Course Toxic Exposures

The first goal in the management of any type of disaster is to enhance the safety of the medical and rescue personnel while saving the greatest number of lives possible. To fulfill this goal, some universal principles apply to the management of any type of disaster. First, a chain of command must be established. An incident commander will need to oversee the scene and establish contact with a nearby base hospital. In hazardous materials (HAZMAT) incidents, a medical toxicologist and/or HAZMAT specialist, if available, should be designated as medical coordinator of the command post (see Module 3). Contact the regional Poison Control Center and local HAZMAT team to participate in the response. The chain of command must be strictly honored by all first responders.

The next task will be to set up appropriate zones for the management of the disaster (Box 3). The type of disaster will determine what zones are needed. The hot zone is the primary zone and essentially is the disaster site. This zone represents an area of continued danger, such as ongoing fires, falling debris, or exposure to hazardous materials. Mark off the perimeter of the hot zone with tape or rope if available. The incident commander will decide who is allowed into the hot zone. In general, no medical treatment should be given in the hot zone. If needed, set up a decontamination or warm zone just outside the perimeter of the hot zone. Also, mark off the perimeter of this zone with tape or rope. The decontamination zone represents an area of hazardous materials contamination. In this zone, patients can be stabilized and decontaminated. Ideally, this zone should be upwind, uphill, and/or upstream from the hot zone.

The next zone is the support zone or cold zone. This zone is located beyond the decontamination zone. It should contain no threat of secondary contamination to equipment, victims, or personnel. It is the area of definitive patient treatment and triage. The support/cold zone typically houses the incident command post. No one from the general public or media should be allowed into any of these zones.

A key point in disaster scene management is the prevention of unauthorized entry and exit between zones. In large scale disasters, the capacity for policing of these zones by local authorities will likely be exceeded and the uniformed armed services or National Guard forces will be required to maintain security.

If any disaster scene is suspected to involve hazardous materials (HAZMAT), verify the release and identify the toxin as rapidly as possible. HAZMAT is defined as any material that can cause harm to people, property, or the environment. Release of hazardous materials can include a large number of toxins. Mobilize adequate resources of trained personnel and appropriate equipment as quickly as possible. Upon the first suspicion of a hazardous material incident, rescue workers should call for extra help, specifically a HAZMAT response team if available. A hazardous materials incident will require all 3 zones (hot, decontamination, and support/cold).

Emergency medical service (EMS) personnel should guide their planning using 6 important principles:

• The number of victims with medical problems will be potentially overwhelming
• The number of individuals (the “walking and worried well”) will likely exceed those with true injuries
• The onset of symptoms and signs may be precipitous (e.g., Bhopal or Tokyo sarin attacks)
• The onset of signs and symptoms may be delayed (e.g., phosgene gas)
• Multiple toxins may be involved in a single incident
• The victims may be EMS personnel themselves if not properly protected or if unexpected events occur (e.g., World Trade Towers terrorist event on September 2011)