chapter 15 - triage of chemical causal ties - pg. 511 - 526

8/3/2019 Chapter 15 - Triage of Chemical Causal Ties - Pg. 511 - 526

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Triage of Chemical Casualties

Chapter 15

TRIAGE OF CHEMICAL CASUALTIES

SHIRLEY D. TUORINSKY, MSN*; DUANE C. CANEVA, MD; ANDFREDERICK R. SIDELL, MD

INTRODUCTION

TRIAGE PRINCIPLES AND PROCESSES

Levels of CareDecontaminationTreatment, Decontamination, and Transport Linkage

TRIAGE CATEGORIES FOR CHEMICAL CASUALTIESUS Military Triage CategoriesOther Triage Systems

MEDICAL MANAGEMENT OF CHEMICAL CASUALTIESNerve AgentsCyanideVesicantsLung-Damaging AgentsIncapacitating Agents

Riot Control Agents

TRIAGE BY CATEGORY AND AGENTImmediateDelayedMinimalExpectant

CASUALTIES WITH COMBINED INJURIESNonpersistent Nerve AgentsPersistent Nerve AgentsVesicantsLung-Damaging AgentsCyanideIncapacitating Agents

SUMMARY

*Lieutenant Colonel, AN, US Army; Executive Officer, Combat Casualty Care Division, US Army Medical Research Institute of Chemical Defense, 3100Ricketts Point Road, Aberdeen Proving Ground, Maryland 21010-5400

Head, Medical Plans and Policy, Navy Medicine Office of Homeland Security, 2300 E Street, NW, Washington, DC 20372Formerly, Chief, Chemical Casualty Care Division, and Director, Medical Management of Chemical Casualties Course, US Army Medical Research

Institute of Chemical Defense, Aberdeen Proving Ground, Maryland


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Medical Aspects of Chemical Warfare

INTRODUCTION

be relevant to the available medical units capabilities,and triage process should be planned in advance andpracticed. In general, triage is performed at naturallyoccurring bottlenecks, where delays in medical care

may occur, and when medical requirements exceedcapabilities or resources, which may cause a breech inthe standard of care. The ultimate goal of triage is tooptimize the use of available medical resources to pro-vide the best medical care possible by identifying thecorrect priority of patients.1This chapter will focus onthe process of triage in chemical agent mass casualties.Specific chemical warfare agent classes, current triagesystems, and classifications of triage will be reviewed,with discussion of issues specific to the battlefield andinstallation setting.

The term triage has come to have different mean-ings depending on the situation in which it is used.Derived from the French word trier,meaning to sort,categorize, or select, its initial use is thought to have

been in reference to the sorting of crops according toquality. Triage soon became used on the battlefield asthe sorting of casualties into three groups: (1) thoseneeding immediate care, (2) those who could waitfor treatment, and (3) those not expected to survive.Military triage has certain definitions codified indoctrine and policy. The term also refers to the initialscreening and prioritization process in emergencydepartments.

Triage is one of the most important tools in the han-dling of mass chemical casualties. Triage criteria must

TRIAGE PRINCIPLES AND PROCESSES

In a mass casualty situation, whether in peacetimeor on a battlefield, triage is carried out to provideimmediate and appropriate care for casualties withtreatable injuries, to delay care for those with lessimmediate needs, and to set aside those for whomcare would be too timely or asset-consuming. Triageensures the greatest care for the greatest number andthe maximal utilization of medical assets: personnel,supplies, and facilities. To effectively triage a givenpopulation, a triage officer should know the followingessential information:

The current environment and potential threat,course, and harm. Situational awareness mustinclude current tactical goals and conditions,the potential evolution of hazardous materi-als or conditions, and the impact these mighthave on the patients and providers.

The ongoing medical requirements, includingthe number and type of current casualties andpotential population at risk.

The medical resources on hand. The natural course of a given injury. The current and likely casualty flow. The medical evacuation capabilities. The decontamination requirements in a chemi-

cal incident.

According to FM 8-10, Health Service Support in aTheater of Operations,2 the triage officer should be ahighly experienced medical provider who can makesound clinical judgments quickly. Ideally, a surgeonexperienced with combat trauma would be used inthis capacity; however, once casualty flow progresses,

surgeons must spend time in the operating suite, andtheir available time to perform triage will be limitedbeyond the initial efforts and between operations.Additionally, the expertise of surgical triage appliesto traumatic injuries, and may not be as applicable tochemical incidents. Commonly,the most experiencedcombat medic performs triage; however, other physi-cians, dentists, or nurses with appropriate training andexperience can also accomplish this arduous task.

Part of the triage process is the evaluation of thebenefit that immediate assistance will provide. Thisevaluation is based, in part, on the natural course of

the injury or disease. For example, dedicating medicalassets to a casualty with an injury that will either healor prove fatal no matter what immediate care is givenwould be of little benefit. Another part of the process isconsidering the overall tactical mission requirements,which may change rapidly in the battlefield setting.The ultimate goal of combat medicine is to return thegreatest possible number of soldiers to combat and thepreservation of life, limb, and eyesight in those whomust be evacuated.3

Setting aside casualties who are in need is unpopu-lar among medical care providers, and poses an ethicaldilemma on how to provide the ultimate care for eachpatient. The Hippocratic Oath is not helpful in thissorting process, because the modern interpretation ofthe Oath states that the duty of physicians and nursesis to protect and promote the welfare of their patients.Furthermore, according to the Oath, caregivers mustfocus their full attention on that patient until thepatients needs are met, before turning their attentionto another patient. Additionally, in peacetime, everypatient who enters the hospital emergency room


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receives the full attention of all personnel needed toprovide optimal care. For these reasons, the thoughtof setting aside a critically sick or injured patient maywell be repugnant to someone who has not been in amass casualty situation or who has given little thoughtto such situations.4

In addition to knowing the natural course of thedisease or injury, the triage officer should also beaware of current medical assets, the current casualtypopulation, the anticipated number and types of in-coming casualties, the current status of the evacuationprocess, and the assets and casualty population at theevacuation site. Committing assets to the stabilizationof a seriously injured casualty in anticipation of earlyevacuation and more definitive care would be point-less if evacuation could not be accomplished withinthe time needed for the casualtys effective care, orif the assets at the evacuation site were already com-mitted. The officer might also triage differently if, for

example, he or she knew that the 10 casualties presentwould need care in the next 24 hours, or, on the otherhand, that those 10 casualties were to be followed by50 more within an hour.5 In an unfavorable tacticalsituation, another consideration may arise: casualtieswith minor wounds, who otherwise may be classifiedminimal, might have highest priority for care to en-able them to return to duty. The fighting strength thuspreserved could save medical personnel and casualtiesfrom attack.

