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Hazmat

  • Author: Robert D Cox, MD, PhD; Chief Editor: Zygmunt F Dembek, PhD, MPH, MS, LHD  more...
 
Updated: Aug 14, 2015
 

Overview

One of the most challenging aspects of providing emergency medical care is attending to patients who have been contaminated with hazardous materials. HAZMAT is a term used to describe incidents involving hazardous materials or specialized teams who deal with these incidents. Hazardous materials are defined as substances that have the potential to harm a person or the environment upon contact. These can be gases, liquids, or solids and include radioactive and chemical materials. Biological organisms, such as viruses and bacteria, are not included as hazardous materials in this article. Following are images of burns due to radiation exposure.

Early erythema in the frontal and antelateral righ Early erythema in the frontal and antelateral right side of the chest 5 days after the exposure to an iridium-192 source (185 GBq, 5 Ci) mounted in a pen-size sourceholder for industrial radiography, which was placed to the pocket of the worker's overall and kept there for about 2 hours. Image courtesy of the WHO.
Early erythema 11 days after exposure. Image court Early erythema 11 days after exposure. Image courtesy of the WHO.
Tense painful bulla of the left palm on day 20 evo Tense painful bulla of the left palm on day 20 evolving from erythema with early blistering, which had appeared on day 10 after the initial contact for a few minutes with the iridium-192 source. Image courtesy of the WHO.
An ulcer in subacute stage and 5 ulcers following An ulcer in subacute stage and 5 ulcers following self-healing with depigmentation caused by being unawarely exposed 4-8 months earlier to the same164 GBq (4.4 Ci) cesium-137 source (placed in a pocket of a trench coat used as a blanket). Image courtesy of the WHO.
Desquamation and skin necrosis 21 days after expos Desquamation and skin necrosis 21 days after exposure. Note: the white areas correspond to silver ointment. Image courtesy of the WHO.

Most hospitals in the United States lack plans or facilities for attending to patients exposed to hazardous materials, even though this can be a common problem in some areas. Terrorist activities in the United States, Japan, Europe, and Asia and the fear of contamination from radiation from the Fukushima Daiichi nuclear power plant in Japan (see image below) stemming from the March 2011 massive earthquake highlight the need for hospital preparedness. Federal statutes require hospitals to participate in the planning and care of persons exposed to hazardous materials and to train and provide protection for employees who may be exposed while providing medical care.

Earthquake and tsunami damage to the Fukushima I n Earthquake and tsunami damage to the Fukushima I nuclear power plant in Japan. This is a satellite image showing damage at 9:35am on March 16, 2011, 5 days after the earthquake struck. Image courtesy of DigitalGlobe-Imagery and licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

The potential for exposure to hazardous materials in the United States is significant. More than 60,000 chemicals are produced annually in the United States, of which the US Department of Transportation (DOT) considers approximately 2000 hazardous. More than 4 billion tons of chemicals are transported yearly by surface, air, or water routes. These shipments are initiated from more than 100,000 different locations, with more than 1 million people directly involved in the transportation process. More than 500,000 shipments of hazardous materials are made every day, totaling approximately 1.5 billion tons per year.[1, 2, 3]

The incidence of hazardous materials exposures cannot be ascertained accurately because a national reporting system does not exist. In an attempt to better define the magnitude of this problem, the Agency for Toxic Substances Disease Registry developed the Hazardous Substances Emergency Events Surveillance (HSEES) system in 1990. Fifteen state health departments participate in the reporting system. In these states, the system has shown the following findings[4] :

  • About 9000 releases of hazardous substances occur annually, with 75% occurring at chemical facilities and 25% occurring during transportation.
  • Most transportation-related incidents occurred during ground transport (85%) and 26% occurred in residential areas.
  • Human error and equipment failure account for most releases.
  • The most common substances involved were inorganic substances (24%) followed by volatile organic compounds (20%).
  • More than 2000 people are victims of hazardous materials releases in these states each year. Approximately 50% of these are transported to hospitals. Respiratory and eye irritation are the most common types of injury. Over a 4-year period, 132 hazardous material–related deaths occurred.
  • More than 7500 people required decontamination during HAZMAT events over a 4-year period in these states. Of these, 2643 were decontaminated at medical facilities.

Several important points can be drawn from the above statistics. Most importantly, this is not a rare problem. Cities, prehospital-care providers, and hospitals need to have plans for dealing with these incidents and caring for victims of hazardous material exposures. Because most incidents occur at fixed sites, knowing the industries that operate in the catchment area of a hospital and the chemicals used or stored at those sites is imperative. Trauma centers need to have a plan to care for trauma patients who are contaminated because 25% of the incidents occurred during transportation and 9% of victims of hazardous materials exposure also had traumatic injuries.

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Hospital and Community Planning for Hazmat Incidents

There are requirements by several different federal agencies, as well as the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), for hospitals to participate in community planning for HAZMAT incidents. The most important federal statute that hospitals must be familiar with is SARA Title III, a portion of the Superfund Amendments and Reauthorization Act, otherwise known as the Emergency Planning and Community Right to Know Law.

SARA Title III states that facilities manufacturing or storing hazardous chemicals must report inventories and every hazardous material release to public officials and emergency health agencies.[5] This act also requires the establishment of state emergency response commissions (SERC) and local emergency planning committees (LEPC). The LEPC includes local officials, police, fire, and public health authorities in addition to representatives of local hospitals, media, and the community. Hazardous chemical and preparedness information from LEPCs is compiled by and available at each SERC. 

