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Chemical, Biological, Nuclear, Radiological, Explosive Weapons of Mass Destruction

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Chemical, Biological, Nuclear, Radiological, Explosive Weapons of Mass Destruction I. Overview Some general principles of Hazmat/WMD/NBC Incidents: A. Rescuer safety is the first priity. B. The possibility
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Chemical, Biological, Nuclear, Radiological, Explosive Weapons of Mass Destruction I. Overview Some general principles of Hazmat/WMD/NBC Incidents: A. Rescuer safety is the first priity. B. The possibility of ongoing respiraty exposure chemical contamination should prompt a APPROACH *response by EMS units until the scene is secured by the fire service/haz MAT team. C. EMS will not operate in the hot zone D. Do not become part of the problem E. Under Incident Command, the fire service commands the scene. * APPROACH does not mean do nothing. Ambulaty patients may be directed out of the area of ongoing chemical exposure, without coming in direct contact with them. Keep other arriving rescuers from becoming contaminated. Always be aware of possible rescuer exposure. II. Personal Protective Equipment (PPE) A. NIOSH/OSHA/EPA Classification System: Level Protection Description A Maximum protection against vap and liquids Fully encapsulating, chemical resistant suit, gloves, boots and a pressure demand, self-contained breathing apparatus (SCBA) a pressure-demand supplied air respirat (air B Full respiraty protection is required but danger to skin from vap is less hose) and escape SCBA. Non-encapsulating, splash protective, chemical-resistant suit that provides Level A protection against liquids but is not air tight. C Utilizes a splash suit along with a full-faced positive negative pressure respirat (a filter type air purifying respirat PAPR rather than an SCBA air line. D Minimal Coveralls, other wk clothing, boots gloves B. Universal Precautions 1. Assume that all patients are potentially contagious and use appropriate barriers to prevent the transmission of pathogenic ganisms. 2. PPE includes gloves, gowns, HEPA respirats, face shields, and appropriate handwashing. 3. If a chemical exposure is suspected, coated Tyvek suits and respirats with Organic Vap/HEPA cartridges are recommended. Page 1 III. Fast Facts f Chemical, Biological and Nuclear Terrism A. Chemical Terrism Recognition, Decontamination and Treatment Personal Protective Equipment: Level A f Hot Zone exposures to unknown chemicals, Level C better f hasty escape Agent Type Nerve Sarin (GB) Soman (GD) Tabun (GA) VX Asphyxiant/Blood Cyanogen chlide Hydrogen Cyanide Blistering/Vesicant Mustard/Sulfur mustard Lewisite Chemical Terrism Recognition, Decontamination and Treatment Mechanism of Unique Initial Effects Decontamination Medical Toxicity characteristics Intervention Anticholinesterase: Miosis (pinpoint Diarrhea Atropine Muscarinic, pupils) Urination Pralidoxime (2- nicotinic Copious Miosis PAM) CNS Effects secretions Bradycardia Benzodiazepines Bronchrhea Muscle should be used f Emesis twitching/ seizures Lacrimation fasiculations agitation Salivation Sweating Cytochrome oxidase inhibition: cellular anoxia, lactic acidosis Alkylation Arsenical Possible cherry red skin Hydrogen cyanide has a bitter almond od Mustard has an od like garlic hseradish Lewisite has an od like geranium Then Coma, Convulsions and Death Confusion Nausea Patients may gasp f air, similar to asphyxiation but me abrupt onset Seizures pri to death Severe irritation Redness and blisters of the skin Tearing, conjunctivitis, cneal damage Mild respiraty distress to marked airway damage May cause death Remove clothing immediately Gently wash skin with soap and water Do not abrade skin F eyes, flush with plenty of water nmal saline Remove clothing immediately Gently wash skin with soap and water Do not abrade skin F eyes, flush with plenty of water nmal saline Remove clothing immediately Gently wash skin with soap and water Do not abrade skin F eyes, flush with plenty of water nmal saline # of Mark 1 Kits f confirmed exposure One f Standing/minimal Two f Sitting, vomiting Three f seizures, near arrest Rapid treatment with oxygen F