Chapter 193. Hazmat Patient Management

Hazardous materials (hazmat) incidents occur most often during the transport of chemicals or at industrial site accidents. Hazmat incidents may strike any community at any time.1 Every Emergency Department must be prepared to respond to victims of a hazmat exposure.

Decontamination is the procedure of eliminating or reducing to a safe level any harmful substances on persons and equipment.2 Decontamination of victims in the field should always be performed by Emergency Medical Service (EMS) providers or before the patient enters the Emergency Department. However, this does not always occur. Patients may be too ill for lengthy decontamination procedures prior to transport. Exposed patients may leave the scene and present to the Emergency Department on their own.3–5 Basic decontamination by Emergency Department personnel can be safely performed outdoors in a designated decontamination area.6,7

Exposure to a hazmat contaminated patient who has been inadequately decontaminated or not decontaminated at all is a real possibility. This can result in exposure and secondary injury to healthcare personnel, other patients, and visitors.5 The Emergency Department may be closed in part or in whole until the facility can be decontaminated. The panic and fear induced by rumors or odors can lead to unnecessary facility closure, delayed or inadequate patient treatment, and psychogenic illness in both healthcare personnel and bystanders.3,4

The three primary goals for the Emergency Department are to isolate and contain the contamination; decontaminate and treat exposed patients while protecting staff, other patients, and visitors; and maintain normal services, or reestablish them, as soon as possible.3

Early recognition of potentially hazmat contaminated patients will aid in preventing secondary contamination and Emergency Department closures. Numerous clues may identify a patient for hazmat contamination at triage.3,4 These include accidents at agricultural or industrial sites, accidents involving chemical transports, suspected mass casualty incidents, a cholinergic toxidrome, mucous membrane irritation, chemical burns, soiling with unidentified liquids or powders, intentional overdose with chemicals, unexplained unconsciousness or cardiac arrest, and symptoms occurring in Paramedics or Emergency Medical Technicians (EMTs) after patient transport.

Information management is critical to the response.4 Designate a person to obtain as much information as possible on the involved substance. Even preliminary and general information is useful and should be immediately conveyed to the treating Emergency Physician.1 The maintenance of material safety data sheets (MSDS) is mandatory for each chemical used or stored at an industrial site or during transport. Request information on the MSDS from fire or EMS services at the scene. Further information resources are listed after the “References” section of this chapter. Verify all information for accuracy by cross-referencing several sources.4

This chapter describes a general approach to the management of the hazmat contaminated patient. The Emergency Department response and patient management will have to be tailored to the specific agent(s) and circumstances, such as number of patients and facility resources. All Emergency Departments are strongly encouraged to conduct regular inservice training sessions and drills on hazmat decontamination procedures. Information on hospital-based decontamination best practices is available from the United States Department of Labor, Occupational Safety & Health Administration.7

Hazardous materials can enter the body through inhalation, absorption, and ingestion.8 The total dose is a function of the concentration and properties of the substance, the exposure time, and the exposure route. There is a dose–response relationship between the absorbed dose and toxic effects for most toxic chemicals.8 The effects can be local, systemic, and quite variable for different agents.

Inhalation is the most common route of exposure. It may lead to local irritation, airway obstruction, and/or pulmonary systemic absorption. Absorption through intact skin is facilitated by fat solubility, open wounds, burns, exposure of the eyes and mucous membranes, and by dermal contamination underneath soiled clothing leading to an occlusive dressing effect.2,4 The axillae, groin, and skin folds have a thin epidermal layer that facilitates the absorption of a contaminant. Children have a larger surface area to body weight ratio and more permeable skin, making them more vulnerable to absorption of toxins.9 Ingestions can be accidental or intentional.

