Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations,...

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations, 3rd. Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Care:Principles & Practice

Volume 5Special Considerations/

Operations


Chapter 11Hazardous Materials Incidents


TopicsRole of the ParamedicIncident Size-UpSpecialized TerminologyContamination and Toxicology ReviewApproaches to Decontamination Hazmat Protection EquipmentMedical Monitoring and RehabilitationImportance of Practice


Introduction

Hazardous materials are shipped throughout the United States by truck, pipeline, railroad, and tankers


Hazardous Material

“Any substance which may pose an unreasonable risk to health and safety of operating or

emergency personnel, the public, and/or the environment if not properly controlled during handling, storage, manufacture, processing, packaging, use, disposal, or transportation.”

United States Department of Transportation


Role of the Paramedic


Role of the Paramedic

EMS agencies should train all of their personnel in how to respond to hazmat incidents

Responsibilities include:– Size-up the incident, assess the toxicological

risk, and activate the incident management system

– Evaluate decontamination methods, to treat and transport exposed patients, and to perform medical monitoring of hazmat teams


Hazmat Standards

OSHA publication CFR 1910.120– Hazardous Waste Operations and Emergency

Response Standard (2004)

EPA regulation 40 CFR 311– Mirror regulation of CFR 1910.120

NFPA standard 473– Standard Competencies for EMS Personnel

Responding to Hazardous Materials Incidents


Levels of Training

Awareness level– Recognition

EMS Level I (operations level)– Patient care in cold zone

EMS Level II (technician level)– Patient care in warm zone


Incident Size-Up


Incident Size-Up

IMS and Hazmat situations– Priorities for a hazmat incident are the same as

for any other major incidentLife safety

Incident stabilization

Property conservation

– Quickly determine if open incident or a closed incident

– Basic IMS at a hazmat incident


Incident Awareness

Every emergency site has the potential to be a hazmat incident

Inspect the scene from a distance


Transportation

Maintain suspicion of the presence of hazardous materials at any vehicle accident

Railroad accidents– Volume– Number of cars

involved


Fixed Facilities

Facilities where dangerous substances are produced or stored – Chemical plants – Other facilities– Rural areas

Many communities have some kind of fixed pipelines


Terrorism

The terrorist may use any variety of chemical, biological, or nuclear devices– Weapons of mass destruction

Lack of predictability about when or where an attack might take place

Look for potential clues


Recognition of Hazards

Placard Classifications– Absence of a

placard does not mean the absence of a hazmat threat

– Regulations vary


Placard Classifications

Diamond shape

Indicates hazmat classifications – Color code– Hazard class

number

UN number

Use of symbols


Hazard Classes and Placard Colors


Placard Classifications

Several shortcomings of placards– Quantity may not be sufficient to require placard– “Dangerous” placard

Does not indicate substance present

– Lack of placard


NFPA 704 System

Identifies hazardous materials at a fixed siteUses diamond-shaped figures divided into four sections:– Red

Flammability

– BlueHealth hazard

– YellowReactivity

– WhiteSpecific information


Identification of Substance

Emergency Response Guidebook

Shipping papers

Material safety data sheets (MSDS)

Databases

Hazmat telephone lines (CHEMTREC, CHEMTEL, Inc.)

Poison control centers

Toxicologists

References


Emergency Response Guidebook

Should be carried on every emergency vehicle

Lists more than a thousand hazardous materials

Specific emergency procedures

Shortcomings


Shipping Papers

Contains the most accurate information about a transported substance – Bill of Lading

May not be with driver if they have left vehicle


Material Safety Data Sheets

Present at fixed facilities

Data

Should be posted in easily accessible location


Monitors and Testing

Air and gas monitors– Determines the percentage of oxygen in the air – Measures the presence of explosive gases,

carbon monoxide, and toxic gases

Litmus paper – Measures the approximate pH of a liquid

Colormetric tubes – Suction the air and search for specific chemicals


Other Sources of Information

Textbooks, handbooks, or technical specialists

Computerized database – CAMEO®—Computer-Aided Management of

Emergency Operations

Local or regional poison control center


Other Sources of Information

CHEMTREC– Maintains a 24-hour, toll-free hotline

800-424-9300

CHEMTEL, Inc.– Maintains another 24-hour, toll-free emergency

response communications center 800-255-3024

– Supplies the names of state and federal authorities that deal with radioactive incidents


