8 MODULE 8 Toxic Exposures Kathy L. Leham-Huskamp / William J. Keenan / Anthony J. Scalzo / Shan Yin 8 Toxic Exposures Kathy L. Lehman-Huskamp, MD William J. Keenan, MD Anthony J. Scalzo, MD Shan Yin, MD InTrODUcTIOn The first large-scale production of chemical and biological weapons occurred during the 20th century. World War I introduced the use of toxic gases such as chlorine, cyanide, an arsine as a means of chemical warfare. With recent events, such as the airplane attacks on the World Trade Center in New York City, people have become increasingly fearful of potential large-scale terrorist attacks. Consequently, there has been a heightened interest in disaster preparedness especially involving chemical and biological agents. The U.S. Federal Emergency Management Agency (FEMA) recommends an "all-hazards" approach to emergency planning. This means creating a simultaneous plan for intentional terrorist events as well as for the more likely unintentional public health emergencies, such as earthquakes, floods, hazardous chemical spills, and infectious outbreaks. Most large-scale hazardous exposures are determined by the type of major industries that exist and/or the susceptibility to different types of natural disasters in a given area. For example, in 1984 one of the greatest man-made disasters of all times occurred in Bhopal, India, when a Union Carbide pesticide plant released tons of methylisocyanate gas over a populated area, killing scores of thousands and injuring well over 250,000 individuals. The 2011 earthquake and tsunami in Japan demonstrated the vulnerability of nuclear power stations to natural disasters and the need to prepare for possible widespread nuclear contamination and radiation exposure. This module provides universal guidelines for interventions during toxicological disasters. SEcTIOn I / VULNERABILITY OF CHILDREN vULnErABILITY OF cHILDrEn higher concentrations closer to the OBjEcTIvES ground. The same principle applies to nuclear contamination. A shorter per - G Understand the increased vulnerability of son will be exposed to a higher concen - Differences children exposed to toxins. tration of chemicals and radiation simply between children G Analyze the causes of the increased and adults place vulnerability of children to toxins. by being closer to the ground. Children also have a larger skin surface children at increased risk for area to body mass ratio than adults. This exposure in many Differences between children and adults increases their risk of absorption of toxins toxicological disasters. place children at increased risk for expo - through the skin. A larger skin area to body sure in many toxicological disasters mass ratio together with less subcuta - (Box 1) . Shorter stature can make chil - neous fat places a child at higher risk for dren more vulnerable than adults. Many hypothermia with decontamination. A chemical agents are more dense or heav - child's skin has less keratinization, allowing ier than air and consequently exist in corrosives to cause greater injury. Children also have higher minute ventilation per body mass. Therefore, pediatric exposures BOX 1. Factors increasing to aerosolized or gaseous toxins will be children’s vulnerability in more extensive than with adults. toxicological disasters Children also have a decreased fluid reserve compared with adults, and are at G Shorter stature G Larger skin surface area to body mass increased risk for dehydration with ratio repetitive vomiting or diarrhea associat - G Skin with less keratinization ed with toxic exposures or food-born ill - G Higher minute ventilation ness. In addition, immature motor skills G Decreased fluid reserve and cognitive functioning may make it G Immature motor skills and cognitive functioning less likely that the children will remove themselves from a dangerous situation. SEcTIOn II / RESPONSE rESPOnSE In TOXIcOLOGIcAL DISASTEr SITUATIOnS Priorities in response to a OBjEcTIvES Toxic Disaster Scene The first goal in the management of any G Identify the basic goals of toxicological type of disaster is to enhance the safety of disaster preparedness. the medical and rescue personnel while G Delineate the priorities of disaster scene staging and patient management in the saving the greatest number of lives possi - event of an incident involving hazardous ble. To fulfill this goal, some universal prin - materials. ciples apply to the management of any G Define a hazardous material. type of disaster. First, a chain of command G List the factors to be considered in the planning of and response to a must be established. An incident com - toxicological disaster. mander will need to oversee the scene and establish contact with a nearby base hospital. In hazardous materials incidents, a medical toxicologist, if