Download - Medical Management Of Chemical Casualties
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Emergency Response in Chemical Casualties:System Approach to Effective Hospital
Preparedness
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Objectives• Lessons Learned & Event Characteristics
• Incident Response Requirements
• Scene Safety
• Medical Management of Hazmat Victims
– Primary Survey & Resuscitation
– Decontamination
– Hazmat Patient Assessment
– Poisoning Treatment Paradigm
• Antidote and chemical stockpile
• Chemical protective clothing
• Hazmat traing trends
• Summary
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Lessons Learned From Coaminated Casualties Incidents
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INCIDENTS
EMERGENCY INCIDENT TIMELINES
RESPONSESPOTENTIAL CASUALTIES
- Flood
- Chemical
-Tornado
-Earthquake
-Hurricane
-Explosives
Tens ofMillions
Thousands
Hundreds
Tens
HoursMinutes
Seconds Days
MonthsWeeks
- NuclearMillions
(contagious)
(non-contagious)
- Biological
- Radio-logical
Everyday Life
- Accidents- First Aid- Rescue- Fire- Police
First Response
- Explosives
Criminal Terrorism
- Bomb Squad
- Flood- Earthquake- Hurricane- Tornado
Natural Disasters
- Search & Rescue- Sustainment- Medical Triage- Temp Morgue
State-Fed Escalation
- Chemical- Biological- Nuclear- Radiological
Super Terrorism
- Evacuation- Containment- Decontamination- Quarantine- Vaccination- Antidotes- Detoxification
Warfare Type Ops
Escalation
<991130v30>
Emergency Management Consequence Timelines
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Bhopal Disaster3 Dec.1984
8,000 died300,000 injured
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Tokyo March 20, 1995• 5,500 People Exposed• 3,227 Went to Hospital• 550 Transported Via
EMS• Essentially no
Decontamination of Patients
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SARIN Clip
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October 26, 2002
•50 Chechen rebels, storm Moscow’sHouse of Culture Theatre during aperformance of Nord-Ost, taking 700hostages. The rebels demand Russianwithdrawal from Chechnya, and threatento kill the hostages if demands are not met.
•After three days of fruitless negotiationsan unknown gas, meant to incapacitate therebels, is released in the theatre. Most ofthe rebels and 116 hostages die.
What kind of gas was released? …
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Event Characteristics
• Most Victims are Exposed to Vapor• No warning• Victims Will Not Wait In Line to Decon.• Most Decontamination Needs to be Done
at the Hospital Not the Scene • Mass Disaster Response Occurs With
Local Resources
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Event Characteristics
• Agent will likely be unknown• Dry Decontamination Suitable for Most• Only 10%-15% of Patients Via EMS• Emergency Department Resources Limited
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Most Common Fatal Injuries
– Trauma (65%)
– Thermal burns (16%)
– Respiratory irritation with airway obstruction
&/or respiratory failure (10%)
– Chemical burns (6%)
– Other causes (3%)
Hazardous Substances Emergency Events Surveillance (HSEES)
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What is wrong with the patient
• Physical Trauma• Exposure to Chemical HAZMAT
– Inhalation• Most common
– Skin & mucous membranes• Common
– Ingestion & Injection• Unlikely
• Toxicity – Local– Systemic
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The World Of Chemical Agents
• The vast majority of HazMat incidents resulting in the contamination of people involve common industrial chemical agents.
• The study of all potential sources of contamination are best supported by looking at these chemicals in a categorical system.
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Agents Categories
1. Industrial Chemicals. 2. Chemical Warfare Agents. 3. Biological Warfare Agents. 4. Radiological Materials.
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Incident Response Requirements
• Protect patients, staff, and facility• Rapid decon• Expert informations• Surge capacity• Some specialized expertise
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Hospital Preparedness
•Medicare
•Manage care
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Reasonable ≠ Adequate
“Best possible care for victimswhile not compromising the safetyhospital staff and current patients”
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Hospital Plan
• Cost effective• Simple as possible• Minimized manpower• Immediate availability• Rapid patient processing
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Scene SafetyHot, Warm and Cold zones
Hot ZoneContaminated area
Need PPE
Warm ZoneContamination
reduction
Cold ZoneNormal function
You will be here. Public Health does not usually
decontaminate or function in the hot zone
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Zone rules
Hot ZoneContaminated area
Need PPE
Warm ZoneContamination
reduction
Cold ZoneNormal function
Control access to zones
Temporary
Morgue
Very limited treatment before decontamination
Isolate cadavers
Decontamination direction No back flow!!
