Managing Hazardous Materials Incidents Volume I

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.

Emergency medical services (EMS) must protect their personnel on-site and en route to the hospital, and other people within the hospital, while providing the best care for the chemically contaminated patient. This guide is intended to help emergency medical services 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 responders, 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 the Management of Contaminated Patients. The second document is designed for use by emergency department personnel to minimize their risks of exposure within the emergency department and to provide for the safe and effective treatment of chemically contaminated patients.

This guide for emergency response 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 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 community emergency response systems and hospitals 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, and this document is also intended to provide source material for developing local training and safety protocols.

Emergency Medical Services 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 effectively conduct patient assessments is presented, as well as an outline of personal protective equipment such as respiratory devices and protective clothing.

Response and Patient Management, includes guidelines for preparation and response to a potential hazardous materials incident. In addition, this chapter discusses patient assessment and decontamination guidelines.

Lastly, Systems Approach to Planning, details the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines for 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 that could be a threat to the community given existing transportation routes.

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 Medical Services 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 medical services personnel should always be alert to the possibility that they may be dealing with a chemically contaminated individual, and should ask the victims and dispatch personnel about the nature of the incident. Although an injury at a hazardous material 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. Dispatch 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, burning eyes, or cyanosis or cyanosis -could suggest to the dispatch staff the presence of hazardous materials. Knowledgeable dispatch 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 dictate certain shapes 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 hazardous materials that may be packaged in fiberboard boxes, drums, or cylinders with labeling.
Markings/Colors. Transportation vehicles must use DOT markings, including identification (ID) numbers. Identification numbers, located on both ends and both sides, are required on all cargo tanks, portable tanks, rail tank cars, and other small 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, ED number, and quantity, and may indicate "waste" or It 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 (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 fail and should not be counted on as a 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 of 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 understand 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 pre hospital 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 response 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

As mentioned above, 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 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 or workers with asthma may be triggered by exposure to toxic chemicals at lower levels than might be expected to produce the same effect in individuals without respiratory disease. Factors such as age, personal habits (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 exposure limits 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 exposure. 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 receive a relatively large number of contaminated victims, 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, EMS 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 EMS, given their workload mix, may not be able to expend the funds and time necessary to accomplish this task. In these cases, the EMS 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 an EMS'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 Ill).

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 responders 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. EPA and NIOSH recommend that initial entry into unknown environments, unknown container sampling, and entry into a confined space that has not been chemically characterized warrants 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 be fitted properly and 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 selfcontained breathing apparatus (SCBA) and supplied-air respirators (SAR). 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 cartridges 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 cartridge 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 most 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 ambient 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 air pressure 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 contaminant may enter the face mask 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-air respirators 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- 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.

Site Control

Hazardous materials incidents can and often do attract large numbers of people and equipment, complicating the imposition of adequate controls to minimize risks of human injury or death, property damage, and environmental degradation.

An Incident Command System (ICS) allows for the coordination and management of facilities, equipment, personnel, and communications during a hazardous materials incident. In order to keep the contaminants on-site, an Incident Commander (IC) is responsible for the control of the scene, which includes delineating work zones, establishing levels of protection, and implementing decontamination activities.

Rules to keep in mind to enhance control at the site of a chemical incident include the following: inactive individuals and equipment should be kept at a safe distance from the area of possible contamination; public access from all directions must be restricted as soon as possible; media access should be limited to the staging area, and any closer approach should involve escort by a designated public Information Officer.

Work Zones --

NIOSH/OSHA/USCG/EPA recommend dividing the incident into three zones, establishing access control points, and delineating a contamination reduction corridor. (Figure 5) presents a diagram of the recommended zones. The Exclusion Zone (hot zone) should encompass all known or suspected hazardous material contamination. The respective radius of the Contamination Reduction Zone (warm zone) is determined by the length of the decontamination corridor, containing all of the needed "decon" stations. The Support Zone (cold zone) should be "clean" - free of hazardous material contamination of all kinds, including discarded protective clothing and respiratory equipment. The command post and staging areas for necessary support equipment should be located upwind and uphill of the Exclusion Zone in the support area. Equipment that may eventually be needed should be kept in staging areas beyond the crowd control line. Access to the different zones should be tightly controlled and limited to as few locations as possible.

Decontamination Of Emergency Medical Service Personnel

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 incident 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 incident 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 Section 11. 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. It should be noted that 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 6), need not be set up if only a boot-wash 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 7).