Levels of Care

Triage is a dynamic rather than a static process,in which casualties are periodically reevaluated forchanges in condition and retriaged at various levelsof medical care, ranging from the battlefield to thebattalion aid station to the combat support hospital.The first triage is done by the corpsman, medic, or unitcombat lifesaver in the field. The medic first evaluatesthe severity of injury and decides whether anythingcan be done to save life or limb. If the answer is no,the medic moves on, perhaps after administering ananalgesic. More commonly, the medic decides thatcare is indicated. Can the medic provide that care onthe spot to return the service member to duty quickly?Can the care wait until the battle is less intense or anambulance arrives? Or must the care be given imme-diately if the casualty is to survive? In the latter case,the medic ensures that the casualty is transferred tothe medical facility if possible.

A casualty is triaged once more upon entry into amedical care facility, followed by repeated triage withinthe facility as circumstances (eg, the casualtys condi-tion and the assets available) change. For example, a

casualty set aside as expectant (see Triage Categoriesfor Chemical Casualties, below, for definitions ofclassification groups) because personnel are occupiedwith more salvageable casualties might be reclassi-fied as immediate when those personnel become free.On the other hand, a casualty with a serious but not

life-threatening wound, initially classified as delayed,could suddenly develop unanticipated bleeding and,if treatment assets were available, might be retriagedas immediate.

Even in the most sophisticated medical setting, aform of triage is usually performed (perhaps not al-ways consciously): separation of those casualties whowill benefit from medical intervention from those whowill not be helped even by maximal care. However, inmost circumstances in a large medical facility, care isadministered anyway; for instance, an individual witha devastating head injury might receive life-supportmeasures. The realization that in some settings assets

cannot be spent in this manner is an integral part oftriage.6

Decontamination

At the first level of medical care, the chemical casual-ty is contaminated, and both the casualty and the triageofficer are in protective clothing (mission oriented pro-tective posture [MOPP] level 4 or Occupational Safetyand Health Administration level C). Furthermore, thefirst medical care given to the casualty is in a contami-nated area, on the hot or dirty side of the hotline atthe emergency treatment station (see Chapter 14, Field

Management of Chemical Casualties). This situation isin contrast to any level of care in which casualties werepreviously decontaminated, and to a conventionalsituation with no contamination involved. Examina-tion of the casualty is not as efficient or effective as itmight be in a clean (not contaminated) environment,and very little care can be given to a casualty in theemergency treatment section in the contaminated area.In a chemically contaminated environment, in contrastto other triage situations, the most experienced medicalstaff work in the clean treatment area, where they canprovide maximum care.

It is extremely unlikely that immediate decontami-nation at the first level of medical care will changethe fate of the chemical casualty or the outcome of theinjury. Various estimates indicate that the casualtyusually will not reach the first level of care for 15 to60 minutes after the injury or onset of effects, exceptwhen the medical treatment facility (MTF) is close tothe battle line or is under attack and the injury occursjust outside. The casualty is unlikely to seek care untilthe injury becomes apparent, which is usually long


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after exposure. For example, mustard, a vesicant, maybe on the skin for many hours before a lesion becomesnoticeable. Thus, it is likely that the agent has beencompletely absorbed or has evaporated from the skinby the time the casualty reaches the MTF, and the smallamount unabsorbed, or absorbed during a wait for

decontamination, is very unlikely to be significant.The process of patient decontamination must be fac-tored into the triage decision. (It must be rememberedthat triage refers to priority for medical or surgicalcare, not priority for decontamination. All chemicalcasualties require decontamination. Although a ca-sualty exposed to vapor from a volatile agent such ascyanide, phosgene, or a nerve agent may not appearto need decontamination, verifying that no liquid ispresent on the casualty is difficult.) In a contaminatedenvironment, emergency care is given by personnelin MOPP 4, the highest level of protective gear, whichlimits their capabilities. After receiving emergency

care, a casualty must go through the decontamina-tion station before receiving more definitive care ina clean environment. Decontamination takes 10 to 20minutes. As a rule no medical care is provided duringthis time or during the time spent waiting to begin thedecontamination process. Therefore, before leaving theemergency care area, patients must be stabilized to anextent that their condition will not deteriorate dur-ing this time. If stabilization cannot be achieved, thetriage officer must consider this factor when makingthe triage judgment. If the casualty has torn clothingor a wound suspected to be the source of contamina-tion, a different type of decontaminationimmediate

decontaminationmust be performed at the triage oremergency treatment station in the dirty or chemicallycontaminated area.

Casualties exposed to certain chemical agents suchas nerve agents may be apneic or nearly apneic; one ofthe first interventions required is assisted ventilation.Special, air-filtering assisted ventilation equipment, achemical mask-valve-bag device (called resuscitationdevice, individual chemical), is available for use in achemical environment. However, personnel availableto provide ventilator assistance in the contaminatedenvironment are likely to be limited. Also, if a briskwind is present and the medical facility is far upwindfrom the source of contamination, very little agentvapor will remain in the air. If no air-filtering ventila-tion equipment is available, medical personnel mustdecide whether to ventilate with air that is possiblyminimally contaminated or let the casualty remainapneic. Once assisted ventilation is begun, the careprovider is committed to the process and cannot carefor other casualties, so the number of medical person-nel available in the contaminated area influences the

ventilation decision. However, a walking woundedcasualty (in the minimal category) can quickly betaught how to ventilate other casualties.7

Treatment, Decontamination, and Transport Linkage

Triage is always linked to treatment; in a masscasualty event, triage and treatment are also linked totransport. In a chemical weapons mass casualty event,decontamination is also linked, and transport is fromthe contaminated environment. This linked processoccurs at the incident site, and is somewhat duplicatedat the MTF; however, different statutory codes, poli-cies, and requirements are relevant in each place. Asthe preparedness and response efforts for homelandsecurity mature, the tactics, techniques, and proceduresused in military settings or homeland settings are con-verging. Likewise, the regulatory statutes, includingbest practices, certification processes for equipment,

training, and competencies, are showing a pattern ofconvergence. Further alignment should be driven bysuch initiatives as development of national resourcetyping systems (discussed in Other Triage Systems,below) in support of national preparedness goals.

