Technological Programs
Division Emergency Management Institute
Federal Emergency Management Agency
Building "N" NETC Campus
Emmitsburg, Maryland 21727
(301) 447-1282
-
John Friery,
NREMT-A Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Niel Holtz, NREMT-P
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway Kansas City, Missouri 64114
(816) 444-3500
-
Winston E. Jones, R.N.
NREMT-P, NAEMT Board of Directors
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway Kansas City, Missouri 64114
(816) 444-3500
-
William J. Keffer,
Senior Engineering Advisor
Environmental Services Division
U.S. Environmental Protection Agency, Region VII
25 Funston Road
Kansas City, Kansas 66115
(913) 551-5009
-
Gus A. Koehler, Ph.D.
Disaster Medical Response Planner
California Emergency Medical Services Authority
1930 9th Street, Suite 100
Sacramento, California 95814
(916) 322-2300
-
Kenneth Kuntz
Fire Data Specialist
Office of Fire Data and Analysis
U.S. Fire Administration
16825 South Seton Avenue
Emmitsburg, Maryland 21727
(301) 447-1272
-
Paul Manascalo,
NREMT-P, NAEMT Vice President
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Kent R. Olson, M.D., F.A.C.E.P.,
Medical Director
San Francisco Area Regional Poison Control Center
San Francisco General Hospital
1001 Potrero Avenue
San Francisco, California 94110
(415) 821-5526
-
Chappell D. Pierce, Director
Office of Fire Protection Engineering and Systems Safety Standards
U.S. Department of Labor
Occupational Safety and Health Administration
200 Constitution, N.W.- Room North 3609
Washington, D.C. 20210
(202) 523-7216
-
Alonzo Smith, NREMT-P
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Clark Staten, NREMT-P,
Co-Chairman Hazardous Materials Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Dave Tauber, NREMT-P
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
-
Joe E. Taylor, R.N., Ph.D.
Emergency Nurses Association
16 Chickasaw Drive
Laurel, Mississippi 39440
(601) 425-6809 (pager)
(601) 426-4720 (office)
-
Sandra L. Tirey, Associate Director
Health, Safety, and Chemical Regulations
Chemical Manufacturers Association
2501 M Street, N.W.
Washington, D.C. 20037
(202) 887-1274
-
Wallace Weaver
Emergency Management Specialist
U.S. Department of Energy
EM-50. I
12800 Middlebrook Road
Germantown, Maryland 20585
(301) 353-7669
-
Steve White, NREMT-P, NAEMT Board of Directors
Emergency Management Committee
National Association of Emergency Medical Technicians
9140 Ward Parkway
Kansas City, Missouri 64114
(816) 444-3500
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service
Agency for Toxic Substances and Disease Registry
The Agency for Toxic Substances and Disease Registry (ATSDR) has produced a
three-volume series entitled Managing Hazardous Materials Incidents. The
series is designed to assist emergency response and health care
professionals plan for and respond to hazardous material emergencies.
Volume I Emergency Medical Systems: A planning Guide for the Management of
Contaminated Patients.
Volume II Hospital Emergency Departments: A Planning Guide for the
Management of Contaminated patients.
Volume III Medical Management Guidelines for Acute Chemical Exposures.
Volumes I and II are planning guides to assist first responders and
hospital emergency department personnel in planning for incidents that
involve hazardous materials.
Volume III is a guide for health care professionals who treat persons who
have been exposed to hazardous materials.
Agency for Toxic Substances and Disease Registry
William L. Roper, M.D., Administrator
Barry L. Johnson, Ph.D., Assistant Administrator
Division of Health Assessment and Consultation
Robert C. Williams, P.E., Director
Juan J- Reyes, Acting Deputy Director
Emergency Response and Consultation Branch
C. Harold Emmett, P.E., Chief
Additional copies of this report are available from:
Emergency Response and Consultation Branch (E57), Division of Health
Assessment and Consultation, Agency for Toxic Substances and Disease
Registry, 1600 Clifton Road, N.E., Atlanta, Georgia 30333, (404) 639-6360
Use of trade names is for identification only and does not constitute
endorsement by the Public Health Service or the U.S. Department of Health
and Human Services.
