Module 12: Patient Support

Transcription

1 Student Text IAFF Training for Hazardous Materials: Technician Module 12: Patient Support Module 12: Patient Support 12-1

2 IAFF Training for Hazardous Materials: Technician Student Text 12-2 Module 12: Patient Support

3 Student Text IAFF Training for Hazardous Materials: Technician Module 12: Patient Support Module Description This module describes how to assess, treat, and transport patients who have been exposed to hazardous materials or injured in such incidents. The first part of the module covers the assessment and treatment of emergency personnel as patients, while the latter part covers patients who are not connected with the response. Prerequisites Students should have completed a hazardous materials operations level training program. Students must be certified to the Emergency Medical Technician or Paramedic level. Module 12: Patient Support 12-3

4 IAFF Training for Hazardous Materials: Technician Student Text Objectives Upon completion of this module, participants will be able to: Objectives Describe the major tasks of EMS providers at a hazardous materials incident List the limitations of chemical protective clothing Discuss health risks associated with PPE use at a hazardous materials incident Describe the elements of pre- and post-entry assessments Describe how to perform gross decontamination on an exposed patient Perform a thorough assessment of patients who have been contaminated with hazardous materials Provide appropriate supportive care depending on the organ system affected Perform or describe the specific care that should be given for exposure to: Asphyxiants Irritants Organophosphate insecticides Smoke inhalation Heat and cold injuries Safely transport patients who have been exposed to hazardous materials NFPA Standards NFPA (b) NFPA NFPA NFPA NFPA (d) (e) 3-4 (a) (b) NFPA (b), 3-4.1, NFPA (b) NFPA , (c) OSHA Standards 29 CFR (q) (6) (iii) (C) 29 CFR (q) (6) (iii) (C) 29 CFR (q) (6) (iii) (C) 29 CFR (q) (6) (iii) (C) 29 CFR (q) (6) (iii) (C,G) 29 CFR (q) (6) (iii) (C) 29 CFR (q) (6) (iii) (C, I) 29 CFR (q) (6) (iii) (C, I) 29 CFR (q) (6) (iii) (C) Instructor Preparation 12-4 Module 12: Patient Support

5 Student Text IAFF Training for Hazardous Materials: Technician References Emergency Medical Response to Hazardous Materials Incidents, Richard Stilp and Armando Bevelacqua Approximate Length This module requires approximately eight to sixteen hours, depending on the experience level of your students and the activities you schedule. Module 12: Patient Support 12-5

6 IAFF Training for Hazardous Materials: Technician Student Text 12-6 Module 12: Patient Support

7 Student Text IAFF Training for Hazardous Materials: Technician Module 12 Prerequisite Quiz 1. How should a seriously injured patient who has been contaminated with a toxic chemical be decontaminated? A. The patient should undergo full decontamination prior to medical treatment B. The patient should undergo full decontamination after medical treatment C. The patient should undergo gross decontamination prior to medical treatment D. Medical treatment takes priority; the patient should not be decontaminated at the scene 2. How should burns from alkali corrosive agents be treated? A. The chemical should be blotted dry and the burn covered with a dry dressing B. The chemical should be blotted dry and the burn covered with a wet dressing C. The chemical should be thoroughly flushed and the burn covered with a dry dressing D. The chemical should be thoroughly flushed and the burn covered with a wet dressing 3. Which of these asphyxiants carries the highest risk of secondary contamination? A. Carbon monoxide B. Cyanide C. Hydrogen sulfide D. Methane 4. The acronym DUMBELS is associated with symptoms produced by exposure to which of the following insecticides? A. Organophosphates B. Organochlorines C. Pyrethrins D. Carbamates 5. Victims of heat stroke experience: A. Rapid, weak pulse and flushed, dry skin B. Rapid, strong pulse and flushed, dry skin C. Rapid, weak pulse and heavy perspiration D. Slow pulse and flushed, dry skin 6. Exposure to hydrogen fluoride can cause depletion of blood: A. Oxygen B. Nitrogen C. Red blood cells D. Calcium Module 12: Patient Support 12-7

8 IAFF Training for Hazardous Materials: Technician Student Text 7. Carboxyhemoglobin occurs when carbon monoxide inhibits: A. The blood s ability to carry oxygen B. Gas transfer through the lungs C. Blood flow D. Heart rhythm 8. Cyanide is easily absorbed through: A. Inhalation B. Skin absorption C. Ingestion D. All three routes of exposure 9. How should hypothermic patients be treated? A. The patient should be warmed quickly by total immersion in warm water B. The patient should be warmed slowly by placing heat packs close to the body C. The patient should be warmed quickly by placing heat packs on the extremities D. Extremities should be warmed quickly and the torso slowly 10. Which of the following chemicals can produce methemoglobinemia? A. Hydrogen sulfide B. Carbon monoxide C. Cyanide D. Nitrates 12-8 Module 12: Patient Support

