Medical Management Guidelines
(MMGs) |
for |
Unidentified Chemical |
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General
Information |
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Description |
All attempts should be made to determine
the identity of the hazardous material before the Unidentified
Chemical guideline is used. Responders should obtain assistance
in identifying the chemical(s) from container shapes, placards,
labels, shipping papers, and analytical tests. General information
on these identification techniques is located in Managing
Hazardous Materials Incidents Volumes I and II. The Unidentified
Chemical protocol provides basic victim management recommendations
but the techniques for a specific chemical could provide information
which would allow more effective patient treatment.
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Prehospital
Management |
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Potential for Secondary Contamination.
The route and extent of exposure are important in determining
the potential for secondary contamination. Victims who were
exposed only to gas or vapor and have no gross deposition
of the material on their clothing or skin are not likely to
carry significant amounts of chemical beyond the Hot Zone
and are not likely to pose risks of secondary contamination
to response personnel. However, victims whose skin or clothing
is soaked with liquid chemical or victims who have condensation
of chemical vapor on their clothes or skin may contaminate
others by direct contact or by off-gassing vapor. If the victim
has ingested a chemical, toxic vomitus may also pose a danger
to others through direct contact or off-gassing vapor.
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Hot Zone |
Rescuers should be trained and appropriately
attired before entering the Hot Zone. If the proper equipment
is not available, or if rescuers have not been trained in
its use, call for assistance from a local or regional HAZMAT
team or other properly equipped response organization.
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Rescuer Protection |
When a chemical is unidentified, worst-case
possibilities concerning toxicity must be assumed. The potential
for severe local effects (e.g., irritation and burning) and
severe systemic effects (e.g., organ damage) should be assumed
when specific rescuer-protection equipment is selected.
Respiratory Protection: Pressure-demand,
self-contained breathing apparatus (SCBA) should be used in
all response situations.
Skin Protection: Chemical-protective
clothing should be worn when local and systemic effects are
unknown.
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ABC Reminders |
Quickly ensure a patent airway. If trauma
is suspected, maintain cervical immobilization manually and
apply a cervical collar and a backboard when feasible.
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Victim Removal |
If victims can walk, lead them out of
the Hot Zone to the Decontamination Zone. Victims who are
unable to walk may be removed on backboards or gurneys; if
these are not available, carefully carry or drag victims to
safety.
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Decontamination
Zone |
Victims exposed only to gas or vapors
who have no skin or eye irritation may be transferred immediately
to the Support Zone. All others require decontamination (see
Basic Decontamination below).
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Rescuer Protection |
If the chemical or concentration is unidentified,
personnel in the Decontamination Zone should wear the same
protective equipment used in the Hot Zone (see Rescuer Protection,
above).
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ABC Reminders |
Quickly ensure a patent airway. Stabilize
the cervical spine with a collar and a backboard if trauma
is suspected. Administer supplemental oxygen as required.
Assist ventilation with a bag- valve-mask device if necessary.
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Basic Decontamination |
Victims who are able and cooperative
may assist with their own decontamination. Remove and double-bag
contaminated clothing and personal belongings.
Flush exposed or irritated skin and hair
with plain water for 3 to 5 minutes. For oily or otherwise
adherent chemicals, use mild soap on the skin and hair.
Flush exposed or irritated eyes with
plain water or saline for at least 5 minutes. Remove contact
lenses if present and easily removable without additional
trauma to the eye. If a corrosive material is suspected or
if pain or injury is evident, continue irrigation while transferring
the victim to the Support Zone.
In cases of ingestion, do not induce
emesis. Victims who are conscious and able to swallow should
be given 4 to 8 ounces of water. Obtain medical care immediately.
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Transfer to Support
Zone |
As soon as basic decontamination is complete,
move the victim to the Support Zone.
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Support Zone |
Be certain that victims have been decontaminated
properly (see Decontamination Zone above). Victims who have
undergone decontamination or who have been exposed only to
gas or vapor and who have no evidence of skin or eye irritation
generally pose no serious risks of secondary contamination.