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Medical Management of Hazmat Victims
• Primary Survey & Resuscitation
• Decontamination
• Hazmat Patient Assessment
• Poisoning Treatment Paradigm
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Primary Survey & Resuscitation: The Basics
• Airway with cervical spine control
• Breathing
• Circulation
• Disability (nervous system)
• Exposure with environmental control
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“The process of removing or neutralizing surface contaminants thathave accumulated on personnel and equipment.”
Decontamination
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Chemical Victim Triage
High Priority for Decontamination: • Victims closest to point of release and reporting exposure. • Victims showing some evidence of contamination on clothing or skin. • Victims demonstrating serious symptoms.
Medium Priority for Decontamination: • Victims not as close to point of release, and who have minimal
evidence of contamination on clothing or skin. • Victims who are mildly symptomatic.
Low Priority for Decontamination: • Victims who are far away from point of release. • Victims who have no verified contamination. • Victims who are asymptomatic.
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Urgency for Medical Care
Low risk for secondary contaminationCritically illFocus on Treatment
High risk for secondary contaminationCritically illSimultaneous decontamination and treatment
Low risk for secondary contaminationMild or no illnessDecontamination not needed
High risk for secondary contaminationMild or no illnessDecontamination before treatment
Triage Urgency for decontamination
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General Principles
• Decontaminate victims as soon as possible.• Disrobing is decontamination; head to toe, more
removal is better.• Water flushing generally is the best mass
decontamination method.• After a known exposure to a liquid chemical
agent, emergency responders should be decontaminated as soon as possible to avoid serious effects.
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Decontamination Site Selection
• Outside!• Level impermeable surfaced area• Up wind• Water supply/collection• Illuminated• Ingress and Egress routes
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Layout of Hospital Decontamination Zone
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Decontamination Station 2 lines
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Decontamination Station 3 lines
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Suggested Cut-Out Procedures (Non-ambulatory Patient’s Clothing)
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Ideal Decontaminants
• Neutralize all Agents• Safe• Easy to use• Available• Rapid acting• No toxic end products• Affordable• No irritability
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Dry Decontamination• Remove clothing/personal effects –
85% decon performed by this step• Vapor or no exposure• Removal of clothing• Modesty concerns• Requires large amounts of
disposable clothing• Clothing disposition
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Wet Ambulatory Decontamination
Requires only one or two personnel to perform, primarily supervisory roleAt least one person should be medically trainedMay be quicker than non-ambulatory process, should utilize about the same amount of solutionFocus on non-clothed/exposed areasDecon wounds and bandage before entering shower (occlusive dressing)
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Wound Decontamination
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Wet Ambulatory Decontamination
• Remove clothing/personal effects• Decontaminate from head down
– Lean head back to avoid runoff ineyes
• Encourage careful scrubbing of warm,moist regions – axilla, groin, etc.
• Rinse thoroughly, copious water
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Wet Ambulatory Decontamination
• Once decontaminated, patientmoves to cold zone staging area
• Re-clothed• Status monitored until
transport available
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Do not need to decon if itcan be confirmed that patient:
• Never in contaminated area• Without signs and symptoms of exposure
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Litter Wet Decontamination
• Requires minimum of 2-4 persons per patient• 10 to 20 minutes per patient• Average resources per patient: 35 – 50 gallons• Decontamination solutions:
– Water and Detergent– Hypochlorite 0.5% and 5% (do not use in eye,
open head or abd wounds, must be made daily)• Scrape off visible contamination
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Litter Wet Decontamination
• Decontaminate with copious decontaminating fluid• Transfer to clean stretcher• Monitor patient and move to clean area
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Litter Wet Decontamination
• Non-ambulatory patients displaying serious signs and symptoms
• Rapid decontamination• 5-10 minutes per patient
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Skin Decon: Special Areas
• Commonly ignored during decon• Including
– Scalp– Body hair– Genitalia– Skin creases & folds– Hands– Feet– Nails
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CORRIDORDECONTAMINATION
• The simplest solution• The nozzles are set at low pressure and high
volume so as not to inflict damage but which maximize the amount of water each victim is exposed to.
