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Emergency
Room Procedures in Chemical Hazard Emergencies A Job Aid
Preparations
1.
Try to determine agent identity.
2.
Break out personal protection equipment, decon supplies, antidotes,
etc.
3.
Is chemical hazard certain or very likely?
YES:
•Don personal protective equipment.
•Set up hot line.
4. Clear and secure all areas which could become contaminated.
5. Prepare to or secure hospital entrances and grounds.
6. Notify local emergency management authorities if needed.
7. If chemical is a military agent and Army has not been
informed. call them.
8. If an organophosphate is involved, notify hospital pharmacy that
large amounts of atropine and 2-PAM may be needed.
When
victim arrives
(Note: A contaminated patient may present at an emergency room without
prior warning.)
9.
Does chemical hazard exist?
-
Known
release/exposure (including late notification)
-
Liquid
on victim's skin or clothing
-
Symptoms
in victim, EMTs, others
-
Odor
(H, L, phosgene, chlorine)
-
M-8
paper, if appropriate
YES: Go to 10.
NO:
Handle victim routinely.
10.
Hold victim outside until preparations are completed (don personal
protective equipment to assist EMT’s as necessary).
11. If
patient is grossly contaminated (liquid on skin, positive M-8 paper)
OR if there is any suspicion of contamination, decontaminate patient
before entry into building.
Initial
Treatment and Identification of the Chemical Agent
1.
Establish airway if necessary.
2. Give
artificial respiration if not breathing.
3. Control
bleeding if hemorrhaging.
4. Symptoms
of cholinesterase poisoning?
- Pinpoint pupils
- Difficulty
breathing (wheezing, gasping, etc)
- Local or
generalized sweating
- Fasciculations
- Copious
secretions
- Nausea,
vomiting, diarrhea
- Convulsions
- Coma
YES: Go to NERVE AGENT PROTOCOL
5. History of
chlorine poisoning?
YES: Go to CHLORINE PROTOCOL.
6. Burns that
began within minutes of poisoning?
YES: Go to 7.
NO: Go to 8.
7. Thermal burn?
YES: Go to 9.
NO: Go to LEWISITE PROTOCOL
8. Burns or eye
irritation beginning 2-12 hours after exposure?
YES: Go to MUSTARD PROTOCOL.
NO: Go to 9.
9. Is phosgene
exposure possible?
- Known exposure
to phosgene
- Known exposure
to hot chlorinated hydrocarbons
- Respiratory
discomfort beginning a few hours after exposure
YES: Go to PHOSGENE
PROTOCOL.
10. Check other
possible chemical exposures:
- Known exposure
- Decreased level
of consciousness without head trauma.
- Odor on clothes
or breath
- Specific signs
or symptoms
| PHOSGENE
PROTOCOL
1. Restrict
fluids, chest x-ray, blood gases
Results
consistent with phosgene poisoning?
YES: Go to # 4
2. Dyspnea?
YES:
OXYGEN, positive end-expiratory pressure
3. Observe
closely for at least 6 hours.
- IF
SEVERE DYSPNEA develops, go to 4.
- IF MILD
DYSPNEA develops after several hours, go to 1.
4. Severe
dyspnea develops or x-ray or blood
gases consistent with phosgene
poisoning-
- Admit
- Oxygen
under positive end-expiratory pressure
- Restrict
fluids
- Chest
x-ray
- Blood
gases
- Seriously
ill list
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MUSTARD
PROTOCOL
1.
Airway obstruction?
YES:
Tracheostomy
2. If
there are large burns:
- Establish
IV line - do not push fluids as for thermal burns.
- Drain
vesicles - unroof large blisters and irrigate area
with tropical antibiotics.
3.
Treat other symptoms appropriately:
- Antibiotic
eye ointment
- Sterile
precautions prn
- Morphine
prn (generally not needed in emergency treatment; might be
appropriate for in-patient treatment.)
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| LEWISITE
PROTOCOL
1.
Survey extent of injury.
2.
Treat affected skin with British Anti-Lewisite
(BAL) ointment (if available).
3.
Treat affected eyes with BAL ophthalmic
ointment (if available).
4.
Treat pulmonary/severe effects
- BAL in
oil, 0.5 ml/25 lbs body wt. deep IM to max of 4.0 ml.
Repeat q 4 h x 3 (at 4, 8, and 12 hours).
- Morphine
prn
5. Severe
poisoning?
YES:
Shorten interval for BAL injections to q 2 h.
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CHLORINE
PROTOCOL
1.
Dyspnea?
- Try
bronchodilators
- Admit
- Oxygen
by mask
- Chest
X-ray
2.
Treat other problems and reevaluate
(consider phosgene).
3.
Respiratory system OK?
YES: Go
to 5.
4. Is
phosgene poisoning possible?
YES:
Go to PHOSGENE PROTOCOL.
5.
Give supportive therapy; treat other problems
or discharge.
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NERVE AGENT PROTOCOL
1.
Severe respiratory distress?
YES:
- Intubate
and ventilate
- ATROPINE
Adults: 6 mg IM or IV
Inf/ped: 0.05 mg/kg IV
- 2-PAM C1
Adults: 600-1000 mg IM or slow IV
Inf/ped: 15 mg/kg slow IV
2. Major
secondary symptoms?
NO: Go to 6.
YES:
- ATROPINE
Adults: 4 mg IM or IV
Inf/ped: 0.02 - 0.05 mg/kg IV
- 2-PAM C1
Adults: 600-1000 mg IM or slow IV
Inf/ped: 15 mg/kg
- OPEN IV
LINE
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3.
Repeat atropine as needed until secretions decrease and
breathing easier
Adults: 2 mg IV or IM
Inf/ped: 0.02 - 0.05 mg/kg IV
4. Repeat
2-PAM C1 as needed
Adults: 1.0 gm IV over 20-30 min
Repeat q lh x 3 prn
Inf/ped: 15 mg/kg slow IV
5.
Convulsions?
NO: Go to 6.
YES: DIAZEPAM 10 mg slow IV
Inf/ped: 0.2 mg/kg IV
6.
Reevaluate q 3-5 min.
IF SIGNS WORSEN, repeat from 3.
Note: Warn
the hospital pharmacy that unusual amounts of atropine and
2-PAM may be needed
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