CBRNE Training Academy
Introduction and Overview
What Will You Get From This?
• Recognize your importance
• Appreciate that you have the
knowledge necessary to:
– Understand your personal risk
– Minimize that risk
– Minimize the risk to others
– Understand your role in an event
• Demystify terrorism
• Have fun
C hemical
B iological
R adiological
N uclear
E xplosive
Who are you?
Who is this for?
• Who has direct contact with the public?
• Who is likely to witness or discover a
hazardous substance?
• Who can initiate an emergency
response (call for help)?
Everyone
YOU
Program Outline
• Understanding your environment
• Recognizing hazards
• Safety and Response
• Relating the Exotic to the Mundane
• Decontamination
• Personal Protective Equipment (PPE)
• Risk Assessment
What we ask of you
• Please ask questions
• Multi faceted approach to learning
– Not everything works for everyone
– Comments and suggestions
• Please fill out the evaluation forms
• Enjoy yourself and have fun
Questions ?
CBRNE Training Academy
Understanding your environment
Lecture Goals
Help You To:
•
•
•
•
Define awareness
Understand your environment
Recognize an event has occurred
Understand your role
Awareness, defined
• Watchful, vigilant, cautious, on one's
guard.
• Informed, cognizant, conscious,
sensible, to know.
– The Oxford English Dictionary, 2nd Ed.
Awareness continued
• Healthy suspicion without paranoia
• When something happens . . .
– Recognize that it is out of the ordinary
– Ensure safety (your own, and others)
– Identify the problem
– Isolate the problem
– Control the event
– Prevent further harm
Just like the subway . . .
Just like the subway . . .
• “If you see something, say something”
• Clues
– Evidence that helps solve a problem
– Odors, colors, patterns of injury or disease,
similar complaints, etc.
• Don’t rely on just one sense or source
of information
• If there is any suspicion, ask for help
What is going on here?
• Many people are covered in paint
• One person is seizing
• Two people are seizing
• You register someone named Michael
Jackson
Why be aware?
•
•
•
•
Know normal, know abnormal
Allows you to “sound the alarm”
What do you encounter every day?
Participate through normal job function
Practical awareness
•
•
•
•
•
Conscious of work environment
Cautious and vigilant
Watchful and on guard
React sensibly
Know what to do
Awareness prepares
Disaster
An event where. . .
Needs > Resources
Mass Casualty Incident
A disaster where. . .
Healthcare needs > Resources
The “T” Word
“The unlawful use of force against
persons or property to intimidate or
coerce a government, the civilian
population, or any segment there of, in
the furtherance of political or social
objectives.”
It is not nuclear, biologic or chemical.
It is fear.
Intent
Northridge earthquake vs. WTC
Intent
Food poisoning (spoiled meat) vs.
Salmonella sprayed on a salad bar
Intent
Lake Nyos, Cameroon vs. Tokyo subway
Demystify
•
•
•
•
•
Terrorism is fear
Can’t prepare for everything
Minimize fear through knowledge
Knowledge is preparedness
Preparedness applies to everything
You are already ready
• Take what you know everyday
• Apply it to what you don’t know
• Same professional, logical, organized
outcome
• You have the ability, knowledge and
understanding necessary to respond
Remember this
Prepared for the
mundane =
prepared for the
exotic
Questions?
CBRNE Training Academy
Recognizing Hazards
Lecture Goals
•
•
•
•
Define what a hazard is
Define “all hazards” approach
Describe where hazards exist
Explain hazard recognition
What is a hazardous substance?
• Any substance . . .
– Solid
– Liquid
– Gas
– Other
• Capable of harming . . .
– People
– Property
– Environment
What is a hazardous substance?
• Any substance to which exposure
– “Results or may result in adverse affects on
the health or safety of employees”
– “Any chemical which is a physical hazard or
a health hazard”
• OSHA 29 CFR 1910.1200 (c)
• Bottom line: Adversely affects health or
safety (not only chemicals . . .)
“All Hazards”
“All Hazards”
• Knowledge that you have
• Applied to unknown situations
• Common, standard approach
– Instills confidence
– Quells fear
– Ensures safety, always
Prepared for the mundane =
Prepared for the exotic
Hazards = Potential Events
• Awareness identifies hazards
• “Guns don’t kill people . . .”