9 Student Text IAFF Training for Hazardous Materials: Technician Introduction Questions 1. A patient contaminated with an organophosphate insecticide is in severe respiratory distress. Should s/he be decontaminated prior to treatment? Why or why not? 2. For hazardous materials entry team members, what are the exclusion criteria for vital signs (temperature, resting pulse, and blood pressure)? 3. What effect does carboxyhemoglobin have on the body? What is one chemical that can cause this? A primary role of EMS personnel at hazardous materials incidents is to help protect the health and safety of emergency responders. The safety of response personnel, however, is ultimately the responsibility of the Incident Commander. The Incident Commander appoints an Incident Safety Officer, who ensures that the following tasks are accomplished: Adequate personnel are on hand to safely achieve objectives Personal protective equipment (PPE) is appropriate for the tasks to be performed Work/rest cycles reflect on-site conditions and are supervised and controlled Activities in Warm and Hot Zones are closely monitored and dangerous conditions are identified and corrected Personnel working in the Warm and Hot Zones are properly trained to wear PPE and receive medical monitoring before and after entry Adequate records concerning the health status of personnel and incident related activities are maintained Module 12: Patient Support 12-9

10 IAFF Training for Hazardous Materials: Technician Student Text Emergency medical personnel can provide important assistance in each of these areas. In doing so, they help ensure the health and safety of emergency responders Module 12: Patient Support

11 Student Text IAFF Training for Hazardous Materials: Technician Personal Protective Equipment The purpose of personal protective clothing and equipment is to protect emergency responders from chemical, physical, and biological hazards they may encounter during hazardous materials emergency response. Select PPE carefully so that it provides adequate protection against the hazardous materials that are present, while allowing you to complete response tasks. For this reason, PPE can only be used in conjunction with other protective measures, including work/rest cycles and a medical surveillance program. Moreover, personnel should never don protective clothing if they have not been trained in its use. The use of personal protective equipment can present significant hazards. Generally, increased levels of PPE are associated with increased risks for the wearer. Limitations/Complications When working in EMS, you must recognize the limitations or complications that PPE can impose on emergency responders. These include: Limited mobility: PPE adds bulk and weight that can slow movement, restrict activity, and contribute to increased oxygen needs and fatigue. Limited visibility: Face masks of SCBA and the face shields of encapsulated suits diminish peripheral vision and can distort the wearer s view. This compounds visibility problems that may already be present as a result of smoke, darkness, or other environmental conditions. Limited communication: Voice communication is impaired or impossible unless radio transmitters are available within encapsulated suits. Even these radio systems can fail or operate poorly. Hand signals are often the only means of communication, particularly if the ambient sound is high. Module 12: Patient Support 12-11

12 IAFF Training for Hazardous Materials: Technician Student Text Limited dexterity: Multiple layers of gloves and bulky protective clothing can interfere with fine motor dexterity, limiting the types of work that can be safely performed. Limited endurance: The extra energy required to carry the weight of protective clothing and the use of SCBA reduces the wearer s level of endurance, making work scheduling an important factor. Limited air supply: Most chemical protective fullyencapsulating clothing is worn with self-contained breathing apparatus (PP SCBA). PP SCBA provides a limited quantity of air and this governs the amount of time emergency responders can remain in the hazard zone. In addition, the increased exertion caused by the physiological and psychological stress of PPE may further reduce the duration of the air supply. It is easy to see how these factors complicate the use of PPE during emergency response. Such limitations can substantially impact the safety of emergency responders. Because patient assessment and treatment requires the use of the senses and fine motor dexterity, you may need to modify your approach to health care when you are wearing PPE or assisting someone who is wearing it. Health Risks General Considerations The limitations of personal protective equipment clearly have the potential to affect scene safety. In addition to interfering with normal activities, the use of PPE creates physical and psychological stresses. All responders operating at the emergency incident scene must be properly trained to detect and report these stresses. Potential health problems should then be brought to the attention of the appropriate sector officer or EMS provider. Examples of possible problems include: Degradation of personal protective equipment Perception of odors Module 12: Patient Support

13 Student Text IAFF Training for Hazardous Materials: Technician Skin irritation Unusual residues on PPE Discomfort or pain Trouble breathing Fatigue due to respirator use Unexplained problems with vision or communication Abnormal restriction of movement Other symptoms such as rapid pulse, nausea, or chest pain Evidence of heat stress Neurological problems Hazardous Exposures You may be exposed to hazardous materials at an incident if your PPE is inappropriate or it fails. Proper protective ensemble selection is a key factor in preventing exposures. Throughout the incident, monitor the integrity of your PPE for degradation or any damage that would allow chemicals to breach its protective barrier. Asphyxiation Asphyxia is a medical condition caused by a lack of oxygen in the blood. The obvious causes of asphyxiation are related to oxygen-deficient atmospheres or the presence of chemical asphyxiants such as cyanide that disrupt the body s ability to process oxygen and carbon dioxide. Identify these conditions through proper scene assessment so that you can use adequate respiratory protection, including breathing air supplied under positive pressure. Monitor your supply of breathing air closely. Adequate breathing air must be on hand for all phases of emergency response, including the decontamination process. The exact time an entry team member is on air must be monitored, taking into account the added use rate that occurs with increased activity and workload. Heat Injuries Heat-related injuries are a serious health problem during emergency operations, particularly when fully encapsulating PPE is worn. Health effects due to hyperthermia or high body temperature can range from transient fatigue to serious Module 12: Patient Support 12-13

