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Hazardous Materials Medicine. Treating the Chemically Injured Patient. Edition No. 1

  • Book

  • 368 Pages
  • April 2023
  • John Wiley and Sons Ltd
  • ID: 5840368
Hazardous Materials Medicine

Complete background on chemical exposures that create illnesses, including assessment, diagnosis, and treatment protocols

Written on a level that can be understood by field practitioners and/or first responders, Hazardous Materials Medicine: Treating the Chemically Injured Patient provides an in-depth understanding of how to diagnose and treat toxic chemical exposures in a prehospital or emergency department setting.

The protocols used in this book conform to the guidelines set forth in the NFPA 470 standard, and the medical guidance developed by FEMA for Type I, II & III Deployable Hazmat Response Teams. The hazardous materials medical protocols in this book have been fully vetted by three poison control toxicologists, multiple emergency physicians, and paramedics.

Hazardous Materials Medicine: Treating the Chemically Injured Patient covers sample topics such as: - Scene assessment, to help determine the cause of the exposure, and exposure assessment, to determine what physiologic systems are affected - Toxic syndromes/toxidromes to appropriately treat the exposed patient, including corrosive and irritant, asphyxiant, cholinergic, and hydrocarbon and derivative toxidromes - Science behind a chemical exposure, to allow for a complete understanding of both the chemistry and physiology of what is occurring because of the exposure - Interfacing between the on-scene response team and the hospital, to ensure consistency and continuity of care from the field into the hospital

Enabling public safety and health professionals to administer effective care while retaining their own personal safety, Hazardous Materials Medicine: Treating the Chemically Injured Patient is a must-have resource for emergency medical technicians, paramedics, hazmat technicians, and emergency physicians and nurses working in high-risk field situations with chemically injured patients.