Emergency response plans

The primary responsibility of the LEPC is to develop emergency response plans (ERPs) to do the following:

  • Identify local facilities using hazardous substances
  • Designate community and industrial coordinators
  • Establish mechanisms of emergency notification
  • Establish procedures for determining the occurrence of a release and an estimation of the affected population [6]
  • Identify community emergency equipment facilities
  • Establish evacuation plans
  • Establish and schedule training programs for emergency personnel

Hospitals are required to be an integral part of the ERP. Additionally, emergency medical services (EMS) units and coordinators have critical roles in the planning and execution of an emergency response. The plan for each community varies depending on the types of industries involved, chemicals used, and resources available. For example, many fire departments in metropolitan areas have developed specialized HAZMAT teams to respond to these situations. These teams are responsible for containing releases and for decontaminating persons exposed to hazardous materials. After decontamination, these patients can be transported safely and treated in the hospital with minimal precautions.

In communities where a HAZMAT team is not available, the ERP must consider how persons exposed to hazardous materials will be decontaminated and transported. Hospitals must be capable of caring for severely contaminated patients under the ERP guidelines. Because many hospitals are poorly prepared to attend to a severely contaminated patient, early involvement of hospital representatives in the planning process is critical. Similarly, EMS coordinators must train emergency medical personnel to attend to contaminated patients and to establish contingency plans for their transport and care.

Joint Commission for Accreditation of Healthcare Organizations guidelines

Several JCAHO requirements relating to hazardous materials affect hospitals. Some of the more specific JCAHO guidelines are as follows:

  • EC 01.01.01: The hospital plans activities to minimize risks in the environment of care.
  • EC.02.02.01: The hospital manages risks related to hazardous materials and waste.
    • EP3: The hospital has written procedures, including the use of precautions and personal protective equipment, to follow in response to hazardous material and waste spills or exposures.
    • EP4: The hospital implements its procedures in response to hazardous material and waste spills or exposures.
    • EP10: The hospital monitors levels of hazardous gases and vapors to determine that they are in safe range. Note: Law and regulation determine the frequency of monitoring hazardous gases and vapors as well as acceptable ranges.
  • EM.02.01.01: The hospital has an Emergency Operations Plan. Note: The hospital’s Emergency Operations Plan is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency.

Occupational Safety and Health Administration regulations

The Occupational Safety and Health Administration (OSHA) has issued several regulations that pertain to any hospital employee who may come into contact with hazardous materials, including those on patients seeking medical care. Regulation 29 CFR 1910.120 (q) standard describes respiratory protection for all employees potentially exposed to hazardous chemical vapors as well as the minimal degree of training for any employee involved in decontamination. Other standards (ie, 29 CFR 1910.132 [d], 1988) delineates that employers must assess the workplace for potential hazards and have employees use personal protective equipment (PPE) appropriate for that hazard.

Under OSHA standards, an emergency response team is defined as an individual or group who responds to a release of a hazardous material, no matter where it occurs. This regulation initially was intended for hazardous waste operators and emergency response personnel at hazardous waste facilities; however, in the case of a patient who has been contaminated, hospital and EMS personnel also may be included.

The current regulations state that all ED personnel must be trained at a minimum of first responder awareness level (level 1), and any personnel involved in patient decontamination must be trained to first responder operation level (level 2). OSHA has not fully determined how these standards will apply to hospitals and healthcare facilities that are off-site. Planning the roles of HAZMAT and EMS workers requires familiarity with the definitions and training requirements (described below) of individuals who may respond to a HAZMAT incident as defined by the Hazardous Waste Operations and Emergency Response (HAZWOPER) standards. If emergency medical transport personnel are expected to transport contaminated individuals or to provide medical care in the field prior to decontamination, they at least should have the appropriate level of training. Five levels of HAZMAT responder training are defined in CFR 1910.120 (q).

Environmental Protection Agency

Under the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), EMS scene responders are protected under a "Good Samaritan" clause. However, healthcare facilities must contain any runoff from decontamination activities.

Hospital and community planning

Hospitals must have adequate plans for addressing HAZMAT incidents and incorporate these into community plans. Some of the aspects that need to be included in the plans include the following:

  • Triage
  • Personal protective equipment (PPE)
  • Decontamination procedures
  • Crowd control
  • Dealing with victims who arrive by private vehicle
  • Medical care after decontamination
  • Public relations and press releases

The responsibility of hospitals cannot stop at the planning stage. Employees must be trained to use the PPE and how to perform decontamination. Incidents of hospital workers becoming ill as a result of chemical exposure when caring for a contaminated patient have been reported. If this occurs, the legal position of the hospital is tenuous.

Providing universal guidelines for all communities is difficult. In formulating hospital and community response plans, the most critical aspects to consider are location of and responsibility for decontamination. Ideally, decontamination takes place in the field and is performed by specially trained HAZMAT teams. In this case, subsequent prehospital and hospital care can be performed with little change in the usual routine and with minimal risk to healthcare providers. In situations where several hospitals are located in a given area, it is not financially feasible for all hospitals to have good decontamination facilities. One hospital should be chosen as the receiving facility. The choice of hospital should be based on the availability of decontamination facilities, intensive care facilities, training of ED personnel, and staff trained in medical toxicology.

Regardless of whether a hospital is a receiving facility or if it is in an area where a trained HAZMAT team is located, situations always occur when contaminated patients present to other prehospital or hospital systems. In any mass casualty situation, it is likely that victims will leave the scene and travel by private vehicle to the healthcare facility of their choice. For a hospital that was not a designated decontamination facility to send these patients to another facility prior to decontamination would constitute an Emergency Medical Treatment and Active Labor Act (EMTALA) violation. Consequently, all hospitals should have a plan and appropriate employee training for attending to the contaminated patient.

