Pediatric emergency medicine trisk 1141
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FIGURE 132.3 Approach to the recognition and diagnosis of an attack with an unknown
chemical agent.
FIGURE 132.4 A fixed, indoor decontamination facility, contiguous with, but structurally
separate from, the main ED. A : The external entrance from the ambulance bay. B : Three
parallel lanes to provide capacity for both ambulatory and nonambulatory victims. (Courtesy of
Tony Van Dyke and Michael Goldberg, Department of Environmental Health and Safety,
Children’s Hospital of Philadelphia, Philadelphia, PA.)
Decontamination of casualties contaminated with chemical agents should occur
as soon as possible. Chemical agents, particularly liquid nerve agents and
vesicants as either liquids or vapors, can be absorbed through intact skin within a
few minutes. Although the effects of percutaneously absorbed chemical agents
may not appear for minutes to hours, tissue damage from vesicants occurs within
a few minutes, and agent that penetrates the skin is far less amenable to
decontamination than the agent that has not yet been absorbed.
Patient decontamination has two important purposes: prevention or
minimization of continuing absorption of agent into the patient and prevention of
secondary exposure of healthcare workers. By preventing absorption of a lethal
dose of agent, immediate decontamination can be the most important lifesaving
action available for a chemical casualty. This process would ideally occur at the
scene; however, in a large-scale terrorist incident, it is far more likely that some
victims will self-transport to the ED. A special decontamination and treatment
area in the decontamination corridor outside or adjacent to the ED markedly
facilitates casualty processing and management, and accreditation agencies have
mandated that all hospitals provide such decontamination capacity.
FIGURE 132.5 A rapidly deployable outdoor decontamination facility.
Capability for thorough decontamination must be available quickly with little
setup time. Many models have been proposed, but most authorities recommend
an outdoor facility with multiple patient stations, arranged so that parallel lines of
ambulatory and nonambulatory patients may be processed simultaneously ( Fig.
132.5 ). An outdoor facility is more capable of handling multiple patients and
may make the use of copious water irrigation easier; however, it may be
challenging to protect victims from inclement weather in temperate climate
zones, an issue especially important in the management of young children. Thus,
an outdoor facility must provide adequate water, temperature control, and curtains
separating shower lines for males and females. An alternative might be the use of
a facility that is enclosed, and adjacent to, but separate structurally from, the main
ED, with a separate and high-volume ventilation system vented directly outdoors
( Fig. 132.4 ). Optimally, the surface of the decontamination facility would allow
drainage, minimizing risk of patients slipping and falling and risk of further
exposure to contaminated rinse water. Young children requiring assistance may be
accompanied by parents if they are contaminated, as well. Older ambulatory
patients can be instructed in self-decontamination.
Decontamination efforts should stress physical and mechanical removal over
chemical decontamination. For vapor-exposed patients, decontamination is
effected primarily by clothing removal and hair washing with soap and water. In
contrast, those patients with liquid dermal exposure require disrobing and
thorough skin decontamination. Agent on their skin or in their clothing poses a
serious threat to ED personnel. Clothing must be carefully removed and double
bagged. Patients with ocular exposure require copious eye irrigation with saline
or water. Skin and hair should be washed thoroughly with soap and tepid water.
Previously, some authorities have recommended 0.5% sodium hypochlorite
(dilute bleach) for skin decontamination of nerve agents and vesicants. However,
even dilute bleach may be a skin irritant, thus increasing permeability to agent,
and application is time-consuming and not proven superior to copious soap and
water washing. A decontaminant that is now the standard for U.S. military field
use is reactive skin decontamination lotion (RSDL), which is packaged as a
lotion-impregnated sponge and acts by both physical removal and also
neutralization of chemical agents. RSDL is orders of magnitude superior to
standard decontamination methods and is particularly useful for immediate (local,
or “spot”) skin decontamination; the FDA has not yet approved it for whole-body
decontamination or use in eyes or wounds.
FIGURE 132.6 The pediatric emergency care provider is garbed in appropriate level C
personal protective equipment.
OSHA provides a list of suggested PPE for healthcare workers to use in the
warm zone. Most authorities believe that adequate protection for ED staff is
afforded by Level C PPE, which consists of a nonencapsulated chemically
resistant body suit, gloves, and boots, with a full-face air-purifying mask
containing a cartridge with both an organic-vapor filter for chemical gases and
vapors and a HEPA filter to trap aerosols of biologic and chemical agents ( Fig.
132.6 ). Such PPE is much less cumbersome to work in than level A or B outfits
(which use self-contained breathing apparatus) and is much less expensive.
Finally, current guidelines from the Environmental Protection Agency (EPA) and
from The Joint Commission stress that a plan for disposal of contaminated waste
needs to be put into place by hospitals as part of their preparation for an event.
CLINICAL ASSESSMENT AND MANAGEMENT
Specific Agents
Nerve Agents
CLINICAL PEARLS AND PITFALLS