Table of Contents

Author Biographies and Acknowledgments xvii

Foreword xxi

Preface xxiii

1 HazMat Medicine and the HazMat Medic 1

Introduction 1

Case Study - Sarin Attack in the Tokyo Subway 3

History 4

Events 7

Situational Assessment Continuum 8

Patient Presentation 9

Event Conditions (Scene Evaluation and Size- up) 9

Scene Assessment (Hazard Identification) 9

Summary 10

2 Exposures 11

Introduction 11

Case Study - Derailment in South Carolina, a No- Notice Evacuation Event 11

Patient Presentation 12

The Toxidrome Exam 14

Respiratory System 14

Overview 14

Respiratory System Anatomy and Physiology 16

External Respiratory System 16

Internal Respiratory System 19

Chemical and Physical Form of Respiratory Exposure 22

Gases, Vapors, and Fumes 22

Solid Particles 22

Aerosols/Mists 23

Concentration and Duration 23

Types of Injuries Resulting from Chemical Exposure 23

Chemically Induced Bronchiole Constriction 23

Atelectasis and Disruption of Surfactant 24

Chemically Induced Pulmonary Edema (Noncardiogenic Pulmonary Edema) 25

Chemical Sensitivity 26

Types of Chemicals that Injure the Respiratory System 26

Asphyxiants 26

Simple Asphyxiants 26

Chemical Asphyxiants 27

Irritants (Corrosives) 27

Respiratory System Injury Recognition (Assessment) and Diagnostics 27

Pulse Oximetry 27

Specific Oximetry Considerations When Assessing HazMat Exposures 28

Capnography 29

Masimo™/Rainbow Technology 32

Cardiovascular Abnormalities Related to Exposure 33

Description 33

Vasogenic Shock 33

Hypovolemic Shock 33

Heart Failure 34

Neurological Abnormalities Related to Exposure 34

Central Nervous System (CNS) Exposure 34

CNS Depression 34

CNS Stimulation 35

Parasympathetic Nervous System 35

Parasympathetic Stimulation 35

Parasympathetic Depression 36

Integumentary System (Skin) 36

Skin Anatomy and Physiology 36

Structure 37

Function 38

Types of Chemical Injuries to the Skin 38

Chemical- Related Irritation 38

Chemical Skin Burns 39

Ocular Exposure and Injury 41

Eye Anatomy and Physiology 42

The Globe 42

The Ocular Surface 42

Assessment of Eye Injury After Exposure 43

Normal Eye Assessment 44

Chemical Eye Burns 45

Surface Toxins 46

Treatment of Eye Exposure 48

Specialized Eye Equipment 49

The Morgan Lens 49

Nasal Cannula for Eye Irrigation 51

Gastrointestinal Exposure to Toxic Materials 51

Absorbing Chemicals and Nutrients 51

Liver 51

Phase I and II Detoxification 52

Environmental Exposures 53

The Hot Environment - Hydration and Hyperthermia 53

Physiology 54

Absorption of Water 55

Acclimation 57

Metabolic Thermoregulation 58

Determining Severity of Heat 60

Effects of Heat in an Encapsulated Suit 60

Factors Contributing to Heat Emergencies/Injuries 62

Treatment 63

The Cold Environment 64

Exposure to Liquefied Gas and Cryogenics 64

Frostbite Injuries 65

Assessment 66

Treatment 67

Summary 67

3 Toxidromes 69

Introduction 69

Case Study - Silver Cyanide Exposure 69

Assessment Capabilities 70

Blood Pressure 70

Increase in Blood Pressure 71

Decrease in Blood Pressure 71

Pulse 72

Toxidromes 72

Corrosives and Irritants Toxidromes 72

Chlorine (Cl 2) 72

Agent Identification 72

History 73

Pathophysiology 73

Signs and Symptoms 73

Where Is Chlorine Found 74

Decontamination 75

Emergency Field Treatment 75

Basic Life Support 75

Advanced Life Support 75

Ammonia (NH 3) 76

Agent Identification 76

History 76

Physiology 76

Signs and Symptoms 76

Where Is Ammonia Found 77

Decontamination 77

Emergency Field Treatment 77

Assessment/Treatment 77

Basic Life Support 77

Advanced Life Support 77

Phosgene, aka. Carbonyl Chloride 78

Agent Identification 78

History 78

Physiology, Signs, and Symptoms 78

Where Phosgene Is Found 78

Decontamination 79

Emergency Field Treatment (Chloramine, Ammonia, and Phosgene) 79

Basic Life Support 79

Advanced Life Support 79

Pediatric Considerations (Chlorine, Chloramine, Ammonia, Phosgene) 80

Hydrofluoric Acid and Fluorine- Based Chemicals 80

History 80

Pathophysiology 80

Signs and Symptoms of Exposure 82

Where Hydrofluoric Acid Is Commonly Found 82

Decontamination and Significant Danger to Rescuers 83

Treatment 83

Eye Injury Treatment (Hydrofluoric Acid) 83

Skin Burn Treatment (Hydrofluoric Acid) 84

Respiratory Injury Treatment (Hydrofluoric Acid) 84

Systemic Injury from Hydrofluoric Acid (Hypocalcemia) 85

Phenol (Carbolic Acid) 85

History 85

Pathophysiology, Signs, and Symptoms 86

Where Phenol Is Commonly Found 86

Field Treatment and Decontamination 87

Assessment/Treatment or Phenol 87

Lacrimatory Agent Exposure 87

Chemical Currently Being Used 88

Effect 88

Treatment 88

Asphyxiant Toxidromes 89

Effects of Hypoxia 90

Simple Asphyxiants 92

Experience; Death at McDonald’s: “Five Lousy Feet” 93

Assessment/Treatment for Simple Asphyxiants 93

Chemical Asphyxiants 93

Carbon Monoxide Poisoning 93

History 94

Pathophysiology 94

Concerns 96

Signs and Symptoms 97

Where Carbon Monoxide Is Typically Found 98

Decontamination and Danger to Responders 98

Field Treatment 98

Cyanide Poisoning - Hydrogen Cyanide, Cyanide Salts, and Cyanide Containing Gases 99