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Hazmat Incident Management

Chain of command

The HAZMAT disaster plan for a community clearly should define who is in charge of a situation. This person ultimately is responsible for protecting public health and the environment and ideally should be a specially trained individual representing either the HAZMAT team or the LEPC. The ERP should clearly delineate the authority of this person, even on private property or private facilities.

The ERP must address many aspects other than medical care. The plan should stipulate the reasons for evacuation as well as local evacuation centers. The incident commander must consider public and rescuer hazards from toxic and corrosive materials as well as those from explosive or flammable materials. Finally, the plan must stipulate at what point EMS personnel not trained to attend to HAZMAT issues will interact in patient care.

The community disaster response plan delineates the chain of command for a situation and specifies how the EMS system will interact with the HAZMAT team. Defining the point at which the EMS system gets involved with injured persons is not an easy task. Ideally, specially trained HAZMAT workers decontaminate all exposed individuals prior to turning them over to the EMS system. However, in any individual situation, the severity of a patient's injuries and degree and type of contamination must be weighed against the medical training of the HAZMAT worker and the EMS system.

The ideal situation is to have the HAZMAT team is made up of specially trained members of the fire department who also are cross-trained as paramedics or emergency medical technicians (EMTs). However, smaller communities commonly do not have this luxury. Especially in situations in which the HAZMAT team is not trained in prehospital care, involving medical control physicians and poison control centers in patient care decisions is essential.

Goals in managing a HAZMAT incident

The goals of managing a HAZMAT incident include the following:

  • Recognition of the situation and notification of emergency services
  • Establishment of a command center
  • Protection of site and emergency workers from any further exposure
  • Identification of the hazardous materials involved
  • Assessing the hazard risk and the degree of personal equipment required
  • Rescuing any victims of hazardous materials exposure that are on-site
  • Crowd control and keeping ambulatory exposure victims on-site until they are decontaminated
  • Notifying local healthcare facilities of the incident and the number and type of victims
  • Decontamination and initial medical care of victims
  • Containment of the hazardous material, including runoff from decontamination activities
  • Evaluation of further public exposure and evacuation where necessary

Obviously, many of these functions are performed concurrently. Recognition of the danger may seem a simple matter, but this usually depends on local workers or first responders. Most industrial site workers should be familiar with the site's ERP, including contact information in case of emergency and what to report. Potentially disastrous situations occur with motor vehicle or agricultural accidents in which the first responders are not aware of hazardous material dangers. In one series of HAZMAT incidents, 14% of exposed individuals were first responders. This emphasizes the importance of emergency medical personnel being trained, at a minimum, to the level of first responder awareness.

Site command center

One of the earliest priorities is the establishment of a site command center. Ideally, locate this command center near the incident but far enough away to avoid any exposure. The command center should be located upwind and uphill to avoid contact and should have a wind monitor and alarm system to warn of any shifting wind currents that may carry hazardous materials toward the command center. The command center should have a rapidly deployable communications system. This is critical to maintain contact with on-site workers and off-site emergency management and medical personnel to access information on the hazardous substances involved and necessary containment and safety procedures.

The site should be divided and managed within 3 zones (see image below):

Zone control of the hazardous materials site. Zone control of the hazardous materials site.

See the list below:

  • The contaminated area is known as the hot zone. Only individuals with appropriate PPE and specialized training are allowed into this zone.
  • The intermediate zone, also known as the decontamination zone, is where patient decontamination should take place. A degree of contamination still is found in this zone; thus, some PPE is required, although it is usually of a lesser degree than that required for the hot zone.
  • The command zone is located outside the decontamination zone. All exposed individuals and equipment from the hot zone and decontamination zone should be decontaminated before entering the command zone. Access to all zones must be controlled. Keeping the media and onlookers well away from the site is critical.

After decontamination, victims who require medical care can be picked up in the command zone. Only trained individuals wearing necessary PPE should be allowed into the decontamination zone. This produces a dilemma when persons exposed to hazardous materials require immediate medical attention. If this is the case, the ideal situation is for some EMS personnel to have the appropriate level of training to work in PPE. If this is not possible, the medical control physician and the site commander must make decisions on an individual basis.

Transportation

Placing a contaminated patient in an ambulance is strongly discouraged. This is a closed environment and presents increased risk to those in the ambulance. This action also results in the contamination of the ambulance and its equipment. No further use of the ambulance is allowed until it can be decontaminated appropriately. Ambulances usually are resources that most communities cannot spare. Transportation prior to decontamination increases the amount of time the patient is in contact with the hazardous material.

Some have recommended that patients be transported in the back of open trucks. In this situation, these patients are not medically monitored or treated while being transported. Transportation in the back of an open truck should only be considered in those situations where no decontamination options exist at the scene and the hospital is prepared for decontamination.

Hazard identification

Identification of the hazardous materials involved is critical to all aspects of the rescue operation. As part of the SARA legislation, industrial sites are required to report all hazardous materials at their facility to the local emergency planning agency. In most instances, this information is maintained by the fire department or emergency planning agency. Industries also are required to post this information in a location external to the site, usually in an external electrical box or fire safety location. This assumes that the information contained in the external location or by the fire department is current. Problems may arise when new chemicals are added to an inventory and the lists are not updated.