POINT OF CONTACT FOR THIS DOCUMENT:
To request a copy of this document or for questions concerning this
document, please contact the person or office listed below. If
requesting a document, please specify the complete name of the
document as well as the address to which you would like it mailed.
Note that if a name is listed with the address below, you may wish
to contact this person via CDC WONDER/PC e-mail.
SCOTT V WRIGHT
AGENCY FOR TOXIC SUBSTANCES AND DISEASE REGISTRY
Centers for Disease Control
1600 Clifton Rd, NE MS(E-57)
Atlanta, GA 30333
Table 1
Table 1 Telephone Information and Technical Support References
========================================================================================================================================================================================
Resource Contact Services Provided
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CHEMTRAC 1-800-424-9300 24-hour emergency number. Connection with manufacturers and/or shippers who will provide
(Chemical Transportation Emergency advice on handling rescue gear needed, decontamination considerations, etc. Also provides
Center) access to Chlorine Emergency Response Plan (CHLOREP)
ATSDR 1-404-639-0615 24-hour emergency number for health-related support in hazard materials emergencies,
(Agency for Toxic Substances including on-site assistance, if necessary.
and Disease Registry)
Bureau of Explosives 1-202-639-2222 24-hour emergency number for hazardous materials incidents involving railroads.
Emergency Planning and Community Right- 1-800-535-0202 8:30 am-7:30 pm (EST) Provides information on SARA Title III. Provides list of extremely
to-Know Information Hotline hazardous substances and planning guidelines.
EPA (Environmental Protection Agency) Environmental response team available.
Regional Offices Region I - (617)565-3698
CT, ME, MA, NH, RI, VT
Region II - (212) 264-0504
NJ, NY, PR, VI
Region III - (215) 597-0980
DE, DC,MD, PA, VA, WV
Region IV - (404) 347-3454
AL, FL, GA, KY, MS, NC, SC, TN
Region V - (312) 886-7579
IL, IN, MI, MN, OH, WI
Region VI - (214) 655-6760
AR, LA, NM, OK, TX
Region VII - (913) 236-2850
IA, KS, MO, NE
Region VIII - (303) 293-1720
CO, MT, ND, SD, UT, WY
Region IX - (415) 974-7460
AM, SAMOA, AZ, CA, GU, HI, NV, Trust Territory of
the Pacific Isl., Marshall Isl.,Palau, Ponape
Region X - (206) 442-2782
AK, ID, OR, WA
National Animal Poison Control Center 1-217-333-3611 24-hour consultation concerning animal poisonings or chemical contamination. Provides an
emergency response team to investigate incidents and perform laboratory analysis.
National Response Center 1-800-424-8802 For reporting transportation incidents where hazardous materials are responsible for death,
serious injury, property damage in excess of $50,000, or continuing danger to life and
property.
========================================================================================================================================================================================
Table 2
Table 2 Local Telephone Information and Technical Support Resource Worksheet
=============================================================================================================================
Resource Contact Services Provided
(fill in future reference) (fill in for future reference)
-----------------------------------------------------------------------------------------------------------------------------
EPA Regional Office
-----------------------------------------------------------------------------------------------------------------------------
Regional Poison Control Center
-----------------------------------------------------------------------------------------------------------------------------
State Emergency Response Commission
-----------------------------------------------------------------------------------------------------------------------------
State Health Department
-----------------------------------------------------------------------------------------------------------------------------
Community Fire Department
-----------------------------------------------------------------------------------------------------------------------------
Community Police Department
-----------------------------------------------------------------------------------------------------------------------------
Local Emergency Planning Committee
-----------------------------------------------------------------------------------------------------------------------------
Local Health Department
-----------------------------------------------------------------------------------------------------------------------------
State Department of Natural Resources
-----------------------------------------------------------------------------------------------------------------------------
=============================================================================================================================
Table 3
Table 3 Computerized Data Sources of Information and Technical Support
===============================================================================================================================================================================
Data Systems Contact Description
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ANSWER ANSWER National Library of Medicine's Workstation of Emergency Response (ANSWER) - to advise
Specialized Information Svcs. emergency response health professionals on potential hazardous chemical emergencies.