During response preparations, the triage and treat-ment teams are best placed at naturally occurringbottlenecks as patients are processed through thedecontamination corridor (Figure 15-1). At least threetriage locations should be placed at the incident site.Triage and treatment teams must integrate their workwith patient transport teams (litter bearers and ambu-lance staff). They must also integrate with decontami-

nation teams, which may be comprised of personnelwith very limited medical training. Medical oversightof the patients must be clearly defined and understoodby all personnel, including recognition of and properalerts for changes in patient condition, continuationof any supportive measures, and strict adherence toprotocol and procedure.

The initial casualty collection point is located nearthe border of the hot and warm (contamination reduc-tion) zones. This location allows for initial collectionof nonambulatory victims from the incident site inthe hot zone and provides shorter distances and cycletimes for teams retrieving the casualties from the inci-dent site. It also provides a working environment formedical personnel who are initially uncontaminated.Antidote administration and airway managementare the mainstays of treatment at this point. The nextbottleneck generally occurs on both sides of the decon-tamination shelter. Current methods for mass casualtydecontamination allow for very limited throughput,even by the most experienced of teams with the besttechnology, leading to a backup of patient flow at the


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entrance. These decon triage teams provide retriageand basic treatment including airway management,additional administration of antidote, and perhapsmore invasive medical intervention.

On the clean side of the decontamination shelter isanother typical bottleneck as patients await transport

from the incident scene to more definitive treatmentfacilities. Here, medical personnel are not encumberedwith personal protective equipment and are able toevaluate patients in an uncontaminated environment.More invasive medical intervention is possible with-out concern for further contaminating the patient. Abalance among condition, transport times, medicalresources, and interventional requirements must besought in the prioritization and triage of the patients.In incidents conducted in a noncombat situation, suchas might occur on an installation during peacetime,first responders adhere to federal statutes for trainingqualifications.8

A somewhat similar scenario occurs at the MTF

(see Figure 1412). At the MTF, training requirementsare governed by different regulations than those forthe incident site. For example, current OccupationalSafety and Health Administration guidelines require8 hours of hazardous waste operations and emergencyresponse (HAZWOPER) first responder operations

level training for first receivers who are expectedto decontaminate victims or handle victims beforethey are thoroughly decontaminated at the MTF. Theguidelines include additional criteria for the personalprotective equipment levels recommended (level C),no more than a 10-minute time period from patientexposure at the incident site to presentation to theMTF, and a thorough hazard vulnerability assessmentto identify specific threats or hazards that might driveadditional requirements. Additionally, the hazard-ous zones are recognized as different from those atthe decontamination incident site, referred to as thewarm (contamination reduction) zone and cold

(postdecontamination) zone (see Figure 14-12). At

DeconTriage

Hot (Exclusion)

Zone

Warm

(ContaminationReduction)

Zone

Cold (Support)

Zone

Hot Zone

Assembly Area

ColdZone

StagingArea

Medical Triage& Treatment

Emergency OperationsCenter (EOC)

ChemicalIncident Site

InitialFire Dept/EMS

Wind

Downslope

EMS

CasualtyCollection

Point Hot ZoneCoordinator

Water Heater

Water Source

First Responder Flow

Casualty Flow

Triage and Treatment Groups

Waste Water

HospitalEMS Transport Group

IncidentCommand

Post

Entry/ExitControlPoint

Reconstitution ofsupplies/equipmentand personnel

First ResponderDecon Lane

Chemical Incident Site Setup

Fig. 15-1. National site setup and control zones for a hazardous materials site. All distances are notional.EMS: emergency medical serviceDiagram: Courtesy of Commander Duane Caneva, US Navy.


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the MTF, the casualty receiving and decontamina-tion triage areas are likely to be co-located or simplycombined. Additionally, a separate evaluation area

may be needed where those who received thoroughdecontamination at the warm or contamination reduc-tion zone are confirmed clean.9

TRIAGE CATEGORIES FOR CHEMICAL CASUALTIES

Chemical casualty triage poses unique challengesbeyond the normal triaging of patients with trau-matic injuries. Current triage systems are designedfor traumatic injuries and, to the degree that they areevidence-based, are based on trauma data. Criteriaused, such as respiratory rate and effort, pulse, mentalstatus, and motor function, are specifically affectedby many chemical weapons agents; however, correla-tion with degree of abnormality, course of injury, andsurvivability is not as well understood as in cases oftraumatic injury. Complicating the situation may bethe occurrence of combined injury, both poisoning andtrauma, if the chemical agent was dispersed through

explosive ordnance (see Casualties with CombinedInjuries, below). Such a situation requires decisionsto be made balancing emergency medical treatmentswith chemical decontamination: airway managementor control of hemorrhage may be equally urgent ormore urgent than the treatment for chemical agent poi-soning. Emergency medical treatment triage measuresmay need to be performed simultaneously or in rapidsequence with decontamination procedures.

The simplest form of triage is placing the casualtiesinto treatment priority categories. In a conventionalsituation (uncontaminated environment), casualtieswho require immediate intervention to save their lives

usually have injuries affecting the airway, breathing,or circulationthe ABCsthat can be treated ef-fectively with the assets available within the timeavailable. The second conventional category consists ofcasualties with injuries that pose no immediate dangerof loss of life or limb. Casualties in this group might in-clude someone with a minor injury who merely needssuturing and a bandage before being returned to duty,or someone who has an extensive injury necessitatinglong-term hospitalization, but who at present is stable.The third conventional category consists of those forwhom medical care cannot be provided because oflacking medical assets or time or because the triageofficer knows from experience that the casualty willdie no matter what care is given. Again, a casualtysclassification might change as assets become availableor when later reevaluation shows that the casualtyscondition was not as serious as first anticipated.

US Military Triage Categories

The triage system commonly used by US militarymedical departments and by many civilian medical

systems, based on the North Atlantic Treaty Organi-zation mass casualty triage standard, contains fourcategories:

1. Immediate treatment (T1): Casualties whorequire emergency life-saving treatment. Thistreatment should not be time consuming or re-quire numerous or highly trained personnel,and the casualty should have a high chanceof surviving with the medical treatment.

2. Delayed treatment (T2): Casualties whosecondition permits some delay in medicaltreatment. However some continuing care

and pain relief may be required before defini-tive care is given.

3. Minimal treatment (T3): Casualties with rela-tively minor signs and symptoms who cancare for themselves or who can be helped byuntrained personnel.

4. Expectant treatment (T4): Casualties with alow chance for survival whose life-threaten-ing condition requires treatment beyondthe capabilities of the medical unit. Placingcasualties into this category does not neces-sarily mean that no treatment will be given;rather, the category determines the priority

in which treatment will be given.