14 IAFF Training for Hazardous Materials: Technician Student Text illness or death. There is a direct relationship between the amount and type of PPE worn and reduced work tolerance and heat stress. This is because PPE adds weight and bulk, increases energy expenditure, and interferes with the body s normal heat exchange mechanisms such as evaporation. Effective prevention of heat injuries is based on adequate hydration of personnel, control of work schedules and their duration, and monitoring for early signs of hyperthermia and level of fitness. Psychological Effects of PPE Wearing personal protective equipment can produce strong and potentially uncontrollable behavioral reactions in some emergency responders. Fully encapsulated suits, for example, can cause a sense of claustrophobia and constraint. These types of problems are often related to lack of familiarity with PPE and can be minimized with adequate training in its use. Despite training, however, combined events during an incident may bring about stress reactions that can be manifested in various ways. As part of safety monitoring, watch for signs of panic or other psychological distress in those who wear PPE. You must be constantly aware of the health and safety status of your partners. Monitoring for distress is part of that awareness Module 12: Patient Support

15 Student Text IAFF Training for Hazardous Materials: Technician Pre and Post Entry Assessment of Personnel All responders must have a baseline assessment before donning chemical protective clothing. This applies to members of the decontamination team as well as the entry and backup teams. The assessment has two purposes. The first is to determine whether the responder is fit at that time to conduct operations while wearing the required level of PPE. The second is to establish baseline data on physical factors that will be monitored for changes throughout the work period. Prior to Entry Only individuals who have previously been approved by a physician for work in chemical protective clothing and the use of self-contained breathing apparatus can be considered for work in such equipment. The health status of potential members of the Entry Team and Backup Team must be checked before protective clothing is donned. At a minimum, check and record blood pressure, pulse, respiratory rate, oral temperature, and weight. In addition, follow a checklist to assess each individual regarding: Recent illness (especially with diarrhea or vomiting) Sunburn Recent medication use, such as antihistamines, that might affect fluid balance Any responder with upper respiratory tract infection or signs of a gastrointestinal illness should not be allowed to wear PPE. Consult your department s physician or an occupational health physician regarding criteria for excluding an individual from work in chemical protective clothing based on this pre-entry assessment. In general, it is a good idea to recheck the vital signs of any individual with an elevated Module 12: Patient Support 12-15

16 IAFF Training for Hazardous Materials: Technician Student Text oral temperature (greater than 99 F), a resting pulse greater than 100 beats per minute, or a blood pressure in excess of 150/90. If any of these vital signs remain elevated after resting for several minutes, the individual should not don and work in protective clothing. Fluids should be taken by all members donning protective equipment to compensate for excessive water loss through sweating. Fluid consumption should be about 8-16 ounces; additional fluids may cause bloating. Each individual donning chemical protective clothing must be assessed before donning the suit, between any air bottle changes and after completion of the assigned work. Your initial assessment must be quick but thorough and you should have authority to make final recommendations regarding each individual s suitability for the work. Your baseline findings must be recorded so that you can compare them with later assessments. The findings from periodic and post-entry assessments must also be recorded. These should help you determine whether the responder needs further medical attention. If no further attention is needed, the responder can return to the staging area after adequate time in the rehabilitation area. Exclusion criteria for donning PPE should be established well in advance. All EMS personnel should be familiar with these criteria and should strictly follow them. During Rehabilitation Breaks Monitor each individual s physical condition as early as possible during each rest period. Observe and record the following to detect early signs of heat-related injuries. Heart Rate: The radial pulse during a 30-second period should be counted as early as possible in any rest period. If the heart rate exceeds 110 beats per minute at the beginning of the rest period, the next work cycle should be shortened by one-third. Other indications that the work is too strenuous under ambient conditions include a resting heart rate (after 3 minutes) greater than 90 beats per minute. If the pulse is irregular, the fire fighter should not be allowed to work and should be evaluated by a physician Module 12: Patient Support

17 Student Text IAFF Training for Hazardous Materials: Technician Temperature: A clinical thermometer should be used to measure temperature orally or aurally at the end of the response activity and before fluids are taken. If temperature exceeds 99.5 F (37.5 C), the next work period should be shortened by at least one-third. Never permit a fire fighter to work when his or her temperature exceeds F (38 C). In addition, skin temperature may be checked with a disposable, adhesive device applied to the chest. As the skin temperature and oral/ aural temperature approach the same value, the risk of heat-related illnesses increases. Blood Pressure: Although guidelines for blood pressure with regard to preventing heat stress have not been established, a responder should extend his or her rest period if blood pressure exceeds 150/90. A blood pressure of less than 90/60 may indicate a state of dehydration in which the body is failing to compensate. In that case, additional fluids, rest, and monitoring are required. Body Water Loss: Weight should be measured on a scale accurate to pounds prior to any response activity. Compare this weight with the individual s normal body weight to determine if enough fluids have been consumed to prevent dehydration. Similar clothing (always dry) should be worn each time the individual is weighed. The body water lost should not exceed 1.5 percent of total body weight. Follow the above guidelines to monitor all personnel for signs of heat injury, even those who are not wearing protective equipment but are judged to be at risk of a heat-related illness. In addition to signs of heat injury, observe responders for signs and symptoms of chemical exposure. Activity Module 12: Patient Support 12-17