Decontamination of EMS Personnel

EMS 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 improperly 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 EMTs to the hospital emergency room and one dedicated for use by the teams in the Exclusion Zone. If a sufficient number of radios are not available for use in the exclusion zone, then line of sight must be maintained at all times for those personnel in the zone. Often when an Incident Command System is activated, one person is assigned to manage communications.

Selected Bibliography

American Conference of Governmental Industrial 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., Barceloux, 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.0., Weitzman, D.J. Guidelines for the Selection of Chemical Protective Clothing. Third Edition. American Conference of Governmental Industrial Hygienists, Cincinnati, Ohio, 1987.

Windholz, M., eds. The Merck Index. Tenth Edition. Merck and Co., Rahway, New Jersey, 1983.

Response and Patient Management

In the protocol for responding to potential hazardous materials incidents, the following primary considerations should be included: activities to undertake en route to the scene and upon arrival at the scene; guidelines for assessment, decontamination, and treatment of victims; and patient transport to the hospital.

En Route To A Hazardous Materials Scene

First responders need to be alert for hazardous materials when responding to every call. Hazardous materials can be obvious (i.e., noxious fumes, gasoline, or corrosive liquid spills) or they can be unnoticeable (odorless, but poisonous and/or flammable vapors and liquids, or radioactive). If a vehicle has a diamond-shaped placard or an orange-numbered panel on the side or rear, the cargo should be assumed to be hazardous. Unfortunately, not all hazardous materials carriers will be clearly marked. For example, delivery trucks regularly carry hazardous materials that can be released in a collision, yet rarely are marked. Therefore, first responders should use caution when attempting rescue at any incident scene. The hazard, or lack thereof, must be determined immediately - before first responders enter a chemically contaminated area.

The responder should pay attention to certain clues en route to an incident scene that could tip off the possibility of hazardous material involvement. Billowing smoke or clouds of vapor could give advanced warning that a dangerous substance may be involved. Senses are one of the best ways to detect chemicals, particularly the sense of smell. However, if you smell something you are too close and should remove yourself to a safe distance until you know more about the source of the odor. Failure to do so could cause injury. The nature of an incident should also be a key to identifying the possibility of a hazardous materials involvement. Tank trucks, train wrecks, and incidents at fixed facilities where chemicals are used could indicate hazardous materials involvement. The dispatcher may have clues that could indicate hazardous materials precautions are necessary. These could include the nature of an incident (e.g., leaking tank) and the nature of injuries (e.g., 25 workers with shortness of breath).

It is important that emergency responders pay attention to factors such as wind direction and topography when approaching a suspected hazardous materials incident. Responders should always approach upwind and upgrade from an incident, taking note that low lying areas such as stream beds and gulleys, or in urban areas, places such as courtyards or tall buildings, may contain vapor clouds that prevent dispersal by the wind.

Responders should also attempt to gather as much information as possible while en route to an incident. Using resources outlined in under Hazard Recognition, they can relay this information to a predesignated information center (e.g., regional poison control center, ATSDR) to obtain information about definitive care procedures including:

Possible health effects
PPE required
Treatment/antidote therapy
Decontamination procedures.

Information that will be needed to determine appropriate care will include:

Knowledge of whether a chemical may be involved
Chemical name of substance involved
State of material (solid, liquid, gas)
Quantities involved
Number of victims
Signs or symptoms
Nature of exposure (inhalation, dermal, etc.)
Length of exposure.

If a hazardous substance is involved and has been identified,responders should locate information concerning that substance using appropriate references, such as Material Safety Data Sheets (MSDS), the Department of Transportation (DOT) Emergency Response Guidebook, and CHEMTREC, as outlined under Hazard Recognition. This information can also help responders identify possible health hazards, including the nature of possible injuries; routes of exposure; proper level of PPE required; and the appropriate safe distance from the hazard to protect EMS personnel, the public, and property from exposure or other dangers, such as explosion or fire. This information may be available from a command post if one has been established. Emergency Medical Services Response to Hazardous Materials Incidents outlines these procedures for PPE, and Systems Approach To Planning describes guidelines for planning.

Communications with other agencies or services involved should also begin en route to an incident. If an Incident Command System (ICS) is implemented, interactions with an incident commander will identify the best route of approach, the possible dangers involved, and the estimated number of injuries. Communications between on-site response personnel and receiving facilities should be kept open to relay as much advance information as possible. Communications with other services should include the fire department, police, and hazardous materials response team (if one exists).