• Potential depends on scale and scope
– Spill coffee
– Spill sarin
– Spill oil (tanker)
What’s in your hospital?
•
•
•
•
•
•
Lab
Pharmacy
OR
Building Services
Engineering
Environmental
Services
• Bio-med
• Central Supply
•
•
•
•
•
•
•
•
•
Respiratory
Dietary
Radiology
Nuclear Medicine
Oncology
Laundry
EMS
ED
Med Air / O2
Where do hazards exist?
EVERYWHERE
• Setting is artificial distinction
– Familiarity creates false comfort
• Things we know, context we don’t
– Medical O2 vs. Industrial O2
• Location doesn’t modify nature*
• Awareness recognizes potential harm
All Hazards
•
•
•
•
•
•
People at risk = hazard
Site independent
Preparation and prevention is the same
Scale and scope is different
Intent is the confounding factor
Remove intent, left with event
Specific hazards
•
•
•
•
•
•
•
Things that are infectious
Things that explode
Things that burn, shock
Things that are corrosive
Things that are radioactive
Things that cause cancer
Things that are poisonous through
other means
• “Others”
D.O.T. Classification
Specific examples
• Scale, scope and intent
• Things that are familiar
• Things in unfamiliar context
• Things with malicious intent
Flammable liquids
• Found in all environments
• Often overlooked, ignored as risk
• Fire and explosive risk
• Let’s take a look at a familiar example…
Flammable liquids
Ethyl alcohol
Flammable liquids
Gasoline
Flammable liquids
All Hazards
•
•
•
•
•
Everything is a potential hazard
Hazards have many faces
Recognize the potential exists
Remove the intent
Prepared and ready
Gases
• Found everywhere in a hospital
• Flammable, compressed
– Boiling Liquid Expanding Vapor Explosion
(B.L.E.V.E.)
• Some are toxic
• Let’s take a look at another familiar
example…
Chlorine gas
• Severe pulmonary toxin
• Causes delayed lung injury
Cl2 +
=
Normal chest x-ray
ARDS chest x-ray
My bathroom January 10, 2005
HCl
+ HOCl
Cl2
South Carolina January 6, 2005
Ypres, Belgium April 22, 1915
Other gas examples
Oxygen & other compressed gases
In a different context
All Hazards
•
•
•
•
•
Everything is a potential hazard
Hazards have many faces
Recognize the potential exists
Remove the intent
Prepared and ready
Oxidizers
• Enhance / cause combustion of others
• Cause fire by itself, or by releasing O2
• Involved in reactive processes
Oxidizers
Ammonium nitrate
Oxidizers
Ammonium nitrate
Oxidizers
All Hazards
•
•
•
•
•
Everything is a potential hazard
Hazards have many faces
Recognize the potential exists
Remove the intent
Prepared and ready
Toxins or poisons
• Vast category, hard to generalize
• Found everywhere
– Especially in healthcare
– Home
– Industry
• Lets take a look at an example from the
hospital lab . . .
Toxins or poisons
Toxins or poisons
Toxins or poisons
All Hazards
•
•
•
•
•
Everything is a potential hazard
Hazards have many faces
Recognize the potential exists
Remove the intent
Prepared and ready
Radioactivity
• Cause harm through energy
• Background radiation and specific
sources
– Radiology department
– Nuclear medicine
– Power plants
– Industry
• Lets take a look at an example from the
nuclear medicine department . . .
Internal, External, Other
Internal, External, Other
Internal, External, Other
All Hazards
•
•
•
•
•
Everything is a potential hazard
Hazards have many faces
Recognize the potential exists
Remove the intent
Prepared and ready
Where can we learn more?
• On-scene personnel
– Police, Fire, EMS, HazMat, etc.
– Industrial Safety officer
• Poison Control Center
• Labels
• Material Safety Data
Sheets (MSDS)
• Emergency Response
Guidebook (ERG)
• Agency for Toxic Substance
& Disease Registry (ATSDR)
• Internet resources
Questions?