available, should Toxicological Disaster be designated as medical coordinator of Preparedness As in any type of disaster, in events involv - ing a hazardous material, prior prepared - BOX 2. Goals of toxicological ness is critical to minimize the effects on disaster preparedness victims, rescuers, and other emergency personnel. In addition, it is essential to G Prepare for a wide range of disasters take the measures needed to avoid toxic G Know the signs and symptoms consistent contamination in non-exposed sectors of with toxic syndromes or have resources the community. readily available for rapid identification of Bear in mind that various toxins can be these syndromes G Acquire skills and practice on how to involved in disasters and their effects vary. properly treat injuries associated with Rapid identification is critical to take toxic exposures The first goal in the appropriate measures in a timely manner. G Prepare to respond rationally, effectively management of any Although community education recognizing and minimizing dangers type of disaster is to regarding disasters is always an impor - affecting rescuers personal safety enhance safety of G Provide anticipatory and prospective the medical and tant issue of prior preparedness, in toxi - community education regarding the rescue personnel cological disasters this holds even more appropriate levels of community concern while saving the importance. In Box 2 are listed the and response to each type of toxicological greatest number of disaster lives possible. basic goals of toxicological disaster pre - paredness. SEcTIOn I1 / RESPONSE 7 the command post (see Module 3). these zones by local authorities will likely Contact the regional Poison Control be exceeded and the uniformed armed Center to participate in the response. The services or National Guard forces will be chain of command must be strictly hon - required to maintain security. No one from the general public or ored by all first responders. If any disaster scene is suspected to media should be The next task will be to set up appro - involve hazardous materials (HAZMAT), allowed into any priate zones for the management of the verify the release and identify the toxin as of these zones. disaster (Box 3) . The type of disaster rapidly as possible. HAZMAT is defined will determine what zones are needed. as any material that can cause harm to The hot zone is the primary zone and people, property, or the environment. essentially is the disaster site. This zone Release of hazardous materials can represents an area of continued danger, include a large number of toxins. Mobilize such as ongoing fires, falling debris, or adequate resources of trained personnel exposure to hazardous materials. Mark and appropriate equipment as quickly as off the perimeter of the hot zone with possible. Upon the first suspicion of a tape or rope if available. The incident hazardous material incident, rescue If any disaster scene commander will decide who is allowed workers should call for extra help, specif - is suspected to into the hot zone. In general, no medical ically a HAZMAT response team if avail - involve hazardous treatment should be given in the hot able. A hazardous materials incident will materials, verify the release and identify zone. If needed, set up a decontamination require all 3 zones (hot, decontamination, the toxin as rapidly or warm zone just outside the perimeter and support/cold). as possible. of the hot zone. Also, mark off the Emergency medical service (EMS) per - perimeter of this zone with tape or rope. sonnel should guide their planning using The decontamination zone represents an 6 important principles: area of hazardous materials contamina - tion. In this zone, patients can be stabi - lized and decontaminated. Ideally, this BOX 3. Disaster scene staging zone should be upwind, uphill, and/or upstream from the hot zone. G The next zone is the support zone or Hot zone cold zone. This zone is located beyond the —Possible ongoing exposure decontamination zone. It should contain —Full protective gear no threat of secondary contamination to —Possible initial triage equipment, victims, or personnel. It is the G Decontamination zone (Scene and/or area of definitive patient treatment and hospital) triage. The support/cold zone typically —Contaminated clothing removed houses the incident command post. No —Flushing/washing one from the general public or media —Thermal protection of children should be allowed into any of these zones. G Support/cold zone A key point in disaster scene manage - —Examination ment is the prevention of unauthorized —Stabilization entry and exit between zones. In large- —Triage scale disasters, the capacity for policing of 8 SEcTIOn I1 / RESPONSE • The number of victims with