Arrival at the Scene --

Many first responders (police, fire-rescue, and EMS personnel, including physicians and nurses) are accustomed to immediately attending an injured victim; often they disregard the possibility of danger to themselves. Consequently, a rescuer entering a contaminated area also risks exposure and the potential for becoming a victim. Even though rescue of any injured patient is important,it should only be attempted after it is certain that the responders, themselves, will not become injured. Responders must use judgement when assessing the dangers involved in a possible hazardous materials incident. Patient care should not be delayed unnecessarily when only minimal risk is involved, but many factors must be considered in determining the level of danger. Training and experience are essential for decision-making and those decisions, at best, are often a judgement call. As a rule, however, rescue should not be attempted by individuals who are not properly trained and equipped with appropriate PPE. Rescue should only be attempted by trained and equipped emergency personnel, fire department, or hazardous materials response team personnel. (Figure 8) represents a typical decision tree that may be used in making decisions about risk and response.

Upon arrival at a scene, an initial assessment of the situation and the size of the incident should be conducted. Additional support should be requested, if necessary. Sources of on-scene assistance may include:

Fire Departments
Police Departments
Health Departments
Hazardous Materials Response Teams
Local Industry Response Teams

Unless otherwise directed, responders should park upwind, upgrade, pointing away from, and a safe distance from any incident where hazardous materials are suspected. Safe distances for specific chemicals may be determined using the DOT Emergency Response Guidebook, by consulting CHEMTREC, or by using other response references. Responders should not drive or walk through any spilled or released materials (i.e., smoke and vapors as well as puddles). Also, a first-in responder should confirm that local authorities have been notified and are aware that hazardous materials might be involved.

Don't

Don't drive or walk through any spilled materials.
Don't allow unnecessary contamination of equipment.
Don't attempt to recover shipping papers or manifests unless adequately protected.
Don't become exposed while approaching a scene.
Don't approach anyone coming from contaminated areas.
Don't attempt rescue unless trained and equipped with appropriate PPE for the situation.

For first-in responders, the first priority is scene isolation. KEEP OTHERS AWAY! KEEP UNNECESSARY EQUIPMENT FROM BECOMING CONTAMINATED.

Immediately establish an Exclusion (Hot) Zone, but do not become exposed in doing so (see (Figure 5). The Exclusion Zone should encompass all contaminated areas, and no one should be allowed to cross into that zone. Assume that anyone leaving the Exclusion Zone is contaminated, and should be assessed and decontaminated if necessary. Additional zones, such as Contamination Reduction (Warm), Support/Clean (Cold), and Crowd Control, should be determined as soon as the opportunity becomes available. Do not remove nonambulatory patients from the Exclusion Zone unless properly trained personnel with the appropriate PPE are available and decontamination has been accomplished.

Not all hazardous substances have color or odor. Therefore, a responder with appropriate PPE may be required for rescue. If an incident commander has been identified, report to him or her and coordinate patient access and emergency care activities. Unless appropriately trained and protected, responders must not attempt entry into the Exclusion Zone to rescue patients or to recover shipping papers or manifests.

Do not approach any victims without first consulting with the incident commander. No rescue should be attempted unless the responder is trained and equipped with appropriate PPE for the situation. Likewise, response personnel should not approach anyone coming from contaminated areas (particularly those potentially contaminated) until given permission by the incident commander.

It must be emphasized that EMS responders who have not been trained should stay out of the hot zone and decontamination area. Sophisticated protective gear should only be used by those with proper knowledge and experience. If decontamination is carried out before the patient is transported to the EMS personnel at the perimeter, then no special gear may be needed.

Assessment, Decontamination, and Initial Treatment Of Patients

Primary goals for emergency personnel in a hazardous materials incident include termination of exposure to the patient, removal of the patient from danger, and patient treatment - while not jeopardizing the safety of rescue personnel. Termination of exposure can best be accomplished by removing the patient from the exposure area and removing contaminants from the patient. If the patient is removed from the possibility of additional exposure or other dangers and the patient is no longer contaminated, the level of protection for personnel can be downgraded to a level that will better facilitate the provision of patient care. The potential for additional or increased danger to patient and responder prohibits any treatment inside the Exclusion Zone other than basic life support. The probability of contact with hazardous substances either by subsequent release of materials still in the area, along with the dangers of fire or explosion, and the restriction of movement by necessary PPE outweighs the time saved by attempting patient care in a dangerous area. Gross management of Airway, Breathing, and Circulation (ABC) is all that should be undertaken while there is potential for further injury to patient or response personnel.