CBRNE Training Academy
Safety and Response
Lecture Goals
• Explain the first steps in confronting a
hazardous event
• Introduce the concept of notification
• Describe zones of control
S-I-N
• Awareness and recognition leads to SIN
– Safety
– Isolation
– Notification
• What to do when something happens
Always count to TEN
• Take your time
• Evaluate your surroundings/situation
• Never rush in, or get in over your head
SAFETY
• Once you have identified that a problem
has occurred . . .
PROTECT YOURSELF
• Only if you are safe can you ensure the
safety of others
ISOLATE
• To separate from everything else
– Close a door, close a window
– Cover a spill
– Set up a barrier
– Keep people from entering a building
– Establish a decontamination area
Clean and Dirty
Warm is dirty
Cold is clean
ISOLATE
• Keep clean from getting dirty
– Establish perimeters and control zones
• Can range from basic to complex
Cold zone
• Support zone
– “Green Zone”
– No contamination
Warm zone
• Contamination zone
– “Reduction zone”, “Yellow zone”
– Secondary contamination
Hot zone
• Exclusion zone
– “Red Zone”
– Primary release / contamination
ISOLATE
• Security is the key to isolation
• Impede entry into hospital
– Barricades
– Locked entryways
– Close fire doors / internal barriers
– Post guards
• Control access while protecting staff
ISOLATE
• Inhibit contamination
– Cohort contaminated patients
– Prevent contact with non-contaminated
– Isolate to one area of hospital
ISOLATE
• Water purification
– Is it safe to drink the water?
• Ventilation system
– Is it safe to breathe the air
• Waste disposal
– What do I do with all this trash?
NOTIFY
• Who you gonna call?
• Follow the chain of
command
• Your immediate
supervisor is your best
contact
• Activate the hospital
plan for events
NOTIFY
• Other contacts include . . .
– Your administrator
– The hospital HazMat person
– 911
– Poison Control
– Publicly Owned Treatment Works
(POTW - waste water management)
– National Response Center
– FBI
• These contacts are not for everyone
Remember . . .
• Awareness leads to SIN
• Always count to TEN
Questions?
CBRNE Training Academy
Relating the Exotic to the
Mundane
Objectives
• Integrate Awareness, Hazard
Recognition and SIN
• Illustrate the “All Hazards” approach
• Personal empowerment
Scenario #1
• You are a security guard
• You work at the large county hospital
• You control flow into the emergency
department
Here’s what you see . . .
•
•
•
•
Patient presents with a cough
Fifth patient in last hour with cough
They all also have fever
They are all from the same place
• What do you do now?
Approach
• Awareness
– Abnormal for time of year, hospital
• Hazard Recognition
– Cough and fever is infectious
• S-I-N
– Protect yourself (mask, isolate)
– Protect others (isolate, masks, etc.)
– Notify the triage nurse or supervisor
Gather information
• They are all from
prison
• They are all from
building / office
• They are all from
nursing home
• They are all from
• They are all from
the same shelter /
the same apartment
the same day care /
Hong Kong
the same train
What is this?
•
•
•
•
•
•
“A cold?”
Influenza?
Tuberculosis?
Atypical pneumonia (Legionella)?
SARS?
Anthrax?
• More importantly, does it matter?
Common ground
• This is an infectious disease problem
– The organism defines the menace
– The intent defines the malice
• A biological terrorism event is an
“Infectious Disease Outbreak”
– Initial approach is the same
– Subsequent is modified by what you learn
Anyone can sound the alarm
Scenario #2
• You work at the gift shop in the hospital
lobby
• It is a popular place for employees
• They get discounts on medicine, food
and drink
• It is a slow day because of the blizzard
Here’s what you see. . .
• An employee has tearing, and difficulty
breathing
• Third employee in last hour with similar
problem
• They all smell funny
• You start to feel the same symptoms
• What do you do now?
Approach
• Awareness
– This is not normal; you are healthy
• Hazard Recognition
– Something is causing irritation
– This is being brought by the employees
• S-I-N
– Close up shop, find clean air
– Remove contaminated clothing, seek care
– Notify your supervisor, security, the ER,
etc.
