Toxic Exposures

Decontamination is necessary in any disaster in which a toxic exposure is suspected. The goal of decontamination is to prevent further patient exposure and to prevent contamination of the staff. Assess all stable patients for the need of decontamination prior to further examination, triage, or treatment. Decontamination is usually more important with chemical and radioactive exposures than with biologic exposures.

Victims in whom toxic exposure has been limited to a gas or vapor, and who have no local skin or eye irritation and no condensation of gas on their clothing are not likely to cause secondary contamination. These circumstances allow selected patients to proceed directly to the support zone. In all other circumstances, once a victim is stabilized, decontamination, should occur immediately. In general, it is not recommended to send a critically ill patient to the hospital prior to decontamination, because the patient will have to undergo decontamination before entering the hospital. In addition, the contaminated patient poses risk of secondary contamination to healthcare workers, emergency equipment, and the transport vehicle. If the contaminated patient is transported, transport personnel should wear protective clothing and the equipment in the vehicle should be protected from contamination. In addition, notify the receiving hospital that a patient who requires decontamination will be arriving. Establish the hospital-based decontamination area before such a patient arrives. In the hospital-level planning, account for patients who could arrive from the disaster scene on foot or in a private vehicle and will also require decontamination.

In the decontamination zone, divide victims into 2 groups: those who can remove their own clothing and those who require assistance. Most children will require assistance, so adequate staff will be needed. Remove and double bag all clothing and personal belongings. Place items slowly and carefully in small bags. This is especially important when handling clothes with radioactive dust. Label bags with the patient’s name, address, and phone number. In some disasters, patients are considered crime victims. In these cases, clear documentation and preservation of evidence are necessary.

Moving from head to toe, flush the skin and hair with water for 3 to 5 minutes, avoiding getting water into the airways or eyes. Flush irritated eyes with water or saline for at least 5 minutes. Remove contact lenses when present. Wash all skin areas with extra attention paid to skin folds, the axillae, and genital area. Use a mild soap to help remove oily contaminants. If there are large number of victims, consider the use of communal decontamination showers. Children are more susceptible to hypothermic stress when undergoing decontamination. If possible, use lukewarm water when flushing a child’s skin, dry promptly, and then swaddle warmly. When possible, drain water from decontamination into plastic containers that are labeled as “toxic waste”. With large-scale disasters, however, this becomes of less priority. A decontamination sequence is displayed in Box 4.

In an unknown situation or exposure, it is appropriate to use full PPE and decontamination procedures. However, reassessment of the situation should be done on a periodic basis in conjunction with toxicologists. As more information becomes available, it may not be necessary to decontamination resources.