18 IAFF Training for Hazardous Materials: Technician Student Text Post-Entry Assessment Everyone going through decontamination procedures should be assessed for signs and symptoms of exposure. If it appears that a worker has been exposed, inform the Safety Officer immediately since there may be an unknown or unexpected problem that is causing additional workers to be exposed. Persons who have been exposed must then be treated as patients. If there is any possibility of secondary exposure, EMS personnel should be appropriately protected. Post-incident assessment should include a final check of vital signs and a comparison to baseline data as well as an evaluation of any signs of exposure or injury. It is important to do a neurological assessment to determine if level of consciousness has been affected. Entry team members should also have fluids replenished with at least eight ounces of water or other hydrating liquid. Arrangements must be made, in consultation with the physician, to provide for follow up care for any problem that has occurred and for any exposures that may result in a delayed toxic response. In some cases, it may be necessary to devote time to a Critical Incident Stress Debriefing (CISD). The purpose of CISD is to help responders deal with traumatic events. This debriefing may be helpful in several situations, such as incidents where response personnel were exposed to hazardous materials with unknown effects; incidents involving chemicals linked with long-term health effects, such as cancer; or incidents involving civilian or fire fighter death. CISD should be held within 48 hours of the event to be most effective. Further information about stress management programs can be obtained from the U.S. Fire Administration, Office of Fire Fighter Health and Safety, S. Seton Avenue, Emmitsburg, Maryland Module 12: Patient Support

19 Student Text IAFF Training for Hazardous Materials: Technician Records Documents of all monitoring and health care during the incident should be completed and maintained in the confidential health records of each individual. It is also important to complete incident and exposure reports. These reports will help health and safety personnel determine whether responders require follow-up or postexposure monitoring. They will also serve as a future reference if any health problems develop later. Records of an incident should include the following information: Incident factors such as time and weather Agent(s) involved Measured exposure levels On-scene action taken Injuries sustained, treatment given Follow-up action taken Short term effects Long term effects By documenting and tracking exposures, your department may be able to discover reasons for the exposures and take measures to prevent them in the future. Module 12: Patient Support 12-19

20 IAFF Training for Hazardous Materials: Technician Student Text Module 12: Patient Support

21 Student Text IAFF Training for Hazardous Materials: Technician Patient Care In many ways, patient care at hazardous materials incidents is similar to patient care at EMS calls. Your assessment of the patient is systematic. Your priorities include establishing an airway and ensuring breathing and circulation, then addressing other injuries or medical conditions in order of severity. Since you should already be proficient in routine patient care, only the areas specific to hazardous material contamination, health effects, and treatment strategies are presented. There are a few antidotes for specific chemical exposures and these are discussed after general treatments for each body system. Decontamination Typically, EMS personnel are not trained and are not expected to perform patient decontamination. However, you should be familiar with these procedures so that you will know what to expect at hazardous materials incidents. Remember that exposure to a hazardous substance and contamination with that substance are two different problems. For example, a victim who has been exposed to carbon monoxide or another simple asphyxiant must be moved to fresh air, but does not need to be decontaminated. However, exposures to other substances are likely to result in contamination, in which the substance clings to the patient s skin, clothing, or hair. In order to prevent continued exposure and the risk of secondary contamination, patients must undergo decontamination prior to treatment. If patients need immediate medical treatment, emergency decontamination should be performed. In emergency decontamination, the primary concern is to prevent severe injury or loss of life. At the same time, contaminants must be removed to prevent ongoing exposure to the patient and exposure to response personnel through secondary contamination. Even in an emergency, decontamination should follow a specific sequence. Outer, more heavily contaminated items are decontaminated and removed first, followed by less contaminated Module 12: Patient Support 12-21

22 IAFF Training for Hazardous Materials: Technician Student Text articles of clothing. Gloves and boots or shoes may require more extensive decontamination than shirts or jackets. In cases where the victim is wearing street clothing or other materials that are not easily decontaminated, the outer clothing should be removed. Dry contaminants should be brushed off the skin. Liquid contaminants can be blotted dry. Care must be taken to keep all contaminants away from the face and open wounds. Affected skin and mucous membranes (including the eyes) should be flushed with lukewarm water for at least 15 minutes. Cold water can be used if lukewarm water is not available. Large amounts of water must be used when corrosives are involved. When multiple areas of the body are affected, priority should be given to particularly vulnerable areas, such as the eyes. If the contaminating substance is not water soluble, as with oily materials, the skin (but never the eyes) should be washed gently with a solution of liquid soap in water. The solutions and water used for decontamination should not be allowed to run onto unprotected areas of the body. Used water and solutions should be contained if possible. This protects the environment and simplifies cleanup. However, individual emergency care is a high priority, so delays in decontamination due to concern about runoff should be avoided. Like all standard operating procedures, decontamination and emergency decontamination must work in a wide range of environments. For example, decontamination procedures should be written so that they are easily modified during winter. All procedures, including alternative procedures, must be developed and practiced in cooperation with other involved organizations, such as hospital emergency departments. Patients and personnel who do not need immediate medical attention should undergo thorough decontamination. For responders in turnout gear, the surface of clothing should be scrubbed with a detergent solution and thoroughly rinsed with water. The clothing is then removed so the responder can take a personal hygiene shower at the scene to prevent the spread of offsite contamination. Protective clothing and equipment is bagged for testing and treatment or disposal Module 12: Patient Support