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SPRINKLER HEADDECONTAMINATION
• water delivered at 500 gallons a minute• If the victim remains in the shower for 3
seconds on average, and assuming the person is exposed to 50% of the water
• 500 gals./minute = 8 gals/second• 8 gals./second × 3 seconds = 24 gals.• 24 gals. × 50% = 12 gals.
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Other Field-Expedient Water Decontamination Methods
• should not overlook existing facilities whenidentifying means for rapid decontaminationmethods.
• although water damage to a facility might occur,the necessity of saving lives would justify theactivation of overhead fire sprinklers for use asshowers.
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Other Field-Expedient Water Decontamination Methods
• wade and wash in water sources such as publicfountains, chlorinated swimming pools, swimmingareas, etc., provides an effective, high-volume decontechnique.
• Car washes with hand-held wands should also beconsidered. Water used for decontamination inlifesaving operations should be properly handledand disposed of in compliance with environmentaland health regulations, whenever possible.
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Hazmat & Children
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Children: Not “Small Adults”
• Anatomical/ physiological differences• Vital signs vary with age• Smaller, shorter stature
– lower “breathing zones”
• Higher minute volume• Less intravascular volume reserve
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Uniquely Vulnerable
• Greater body surface area to weight ratio• Increased skin permeability• More pliable skeleton• Weight is critical in determination of:
– drug dosages– fluid requirements– equipment sizes
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Example:Decontamination of Children
• Must be done with high-volume, low-pressure,heated water systems
• Must be designed for decontamination of allages and types of children
• All protocols and guidance must address:– Water temperature and pressure– Nonambulatory children– Children with special health care needs– Clothing for after decontamination
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Pediatric Disaster Toolkit: Hospital Guidelines for Pediatrics in Disastershttp://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml
Decon Shower- Infants & nonambulatory kids
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Pediatric Disaster Toolkit: Hospital Guidelines for Pediatrics in Disastershttp://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml
Decon Shower- Child
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From a Child’s Perspective?
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Operations Set-up• Arrival Point
– Staffed by Animal Control Staff and oneveterinary tech in appropriate PPE
– Personnel arriving for decontamination with pets willbe relieved of the animal
– Animals will be evaluated for injuries and extent ofcontamination
– Animal will be tranquilized (if necessary) for handlingand decontamination, or will be euthanized if injuriesare too severe
– Disposable leash will be placed on animal and movedto the gross decontamination area
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Operations Set-up• Gross Decontamination Area
– Staffed by Animal Control personnel in appropriatePPE
– All collars and tags removed and discarded– Animal washed with soap and water solution and rinsed– Leash is again removed after the gross decon and
discarded– Animal wrapped in large blanket or towel to prevent
environmental exposure– Clean leash will be placed on animal prior to transfer to
second decontamination area
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Operations Set-up• Second Decontamination Area
– Staffed with two Animal Control staff– Leash and blanket or towel removed, discarded– Animal sprayed with soap and water solution– Clean leash and blanket placed on animal for transport to
third decontamination area
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Operations Set-up
• Third Decontamination Area– Staffed with two Animal Control staff– Leash and blanket removed, discarded– Animal rinsed with clean water, wrapped in new blanket– New leash will be placed on the animal
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• Clean Area– Decontamination identification tags placed on animal– Animal evaluated by veterinarian and Animal Control staff– Wounds will be treated or animal will be transported to veterinary
clinic for further treatment– Animals reunited with owners if possible– Unclaimed animals transported to Animal Shelter or other
shelter facilities• Photo of animal displayed at scene
– Contaminated deceased animals will be placed in appropriatecontainer at site
• Container will be left in hot zone for mitigation contractor
Operations Set-up
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Planning for Decontamination Washwater
• Decon washwater is an issue that has gained prominence in the last couple of years
• Hospital washwater only one possible source
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In the real world• Hospitals required to plan for rapid influx of
victims in mass-contamination incident– Increased numbers, may not be deconned prior
to arrival, contaminant unknown or unusual
• May need to rapidly perform emergency mass decontamination – life saving, personnel/facility protection
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In the real world• Capacity for mass decon limited in most
hospitals (a few victims) • Proper on-site washwater management
identified as barrier– containment ~ 90% of cost – may not solve problem anyway
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What is the Problem?