History 100

Pathophysiology 101

Signs and Symptoms 102

Definitive Diagnosis 103

Where Cyanide Is Commonly Found 103

Decontamination of Patients 104

Emergency Medical Field Treatment 104

CyanoKit - Hydroxocobalamin (Preferred Treatment for Cyanide Poisoning) 105

(Lily or Pasadena) Nitrite- Based Cyanide Antidote Kit (Used for hydrogen sulfide or (Cyanide if the CyanoKit Is Not Available) 106

Hydrogen Sulfide Poisoning 106

History 107

Pathophysiology 107

Signs and Symptoms 108

Where Hydrogen Sulfide Is Commonly Found 108

Decontamination and Significant Danger to Rescuers 108

Field Treatment 108

Definitive Treatment and Follow- up Care 109

Nitrites, Nitrates, Nitrobenzene Poisoning 109

History 109

Pathophysiology 110

Signs and Symptoms 111

Where Are Nitrogen Compounds Found 111

Field Treatment 112

Cholinergic Toxidrome 113

Organophosphate Insecticide Poisoning 113

Experience: Novichok Nerve Agent Used Against Russian Dissident Has Dark History 114

Experience: Tokyo Subway, Site of an Attack Using Sarin Nerve Agent 115

Pathophysiology 115

Signs and Symptoms 116

Location of Organophosphate Insecticides 117

Decontamination and Significant Danger to Rescuers 117

Treatment 118

Experience: Malathion Overdose Treated Without Protopam 119

Treatment 119

Carbamate Poisoning 121

Treatment 121

Hydrocarbons and Derivatives Toxidrome 122

Hydrocarbon Toxicity 122

Pathophysiology 123

Cardiac Effects 124

CNS Effects 124

Emergency Medical Care 124

Signs and Symptoms 124

Treatment 125

Toxic Alcohols 127

Treatment 127

Etiological Toxidrome 127

Overview 127

Vancomycin- Resistant Enterococci (VRE) 130

Symptoms 130

Diagnosis 130

Treatment 130

Methicillin- Resistant Staphylococcus aureus (MRSA) 130

Pathophysiology 131

Signs and symptoms 131

Treatment 131
Clostridium Difficile (C. Difficile) 131

Overview 131

Symptoms 132

Other Risk Factors 132

Complications from C. Difficile Include 132

Prevention 132

Necrotizing Fasciitis 133

Overview 133

Symptoms 133

Cause 133

Treatment 133

Means of Entry 133

Virulence 134

Exposure 134

Radiological Toxidrome 135

Overview 135

Types of Radiation 136

Alpha Particles 136

Beta Particles 136

Gamma Rays 137

Neutrons 137

X- Rays 137

Measuring Radioactivity 137

Principles of Protection 139

Location of Radiation and Common Sites for Accidents 140

Types of Injuries 140

Rescue and Emergency Treatment 142

Treatment 143

Associated Toxic Conditions 144

Closed Space Fires 144

History 144

Fire Toxicology 145

Danger to Firefighters 147

Treatment 147

Wheezing Secondary to Toxic Inhalation 149

Overview 149

Tachycardia Secondary to Chemical Exposure 150

Hypotension Caused by Exposure 151

Seizures Post- Exposure 151

Opioids Overdose/Exposure 152

History 152

Opium Alkaloids 152

Synthetic Opioids 153

Semisynthetic Opioids 153

Today’s Fentanyl and Carfentanil 154

Signs and Symptoms 154

Summary 155

Reference 156

4 Event Conditions 157

Introduction 157

Case Study - Fertilizer Explosion in West Texas 158

Operational Hazards 159

Dispatch Information 159

Scene Safety 160

Upon Arrival - Stop, Look, and Listen 162

Weather Conditions 162

Witnesses Accounts 163

Risk Awareness 163

The North American Emergency Response Guidebook (ERG) 173

NIOSH Pocket Guide 175

Cameo 176

Marplot 177

Aloha 177

Wiser 177

ToxNet and the Hazardous Substance Database 177

Resources 178

Summary 178

5 Hazard Identification 181

Introduction 181

Case Study - Phosgene Exposure 182

States of Matter 182

Solid 184

Liquids 186

Vapors and Gases 186

Mists and Aerosols 186

Gases 186

Compressed Gas 186

Liquified Gas 186

Cryogenic Gas 187

Chemical and Physical Properties 187

Chemical Properties 188

pH (Corrosivity) 188

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Ignition Temperature (IT) 188