cyanide, use oxygen, sodium bicarbonate, and specific antidotes (such as nitrites and/ sodium thiosulfate) Immediately decontaminate skin Flush eyes with water nmal saline f minutes Give oxygen if there is difficulty breathing Supptive care Page 2 Agent Type Choking/Pulmonary Chline Nitrogen oxides Phosgene Ammonia Chemical Terrism Recognition, Decontamination and Treatment Mechanism of Unique Initial Effects Decontamination Medical Toxicity characteristics Intervention Liberate HCL, alkylation Chline is a greenish-yellow gas with pungent od Phosgene gas smells like newly mown hay grass Eye and skin irritation irritation Dyspnea, cough Se throat Chest tightness Remove clothing immediately Gently wash skin with soap and water Do not abrade skin F eyes, flush with plenty Fresh air, fced rest If signs of respiraty distress are present, oxygen with without positive airway pressure Other supptive therapy, as needed, fced rest B. Nuclear Terrism Nuclear Terrism Type of Exposure What it is Potential Health Effects Decontamination Dirty Bomb Isotope exposure Thermonuclear Explosion Conventional Explosive with some radioactive isotopes Placement of radioactive materials to expose individuals Large scale blast of nuclear device Blast injury Exposure to isotope likely to have no immediate effect Supptive Care Other treatment based on exposure Radiation sickness Vomiting, malaise, weakness. The sooner the victim has symptoms the wse the exposure Supptive care Other treatments based on exposure Massive injuries and radiation sickness Supptive care Remove from area Remove clothing immediately Gently wash skin with soap and water head to toe Do not abrade skin F eyes, flush with plenty of water Remove victim from area Remove clothing immediately Gently wash skin with soap and water head to toe Do not abrade skin F eyes, flush with plenty of water Shampoo thoughly, head back Mass casualty care C. Biological Terrism: Agents and In General: These are diseases, and most have similar initial symptoms. Suspect Biologic Agents: Cluster of disease, common site source of infection. With exception of toxins, most have 3 to 7 day symptom free period after exposure. Personal Protective Equipment: As f any infectious agents, N-95 Mask, Gloves and Body Fluid, Eye and Respiraty Protection. Biological Terrism: Agents and Type of Agent Dissemination Initial Medical Interventions Bacteria Anthrax Bacteria Plague (Y. Pestis) Airbne, Cutaneous No person to person transmission except cutaneous Airbne Contact Low grade fever cough malaise Cutaneous ulcers Low grade fever, cough malaise Supptive Care Antibiotic therapy Prophylaxis Supptive Care Antibiotic Therapy in Hospital Page 3 Biological Terrism: Agents and Type of Agent Dissemination Initial Medical Interventions Viruses Smallpox Viruses Ebola, Marburg etc Viruses Encephalitis Toxins Ricin Toxins Staph toxin and similar Toxins Botulism Contagious Contact Airbne Contagious Contact Airbne Contagious Airbne, Vect No Person to person transmission Airbne ingested Ingested, possible airbne Airbne Ingested Plague may have large swollen lymph nodes. Rash (see picture) Fever, Malaise Bleeding and Bruising Confusion Fever, Malaise Malaise, vomiting, weakness Vomiting and diarrhea within hours of exposure Respiraty symptoms if inhaled Descending paralysis within hours to days Double vision followed by arm weakness Prophylaxis Isolation Supptive care Vaccination Isolation Supptive Care Supptive Care Supptive Care Supptive Care Supptive Care Antitoxin Page 4 IV. Treatment Alghythms All treatment s apply to pediatric and adult patients unless specifically noted in the. A. General CBRNE WMD Protocol (Entire applies to all license levels [MFR, Basic, Specialist, Paramedic]) Always be alert f potential secondary devices events. Follow Incident Command Scene Safe? Notify Dispatch Medical Stage a safe distance away, up wind, up hill, up stream Await clearance to enter scene If necessary, has the patient been decontaminated? Assess and Treat accding to license level Send f decontamination Treat patients only in cold zone and only after they have been decontaminated you have the appropriate training and are wearing the appropriate HazMat PPE Go to appropriate treatment Suspected Biologic Agent Suspected