Patients exposed to hazardous materials may show any or all of the following: local effects such as chemical burns, respiratory tract effects of inhaled toxins, systemic effects of absorbed toxins, associated trauma, psychiatric reactions (e.g., agitation and anxiety), or contamination without apparent injury.4

The hazard to personnel, or risk of secondary contamination, is determined by the dose of the hazardous material that is carried by the victim and absorbed by the caregiver.10 Toxic liquids and solids can pose a dermal contact hazard.3 Solids or volatile liquids can pose an inhalational hazard.3 Most gases or vapors dissipate quickly and are unlikely to pose a secondary contamination hazard.7,10 However, the risk to emergency personnel is real.4,5,11 Contamination with corrosives or pesticides may indeed cause illness in personnel.4,10,11 Toxins can rarely be emitted from vomitus (e.g., hydrogen cyanide after cyanide salt ingestion) or exhaled breath (e.g., after ethylene oxide exposure).2

Decontaminate any potentially contaminated patient prior to their entry into the Emergency Department.11 The more toxic the substance, the more rapidly the decontamination should be performed. Pesticides and corrosives are common and worrisome contaminants.10 Asymptomatic contaminated patients can be triaged for decontamination before those with symptoms to prevent toxicity if the risk of toxicity is high. Decontaminate symptomatic patients before asymptomatic patients if the risk of toxicity is low.4 Initiate any life support measures simultaneously with decontamination.4 Patients who have been decontaminated or exposed to gases or vapors without signs of skin or eye irritation do not require further decontamination.2,4,6

Patients should never be made to wait in their contaminated clothing. They need to be given the means to undress in privacy, change into clean clothing, and await decontamination by hospital personnel.

The absence of a system to isolate wastewater is not a contraindication to water decontamination. When in doubt, decontaminate the patient. Dilution will suffice to reduce the hazardous substance to a safe level.

Contraindications to water decontamination include contamination with metallic sodium, lithium, calcium, potassium, cesium, and rubidium.1,12 Other contraindications to water decontamination include exposure to dusts of pure magnesium, sulfur, strontium, titanium, uranium, yttrium, zinc, and zirconium.1,12 These substances react violently with water and can cause secondary injury.1,12 Cover the patient and/or substance with mineral oil, remove the substance with forceps, and store it in a container with mineral oil.4,12 However, many of these substances may already have reacted with moisture on the patient's skin.1,12,13 Rapid removal of the chemical agent is better than allowing continuing injury to occur.6,13 Adding large amounts of water to the small amount of residual chemical on the patient's body poses little risk of creating a serious reaction hazard.13,14

Patients soaked in flammable liquids pose special problems. Water decontamination may be inadequate to completely remove the substance from the patient's skin. Do not cardiovert or defibrillate the patient until the material is completely removed from the skin, so as to prevent an explosion or a fire.6

The use of chemical agents for neutralization is contraindicated. These substances may cause secondary injury, toxicity, or react with another substance in an adverse manner. Use large quantities of water for decontamination (e.g., a shower) rather than a neutralization agent.6

Personal Protective Equipment (per Person)

• Scrub suit and closed shoes
• Plastic shoe covers
• Protective goggles
• Water resistant face mask
• Latex gloves
• Chemical resistant (i.e., nitrile) gloves
• Chemical resistant coverall suit with booties and hood
• Duct tape
• Rubber apron
• Butyl rubber gloves
• Chemical resistant rubber boots or shoe covers
• Respiratory protection (i.e., PAPR with assigned protection factor 1000)7

Patient Decontamination

• Decontamination unit located outside of the hospital
• Designated decontamination facility inside the hospital
• Decontamination stretchers, if applicable
• Portable wading pools for ambulatory patients
• Warm running water source with a hose and soft-stream nozzle
• Portable barriers to assure privacy and protect from wind
• Liquid hand or dishwashing soap
• Liquid shampoo
• Soft-bristled brushes
• Devices to decontaminate hands and nails (e.g., surgical scrub sets)
• Eye irrigation equipment

Miscellaneous Supplies

• Polyethylene plastic bags
• Name tags
• Yellow tape and signs to mark decontamination zones
• Scissors to cut clothing
• Scrub suits, towels, and blankets for patients before and after decontamination

The Occupational Safety and Health Administration (OSHA) requires level B protection for responders to an unknown chemical hazard, with a positive-pressure self-contained breathing apparatus and chemical resistant clothing.3,8,11 The high cost of such equipment and constant skills retraining required to use it may prohibit some hospitals from purchasing it and has made compliance difficult.8 The OSHA has published best practice guidelines for hospital-based chemical decontamination procedures, including detailed recommendations for personal protective equipment (PPE).7

