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Nerve Agents Wound Management

• Following total body decontamination the plastic wrap is removed and the wounds are flushed. Bandages are replaced only if bleeding reoccurs. Tourniquets are replaced with clean tourniquets and the sites of the original tourniquets are decontaminated. Splints are thoroughly decontaminated (removed only by a physician).
• The new dressings are removed in the operating room and submerged in a 5% solution of hypochlorite or placed in a plastic bag and sealed
• The blood and necrotic tissue of the wound "buffers" the nerve agents. Nerve agent that reaches viable tissue is rapidly absorbed. The potential risk from contaminated wounds arises from chemical agent in the wound and from thickened agents combined with the debridement process.
• Wound contamination assessment - The Chemical Agent Monitor (CAM) can be used to locate contaminated objects within a wound (30 seconds are require to achieve a bar reading). The CAM detects vapor, but may not detect a thickened agent or liquid on a foreign body.
  
  
• Thickened Agents
  • Thickened agents are chemical agents that have been mixed with another substance (commonly an acrylate) to increase their persistency.
  • They do not dissolve as quickly in biological fluids, nor are they absorbed as rapidly by tissue as other similar agents.
  • Though the vapor hazard to surgical personnel is extremely low, contact hazard does remain.
• Off-Gassing
  • The risk from vapor off-gassing from chemically contaminated shrapnel and cloth in wounds is low and not significant.
  • There is no vapor release from contaminated wounds without foreign bodies.
  • Off-gassing from a wound during surgical exploration will be negligible.
  • No eye injury will occur from any of the agents (a chemical-protective mask is not required for surgical personnel)
• Wound Exploration/Debridement
  • No single glove material protects against every substance. Butyl rubber gloves generally provide better protection against chemical warfare agents and most toxic industrial chemicals (but not all) than nitrile gloves, which are generally better than latex surgical gloves.
  • Surgeons and assistants are advised to wear two pair of gloves: a nitrile (latex if nitrile is not available) inner pair covered by a butyl rubber outer pair.
  • Thicker gloves provide better protection but less dexterity. Latex and nitrile gloves are generally 4 to 5 mils thick (1 mil = 1/1,000 of an inch). The recommended butyl rubber glove is 14 mils thick; if greater dexterity is needed a 7-mil butyl glove may be worn. A study at the US Army Soldier and Biological Chemical Command showed breakthrough times for distilled mustard (HD) and sarin (GB) depended on glove material and thickness. N-Dex (Best Manufacturing, Menlo, GA) nitrile gloves (4 mil) had a breakthrough time of 53 minutes for HD and 51 minutes for GB. North (North Safety Products, Cranston, RI) butyl gloves (30 mil) had a breakthrough time of over 1,440 minutes for both HD and GB. The safety standard operating procedure at USAMRICD for working with neat (referring to a chemical's neat means it's full-concentration, undiluted state) agents requires a maximum wear time of 74 minutes for HD and 360 minutes for G agents (volatile nerve agents) and VX (a low volatility nerve agent) when wearing 7-mil butyl rubber gloves over 4-mil N-Dex nitrile gloves. Wearing this glove combination is recommended until users ascertain that no foreign bodies or thickened agents are in the wound [2].
  • Double latex surgical gloves have no breakthrough for 29 minutes in an aqueous medium; they should be changed every 20 minutes (changing gloves is especially important when puncture is likely because of the presence of bone spicules or metal fragments).
  • The wound should be explored with surgical instruments rather than with fingers.
  • Superficial wounds should be subjected to thorough wiping with 0.5% hypochlorite and subsequent irrigation with normal saline or irrigation with saline or water for an additional 5- 10 minutes [3]
  • Removed fragments of tissue, pieces of cloth and associated debris must not be examined closely, and quickly disposed of in a container of 5% hypochlorite.
  • Bulky tissue such as an amputated limb should be placed in a plastic or rubber bag (chemical proof) which is then sealed.
  • The wound can then be checked with the CAM which may direct the surgeon to further retained material. It takes about 30 seconds to get a stable reading from the CAM. A rapid pass over the wound will not detect remaining contamination.
  • The wound is debrided and excised as normal, maintaining a no-touch technique.
  • Hypochlorite solution (0.5%) may be instilled into deep non-cavity wounds following the removal of contaminated cloth. This solution should be removed by suction to an appropriate disposal container. Within a short time, i.e., 5 minutes, this contaminated solution will be neutralized and nonhazardous. Subsequent irrigation with saline or other surgical solutions should be performed.
  • Penetrating abdominal wounds caused by large fragments or containing large pieces of contaminated cloth chemically contaminated cloth will be uncommon.
  • Surgical practices should be effective for the majority of wounds in identifying and removing the focus of remaining agent within the peritoneum. When possible the CAM may be used to assist.
  • Saline, hydrogen peroxide, or other irrigating solutions do not necessarily decontaminate agents, but may dislodge material for recovery by aspiration with a large bore sucker. The irrigation solution should not be swabbed out manually with surgical sponges. The risk to patients and medical attendants is minuscule. However, safe practice suggests that any irrigation solution should be considered potentially contaminated.
  • Following aspiration by suction the suction apparatus and the solution should be disposed of in a solution of 5% hypochlorite.
  • Instruments that have come into contact with possible contamination should be placed in 5% hypochlorite for 10 minutes prior to normal cleansing and sterilization.
  • Reusable linen should be checked with the CAM, M-8 paper, or M-9 tape for contamination. If found to be contaminated it should be disposed of in a 5-10% hypochlorite solution.

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1. Medical Management of Chemical Casualties Handbook, 2nd edition, September, 1995
2. Braue EH, Boardman CH. Decontamination of Chemical Casualties
3. Jagminas L. CBRNE - Chemical Decontamination (eMedicine)