One of the most important steps in scene hazard assessment should be obtaining immediate assistance from a regional poison control center. The poison center can help determine the risk for secondary contamination, the need for special protective gear and decontamination procedures, and the toxic effects of the chemical.

Primary assessment can be undertaken while simultaneously performing decontamination in the Contamination Reduction Zone. Priority should be given to the ABC: Airway, Breathing, and Circulation. Once life-threatening matters have been addressed, rescue personnel can then direct attention to secondary patient assessment. It is important to remember that appropriate personal protective equipment and clothing must be worn until the threat of secondary exposure is no longer a danger. Therefore, the sooner the patient becomes decontaminated the sooner response personnel may reduce protective measures or downgrade the level of protection.

During initial patient stabilization, a gross decontamination 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 obvious contamination. Care should be taken to protect any open wounds from contamination. Every effort should be made by personnel to avoid contact with any potentially hazardous substance.

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.

Decontamination --
Directives for decontamination include the reduction of external contamination, containment of the contamination present, and prevention of 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 less absorptive 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 as not to recontaminate them. 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 eyes with water or normal saline for several hours. (Table 9) outlines the minimum equipment that is required for decontamination of patients by emergency response personnel. These lists are not detailed; they are only provided to guide departments in developing their own equipment lists based on their community needs and requirements. Many chemical substances, even though highly toxic, carry no intrinsic risk for contamination to others. Most toxic gases, such as carbon monoxide or arsine, are highly poisonous, but once the victim has been brought out of the exposure area and into the fresh air, the amount of leftover gas in and around the patient simply cannot poison others. Even many chemicals that have the potential for spreading contamination can be made less hazardous by simply diluting them with copious amounts of water.

External decontamination should be performed using the least aggressive methods. Limit mechanical or chemical irritation to the skin to prevent increased permeability. Wash contaminated areas gently under a gentle spray of water, and wash with a soft sponge using a mild soap such as dishwashing liquid. Use warm, never hot, water. The degree of decontamination should be completed based on the nature of the contaminant, the form of contaminant, the patient's condition, environmental conditions, and resources available. Care should be taken so that contaminants are not introduced into open wounds. Responders should try to contain all runoff from decontamination procedures for proper disposal. The patient should be isolated from the environment to prevent the spread of any remaining contaminants.

Ensure that all potentially contaminated patient clothing and belongings have been removed. Properly label bags that contain clothing or other potentially contaminated articles. Contaminated clothing and belongings should not be transported with the patient in the ambulance unless the incident commander approves, and the clothing and belongings have been adequately bagged.

Decontamination

Decontaminate from the head down
- take care not to introduce contaminants into open wounds
- decontaminate exposed wounds and eyes before intact skin areas
- cover wounds with a water-proof dressing after decontamination
For external contamination, begin with the least aggressive methods
- limit mechanical or chemical irritation of the skin
- wash contaminated area gently under a stream of water, and scrub with a soft brush or surgical sponge
- use warm, never hot, water
Remove contaminants to the level that they are no longer a threat to patient or response personnel
Isolate the patient from the environment to prevent the spread of any remaining contaminants
If possible, contain all runoff from decontamination procedures for proper disposal
Ensure that all potentially contaminated patient clothing and belongings have been removed
- properly label bags that contain clothing or other potentially contaminated articles

Considerations For Patient Treatment

Basically, a contaminated patient is like any other patient and may be treated as such except that responders must protect themselves and others from dangers due to contamination. Response personnel must first address life-threatening issues and then decontamination and supportive measures. Primary surveys will be accomplished simultaneously with decontamination; and secondary surveys should be completed as conditions allow. The chemical-specific information received from the hazardous materials response resources should be incorporated into the proper patient treatment procedures. In multiple patient situations, proper triage procedures should be implemented using local community emergency response plans (see, SARA Title 111). Treat presenting signs and symptoms 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.Administer orders of the designated poison control center when conditions allow. Unless required by life-threatening conditions prophylactic invasive procedures, such as intravenous injections (I.V.s) or intubation, should be performed only in fully decontaminated areas where conditions permit. These procedures may create a direct route for introducing the hazardous material into the patient. Oxygen should be given using a bag valve mask with reservoir device (rebreather) or manually triggered oxygen-powered breathing device. The contaminated atmosphere should not mix with the oxygen if possible. Reassess the patient frequently because many hazardous materials have latent physiological effects. While some cases may require treatment with antidotes, most cases will be handled with symptomatic care.