The DOT requires all vehicles carrying chemicals to display placards identifying them. Generally, these are diamond-shaped signs that have specific colors and numbers that define the class of hazardous material that is present. The DOT classes and defining colors of hazardous materials include the following:

  • Explosives (solid orange color)
  • Nonflammable gases (solid green color)
  • Flammable liquids (solid red color)
  • Flammable solids (white and red stripes)
  • Oxidizers and peroxides (solid yellow color)
  • Poisons and biohazards (solid white color)
  • Radioactive materials (half white, half yellow with black radiation symbol)
  • Corrosives (half white, half black)
  • Other (usually white)

Each placard usually contains a descriptive color, symbol, and number. The triple redundancy is so that, in case of an explosion, any remaining portion of it can be used to identify the type of material present. The DOT identification system only identifies the type of hazard present and does not identify specific chemicals or materials.

Many placards also contain a 4-digit number, known as the United Nations (UN) identification number. These numbers identify individual chemicals or groups of chemicals. Because several hundred thousand chemicals are known, obviously, only a relatively few can be identified by a 4-digit classification system. For this reason, many chemicals with similar characteristics are given the same UN number.

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Personal Protective Equipment

Specialized equipment, known as personal protective equipment (PPE), is required to adequately protect rescue personnel and healthcare providers from secondary contamination. The type of PPE used depends entirely on the situation and the level of training of the user. HAZMAT workers required to enter the hot zone require a greater level of protection than medical personnel providing care to contaminated patients.

This image shows a Naval Medical Center San Diego This image shows a Naval Medical Center San Diego decontamination team member as a part of a drill to treat patients in a radiation contaminated mass casualty scenario. Image courtesy of Wikimedia.

Levels of protection for work involving hazardous materials

Four levels of protection have been defined for work involving hazardous chemicals. Although these levels originally were intended for work at hazardous waste disposal sites, they have been adopted widely in other situations, such as rescue work.

  • Level A is the maximum level of protection and usually is required only of HAZMAT personnel and others working in areas of very high concentrations of toxic agents, such as those entering the hot zone. It consists of a fully encapsulating chemical-resistant suit, positive-pressure self-contained breathing apparatus (SCBA), double layers of chemical-resistant gloves, and chemical-resistant boots. Airtight seals should be in place between the suit and the inner layer of the hands, face, and feet protection.
  • Level B is used when full respiratory protection still is required but dangers to the skin are less. It consists of a SCBA and a chemical-resistant suit with resistant gloves and boots. No airtight seals on the face, hands, and feet are necessary.
  • Level C is required when air concentrations are expected to be much lower and less likelihood of skin exposure exists. It consists of a full-face air purification device and a nonencapsulating chemical-resistant suit with gloves and boots.
  • Level D level of protection is used only when no danger of chemical exposure exists. It consists of standard work clothes and no respiratory protection.

Most HAZMAT workers who enter the hot zone require Level A protection. This is very expensive, bulky, and requires specialized training in its use. The typical Level A HAZMAT suit costs several thousand dollars and must be cleaned between uses. Manual dexterity is poor, and the suits are very hot, limiting the amount of time that they can be worn.

HAZMAT teams usually use Level B or C PPE for decontamination. This takes place away from the hot zone and when the amount of chemical present on a patient is significantly less than those that exist in the hot zone. Also, quantities of chemicals that might present physical hazards, such as explosions, should not be present on a patient. EMS workers and other healthcare providers require less protection than HAZMAT workers, but they still must be protected adequately when attending to contaminated patients. The level of protection required is usually Level C or B. This includes a chemically resistant suit, gloves, and boots; respiratory protection; face protection; and disposable boots.

OSHA is still unclear on the level of protection that is recommended for medical personnel performing decontamination. The recommendations previously discussed suggest that Level B should be used in this situation. A considerable difference exists between Level B and Level C. Level B requires an external air source, either by SCBA or by a forced air supply through hoses. Either of these adds considerable expense and training compared with the use of air-purifying respirators used in Level C protection. Several research studies have concluded that Level C protection is sufficient for hospital decontamination.

Recommendations for PPE to be used in situations of radiation contamination suggest only Level D–type protection plus a dust filter for respiratory protection.

Protective suits and gloves

For medical applications, inexpensive ($50-100) and disposable chemical-resistant, multilayer polymer suits are available. Suits much more expensive than this commonly are used for surgery involving patients with HIV or other infectious diseases. One common misconception is that Tyvek suits, which are very inexpensive and readily available around hospitals and laboratories, are suitable for decontamination work. This material provides no chemical protection, and most chemicals can penetrate this material immediately, although it suffices for work with dusts, including radioactive dusts and biological agents. These suits are recommended for training exercises but should not be relied upon for chemical protection.

Glove material also is an important consideration, because the hands have the most contact with the patient. Unfortunately, no single glove material provides adequate protection against all chemicals. To counter this situation, most HAZMAT workers use several gloves of different materials. An ideal combination is nitrile and Viton. However, this is bulky and markedly limits manual dexterity. Because patients should be washed immediately with large quantities of water during decontamination, actual contact with pure chemicals is generally minimized. Typical latex gloves used in most hospitals offer little chemical protection. Nitrile has much better chemical resistance than latex and is now available in a thin, flexible, disposable glove that permits good manual dexterity. This is presently the ideal glove material for use when providing medical care to a patient who has undergone chemical contamination.

Aldehydes, halogenated hydrocarbons, ketones, aromatic hydrocarbons, nitro-organic compounds, and carbon disulfide rapidly can permeate nitrile. Unfortunately, most common solvents consist of chemicals within these classes. If these are encountered, a thicker overglove, preferably made of Viton, should be used until the patient is at least partially decontaminated. Most chemicals are removed just by removing the clothes. Once no chance exists of coming into contact with large quantities of pure chemical, such as during removal of the patient's clothes, disposable nitrile gloves should be sufficient.