These are the categories that will be used in thischapter. This chapter will not cover triage of the con-ventionally wounded casualty except in the contextof combined injury.

Alternative triage categories are emergent (his-torically subdivided into immediate and urgent),nonemergent (historically subdivided into delayed andminimal), and expectant. Sometimes the term chemi-cal intermediate is used for a casualty who requiresan immediate life-saving antidote (as in nerve agentor cyanide poisoning).

Triage categories are based on the need for medicalcare, and they should not be confused with categoriesfor evacuation to a higher-level MTF for definitive care.However, the need for evacuation and, more impor-tantly, the availability of evacuation assets influencesthe medical triage decision. For example, if a casualtyat a battalion aid station is urgently in need of short-term surgery to control bleeding, and evacuation is notpossible for several hours, the triage category mightbe expectant instead of immediate. The evacuation


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categories are urgent (life immediately threatened),urgent-surg (must receive surgical intervention tosave life and stabilize for further evacuation), priority(life or limb in serious jeopardy), routine, and conve-nience (evacuation is matter of medical convenience).10The distinction between the urgent and immediate

groups has often been ignored, as has the separationof the chemical immediate and immediate groups.

Other Triage Systems

In an attempt to eliminate subjectivity from the triageprocess, various systems have been created to identifyspecific criteria for categorization and to correlate thesecriteria to data from trauma registries; however, veryfew systems address the impact of chemical toxidromes.Cone and Koenig provide a comprehensive summary ofvarious systems and propose algorithms for chemical,biological, radiological, and nuclear incident types.11

The commonly used simple triage and rapid treat-ment (START) system, based on the respiratory rate,pulse, and motor function (collectively referred to asthe RPMs), provides an algorithm that allows for apatient to be evaluated, classified by color, and receiveminimal lifesaving measures within about 30 to 60 sec-onds. The START process begins with an initial safetysurvey, followed by the identification of ambulatorypatients considered green, or having minimal injury,to be moved to a safe gathering place, and the evaluationof the remaining nonambulatory victims. These victimsare then triaged as immediate (red), delayed (yellow),minimal (green), or expectant (black).12 Largely objec-

tive, the START algorithm is correlated with a traumaregistry that identifies which field-measurable physi-ological parameters correlate with survival and severityof injury. The RPMs are used to determine the revisedtrauma score for a predictable outcome.13

The Sacco triage method (STM) builds on thisconcept through a more complex algorithm. Usingthe criteria developed for START, the RPMs are usedto provide a revised trauma score ranging from 0 to12. STM then considers the available resources (eg,receiving hospital beds), transport times, and scoringdistribution of all known patients, and optimizes theorder of patients by their revised trauma score. For ex-ample, if an incident occurs with long transport times,the model predicts that patients with lower scores willnot survive. Higher scored patients are thus prioritizedfor transport first so as to not use limited resources on

patients who are statistically unlikely to survive.Although STM is more complex than other sys-

tems, it has several advantages.14 Like START, itsbasic evaluation is fairly objective, using criteria cor-related to actual trauma data registry. Unlike othersystems, STM accounts for other critical factors such

as transport times and receiving hospital resources. Italso provides a better stratification of critical patients,with a more practical, realistic spectrum of severity ofcondition. Furthermore, STM recognizes that patientswith more severe injury tend to decompensate fasterand sooner and considers differing transport timesto separate hospitals, as well as the availability ofhospitals to receive patients. Through use of an inci-dent management system, STM links on-scene triageand treatment, transport, and patient reception at thehospital, providing the data for a unified commandsystem to secure transport routes. The system cantherefore be customized for specific municipalities or

operational scenarios, as well as providing strategiesto maximize survivability during preparedness andresponse phases.

Current military doctrine provides limited insightinto specific criteria for mass casualty triage in achemical environment. Although the triage criteria forcasualties exposed to a chemical agent may be similaror even the same as those for traumatic injury, substan-tial differences in the triage process exist. Additionalsteps in the process of care for casualties exposed toa chemical agent include, for example, the adminis-tration of antidote, if efficacious; extraction from thearea of chemical exposure; proper management and

removal of any personal protective equipment wornby the patient; and medical management through adecontamination corridor. Medical personnel mustcarry out these procedures while wearing personalprotective equipment.

Furthermore, changes in vital signs of chemical ca-sualties are generally predictable given the severity ofexposure, but their correlation with injury is not nearlyas well understood as that for traumatic injury and vitalsigns. No easily measurable, dose-response parametershave been predictably correlated to survivability witha known time course for decompensation. No criteriaare available, therefore, to prioritize, for example, theevacuation of an unconscious, nearly apneic casualtyversus one who is alert and dyspneic. Applying thesecriteria to an algorithm is further complicated by dif-fering toxicity levels across the general population.15

MEDICAL MANAGEMENT OF CHEMICAL CASUALTIES

The initial management and treatment of contami-nated chemical agent casualties varies according to theagent as well as the tactical situation. For this reason,

each MTF must have a plan that can be modified asneeded for specific situations. Unless the chemicalagent is dispensed downwind or at the site of the inci-


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dent, casualties will probably take at least 15 minutesafter the exposure to reach a medical treatment area.Furthermore, some casualties will not seek medicalattention until effects from the agents are apparent,and an appreciable amount of time may elapse beforethe casualty is seen.

Nerve Agents

In a unit-level MTF, nerve agent casualties might beclassified as immediate, minimal, delayed, or expectant.In a full-care MTF, a nerve agent casualty is unlikely tobe classified as expectant because treatment should beavailable. A nerve agent casualty who is walking andtalking can generally be treated and returned to dutywithin a short period (see Chapter 5, Nerve Agentsfor a more complete discussion of nerve agent effectsand treatment). In most cases, rather than reporting tothe triage point, military personnel exposed to nerve

agents should self-administer the Mark I or antidotetreatment nerve agent autoinjector (ATNAA), either ofwhich should reverse the respiratory effects of vaporexposure. Casualties who appear at the triage stationshould be classified as minimal because they are able toself-administer the antidote (or it can be administeredby a medic), evacuation is not anticipated, and theycan return to duty shortly.