Gather information
•
•
•
•
•
•
They
They
They
They
They
They
all
all
all
all
all
all
work
work
work
work
work
work
in the kitchen
as groundskeepers
in environmental services
in the same lab
in security
in the mailroom
What is this?
•
•
•
•
•
Environmental allergy?
Pesticide?
Chlorine gas?
Tear gas?
Nerve agent?
• More importantly, does it matter?
Common ground
• This is an chemical exposure problem
– The chemical defines the menace
– The intent defines the malice
• A chemical terrorism event is a
“Hazardous Materials Incident”
– Initial approach is the same
– Subsequent is modified by what you learn
Anyone can sound the alarm
Scenario #3
• You are an emergency physician
• You are responsible for medical
command of the local EMS units
• It is three o’clock in the morning
Here’s what happens . . .
•
•
•
•
EMS calls
There was an explosion
They are bringing five critical patients
They are all coming from the same
place
• What do you do now?
Approach
• Awareness
– Know resources, staff and community
• Hazard Recognition
– Know what exists near the hospital
– Know your EMS units and paramedics
• S-I-N
– Prepare
– Activate trauma team, plan; get info
– Let people know (administration, etc.)
What you learn
•
•
•
•
•
•
•
Construction site
Fireworks factory
Chemical production plant
Nuclear power plant
Subway car / Train station
Church / Synagogue
FBI building
What is this?
• Explosive + Thermal?
• Explosive + Thermal + Chemical?
• Explosive + Thermal + Radiological?
• More importantly, does it matter?
Common ground
• This is an fire / explosive problem
– The blast defines the menace
– The intent defines the malice
• A fire / explosion terrorism event is a
“Mass Casualty-Trauma/Burn Incident”
– Initial approach is the same
– Subsequent modified by what you learn
Anyone can sound the alarm
Summary
•
•
•
•
•
•
•
Be calm
Be aware
Recognize hazards
Remember to S-I-N and count to T-E-N
Healthcare focuses on the menace
Consistent, common approach
Anyone can sound the alarm
Questions?
CBRNE Training Academy
Decontamination
Lecture Goals
•
•
•
•
•
Describe decontamination
Discuss how decontamination works
Detail what techniques are available
Describe personal protective equipment
Describe complications of PPE
What is decontamination?
• An attempt to alter absorption
• Prevent secondary contamination
• The removal of hazardous substances
from employees and their equipment to
the extent necessary to preclude the
occurrence of foreseeable adverse
health effects
• OSHA 29CFR1910.120
Who needs decontamination?
• Powder, liquid or vapor exposure
• Decontaminate exposed* areas
• Situation in which you are unsure
Everyone
Basic assumptions
• Hospital, POD, or NEHC is not the scene
• EMS/Fire decontaminate patients, but…
• 60-80% of people self present
Self presentation
• 90% contamintaion on clothing and hair
So, if someone is exposed . . .
. . . and he self-presents . . .
. . . and he is not sick . . .
He is likely only mildly contaminated . . .
. . . and can self-decontaminate . . .
. . . and poses little risk.
Decontamination triage
• Contaminated, sick
– Assisted decontamination and therapy
• Contaminated, not sick
– Self-directed decontamination
• Decontaminated (at scene)
– Medical evaluation and treatment
Decontamination is simple…
Get Naked
Get Wet
A note about washing . . .
• Copious water is
most important
• Mild detergent is all
you need, if at all
• Bleach is not
necessary
– Irritant in wrong
concentration
Types of decontamination
• Mass Decontamination
• Ambulatory Decontamination
– Directed Self-decontamination
– “Trash Bag” Decontamination
• Non-ambulatory Decontamination
Mass decontamination
• Dilution is the solution to pollution
• Many people, little finesse
• Fire department / HazMat team
Ambulatory decontamination
• What is wrong with this picture?
• Get naked, get wet
Non-ambulatory decontamination
• Help those who can’t help themselves
Directed self-decontamination
• Do-it-yourself decontamination
– Instructions posted or broadcast
– Something to do besides wait . . .
