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Australian Clinical Guidelines for Acute Exposures to Chemical Agents of Health Concern: a Guide for the Emergency Department Staff

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Australian Clinical Guidelines for Acute Exposures to Chemical Agents of Health Concern: a Guide for the Emergency Department Staff Australian Clinical Guidelines for Acute Exposures to Chemical Agents of Health Concern: A Guide for the Emergency Department Staff October 2007 Australian Clinical Guidelines for Acute Exposures to Chemical Agents of Health Concern: A Guide for the Emergency Department Staff Prepared by The Australian Health Protection Committee Working Group October 2007 © Australian Government 2007 Publication approval number: 3956 ISBN: 1 74186 156 X (c) Commonwealth of Australia 2007 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced, by any process, without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca Photographs on pages 7 (left), 10 (left), 11 and front cover (centre and far right) copyright Victorian Department of Human Services, and used by permission. Photographs on pages 4, 9 and front cover (centre left) copyright Western Australian Department of Health, and used by permission. AUSTRALIAN HEALTH PROTECTION COMMITTEE The Australian Health Protection Committee (AHPC) is a subcommittee of the Australian Health Ministers Advisory Committee. Chaired by the Deputy Secretary of the Department of Health and Ageing, the Committee includes representation by the Chief Health Officers of all States and Territories, the Department of Defence, Emergency Management Australia, the Chairs of its key subcommittees (Communicable Disease Network Australia, Public Health Laboratory Network and the Environmental Health Council) and key subject matter experts. To obtain details regarding AHPC publications, contact email [email protected] At the time of publication, the links to websites referred to in this document were correct. AHPC acknowledge that, at times, organisations change internet addresses, or remove information from the internet. ii Foreword mproved telecommunications and transportation have led to increased mobility, Iaccessibility and diversity around the world. Undoubtedly, all these have led to the growing threat of chemical, biological and radiological terrorism and the advent of new weapons. While biological and radiological agents pose serious threats, chemical agents are easier to fabricate and can produce the desired acute impact. There are various versions of clinical guidelines on chemical warfare agents, mostly with a non-Australian focus. New agents are added every day and many industrial and commercial chemicals of interest are not covered. These Clinical Guidelines have been produced in collaboration with various Australian surgical and medical specialists, with the intention to provide health facilities around Australia with standardised management of chemical warfare, toxic industrial and commercial chemical agent exposure, which may occur in a disaster. Where possible, a consensus has been achieved between practicing specialists. The Clinical Guidelines do not however necessarily represent the views of all the clinicians in Australia. It is important to note that the Clinical Guidelines do not constitute a textbook and therefore deliberately provide little, if any, explanation or background to the chemicals and treatment outlined. They are designed to acquaint the reader rapidly with the chemical and the clinical picture it can produce, thereby providing practical advice regarding assessment and management. The recommendations contained in these guidelines do not indicate an exclusive course of action or serve as a standard of medical care. Variations, taking individual circumstances into account, may be appropriate. The authors of these Clinical Guidelines have made considerable efforts to ensure the information upon which they are based is accurate and up to date. Users of these guidelines are strongly recommended to confirm that the information contained within them is correct by way of independent sources. The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success of any treatment regimen detailed in the guidelines. The authors encourage all clinicians, hospital and health care managers to make themselves aware of these Clinical Guidelines and to become adequately prepared to provide a suitable response to a chemical event within their area. iii Contents Contents Foreword iii Figures and Tables v Acknowledgements vi Abbreviations viii Chapter 1: How To Use This Document 1 Chapter 2: Hospital Management Of A Chemical Event 3 Section 2.1: Management Of An Unidentified Chemical Agent 15 Section 2.2: Aids To Chemical Agent Recognition 21 Chapter 3: Individual Chemical