Casualties who have received the contents of allthree Mark I or ATNAA kits and continue to have dys-pnea, have increasing dyspnea, or begin to have othersystemic symptoms (such as nausea and vomiting,muscular twitching, or weakness) should be classified

as immediate. A source of continuing contaminationwith liquid agent, such as a break in protective clothingor a wound, should be given immediate decontamina-tion and irrigated with water or saline solution (thisprocedure is not included in the general advice aboutdecontamination in Warrior Task Training16; however,the newest version of FM 8-2855directs caregivers toprovide treatment as described here). If the casualtyis conscious, has not convulsed, and is still breath-ing, prevention of further illness will ensure a quickreturn to duty. The casualty will survive unless he orshe continues to absorb agent. Also, administration ofmore atropine should help considerably. With thesemeasures, the progression of nerve agent illness canbe stopped or reversed with a minimal expenditure oftime and effort in the emergency treatment area.

At the other end of the spectrum, casualties whoare seriously poisoned will usually not survive longenough to reach an MTF. However, there are excep-tions. If the attack is near an MTF, casualties who areunconscious, apneic, and convulsing or postictal mightbe seen within minutes of exposure. Or, if the casual-

ties have taken soman nerve agent pyridostigminebromide pretreatment, they might remain unconscious,convulsing, and with some impairment (but not cessa-tion) of respiration for many minutes to hours. Thesepatients, as well as those in a similar condition whohave not used the pretreatment, require immediate

care. If they receive that care before circulation failsand convulsions have become prolonged (see Chapter5, Nerve Agents), they will eventually recover and beable to return to duty.

Supporting this view is a report from the Tokyo sub-way terrorist incident of 1995. One hospital receivedtwo casualties who were apneic with no heartbeat.With vigorous cardiopulmonary resuscitation, cardiacactivity was established in both. One resumed sponta-neous respiration and walked out of the hospital sev-eral days later; the other was placed on a ventilator butdid not start breathing spontaneously and died dayslater. These anecdotes suggest that when circumstances

permit, resuscitation should be attempted, for recoveryby such patients after nerve agent exposure is clearlypossible. In a contaminated area where resources, in-cluding personnel, are limited, the use of ventilatorysupport and closed chest cardiac compression mustbe balanced against other factors (discussed above),but the immediate administration of diazepam andadditional atropine requires little effort and can bevery helpful in the casualty who still has recoverablecardiopulmonary function.

Cyanide

Symptoms of cyanide poisoning depend upon theagent concentration and the duration of exposure.High concentrations of cyanide gas can cause deathwithin minutes; however, low concentrations mayproduce symptoms gradually, causing challenges forthe triage officer. Generally, a person exposed to a lethalamount of cyanide will die within 5 to 10 minutes andwill not reach an MTF. Conversely, a person who doesreach the MTF may not require therapy and could pos-sibly be in the minimal group, able to return to dutysoon. If the exposure occurs near the treatment area, aseverely exposed casualty might appear for treatment.The casualty will be unconscious, convulsing or post-ictal, and apneic. If circulation is still intact, antidoteswill restore the person to a reasonably functional statuswithin a short period of time. The triage officer, how-ever, must keep in mind that it takes 5 to 10 minutesto inject the two antidotes needed. In a unit-level MTF,a cyanide casualty might be immediate, minimal, orexpectant; the last classification would apply if theantidote could not be administered or if circulationhad failed before the casualty reached medical care.


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In a full-care facility, the casualty might be classifiedas immediate or minimal.

Vesicants

Most casualties from mustard exposure require

evacuation to a facility where they can receive carefor several days to months. The exceptions are thosewith small areas of erythema or with only a few small,discrete blisters. However, even these guidelines arenot absolute. If the casualty is seen early after exposure,erythema may be the only manifestation, but it maybe the precursor of blister formation. Small, discreteblisters may appear innocuous, but on certain areasof the body they can be incapacitating, rendering asoldier unfit for duty (see Chapter 8, Vesicants,for amore complete discussion).

Mustard casualties, especially those with eyeinvolvement, are often classified as immediate for

purposes of decontamination. However, immediatedecontamination within 2 minutes can decrease thedamage of mustard to the tissues. This classificationis not helpful unless the casualty presents to the MTFwithin 2 minutes of exposure, which is very unlikelybecause of mustards latent effects. By the time themustard lesion forms, the agent has been in contactwith the skin, eye, or mucous membrane for a numberof hours, and irreversible effects have already begun.

Casualties who have liquid mustard burns over 50%or more of body surface area or burns of a lesser extentbut with more than minimal pulmonary involvementpose a challenge for the triage officer. The medial lethal

dose (LD50) of liquid mustard, estimated at 100 mg/kg,covers 20% to 25% of body surface area. It is unlikelythat a casualty will survive twice the LD50, whichwould cover about 50% of body surface area, becauseof the tissue damage from the radiomimetic effects ofmustard. Casualties with a burn this size or greaterfrom liquid mustard should be considered expectant.They require intensive care (which may include carein an aseptic environment because of leukopenia)for weeks to months, which can be provided only atthe far-rear level of care or in the continental UnitedStates. Chances of survival are very low in the best ofcircumstances and are decreased by delays in evacu-ation. Furthermore, even in a major hospital duringwartime, long-term care will require assets that mightbe needed for casualties more likely to survive.

Under battlefield or other mass casualty conditions,casualties with conventional thermal burns coveringgreater than 70% of body surface area are usuallyput in the expectant group when medical facilitiesare limited. This percentage is subject to downwardmodification (in increments of 10%) by other factors,

including further restriction of healthcare availability,coexisting inhalational injury, and associated traumaticinjury. However, differences exist between conven-tional burns and mustard burns: conventional burnsare likely to have a larger component of third-degreeburns, whereas mustard burns are mostly second-de-

gree. On the other hand, exposure to mustard causesproblems not seen with conventional burns, such ashemopoietic suppression and the ensuing susceptibil-ity to systemic infection, which is greater than that seenwith conventional burns.

Mustard casualties are generally classified as de-layed for both medical attention and decontamination.Exceptions are casualties with a very small lesion ( 50% of body surface area) and moderate to severepulmonary involvement, who are usually classified as

expectant. In a more favorable medical environment,every effort should be made to provide care for thesecasualties; at least those in the latter group should beclassified as immediate.

In a unit-level MTF, a mustard casualty might be cat-egorized as minimal, delayed, or expectant, but prob-ably not immediate, because required care would notbe available. Even if immediate evacuation is possible,the eventual cost in medical care for a casualty need-ing evacuation must be compared to the probable costand outcome of care for a casualty of another type. In alarge medical facility where optimum care is availableand the cost is negligible, a mustard casualty might be

classified as minimal, delayed, or immediate.