Flashpoint (FP) 188

Heat Transfer 188

Physical Properties 188

Appearance 189

Viscosity 189

Melting Point (MP) 189

Freezing Point (FrPt) 189

Boiling Point (BP) 189

Flammable Range 190

Density 190

Specific Gravity (SG) 190

Vapor Density (VD) 191

Vapor Pressure (VP) 192

Expansion Ratios 193

Properties and Their Medical Implications 193

Vapor Pressure, Medical Implications 194

Vapor Density, Medical Implications 195

Specific Gravity, Medical Implications 195

Solubility, Medical Implications 195

History of Toxicology 196

Exposure vs. Contamination 197

Toxin vs. Poison 198

Toxicity of a Poison or Toxin 198

Standards, Guidelines, and Acts Regulating Hazardous Materials 200

NFPA and OSHA 200

Environmental Protection Agency (EPA) 200

Time Weighted Average 201

Short- Term Exposure Limits (STELs) 201

Immediately Dangerous to Life and Health (IDLH) 201

Control Banding 203

Basic Toxicology Definitions 205

Acute Exposure 206

Sub- Chronic/Sub- Acute 208

Chronic Exposure 209

Noel, Noael, Loael 209

Levels of Concern 210

Dose Response and Exposure 210

Graded Response 211

Quantal Response 211

Response Curve 212

Lethal Concentrations and Lethal Doses 213

Chemical Time lines 214

Additional Toxic Effects 216

Toxic Influences 217

General Health 217

Diet 217

Previous Exposure 218

Age 218

Gender 219

Genetics 220

Sleep 220

Biochemistry 221

Detoxification 221

Phase I and Phase II Reactions 221

Detoxification by the Lungs 224

Chemical Toxic Qualities 224

Chemical Excretion 225

Nanotoxicology 225

Determining the Level of Medical Surveillance 226

Risk Assessment and Detection 226

Identification of Hazards 227

Assess Hazards to Determine the Risks 227

Develop Controls to Manage the Risks 227

Implementing Controls 227

Supervise and Evaluate the Process 228

Summary 230

6 Team Capabilities 231

Introduction 231

Case Study - Sodium Nitrate Overdose 231

Technician Operational Considerations 232

Personnel Protective Equipment (PPE) 232

Rehabilitation 235

Decontamination 236

Occupational Safety and Health Administration 237

National Fire Protection Association 237

Environmental Protection Agency 237

Science Behind Decontamination 237

Types of Decontamination 239

Gross Decontamination 239

Secondary Decontamination 240

Tertiary Decontamination 240

Emergency Decontamination 240

Techniques 240

Physical Decontamination 241

Factors to Consider During Decontamination 241

Equipment Uses 242

Choosing a Decontamination Site Location 243

Detection and Monitoring 243

The Approach 244

The System of Detection 245

Radiation 246

pH 247

Oxygen 247

Organic Compounds 247

Biologicals 249

Detection and Monitoring Responses 249

Current Detection Technologies 250

Radiation Detectors 250

pH Paper and Impregnated Papers 252

KI Paper or Oxidizer Paper 252

Wet Chemistry 252

Electrochemical Sensors 253

Catalytic Bead 253

Colorimetric Tubes 254

Photoionization Detection (PID) 254

Flame Ionization Detection (FID) 255

Ion Mobility Spectroscopy (IMS) 255

Infrared Spectroscopy (FT- IR) 256

Raman Spectroscopy 256

Positive Protein 257

Handheld Immunoassay (HHA) 257

Polymerase Chain Reaction (PCR) 258

Mass Causality Incidents 259