Patient Treatment

Assign highest priorities to ABC and decontamination
Complete primary and secondary surveys as conditions allow. Bear in mind the chemical specific information received from the designated poison control or information center
In multiple patient situations, begin proper triage procedures
Treat presenting signs and symptoms as appropriate and when conditions allow
Administer orders of the designated poison control center when conditions allow
Perform invasive procedures only in uncontaminated areas
Reassess the patient frequently because many chemicals have latent physiological effects
Delay prophylactic measures until the patient is decontaminated

Patient Transport To Hospital

When transporting a contaminated patient by ambulance, special care should be exercised in preventing contamination of the ambulance and subsequent patients. Exposed surfaces that the contaminated patient is likely to come into contact with should be covered with plastic sheeting.

Fiberglass backboards and disposable sheeting are recommended. If a wood backboard is used, it should be covered with disposable sheeting or it may have to be discarded afterwards. Equipment that comes in contact with the patient should be segregated for disposal or decontamination. EMS personnel should wear protective clothing appropriate for conditions (e.g., surgical gloves, CPC, etc.), and respirators, if indicated (see Section I, PPE). (Table 10) outlines suggested equipment required for care and transport of contaminated patients. Like other listings provided, it is only for guidance, and items may be added or deleted with experience.

The patient should be as clean as reasonably possible before transport, and further contact with contaminants should be avoided. Protective clothing should be worn by response personnel as appropriate. If decontamination cannot be performed adequately, responders should make every attempt to prevent the spread of contamination and at the very least remove patient clothing, wrap the patient in blankets, followed by body bags or plastic or rubber sheets to lessen the likelihood of contamination to equipment and others. Considerations should be made for chemicals that present the added danger of accelerated skin absorption due to heat. In these cases body bags and plastic or rubber sheets should not be used. Minimize contamination from shoes. The name of the involved chemicals, if identified, and any other data available, should be recorded before leaving the scene. Oxygen should be administered by rebreather mask for any victim with respiratory problems unless contraindicated (e.g., paraquat). Eyes that have been exposed should be irrigated with available saline or water, and such irrigation should be continued en route to the hospital. Personnel also should be alert for any respiratory distress.

In an ambulance during transport, personnel should use appropriate respiratory protection. Provide the maximum fresh air ventilation (e.g., open windows) that weather conditions permit to the patient and driver's compartment regardless of the presence or absence of odors.

Re-contact the receiving hospital and provide an update on treatment provided or required and any other information received from the designated poison control center. Instructions for the procedure to enter the hospital with a contaminated patient should also be requested. Facilities receiving a potential hazardous material patient will need as much information as possible.

A checklist should be developed and made available for all vehicles and telephone or radio communication centers. Information that will aid in initiating appropriate actions includes:

Type and nature of incident
Number of patients
Signs/symptoms being experienced by the patients
Nature of injuries
Name of chemical(s) involved
Information available at the site concerning the chemical(s)
Extent of patient decontamination in the field
Estimated time of arrival

The ambulance should park in an area away from the emergency room or go directly to a predesignated decontamination center or area, thereby limiting exposure to hospital facilities. In order to protect staff and other patients, the patient should not be brought into the emergency department before ambulance personnel receive permission from the hospital staff.

Upon the release of the patient to the hospital, any equipment that is believed to have become contaminated should be double bagged. The use of disposable equipment is recommended whenever possible. Contaminated articles should be kept sealed until the Incident Commander or his designee gives further instructions. If possible, send any material safety data sheets concerning the involved hazardous materials with the patient.

The ambulance should not go back into service unless the vehicle is clean. This again emphasizes the importance of thorough patient decontamination; if the patient is clean, then the vehicle (interior) is clean. After the patient is unloaded from the ambulance, a check should be made with the hospital to determine where the ambulance can be safely decontaminated, and whether equipment is available for this purpose. When decontamination is required, the most appropriate method should be identified using information resources. In most cases soap and water are adequate for decontaminating of the vehicle.

Transport to Hospital

Re-contact the receiving hospital
- update the hospital on treatment provided and any other information received from the designated poison control center, and
- obtain instructions on approaching and entering the hospital.
Avoid contact with contaminants; provide protection to the vehicle; wear protective clothing as appropriate.
Get patient as clean as possible prior to transport.
Administer oxygen by mask for any patient with respiratory problems (except as contraindicated).
Before leaving the scene, write down the name of the involved chemicals, if identified, and any other data available.
Provide fresh air ventilation to patient and driver's compartment.
Continue to irrigate eyes that have been exposed with normal saline or water en route to the hospital and be alert for any respiratory distress.
Park the ambulance in an area away from the emergency department or go directly to a predesignated decontamination area.
Do not bring patients into the emergency department before ambulance personnel receive permission from the hospital staff.
After unloading the patient, check with the hospital to determine where the ambulance can be safely decontaminated, and the availability of equipment for this purpose.
Decontaminate exposed personnel.

Air Transportation of Chemically Exposed Patients --

There is a potential danger in transporting patients in a helicopter from a hazardous materials incident. Often decontamination is not complete, and the flight crew could experience difficulty breathing or seeing. Also the area of the incident needs to be clearly communicated with the flight crew to avoid traveling through an unsafe area. Furthermore, the downdraft from the helicopter could affect vapors or fumes on the scene. Considerations should be made for each specific incident and chemical.

Critique

As soon as possible after each incident, all participating units should send personnel involved 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 (i.e., Airway, Breathing, and Circulation) continues to have first priority.

There are, however, several important differences in disasters involving hazardous materials. A chemical mass casualty incident may also require setting up mass screening and decontamination centers. It may also be necessary to establish casualty collection points to provide stabilizing care in the field prior to transport. A major chemical disaster may accompany other disasters such as an earthquake. Such an event would drastically increase the number of casualties and the complexity of the medical care that must be provided (crushing and broken bones vs. gas inhalation, for example). This would require increased numbers of personnel, perhaps more sophisticated medical equipment, and a better transport system for taking stabilized victims out of the area. Training in the appropriate procedures to be followed is essential for potential responders to a hazardous materials incident involving mass casualties. Triage may be complicated for chemical exposure by delayed onset of signs and symptoms. 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 198 1. 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 EMS 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 specific 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.

EMS 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.

EMS must acknowledge their role as a component of the community-wide emergency response system. 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, EMS 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 or EMS 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 and EMS 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:
- May involve several locations.
- May involve 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.
- May involve 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: 1) Has the organization identified alternate sources of essential utilities? 2) Is there an emergency communication system? 3) Is there a procedure for identifying an alternate care site? 4) Are facilities available for radioactive or chemical isolation and decontamination? and 5) Is there a workable plan for total facility evacuation? JCAHO Accreditation Standards for Hospitals, 1989 outlines the JCAHO standards and indicator probes that are relevant for treating chemically contaminated patients.

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 Ill.

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

SARA Title III

Title Ill 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 Ill, "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 Ill'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 EHS 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 HI 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.

Emergency medical personnel can be better prepared for response to incidents that involve contaminated victims 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 Ill 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. 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 victim 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 Bum 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. Preplanning and coordination of services are equally critical at the national level. A National Contingency Plan (NCP) has been established by the federal government 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 Ill) 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-I 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 the 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-1 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-I recommends that medical personnel be made aware of significant chemical hazards in the community 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 Analysis

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 Ill 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.Local emergency planning committees 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, spill 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 Hazards 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 Analysis: 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 Check list 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 III 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 Programs Administration 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 9

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 9

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 9

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 9

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 10

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 10

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 10

Section 7 lists the procedures that should be used if the product spills or leaks, including waste disposal methods.

SECTION 8 -- Figure 10

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 11

Appendix C; Levels of Protection

Table 12

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-E57)
Atlanta, GA 300333

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 Suggested Decontamination Equipment
==================================================================================================================
At a minimum, the protective equipment listed is necessary to participate in decontamination procedures.
Protective equipment used for decontamination should be no less than one level below that used for entry
into the hazardous environment. Positive-pressure self-contained breathing apparatus (SCBA) and fully
encapsulated suits may be necessary in extreme cases.

