Hazardous Area Response Teams: the clinical aspects
David Baker DM FRCA
Chemical Hazards and Poisons Division (London)
Health Protection Agency (UK)
Objectives
Introduction to Hazardous Area Response Team (HART) project
Why HART is needed
What can and should be done for casualties from chemical release
Problems in providing care
Basis and development of the HART clinical standard operating procedures (SOP)
Provision of pre - hospital emergency care – the case for a combined paramedical – medical response in HART and USAR
Toxic hazards and threats in civil life
Deliberate or accidental release of toxic chemical agents is an established hazard
Hazards may be established agents of chemical warfare (CW) or toxic industrial chemicals (TIC)
Some TIC are also CW agents
CW agents classed as part of Chemical, Biological, Radiological and Nuclear (CBRN) releasesNot an appropriate classification in terms of emergency medical responses
Properties of toxic agents
Toxicity
Latency of onset of signs and symptoms
Persistency
Transmissibility
In chemical releases toxicity and latency determine the management of the patient but persistency and transmissibility determine the management of the incident and the health risks to others
Specific Chemical Hazards
Nerve agents (eg sarin)
High toxicity, short latency, variable persistency, high transmissibility
Cyanide agents (eg hydrogen cyanide
High toxicity, short latency, limited persistency and transmissibility
Lung damaging agents (eg phosgene, methyl isocyanate)
Toxic after a variable latency period
Vesicant agents (eg mustard gas)
Relatively long latency period to clinical manifestation but early lung damage occurs in high temperatures
Somatic systemic attack by chemical agents
CNS
PNS
Autonomic
voluntary
Epithelial and cellular
Gastrointestinal
Urinary
Circulatory
Haemopoeitic
Respiratory
Control, mechanics, airways (large and small), alveoli
Decon Shower
Decon Shower
Inner
Cordon
HOTZONE
WIND
TriageSieve
CasualtiesTriageSort
A&E
Loading Point
Outer
Cordon
WARMZONE
COLDZONE
Chemical incidents: the civil Hazmat response
Chemical agent medical response realities
HAZMAT protocols confine victims to the warm zone prior to decontamination
Requirement in certain cases for early and continuing medical care before decontamination
Antidotes alone may not enough for patient support
Life support required in a contaminated zone by trained and protected personnel
Problems of working in a contaminated zone
Need for personal protection
Loss of contact with patient
Difficulties in physical examination
Normal emergency medical procedures for airway, ventilation and vascular access are all made more difficult
What care must be given in the contaminated zone?
Triage (P1 – P4)
Airway management
Artificial ventilation
Vascular access
Control of haemorrhage from associated physical injury
What primary care is feasible in the contaminated zone?
Application of skills used in normal emergency practice
Triage: primary triage sieve
Recognition of key signs and symptoms
Airway management: position, suction, airway insertion
Ventilation: use of specially designed equipment
Vascular access: intraosseous approach
Early administration of antidotes
Contaminated zone care – a Cold War view
TOXALS Protocol (1996) for advanced life support in a contaminated zone or decontamination area
Assessment (patient and site)
Airway
Breathing
Artificial ventilation
Circulatory
- control of haemorrhage and cardiac abnormalities
Disability (AVPU scale)
Drugs and antidotes
Decontamination
Evacuation
Department of Health Emergency Preparedness Division project
Two-year investigation into Hot Zone Working
Final report submitted in Jan 05Ministerial approval in Aug 05
Hazardous Area Response Teams (HART) origins
HART: Development of Standard Operating Procedures
SOP define the following and provide the bibliography for the project
Tactical Role and ResponsibilitiesHealth and Safety & Risk AssessmentTeam Structures, Concept of Operations, Objectives and Roles Vehicles & Areas of OperationPPE, Deployment Criteria Communications Clinical procedures
HART - clinical objectives
Provision of essential immediate care for chemical casualties before and during decontamination
Provision of continued care from point of chemical release to A and E and beyond – treatment protocols, decontamination, life support equipment and antidote stockpiles
To train and equip paramedical personnel to operate safely in a contaminated zone
Integration with other dangerous environment responses – urban search and rescue (USAR)
HART: the paramedic challenge
Extension of current clinical skills
Special training to operate safely inside a contaminated zone
To provide essential early life support before and during decontamination and to deliver the patient quickly to definitive hospital treatment
HART clinical sub – group
Input from specialists in:
Accident and emergency medicine
Anesthesiology
Medical Toxicology
Paramedic Training
Clinical Rationale
TriageAdvanced clinical life support with early intervention Airway and ventilation management.Infusion control of major haemorrhageAntidotes Support drug administration
Hart Clinical Subgroup: basis for warm zone treatment protocols
Findings of the DH Expert Group on the Management of Chemical Casualties Caused by Terrorist Activity (Blain Committee) report 2003
Existing JRCALC paramedic training protocols
Medical and paramedical experience
Patients in hot and warm zones: levels of care