Hospital gowns, standard Tyvek suits, surgical masks, and latex gloves are not considered adequate protection.4,10,12 Personal protective equipment is available through specialized dealers and requires training to provide reliable protection.4,8,11,12 The minimum protection recommended for hospital decontamination personnel includes a scrub suit, a chemical resistant suit with booties and hood, plastic shoe covers, at least two layers of gloves (surgical and nitrile) taped at the sleeve, protective eyewear, and respiratory protection.4,7,8

There is little consensus on how to provide respiratory protection. The required level of respiratory protection, if any, will depend upon the agent, the dose, prior training, and decontamination circumstances.4,8,11 The OSHA has published guidelines under which the use of powered air-purifying respirators (PAPR) is sufficient.7 The use of PAPRs requires regular training. Respiratory protection is rarely necessary if decontamination is performed outdoors.10 Information obtained about the contaminant will aid in determining the level of protection required.

Patients should be initially received in a secured area outside of the Emergency Department. Clearly mark the area with yellow tape or other similar device. This is considered a contaminated “hot zone.” Triage, a primary survey, and any required immediate lifesaving interventions (e.g., Basic Life Support and CPR) may be performed here by appropriately protected personnel.4,8,15 Rapid removal of clothing is essential as absorption is time dependent, and contaminated clothing can act as an occlusive dressing or continue to off-gas contaminant.13 Patients should not wait for decontamination in their contaminated clothing. Instead, patients who are able should remove their own clothing and be given clean clothing or blankets for warmth and modesty. Children should not be separated from their caregivers if at all possible.9

Patients who present to the Emergency Department with real or imagined contamination are under high stress and are likely to act out if left unattended. Early self-removal of clothing will help alleviate fears and provide real early decontamination benefit.

The decontamination area is also considered a contaminated “hot zone.”4 Perform basic life support and immediate life-saving measures only in the decontamination area.12 However, the extent of medical treatment in the decontamination area will need to be decided on a case-to-case basis. Treatment of cardiac dysrhythmias and wounds or administration of toxin-specific antidotes may have to be initiated prior to complete decontamination.12,15 Keep in mind that invasive procedures prior to decontamination may provide a percutaneous route of contamination with the hazardous substance. Devices, such as monitors, used in the decontamination area will have to be decontaminated after use.12 Use long leads, if available, that extend into the clean support area to prevent having to decontaminate monitoring devices.12 Patients are considered safe to move into the contamination reduction area (“warm zone”) and then the Emergency Department (support area, “cold zone”) only when decontamination is completed. Perform a secondary survey, including a search for any toxidromes, and begin definitive medical treatment after decontamination.4

Don personal protective equipment before approaching the contaminated patient.4 This will prevent the healthcare worker from becoming contaminated, now making them a patient, and requiring the healthcare worker to be removed from duty. Suggested minimum personal protective equipment and its application is described here. Wear standard work attire, such as a scrub suit, and closed shoes (no clogs or slippers). Place plastic shoe covers over shoes. Don goggles and a water resistant face mask if no PAPR is worn. This is for splash protection only. Don latex gloves followed by nitrile or other chemical resistant gloves. Don a chemical resistant coverall suit with booties and a hood. Tape the sleeves to the gloves with duct tape. Don a butyl rubber apron and butyl rubber gloves for protection against water and chemicals. This protocol provides no respiratory protection. Don a PAPR if respiratory protection is desired or required.

Perform a primary survey and treat any life-threatening conditions with basic life support interventions.4 Remove all of the patient's clothing. This includes shoes and jewelry. Cut off the clothing if necessary. Place the clothing in a plastic bag and seal it with duct tape. Place this bag into another bag and seal it to “double bag” the clothing. Double bag any jewelry and watches separately if time and circumstances permit. This allows for possible later decontamination and salvage. Label the bags with the patient's name or medical record number. Patients may assist with their own decontamination. Do not irrigate the patient prior to complete clothing removal. Chemicals on clothing will soak through wet clothing and onto the skin, resulting in additional injury or absorption.2,6

Remove any visible chemicals on the patient's body by gently washing off liquids or brushing off solids. Avoid skin irritation or injury, as both will lead to increased absorption of any remaining chemicals. Avoid aerosolization of the contaminant. Blot any heavy liquids with absorbent towels.2,6

Patients with open wounds require the area surrounding the wound to be gently washed with water. Irrigate the wound with clean water. Cover large wounds with plastic wrap to prevent runoff into the wound during the remaining decontamination procedure.2 Do not delay copious water irrigation if this wound care cannot be accomplished rapidly.

