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Strategy for Developing a Community Chemical Response Plan 1

Myths About Chemical Disasters
  • Myth 1. Hospitals will be notified in advance of arrival of chemically exposed patients.
  • Myth 2. The offending toxin will be rapidly identified so that on-scene and emergency department care providers will give specific and appropriate treatment.
  • Myth 3. Dispatchers will send emergency response units to the scene so that trained personnel will triage, treat, and decontaminate victims.
  • Myth 4. Casualties will be transported by ambulance and they will first transport the most serious patients already decontaminated.

Five "Myth-buster" Realities
  • Reality 1. Medical personnel must often "operate in the blind" during the early stages of an event.
  • Reality 2. The offending chemical may not be identified for hours, or even days.
  • Reality 3. Emergency response personnel seldom have adequate tools or resources to effectively triage, decontaminate, and treat the large numbers of victims of a large-scale chemical exposure.
  • Reality 4. The first victims arriving at the hospital often arrive under their own power without direct involvement from emergency response personnel on the scene.
  • Reality 5. The general public can behave in ways that significantly erode the effectiveness of the emergency medical response.



Strategy — Doing the Best for the Most


A community could devise an effective response strategy if it focuses on:

  • Planning for expected challenges to the emergency response and health care systems
  • Identifying the greatest chemical risks that could cause harm if accidentally or deliberately released
  • Using critical decision pathways during the emergency response that apply basic toxicology principles



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Focusing on the Priorities


  • Identifying an event:
  • Taking actions to close the silent gap:
    • Creating a community-specific risk assessment to determine the most likely chemicals to be involved in an accident
    • Using a tiered response strategy:
      1. Initial patient assessment: using toxic syndromes as a diagnostic framework, medical personnel identify the toxic syndrome(s) present in the victims.
      2. Staff protection: based on the toxic syndrome(s) identified, medical personnel (prehospital care providers and hospital staff) refer to "just in time" training to guide efforts at personal protection and decontamination of staff and victims.
      3. Empiric treatment and antidote administration: the knowledge of the toxic syndrome immediately identifies the most appropriate treatment options including time urgent and life-saving antidotes (eg, Mark 1 kits and cyanide antidotes).
      4. Confirmation of causative chemicals: the toxic syndrome narrows down the list of potential causative chemical agents to a manageable level. This in turn provides guidance to clinicians about which tests to run to identify and confirm the specific agents involved, thereby assuring that laboratory resources are applied in the most effective way possible. In addition, over time, several lines of investigation, such as scene analyses or factual details of the incident, will help to clarify/confirm the identity of the causative chemical.
      5. Chemical-specific therapies: once the specific causative agents are identified, medical personnel are able to administer any chemical-specific therapies that might be needed and make more informed decisions about patient disposition.
    • Creating a communications network to effectively manage information
  • Providing medical care:
    • Providing care that will do the best for the most victims of the incident
    • Recognizing four classes of medical needs:
      1. Patients needing decontamination
      2. Patients needing immediate life-saving care (advanced life-support measures)
      3. Patients needing urgent antidote therapy or other specialized therapy
      4. The psychological needs of patients, families, care providers, media, and the community


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Which Chemicals Should We Prepare For?


  • To be better prepared, emergency planners must focus on getting the right information into the right hands at the right time.
  • One of the most critical pieces of information is the identity or nature of the offending chemical agent. Access to this information by medical personnel and on-site first responders would dramatically reduce the chaos and its consequences during the early stages of an event. This would give clinicians increased confidence in their therapeutic and disposition decisions.
  • Common sources of chemical events
    • Chemical warfare agents: Before September 11, 2001, training and planning for anticipated deliberate toxic chemical attacks mainly concentrated on chemicals designed specifically as military weapons such as nerve agents, sulfur mustard, and phosgene.
    • Weapons of opportunity: Over 80,000 potentially toxic substances are produced, stored, and moved for manufacturing, agriculture, and service industries throughout the U.S. Any of these could be released accidentally or deliberately, putting many people in danger. Because of their availability and toxicity, these chemicals in our communities are increasingly referred to as "weapons of opportunity." Upon release, many of these highly toxic chemicals are readily airborne, leading to inhalation exposure and toxic effects.
  • Training for emergency response
    • It is unrealistic for first responders or emergency personnel to know all of the above types of substances in enough detail to make confident decisions during the early phases of a crisis. This approach is not realistic and leads to training that is too generic to be of practical use during an event.
    • It is realistic to train medical personnel for response to chemical events based on community-specific risk analysis that takes into account the chemicals posing the greatest risks in the community, as well as the potential high-impact scenarios involving those chemicals.
    • First responders and medical personnel can learn to rapidly identify potential chemical classes based on toxic syndromes.


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References

  1. Kirk MA, Deaton ML. Bringing order out of chaos: effective strategies for medical response to mass chemical exposure. Emerg Med Clin North Am. 2007 May;25(2):527-48. [PubMed Citation]
Additional Resources
  1. AEGLs (Acute Exposure Guideline Levels) (EPA)
  2. AEGL Chemicals (EPA)
  3. NIOSH Pocket Guide to Chemical Hazards (HHS/CDC/NIOSH)
  4. Protective Action Criteria for Chemicals (DOE Subcommittee on Consequence Assessment and Protective Actions (SCAPA))