Hazardous Materials Medicine: Treating the Chemically Injured Patient

Cover
Title Page
Copyright Page
Contents
Author Biographies and Acknowledgments
Foreword
Preface
Chapter 1 HazMat Medicine and the HazMat Medic
Introduction
Case Study – Sarin Attack in the Tokyo Subway
History
Events
Situational Assessment Continuum
Patient Presentation
Event Conditions (Scene Evaluation and Size-up)
Scene Assessment (Hazard Identification)
Summary
Chapter 2 Exposures
Introduction
Case Study – Derailment in South Carolina, a No-Notice Evacuation Event
Patient Presentation
The Toxidrome Exam
Respiratory System
Overview
Respiratory System Anatomy and Physiology
External Respiratory System
Internal Respiratory System
Chemical and Physical Form of Respiratory Exposure
Gases, Vapors, and Fumes
Solid Particles
Aerosols/Mists
Concentration and Duration
Types of Injuries Resulting from Chemical Exposure
Chemically Induced Bronchiole Constriction
Atelectasis and Disruption of Surfactant
Chemically Induced Pulmonary Edema (Noncardiogenic Pulmonary Edema)
Chemical Sensitivity
Types of Chemicals that Injure the Respiratory System
Asphyxiants
Simple Asphyxiants
Chemical Asphyxiants
Irritants (Corrosives)
Respiratory System Injury Recognition (Assessment) and Diagnostics
Pulse Oximetry
Specific Oximetry Considerations When Assessing HazMat Exposures
Capnography
Masimo™/Rainbow Technology
Cardiovascular Abnormalities Related to Exposure
Description
Vasogenic Shock
Hypovolemic Shock
Heart Failure
Neurological Abnormalities Related to Exposure
Central Nervous System (CNS) Exposure
CNS Depression
CNS Stimulation
Parasympathetic Nervous System
Parasympathetic Stimulation
Parasympathetic Depression
Integumentary System (Skin)
Skin Anatomy and Physiology
Structure
Function
Types of Chemical Injuries to the Skin
Chemical-Related Irritation
Chemical Skin Burns
Ocular Exposure and Injury
Eye Anatomy and Physiology
The Globe
The Ocular Surface
Assessment of Eye Injury After Exposure
Normal Eye Assessment
Chemical Eye Burns
Surface Toxins
Treatment of Eye Exposure
Specialized Eye Equipment
The Morgan Lens
Nasal Cannula for Eye Irrigation
Gastrointestinal Exposure to Toxic Materials
Absorbing Chemicals and Nutrients
Liver
Phase I and II Detoxification
Environmental Exposures
The Hot Environment – Hydration and Hyperthermia
Physiology
Absorption of Water
Acclimation
Metabolic Thermoregulation
Determining Severity of Heat
Effects of Heat in an Encapsulated Suit
Factors Contributing to Heat Emergencies/Injuries
Treatment
The Cold Environment
Exposure to Liquefied Gas and Cryogenics
Frostbite Injuries
Assessment
Treatment
Summary
Chapter 3 Toxidromes
Introduction
Case Study – Silver Cyanide Exposure
Assessment Capabilities
Blood Pressure
Increase in Blood Pressure
Decrease in Blood Pressure
Pulse
Toxidromes
Corrosives and Irritants Toxidromes
Chlorine (Cl2)
Agent Identification
History
Pathophysiology
Signs and Symptoms
Where Is Chlorine Found
Decontamination
Emergency Field Treatment
Basic Life Support
Advanced Life Support
Ammonia (NH3)
Agent Identification
History
Physiology
Signs and Symptoms
Where Is Ammonia Found
Decontamination
Emergency Field Treatment
Assessment/Treatment
Basic Life Support
Advanced Life Support
Phosgene, aka. Carbonyl Chloride
Agent Identification
History
Physiology, Signs, and Symptoms
Where Phosgene Is Found
Decontamination
Emergency Field Treatment (Chloramine, Ammonia, and Phosgene)
Basic Life Support
Advanced Life Support
Pediatric Considerations (Chlorine, Chloramine, Ammonia, Phosgene)
Hydrofluoric Acid and Fluorine-Based Chemicals
History
Pathophysiology
Signs and Symptoms of Exposure
Where Hydrofluoric Acid Is Commonly Found
Decontamination and Significant Danger to Rescuers
Treatment
Eye Injury Treatment (Hydrofluoric Acid)
Skin Burn Treatment (Hydrofluoric Acid)
Respiratory Injury Treatment (Hydrofluoric Acid)
Systemic Injury from Hydrofluoric Acid (Hypocalcemia)
Phenol (Carbolic Acid)
History
Pathophysiology, Signs, and Symptoms
Where Phenol Is Commonly Found
Field Treatment and Decontamination
Assessment/Treatment or Phenol
Lacrimatory Agent Exposure
Chemical Currently Being Used
Effect
Treatment
Asphyxiant Toxidromes
Effects of Hypoxia
Simple Asphyxiants
Experience; Death at McDonald’s: “Five Lousy Feet”
Assessment/Treatment for Simple Asphyxiants
Chemical Asphyxiants