Boots should be worn, since the feet are in constant contact with contaminated water during patient decontamination. Because chemicals are diluted, inexpensive disposable boots should suffice. Boots also provide slip resistance on wet floors. Avoid leather and cloth footings since these materials may wick up contaminants and are impossible to clean.

Respiratory exposure to vapors is an additional risk to the healthcare worker. The small quantity of materials present on a patient makes generation of toxic concentrations of vapors unlikely. Respiratory protection especially is important when working in enclosed spaces, such as transport vehicles or medical care rooms.

Available types of respiratory protection - Cartridge respirators and supplied air respirators

Air-purifying cartridge respirators function by allowing the wearer to inhale air through a canister filled with a special sorbent material that binds chemical vapors. Cartridge respirators are inexpensive, portable, and easy to use and store. However, drawbacks exist to their general use. The type of cartridge used must match the chemical vapor in question. Different cartridges must be used to protect from organic vapors, acid gases, chlorine, ammonia, and methylamine. The sorbent materials also have a breakthrough phenomenon, in which chemicals elude off the sorbent after a period of use and then expose the user. Multisorbent cartridges are available that do not require matching with the vapor in question. In general, these have a shorter breakthrough period. These factors limit cartridge respirators to short-term use and to low concentrations of chemicals in the air. This is the situation that exists when patients require decontamination.

Cartridge respirators depend on an airtight seal against the face. They require a good fit and cannot be used with facial hair. A moderate amount of work is involved when inhaling across the pressure resistance of the cartridge. All of this requires that any individual using this type of respirator be fitted properly and trained in its use. Cartridge respirators are very versatile for short-term use. They require adequate training of all personnel who may be expected to use them and require someone available at all times to decide which type of cartridge to use. Cartridge respirators are ideal for performing decontamination outside the ED.

To overcome many of the problems with air-purifying cartridge respirators, battery-operated cartridge respirators were developed. These use a battery-operated pump to draw air across the sorbent cartridge and pump it into a hood that surrounds the user's head. These do not require an airtight fit and can be used with facial hair. They do not require the user to work to draw air across the cartridge and, thus, are much cooler and less anxiety provoking. They also require less individual training. They still depend upon the cartridge to remove the vapor in question; thus, the cartridge must match the vapor. The time of use must be limited because of both chemical breakthrough in the cartridge and battery life. Since a clear shield surrounds the face, they provide better eye contact with the victims. These are probably the simplest and most versatile form of air purification device for hospital decontamination use. These devices are shown in the images below.

Battery powered air-purifying hood respirator. Ima Battery powered air-purifying hood respirator. Image courtesy of A. J. Anderson, MD.
Battery powered air-purifying hood respirator and Battery powered air-purifying hood respirator and decontamination shelter. Image courtesy of A. J. Anderson, MD.

Supplied air respirators provide a source of clean breathing air through a hose and an external supply. The external supply can be provided from a pump or compressed air. Two types of masks are available: one with a pressure-actuated valve and one that continuously blows fresh air across the face. The second type uses much more air than the first. The fit is less critical since any leaks always have air flowing from inside to out. The supplied air respirators can be used in all situations and for any length of time without worry about choice of the proper cartridge and breakthrough.

Use of supplied air respirators also requires training, although proper fit is less critical, at least with the continuous flow type. Because of the necessary air supply and hoses, supplied air respirators are impractical for use with outside decontamination. Some HAZMAT teams use this method for personnel providing decontamination close to a supply vehicle that can pump the necessary air. If a decontamination room is to be established inside a hospital, supplied air respirators are the ideal choice.

Most respiratory protection can be obtained using a half-face design, which covers the nose and mouth, or a full-face design that also covers the eyes. If the half-face design is used, goggles also must be worn to protect the eyes from splashes. However, the eyes are still exposed to vapors that can be irritating or toxic. If respiratory protection is to be used, choosing the full-face version to protect the eyes and entire face makes much more sense.

Protection of healthcare workers from hazardous materials exposures can be achieved with some degree of advance planning and training. Chemically protective suits that are inexpensive and disposable are available. Respiratory protection also can be obtained without significant expense; however, the least expensive type, cartridge respirators, requires some additional training.

The recommended PPE for decontamination of victims of radiation exposure, usually consists of a filter-type dust mask, gloves, and Tyvek or surgical scrub suit. This was intended to protect the healthcare provider from radioactive dust particles. Unfortunately, this PPE is completely inadequate to protect from chemicals in the liquid or vapor states. Alternatively, PPE designed for chemical protection is more than adequate to provide protection in the case of a patient exposed to radiation. To avoid confusion and simplify the protocol, only one type of PPE is recommended. This may be more elaborate and expensive than that needed for a radiation protocol; however, it can be used in all situations involving persons exposed to hazardous materials.

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Decontamination

Decontamination is the process of removing or neutralizing hazardous materials on people or equipment. Removal of chemicals on skin is important for 2 reasons:

  • To prevent further absorption and subsequent toxicity because many substances disrupt the integrity of the skin and then become systemic toxins following absorption
  • To prevent other persons or equipment from becoming contaminated with substances on the patient's clothes or skin (secondary contamination)
    Decontamination. Image courtesy of Wikimedia. Decontamination. Image courtesy of Wikimedia.