Lung-Damaging Agents

Casualties exposed to lung-damaging agents (toxicindustrial chemicals) may also present a dilemma tothe triage officer. A casualty who is in marked distress,severely dyspneic, and productive of frothy sputummight recover in a fully equipped and staffed hospital;however, such a casualty would not survive withoutventilatory assistance within minutes to an hour. Thisassistance is not possible in the forward levels of medi-cal care, nor is it possible to transport the casualty toa hospital within the critical period. Casualties withmild or moderate respiratory distress and physicalfindings of pulmonary edema must also be evacuatedimmediately; if evacuation to a full-care MTF is notforthcoming in a reasonably short period, the prog-nosis becomes bleak. (These casualties would not betriaged as immediate because the required immediatecare is probably unavailable at the forward levels ofmedical care.) Thus, with lung-damaging agent casual-


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ties, availability of both evacuation and further medicalcare is important in the triage decision.

Peripherally acting lung-damaging agents inducepulmonary edema that varies in severity; a casualtymight recover with the limited care given at the unit-level MTF. However, a casualty who complains of

dyspnea but has no physical signs presents a triagedilemma: to evacuate this casualty might encourageothers to come to the MTF with the same complaints,anticipating evacuation from the battle area, butrefusing to evacuate might preclude timely care andpotentially cause an unnecessary fatality, and observ-ing the individual until signs of illness appear mightalso delay medical intervention until the damage isirreversible. Knowledge about the following physicalmanifestations of peripherally acting lung-damagingagent intoxication may be helpful to the triage of-ficer if a reliable history of the time of exposure isavailable:

The first physical signs, crackles (rales) orrhonchi, occur at about half the time it takesfor the injury to become fully evident. Thus, ifcrackles are first heard 3 hours after exposure,the lesion will increase in severity for the next3 hours.

If no signs of intoxication occur within thefirst 4 hours, the chance for survival is good,although severe disease may ultimatelydevelop. In contrast, if the first sign occurswithin 4 hours of exposure, the prognosis isnot good, even with care in a medical center.

The sooner after exposure that symptomsdevelop, the more ominous the outlook.

Casualties with crackles or rhonchi 3 hours afterexposure must reach a medical facility that can providecare as soon as possible. Even with optimal care, thechances of survival are not good. It should be empha-sized that these guidelines apply only to objectivesigns, not the casualtys symptoms (such as dyspnea).In a contaminated area, where both medical personneland casualties are wearing MOPP 4 gear, it will not beeasy and may not be possible to elicit these signs.

In a unit-level MTF, casualties from peripher-ally acting lung-damaging agents might be triagedas minimal or expectant, with a separate evacuationgroup for those who require immediate care, if timelyevacuation to a higher-level facility is possible. In alarge, higher-level MTF, these casualties might be clas-

sified as minimal or immediate because full care canbe provided on-site.

Incapacitating Agents

An incapacitating agent is a chemical warfare agentthat produces temporary disabling conditions thatcan last hours or even days after exposure. Casualtiesshowing the effects of exposure to an incapacitatingagent may be confused, incoherent, disoriented, anddisruptive. They cannot be held at the unit-level MTF,but they should not be evacuated ahead of casualtieswho need lifesaving care unless they are completely

unmanageable and threatening harm to themselves orothers. Casualties who are only mildly confused fromexposure to a small amount of agent, or whose historyindicates they are improving or near recovery, may beheld and reevaluated in 24 hours. In a unit-level MTF,a casualty from exposure to an incapacitating agentmight be minimal or delayed, with little need for highpriority in evacuation. In a higher-level MTF, thesecasualties would be cared for on a nonurgent basis.7

Riot Control Agents

Riot control agents, which include irritant agents

(eg, CN [chloroacetophenone]) and vomiting agents(eg, DA [diphenylchlorarsine]), have been availablefor many years and are used in uncontrolled distur-bances to render people temporarily incapacitatedwithout injury, although use of the agents includesrisks of persistent skin effects, eye effects, and allergicreaction after exposure. Decontamination can relieveirritation of symptoms and decrease risk of injury ordelay effects of contact dermatitis. Casualties exposedto riot control agents will most likely not be seen at anMTF, but if they do present with complications, triageaccording to the nature of the injuries.17

TRIAGE BY CATEGORY AND AGENT

Immediate

Nerve Agents

A nerve agent casualty in severe distress would beclassified as immediate. The casualty may or may notbe conscious; may be in severe respiratory distress ormay have become apneic minutes before reaching the

facility; may not have convulsed or may be convulsingor immediately postictal. Often the contents of threeMark I or ATNAA kits (or more) plus diazepam and,possibly, short-term ventilatory assistance will be allthat is required to prevent further deterioration anddeath. In addition, a casualty with involvement of twoor more systems (eg, neuromuscular, gastrointestinal,and respiratory, but excluding effects on the eyes and


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nose) should be classified as immediate and admin-istered the contents of three Mark I or ATNAA kitsplus diazepam.

Phosgene and Vesicants

Casualties of phosgene (or any peripherally actinglung-damaging agent) or vesicants who have moderateor severe respiratory distress should be placed in theimmediate group when intense ventilatory and otherrequired support is immediately available. In a battal-ion aid station or other unit-level MTF, these supportsystems may not be available immediately, and wouldprobably not be available during transport to a largemedical facility. In general, limited assets would best beused for casualties more likely to benefit from them.

Cyanide

A cyanide casualty who is convulsing or who hasbecome apneic minutes before reaching the medicalstation and has adequate circulation should be in theimmediate group. If circulation remains adequate, theadministration of antidote may be all that is requiredfor complete recovery. However, since death may oc-cur within 4 to 5 minutes of exposure to a lethal doseof cyanide unless treatment is immediate, this type ofcasualty is unlikely to be seen in an MTF.


Casualties with cardiovascular collapse or severe

hyperthermia following the exposure to incapacitatingagents such as BZ (3-quinuclidinyl benzilate) shouldbe placed in the immediate category.

Delayed

Nerve Agents

Casualties who require hospitalization but have noimmediate threat to life should be placed in the delayedgroup. This is generally limited to a casualty who hassurvived a severe nerve agent exposure, is regainingconsciousness, and has resumed spontaneous respira-tion. These casualties will require further medical carebut cannot be held in the unit-level MTF for the timenecessary for recovery.

Vesicants

Casualties with a vesicant burn between 5% and50% of body surface area (if by liquid) or with eye in-volvement require hospitalization but not immediatelifesaving care. These casualties must be observed for

pulmonary symptoms and hemopoietic complications.Pulmonary complications generally occur about thesame time that dermal injury becomes apparent.

