Bioterrorism Watch: Triage, decontamination after chemical exposures

Triage, decontamination after chemical exposures

Have outdoor shower area ready

To increase preparedness for chemical exposures, clinicians at George Washington University in Washington, DC, have developed triage and decontamination plans that include the use of outdoor showers.¹ Some of the key points of the plan for dealing with chemically contaminated patients include:

• Initial triage.

Exposed and potentially exposed individuals should receive an initial brief triage, performed by medical personnel in personal protective equipment (PPE), before decontamination. They should then be directed to one of two areas, nonmedical decontamination or medical decontamination. The uninjured, those with minor injuries requiring no medical intervention during decontamination, and the majority of ambulatory patients will be assigned to nonmedical decontamination.

A brief sign-in process should record name and date of birth. (Full registration can occur after decontamination and should be consistent with the community patient tracking system.) A number on a log can be assigned to each patient, who would receive two identically numbered plastic bags and a nonpermeable wristband. Clothing would be placed into the larger clear, impervious bag. Valuables should be placed in the second, smaller bag.

• Patient decontamination.

It is recommended that the facility have partially fixed or preconstructed decontamination areas that can be activated immediately. This area should be designed to occupy little storage space and not disrupt routine operations while in use. The Israeli model, developed during the Gulf War, consists of showers permanently fixed to the ceiling structure of an open-air parking garage or the side of a building. The George Washington University Hospital model uses fire exit alleyways. Outdoor decontamination, however, must offer protection from inclement weather and have adequate lighting for night operations. Because clothing will be removed before decontamination, privacy must be protected to ensure compliance with full decontamination. The sexes should be separated, with a visual barrier between shower lines.

The water temperature must be adjustable. Excessively warm water should be avoided, as this may promote peripheral vasodilatation and toxin absorption. Stiff brushes or abrasives also should be avoided as they may enhance dermal absorption of the toxin and can produce skin lesions that may be mistaken for chemical injuries. Sponges and disposable towels are affordable and effective alternatives.

Decontamination can be accomplished by using a sequential copious warm water rinse, a hypoallergenic liquid soap wash, another warm water rinse, and then a final rinse after walking past other in-use showers. Promoting patient self-decontamination will significantly decrease the required number of health care workers. Of course, decontamination assistance for some patients in the nonmedical decontamination area and full passive decontamination in the medical decontamination area must still be available.

Decontamination facilities should contain multiple shower stations that are designed to allow patients to progress at various rates without compromising overall flow. Patients whose clinical condition deteriorates in the decontamination line can impede the progress of others. Plans must include means for sidetracking these patients into an area separate from the main decontamination sites, where treatment can be initiated.

Reference

1. Macintyre A, Christopher G, Eitzen E, et al. Weapons of mass destruction events with contaminated casualties. JAMA 2000; 283:242-249.