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Hazardous Materials Emergencies

Hazardous Materials Emergencies. Kent R. Olson, MD, FACEP Medical Director, SF Division California Poison Control System. Hazardous Materials Emergencies. Course Objectives: Describe common routes of exposure to hazardous materials Differentiate exposure versus health hazard

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Hazardous Materials Emergencies

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  1. Hazardous Materials Emergencies Kent R. Olson, MD, FACEP Medical Director, SF Division California Poison Control System

  2. Hazardous Materials Emergencies • Course Objectives: • Describe common routes of exposure to hazardous materials • Differentiate exposure versus health hazard • Discuss the concept of secondary contamination and its implications for decontamination and triage • Describe pre-hospital and ED response to victims of hazmat exposure

  3. Types of Hazards • Physical • Explosion • Fire • Poisoning • Corrosive or irritant effects • Systemic poisons

  4. Physical States of Hazardous Materials • Gas • Liquid • Vapor • Mist/Aerosol • Solid • Fume • Dust

  5. Potential Routes of Exposure • Inhalation • Skin & Eyes • Ingestion • Injection

  6. Toxic Effects • Local injury • Upper airway or lung injury • Skin or eye burns • Corrosive injury to GI tract • Systemic effects • Dizziness, nausea, vomiting • Coma, seizures, arrhythmias • Cancer, Reproductive effects

  7. Case Study A 44 yo man spilled concentrated phenol on his legs and did not wash it off immediately. In addition to the chemical burns, he developed agitation, confusion, and seizures.

  8. Some Corrosives with Systemic Toxicity Agent Systemic Toxicity Formaldehyde metabolic acidosis (formate) Hydrofluoric acid hypocalcemia, hyperkalemia Permanganate methemoglobinemia Phenol seizures; coma; liver and kidney injury Phosphorus liver, kidney injury Silver nitratemethemoglobinemia

  9. Inhalation Toxicology • Irritant or corrosive effects • Highly water soluble gases and vapors, larger mists and fumes upper airway • Less soluble, smaller lower airway Systemic effects • Simple asphyxia • Target organ toxicity

  10. Hazard is Determined By: TOXICITY and EXPOSURE Toxic + Significant Exposure = HAZARD Toxic + No Serious Exposure = No Hazard

  11. Dose-Response Concept “All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy.” - Paracelsus (1493-1541)

  12. Dose is Determined By: • Route of exposure • Amount • Duration

  13. Common Dose Terminology • Inhalation: • ppm: parts per million • ppb: parts per billion • mg/m3:mg per cubic meter of air • Ingestion, Injection, Skin absorption: • mg/kg: mg per kg of body weight • LD50 and LC50: • Animal studies: 50% mortality dose

  14. Examples of Acute Oral LD50 Substance: LD50 (mg/kg) Ethyl alcohol 10,000 Sodium chloride 4,000 DDT 100 Nicotine 1 Dioxin 0.001 Botulinus toxin 0.00001

  15. Toxicity Ratings Rating LD50 (oral) LC50 (4 hr) Extremely toxic < 1 mg/kg < 10 ppm Highly toxic 1-50 10-100 Moderately toxic 50-500 100-1,000 Slightly toxic 0.5-5 g/kg 1,000-10,000 Pract. nontoxic 5-15 10,000-100,000 Relatively harmless > 15 > 100,000

  16. Workplace Exposure Limits Chronic average daily exposure: (8-hour Time-Weighted Average) • TLV: Threshold Limit Value • ACGIH recommended standard • PEL: Permissible Exposure Limit • OSHA enforceable limit • If the exposure is < TLV or PEL, • it is safe for Hazmat operations

  17. Workplace Exposure Limits Brief higher exposures: (20-30 minutes or less) • STEL: Short-Term Exposure Limit • C: Ceiling limit • IDLH: Immediately Dangerous to Life or Health Exposures in this range can cause serious injury - need protective gear

  18. Estimating Exposure Risk • Vapor Pressure • Multiply by 1,300 to estimate maximum air concentration in ppm from a liquid spill • Vapor Density • If > 1, vapor may collect in low-lying areas • Warning Properties • Odor • Irritation

  19. Methylene Chloride • Vapor Pressure = 349 mm • Maximum air conc. = 453,700 ppm • IDLH = 5,000 ppm • Vapor Density = 2.9 • Will collect in low-lying areas asphyxia • Warning Properties • Sweet, ether-like odor at > 200 ppm • Olfactory fatigue may occur w/chronic exp.