In such cases, Support Zone personnel require no specialized
protective gear.
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ABC Reminders |
Quickly ensure a patent airway. If trauma
is suspected, maintain cervical immobilization manually and
apply a cervical collar and a backboard when feasible. Ensure
adequate respiration; administer supplemental oxygen as required.
Ensure a palpable pulse. Establish intravenous access if necessary.
Attach a cardiac monitor.
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Additional Decontamination |
Continue irrigating exposed skin and
eyes, as appropriate.
In cases of ingestion, do not induce
emesis. If the patient is conscious and able to swallow, administer
4 to 8 ounces of water if it has not been given previously.
Obtain medical care immediately.
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Advanced Treatment |
Intubate the trachea in cases of respiratory
compromise. When the patient's condition precludes endotracheal
intubation, perform cricothyroidotomy if equipped and trained
to do so.
Treat patients who have bronchospasm
with aerosolized bronchodilators. Use these and all catecholamines
with caution because of the enhanced risk of cardiac dysrhythmias
after exposure to certain chemicals.
Patients who are comatose, hypotensive,
or have seizures or cardiac dysrhythmias should be treated
according to ALS protocols.
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Transport to Medical
Facility |
Report to the base station and the receiving
medical facility the condition of the patient, treatment given,
and estimated time of arrival at the medical facility.
If a chemical has been ingested, prepare
the ambulance in case the victim vomits toxic material. Have
ready several towels and open plastic bags to quickly clean
up and isolate vomitus.
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Multi-Casualty Wage |
All exposed patients should be transported
to a medical facility for evaluation.
Asymptomatic patients who have not had
direct chemical exposure can he discharged from the scene
after their names, addresses, and telephones numbers are recorded.
Those discharged should be advised to seek medical care promptly
if symptoms develop.
Consult with the base station physician
or regional poison control center for advice regarding triage
of multiple victims.
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Emergency
Department Management |
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Potential for Secondary Contamination.
Victims who were exposed only to gas or vapor and have no
gross deposition of the material on their clothing or skin
are not likely to carry significant amounts of chemical beyond
the Hot Zone and are not likely to pose risks of secondary
contamination to hospital personnel. However, victims whose
skin or clothing are covered with liquid or solid chemical
or victims who have condensation of chemical vapor on their
clothes or skin may contaminate hospital personnel and the
ED by direct contact or by off-gassing vapor. If the victim
has ingested a chemical, toxic vomitus may also pose a danger
through direct contact or off-gassing vapor.
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Decontamination
Area |
Previously decontaminated patients and
patients exposed only to gas or vapor who have no evidence
of skin or eye irritation may be transferred immediately to
the Critical Care Area. Other victims will require decontamination
as described below
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ABC Reminders |
Evaluate and support airway, breathing,
and circulation. Intubate the trachea in cases of respiratory
compromise. If the patient's condition precludes intubation,
surgically create an airway.
Treat patients who have bronchospasm
with aerosolized bronchodilators; use these and all catecholamines
with caution because of the possible enhanced risk of cardiac
dysrhythmias.
Patients who are comatose, hypotensive,
or have seizures or ventricular dysrhythmias should be treated
in the conventional manner.
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Basic Decontamination |
Patients who are able and .cooperative
may assist with their own decontamination. Remove and double-bag
contaminated clothing and personal belongings.
Flush exposed or irritated skin and hair
with plain water for 3 to 5 minutes. For oily or otherwise
adherent chemicals, use mild soap on the skin and hair. Rinse
thoroughly with water.
Flush exposed or irritated eyes with
plain water or saline for at least 5 minutes. Remove contact
lenses if present and easily removable without additional
trauma to the eye. If a corrosive material is suspected or
if pain or injury is evident, continue irrigation while transferring
the patient to the Critical Care Area.