• Gives time for team to assemble
– Appropriately don PPE
– Focus on those who can’t help themselves
• Simple
– Disrobe, collect valuables
– Wash
“Trash bag” Decontamination
• Do-it-yourself kit
– Large, opaque plastic bag
– Large clear plastic bag
– Small clear plastic bag
– Pre-numbered tags/labels
• Opaque bag is portable dressing room
• Clear bags for clothes, valuables
• Labels to assist in tracking
Decontamination issues
• Safety
– Establishing security, zones
• Environment
– Waste water, temperature, ground cover
• Property
– Valuables, tracking
• Modesty
– Cultural, religious and personal values
• Special
– Language, adults & kids, special needs
A brief note on therapy. . .
• Decontamination is a priority
• Pre-decontamination therapies are basic
– Bag-valve-mask with oxygen
– Spine board and cervical collar
– Compression dressing / bandage
– Mark I auto-injectors
• Do not delay for more than this!
Remember
Warm is where decontamination occurs
Cold is where treatment occurs
CBRNE Training Academy
Personal Protective Equipment
(PPE)
Nothing special about it
• Used everyday, often overlooked
• Three layers of protection
– Basic protective and safety gear
• Skin and work clothes
• Oven mitt, apron, glasses
• Earplugs, back belts, work boots, hard hat
– Standard infectious precautions
• Gowns, gloves, booties, masks
– Advanced Personal Protective Equipment
• PAPR, SCBA
How are we exposed?
• Determines decontamination
• Determines what PPE we wear
The last line of defense. . .
• Ideally, we aren’t exposed
• Healthcare has chemical and biological
protective gear
• We don’t have protection against . . .
– Fire
– Explosions
– High energy radiation
• No gear protects against everything
The Basics
Before anything else. . .
Drink water
Go to the bathroom
Standard precautions
•
•
•
•
•
Hand washing
Clothes (uniforms, gowns, etc.)
Gloves, glasses
Masks and splash shields
Limited respiratory & splash protection
Standard Precautions
Standard precautions
Doffing…first, the gloves
Grasp outer, peel off
Peel off, like a banana
Now the other glove
Slide under cuff, peel out
Peel away from skin
Throw into receptacle
Now the gown . . .
Just like a banana
Always in front of you
Into the trash
Now the goggles & mask . . .
Fini!
(don’t toss the goggles!)
Hospital PPE
• Add liquid splash
protection
– Fluid resistant suit
• Add higher respiratory
protection
– Air purifying respirator
Industrial PPE
• Same skin protection
• Highest level of respiratory protection
– Atmosphere supplying respirator
– Don’t need oxygen atmosphere
Hot zone PPE
• Highest level of skin and respiratory
protection
– Atmosphere supplying respiratory
– Vapor protective suit
• A body bag with a window
The Hierarchy
• In healthcare, we work in the cold zone
– Standard precautions, hand washing
– Use this everyday
• In an event, we add a warm zone
– Level C PPE
– You may be asked to use this
• We NEVER work in the hot zone
– Level A and B
– You will NEVER be asked to do this
When should we use PPE?
ALWAYS
• At a minimum, standard precautions
• If you are unsure of the exposure, use
the highest level available to you
• As directed by HEICS
Important
• Be aware
• Remember potential exists
– Situation can and may change
• Follow HEICS
• Need more protection than you have?
– If so, get out (S-I-N)
– Call for help (911, HazMat, etc.)
Advanced PPE = Bag
• You are living in a bag
– Can’t eat, drink, go to the bathroom
• You are working in a bag
– You can’t hear or talk
– Slips, trips and falls
– Claustrophobic
• You are exercising in a bag
– Dehydration
– Heat exhaustion, stress and stroke
Health and monitoring
• Hydrate
– Before and after
– At least 8 oz. of water
• Brief assessment
– Before and after
– Pulse, blood pressure
• Be aware of how you feel
• 20 to 30 minutes per “shift”
Summary
• Decontamination removes secondary
contamination
• Get naked, get wet
• Maintain the zones
• PPE is the last line of defense
• It is not perfect
• It is difficult and hot
Questions ?
CBRNE Training Academy
Risk Assessment
Lecture Goals
• Understand the basics of:
– Biological exposure
– Chemical exposure
– Nuclear/Radiological exposure
– Transmission and contamination
• Develop personal risk assessment
– Am I in danger?