Begin copious water irrigation with warm water using low water pressure (normal shower pressure) for 3 to 5 minutes. Use liquid soap, shampoo, and soft brushes to gently cleanse the skin and any body hair.5 Thoroughly rinse the patient after soaping and shampooing. Repeat the procedure until all visible contamination is removed. Do not forget to thoroughly clean any mucous membranes, the nails, the external auditory canals, the axillae, the groin, and any other skin folds. Use cleaning devices such as surgical scrub sets for nail folds or syringes to flush the external auditory canals.

Irrigate the eyes, if contaminated, for 5 minutes. Remove any contact lenses and place them in a double bag. A Morgan lens may be used if the globe is intact. Irrigation with running water is also an option but may be less thorough than with a Morgan lens. A nasal oxygen cannula may be placed on the bridge of the nose if both eyes are affected.2 Allow water to flow through the cannula and direct it from the medial canthus outward. Refer to Chapter 155 for the details regarding eye irrigation.

Do not let caregivers carry children in a wet decontamination environment as they may fall and injure themselves and the child. Instead, have decontamination personnel carry the child. It may take two providers to safely carry a struggling wet child while wearing personal protective equipment.9 An alternative is to use a gurney or wheelchair.

The nonambulatory contaminated trauma patient or a patient with altered mental status may need to be decontaminated on a specialized stretcher that is equipped to catch wastewater. Autopsy tables from the morgue may be used after covering the surface with plastic. Enough decontamination personnel must be available to maintain cervical spine immobilization while log-rolling the patient as the decontamination process is performed.

Biological weapons agents include bacteria, spores, viruses, and toxins. Chemical decontamination renders biological weapons agents harmless by the use of disinfectants.14 Most biological warfare agents are transmitted by inhalation; therefore, respiratory protection is highly recommended. Treat dermal exposures immediately with soap-and-water decontamination using a soft brush followed by rinsing with copious amounts of water. This alone is often sufficient to avert contact infection. Wash with a dilute bleach (hypochlorite) solution to eradicate any remaining biological agent.

Mix one part Clorox bleach and nine parts water, as standard stock Clorox is a 5% solution, to make a 0.5% sodium hypochlorite solution. The diluted bleach solution must be made fresh daily with a pH in the alkaline range. Diluted and undiluted bleach solutions evaporate quickly. Store the bleach solution in closed and distinctly marked containers to avoid confusing the 5% and 0.5% solutions. Wash the contaminated areas with a soaked cloth or swab for 10 to 15 minutes with the 0.5% sodium hypochlorite solution. A contact time of 10 to 15 minutes is required.14 Rinse thoroughly with water.

The dilute bleach solution is contraindicated for application into the eyes, into open brain and spinal cord injuries, or for surgical irrigation of the abdomen. However, it may be used for lavage of other noncavity wounds and removed by suction to an appropriate disposal container. Within 5 minutes, the now contaminated bleach solution will be neutralized and is considered nonhazardous.

Use a 5% hypochlorite solution (undiluted Clorox) to decontaminate fabric, clothing, and equipment. A contact time of 30 minutes prior to normal cleaning is required for the decontamination of equipment. The 5% bleach solution is corrosive to most metals and injurious to most fabrics. Thoroughly rinse and oil metal surfaces after completion.

Physical methods to render biological weapons agents harmless include heat and radiation. Dry heat requires 2 hours of treatment at 160 °C to render biological agents completely harmless. Autoclaving is effective. Steam at 121°C and 1 atmosphere of overpressure (15 psi) will reduce the required time to approximately 20 minutes, depending upon volume.