  20. Secondary Contamination Substance is toxic . . . and . . . Is likely to be carried on victim’s clothing, hair or skin in sufficient amounts to threaten others

  21. Secondary Contamination Serious potential for contamination: • Poisons with high skin toxicity • eg, organophosphate pesticides • Volatile liquids • eg, methylene chloride • Radioactive dusts or liquids • Etiologic agents (viruses, bacteria)

  22. Secondary Contamination Little or no risk of contamination: • Gases • eg, carbon monoxide • Vapors (unless condensation occurs) • eg, methylene chloride • Non-volatile liquids with no skin toxicity • eg, ethylene glycol (antifreeze)

  23. Secondary Contamination Implications for Decontamination: • Serious risk of secondary contamination: • Decontamination is mandatory • Decon may take priority over victim Rx • No risk: • Decon optional • Victim treatment is priority

  24. Case Study A 21 yo student spilled concentrated sulfuric acid on herself when the bottle slipped off the shelf. Quiz: Your first management priority is: • ABCs • Give Diazepam • Determine her insurance coverage • Immediately wash thoroughly with water

  25. Case Study A 32 year old farmworker was heavily doused with liquid parathion from a storage container. He is lying in a pool of liquid, and he is convulsing. Quiz: Your first management priority is: • Airway (ABCs) • Diazepam for the seizures • Atropine • Rescuer protection & victim Decon before Rx

  26. Case Study A 22 yo worker inhaled chlorine gas produced when he mixed bleach with an acid cleanser. He immediately developed severe coughing and wheezing. Quiz: Your first management priority is: • Criticize him for mixing the chemicals • Give oxygen and bronchodilators • Perform thorough Decon BEFORERx

  27. Basic Goals for EMS Hazmat Responders • Recognize Hazmat incident • Protect yourself & others • Identify toxic material(s) • Determine toxicity and hazard • Use appropriate protective gear • Decontaminate before transport • Provide specific treatment

  28. Hazmat Scene Zones HOT ZONE DECON ZONE SUPPORT ZONE Spill Properly protected personnel only EMS and other support personnel

  29. Recognize Hazmat Incident • Scene clues: • People down, dead animals • Vapor cloud • Fire • Warning properties (may be unreliable): • Odor • Color • Irritation

  30. Protect Yourself & Others • Prevent primary exposure: • Approach cautiously, upwind, uphill • Isolate area and deny entry • Stay out of Hot Zone • Prevent secondary contamination: • Determine risk of secondary contamination • If Decon required, should be done by properly protected personnel

  31. Identify the Toxic Material(s) • DOT Guide • Placards • Labels • Shipping papers • NFPA marking system labels • Material Safety Data Sheets (MSDS) • On-scene chemical analysis

  32. Determine Toxicity & Hazard • Regional Poison Control Centers • Back-up by medical toxicologists • CHEMTREC: 1-800-424-9300 • Large file of MSDSs • Contacts in key chemical industries • Written materials • Books • On-line databases

  33. Determine Toxicity & Hazard Specific information that may be available from the regional Poison Control Center: • Toxicity/symptoms of exposure • Level of protective gear required • Potential for secondary contamination • Decontamination required? • Specific treatment

  34. Respiratory Protective Gear • Air-purifying respirators (gas masks) • Do not provide oxygen • Must be chemical-specific • Chemical may break through • Air-supplied respirators (SCBA) • Safe air supply • Limited duration of tanks All gear must be fit-tested

  35. Chemical Protective Clothing • Completely or partially encapsulating • Completely encapsulated requires SCBA • Varying resistance to chemicals • Need chemical compatibility and breakthrough data for each chemical • Serious risk if used improperly • Not flame-resistant • Chemical penetration • Heat stress