Basic assumptions
• The hospital is not the scene
• EMS/Fire decontaminate patients
• 60-80% of people bypass EMS
Why are hazards hazardous?
•
•
•
•
•
“Chemical” nature
Host factors
Environmental issues
Exposure
Dose
Philip Theophrastus Bombast
von Hohenheim
aka PARACELSUS (1493-1541)
What it is makes it bad
• Chemical nature and physical properties
Who you are makes it bad
• Age, health and disease
Where you are makes it bad
• Wind, water and weather
Exposure
• Route, duration
and degree
The Specifics
Biological agents
ready.gov
If you see signs
of a chemical
attack, quickly
try to define the
impacted area or
where the
chemical is
coming from, if
possible.
Not ready.gov
Hurricanes,
animal corpses
and the
biohazard symbol
have a lot in
common. Think
about it.
Biological basics
• Particles that cause disease
– Bacteria
– Viruses
– Fungi
Awareness
• Unusual syndromes
– Flu out of flu-season
• Unexpected geography or clusters
– Plague in NYC
– Pets and humans
– Whole neighborhoods
– Everyone from a Knicks game
• Unusual diseases
– Hemorrhagic fevers
Examples of biologic agents
• Bacteria
Anthrax
Tularemia
Pneumonic Plague
• Viruses
Smallpox
Influenza
Viral Hemorrhagic Fevers (VHFs);
Lassa, Ebola, Marburg
• Biological Toxins
Botulism
How do they present?
• “Flu” like symptoms
– Inhalational anthrax
– Smallpox
– Pneumonic plague
– Viral Hemorrhagic fever
– Tularemia
– Pandemic influenza
– Avian influenza
– SARS
• Almost all of them
Can I catch this?
•
•
•
•
•
•
Anthrax
Brucellosis
Q fever
Tularemia
Equine encephalitis
Toxins: Botulism, Staph enterotoxin B,
Ricin
NO
Can I catch this?
• Pneumonic plague
• Smallpox
• Viral hemorrhagic fevers (VHF)
– Lassa, Ebola, Marburg
MAYBE
• Not contagious prior to symptoms
Pneumonic Plague
• Naturally transmitted from person to
person through large respiratory droplets
• Surgical mask is adequate for most people
in most situations
• Droplet precautions
Smallpox
• Naturally transmitted from person to
person through large respiratory
droplets & through direct contact with
oral/pharyngeal secretions
• Less contagious than measles, chicken
pox
N100
Quarantine
I’m exposed, now what?
• Antibiotics (Doxycycline, Ciprofloxacin)
– Anthrax, Plague
• Vaccine
– Smallpox (within 4 days of exposure)
• Supportive care and experimental
– Botulism
– VHF
– Equine encephalitis
– Ricin exposure
Biological summary
•
•
•
•
•
Exposed
Bag clothes
Shower
Universal
precautions
Quarantine
Post-exposure
prophylaxis (patient)
Sick and contagious
• Isolate
• Universal
precautions
• Respiratory
precautions
• Post-exposure
prophylaxis (patient
and maybe staff)
Risk summary
•
•
•
•
•
Not sick, unlikely to be contagious
Decontaminate (maybe)
Universal and respiratory precautions
Isolation and hand washing
Post exposure prophylaxis
The Specifics
Chemical hazards
ready.gov
If you become
aware of an
unusual or
suspicious
release of an
unknown
substance
nearby, it
doesn't hurt to
protect yourself.
Not ready.gov
If you are
sprayed with an
unknown
substance,
stand and think
about it instead
of seeing a
doctor.
Awareness
• Five senses
• Toxidromes
– Skin
– Pupils
– Bowels
– Bladder
– Mucous membranes
– Mental status
Chemical basics
• What are its properties?
– Solid, liquid, gas
• Any properties of concern?
– Volatility
– Flammability
• How was it released / distributed?
• How did it get here?
If you remember one thing. . .
• Decontamination
•Decontamination
•Decontamination
What do we worry about?