Hazardous Materials Zones

Your main priority at a hazmat incident is safety

Request help right away and establish command

Evacuate people from the area around the incident


Hazardous Materials Zones

Establish zones– Hot (Red) – Warm (Yellow)– Cold (Green)


Specialized Terminology


Specialized Terminology

Boiling point

Flammable/ explosive limits– LEL– UEL

Flash point

Ignition temperature

Specific gravity

Vapor density

Vapor pressure

Water solubility

Alpha radiation

Beta radiation

Gamma radiation


Contamination and Toxicology Review


Contamination and Toxicology Review

Threshold limit value/time weighted average (TLV/TWA)

Threshold limit value/short-term exposure limit (TLV/STEL)

Threshold limit value/ceiling level (TLV-CL)

Lethal concentration/lethal doses (LCt/LD)

Parts per million/parts per billion (ppm/ppb)

Immediately dangerous to life and health (IDLH)


Types of Contamination

Primary– Direct contact

Secondary– A contaminated person or object comes in

contact with an uncontaminated person or object


Routes of Exposure

Respiratory inhalation

Topical absorption

Parenteral injection

Gastrointestinal ingestion


Routes of Exposure

Click here to view an animation on poisons.


Cycles and Actions of Poisons

Acute effects

Delayed effects

Local effects

Systemic effects

Biotransformation

Synergism


Treatment of Common Exposures

Treatment ranges from supportive care to specific antidotes

Before administering specific pharmacological treatment, at least two sources should agree on the medication


Corrosives

Brush off dry particles

Flush liquid corrosives with large quantities of water

Tincture of green soap may help in decontamination

Irrigate eye injuries, possibly with proparacaine hydrochloride to assist


Corrosives

If the corrosive has been ingested, do not induce vomiting

If the patient can swallow and is not drooling, give the person 5cc/kg water up to 200 cc

Support the ABCs


Pulmonary Irritants

Cannot be decontaminated

Remove patient’s clothing

Flush exposed skin with large quantities of water

Irrigate eyes with water– Tetracaine to reduce eye discomfort

Treat pulmonary edema with furosemide and albuterol

Support the ABCs


Pesticide Actions

S—Salivation

L—Lacrimation

U—Urination

D—Diarrhea

G—Gastrointestinal distress

E—Emesis

Involuntary muscle contraction

Pinpoint pupils

Blocks acetylcholinesterase (AChE) causing:


Pesticide Treatment

Remove all clothing and jewelry

Maintain and support ABCs

Suction if needed

Administer atropine 2 mg IV push until SLUDGE symptoms resolve

If an adult has seizures, administer 5–10 mg of diazepam

If the patient can swallow, give 5cc/kg up to 200 cc of water


Chemical Asphyxiants

The most common chemical asphyxiants include:– Carbon monoxide

Has a high affinity for hemoglobin and displaces oxygen in the red blood cells

– CyanidesInhibit cytochrome oxidase that enables oxygen to create adenosine triphosphate (ATP) required for muscle energy


General Treatment for Chemical Asphyxiants

Decontamination is usually not necessary

Remove from the toxic environment

Remove patient’s clothes to prevent trapped gases


Treatment for CO Exposure

Oxygenate patient

Hyperbaric therapy is necessary in some cases– Increases the displacement of carbon monoxide

from hemoglobin molecules by oxygen


Treatment for CyanidePasadena, Lilly, or Taylor kit

Administer amyl nitrate ampulesPrepare and administer sodium nitrite– 300 mg IV push over 5 minutes

Follow with an infusion of thiosulfate, – 12.5 g IV push over 5 minutes

Repeat at half doses if necessary


Treatment for CyanideCyanokit

Hydroxocobalamin– Binds cyanide from

cytochrome oxidase

– Forms cyanocobalamin (Vitamin B12)

– Excreted by the kidneys © Courtesy Dey, L.P.