The type of decontamination procedure used depends on the situation. Removing all clothes will also remove most of the contaminants. Most decontamination can be accomplished by simple high-volume dilution with water. Occasionally, mild soaps are required to remove oily or greasy substances. Phenol can be removed better with polyethylene glycol if available. If not available, use water. Also, see CBRNE - Chemical Decontamination.

Avoid water in the presence of metallic sodium, potassium, lithium, cesium, and rubidium because these react on contact with water. Dusts of pure magnesium, white phosphorus, sulfur, strontium, titanium, uranium, yttrium, zinc, and zirconium ignite on contact with air. If burning, many of these explode if exposed to water. If these substances are suspected, remove residual metal with forceps and store it in a container of mineral oil. If radioactive particles are on or embedded in the skin, remove them by forceps. The radiation safety officer should dispose of them. Some HAZMAT teams use 4 special solutions recommended by the National Fire Protection Association for patient decontamination. Little evidence exists that these solutions are more effective at decontaminating human skin than water alone. In addition, none of the solutions can be used on open skin, mucous membranes, or the eyes.

Collect the water runoff from the decontamination, and do not allow it to enter parking lots or storm drains. However, if a drain is readily available and arranging a collection system will require considerable time, decontaminating the patient and allowing the water to enter the drain may be prudent. Although this action theoretically can result in a fine from the EPA for an unscheduled discharge, to date, this situation has not happened to a hospital.

The collected water should be considered to be contaminated with a hazardous substance. If it is allowed to spread into an open area, it likely will be tracked off-site into private vehicles and homes. Collection of the decontamination runoff is accomplished by using a series of collection pools, which can be specially designed devices or can be as simple as inflatable children's pools. For ambulatory patients, a series of 3 collection pools usually is used, with contaminated patients or workers always starting in the most contaminated pool and finishing in the least contaminated pool. For nonambulatory patients, specialized runoff collection litters are available.

Remove clothes and place them in a plastic bag, and mark it as contaminated. Give priority to decontaminate the eyes, mucous membranes, and severely affected areas of the skin. Take care not to wash contaminants onto unaffected areas of the skin. Thoroughly irrigate areas of skin where the surface is broken. Avoid abrasive cleansing.

For radioactive materials, a Geiger counter can be used to detect any residual contamination. Unfortunately, no simple instrument is available for the wide range of chemical contaminants. Portable handheld monitors are available for detecting hydrocarbon vapors, but these usually are not available in hospitals. Copious irrigation is the standard rule; however, this should not be to the point of irritating or denuding the skin.

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Hospital Protocol for Hazmat Incidents

Hospital care for a person exposed to hazardous materials should begin with adequate planning well before the incident occurs. Failure to have an adequate plan to attend to a HAZMAT situation can result in injury to hospital employees and subsequent liability to the hospital for not meeting OSHA standards. More importantly, most hospital EDs serve integral functions to the hospital and the community. Closure of an ED because of contamination can have dire effects on hospital function and the community's medical resources.

Decontamination plan

Most hospitals are poorly prepared to care for a contaminated patient and have little protection for hospital employees who are involved. This is even more reason to be involved in the community planning process. If hospitals are unprepared to decontaminate persons exposed to hazardous materials, every effort should be made to decontaminate patients in the field. Even if this is the case, hospitals should have some plan to decontaminate victims who arrive by private vehicle or by an inadvertent ambulance transport. In the worst-case scenario, the contaminated patient should be held outside the ED until the community HAZMAT team can assist with the decontamination. Whatever the situation, decontaminating the patient prior to entering the ED is essential.

The first decision to be made in formulating a HAZMAT plan for the ED is where decontamination is to take place. An inside decontamination area is ideal, although it often may not be practical or possible. Locate an inside decontamination room so that it can be accessed without entering the hospital or the ED. The room can be used for other purposes, although anything inside the room should be easy to remove. An advantage of an inside area is proximity to ED personnel, supplies, and electrical and water sources. Monitoring patients and providing critical medical care obviously is easier in a room adjacent to or in the ED. Controlling access to a single room also is much easier. However, after the room is used, provisions need to be made to clean the room and remove wastes. Performing decontamination outside the ED is probably more practical in most situations, although it detracts from the care of the patient who is critically ill.

If the decontamination area is located inside, it should be adjacent to an entrance, preferably the ambulance entrance. Gaseous, liquid, and solid wastes must be collected. The room should be under negative pressure and have a separate ventilation system that discharges to the outside. Contaminated irrigation water should not be discharged into the general hospital drain system but should be collected in a specialized holding tank under the decontamination room. The expense of installing a tank for this purpose is difficult to justify unless a new room is being constructed specifically for decontamination. Alternatively, liquid wastes can be collected in inflatable plastic children's swimming pools or expandable plastic containers designed for this purpose. For patients who are not ambulatory, specialized litters are available to collect water runoff in special collection barrels. Plans need to be made for eventual removal and disposal of collected wastewater.

Planning for outside decontamination is simpler and less expensive than equipping an indoor decontamination room. Ventilation is not a significant problem outside, although the decontamination team should wear respiratory protection if indicated by the type of hazardous material. The prospective site must have a water hose for decontamination. Ideally, the water supply should be temperature controlled. The wastewater still must be collected and not allowed to run over lawns or pavement into sewer drains. Portable pools can be used for collection, but provisions must be made to prevent access to these prior to removal.

Similarly, solids must be collected and properly stored prior to disposal. Two of the drawbacks to outside decontamination are patient privacy and weather. These problems can be handled by using tarps and portable heaters. Portable showers that can be assembled easily are now available commercially. External decontamination shelters that are portable and easily assembled are now available. Some have access for ambulatory patients as well as patients on stretchers. Pumps are provided to store water in barrels. All that is required is a water supply and a power source. An example of one of these shelters is shown in the images below.