•
•
•
•
•
Nerve Agents
Blood Agents
Choking Agents
Blister (vesicant) Agents
Riot Control Agents
Nerve Agents
• Anti-human pesticide
• Absorbed through ALL routes, inhalation
causes most rapid onset of symptoms
• Cholinergic toxidrome; SLUDGEM
Primary effects observed in Tokyo were
pinpoint pupils, dimmed vision,
weakness
• Decontamination & PPE vital
Nerve Agents
•
•
•
•
March 1995
Sarin release
11 killed
5510 sought
emergency
medical care
How do I treat this?
• Decontaminate
• ABC’s
• Antidotes
– Mark I kit
– Atropine
– Oximes for aging
• Central Nervous System (CNS)
depressants
“Off-gassing”
• “Contagious” chemical
– Georgia nurse
– Tokyo doctors
• No decontamination performed
• No PPE used in any cases
“Blood” or metabolic agents
• Cyanide is primary example
• Common industrial agent
• Interrupts aerobic respiration (ability to use
oxygen)
• Rapid, severe clinical deterioration
Leads to collapse, apnea, seizures,
severe metabolic acidosis & death
• Therapy
Decontaminate
Oxygen, bicarbonate, sodium thiosulfate
Blister (vesicant) agents
• Sulfur Mustard
Environmental persistence
Dermal effects in 1-2 minutes
Systemic effects in 4-8 hours
• Decontamination
and supportive care
Choking (pulmonary) agents
• Phosgene and Chlorine
– Common industrial agents
• Cause delayed lung injury
Chlorine + water = HCL
• Airway management
• Decontamination (maybe)
• Supportive care
“Riot control” agents
• Many compounds
– Solids within liquids
• Primarily irritants
– High pressure particulate
– Burns (eyes, skin)
– Coughing, asthma-like
symptoms
• Decontamination is key
Chemical summary
• Decontamination
•
•
•
•
•
Protect yourself
Identify the toxidrome
Many agents have specific therapies
Aggressive supportive care
Monitor for delayed toxicity
• Decontamination
Risk summary
• Whatever patient had, staff has less
• Protect yourself
– Decontamination . . .
– Personal protective equipment
• Low risk once clean
The Specifics
Nuclear/Radiological hazards
ready.gov
Or if it would be better to go inside a building
and follow your plan to shelter-in-place.
Not ready.gov
After exposure to radiation it is important to
consider that you may have mutated to gigantic
dimensions: watch your head.
Basics of radiation
Contamination
Incorporation
Irradiation
Risk
Maybe Risk
No Risk
Awareness and protection
•
•
•
•
Detection
Decontamination
Distance
Deflection
Radiologic principles
• Alpha, Beta, Gamma, Neutron
• RAD’s and REM’s
0.003 REM
200 REM
0.005 REM
6 REM/yr
> 400 REM
45 REM
??? REM
What do we worry about?
•
•
•
•
•
Simple radiological device
Radiological dispersal device
Reactor
Improvised nuclear device
Nuclear weapon
Acute Radiation Syndrome
• Associated effects
– Rapidly dividing cell populations
– GI distress, altered mental status, shock
– Therapy is primarily supportive
• Trauma and radiation
– Treatment within 48 hours
– Or delay 2 to 3 months
Radiation summary
•
•
•
•
You must think about it
Detection, decontamination, distance
Treatment is primarily supportive
Trauma and radiation within 48 hours
– Stabilize first, decontaminate second
Risk summary
• Stay away from source (distance)
• Whatever patient had, staff has less
• Decontaminate contaminated patients
– Irradiated patients pose no risk
– Incorporated depends on source
• Very low risk to staff
Am I safe?
Risk Assessment
General Rule #1
• Take care of yourself and fellow
workers first.
Corollary
If you are sick or injured,
you can’t help anyone else.
General Rule #2
• Unless patient is sick with a contagious
illness, they pose no threat to staff.
Corollary
Treat all patients as contagious.
Decontaminate everyone.
Protect yourself.
General Rule #3
• Whatever the patient was exposed to,
the staff will be exposed to far less.
Corollary
Decontamination reduces risk even more.
Decontaminate everyone.
Protect yourself.
General rule #4
• You can only detect radiation if you
think about radiation.
Corollary
Screen everyone with a Geiger counter.
Decontaminate everyone.
Protect yourself.
Questions?