Triage Considerations (Non- START Triage) 259

Stilp and Bevelacqua Exposure Score 259

Cardiovascular 260

Breathing (Respiratory) 261

Rx - Immediate Basic Treatment 261

Neurological 261

Mass Decontamination 261

Initial Operations 261

HazMat Alert 262

Hospital Interface 263

Casualty Collection Points (Field Treatment Site) 266

Temporary Medical Care Units (Alternate Care Facilities) 266

The Medical Reserve Corp 266

Hospital Decontamination Considerations 268

PPE in the Hospital Environment 268

Hospital Isolation Rooms 269

Notification and Preparation 269

Hospital Scenario Possibilities 270

Hospital Decontamination Corridor 271

Hospital Decontamination Sequence Model 272

Summary 274

7 HazMat Safety Officer 275

Introduction 275

Case Study - Lieutenant Dan 275

Medical Assessment 276

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Medical Surveillance 278

Initial Baseline Physical and Annual Physical 279

Pre- Entry Physical 281

Considerations of the Entrance Physical 283

Post- Entry Physicals 285

Use of Findings 286

Preventive Health Screening 288

Post- Exposure Physicals 288

Biological Monitoring 289

Team Exit and Retirement Physicals 290

Program Review 290

ADA, Civil Rights, and Health Insurance Portability and Accountability Act (hipaa) 290

Critical Incident Stress Debriefing 291

Developing a Medical Surveillance Program 293

Summary 294

8 Terrorism 297

Introduction 297

Case Study - Salmonella Salad Bar 298

Terrorism Using Chemical Warfare Agents 299

Nerve Agents (Cholinergic Toxidrome) 299

Military Nerve Agents 299

Physical Properties and Routes of Entry 300

Decontamination 301

Treatment 301

Blood Agents - Asphyxiants Toxidrome 301

Military Blood Agents 301

Physiology 302

Physical Properties and Routes of Entry of Cyanide Agents 302

Decontamination 302

Treatment 302

Choking Agents - Irritant Gas Toxidrome 302

Military Choking Agents 303

Physiology of Respiratory Irritant Injury 304

Physical Properties and Routes of Entry 304

Decontamination 304

Treatment 304

Vesicants - Corrosive Toxidrome (Military Blister Agents) 305

Military Blister Agents (Vesicants) 305

Physiology of Blister Agent Exposure 306

Physical Properties and Routes of Entry 306

Decontamination 306

Treatment 306

Lacrimators (Riot Control Agents) 306

CN and CS 307

Oc 307

Decontamination 307

Treatment 308

Terrorism Using Biological Agents 308

Bacteria 308

Viruses 309

Biological Toxins 309

Bacterial Agents 309

Anthrax (B. anthracis) 309

Cholera (Vibrio cholerae) 310

Pneumonic/Bubonic Plague (Y. pestis) 310

Tularemia (F. tularensis) 311

Q Fever (Coxiella burnetii rickettsia) 311

Salmonellae (Salmonella typhimurium) 311

Viral Agents 312

Smallpox (Variola virus) 312

Venezuelan Equine Encephalitis (VEE) 312

Viral Hemorrhagic Fevers (VHFs) 313

Biological Toxins 313

Botulinum Toxin 313

Staphylococcal Enterotoxin B (SEB) 314

Ricin 315

Trichothecene Mycotoxins (T2) 315

Explosives and Incendiary Devices 316

Bomb Incidents 316

Anatomy of Explosives 316

Expected Effects from Explosions 317

Physiology of Blast Effects 318

Blast Effects 318

Summary 320

Epilogue 323

Index 325

Authors

Richard Stilp Armando Bevelacqua