• Is there a problem if decon washwater enters the sanitary sewer system?– Yes– No – Maybe, not enough information….depends on
contaminant type/amount/concentration, exposure potential, impacts to wastewater system or environment, legal concerns
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Plausible Scenario
• Hospital needs to provide urgentdecontamination for large number victims
• Contaminant(s) uncertain or unknown• Decon by disrobing and showering or
flushing with copious amounts of water• Large volume of washwater generated• Capacity to collect and test washwater on-
site overwhelmed
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Quantitative Solution
• Attempted calculation based on plausible“worst-case” scenario
• 2.5 mg VX / victim -- 25% of LD50• VX selected -- low vapor pressure and
relative persistence• 90% removal by disrobing• 10:1 ratio uncontaminated to contaminated
victims
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Quantitative Solution
• 1000 victims x 10 gal/person = 37854 liters• 100 contaminated with 2.5 mg VX = 250 mg• 90% removed with disrobing = 25 mg• 25 mg/37854 L = 0.00066 ppm = 0.66 ppb
at most concentrated point
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Quantitative Solution
• is this (0.66 ppb VX) a problem?• Is this the worst case?• have we considered all down stream issues?• could other contaminants be worse?
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Key Uncertainties
• Scenario Uncertainties –– how many victims total? – at what rate? – how much contamination?– how much water used?– amount of dilution in system?– effects of treatment processes (e.g., retention
time for short-lived radionuclides)
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Key Uncertainties
• Contaminant(s) unknown– Amount (total and concentration)– Behavior/fate– Exposure potential– Toxicity– Treatability– Impacts on people, system, environment
• May not have opportunity to test waste stream forhazardous properties and make treatment ordisposal decisions
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Problem Summary
• Theoretical hazard – nature and magnitudeof downstream risks uncertain
• Hazard-specific assessment not be possibleduring incident
• Decisions must be made rapidly based onlimited, if any, information aboutcontaminants
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Nopparat capacity• 12 Non ambuatory victims per hour• 48 Ambulatory victims per hour• Ability to CPR 6 Pts. at Red Zone• Information services (MSDS)• Chemical (antidote) stockpile in term
of Network ( local, regional )• Level C and PPE• Health surveillance for Decon team
and Hazmat team
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Hazmat Patient Assessment
• Occurs concurrently
• Only once Resuscitated and Stable
• Patient history
• Secondary survey
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Secondary Survey
• Identify poisoning complications
• Recognize preexistent problems
• Assess for trauma & burns
• Recognize toxic syndromes (toxidromes)
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Identify Poisoning Complications• Airway Insufficiency
– Ammonia etc.
• Breathing Insufficiency– Aspiration pneumonitis, Noncardiogenic pulmonary edema– Sarin, Phosgene etc.
• Cardiovascular– Bradydysrythmias, Tachydysrythmias, Hypotension, Hypertension
• Disability (nervous system)– Confusion, Agitated delirium, Combativeness, Seizures, Coma
– Weakness, Paralysis, Sarin, etc.• Elimination (liver & kidneys)
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Preexistent Problems• Airway
– Overbite– Small jaw– Big tongue
• Breathing– Asthma– COPD
• Cardiovascular– Coronary Artery
Disease (CAD)– Anemia
• Disability– Epilepsy
• Elimination– Renal failure– Liver failure
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Recognize Toxic Syndromes
• Toxic + syndrome = Toxidrome• 5 fundamental hazmat toxidromes
– Irritant gas– Asphyxiant – Cholinergic– Corrosive– Hydrocarbon & halogenated
hydrocarbon
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Antidotes
• There is no for 99% of Chemicals
• There is only supportive treatment for 99% of Chemicals
• There are standard WHO guidelines for antidotes in an industrial setting, where chemicals enter through lungs or skin
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Only Supportive treatmentNo Antidotes for following
• Ammonia• Chlorine• Hydrogen sulphide• Phosgene• Carbon monoxide• Nitrogen Oxides• Formalin• Acids
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Chemical Protective Clothing
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Levels of Protection
Greater Hazard
Higher Burden
Level
A
Level
B
Level
C
Level
D
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Hazmat PPE
• Levels of PPE– A: big suit, big tank– B: little suit, big tank– C: little suit, little mask– D: no suit, no mask
• Level A for entry• Level C for known hazard• Level B or C for unknown?