In cases of ingestion, do not induce
emesis. Administer 4 to 8 ounces of water to dilute stomach
contents if the patient is conscious and able to swallow.
Immediately transfer the patient to the Critical Care Area.
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Critical Care Area |
Be certain that appropriate decontamination
has been carried out. (See Decontamination Area, above.)
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ABC Reminders |
Evaluate and support airway, breathing,
and circulation as in ABC Reminders, page 7. Establish intravenous
access in seriously ill patients. Continuously monitor cardiac
rhythm.
Patients who are comatose, hypotensive,
or have seizures or ventricular dysrhythmias should be treated
in the conventional manner.
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Inhalation Exposure |
Administer supplemental oxygen by mask
to patients who have respiratory complaints. Treat patients
who have bronchospasm with aerosolized bronchodilators; use
these and all catecholamines with caution because of the potential
or possible enhanced risk of cardiac dysrhythmias.
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Skin Exposure |
If chemical burns are present, treat
as thermal burns.
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Eye Exposure |
Ensure that adequate eye irrigation has
been completed. Test visual acuity. Examine the eyes for corneal
damage using a magnifying device or a slit lamp and fluorescein
stain. For small corneal defects, use ophthalmic ointment
or drops, analgesic medication, and an eye patch. Immediately
consult an ophthalmologist for patients who have severe corneal
injuries.
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Ingestion Exposure |
Do not induce emesis. If the patient
is alert and charcoal has not been given previously, administer
a slurry of activated charcoal. If a corrosive material is
suspected, administer 4 to 8 ounces of water do not give a
slurry of activated charcoal. Consider endoscopy to evaluate
the extent of gastrointestinal-tract injury. If a large dose
has been ingested and the patient's condition is evaluated
within 30 minutes after ingestion, consider gastric lavage.
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Antidotes and Other
Treatments |
Treatment consists of supportive measures.
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Laboratory Tests |
Routine laboratory studies for all exposed
patients include CBC, glucose, and electrolyte determinations.
Additional studies for patients exposed to an unidentified
chemical include ECG monitoring, renal-function tests, and
liver-function tests. Chest radiography and pulse oximetry
(or ABG measurements) are recommended for severe inhalation
exposure.
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Disposition and
Follow-up |
Consider hospitalizing patients who have
suspected serious exposures and persistent or progressive
symptoms
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Delayed Effects |
When the chemical has not been identified,
the patient should be observed for an extended period or admitted
to the hospital.
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Patient Release |
Asymptomatic patients who have minimal
exposure, normal initial examinations, and no signs of toxicity
after 6 to 8 hours of observation may be discharged with instructions
to seek medical care promptly if symptoms develop.
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Follow-up |
Provide the patient with follow-up instructions
to return to the emergency department or a private physician
to reevaluate initial findings. Patients who have corneal
injuries should be reexamined within 24 hours.
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Reporting |
If a work-related incident has occurred,
you may be legally required to file a report; contact your
state or local health department. Other persons may still
be at risk in the setting where this incident occurred. If
the incident occurred in the workplace, discussing it with
company personnel may prevent future incidents. If a public
health risk exists, notify your state or local health department
or other responsible public agency. When appropriate, inform
patients that they may request an evaluation of their workplace
from OSHA or NIOSH. See Appendices III and IV for a list of
agencies that may be of assistance.
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Where can
I get more information? |
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ATSDR can tell you where to find occupational
and environmental health clinics. Their specialists can recognize,
evaluate, and treat illnesses resulting from exposure to hazardous
substances. You can also contact your community or state health
or environmental quality department if you have any more questions
or concerns.
For more information, contact:
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Agency for Toxic Substances and Disease Registry
Division of Toxicology
1600 Clifton Road NE, Mailstop F-32
Atlanta, GA 30333
Phone: 1-888-42-ATSDR (1-888-422-8737)
FAX: (770)-488-4178
Email: ATSDRIC@cdc.gov
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