Peripherally Acting Lung-Damaging Agents

Casualties who have been exposed to peripher-ally acting pulmonary agents such as phosgene withdelayed onset of respiratory distress (> 4 hours afterexposure) can be placed in the delayed category. Forcasualties with significant exposure, evacuation shouldnot be delayed because pulmonary edema can rapidlybecome life threatening. Medical intervention must beinitiated quickly for the casualty to survive (as notedabove; however, this care may not be available).

Cyanide

Casualties exposed to cyanide vapor who have

survived for 15 minutes can be categorized as minimalor delayed.


Casualties showing signs of exposure to an incapaci-tating agent (such as BZ; see Chapter 12, IncapacitatingAgents) usually does not have a life-threatening injury,but must be evacuated because of long recovery times.A casualty who has had a very large exposure, how-ever, and is convulsing or has cardiac arrhythmias re-quires immediate attention if it can be made available.

Minimal

Nerve Agents

A nerve agent casualty who is walking and talkingand has only mild effects from the agent vapor (suchas miosis, rhinorrhea, or mild-to-moderate respiratorydistress) should be categorized as minimal. If anytreatment is indicated, the contents of one or moreMark I or ATNAA kits will suffice. A casualty whohas administered self-aid for these effects may needno further therapy and can often be returned to dutyin 24 hours or sooner, if the degree of miosis does notinterfere with performance of duty.

Vesicants

A vesicant casualty with a small area of burngenerally less than 5% of body surface area in a non-critical site (but the critical size depends on the site[see Chapter 8, Vesicants])or minor eye irritationcan be placed in the minimal category and possiblyreturned to duty after treatment. Lesions covering


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larger areas or evidence suggesting more than minimalpulmonary involvement would place this casualty inanother triage group.


A casualty exposed to phosgene or other peripher-ally acting lung-damaging agents rarely belongs in theminimal group. If development of pulmonary edemais suspected, the casualty is placed in a different triagegroup. On the other hand, if a casualty gives a reliablehistory of exposure several days before, reports milddyspnea in the intervening time, and is now improv-ing, the triage officer should consider holding the ca-sualty for 24 hours for reevaluation and determinationof return-to-duty status.

Cyanide

A casualty who has been exposed to cyanide but hasnot required therapy will recover quickly.


Casualties exposed to an incapacitating agentshould be evaluated in a similar manner as those ex-posed to peripherally acting lung-damaging agents.If the casualtys condition is worsening, evacuationis necessary. On the other hand, if there is a reliablehistory of exposure with an intervening period ofmild symptoms and evidence of recovery, the casualtymay be observed for 24 hours on-site and returned to

duty.

Expectant

Nerve Agents

Any nerve agent casualty who is pulseless or ap-neic (duration unknown) should be categorized as

expectant. (However, as noted above, some of thesecasualties may survive if prolonged, aggressive careis possible.)

Vesicants

A vesicant casualty who has burns covering morethan 50% of body surface area from liquid exposure,or who has signs of more than minimal pulmonaryinvolvement, can survive only with extensive medi-cal care. This care may be available at rear levelsof medical care, but advanced treatment shouldbe initiated for those with the greatest chance of

survival.7


A casualty with moderate or severe dyspnea andsigns of advanced pulmonary edema from exposureto phosgene or other peripherally acting lung-damag-ing agents requires a major expenditure of rear-areamedical assets.7

Cyanide

A cyanide casualty who is pulseless belongs in the

expectant group.

CASUALTIES WITH COMBINED INJURIES

Combined injury casualties have wounds causedby conventional weapons and have been exposedto a chemical agent. The conventional wounds mayor may not be contaminated with chemical agent.Limited experimental data on this topic exists, andlittle has been written about the treatment for com-bined injury chemical casualties in World War I orthe IranIraq War. Uncontaminated wounds shouldbe dressed and treated in the usual way. The woundshould be covered with agent-proof (nonporous)material (for additional information, see Chapter16, Decontamination of Chemical Casualties), and ifa pressure bandage is needed, it should be appliedafter the protective covering. These safety measuresmay prevent the patient from becoming a combinedchemical and conventional casualty. This section willconsider the effects of chemical agent poisoning on

conventional wounds, the results of treatment forsuch poisoning, and possible drug interactions ofthe treatments.

Nonpersistent Nerve Agents

Nerve agents interact with anesthetic drugs, causingincreased respiratory depression and reduced cho-linesterase activity, which affects metabolism. Bloodloss complicates respiratory failure, so casualties mayrequire supplemental oxygen or resuscitation withpositive pressure ventilation. Need for replacement ofblood lost through conventional injury is increased inthe presence of respiratory depression. The action ofanticholinesterase (including pyridostigmine pretreat-ment, to a lesser extent) may potentiate or prolong theaction of depolarizing relaxants (eg, succinylcholine).


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With nondepolarizing relaxants (eg, vecuronium), theactions are opposed, leading to a higher effective dose.Opiates and similar drugs reduce respiratory drive andshould be used with caution in cases of nerve agentpoisoning.

Persistent Nerve Agents

When a conventional injury is contaminated by apersistent nerve agent, the danger of absorbing a le-thal dose is great and the prognosis is poor. The skinsurface surrounding the wound must be decontami-nated, followed by application of a surface dressingwith a protective cover to prevent further contamina-tion. In a superficial wound the entire skin surfacewould be decontaminated. Surgery on contaminatedwounds poses minimal danger to medical staff whenbutyl rubber gloves are worn. If these gloves are notavailable, two pair of latex rubber gloves, washed at

short intervals in hypochlorite solution and changedfrequently, should suffice. These casualties requirecareful observation during evacuation to the surgicalunit. If signs of poisoning persist or worsen, Mark Ior ATNAA treatment should be continued (for furtherinformation see Chapter 5, Nerve Agents).

If the wound is not directly contaminated by liquidagent on the skin but the surrounding skin is affected,the casualty should be decontaminated and given theappropriate agent therapy. If the injury is not directlycontaminated but skin absorption is thought to haveoccurred, the skin must be decontaminated. Becauseliquid nerve agent can penetrate the skin within 2

minutes but the effects from agent absorption intothe bloodstream may be delayed up to 18 hours afterexposure, the casualty should be kept under close ob-servation during this period and given an autoinjectorwhen indicated.