Rooms in fixed spaces that become contaminated are best decontaminated with gases or liquids in aerosol form (e.g., formaldehyde). This is combined with surface disinfectants, in most cases, to ensure complete decontamination. Solar ultraviolet radiation that reaches the earth's surface has a certain disinfectant effect, often in combination with drying, and will aid in the decontamination of outdoor decontamination facilities. Chlorine-calcium or lye may be used if it is necessary to decontaminate terrain.

Move the patient after decontamination to the contamination reduction zone (“warm zone”). Assess the patient and initiate any required advanced life support measures. There are no objective criteria to assess whether decontamination was sufficient. There is, however, evidence that copious water irrigation and soap cleansing are highly effective in removing many chemical contaminants.4 Measure the tear film pH if the eyes were exposed to corrosive agents. Continue eye irrigation until the pH is neutral. This may take up to 15 minutes. Assess all wounds. Thoroughly irrigate any wounds. Transfer the patient into the support zone (Emergency Department or “cold zone”) when they are deemed decontaminated.

Healthcare personnel must remove their personal protective equipment in an organized fashion to prevent self-contamination after decontamination of the patient.8 This is a suggested protocol for the minimum personal protective equipment, which may need to be altered if more sophisticated equipment is to be decontaminated and recycled.

Remove the tape securing the gloves to the suit. Place the tape in a plastic bag. Remove the outer gloves, turning them inside out as they are removed. Place the gloves in the plastic bag. Remove the suit, turning it inside out as it is removed. Place the suit in the plastic bag. Seal the bag with duct tape. Remove the plastic shoe cover from one foot and step over the “clean line.” Remove the other shoe cover and put that foot over the line. Place both shoe covers in a plastic bag at the line. Remove the goggles and mask. Place them in the plastic bag. Seal the plastic bag. If a PAPR if worn, an assistant is required to prevent contamination of reusable equipment. The assistant dons gloves and supports the battery pack while the belt is loosened and the hood is removed. Hold the hood away from the body to avoid contamination. Detach the hose. The assistant places the pack and hose in a bag for reprocessing. Place the hood in a separate bag for reprocessing or disposal and seal the bag with duct tape.16 Remove the inner gloves. Place them in a plastic bag and seal it. Close off the dirty area until the level of contamination is established and the area is properly decontaminated. Move to a shower area. Remove the scrub suit and seal it in a plastic bag. Shower thoroughly with soap and water. Dress in normal work attire.

Further patient management will depend on the type of exposure and other circumstances. Perform a thorough secondary survey to detect occult trauma or medical illness. Monitoring for cardiac dysrhythmias or for noncardiogenic pulmonary edema may be necessary after exposure to certain chemicals.2,6 Some toxins necessitate treatment with specific antidotes, which should be initiated as soon as possible.

Dilute ingested chemicals with 4 to 8 ounces of water. Activated charcoal (1 g/kg) may be given to prevent further absorption.6 Ingestion of corrosive agents may necessitate early endoscopy, in which case charcoal should be withheld.6 Induction of emesis is rarely indicated and may pose a hazard to the patient (if they ingested corrosives or hydrocarbons) and to healthcare personnel (if the patient ingested cyanide).2,6 Refer to Chapters 59, 60, and 61 for the details of gastrointestinal contamination.

Hypothermia may be caused or worsened by the decontamination procedures.2,6 This must be anticipated and treated accordingly. Children are especially vulnerable to hypothermia.9 Residues of highly toxic chemicals remaining in skin folds or under nails may pose a risk to the patient and caregivers.6 This should be searched for and removed. Toxic vomitus may pose a risk to healthcare personnel, even after adequate decontamination.2,6 Emesis must be contained and discarded appropriately.

Emergency Departments must be prepared to decontaminate and treat victims of hazardous materials exposures at any time. Procedures must be developed, practiced, and incorporated into the hospital's mass casualty incident plan. Lack of preparation and practice will expose medical personnel to greater risks and lead to less than optimal patient care. This chapter presents a general approach to decontamination procedures, which must be adapted to the individual circumstances and type of exposure.

Information Resources