National Library of Medicine
Building 38A
8600 Rockville Pike
Bethesda, Maryland 20894
(301) 496-6531
CAMEO CAMEO Database Manager Computer-Aided Management of Emergency Operations available to on-scene responder
National Oceanic and Chemical identification database assists in: identifying substance involved, predicting
Atmospheric Administration downwind concentrations, providing response recommendations, and identifying potential
(NOAA) Hazardous Materials hazards.
Response Branch, N/OMA-34
7600 Sand Point Way, NE
Seattle, Washington 98115
(206) 526-6317
CHRIS CIS, Inc. Chemical Hazard Response Information System, developed by the Coast Guard and comprised
Fein Management Associates reviews on fire hazards, fire fighting recommendations, reactivities, physicochemical
7215 York Road properties, health hazards, use of protective clothing, and shipping information for over
Baltimore, Maryland 21212 chemicals
(800) 247-8737
HAZARDTEXT Micromedex, Inc. Assists responders dealing with incidents involving hazardous materials such as spills, leaks,
660 Bannock Street and fires. Emergency medical treatment and recommendations for initial hazardous response
Denver, Colorado 80203-3527 are presented.
(800) 525-9083
HMIS David W. Donaldson Hazardous Material Information Systems provides name and emergency phone number of
Information Sys. Specialist manufacturer, chemical formula, NIOSH number, fire fighting, spill, and leak procedures.
Dept. of Trans/RSPA/OHMT
400 7th Street, S.W.
Washington, D.C. 20590
(202) 366-5869
HSDB Toxicology Data Network Hazardous Substances Data Bank, compiled by the National Library of Medicine, provides
(TOXNET) reviews on the toxicity, hazards, and regulatory status of over 4,000 frequently used chemicals.
National Library of Medicine
Toxicology Information Program
8600 Rockville Pike
Bethesda, MAryland 20894
(301) 496-6531
1st MEDICAL RESPONSE PROTOCOLS Micromedex, Inc. For use in developing training programs and establishing protocols for first aid or initial
660 Bannock Street workplace response to a medical emergency.
Denver, Colorado 80203-3527
(800) 525-9083
MEDITEXT Micromedex, Inc. Provides recommendations regarding the evaluation and treatment of exposure to industrial
660 Bannock Street chemicals.
Denver, Colorado 80203-3527
(800) 525-9083
OHMTADS CIS, Inc. Oil and Hazardous Materials Technical Assistance Data Systems provides effects of spilled
Fein Management Associates chemical compounds and their hazardous characteristics and properties, assists in identifying
7215 York Road unknown substances, and recommends procedures for handling and cleanup.
Baltimore, Maryland 80203-3527
(800) 247-8737
TOMES Micromedex, Inc. The Tomes Plus Information Systems is a series of comprehensive databases on a single CD-
660 Bannock Street ROM disc. It provides information regarding hazardous properties of chemicals and medical
Denver, Colorado 80203-3527 effects from exposure. The Tomes Plus database contains Meditext, Hazardtext, HSDB
(800) 525-9083 CHRIS, OHMTADS, and 1st Medical Response Protocols.
TOXNET Toxicology Data Network Computerized system of three toxicologically oriented data banks operated by the National
(TOXNET) Library of Medicine-- the Hazardous Substances Data Bank, the Registry of toxic Effects of
National Library of Medicine Chemical Substances, and the Chemical Carcinogenesis Research Information System.
Toxicology Information Prog. TOXNET provides information on the health effects of exposure to industrial and environmen-
(301) 496-6531 tal substances.