Cyanide Agent Suspected Nerve Agent Suspect d Blister Vesicant Agent Suspected Choking Agent Suspected Riot Agent Suspected Radiation Nuclear Agent Page 5 B. Suspected Biological Agent (Entire applies to all license levels) Suspect Biological Agent? Apply paper surgical mask to patient if tolerated Assess and Treat accding to license level Follow Communicable Disease Protocol Contact Medical Transpt to the most appropriate facility After transpt, consider post exposure smallpox vaccine other prophylaxis (ie Doxycycline) f responders on scene if appropriate Page 6 C. Suspected Cyanide Agent (Protocol applies to all license levels unless otherwise indicated) This includes the use of inhaled Amyl Nitrite by trained personnel who are authized by their local medical control authity. Additionally, the allows trained and authized paramedics to administer Sodium Nitrite and Sodium Thiosulfate when available. These medications are not required to be carried but may be available from various sources during an event. Common Cyanide Agents Cyanogen Chlide, Hydrogen Cyanide Mild Headache Shtness of Breath Palpitations Chest Pain Dizziness Severe Seizures Coma Suspected Cyanide Agent Assess and Treat accding to license level High Flow O2 Severe Signs and and confirmation of Cyanide from credible operational intelligence and no carbon monoxide exposure? Adult Pediatric MFR, BASIC SPECIALIST 1 perle of Amyl Nitrate, if available, break and: o Hold under nose o Place in Non-rebreather mask, with O2 running o Place in mask of bag valve mask if respiraty assistance needed Administer f 30 seconds each minute and replace perle every 3 minutes if no improvement. Apply EKG Monit Obtain IV Access Apply EKG Monit Obtain IV IO Access Contact Medical Contact Medical Contact Medical Transpt to the most appropriate facility Sodium Nitrite, if available 300 mg IVP over no less than 5 minutes to avoid drop in BP. Monit BP Closely Sodium Thiosulfate, if available 12.5 g/50ml Sodium Nitrite, if available, (3%) 0.33 ml/kg IVP/IO (max of 10 ml) over no less than 5 minutes to avoid drop in BP. Monit BP Closely (Assume avg dose of 0.33 f avg Hgb 12 GM/dL) Sodium Thiosulfate, if available, (25%) 1.65 ml/kg to a maximum dose of 50 ml Page 7 D. Suspected Nerve Agent (Protocol applies to all license levels unless otherwise indicated) Common Nerve Agents Sarin (GB), Soman (GD),Tabun (GA), VX, Organophosphate Pesticides (OPP) Common Clinical Presentations: Vap: Liquid: Unusually Severe Onset of symptoms may be delayed Muscle Fasciculation Immediate onset of Muscle Fasciculations are treated as symptom Seizures Powder Onset of symptoms may be delayed 1. PEDIATRIC Suspected Nerve Agent F specific symptoms and dosing guidelines see Mark 1 Kit Dosing Guidelines Suspected Nerve Agent Assess and Treat accding to license level Is patient less than 8 years old (yo)? Standing with Mild Kneeling with Moderate PARAMDEIC Apply EKG Monit Obtain IV/IO Access Atropine 0.05 mg/kg IV/IO/IM, repeat q 2-5 min as needed f continued marked respiraty symptoms. Minimum Dose 0.1 mg Maximum Dose 5mg Pralidoxime mg/kg If symptoms unresolved patient seizing: Diazepam 0.3 mg/kg IV, max 10 mg If available, Lazepam 0.1 mg/kg IV/IM, max 4 mg If available, Midazolam mg/kg IV/IM, max 10 mg Laying with Severe If less than 1yo MFR/BASIC SPECIALIST If only a Mark 1 Kit is available, use full kit. 1-8 yo, if available administer 1 Mark 1 Kit Standing with Mild If available, administer 1 Mark I Kit Contact Medical Transpt to the most appropriate facility Kneeling with Moderate If available administer 2 Mark I Kits MFR/BASIC SPECIALIST Laying with Severe If available administer 3 Mark 1 Kits Page 8 2. ADULT Suspected Nerve Agent Avoid contact with vomit if ingestion is suspected as vomit may off-gas the agent and present a risk to the rescuers. General Guidelines f Antidote Administration (If Mark l Kits available and Trained in Use): Mild (including self rescue) give 1 Mark l Kit Moderate -give 2 Mark l Kit Severe - give 3 Mark l Kits F specific symptoms and dosing guidelines see Mark 1 Kit Dosing Guidelines Suspected Nerve Agent Quickly assess and treat accding to license level Prepare f excessive suctioning Standing with Mild (including self rescue) Kneeling with Moderate Laying