Battery powered air-purifying hood respirator and Battery powered air-purifying hood respirator and decontamination shelter. Image courtesy of A. J. Anderson, MD.
Portable decontamination shelter. Image courtesy o Portable decontamination shelter. Image courtesy of A. J. Anderson, MD.

Providing medical care to patients who are critically ill is more difficult if decontamination is performed outside. If medically indicated, portable monitors and portable oxygen may be needed. This equipment must be cleaned thoroughly or discarded after use. A special portable communication system may be needed if the decontamination team is using respiratory protection. Additional personnel are needed to obtain necessary medications and supplies from inside the hospital. Finally, if the decontamination is to be performed outside, the area must be secured properly. Encircle the area by rope or tape; security personnel are required to prevent unauthorized entry. The area may need to be secured for several days until all wastes are removed.

The goal of decontamination is to remove enough of the contaminating material so that any danger of secondary contamination to those providing medical care or to the patient no longer exists. Ideally, decontamination should require only 10-20 minutes, although patient stabilization may prolong this period. After decontamination, the patient can be moved into the general treatment area and treated as any other patient. Limit treatment to only basic life support measures and life-saving procedures within the decontamination area.

The choice of which procedures will be performed in the decontamination area must be made on an individual basis. Any medical interventions will prolong decontamination and the time until the victim can be moved into the ED for more definitive care. While conditions such as tension pneumothorax, cardiac dysrhythmias, or respiratory distress should be treated immediately; most conditions can be treated with basic stabilization until the patient has been decontaminated. Consider any item used in the decontamination area contaminated until it has been cleaned thoroughly. Postpone the acquisition of radiographs, ECGs, and routine blood work until the patient is moved out of the decontamination area.

One observer outside the decontamination area should monitor how long team members are working in PPE and limit each individual's time. The equipment can be very hot, and the situation is stressful. Any team member who appears fatigued or stressed should be immediately removed. Decontamination team members should be trained in the proper method of removing the personal protective gear. Equipment should be removed in the opposite order from which it was initially put on. An inner layer of disposable gloves should be the last item removed. Care should be taken to not handle the chemical-resistant suit with bare skin. Items that need to be reused, such as respirators and masks, should placed in a separate area.

Some published radiation protocols recommend long lists of supplies to be maintained in the decontamination area. This should not be a problem if the decontamination area is in or adjacent to the ED, where all necessary supplies should be readily available. Using a runner for needed items is much more efficient.

The hospital protocol should include guidelines that outline who is to perform decontamination. Although having a single team to train is easier, training at least 1-2 members of each shift is more practical. HAZMAT situations occur spontaneously and with no advance notice. The delay of calling a special decontamination team from home is not practical. In the protocol and training, specify how team members are to remove PPE, where the contaminated materials can be stored until they can be disposed, and who is responsible for the disposal of contaminated material.

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Conclusions

See the list below:

  • Hospitals are required to participate in community disaster planning for HAZMAT incidents according to SARA Title III.
  • Hospitals are required to protect their employees from hazardous materials exposures, including exposure that may occur as a result of patient care.
  • Patient decontamination ideally should be performed in the field.
  • Unprepared EMS units should not transport contaminated patients.
  • Adequate PPE for healthcare providers not in a hot zone includes a chemical-resistant suit (Tyvek is not sufficient), nitrile gloves, disposable boots, and full-face cartridge or supplied air respirator. This equipment is less expensive than some operating suits.
  • Healthcare providers need training prior to using PPE.
  • Hospitals should have plans to attend to patients contaminated by hazardous materials.
  • Decontamination can be accomplished safely outside the ED or in specially prepared rooms indoors. Contaminated patients should not enter the main areas of the ED or hospital.
  • If a hospital is unprepared to handle a contaminated patient, one option is to call the local HAZMAT team. However, this should be worked out in advance and there still needs to be a plan if they are not available.
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Additional Information

This article is an overview of issues attending to individuals who have been exposed to hazardous materials. Because entire books have been written on this subject, all aspects cannot be covered here. Listed below are additional sources of information on hazardous materials exposures.

Local resources

See the list below:

  • Regional poison control centers provide information 24 hours per day.
  • LEPC provides information about chemicals in the community. Records of this information and level of preparedness are maintained by each state's SERC.
  • Fire department and/or HAZMAT team assists with response and planning and chemicals in the community.

National resources

See the list below:

Computer-based resources

See the list below:

  • Chemical Hazard Response Information System (CHRIS) (800-247-8737) contains general and health hazard information.
  • The MICROMEDEX (800-525-9083) CD/ROM includes the following databases:
    • POISINDEX contains comprehensive acute and chronic toxicity information and medical management guidelines.
    • The TOMES Plus CD/ROM compiles hazard and toxicity information from the National Library of Medicine Databases, CHRIS, and several other sources (see TOMES System).