===============================================================================================================================================================================
Table 4
Table 4 Examples of Adverse Health Effects from Exposure to Toxic Chemicals
=============================================================================================================
Toxic End Point Target Organ Example of Health Effect
Systems Causative Acute Chronic
Effects
-------------------------------------------------------------------------------------------------------------
Carcinogenicity Multiple Sites Benzene Dermatitis Aleukemia
Tightness in Chest Myeloblastic
leukemia
Hepatotoxicity Liver Carbon Tetra- Vomiting Liver Necrosis
chloride Vesication Fatty Liver
Dizziness
Neurotoxicity Nervous System Lead Nausea Wrist Drop
Vomiting IQ Deficits
Abdominal Pain Encephalopathy
Nephrotoxicity Kidney Cadmium Vomiting Kidney Damage
Diarrhea Anemia
Chest Pain
=============================================================================================================
Table 5
Table 5 Classification of Factors Influencing Toxicity
==================================================================================================================
Type Examples
------------------------------------------------------------------------------------------------------------------
1. Factors related to the chemical. Composition (salt, freebase, etc.);physical characteristics
(size, liquid, solid, etc.); physical properties (volatility, solu-
bility, etc.); presence of impurities; breakdown products; carriers
2. Factors related to exposure. Dose; concentration; route of exposure (inhalation, ingestion,
etc.) duration.
3. Factors related to person exposed. Heredity; immunology;nutrition; hormones; age; sex; health
status; preceding diseases.
4. Factors related to environment. Media (air, water, soil, etc.) additional chemicals present;
temperature; air pressure.
==============================================================================================================
Table 6
Table 6 Dose-Response Relationship for Humans Inhaling Tetrachloroethylene Vapors
===================================================================================================
Levels in Air Duration of Exposure Effect on
Nervous System
---------------------------------------------------------------------------------------------------
50 ppm Odor threshold
100 ppm 7 hours Headache, drowsiness
200 ppm 2 hours Dizziness, uncoordination
600 ppm 10 minutes Dizziness, loss of inhibitions
1000 ppm 1-2 minutes Marked dizziness
intolerable eye and
respiratory tract irritation
1500 ppm 30 minutes Coma
Table 7
Table 7 Acute LD50 Values for Representative Chemicals When Administered Orally to Rats
=========================================================================================
Chemical Acute Oral LD50
(mg/kg)*
-----------------------------------------------------------------------------------------
Sodium cyanide 6.4 - 10
Pentachlorophenol 50 - 230
Chloride 83 - 560
Lindane 88 - 91
Toluene 2,600 - 7,000
Tetrachloroethylene 3,000 - 3,800
-----------------------------------------------------------------------------------------
*Milligrams of the compound administered per kilogram body weight of the
experimental animal.
=========================================================================================
Table 8
Table 8 Occupational Exposure Limits
============================================================================================================================
Value Abbreviation Definition
Threshold Limit Value TLV Refers to airborne concentrations of substances
(3 Types) and represents conditions under which it is
(ACGIH) believed that nearly all workers may be repeatedly exposed
day after day without adverse effect.
1)Threshold Limit Value- TLV-TWA The time-weighted average concentration for a normal
Time-Weighted Average 8-hour workday and a 40-hour workweek, to which
(ACGIH) nearly all workers may be repeatedly exposed, day after
day, without adverse effect.
2)Threshold Limit Value TLV-STEL The concentration to which workers can be exposed
Short-Term Exposure Limit continuously for a short period of time without suffer-
ing from: 1) irritation, 2) chronic or irreversible tissue
damage, or 3) narcosis of sufficient degree to increase the
likelihood of accidental injury, impair self-rescue or mate-
rially reduce work efficiency, and provided that the daily
TLV-TWA is not exceeded.
3)Threshold Limit Value- TLV-C The concentration that should not be exceeded during
Ceiling (ACGIH) any part of the working exposure.
Permissible Exposure PEL Same as TLV-TWA.
Limit (OSHA)**
Immediately Dangerous IDLH A maximum concentration (in air) from which one could to
to Life and Health (OSHA)** escape within 30 minutes without any escape-impairing
symptoms or any irreversible health effects.
Recommended Exposure REL Highest allowable airborne concentration that is not
Limit (NIOSH)*** expected to injure a worker, expressed as a ceiling limit or
time-weighted average for an 8- or 10- hour work day.