with Severe If available, administer 1 Mark I Kit If available, administer 2 Mark I Kits If available, administer 3 Mark I Kits Apply EKG Monit Obtain IV Access Resolved? MFR, BASIC SPECIALIST If available Diazepam 2-10mg, auto inject Lazapam 2mg IVP Contact Medical Atropine 2mg IVP q 3-5 min until secretions begin to dry up Contact Medical If patient seizes, Diazepam 10mg IVP Lazapam, 2mg, if available Transpt to the most appropriate facility Page 9 Clinical Findings Threshold (Self Rescue) Mild and Signs (Standing) Moderate and Signs (Kneeling) Severe Signs (Laying) Adult Mark I Kit Dosing Guidelines Required Signs/ Conditions Dim vision Increased tearing Runny nose Nausea/vomiting Abdominal cramps Shtness of breath Increased tearing Increased salivation Runny nose Sweating Nausea/vomiting Abdominal cramps Diarrhea Dim vision and/ constricted pupils Constricted pupils Difficulty breathing Severe vomiting Constricted pupils Unconsciousness Seizures Severe difficulty breathing Threshold -and- Positive evidence of nerve agent OPP on site Mild -and- Positive evidence of nerve agent OPP on site Constricted Pupils Constricted Pupils Mark I Kits To Be Delivered 1 Mark l Kit (self-rescue) 1 Mark l Kit 2 Mark l Kits 3 Mark l Kits Clinical Findings Pediatric Patient with Non-Severe Signs/ Pediatric Patient with Severe Signs/ Pediatric Mark I Kit Dosing Guidelines Required Signs/ Conditions As Above Constricted pupils Unconsciousness Seizures Severe difficulty breathing Hypotonia Weakenss Stup, coma * Positive evidence of nerve agent OPP on site * Constricted Pupils positive evidence of nerve agent OPP on site * Mark I Kits To Be Delivered Age 8 years old: As Above Age 8 years old Per Medical Age 8 years old: 3 Mark l Kits Age 8 years old 1 Mark l Kit * Children less than 8 years of age may not have constricted pupils show signs of SLUDGE. Signs may be me nonspecific and include stup, hypotonia, weak cry, weakness, and breathing difficulties Page 10 E. Suspected Blister Vesicant Agent (Protocol applies to all license levels unless otherwise indicated) TE: Signs and may be delayed up to 2-4 hours. Latex and Rubber will absb Mustard. Time is critical f decontamination as blister agents become fixed to tissue within two minutes of being deposited. Common Blister Agents Nitrogen Mustard (HN) /Sulfur Mustard (HD), Lewisite, Phosgene Oxime (CX) Signs and : Red Skin Itching Burning Dry couth Hoarse voice Suspected Blister Vesicant Agent Assess and Treat accding to license level Severe Burns Present? Refer to Burn Protocol MFR, BASIC, SPECIALIST Apply EKG Monit Obtain IV Access Contact Medical Transpt to the most appropriate facility Page 11 F. Suspected Choking Agents (Protocol applies to all license levels unless otherwise indicated) Common Choking Agents: Chline, Nitrogen Oxides, Phosgene, Ammonia Signs and : Shtness of breath Choking Secretions Dry Cough Suspected Choking Agent Assess and Treat accding to license level Copious Irrigation MFR, BASIC, SPECIALIST Apply EKG Monit Obtain IV Access If wheezing, Albuterol 2.5mg/3ccNS ADULT If available: Solumedrol 125mg IVP Dexamethasone 10mg IVP PEDIATRIC If available: Solumedrol 2mg/kg IVP Dexamethasone 0.06mg/kg IVP ` Contact Medical Transpt to the most appropriate facility Page 12 G. Suspected Riot Agents (Protocol applies to all license levels unless otherwise indicated) Common Riot Agents: Oleesin Capsicum (OC), Chlobenzalmalononitrile (CS), Chloacetophenone (CN) Signs and : Burning eyes, nose, airways, skin Suspected Choking Agent Assess and Treat accding to license level Copious Irrigation MFR, BASIC, SPECIALIST Apply EKG Monit Obtain IV Access If wheezing, Albuterol 2.5mg/3ccNS ADULT If available: Solumedrol 125mg IVP Dexamethasone 10mg IVP PEDIATRIC If available: Solumedrol 2mg/kg IVP Dexamethasone 0.06mg/kg IVP Contact Medical Transpt to the most appropriate facility Page 13 H. Suspected Radiation Nuclear Agent (Entire applies to all license levels) Suspect Radiation Nuclear Agent? Radiation Confirmed? Notify Disptach Stage a safe distance away, up wind, up hill, up stream until cleared to enter scene Assess and Treat accding to license level Contact Medical Transpt to the most appropriate facility Page 14
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