Internet resources

See the list below:

  • Toxicology Data Network (TOXNET) through the National Library of Medicine. TOXNET is a comprehensive data bank for health effects of industrial and environmental exposures. TOXNET contains the following databases:
    • Hazardous Substances Data Bank (HSDB) provides toxicology, emergency handling, and regulatory requirements on more than 4800 hazardous substances.
    • Toxicology Literature Online (TOXLINE) maintains a large bibliographic database covering the toxicologic, pharmacologic, physiologic, or biochemical effects of drugs or chemical substances.
    • Chemical Carcinogenesis Research Information System (CCRIS) contains carcinogenicity and mutagenicity data on more than 8000 chemicals and is maintained by the National Cancer Institute.
    • Integrated Risk Information System (IRIS), maintained by the EPA, provides health risks and regulations on more than 500 chemicals. IRIS also contains health advisories.
    • Genetic Toxicology Data Bank (GENETOX) provides genetic toxicology on more than 3000 chemicals.
    • Developmental and Reproductive Toxicology Database/Environmental Teratology Information Center Backfile (DART/ETIC) maintains bibliographic databases on teratology and developmental toxicology. DART/ETIC is maintained by the EPA and National Institute of Environmental Health Sciences (NIEHS).
    • Toxic Chemical Release Inventory (TRI), mandated by SARA III, covers releases of hazardous chemicals in local communities. It also contains national chemical mapping programs and a chemical identification program.
  • Envirofacts Master Chemical Integrator, maintained by the EPA, provides detailed information on hundreds of toxic chemicals.
  • OSHA provides information on safety and worker health standards and regulations relating to hazardous materials.
  • Federal Emergency Management Agency (FEMA) provides information on disaster preparedness plans and frequently asked questions.
  • The EPA Web site is another source of information.
  • Comprehensive Environmental Response Compensation and Liability Information System (CERCLIS) provides information on Superfund sites, chemicals involved, and cleanup status (see Superfund Overview).
  • DOT's HAZMAT (see DOT's Office of Hazardous Materials Safety) provides further information.
  • Hazardous Chemical Database is another resource.

Printed resources

See the list below:

  • Sullivan JB, Krieger GR: Hazardous Materials Toxicology: Clinical Principles of Environmental Health. Williams & Wilkins; 1992.
  • Borack J, Callan M, Abbott W: Hazardous Materials Exposure: Emergency Response and Patient Care. Prentice Hall; 1990.
  • Agency for Toxic Substance and Disease Registry: Managing Hazardous Materials Incidents. 3 Volumes; 2001.
  • Schnepp R. Hazardous Materials: Awareness and Operations. Jones and Bartlett Learning. 2016.
  • US Department of Transportation (DOT). Emergency Response Guidebook; 2004.

General toxicology texts

See the list below:

  • Barile FA. Clincal Toxicology: Principles and Mechanisms. Informa Healthcare USA, Inc.; 2010.
  • Dart RC, ed. Medical Toxicology. 3rd ed. Lippincott Williams & Wilkins; 2004.
  • Haddad LM, Winchester JF, 3rd ed. Clinical Management of Poisoning and Drug Overdose. WB Saunders; 1998.
  • Hoffman R, Howland MA, Lewin N, Nelson L, Goldfrank L. Goldfrank's Toxicologic Emergencies. 10th ed. McGraw Hill Professional; 2014.
  • Hodgson E. A Textbook of Modern Toxicology. 4th Edition. Wiley; 2011.
  • Klaassen CD. Casarett and Doull's Toxicology: The Basic Science of Poisons. 8th ed. McGraw Hill Education; 2013.
  • Rom WN, Markowitz SB. Environmental and Occupational Medicine. 4th ed. Lippincott Williams & Wilkins; 2007.
  • Lewis RL. Hazardous Chemicals Desk Reference. 6th ed. Wiley-Interscience; 2008.
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Contributor Information and Disclosures
Author

Robert D Cox, MD, PhD Professor, Department of Emergency Medicine, Associate Professor, Department of Pharmacology and Toxicology, University of Mississippi Medical Center; Medical Director, Mississippi Regional Poison Control Center

Robert D Cox, MD, PhD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Zygmunt F Dembek, PhD, MPH, MS, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Zygmunt F Dembek, PhD, MPH, MS, LHD is a member of the following medical societies: American Chemical Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Zone control of the hazardous materials site.
Battery powered air-purifying hood respirator. Image courtesy of A. J. Anderson, MD.
Battery powered air-purifying hood respirator and decontamination shelter. Image courtesy of A. J. Anderson, MD.
Portable decontamination shelter. Image courtesy of A. J. Anderson, MD.
Early erythema in the frontal and antelateral right side of the chest 5 days after the exposure to an iridium-192 source (185 GBq, 5 Ci) mounted in a pen-size sourceholder for industrial radiography, which was placed to the pocket of the worker's overall and kept there for about 2 hours. Image courtesy of the WHO.
Early erythema 11 days after exposure. Image courtesy of the WHO.
Tense painful bulla of the left palm on day 20 evolving from erythema with early blistering, which had appeared on day 10 after the initial contact for a few minutes with the iridium-192 source. Image courtesy of the WHO.
An ulcer in subacute stage and 5 ulcers following self-healing with depigmentation caused by being unawarely exposed 4-8 months earlier to the same164 GBq (4.4 Ci) cesium-137 source (placed in a pocket of a trench coat used as a blanket). Image courtesy of the WHO.
Desquamation and skin necrosis 21 days after exposure. Note: the white areas correspond to silver ointment. Image courtesy of the WHO.
Earthquake and tsunami damage to the Fukushima I nuclear power plant in Japan. This is a satellite image showing damage at 9:35am on March 16, 2011, 5 days after the earthquake struck. Image courtesy of DigitalGlobe-Imagery and licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.
Decontamination. Image courtesy of Wikimedia.
This image shows a Naval Medical Center San Diego decontamination team member as a part of a drill to treat patients in a radiation contaminated mass casualty scenario. Image courtesy of Wikimedia.
 
 
 
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