----------------------------------------------------------------------------------------------------------------------------
* American Conference of Governmental Industrial Hygienists
** Occupational Safety and Health Administration
*** National Institute for Occupational Safety and Health
============================================================================================================================
Table 9
Table 9 Appendix B Types of Respiratory Protection
======================================================================================================================================
Type of Respirator Advantages Disadvantages
Air Purifying Enhanced mobility. Cannot be used in IDLH or oxygen-
Air-Purifying Respirator deficient atmospheres (less than 19.5%
(Including powered air-purifying Lighter in weight than an SCBA. oxygen at sea level).
respirators [PAPRs].) Generally weighs 2 pounds (1 kg)
or less (except for PAPRS). Limited duration of protection. May be
hard to gauge safe operating time
in field conditions.
Only protects against specific chemicals,
and up to specific concentrations.
Use requires monitoring of contaminant
and oxygen levels.
Can only be used: (1) against gas
and vapor contaminants with adequate
warning properties or (2) for specific gases or
vapors provided that the service is known
and a safety factor is applied, or if the unit
has an ESLI (end-of-service-life-indicator).
Atmosphere-Supplying
Self-Contained Breathing Provides the highest available Bulky, heavy (up to 35 pounds).
Apparatus (SCBA) level of protection against airborne
contaminants and oxygen deficiency. Finite air supply limits work duration.
Provides the highest available May impair movement in confined spaces.
level of protection under strenuous
work conditions.
Positive-Pressure Supplied- Enables longer work periods than Not approved for use in atmospheres
Air Respirator (SAR) an SCBA. immediately dangerous to life or health
(also called air line respirator) (IDLH) or in oxygen-deficient atmo-
Less bulky and heavy than an SCBA. spheres unless equipped with an emer-
SAR equipment weighs less than gency egress unit, such as an escape-only
5 pounds(or around 15 pounds, if SCBA that can provide immediate
escape SCBA protection is included). emergency respiratory protection in
case of air line failure.
Protects against most airborne
contaminants Impairs mobility.
Mine Safety and Health Administration/
NIOSH certification limits hose length to
300 feet (90 meters).
As the length of the hose is increased, the
minimum approved airflow may not be delivered
at the faceplate.
Air line is vulnerable to damage, chemi-
cal contamination, and degradation.
Decontamination of hoses may be difficult.
Worker must retrace steps to leave work area.
Requires supervision/monitoring of the
air supply line.
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Table 10
Table 10 Appendix C Levels of Protection*
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Level of
Protection Equipment Protection Provided Should Be Used When: Limiting Criteria
A Recommended: The highest available level of res- The chemcial substance has been Fully-encapsulated suit material
piratory, skin, and eye protection. identifies and requires the highest must be compatible with the
Pressure-demand, full level of protection for skin, eyes, substances involved.
Fully encapsulating,chemical- and the respiratory system based
resistant suit. on either:
Inner chemical-resistant gloves - Measured (or potential for)
Chemical-resistant safety boots/ high concentration of atmos-
shoes. pheric vapors, gases, or par-
ticulates or
Two-way radio communication. - Site operations and work func-
tions involving a high poten-
OPTIONAL: tial for splash, immersion or
Cooling unit. exposure to unexpected vapors,
gases, or particulates of
Coveralls. materials that are harmful to
skin or capable of being ab-
Long cotton underwear. sorbed through the intact skin.
Hard hat. Substances with a high degree of
hazard to the skin are known or
Disposable gloves and boot cov- suspected to be present, and skin
ers. contact is possible.
Operations must be conducted in
confined, poorly ventilated areas
until the absence of conditions
requiring Level A protection is
determined.
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* Reprinted from NIOSH/OSHA/USCG/EPA
Occupational Safety and Health Guidance Manual for Hazardous Waste Site Activities,
Department of Health and Human Services, October 1985.
Figure 1
Levels Of Protection
Figure 2
Levels Of Protection (Continued)
Figure 3
A Chemical Cartridge Air-Purifying Respirator
Figure 4
A Self-Contained Breathing Apparatus/Supplied-Air Respirator
Figure 5
Nine-Step Personnel Decontamination Plan
Figure 6
Eight-Step Dry Decontamination Plan For Personnel
Figure 7
Material Safety Data Sheet
Figure 8
Material Safety Data Sheet (Continued)
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