Carbon Monoxide Poisoning
History
Pathophysiology
Concerns
Signs and Symptoms
Where Carbon Monoxide Is Typically Found
Decontamination and Danger to Responders
Field Treatment
Cyanide Poisoning – Hydrogen Cyanide, Cyanide Salts, and Cyanide Containing Gases
History
Pathophysiology
Signs and Symptoms
Definitive Diagnosis
Where Cyanide Is Commonly Found
Decontamination of Patients
Emergency Medical Field Treatment
CyanoKit – Hydroxocobalamin (Preferred Treatment for Cyanide Poisoning)
(Lily or Pasadena) Nitrite-Based Cyanide Antidote Kit (Used for hydrogen sulfide or (Cyanide if the CyanoKit Is Not Available)
Hydrogen Sulfide Poisoning
History
Pathophysiology
Signs and Symptoms
Where Hydrogen Sulfide Is Commonly Found
Decontamination and Significant Danger to Rescuers
Field Treatment
Definitive Treatment and Follow-up Care
Nitrites, Nitrates, Nitrobenzene Poisoning
History
Pathophysiology
Signs and Symptoms
Where Are Nitrogen Compounds Found
Field Treatment
Cholinergic Toxidrome
Organophosphate Insecticide Poisoning
Experience: Novichok Nerve Agent Used Against Russian Dissident Has Dark History
Experience: Tokyo Subway, Site of an Attack Using Sarin Nerve Agent
Pathophysiology
Signs and Symptoms
Location of Organophosphate Insecticides
Decontamination and Significant Danger to Rescuers
Treatment
Experience: Malathion Overdose Treated Without Protopam
Treatment
Carbamate Poisoning
Treatment
Hydrocarbons and Derivatives Toxidrome
Hydrocarbon Toxicity
Pathophysiology
Cardiac Effects
CNS Effects
Emergency Medical Care
Signs and Symptoms
Treatment
Toxic Alcohols
Treatment
Etiological Toxidrome
Overview
Vancomycin-Resistant Enterococci (VRE)
Symptoms
Diagnosis
Treatment
Methicillin-Resistant Staphylococcus aureus (MRSA)
Pathophysiology
Signs and symptoms
Treatment
Clostridium Difficile (C. Difficile)
Overview
Symptoms
Other Risk Factors
Complications from C. Difficile Include
Prevention
Necrotizing Fasciitis
Overview
Symptoms
Cause
Treatment
Means of Entry
Virulence
Exposure
Radiological Toxidrome
Overview
Types of Radiation
Alpha Particles
Beta Particles
Gamma Rays
Neutrons
X-Rays
Measuring Radioactivity
Principles of Protection
Location of Radiation and Common Sites for Accidents
Types of Injuries
Rescue and Emergency Treatment
Treatment
Associated Toxic Conditions
Closed Space Fires
History
Fire Toxicology
Danger to Firefighters
Treatment
Wheezing Secondary to Toxic Inhalation
Overview
Tachycardia Secondary to Chemical Exposure
Hypotension Caused by Exposure
Seizures Post-Exposure
Opioids Overdose/Exposure
History
Opium Alkaloids
Synthetic Opioids
Semisynthetic Opioids
Today’s Fentanyl and Carfentanil
Signs and Symptoms
Summary
Reference
Chapter 4 Event Conditions
Introduction
Case Study – Fertilizer Explosion in West Texas
Operational Hazards
Dispatch Information
Scene Safety
Upon Arrival – Stop, Look, and Listen
Weather Conditions
Witnesses Accounts
Risk Awareness
The North American Emergency Response Guidebook (ERG)
NIOSH Pocket Guide
CAMEO
MARPLOT
ALOHA
WISER
ToxNet and the Hazardous Substance Database
Resources
Summary
Chapter 5 Hazard Identification
Introduction
Case Study – Phosgene Exposure
States of Matter
Solid
Liquids
Vapors and Gases
Mists and Aerosols
Gases
Compressed Gas
Liquified Gas
Cryogenic Gas
Chemical and Physical Properties
Chemical Properties
pH (Corrosivity)
Ignition Temperature (IT)
Flashpoint (FP)
Heat Transfer
Physical Properties
Appearance
Viscosity
Melting Point (MP)
Freezing Point (FrPt)
Boiling Point (BP)
Flammable Range
Density
Specific Gravity (SG)
Vapor Density (VD)
Vapor Pressure (VP)
Expansion Ratios
Properties and Their Medical Implications
Vapor Pressure, Medical Implications
Vapor Density, Medical Implications
Specific Gravity, Medical Implications
Solubility, Medical Implications
History of Toxicology
Exposure vs. Contamination
Toxin vs. Poison
Toxicity of a Poison or Toxin
Standards, Guidelines, and Acts Regulating Hazardous Materials
NFPA and OSHA
Environmental Protection Agency (EPA)
Time Weighted Average
Short-Term Exposure Limits (STELs)
Immediately Dangerous to Life and Health (IDLH)
Control Banding
Basic Toxicology Definitions
Acute Exposure
Sub-Chronic/Sub-Acute
Chronic Exposure
NOEL, NOAEL, LOAEL
Levels of Concern
Dose Response and Exposure
Graded Response
Quantal Response
Response Curve