Agents In Detail 25 Bibliography 159 Appendix 1: Index Of Chemical Agents 163 Appendix 2: Useful Phone Numbers 170 Notes 171 iv Figures & Tables Figures Figures and Tables Figure 1 HAZMAT Management At The Incident Scene 5 Figure 2 Patient Management Flowchart For The Hospital 13 Figure 3 Brief Overview Of The Management Of Patients 14 Who Present To EmergencyDepartment Without Prior Notification Or Information Of A Possible CBR Event Figure 4 Emergency Department Management Of Unidentified 20 Chemical Agent Used During A CBR Incident Figure 5 Broad Classifications Of Chemical Agents 21 That Can Be Used As Weapons Table 1 Common Clinical Toxidromes 22 Table 2 Clinical Presentation Of Well-Known Chemical Agents 23 v Acknowledgments Working Group Acknowledgments A project of the scale of the Clinical Guidelines is an accomplishment of many people from many disciplines and skills. From its inception to final production, the Clinical Guidelines passed through many phases each of which required the cooperation and help of distinctive individuals and organisations. We would like to extend our appreciation to the Australian Health Protection Committee (AHPC) Working Group Members for making these guidelines possible. The AHPC Working Group Members comprise: • Dr Andrew Robertson, Chief Health Officer (Chair), Department of Health, Western Australia; • Commander Alison McLaren, RAN, Department of Defence, Australian Capital Territory; • Dr Jane Canestra, CBR Liaison, Program Coordination, Public Health Branch, Department of Human Services, Victoria; • Dr Nicholas Buckley, Associate Professor of Clinical Toxicology and Pharmacology, The Australian National University, Australian Capital Territory; • Dr Nicholas Edwards, Senior Staff Specialist, Intensive Care Unit, Royal Adelaide Hospital, South Australia; and • Dr Luba Tomaska, Office of Chemical Safety, Department of Health and Ageing, Australian Capital Territory. Special thanks to Dr Andrew Robertson for chairing and coordinating the working group of AHPC, as well as to Dr Mukti Biyani (primary author and editor) for compilation of the Clinical Guidelines. Thanks also go to Dr Frank Daly and Dr Tim Inglis, the authors of “Protocol for Hospital Management of Chemical and Biological External Incidents”, published by the Department of Health, Western Australia, for providing the framework on pages 16 to 24. vi Acknowledgments Reviewers Experts from various fields reviewed the first draft of the guidelines. They were chosen because of the personal expertise and / or because they were nominated by their professional associations. They are: Dr Amanda Wilkin Dr Debra Graves Dr Virginia McLaughlin Dr Fergus Kerr Dr Mark Littlle Dr Roger Swift Dr Fiona Wood Dr Peter Leman Ms Lyn Pearson Dr John Vassiliadis Dr Timothy Royle Ms Gaye Hudson Dr Richard Waller Dr Frank Daly Dr Tony Eliseo Dr Yusuf Nagree Dr Indra Ramasamy Dr Ian Spence Mr Jeff Robinson Dr Liz Hanna Dr Tony Eliseo Professor Garry Phillips Dr Roy McCoy Professional organisations represented were the: ACT Health; Australian and New Zealand Burn Association; Australian and New Zealand College of Anaesthetists; Australian College for Emergency Medicine; Australian Faculty of Public Health Medicine; Royal College of Nursing; Royal College of Pathologists of Australasia; School of Medical Sciences, University of Sydney; SA Department of Human Services; The Council of Ambulance Authorities Inc; The Department of Health and Ageing; The Royal Australasian College of General Practitioners; WA Health; WA Poisons Information Centre; Victorian Clinical Toxicologists; Victorian Department of Human Services; Victorian Institute of Forensic Medicine; and Victorian Poisons Information Centre. Ms Mary Murnane as the Chair of the Australian Health Protection Committee takes this opportunity to sincerely thank all of the above. vii Abbreviations Abbreviations ABGs Arterial Blood Gases ADT Adult Diphtheria Tetanus Vaccination Al Aluminium ARDS Adult Respiratory Distress Syndrome AXR Abdominal X Ray BAL British Anti-lewisite (Dimercaprol) Ca Calcium CBR Chemical, Biological and Radiological CK Creatinine Kinase Clinical Guidelines Australian Clinical Guidelines for Acute Exposures to Chemical Agents of Health Concern: A Guide for the Emergency Department Staff CMP Calcium, Magnesium and Phosphate CNS Central Nervous System COHb Carboxy Haemoglobin CT Computed Tomography CW Chemical Weapon CXR Chest X Ray DIC Disseminated Intravascular Coagulopathy ECG Electrocardiograph ED Emergency Department viii Abbreviations EMA Emergency Management Australia EUC Electrolytes, Urea and Creatinine FBC Full Blood Count GIT Gastrointestinal Tract GP General Practitioner HAZMAT Hazardous Materials Hg Mercury HPA Health Protection Agency,
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