Hydrocarbon Solvents

Support the ABCs

Decontaminate the exposed area

Do not induce vomiting

If the patient can swallow and is not drooling, administer 5 cc/kg up to 200cc of water

Seizures– 5–10 mg diazepam


Approaches to Decontamination


Approaches to Decontamination

To reduce or remove hazardous substances from people and/or equipment

Can be accomplished by physical or chemical means

Serves several purposes: – Reduces the dosage of the material – Reduces secondary exposure


Methods of Decontamination

Dilution – Application of large quantities of water to the

person– Water may be aided by soap

Absorption– Use of pads or towels to “blot” up the hazardous

material – Commonly used during environmental cleanup


Neutralization– One substance reduces or eliminates the toxicity

of another – Rarely used by EMS

Isolation/Disposal– Separate the patient or equipment from the

hazardous substance – Establish zones– Items that might contain or trap a hazardous

substance should be removed – Destroy or store contaminated substances

Methods of Decontamination


Decontamination Decision Making

Recall the priorities of incident management – Life safety, incident stabilization, and property

conservation

Environmental considerations form a major concern only in cases where there are no life threats


Modes of Operation

Fast-break Decision Making– Conscious, contaminated victims will often self-

rescue May try to leave the scene entirely

– EMS units must be prepared for gross decontamination

Two-step process

– ImplementationCritical patients and unknown or life-threatening materials


Modes of Operation

Long-Term Decision Making– Occurs when patients remain in the hot zone

and have not self-rescued – Advantages

Better opportunity for thorough decontamination Better PPE Less chance of secondary decontamination Greater consideration of the environment More detailed research of the actual hazardous substance


Field Decontamination

Decontamination method and type of PPE depend on the substance involved – When dealing with unknowns, do not attempt to

neutralize

Brush off dry chemicals

Apply large quantities of water with green soap if available


Two-Step Process

Step 1– Remove patient’s clothing and jewelry

Step 2– Wash and rinse the patient with water and soap– Repeat– Pay attention to difficult areas


Eight-Step Process

1. Rescuers enter the decontamination area at hot end of corridor and mechanically remove contaminants

2. Rescuers drop equipment in a tool-drop area, and remove outer gloves

3. Decontamination personnel shower and scrub all victims and rescuers using gross decontamination. (Victims can be moved to step 6 or step 7)

4. Rescuers remove and isolate their SCBA (continued)


5. Rescuers remove all protective clothing (Victims who are still clothed have their clothes removed)

6. Rescuers remove all personal clothing

7. Rescuers and victims receive a full-body washing

8. Patients receive rapid assessment and stabilization before transport

Eight-Step Process


Transportation Considerations

Field-decontaminated patients may still need to undergo a more invasive decon process at a medical facility – Transport to facilities capable of performing

more thorough decon procedures

Stretcher decon pool


Hazmat Protection Equipment



Level A– Highest respiratory

and splash protection

– Fully encapsulating

Level B– Full respiratory

protection– Non-encapsulating,

but chemically resistant



Level C– Uses an air-purifying respirator– Nonpermeable suit, boots, and eye and hand

protection

Level D– Structural firefighting gear

The level of protection needed depends on the chemical or substance involved


Medical Monitoring and Rehabilitation


Medical Monitoring and Rehabilitation

Blood pressure

Pulse

Respiratory rate

Temperature

Body weight

ECG

Mental/ neurological status

Entry Readiness


Post-Exit Rehab

Complete decontamination

Post-entry monitoring – Measure and

document the same parameters on the flow sheet

Fluid replacement


Heat Stress Factors

Take into account:– Temperature and humidity– Prior hydration status– Duration and degree of activity– Level of protective suit used


Importance of Practice


Importance of Practice

Put on and take off Level B hazmat protective equipment

Set up and practice decon– Two-step process– Eight-step process

Identify a simulated chemical, determine the correct PPE, and establish the proper decontamination methods

Monitoring methods and flowsheets


SummaryRole of the ParamedicIncident Size-UpSpecialized TerminologyContamination and Toxicology ReviewApproaches to Decontamination Hazmat Protection EquipmentMedical Monitoring and RehabilitationImportance of Practice

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 5: Special Considerations/Operations,...

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