23 Student Text IAFF Training for Hazardous Materials: Technician Full Decontamination Civilian patients are likely to have exposed skin surfaces because street clothing will not resist water nor penetration of chemicals. In fact, clothing will tend to trap contaminants close to the skin. Generally, it is most effective to remove clothing by cutting. The patient should then be washed or allowed to shower. Special care must be taken to avoid skin abrasions that allow for easier absorption of hazardous chemicals. Flush any affected skin or mucous membranes (including the eyes) with lukewarm water. Use cold water if lukewarm water is not available. Flood with large amounts of water in all cases. This is especially important because some chemicals, such as calcium chloride (lime), form a corrosive liquid when mixed with water. Other chemicals, such as sulfuric acid, will react with water to produce heat. Using large amounts of water allows the material to be washed away while absorbing some of the heat generated by the reaction. Water being used for flushing should run off the individual and not onto other areas of the body. Cover irrigated wounds with sterile towels or gauze to prevent runoff onto other areas of the body. Replace the dressing as soon as it becomes saturated or irrigation is complete. In any case, contain used rinse water, if possible. When multiple areas of the body are affected, priority should be given to particularly vulnerable areas, such as the eyes. Flush eyes from the inside corner toward the outside corner, holding the eyelids open, if necessary. Flushing should be done gently to avoid splashing or damage to burned skin. Body creases, hair, nail beds, and any open wounds must be flushed. If the contaminating substance is not water soluble, as with oily materials, wash the skin (never the eyes) gently with a solution of liquid soap in water. Contain any waste water for later treatment or disposal. When the contaminant is a dry agent, do not wet it or wash the patient until contaminants have been removed (as much as possible) by lightly brushing the material from the surface. Module 12: Patient Support 12-23

24 IAFF Training for Hazardous Materials: Technician Student Text When a patient is contaminated with liquid materials, remove the clothing quickly and follow with a thorough washing using large amounts of water to dilute the material. Soap can be used as needed to remove remaining contaminant. If contaminants on skin have any corrosive properties (such as acids or bases), continue flushing with water for at least 20 minutes. Patients exposed to toxic gases may still be contaminated even though they are no longer in the gas cloud. This is particularly true of vapors (the gas form of a liquid) and dusts (small solid particles suspended in air). Clothing should be removed rapidly and the patient decontaminated by washing. Activity Remember to confine the runoff so it can be picked up and disposed of, if practical. Do not delay life-saving actions to contain run-off. Contaminated clothing and small equipment should be placed in plastic bags for decontamination or disposal. The bags should be labeled as a biohazard or contaminated and the label should describe what the bag contains. Use transparent bags to contain items contaminated with chemicals so cleanup and disposal personnel can see the extent of contamination. Like all standard operating procedures (SOPs), your department must be able to carry out decontamination and emergency decontamination procedures in a wide range of environments. For example, decontamination procedures may have to be modified during the winter season. Or, alternate procedures may have to be developed in cooperation with other organizations, such as a specific hospital emergency department. SOPs should also include procedures for collecting or containing contaminated runoff. However, since individual emergency care is a high priority, do not delay care due to concern about runoff. All decontamination should occur in the Warm Zone. This removes patients from the area of contamination (the Hot Zone) and prevents the spread of hazardous materials to uncontaminated areas (the Cold Zone). Contaminated victims who are ambulatory upon arrival of emergency personnel should be instructed to wait in a well-ventilated, Module 12: Patient Support

25 Student Text IAFF Training for Hazardous Materials: Technician protected area until a decontamination area is established. Responders performing decontamination must be adequately protected against the hazard. This may mean that decontamination personnel wear chemical protective clothing in addition to self-contained breathing apparatus (SCBA) and other routinely worn gear. Because EMS personnel do not typically use this equipment, your contact with patients will probably begin after most of the hazardous substance has been removed. Patient Assessment Activity A triage area should be established away from (and upwind of) the source of contamination. Impress upon the Incident Commander that the triage area must be far enough from the incident so that it will not have to be moved if there is a shift in wind direction. Always choose security over proximity when selecting this location. In triage, you identify the most critical injuries and establish priorities for treatment. When hazardous materials are involved, however, all personnel must remain on guard to avoid being contaminated by the victims. Though decontamination should eliminate this risk, you and other personnel in the area should be alert to any signs and symptoms of exposure among EMS personnel. Patient Assessment In addition to routine triage assessment of patients, you should determine the following: To what degree is each injury related to the hazardous materials involved? Which injuries are most severe and should be treated first? What is the route of entry to the body (inhalation, ingestion, skin, eye)? Are delayed effects of exposure possible? Module 12: Patient Support 12-25