-  Containment equipment                          -  Sponges and soft brushes
   -  Pool or tank
   -  Tarps                                       -  Large plastic bags for contaminated clothing
   -  6-mil construction plastic
                                                  -  Small plastic bags for patients' valuables
-  Saw horses to support backboards
                                                  -  Tags and waterproof pens to mark bags
-  Fiberglass backboards
                                                  -  Disposable clothes and shoes for ambulatory
-  Supports for ambulatory patients                  patients

-  Water supply                                   -  Towels and blankets

-  Scissors for clothing removal                  -  Clear, zip-front bags to minimize
                                                     contamination to transport personnel and
-  Mild detergent (dishwashing liquid)               ambulances

-  Five-gallon buckets                            -  tape (duct, 4-inch)
==================================================================================================================

Table 10

Table 10  Supplies Needed to Prepare the Ambulance for Care of a Patient
          Contaminated with Hazardous Materials
===================================================================================================
-  Enough 6-mil construction plastic* cut to size to:
   -  Cover floor of ambulance
   -  Cover squad seat
   -  Cover litter

-  Disposable sheets

-  One box of plastic trash bags to contain contaminated medical supply waste,
   gloves and the victim's clothes, and the like

-  Personal protection:
   -  CVC disposable suits with built-in hoods and booty/boot covers
   -  Positive-pressure SCBA
   -  Full-face  mask  respirator  with  an  orange- and purple-type cartridge
      (acid gas, organic vapor, highly toxic dust, mist and fumes, and radionuclides-rated
      cartridge)
   -  Poly Vinyl Chloride (PVC) or duct tape for taping closures
   -  Two-piece rainwear
   -  Rubber boots with steel toes
   -  Nitrite gloves with 14-inch cuffs
   -  Duct tape to seal suit seams if necessary

If the fire department's protective clothing is used, rainwear should be worn as an overgarment.
Hydrocarbons and other chemicals may permeate the "bunker clothes."

NOTE: The protective equipment listed is to be used for patent care situations after initial
decontamination. It is meant to be used when complete decontamination of the patients cannot
be guaranteed or when assisting with decontamination procedures (in extreme cases
positive-pressure SCBA and encapsulated suits may be required for decontamination procedures).
It is not meant to be used in rescue operations of victims found in a hazardous area.  Under
no circumstances should this equipment be relied upon for entry into hazardous environments.
Protective equipment for entry must be appropriate to and compatible with the products involved.
This may include positive-pressure SCBA and fully encapsulated suits.  Many
factors must be taken into consideration when determining the appropriate
level of protection.  Consequently, selection of protccdve equipment must be done by a qualified
individual.

*Wet plastic is slippery; stability is important.
===================================================================================================

Table 11

Table 11 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.

======================================================================================================================================

Table 12

Table 12  Appendix C Levels of Protection*
===============================================================================================================================================================
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.

---------------------------------------------------------------------------------------------------------------------------------------------------------------
* 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

NIOSH/OSHA/USCG/EPA/ Recommended Zones

Figure 6

Nine-Step Personnel Decontamination Plan

Figure 7

Eight-Step Dry Decontamination Plan For Personnel

Figure 8

Sample EMS Decision Tree For Chemical Incidents

Figure 9

Sample Material Safety Data Sheet

Figure 10

Sample Material Safety Data Sheet (Continued)

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Table of Contents

Introduction

Emergency Medical Services Response to Hazardous Materials Incidents

Hazard Recognition

Principles of Toxicology for Emergency Department Personnel

Personnel Protection and Safety Principles

Respiratory Protection

Site Control

Decontamination Of Emergency Medical Service Personnel

Decontamination of EMS Personnel

Communications

Response and Patient Management

En Route To A Hazardous Materials Scene

Assessment, Decontamination, and Initial Treatment Of Patients

Considerations For Patient Treatment

Patient Transport To Hospital

Critique

Patient Management Under Mass Casualty Conditions Involving Hazardou

Selected Bibliography

Systems Approach to Planning

The Role Of The EMS In A Systems Approach To Planning

The Spectrum Of Hazardous Materials Incidents

Joint Commission On Accreditation Of Healthcare Organizations (JCAHO

SARA Title III

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:

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

Table 7

Table 8

Table 9

Table 10

Table 11

Table 12

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

NIOSH/OSHA/USCG/EPA/ Recommended Zones

Figure 6

Nine-Step Personnel Decontamination Plan

Figure 7

Eight-Step Dry Decontamination Plan For Personnel

Figure 8

Sample EMS Decision Tree For Chemical Incidents

Figure 9

Sample Material Safety Data Sheet

Figure 10

Sample Material Safety Data Sheet (Continued)