Level 1: ambulant and asymptomatic
Level 2: ambulant and symptomatic
Level 3: non – ambulant, conscious
Level 4: Unconscious
Level 5: physically – trapped
Level 4 and 5 patients are vulnerable but salvageable and in need of expert clinical care. TOXALS essential to avoid fatality from toxic respiratory failure
Is patient able to walk? YES = P3
NO Is patient conscious? (able to obey commands)
YES = P2 NO
Signs of Life? (open airway & respiratory effort)
YES = P1* NO = P4
HART: primary toxic triage
* Unconscious patients and those with obvious signs of respiratory distress must be
prioritised for immediate assessment and emergency treatment (P1)
Point of injury/poisoning (Hot Zone)
The Casualty Collection Point (Warm Zone),
Casualty Decontamination Area
The Casualty Clearing Station
HART: provision of TOXALS and antidotes
Cold Zone(AMP)
Medical Recce:
Toxic TriageCombopen(s)Evacuation to
warm zone
Hot Zone
DecontaminationContinued Medical careABC’swith antidotes
Continued Medical careRe - triageAdvanced Medical ManagementAnd Transfer to definitive care
Warm Zone(Casualty
collection point)
Warm Zone(decontamina
tion)
Oxygen, LMAPortable gas – powered ventilators
Combo-pens,IO accessAtropine,Diazepam,Salbutamol,Dexamethasone,Dicolbalt Edetate)
Spectrum of HART Clinical Care at toxic primary Incident site
HART airway and ventilation management
Hot zone: simple positioning – lateral
Airway clearance: suction
Warm zone:
Laryngeal mask airway as desired option
ETT as alternative option
Ventilation using VR1 portable gas – powered CBRN ventilator
Oxygen from multi – outlet supply
HART: ventilation capability in a contaminated zone
Multiple outlet oxygen provision
HART: Life support logistics
HART Logistic Unit
Treatment protocols
Simple and straightforward to allow for difficulties of working in PPE in a contaminated zone.
Based upon previous DH consensus for primary treatment of chemical victims
(EXPERT GROUP ON THE MANAGEMENT OF CHEMICAL CASUALTIES CAUSED BY
TERRORIST ACTIVITY, 2003)
Patient group directions (PGDs)
Patient Group Directions (PGDs) are documents which allow medicines to be given to groups of patients - for example in a mass casualty situation - without individual prescriptions having to be written for each patient.
They empower staff other than doctors (for example paramedics and nurses) to give the medicine in question legally
UK National Reserve Stocks: 2002
POD 1
- Modesty Clothing
POD 2
- Nerve Agent antidote
POD 3
- Equipment; Ventilators etc.
POD 4
- Ciprofloxacin
POD 5
- Doxycycline
POD 4POD 4
POD 1POD 1
POD 3POD 3
Replacement of original PODS and transfer of control to ambulance services - ongoing
Strategic supplies to be placed on underground and national main line stations
Upgrading of equipment and drug scales
Drug & Equipment Pods revision 2007
2006 REVISED PODS/HART response drugs
Combopens (P2S, Atropine, Avisophone)Atropine (2mgs/ml) – 50 mlsDiazemuls (1mg/ml) – 10 mls(Amyl Nitrite ampoules)Dicobolt Edetate 300mgs ampoules50% glucose - 50mlsSalbutamol Inhalers 100ugsBeclomethasone inhalers 100ugsSalbutamol 5mgs (for nebuliser)Dexamethasone 8mgsNaloxone 400ugs Flumazanil 500ugs
Urban Search And Rescue
Emergency medical teams working alongside the Fire Service to deliver clinical support to trapped injured persons
New skills must be learned ranging from working underground, in confined spaces and working at height
Wide range of incidents in abnormal environments
USAR Clinical SOP
USAR SOP requirements different from HART
No SOP have yet been drafted
USAR clinical sub – committee not yet formed
Early consultations with clinical expertise taking place
Training to JRCALC standards before USAR training
Issues
Consensus on early management of crush syndrome
Division of crushed tissues for release
Use of chest drains
Airway management in confined spaces
Training and governance for use of ketamine and midazolam
2006 REVISED PODS/USAR response drugs
Etomidate
Suxamethonium
Ketamine
Midazolam
Morphine
Propafol
Cyclizine
Lignocaine 1%
50% glucose
The requirement for a joint paramedical medical entry team in HART and USAR
Difficult triage decisions can be taken by medical personnel on site (the question of P4 triage)
Antidotes and life support drugs can be given without the need to use patient group directions and dose protocols
Difficult airway – ventilation cases can be managed with a team approach
General anaesthesia can be given for extraction
Joint paramedical – medical emergency care
Proven value in conventional attacks
HEMS and BASICS are integrated already into EMS response in UK
Problems
No official recognition or funding of existing arrangements
Lack of co – ordinated policy and structure
HART commissioning: London, December 2006
HART clinical policy – problems identified
Training issues regarding new procedures – regional variations eg LMA
Administration of essential antidotes and support drugs (PGD)
Clinical SOP still being adjusted with user feedback
USAR clinical SOP have yet to be determined but raise questions about medical presence
Conclusions
HART project now active in London
Expansion of project to other cities projected for 2007 -8
Special skills have been taught to paramedics and technicians to enable provision of essential life support in a contaminated zone
USAR has been linked in with HART by DH EP Division
Both initiatives increase the ability of the ambulance services to respond to circumstances outside the remit of usual practice.