Vesicants

Vesicant agents weaken those exposed, and theagents systemic effects could lead to serious delayin the healing of any wound because of depression ofthe immune system (see Chapter 8, Vesicants, for moreinformation) even if the wound is not directly con-taminated. Casualties with a Lewisite-contaminatedwound will feel immediate pain disproportionate tothe severity of the wound. Early treatment with dim-ercaprol (BAL) is required. The first responder (medicor buddy) should decontaminate the area around thewound and dress it with a protective material to pre-vent further contamination.

Thickened vesicant agent may be carried into con-

ventional wounds on fragments and debris. Thesewounds need to be carefully explored using the no-touch technique. Wounds should be irrigated using asolution containing 3,000 to 5,000 ppm free chlorine forapproximately 2 minutes, followed by irrigation withsaline (this can be done by squeezing the fluid from in-

travenous bags into the wound). This technique shouldnot be used in the abdominal or thoracic cavities, or incasualties with intracranial head injuries.

Lung-Damaging Agents

A conventional wound in a casualty exposed to alung-damaging agent is compounded by develop-ment of pulmonary edema. The latent period betweenexposure and the onset of pulmonary edema may beshort. The resultant pulmonary edema may be servere.Casualties exposed to lung-damaging agents shouldbe kept at rest. When indicated, steroid treatment

should be started early. The use of opiates and othersystemic analgesics to treat pain or shock from theconventional injury is not contraindicated. Oxygentherapy is required; however, fluid replacement shouldbe used with caution to avoid precipitating or increas-ing pulmonary edema.

Cyanide

Contamination of conventional injuries with cyanidecan result in respiratory depression and reduction ofoxygen-carrying capacity of the blood. Urgent use ofcyanide poisoning antidote is required (see Chapter

11, Cyanide Poisoning). Oxygen therapy combinedwith positive pressure resuscitation may be requiredsooner in the presence of marked hemorrhage from theconventional injury. Opiates and other drugs that reducerespiratory drive must be used with extreme caution.


A casualty presenting with a major wound andintoxication by an incapacitating compound mightbe delirious and unmanageable. If the compound isa cholinergic-blocking agent such as BZ, the admin-istration of physostigmine may temporarily calm thepatient (the effects diminish in 4560 min) so that carecan be given. However, physostigmine may have a lim-ited effect on muscle relaxants used during anesthesia.At various stages the incapacitating compounds causetachycardia, suggesting that heart rate may not be areliable indication of cardiovascular status. Otherwise,review of these compounds indicates that they do notinterfere with wound healing or further care.7


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SUMMARY

cal capabilities are further diminished because earlycare is given by the medical care provider and to thecasualty in protective clothing. Decontamination, atime-consuming process, must be carried out before

the casualty receives more definitive care, even at thisinitial level. At the rear level of care, or at a hospitalin peacetime, medical capabilities are much greater,and decontamination is anticipated to have been ac-complished prior to casualty arrival.

Triage should be based on knowledge of medical as-sets, the casualty load, and, at least at unit-level MTFs,the evacuation process. Most importantly, the triageofficer must have full knowledge of the natural courseof an injury and its potential complications.

Triage of chemical agent casualties is a dynamicprocess based on the same principles as the triageof conventional casualties, with the same goal ofmaximizing survival. The triage officer must provide

immediate care to those who need it to survive; how-ever, the officer is also faced with the task of deferringtreatment for some casualties or delaying the treat-ment of those with minor injuries or who do not needimmediate medical intervention. The triage officershould judiciously use valuable resources on casual-ties who are certain to die or those who will survivewithout medical care. At the first level of medical careon a battlefield, medical capabilities are very limited.When chemical agents are present or suspected, medi-

REFERENCES

1. Rund DA. Triage. St. Louis, Mo: Mosby Company; 1981: 310.

2. US Department of the Army. Health Service Support in a Theater of Operations. Washington, DC: DA; 1991. FM 8-10.

3. US Department of the Army. Force Health Protection in a Global Environment. Washington, DC: DA; 2003.FM 4-02.

4. Veatch RM. Disaster preparedness and triage: justice and the common good.Mt Sinai J Med.2005; 72(4):236-241.

5. Medical management and treatment in chemical operations. In: US Departments of the Army, Navy, Air Force, andMarine Corps. Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries.Washington, DC: DoD;1995: Appendix C.FM 8-285, NAVMED P-5041, AFJMAN 44-149, FMFM 11-11.

6. Triage. In: Burris DG, FitzHarris JB, Holcomb JB, et al, eds. Emergency War Surgery. 3rd rev ed. Washington, DC: De-partment of the Army, Office of The Surgeon General, Borden Institute; 2004: Chap 3.

7. US Departments of the Army, Navy, and Air Force.NATO Handbook on the Medical Aspects of NBC Defensive Operations.Washington, DC: DoD; 1996: Chap 11. AMedP-6(B), FM 8-9, NAVMED P-5059, AFJMAN 44-151. Available at: http://www.fas.org/nuke/guide/usa/doctrine/dod/fm8-9/toc.htm. Accessed on October 18, 2007.

8. 29 CFR, Part 1910.120.

9. Occupational Safety and Health Agency. OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Ca-sualty Incidents Involving the Release of Hazardous Substances. Washington, DC: OSHA; 2005. Available at: http://www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html. Accessed September 10, 2007.

10. US Department of the Army.Medical Evacuation in a Theater of Operations: Tactics, Techniques, and Procedures. Washington,DC: DA; 2000. FM 8-10-6.

11. Cone DC, Koenig KL. Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur JEmerg Med. 2005;12:287-302.

12. START triage plan for disaster scenarios. ED Manag. 1996;8:103-104.

13. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the trauma score.J Trauma.1989;29:623-629.


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14. Sacco WJ, Navin DM, Fiedler KE, Waddell RK 2nd, Long WB, Buckman RF Jr. Precise formulation and eEvidence-based application of resource-constrained triage. Acad Emerg Med. 2005;12:759-770.

15. Sommerville DR, Reutter SA, Crosier RB, Shockley EE, Bray JJ. Chemical Warfare Agent Toxicity Estimates for the GeneralPopulation. Aberdeen Proving Ground, Md: US Army Edgewood Chemical Biological Center; 2005. AD B311889.

16. US Department of the Army. Soldiers Manual of Common Tasks, Warrior Skills, Level 1. Washington, DC: DA; 2006. STP

21-1-SMCT.

17. Liudvika J, Erdman, DP. CBRNEevaluation of a chemical warfare victim. Emedicine [serial online]. Available at:www.emedicine.com/emerg/topic892.htm. Accessed September 15, 2004.


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chapter 15 - triage of chemical causal ties - pg. 511 - 526

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