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Selecting the Correct Glove
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MATERIAL of CPC GOOD FOR POOR FOR
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MATERIAL GOOD FOR POOR FOR
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MATERIAL GOOD FOR POOR FOR
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Results of Alternate Protective Clothing Performance Test
ClassificationPossible alternate
material
Defense capability Remarks
Method 204(Blister resistance)
Method 206(Gas resistance)
Military standard (butyl coated texture for
protective clothing)
100 min 200 min Defense ministry standard
Military use Officer’s raincoat 2 min 2 min
Sapper’s raincoat, poncho 7 min 7 min
Disposable protective suit 14 min 14 minTyvek
Civilian useDisposable raincoat 2 min 2 min
Sae-ma-eul raincoat 5 min 5 min
Transparent raincoat 6 min 6 min
Raincoat 11 min 11 min
Gentlemen’s raincoat 10 min 10 min
Sportswear raincoat 17 min 17 min
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Results of Alternate Protective hood/ Overboots/ Protective gloves Performance Test
Classification Possible alternate material
Defense capabilityRemarks
Method 204
(Blister
resistance)
Method 206
(Gas
resistance)
Protective
hood
Military Standard(butyl coated texture for protective
clothing)
30 min 30 min MilitaryStandard
Black plastic bag 2 min 4 min
Supermarket plastic bag 2 min 5 min
Standard garbage bag 6 min 10min
Protective
Gloves
Military Standard 360 min 450 min
Taewha rubber gloves 25 min 50 min
Goeunson rubber gloves 25 min 42 min
Overboots
Military standard 360 min 450 min
Farmer’s boots 100~120 min 210 min
Regular boots 220 min 230 min
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Results of Covers/ Adhesive Tapes Performance Test
Classification
Possible
alternate
material
Defense capability
Remarks
Method 204
(Blister resistance)
Method 206
(Gas resistance)
Covers
Military vehicle
cover1 min Less than 1 min
Agricultural
Vinyl
plastic cover
10 min 12 min
Industrial Vinyl
plastic cover2 min 3 min
Adhesive
Tapes
Transparent
tape100 min Over 240 min
Blue tape 25 min 50 min
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Effect of Overlapping Vinyl Plastic Covers
Classification One layer Double layers Triple layers
Agricultural Vinyl
plastic cover
(thickness: 0.1 mm)
Method 204
(Blister Resistance)10 min 26 min 40 min
Method 206
(Gas Resistance) 12 min 50 min104 min
Industrial Vinyl
plastic cover
(thickness: 0.05 mm)
Method 204
(Blister Resistance)2 min 7 min 14 min
Method 206
(Gas Resistance)
3 min 14min 38 min
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Agricultural Vinyl plastic cover (one layer) addedCover/Raincoats
Classification
One layerDouble layers
Triple layers
Original
material
Vinyl plastic
cover addedOriginal
material
Vinyl Plastic
cover added
Military vehicle
cover1 min 50 min 1 min 20 min
Officer’s raincoat 2 min 33 min 2 min 50 min
Sapper’s
raincoat/ poncho7 min 55 min 14 min 180 min
Gentlemen’s
raincoat4 min 45 min 5 min
68 min
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Evatox™ NBC hoods for civiliansBaby Safe Pro Infant Protective Wrap
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โรงพยาบาลนพรัตนราชธานกีับเครอืข่ายศูนย์พิษแห่งชาติ
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โรงพยาบาลนพรัตนราชธานี
โรงพยาบาลล าปาง
โรงพยาบาลขอนแก่น
โรงพยาบาลหาดใหญ่
โรงพยาบาลระยอง
รูปภาพแสดงเครือข่ายศูนย์พิษแห่งชาติ
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ศูนย์พิษวิทยา โรงพยาบาลนพรตันราชธานี
ข้อมูลข่าวสาร
การรักษาพยาบาล
ศูนย์ข้อมูลด้านพิษส าหรับประชาชน
