Pediatric emergency medicine trisk 4559 4559
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bronchorrhea, and bronchospasm. In individual cases, clinical differentiation may
be difficult. Further, features of poisoning may be partially obscured by trauma
when chemicals are disseminated explosively; significant numbers of atraumatic
casualties will be more easily recognized as chemical in nature.
Toxidromes—constellations of signs and symptoms suggestive of a specific
class of poison—can be very useful in narrowing differential diagnoses, although
patients may exhibit incomplete or atypical signs and symptoms such as with the
cholinergic toxidrome (for nerve agents). Just as with biologic agents, it is
convenient to categorize chemical weapons exposures as causing predominantly
neurologic, respiratory, or dermatologic syndromes that can help the practitioner
in identifying an offending agent ( Fig. 132.3 ). There are several resources that
will be helpful to ED physicians, including internet-accessible and downloadable
algorithms and related tools (e.g., the CHEMM Intelligent Syndromes Tool, or
CHEMM-IST, at ), local medical
toxicologists, regional poison control centers (1-800-222-1222), and public health
authorities.
Triage Considerations: General Management, Decontamination, and
Personal Protection
Ideally, the general management of chemically contaminated victims begins with
prehospital providers at the scene (“hot zone”), garbed in appropriate personal
protective equipment (PPE), providing extrication, triage, medical stabilization,
and immediate or spot decontamination such as the prompt removal of any
suspicious liquid from a casualty. Patients are then transferred to the “warm
zone,” a receiving area for chemical casualties ( Fig. 132.4 ). The Occupational
Safety & Health Administration (OSHA) designates sites such as a hospital
corridor as the “warm zone.” The warm zone may also be located outside as with
a tent on hospital grounds ( Fig. 132.5 ). The warm zone is separated from the
“cold zone” (beginning no later than the entrance to the ED) by a “hot line,” or
liquid-control zone, beyond which no liquid contamination is permitted to pass.
That is, patients should be thoroughly decontaminated before entering the cold
zone.
Many patients, especially those who are self-referred, may arrive for ED care
having not been decontaminated at the scene. Unstable and contaminated patients
present a particular challenge. For such patients, it is useful to conceptualize the
phases of emergent resuscitation in the warm zone as the ABCDDs: airway,
breathing, circulation, immediate or spot decontamination, and drugs (including
anticonvulsants and antidotes). It is often mistakenly assumed that
