Guide: Identifying Contaminated Patients

1. Guide: Identifying Contaminated Patients Presentation to: Presented by: Date:

2. Decide whether patient has been exposed to chemicals Patients may have been exposed to chemicals through inhalation, contact with the skin or eyes or by ingestion. Contaminated persons and patients showing signs of exposure should be decontaminated, then triaged and treated in the healthcare facility. Trauma injuries and other medical complications may also be present.

3. Treatment

4. Before the patient enters the healthcare facility: To minimize continued harm to the patient and others, the first step for all first responders and healthcare workers is to apply personal protective measures, including the wearing of appropriate gloves, masks, and gowns, before collecting exposure history, commencing physical examination and treatment. (PAPR or respiratory protection as needed) Ask the following questions: 1. What is the history of exposure of the patient? a. Where was the patient? When did they start experiencing symptoms? What did they experience first? Were others experiencing similar symptoms? b. Take a family / patient / witness / first responder report c. Use contextual information (e.g. health authorities, law enforcement etc.)

5. 2. Can you observe any signs of chemicals on or around the patient? a. Dust, powder or liquid droplets on body surface b. Dust, powder or liquid droplet on clothes, discoloration of clothes, in some instances scorching or damage to clothing c. Do NOT try to smell the patient. An unusual smell, e.g. garlic (indicates mustard gas), bitter almonds (indicates cyanide), fresh hay or grass (indicates phosgene). d. Persons accompanying the patient present with mild/single symptoms of exposure (suggesting concomitant or secondary contamination has occurred) If any of these symptoms occur, you should immediately seek help from medical staff!

6. 3. Are there confirmed signs and symptoms of exposure ? If a chemical event has been confirmed, a patient presenting with signs and symptoms of exposure by default is to be considered as contaminated. Some signs and symptoms may appear after a delay of hours to days. If prior knowledge of a hazardous materials event is given, medical staff and security staff should be following policies/procedures to lock down the facility to avoid contamination and prepare to help those affected by the situation.

7. The following slides show a wide range of signs and symptoms associated with chemical exposure: Be sure to take notice of the symptoms that are bold/red/underlined.

8. CHEMICAL WARFARE AGENTS Nerve agents (e.g. Tabun, Sarin or VX) Miosis(pinpoint pupils), sometimes unequal Blurred/dim vision Tight chest and breathing difficulty Muscle twitching/fasciculation Copious secretions (excessive salivation, runny nose, lachrymation, bronchorrhoea including cough and wheezing) Sweating Headache Nausea, vomiting, Incontinence and diarrhea Seizures Impaired judgment, nervousness, irritability Loss of consciousness and, potentially, CNS depression including secondary respiratory failure

9. Chemical Warfare (Dirty Bomb) Blister agents (eg. mustard gases, lewisite) Lachrymation, eye irritation, conjunctivitis, corneal damage, transient blindness Delayed signs and symptoms (several hours): redness and blisters of the skin with pain. Later on, detachment of the upper skin layers with impaired wound healing Upper airway irritation Respiratory distress – usually a late complication Immune deficiency

10. Chemical Warfare (Dirty Bomb) Cyanide Gasping for air, asphyxiation Seizures Confusion Nausea Cherry pink skin

11. Riot Control Agents Tear gas Stinging and burning sensation to eyes and mucous membranes Lachrymation/salivation Runny nose Tight chest Headache Nausea

12. Chlorine – chemical in pools/bleach Eye redness and lachrymation Upper airway irritation Cough (may be productive) Suffocation or choking sensation Tight chest Shortness of breath/wheezing Hoarse voice Nausea and vomiting Delayed signs and symptoms (a few hours): Pulmonary edema

13. Phosgene- colorless gas Eye redness and lachrymation Nausea and vomiting Tight chest Shortness of breath/wheezing Hypotension Delayed signs and symptoms (up to 72 hours): pulmonary edema

14. Notice each symptom was highlighted in red/bold font throughout the slide show! Quick Reference Guide • D.U.M.B.E.L.S • D- iarrhea- uncontrollable defecation • U- rination- uncontrollable bladder • M- iosis – pinpoint pupils • B- ronchorrhea/bronchospasm- the excessive discharge of mucus • E- mesis- vomiting • L- acrimation- abundance of tears • S- alivation/sweating • Liquid from any orifice, especially foamy- do not let in, get medical help immediately! • Spewing anything?? (vomit/chemicals/etc.) Do they have visible substance on them? Do not let in, get medical help immediately!

15. REFERERENCE Clinical Sources • Murray and Nadel’s Textbook of Respiratory Medicine, 5th Edition. Mason RJ Ed. Saunders, 2010. • Rosen’s Emergency Medicine, 7th Edition. Marx JA Ed. Mosby, 2009. • US Army Medical Research Institute of Chemical Defense, Medical Management of Chemical Casualties Handbook, 4th edition, 2007 • WHO, Public Health Response to Biological and Chemical Weapons, WHO Guidance, Annex 1, World Health Organization, Geneva, 2004 Decontamination • Adapted from CBRN incidents: clinical management and health protection, UK Health Protection Agency 2008 Incident triage • Adapted from JSP 999 clinical guidelines for operations. https://www.gov.uk/government/publications/jsp-999-clinical-guidelines-for-operations

16. REFERENCE CONT: • Nerve agents: • US ATSDR Medical Management Guidelines for Nerve Agents http://www.atsdr.cdc.gov/mmg/mmg.asp?id=523&tid=93 • CBRN Incidents: clinical management & health protection (2008), UK HPA http://www.hpa.org.uk/Topics/EmergencyResponse/CBRNAndDeliberateRelease/CBRNIncidentsAGuideToClinicalManagementAndHealthProtec/ • US CDC Emergency Room Procedures in Chemical Hazard Emergencies: A Job Aid http://www.cdc.gov/nceh/demil/articles/initialtreat.htm • Toxogonin (Obidoxime): Informationssur les médicaments - Recommandationsd'utilisation, Hop. Universit. de Genève http://pharmacie.hug-ge.ch/infomedic/utilismedic/obidoxime.pdf • Cyanide: • IPCS/CEC Antidotes for Cyanide Poisoning (1993) http://www.inchem.org/documents/antidote/antidote/ant02.htm • CBRN incidents: clinical management & health protection (2008) HPA, UK http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947382859 • Hydroxocobalamin: Cyanokit datasheet http://www.cyanokit.com/resources.aspx