  36. Chemical Protective Clothing • EPA Levels A-D: • A: SCBA plus encapsulating (airtight) suit • B: SCBA plus partially encapsulated suit • C: Air-purifying mask plus partial enc. suit • D: No special gear (work clothes) • EPA levels do not address FF gear: • SCBA plus flame-resistant (not chemical-resistant) “bunker” gear

  37. Protective Gear in Hot Zone Known or suspected respiratory hazard? • SCBA required Known or suspected skin hazard? • Level A or B No skin hazard • FD turnouts ok

  38. Heat Illness • Variables that affect body temperature: • Ambient (environmental) temperature • Level of physical activity • State of hydration • Ability to sweat evaporative cooling • Heat stress syndromes: • Heat exhaustion • Heat stroke (LIFE-THREATENING!)

  39. Heat Stress Monitoring & Prevention • Enforced breaks • Rest • Force fluids • Rotate work teams • Safety officer or other designated person • Monitors each person in protective gear • Looks for: altered mental status, increased pulse rate, elevated body temperature

  40. Victim Management in Hot Zone • Only trained and properly protected personnel may enter • Limited activity in Level A or B gear: • Open airway (with C-spine precautions) • Brush off gross contaminants • Carry on backboard or drag to Decon area • Note: ambulatory patients may be able to remove their own clothing and walk to Decon area

  41. Decontamination Area • Medical intervention still limited • Access restricted to trained personnel with protective clothing • Protective gear limits ability to assess patient, start IVs, etc • Decontamination • Determine if needed, based on victim’s Sx and potential for secondary contamination • Have victim assist, if possible

  42. Basic Decontamination • Brush off/soak up gross contaminants • Cut away or remove contaminated clothing • Flush with copious plain water • Head to toes direction • 3-5 minutes (eyes: at least 5 min) • If oily or adherent, use soap or shampoo • Do not use “Decon Solutions” • Collect runoff, if possible

  43. Decontamination Decision Algorithm Was exposure to gas or vapor only? NO YES Vapor condensed on clothing or skin? YES DECONTAMINATE NO YES Eye or skin irritation? DECONTAMINATION NOT NEEDED NO

  44. Support Zone Management • A: Airway • B: Breathing - give supplemental O2 • C: Circulation - start IV • D: Decontamination - continue if needed • Eyes (remove contacts) • Under fingernails, armpits, etc • Activated charcoal for ingestions • S: Specific treatment if indicated

  45. Support Zone Management • Bronchospasm: • Aerosolized bronchodilators • Caution: possible arrhythmias • Arrhythmias: • Standard ALS procedures • Exceptions: eg, Ca++ for HF • Seizures: • Usual anticonvulsants

  46. Transport of Hazmat Victims • Decontaminate BEFOREtransport • Better for patient • Less inhalation risk to ambulance personnel • Ingested poison: • Suspected corrosive: give water • Give AC; do NOT induce emesis • Carry extra towels and have ready some open plastic bags to quickly isolate toxic vomitus

  47. Hospital Preparation Develop protocols in advance, to: • Obtain specific toxicity information • Potential for secondary contamination • Expected health effects, antidotes • Assure on-scene decon, when needed • Designate reception & treatment areas • Plan for the unexpected contaminated pt.

  48. The Unexpected Contaminated Victim Indoor Facilities - Disadvantages: • Poor ventilation • Inhalation hazard from volatile vapors • Surgical masks inadequate for gases or vapors • Respirators impractical • Contaminated ED room

  49. The Unexpected Contaminated Victim Outdoor facility preferred - equip with: • Old gurney • Hose with warm water, shower nozzle • Soap and shampoo • Disposable rubber gloves, chemical-resistant jump suits • Plastic bags for contaminated clothing • Kiddie pool to catch runoff

  50. Medical Treatment in the Hospital • Inhaled poisons • Monitor airway, lung sounds • Oxygen, bronchodilators as needed • Skin & Eyes • Complete decontamination • Treat skin burns as for thermal burns • Eyes: check pH, fluorescein exam

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