บุคลากรทางการแพทย์
เครือข่าย
การให้ความช่วยเหลือในที่เกิดเหตุ
การรับส่งต่อในกรณีทางวิชาการ
เฝ้าระวังและควบคุม จัดท าข้อมูล GIS น าสถิติภัยหรือโรคจากสารพิษมาวางแผนงาน
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ศูนย์พิษวิทยา โรงพยาบาลนพรตันราชธานี
การฝึกอบรมการซ้อมแผน
การประชุมวิชาการ
การประสานเครือข่ายการจัดประชุมเครือข่ายระดับภูมิภาค
การจัดประชุมเครือข่ายระดับประเทศ
ห้องปฏิบัติการ การประสานเครือข่าย สร้างมาตรฐาน ใช้ทรัพยากรร่วมกัน
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ผลของการจัดประชมุเครือขา่ยระดับภูมภิาค
• อยากให้มีการแบ่งระดับศูนย์พิษ• อยากให้มีนโยบายที่ชัดเจน และ มีการถ่ายทอดให้กบัผู้บริหาร• อยากให้มีการสนับสนุนเรื่องงบประมาณ• ต้องการให้มีการซ้อมแผน• ให้ศูนย์พิษขึ้นกับอาชีวก่อนในชั้นแรก• ผู้ปฏิบัติควรเป็น แพทย์และเจ้าหน้าที่ห้องฉุกเฉิน อาชีวจะให้ข้อมูลด้าน
พิษ
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ห้องปฏิบัติการ
• มีการประสานเครือข่ายห้องปฏิบัติการ• มีการจัดท ามาตรฐานห้องปฏิบัติการ• มีระบบส่งต่อตัวอย่างเพื่อการตรวจ• ห้องปฏิบัติการควรไปเป็นกลุ่มกับระดับของศูนย์พิษแม่ข่ายของตนเอง
เพื่อง่ายต่อการบริหารจัดการ• ในการประชุมเครือข่ายควรน าเรื่องห้องปฏิบัติการเข้าประชุมด้วย
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Common pitfalls in Hazmat Drill
In a drill , hospital personnel treatedpatients without wearing PPE
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Common pitfalls in Hazmat Drill
In a drill, contaminated patients would be sentto a designated hospital, but in reality……
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Overlook the timerequired for actions
Before a drill, responderswear PPE and waited forthe signal.
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Photo credit: Mike Vance, MD
Man dropped bucket of silver paint that splattered onto areas ofbody commonly ignored or forgotten during decon.
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Photo credit: Mike Vance, MD
Can of mace went off in pants pocket & pants not removed in timelymanner.
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Photo credit: Mike Vance, MD
What can happen if genitals are forgotten during decontamination.
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Photo credit: Mike Vance, MD
What can happen if skin folds are forgotten during decon.
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Photo credit: Mike Vance, MD
Close-up of what can happen if skin folds are forgotten during decon.
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Photo credit: Mike Vance, MDWhat can happen if feet are forgotten during decon.
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Eye Decon
• Irrigate exposed, symptomatic eyes immediately & continuously
– Use water or saline •Water is best
–Readily available in large quantity
–Efficient
• Check for & remove contact lenses
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Mild corneal chemical burn Fluorescein indicates corneal burn site Adjacent chemical conjunctivitis
Photo credit: Mike Vance, MD
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Severe corneal chemical burn Opaque cornea Blind eye
Requires cadaver corneal transplantPhoto credit: Mike Vance, MD
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HAZMAT Training Trends
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Summary
• Physical removal is BEST decon• Must plan for patient decon at all aspects of care• Decon process is resource intensive and must be
planned and practiced in advanced• Identify and train personnel early• Learn benefits of coordination with medical assets
in your hospital and region
Prior Planning Prevents Poor Performance