26 IAFF Training for Hazardous Materials: Technician Student Text Keep in mind that signs and symptoms related to hazardous materials exposure may not be obvious. Respiratory distress may be delayed, skin may be burned or irritated in areas that are not readily apparent, or patients may not realize they were exposed. Check with the Incident Safety Officer regarding the identity of all materials involved, the likely symptoms of exposure and appropriate protective measures for EMS personnel. Your patient s condition can change rapidly depending on the hazardous materials involved. Vital signs, especially blood pressure, pulse and respiration must be monitored frequently. Tagging Patients Tagging (with triage assessment) allows you to prioritize patient care, particularly when more than one patient is involved. Subsequent treatment for each patient should be based on this information. Tag information should include: Vital signs Signs and symptoms Materials the patient was exposed to Exposure routes and duration Treatment to date Additional injury assessment Chronic illness Allergies Current medication Good triage assessment and tagging (even with a single patient) speeds admitting and treatment at the hospital. General Treatment Check and maintain the patient s airway, breathing and circulation as soon as possible. Begin other treatment only after the patient is in the triage area. As with all patients, BSI (body substance isolation) latex gloves, eye protection, and fluid resistant garments should be used to prevent exposure to blood and body fluids. Also remember that emesis (vomiting) can be a source of secondary contamination. If you are likely to need additional protective garments, you should be trained in their use prior to an incident Module 12: Patient Support

27 Student Text IAFF Training for Hazardous Materials: Technician Protect patients by clothing them in disposable gowns and slippers. If patients still have contaminated possessions, even after leaving the decontamination area, bag these for later decontamination or disposal. Administration of emergency medical care should be based on the type of agent or agents involved, signs and symptoms, and the body systems that are affected. It is also important to prevent secondary contamination of equipment, if possible. Contaminated equipment must remain out of service until it is decontaminated. In some cases, contaminated equipment will have to be disposed of and replaced. While this may limit usable equipment and hinder operations, disposal may be the only safe solution. Module 12: Patient Support 12-27

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29 Student Text IAFF Training for Hazardous Materials: Technician Supportive Care Only a few chemicals have specific antidotes that you can use to reverse their effects. For the most part, you will investigate the organ systems affected by the hazardous materials and provide symptomatic relief for those systems. The following are general guidelines for care based on signs and symptoms. Your department must, however, develop protocols with assistance from a medical director. Cardiopulmonary Effects In hazardous materials incidents, toxic substances that affect the heart and lungs are usually inhaled. This may cause coughing, difficulty breathing, cyanosis, abnormal pulse or respiratory rates, or chest pain. If conscious, the individual should rest in the position where breathing is most comfortable; often this is a sitting position. Keep the affected individual quiet and warm, administer oxygen, and check vital signs frequently. Very slow or very fast resting heart rates (less than 60 or greater than 100) and irregular heart beats are particularly important. Significant changes in either systolic or diastolic blood pressure should also be noted. In all cases, watch for vomiting and never leave the affected individual unattended. If the patient is unconscious but breathing, your priorities are to maintain an airway, administer oxygen, and monitor vital signs. If breathing has stopped, administer artificial respiration. A bag-value mask with oxygen can be used to deliver breaths; however, it is much more effective to deliver breaths through an endotracheal tube. Only those individuals trained and experienced in advanced cardiac life support and intubation should perform such procedures. Keeping in mind the ABCs of basic life support Airway, Breathing, and Circulation it is also essential to monitor the pulse and administer chest compressions if necessary. Again, if personnel trained in advanced cardiac life support are available, protocols for treating cardiac arrhythmias should be implemented. Activity Module 12: Patient Support 12-29

30 IAFF Training for Hazardous Materials: Technician Student Text Skin and Eye Effects Pain, irritation, redness, and other observable changes are indicators of toxic effects. The decontamination procedures already mentioned are the first steps in caring for these injuries. Continued flushing of skin, eyes, and mucous membranes requires large amounts of water in a gentle stream from any source, such as an IV setup, bulb syringe, low pressure hose, or bucket. Flushing to counteract the effects of a corrosive or irritant should be continued for at least 20 minutes. Flushing should begin again if burning or irritation continues. In some cases, it may be necessary to continue flushing procedures during transport. If the effects of the corrosive or irritant are minimal, and you have flushed the affected area for at least 20 minutes, dry the area gently and apply a dry sterile dressing for transport. Wet dressings should not be applied, particularly to burns from alkali corrosive agents such as calcium carbide, sodium hydroxide, or potassium hydroxide. If the skin is not fully decontaminated, application of a wet dressing could result in a reaction between the alkali and the water. This reaction would generate heat, increasing damage to the affected area unless enough water was applied to draw off the heat of the reaction. In case of eye exposure, thoroughly flush the eyes and cover them with moistened pads, unless the exposure involves alkali corrosives. Under no circumstances should an individual rub the eyes. Alkali burns to the eyes are a serious emergency and the eyes must be irrigated for 30 to 60 minutes with normal saline solution. Water may be used if normal saline is not available. Activity Module 12: Patient Support

31 Student Text IAFF Training for Hazardous Materials: Technician Gastrointestinal System Effects Many toxic substances absorbed through different routes of entry can affect the gastrointestinal system. Nausea and vomiting are frequently seen with gastrointestinal exposures to a wide variety of toxicants. Supportive measures that can be given on-scene include keeping the affected individual quiet and comfortable. Never give food or fluid to someone who is feeling very nauseated or who has vomited. There is always the risk that the individual will vomit, then inhale the food or fluid. If a contaminant was ingested, consult the appropriate sources for information on emergency care procedures. Sources include regional poison control centers, manufacturer s medical staff (manufacturer s numbers can be obtained from Material Safety Data Sheets or through CHEMTREC), the Agency for Toxic Substances and Disease Registry, or written references. With many toxic substances, particularly corrosives, vomiting should not be induced. Rather, the material should be diluted with water or milk. If it is not clear that a specific action is appropriate, it is best to simply transport the individual to an emergency medical care facility as soon as possible. Activity Neurotoxicants Toxic substances that affect the nervous system may cause signs and symptoms that range from headache to changes in mental status, altered sensation or muscle control, seizures, or loss of consciousness. It is important to carefully note all symptoms, particularly any changes from baseline behavior or ability. Central nervous system functions such as speech, balance, memory, and personality may be affected. Assess peripheral nervous system functions, including fine motor control and sensation. Keep the affected Module 12: Patient Support 12-31

32 IAFF Training for Hazardous Materials: Technician Student Text individual quiet and minimize stimulus to the patient, such as lights and noise. Since the effects may be unpredictable, take vital signs frequently. Activities Module 12: Patient Support

33 Student Text IAFF Training for Hazardous Materials: Technician Patient Treatment Agent-Specific Care As discussed so far, the overall approach to emergency care at hazardous materials incidents involves gross decontamination, establishing an airway, breathing, and circulation and symptomatic treatment. In addition, there are several toxic agents for which specific treatments or antidotes are available. Asphyxiants Simple Asphyxiants Asphyxiants are agents that produce hypoxia (low oxygen in the body s tissues). As mentioned earlier, asphyxiants are divided into two groups. Simple asphyxiants produce hypoxia by displacing oxygen from the environment. Simple asphyxiants cause no effect other than filling the atmosphere and pushing out the oxygen. Examples of simple asphyxiants are nitrogen (N2), used as an industrial inerting gas; carbon dioxide (CO2), encountered in carbohydrate fermentation sites such as breweries, grain elevators, and winery vats; methane (CH4), found in mine tunnels and manure storage tanks; and other combustible fuels (primarily short-chain hydrocarbons, including ethane (C2H6), propane (C3H8), and butane (C4H10). Signs and symptoms of exposure are caused by hypoxia alone. Symptoms include headache, nausea, confusion, collapse, seizures, and death. Treatment for simple asphyxiants includes removing the affected individual from exposure and delivering 100% oxygen. Do not give high concentrations of oxygen to people with severe chronic lung disease. In these cases, give lower concentrations of oxygen. Simple asphyxiants work only by producing an oxygendeficient atmosphere, so there is no potential for secondary contamination. Module 12: Patient Support 12-33

34 IAFF Training for Hazardous Materials: Technician Student Text Chemical Asphyxiants Chemical asphyxiants act within the body to interfere with either oxygen delivery to cells or oxygen use by cells. The symptoms caused by chemical asphyxiants are similar to those caused by simple asphyxiants, but because of the different mechanisms of action, there is the added danger of secondary contamination. The potential for asphyxiation of unprotected emergency care personnel exists when a chemical asphyxiant is carried on the skin or clothing of the affected individual. Common chemical asphyxiants include carbon monoxide, cyanide, and hydrogen sulfide, with carbon monoxide being the most likely to be encountered by emergency response personnel. Carbon Monoxide Carbon monoxide (CO) exposure is the leading cause of fatal poisoning in the U.S. It is commonly found in the fire environment. Carbon monoxide acts by binding to hemoglobin, the oxygen-carrying component of red blood cells. This carboxyhemoglobin cannot bind with oxygen. As a result, the exposed individual becomes hypoxic because the red blood cells are unable to deliver oxygen to the body s cells. Examples of other situations that may produce carbon monoxide are those that involve poorly functioning engines or heaters, or other sources of incomplete combustion. Signs and symptoms of carbon monoxide poisoning vary according to the level of exposure. At low levels, symptoms include headache, nausea, and possibly chest pain due to poor oxygenation of the heart muscle. Chest pain is usually seen only in individuals with underlying heart disease. At moderate levels of exposure, symptoms may include confusion, dizziness, and loss of consciousness. High-level exposures result in collapse, seizures, and coma Module 12: Patient Support

