1. Mass Chemical Incidents: Principles of Hospital Management P. Halpern, MD Chair, Emergency Department Tel Aviv Medical Center

2. Granitville NC, Jan 2005, 0200am  The rail crew that parked 2 cars on the side rail by the Avondale Mills facility had not switched the diversion switch back and had gone home hours before an oncoming train with the chlorine railcars arrived.  The event killed nine and temporarily displaced thousands in Graniteville.

3.  Responders from the local volunteer fire department responded to the train crash and subsequent chlorine release without first donning personal protective gear.  Neither law enforcement personnel nor emergency responders seemed trained/drilled/prepared for this scenario.

4.  The area of evacuation was insufficient. A woman who lived 2.5 miles downwind was not evacuated. She awoke that morning feeling weak, and noticed “a strange fog” outside.  She learned about the disaster on TV. When her husband came home later, they left their home and went to relatives, but the chlorine came there also, so they went back home.

5.  The woman did not go to an ED until 4 days after the incident.  There was no notification to her or others about health effects to watch out for. The hospital diagnosed her with pneumonia and gave her antibiotics, which did not help at all.

6. Conclusions When a moderate-sized chemical event occurred in the US, appropriate procedures and capacity were in hand locally or in relatively close proximity, yet much of the available capacity was never or sub optimally employed.

7. Why Should Civilian Doctors Know About Chemical Weapons ?  Agents potentially used by terrorists are involved in industrial and in transportation accidents (e.g. cyanide, acids, phosgene).  Some agents are generated in fires.  Organophosphate insecticides act very much like military nerve gases.  The risk of terrorist incidents involving chemical weapons is now considered substantial.

8. Why should hospitals prepare for chemical mass incidents?  It may never happen, but probably WILL.  It is the hospital’s ethical duty to community to prepare;  It is an effective way to upgrade the entire system!

9. The Level of Awareness is Increasing

10. Current State of Preparedness Data from 30 hospitals FEMA Region III 100% of sites not fully prepared for a biological incident 73% not prepared for a chemical incident 73% not prepared for a radiological incident Treat K.N. Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Annals of Emergency Medicine Nov. 2001

11.  73% would set up a “single room” decontamination process.  13% had no decontamination process.  Only 3% (1 hospital) had chemical antidote stockpile  0% had prepared media statements  25% had “some” training in WMD incidents Current State of Preparedness

12. KA Candiotti: Anesth Analg 2005;101:1135-1140  Poll of all 135 US anesthesiology programs;  37% had any form of training, most did not repeat training after initial sessions.  28% of programs east of the Mississippi reported some training, whereas only 17% of programs west of it reported training available.  The majority of anesthesia residency programs in the US provide little or no training in the management of patients exposed to WMD 27

13. The Differences between non- conventional & conventional MCI l Number of casualties X 10, 100. l Event may be overt or covert. l Requirements for decontamination, staff protection and site contamination disrupt normal facility response. l Disruption of external support may impede response (e.g. traffic jams). l Psychological effects on staff & victims.

14. Okumura T, et al: Report on 640 victims of the Tokyo Subway Sarin Attack. Ann Emerg Med 1996;28:129-135. Time course of ED presentation after Tokyo subway sarin attack Vast majority of victims arrived within 2 hr

15. Tokyo Sarin event Total5,510 Critically ill17 Severely ill37 Moderately ill984 Required Mechanical Ventilation54

16. Considerations for Hospital Preparedness Plan  Obtain commitment from management. It costs money, nobody likes the drills. Without authority and funding nothing will happen!  Designate a clear chain of command.  Personnel must have incentives to train.  Include field personnel in planning - not just managers.  Ensure continuing education for retention.  Review plan periodically for changing threats, environment, staff, equipment, concepts of care, hospital capabilities, funding.

17. Types of chemical events  By advance notice: Advance notice sufficient for organized response Advance notice sufficient for gate control No advance notice  By type of agent: Known vs Unknown Persistent vs Non-persistent Dangerous (requiring protection) vs Non-dangerous

18. Level of complexity of response Persistent, dangerous agent (VX) Volatile, dangerous agent (sarin) Volatile, non- dangerous agent (Cl) No advance notice Short advance notice Sufficient advance notice

19. Steps in response:  Notification  Confirmation  Activation (by senior management)  Activation of plan: decide if event requires decontamination and staff protection or not  Establish command structure, based on available personnel  Agent recognition: Initially clinical by medical staff and specialists Then by specialized local or regional or national, civilian or military staff

20. Identifying a Chemical Event Victim characteristics:  Minimal wounds  Strong odors  Unidentified liquids on body  Respiratory complaints  Eye or mucous membrane complaints  Chemical burns  Neurologic complaints  Rapidly decreasing LOC or unconsciousness  Cardiac arrest

21. Identifying a Chemical Event Event characteristics:  Easy (!) chemical container event recognized  Minor explosion  Multiple victims  Odors noted  Immediate complaints by initially uninjured victims  Victims come from large area

22. Hospital Deployment Scheme for Chemical Events Decontamination Intubation Flow Control Site Initial Triage Walking CasualtiesImmediate Casualties Secondary Triage Mild Pediatric Resuscitation Severe CombinedModerate Disrobe

23. Worst Case Scenario: no advance notice, persistent, hazardous agent  Decision making (senior staff +/- in consultation with expert): Chemical event ? (event and victim characteristics) Dangerous chemical ? Persistent chemical (e.g. chlorine vs terrorist release)? Specific therapy exists for chemical (e.g. organophosphates)?  Declare chemical event in the ED and activate emergency plans.