Lethal Concentrations and Lethal Doses
Chemical Time lines
Additional Toxic Effects
Toxic Influences
General Health
Diet
Previous Exposure
Age
Gender
Genetics
Sleep
Biochemistry
Detoxification
Phase I and Phase II Reactions
Detoxification by the Lungs
Chemical Toxic Qualities
Chemical Excretion
Nanotoxicology
Determining the Level of Medical Surveillance
Risk Assessment and Detection
Identification of Hazards
Assess Hazards to Determine the Risks
Develop Controls to Manage the Risks
Implementing Controls
Supervise and Evaluate the Process
Summary
Chapter 6 Team Capabilities
Introduction
Case Study – Sodium Nitrate Overdose
Technician Operational Considerations
Personnel Protective Equipment (PPE)
Rehabilitation
Decontamination
Occupational Safety and Health Administration
National Fire Protection Association
Environmental Protection Agency
Science Behind Decontamination
Types of Decontamination
Gross Decontamination
Secondary Decontamination
Tertiary Decontamination
Emergency Decontamination
Techniques
Physical Decontamination
Factors to Consider During Decontamination
Equipment Uses
Choosing a Decontamination Site Location
Detection and Monitoring
The Approach
The System of Detection
Radiation
pH
Oxygen
Organic Compounds
Biologicals
Detection and Monitoring Responses
Current Detection Technologies
Radiation Detectors
pH Paper and Impregnated Papers
KI Paper or Oxidizer Paper
Wet Chemistry
Electrochemical Sensors
Catalytic Bead
Colorimetric Tubes
Photoionization Detection (PID)
Flame Ionization Detection (FID)
Ion Mobility Spectroscopy (IMS)
Infrared Spectroscopy (FT-IR)
Raman Spectroscopy
Positive Protein
Handheld Immunoassay (HHA)
Polymerase Chain Reaction (PCR)
Mass Causality Incidents
Triage Considerations (Non-START Triage)
Stilp and Bevelacqua Exposure Score
Cardiovascular
Breathing (Respiratory)
Rx – Immediate Basic Treatment
Neurological
Mass Decontamination
Initial Operations
HazMat Alert
Hospital Interface
Casualty Collection Points (Field Treatment Site)
Temporary Medical Care Units (Alternate Care Facilities)
The Medical Reserve Corp
Hospital Decontamination Considerations
PPE in the Hospital Environment
Hospital Isolation Rooms
Notification and Preparation
Hospital Scenario Possibilities
Hospital Decontamination Corridor
Hospital Decontamination Sequence Model
Summary
Chapter 7 HazMat Safety Officer
Introduction
Case Study – Lieutenant Dan
Medical Assessment
Medical Surveillance
Initial Baseline Physical and Annual Physical
Pre-Entry Physical
Considerations of the Entrance Physical
Post-Entry Physicals
Use of Findings
Preventive Health Screening
Post-Exposure Physicals
Biological Monitoring
Team Exit and Retirement Physicals
Program Review
ADA, Civil Rights, and Health Insurance Portability and Accountability Act (HIPAA)
Critical Incident Stress Debriefing
Developing a Medical Surveillance Program
Summary
Chapter 8 Terrorism
Introduction
Case Study – Salmonella Salad Bar
Terrorism Using Chemical Warfare Agents
Nerve Agents (Cholinergic Toxidrome)
Military Nerve Agents
Physical Properties and Routes of Entry
Decontamination
Treatment
Blood Agents – Asphyxiants Toxidrome
Military Blood Agents
Physiology
Physical Properties and Routes of Entry of Cyanide Agents
Decontamination
Treatment
Choking Agents – Irritant Gas Toxidrome
Military Choking Agents
Physiology of Respiratory Irritant Injury
Physical Properties and Routes of Entry
Decontamination
Treatment
Vesicants – Corrosive Toxidrome (Military Blister Agents)
Military Blister Agents (Vesicants)
Physiology of Blister Agent Exposure
Physical Properties and Routes of Entry
Decontamination
Treatment
Lacrimators (Riot Control Agents)
CN and CS
OC
Decontamination
Treatment
Terrorism Using Biological Agents
Bacteria
Viruses
Biological Toxins
Bacterial Agents
Anthrax (B. anthracis)
Cholera (Vibrio cholerae)
Pneumonic/Bubonic Plague (Y. pestis)
Tularemia (F. tularensis)
Q Fever (Coxiella burnetii rickettsia)
Salmonellae (Salmonella typhimurium)
Viral Agents
Smallpox (Variola virus)
Venezuelan Equine Encephalitis (VEE)
Viral Hemorrhagic Fevers (VHFs)
Biological Toxins
Botulinum Toxin
Staphylococcal Enterotoxin B (SEB)
Ricin
Trichothecene Mycotoxins (T2)
Explosives and Incendiary Devices
Bomb Incidents
Anatomy of Explosives
Expected Effects from Explosions
Physiology of Blast Effects
Blast Effects
Summary
Epilogue
Index
EULA