35 Student Text IAFF Training for Hazardous Materials: Technician You will not see the cherry red skin associated with carbon monoxide poisoning until there are very high levels of carbon monoxide in the blood. You can make the definitive diagnosis of carbon monoxide poisoning only by obtaining a carboxyhemoglobin blood level. Treatment for carbon monoxide poisoning is administration of oxygen at 100% with non-rebreather mask. The usual exception for those people with chronic lung disease applies here as well. It will help emergency room personnel make the diagnosis of CO poisoning and plan the appropriate treatment if you draw a carboxyhemoglobin blood level at the scene prior to oxygen therapy and transport it with the affected individual to the hospital. Although carbon monoxide is a chemical asphyxiant, the risk of secondary contamination is low. This gas easily mixes with the atmosphere, so air concentrations of carbon monoxide are likely to be low once the affected individual is moved to fresh air. Cyanide Cyanide (CN) is highly toxic and rapidly fatal at high doses. It is easily absorbed through all three routes of exposure. Since secondary contamination can occur, emergency response personnel must take appropriate precautions. Hydrogen cyanide (HCN) is commonly used in the production of pesticides. Examples of other situations involving cyanide are polyurethane foam fires. The combustion of some plastics, such as acrylonitrile, releases cyanide on burning. Hydrogen cyanide is also formed when acids come in contact with a cyanide compound. It is found in insecticide production, electroplating processes, metal processing, and other industrial settings. Signs and symptoms of cyanide poisoning include headache, dizziness, and confusion. This may progress to hyperventilation and tachycardia, and eventually collapse, seizures, coma, or death. Diagnosing cyanide Module 12: Patient Support 12-35

36 IAFF Training for Hazardous Materials: Technician Student Text poisoning may be difficult. The classic bitter almond smell associated with cyanide is unreliable, and its symptoms are similar to those of carbon monoxide poisoning. Unlike carbon monoxide poisoning, however, routine tests for cyanide poisoning are typically not done. Thorough pre-incident planning and hazard identification should alert emergency response personnel that a cyanide hazard may be present. Treatment of symptoms associated with cyanide poisoning requires 100% oxygen, assisted ventilation, insertion of IV lines, and cardiac monitoring. In individuals with mild symptoms, this supportive care may be sufficient for recovery. In individuals with moderate to severe symptoms, such as deterioration in mental status, start specific treatment for cyanide poisoning. The specific treatment of cyanide poisoning involves several steps. If you expect to treat patients outside a health care setting, protocols and standing orders must be established beforehand. Those responsible for administering the medications must be thoroughly trained in these procedures. Kits for treatment of cyanide poisoning are available. Hydrogen Sulfide Hydrogen sulfide (H2S) is a colorless gas with a smell of rotten eggs. At low levels, hydrogen sulfide is an irritant that affects mucous membranes, the eyes, and the skin. H2S is extremely caustic even at very low concentrations. Examples of situations that may produce H2S are sewers, crude oil storage tanks, crude oil pipeline leaks, coal mines, or anywhere that organic material is decomposing. Signs and symptoms of exposure to hydrogen sulfide at moderate levels include respiratory tract irritation, headache, and dizziness. Continued exposure at high levels may result in pulmonary edema, collapse, coma, and death. Since hydrogen sulfide deadens the sense of smell, it is possible for unprotected individuals to inhale fatal amounts of the gas without realizing it. Brief exposures to high levels (greater than 300 ppm) may Module 12: Patient Support

37 Student Text IAFF Training for Hazardous Materials: Technician cause nearly instantaneous collapse. While there is little risk of secondary contamination to emergency response personnel, the affected person must be removed to an area far from the hydrogen sulfide source before care is given. Treatment for hydrogen sulfide exposure includes adequate ventilation and circulation. As with other asphyxiants, the individual must be given maximum oxygen flow. Supportive care and oxygen may be sufficient for recovery because the life of sulfides in oxygenated blood is short. Toxicants that Induce Methemoglobinemia Hemoglobin carries the oxygen component in blood. The condition known as methemoglobinemia impairs this function. Mild methemoglobinemia (a low concentration of this altered form in the blood) can be tolerated. More severe methemoglobinemias (greater than 25% methemoglobin relative to normal hemoglobin) are dangerous. Examples of chemicals that produce methemoglobinemia are nitrites (NO2) and nitrates (NO3). These chemicals convert hemoglobin into methemoglobin. Methemoglobinemia may result from a number of drug and chemical exposures involving nitrites. Methemoglobinemia has also been associated with smoke inhalation. Depending on the agent and route of exposure, secondary contamination may result in methemoglobin formation. Signs and symptoms may include headache and difficulty breathing with exertion. Higher levels of methemoglobin may produce lethargy, stupor, and death. These symptoms are the same as those of hypoxia, although the concentration of oxygen in the blood is normal. Nitrate or nitrite exposure is also likely to result in dilation of the blood vessels, therefore tachycardia, hypotension, and cardiovascular collapse may result. Cyanosis may appear before other signs and symptoms. Module 12: Patient Support 12-37