24.  Hospital and ED perimeter control (gate triage: allow in immediate ALS only);  Activate decontamination facility;  Call up staff;  Coordinate with EMS etc.  Request support (antidotes, ventilators, secondary transfers); Activities in the Hospital

25. Activities in the ED  Continue life-saving procedures by unprotected staff;  Initiate ED evacuation of “regular pts”;  Disrobe all event casualties;  Mark and isolate contaminated area;  Protected personnel to relieve non-protected teams;  Contaminated staff – to self decontamination;  Staff call-up

26.  Deploy ventilators (human or mechanical).  If antidote or specific meds available for specific agent, bring forward.  Deploy O 2 masks, IVs, intubation kits, meds.  Deploy and ensure staff read treatment cards or computer messages for specific agent.  Use public address system to communicate patient care and staff protection policy. Activities in the ED

27. Medications and specific equipment:  Nerve agent meds: Atropine Pralidoxime Scopolamine Benzodiazepines Eye drops β1 agonist, inhaled  Cyanide meds: Na nitrite Na thiosulfate Bicarbonate  Mustard: Burn care meds and dressings Eye drops β1 agonist, inhaled

28. Factors influencing medical management  Is the agent identified?  Type of agent (toxicity, aging, persistence, specific Rx availability).  Route of exposure: inhalation/percutaneous.  Presence and severity of clinical disease.  Elapsed time after exposure.  Number of victims and rate of arrival.  Advance notification.  Available resources (i.e. AM/PM, level of preparedness of facility, available external support).

29. Decontamination of Victims: Principles  Decon site should be close to ED.  Decon site should be operative within 20 min of event recognition.  Clear demarcation and physical barriers between “hot” and “cold” zones.  Strict patient, staff and crowd control is essential.  Single-channel, one-way patient flow is essential.

30. Ready stores  Coherently arranged, clearly labeled, ready to use equipment, close to ED site

31. Decon area at the TASMC

32. Decontamination site during drill “Yellow line”

33. Decontamination procedure Triage carried out by Level C-protected senior personnel:  Dead or dying  Non-ambulatory, requires emergent intubation  Non-ambulatory, does not require emergent intubation  Ambulatory

34. Patients NOT requiring ventilatory support  Placed on wire-mesh gurneys  Given IM antidote (if nerve gas)  Decontaminated  Taken to “yellow line” and handed over as above

35. Ambulatory pt decon  Disrobe down to underwear.  No decontamination is performed, except for vesicant agents.  Anxiety victims are reassured and discharged.

36. Non-ambulatory pt decon  Full disrobing;  Privacy provided as best possible;  Warm water + liquid soap: head to toe, toe to head x2, or 6 minutes.  Bleach (0.5%) controversial (open wounds, eyes).  Decon staff wear Level C PPE.  Decon staff are nurses or paramedical personnel, who can recognize patient deterioration during decon.

37. Decontamination for Vesicants  Initial “dry decontamination”  No scrubbing of skin  Followed by wet decontamination  Emphasis on irrigation of the eyes  Consider using dilute bleach for extreme skin exposure.

38. Care of Multiple Ventilator- Dependent Patients  Large numbers of ventilated pts anticipated  Designate alternate Intensive Care areas  Ensure O 2 supply  Ensure supply of mechanical ventilators and/or manual resuscitators  Train personnel to care for ventilated patients and to ventilate manually

39.  Identify and designate MD & RN trained in mechanical ventilation.  Ensure supplies of disposables and drugs (e.g. HMEs, tubing, sedatives, paralytics).  Prepare data management system (appropriate forms or computerized system).  Standardize care! Disallow multiple protocols and experimental or unproven therapies.  Ensure staff coordination and information dissemination (daily meetings, bulletins etc.) Care of Multiple Ventilator- Dependent Patients

40. Summary  Preparing medical centers for chemical mass events is critical to successful event management, but also ethically and practically correct.  The unique features of a chemical attack make it probably the most challenging event any hospital may ever face.

41. Addendum: Hospital oxygen supplies:  Assume victims=50% of hospital capacity; 25% ventilated, i.e. for 1,000 bed hospital 500 victims, 125 ventilated pts.  Assume 15 lpm/pt, 21,600 liters/24hr/pt, 2,700,000 liters/24 hr/hospital.  Assume 50% require O 2 by mask at 10 lpm/pt, i.e. 250x10x60x24=3,600,000 liters/24hr.  Assume 2,000,000 for rest of hospital use.  Total: 8,300,000 liters/24 hr.  My hospital’s total storage capacity: ______

42.  Assume 40-bed ward, 20 ventilators @ 15lpm.  Assume ventilators require pressure > 3.5 Atm.  Assume 18 mask O 2 pts @ 10 lpm.  Assume 2 CPAP pts @ 100 lpm.  Assume 100 lpm surge flow (sudden opening of flow meter, new patient connected to CPAP)  Total required FLOW: 680 lpm.  Assume pressure drop along tubing and check most distant room! Addendum: Hospital oxygen supplies: