DISASTER MEDICINE/CONCEPTS
Emergency Department Hazardous Materials
From the Occupational and
Environmental Health Unit,
University of Arizona Prevention
Center,* Tucson, AZ; the Indiana
Poison Center,‡ Indianapolis, IN;
the Medical and Toxicological
Intensive Care Unit, Hôpital
Larioboisière, Paris, France, and
the International Toxicology
Consultants LLC, Washington DC§;
and the Department of Emergency
Medicine, Medical College of
Virginia,II Richmond, VA.
Received for publication
August 29, 1997. Revisions
received May 27, 1998, and
February 22, 1999. Accepted for
publication March 2, 1999.
Address for reprints: Jefferey
L Burgess, MD, MS, MPH,
Occupational and Environmental
Health Unit, University of
Arizona Prevention Center, 1435
North Fremont, Box 210468,
Tucson, AZ 85719-4197.
Copyright © 1999 by the American
College of Emergency Physicians.
0196-0644/99/$8.00 + 0
47/1/98455
AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE
Protocol for Contaminated Patients
Jefferey L Burgess, MD, MPH*
Mark Kirk, MD‡
Stephen W Borron, MD, MS§
James Cisek, MDII
See editorial, p. 223.
Emergency department handling and treatment of chemically
contaminated patients can have potentially serious
consequences. Medical staff can be exposed to hazardous
chemicals through dermal contact or inhalation of volatile
compounds or particulate matter. Exposure can result in
symptomatic illness from either a direct chemical toxic effect or
an odor-mediated psychologic response. Either situation can
severely affect ED function and lead to facility evacuation. The
Joint Commission on Accreditation of Healthcare Organizations
standards and the Occupational Safety and Health
Administration regulations for participation in community
hazardous materials incident emergency response plans require
hospital EDs to prepare for hazardous materials incidents. This
study provides a template protocol for ED preparation for and
treatment of patients exposed to hazardous materials.
[Burgess JL, Kirk M, Borron SW, Cisek J: Emergency
department hazardous materials protocol for contaminated
patients. Ann Emerg Med August 1999;34:205-212.]
BACKGROUND
Hazardous materials incidents and chemically contami-
nated patients pose potentially serious problems for hos-
pital EDs. Secondary contamination from treatment of
patients exposed to hazardous materials can potentially
result in significant injury or illness in emergency care
providers.1-5 Exposure can occur from dermal contact
with chemicals remaining on the patient or through
inhalation of volatile contaminants or particulates. Acute
chemical exposures are not infrequent. A survey of hos-
pital safety officers revealed that 47% of responding hos-
pitals had received an average of 2.4 chemically contami-
nated patients during 1994.6 In Washington State alone,
more than 2,360 individuals had acute exposure to haz-
2 0 5
HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS
Burgess et al
ardous materials from 1993 to 1996; of these, 1,762
(75%) were transported to a health care facility.7
The degree of decontamination performed in the pre-
hospital environment varies with the team providing haz-
ardous materials response and the patient’s medical con-
dition. Ideally, decontamination should be performed
before hospital transport, but in some cases, particularly
when the patient’s condition appears to be unstable, pre-
hospital decontamination may be deferred to hospital
personnel. In addition, exposed patients can transport
themselves to the hospital without previous prehospital
evaluation or decontamination, which can lead to hospi-
tal evacuation without adequate preparation. Conversely,
excessively rigorous interpretation and implementation
of hazardous materials spill protocols can delay definitive
treatment of chemically exposed patients and lead to pro-
longed ED closure. Strong or unpleasant odors from
chemically contaminated patients can also result in hos-
pital staff illness, even if the chemical concentrations in
the air are below levels normally considered injurious.
The Occupational Safety and Health Administration
(OSHA) requires hospitals participating as an integral
unit of a community-wide emergency response to a
release of a hazardous substance to comply with the
Hazardous Waste Operations Emergency Response
(HAZWOPER) standards.8 These standards require staff
training, as well as an emergency response plan that
includes procedures for decontaminating patients and
appropriate personal protective equipment for hospital
staff. Accredited institutions under the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO)
are required to have emergency procedures that describe
the specific precautions, procedures, and protective
equipment used during hazardous materials and waste
spills or exposures.9 Specifically, any institution with an
ED should have plans for treatment of a contaminated
patient. However, a study of Washington State hospital-
based emergency care facilities found only 52 (55%) had
protocols for handling medical facility contamination
and potential evacuation arising during the management
of contaminated patients.10 A similar lack of preparation
would be expected in other states and countries.
Information is currently available to help guide hospitals
in the treatment of hazardous materials exposures.
Guidance materials have been published for managing
hazardous materials incidents, including those pub-
lished by the Agency for Toxic Substances and Disease
Registry.11,12 Protocols are also available for treatment of
exposure to radioactive materials.13 However, to our
knowledge, the peer-reviewed literature currently does
2 0 6
not contain a general protocol for treatment of contami-
nated patients. To prevent secondary injury, while
maintaining ED function when possible, EDs must
devise contaminated patient protocols that correspond
to their capabilities and limitations, provide employees
with appropriate training, practice these protocols dur-
ing simulations, and carefully review both training ses-
sions and actual incidents to improve future perfor-
mance. 1,3,11,14-17 We propose a hazardous materials
template protocol for dealing with contaminated
patients, which can be modified according to local
needs.
C O N TA M I N AT E D PAT I E N T P R O T O C O L
The first steps in handling contaminated patients in the
ED are to recognize the presence of chemical contamina-
tion, and if possible, to identify the hazardous substance
and determine its level of toxicity and risk for secondary
contamination (Appendix). Triage personnel, in particu-
lar, should be trained to recognize high-risk situations for
chemical contamination of patients. In our experience,
nearly all ED evacuations/closures have been related to
lack of early recognition and high levels of concern about
the potential for secondary contamination, and not from
lack of a written protocol or dedicated decontamination
equipment.
Prompt recognition of chemical exposure usually
occurs through history or observation. Accidents at
industrial or agricultural sites and accidents involving
chemical transport should be considered high risks for
chemical contamination as should suspected terrorism
and mass casualty incidents. Patients should be consid-
ered at risk for chemical contamination if they exhibit a
cholinergic syndrome, irritant mucous membrane symp-
toms, chemical burns, soiling of skin or clothing with
unidentified liquids or powders, or if they have intention-
ally overdosed with industrial, cleaning, or agricultural
chemicals. Strong or caustic odors suggest chemical
exposure, although their presence does not prove the
existence of a toxic concentration of chemicals, and their
absence does not rule out contamination. In general,
toxic liquids and solids pose a dermal contact hazard to
ED staff, and only volatile liquid or solid contamination
poses a risk of significant exposure through inhalation.
The process of hazardous substance identification and
the determination of the toxicity level and risk for sec-
ondary contamination may benefit from external consul-
tation. EDs should have direct telephone access to the
hazardous materials team responding to the incident, so
ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999
HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS
Burgess et al
they can gather information about the incident and chem-
icals involved. Medical toxicologists experienced in
chemical exposures may be available with local poison
control centers, or through other local, state, or federal
agencies. It is important that consultants are trained and
experienced in hazardous materials exposures, or the
information provided could be inappropriate or even
dangerous.
Chemical incidents provoke extreme fear among the
public and can result in large numbers of “casualties”
who suffer only from collective hysteria.18-20 Knowledge
of the toxicologic profile of the involved chemical(s) may
allow emergency care providers to rapidly rule out con-
tamination in these patients. When in doubt, however,
symptomatic patients should initially be treated as if
exposed. Once any potential exposure has been dis-
counted, this should be explained to the patient to
address continued health concerns.
This protocol assumes the patient(s) is still contami-
nated at the time of hospital arrival. If adequate previous
decontamination has taken place, then it obviates this
protocol. Ideally, either a portable outside decontamina-
tion unit or a dedicated decontamination facility with
appropriate ventilation and water containment is avail-
able. External decontamination units should be supplied
with warm running water, particularly in cold weather
conditions. Portable curtains of adequate strength can
provide both protection from wind and personal privacy
during decontamination. This protocol also assumes
there is either a separate waste water containment system
or the sewer system for the hospital (municipal or other-
wise) has the capacity to treat the low concentrations of
chemical contaminants that decontamination of exposed
patients would produce, as contrasted with larger-vol-
ume primary spills. If necessary, plastic pools or commer-
cially available specialized decontamination stretchers
can be used for decontamination, and the waste water
kept in sealed containers for later disposal.
The ED staff has 3 primary goals in managing a patient
who has been exposed to a hazardous material and may be
contaminated or who has not undergone adequate decon-
tamination before arrival at the hospital:
1. To isolate the chemical contamination
2. To appropriately decontaminate and treat the
patient(s), while protecting hospital staff, other patients,
and visitors
3. To reestablish normal service as quickly as possible.
These goals should be accomplished concurrently. It
may be necessary to initiate medical care before complete
isolation of the chemical contamination, although rapid
AUGUST 1999 34:2 ANNALS OF EMERGENCY MEDICINE
institution of personal protection of health care providers
should precede intervention. Facility evacuation is rarely
necessary and can generally be avoided by recognizing
chemical contamination and adequately decontaminat-
ing the patient outside the ED, or by using an appropri-
ately designed room within the ED.
DISCUSSION
The keys to effective hazardous materials management
are common sense, preplanning, and training on that
plan. The equipment, training, and preparedness
required for decontamination of chemically exposed
patients will differ from hospital to hospital, depending
on the hospital’s capability to treat seriously poisoned
patients, and its proximity to major industrial sites, agri-
cultural activities, and transportation routes. Major
trauma centers and hospitals designated by local emer-
gency planning committees (LEPCs) for care of chemi-
cally contaminated patients should have a higher level of
preparedness. Any plan must include contingencies for
contamination sources within the hospital and for ED
evacuation. The determination of a workable hazardous
materials plan requires careful thought and often profes-
sional input from medical toxicologists, hazardous mate-
rials teams, and industrial hygiene and safety officers. Use
of a patient decontamination plan implemented without
specific adaptation to the hospital and without practice
can result in undesirable outcomes.
Medically necessary care, such as stabilization of a
traumatized victim of a motor vehicle accident, should
not be delayed because of contamination with relatively
low toxicity substances such as diesel fuel. At the same
time, a patient who is critically ill or in cardiac arrest
assumed to be caused by chemical exposure demands
caregiver protection before treatment intervention if risk
of secondary contamination remains. In such an instance,
basic life support may be provided during initial pro-
tected decontamination and followed up immediately
thereafter with advanced life support.
In general, the amount of contamination on a patient
is much less than what would be present at the actual
site of chemical release. Unless significant solid and liq-
uid chemical contamination of the ED has occurred, it is
unlikely that volatilization of chemicals from a contami-
nated patient would injure hospital staff. Most haz-
ardous material exposure victims are exposed by inhala-
tion only and are unlikely to have enough residual
chemical on their skin to present a risk to hospital per-
sonnel, although strong odors can be present. 21 In an
2 0 7
HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS
Burgess et al
ED study of 72 patients exposed to hazardous materials
during a 6-year period, positive pre-decontamination
swabs analyzed by a certified analytical chemistry labora-
tory using gas chromatography/mass spectrometry were
seen for pesticides and PCBs only.11 Studies of chemical
concentrations in the breathing zone of hospital staff
while decontaminating mannequins soaked with volatile
solvents demonstrated levels well within acceptable
occupational exposure limits.22 Simply removing cloth-
ing will substantially decrease the amount of chemical
contamination and risk of secondary contamination.
However, individual sensitivity to chemicals varies, and it
is not unusual for chemicals with strong odors to elicit a
symptomatic response in hospital staff even at concentra-
tions far below commonly accepted “toxic” levels.
Symptomatic staff will not be able to function optimally,
regardless of the toxicity of the chemical contaminant.
No medical consensus exists for the minimum level of
personal protection required for hospital decontamina-
tion. This is especially true regarding respiratory protec-
tion, which is only necessary when toxic vapors are at
concentrations high enough to cause potentially harmful
effects to staff. After clothing removal, a contaminated
patient poses minimal inhalation risk when decontami-
nation is performed outside the ED. However, if a patient
is placed in a poorly ventilated treatment room (enclosed
space), personnel without respiratory protection could
have symptoms from inhalation of off-gassing vapors
from clothing, skin, or vomitus. Selecting the appropriate
protective equipment depends on the specific hazardous
substance identified. Surgical masks never provide ade-
quate protection from toxic vapors.
Legal requirements do apply to hospital-based decon-
tamination. All EDs incorporated in an emergency
response plan for hazardous materials incidents through
LEPCs, an agreement with a facility or hazardous waste
site, or other means, must meet OSHA requirements (29
CFR 1910.120(q)) for both training and response to haz-
ardous materials, because it is likely they will be faced
with a chemically exposed patient without previous
decontamination at some time. Under these regulations,
emergency medical personnel who would decontaminate
victims exposed to a hazardous substance should be
trained at a minimum to the first-responder operations
level. Additional guidance on OSHA regulations concern-
ing hospitals and emergency response to hazardous sub-
stances is available in an informational booklet.23
For response to an unknown hazard, OSHA regula-
tions require level B protection, which includes a posi-
tive-pressure self-contained breathing apparatus and
2 0 8
splash-protective chemical resistant clothing. However,
these regulations should not interpreted to require the
use of this equipment for treatment of contaminated
patients in all hospitals. Use of self-contained breathing
apparatus can itself pose significant problems to ED staff.
These hazards include increased weight, improper use of
the equipment, problems with donning and doffing, and
decreased dexterity. Other options include having the
patients decontaminate themselves if they are capable,
designating a local fire department hazardous materials
team to assist in or perform the decontamination, or pro-
ceeding with decontamination with less than level B pro-
tection if assistance is not available within a suitable time
interval based on the patient’s condition. Hospitals fre-
quently receiving contaminated casualties or in high-risk
areas may need to consider additional training and equip-
ment, such as specialized chemical-resistant clothing and
respirators.
Evacuation of an ED because of contamination from a
chemically exposed patient is rarely indicated. Moving a
patient outside or to a designated room with separate ven-
tilation and establishing proper ventilation, such as with
large fans, is usually sufficient to prevent exposure to
other patients. Care should be taken to avoid spreading
volatile contaminants throughout the hospital, by venti-
lating to an appropriate outside location and closing
other doors as necessary. Similarly, the facility can be
reoccupied rapidly if evacuation has already occurred
given these conditions. Primary spills of hazardous
volatile liquids or solids that cannot be quickly controlled
may require facility evacuation. The final decision to
reopen the facility may officially lie with the fire chief;
thus a close working relationship between the fire chief,
ED personnel, and toxicology consultants is essential.
The need for rapid, effective, and consistent postinci-
dent debriefing cannot be overemphasized. Appropriate
specialists should review the chemicals involved for
potential toxicity, so hospital staff, patients, and their
families can receive appropriate treatment and follow-up
when necessary, or reassurance in other cases that further
problems are not anticipated. The perception of exposure
to hazardous materials can have profound consequences
on hospital staff and patients. Failure to allay unnecessary
concerns can result in lingering effects. At the same time,
it is important to be sensitive during the delivery of
debriefing information. Staff members who have experi-
enced very real symptoms (such as irritation, nausea and
vomiting, headache) from a presumed exposure are not
likely to appreciate information that fear or “hysteria”
induced their symptoms. It is preferable to state, when
ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999
HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS
Burgess et al

true, that no lasting effects are anticipated in spite of the
symptoms experienced. When specific identification of
involved compounds is not possible, it is imperative that
staff be invited to seek follow-up for symptoms in the
employee health clinic, with occupational medicine, toxi-
cology consultation, or both. Unnecessary laboratory
studies should be avoided, because these may serve to
reinforce the impression that a serious exposure has
occurred. There should be a good reason for each test
ordered and the results should be carefully explained.
Preplanning and preparedness are essential in haz-
ardous materials incidents. JCAHO standards require
semiannual drills of emergency preparedness,9 and
including scenarios requiring treatment of contaminated
patients is advisable. Although no hazardous materials
plan will provide for every possible scenario, a well-prac-
ticed plan will protect hospital staff and patients in the
majority of circumstances.
We thank Julie Briggs, RN, Administrative Director, Good Samaritan Hospital ED,
Puyallup, WA, for use of her contaminated patient treatment protocol, which served as
the basis for the development of our manuscript.
15. Kirk MA, Cisek J, Rose SR: Emergency department response to hazardous materials inci-
dents. Emerg Med Clin North Am 1994;12:461-481.
16. Lavoire FW, Coomes T, Cisek JE, et al: Emergency department external decontamination for
hazardous chemical exposure. Vet Hum Toxicol 1992;34:61-64.
17. Levitin HW, Siegelson HJ: Hazardous materials. Disaster medical planning and response.
Emerg Med Clin North Am 1996;14:327-348.
18. Baker P, Selvey D: Malathion-induced epidemic hysteria in an elementary school. Vet Hum
Toxicol 1992;34:156-160.
19. Gamino LA, Elkins GR, Hackney KU: Emergency management of mass psychogenic illness.
Psychosomatics 1989;30:446-449.
20. Selden BS: Adolescent epidemic hysteria presenting as a mass casualty, toxic exposure inci-
dent. Ann Emerg Med 1989;18:892-895.
21. Burgess JL, Keifer MC, Barnhart S, et al: The hazardous materials exposure information ser-
vice: Development, analysis, and medical implications. Ann Emerg Med 1997;29:248-254.
22. Schultz M, Cisek J, Wabeke R: Simulated exposure of hospital emergency personnel to sol-
vent vapors and respirable dust during decontamination of chemically exposed patients. Ann
Emerg Med 1995;26:324-329.
23. Hospitals and Community Emergency Response—What You Need to Know. Emergency
Response Safety Series, US Department of Labor, Occupational Safety and Health
Administration. OSHA 3152, 1997 (available through OSHA web-site www.osha.gov).

REFERENCES

1. Huff JS: Lessons learned from hazardous materials incidents. Emerg Care Q 1991;7:17-22.
2. Merritt NL, Anderson MJ: Malathion overdose: When one patient creates a departmental
hazard. J Emerg Nurs 1989;15:463-465.
3. Thanabalasingham T, Beckett MW, Murray V: Hospital response to a chemical incident:
Report on casualties of an ethyldichlorosilane spill. BMJ 1991;302:101-102.
4. Wing JS, Brender JD, Sanderson LM, et al: Acute health effects in a community after a
release of hydrofluoric acid. Arch Environ Health 1991;46:155-160.
5. Nozaki H, Hori S, Shinozawa Y, et al: Secondary exposure of medical staff to sarin vapor in
the emergency room. Intensive Care Med 1995;21:1032-1035.
6. Cone DC, Davidson SJ: Hazmat preparedness: Sufficient or so-so? [Abstract]. Prehospital
and Disaster Medicine 1995;10:S62.
7. Hazardous Substances Emergency Event Surveillance System, Washington State
Department of Health, Office of Toxic Substances, Olympia, WA.
8. 29 CFR Part 1910.120. Washington DC: Government Printing Office; 1995.
9. 1996 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint
Commission on Accreditation of Healthcare Organizations, 1996.
10. Burgess JL, Blackmon G, Brodkin CA, et al: Hospital preparedness for hazardous materials
incidents and treatment of contaminated patients. West J Med 1997;167:387-391.
11. Managing Hazardous Materials Incidents Volume II: Hospital Emergency Departments: A
Planning Guide for the Management of Contaminated Patients. Atlanta: US Department of
Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease
Registry, 1991.
12. Managing Hazardous Materials Incidents Volume III: Hospital Emergency Departments:
Management Guidelines for Acute Chemical Exposures. Atlanta: US Department of Health and
Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry.
13. Leonard RB, Ricks R: Emergency department radiation accident protocol. Ann Emerg Med
1980;9:462-470.
14. Cox RD: Decontamination and management of hazardous materials exposure victims in the
emergency department. Ann Emerg Med 1994;23:761-770.

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HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS
Burgess et al
Appendix.
Objective Plan of Action
Isolation
Protect the ED, staff, Isolate the contaminated patient and keep or move him or her
and patients from exposure outside if possible. Personnel should wear protective
equipment if in the isolation area (see Treatment section).
If decontamination must be performed indoors and a fully
equipped decontamination room is not available, use a
single large patient room (preferably one which is not
used often) to limit ED contamination. Maintain ventilation
to the decontamination area. Avoid “sealing the room,”
which may create an enclosed space environment,
augmenting inhalation exposures to hospital personnel.
However, consider risk to other hospital occupants if air
from the room is recycled to other areas of the hospital.
If escaping vapors pose a risk to other staff or patients,
isolate or evacuate them, and discharge or transfer patients.
Remove nonessential and nondisposable equipment from the
decontamination area.
Establish and secure zones with yellow tape on the floor,
including decontamination zone (warm) and clean zone (cold)
to prevent unauthorized entry until clean-up has been completed.
Notification Notify appropriate hospital personnel. Examples include
maintenance, security, hospital supervisor, and ED
director. Contact external agencies (such as the
poison center) as required.
Minimize risk to staff Consider staff potentially contaminated if they provided care
and had direct dermal contact before decontamination with
a patient with liquid or solid on their skin or clothes.
Move staff noticing irritant or other symptoms without direct
patient contact to fresh air.
Communication Communicate frequently with supervisor, security, staff, and
departmental administration.
Notify hospital administrator and public information officer
for hospital.
Determine need for evacuation Assess extent and toxicity of chemical contamination.
If low risk for toxicity, continue operation of department,
institute clean-up, and restore to normal operations.
If highly toxic, more extensive isolation or evacuation may
be required.
If symptoms are noted outside of the isolation area or the
situation warrants urgent decision making without time to
identify the hazardous substance, then consider evacuation.
Determine who is responsible for making the evacuation decision.
Contact local fire department for assistance as needed.
Implement evacuation Establish alternate triage and treatment sites in appropriate
locations and a transfer route to ensure patients with
emergency needs have access to emergency services.
2 1 0
Comments
Keep victim outside patient care and waiting areas until
decontamination is complete if possible. It is best to at
least initiate decontamination outside before entering the
hospital, including removal of clothing and initial brief rinse.
It may be necessary to initiate treatment before decontamination
is accomplished, although personnel should be protected
in advance. Limit number of personnel involved.
Use hospital security to help prevent nonauthorized personnel
from entering or leaving contaminated areas.
If liquid or solid contamination was tracked into the emergency
department, then outline affected areas with yellow
tape and secure.
Establish contact list before actual incident. If the incident occurs
within the hospital, fire department and hazardous materials
teams may be needed.
Contact the poison center or other consultant to determine need
for staff decontamination.
Brief ED staff regarding the chemicals involved, expected toxicity,
and protection needed.
The incident may well be a media event.
Evacuation is rarely indicated. In most instances, isolation
of the contamination will be required, but a complete evacuation
is not necessary. Odor is not a reliable predictor of toxicity.
Reasons to consider evacuation:
(1) Primary spill of toxic chemical in ED
(2) Nearby hazardous materials incident threatening hospital
(3) Patient contaminated with highly toxic volatile chemical
and not decontaminated before entry
Alternate site should be identified in disaster plan. Consider the
possibility of the hospital itself as a hazardous material
incident site.
(Continued)
ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999
HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS
Burgess et al

Appendix (continued).

Objective Plan of Action Comments

Implement evacuation If time permits, assign a staff member to take responsibility for
(continued) organization and movement of essentials, including equipment,
crash carts, staff roster, patient log, personal belongings,
telephone triage references and log book, suture cart, splint cart,
and mobile lighting.

Determine alternate source if unable to relocate essential

equipment and carts because of contaminated environment.

Notify central supply, hospital supervisor, and critical care of

needs and status.

Consult pharmacy regarding antidotes and other medications

including controlled substances in alternate site.

Preserve essential Contact EMS sytem re: Divert status and switchboard to divert Moving ED to a new location may limit ability to accept patients
communications calls to new location. by ambulance.

If necessary, contact alternate hospital to assume base station Alternate hospital should be identified in disaster plan.
functions and inform other hospitals of situation.
Treatment

Lifesaving intervention Evaluate patient, determine urgency for care, and initiate May occur at same time as or before decontamination.
lifesaving procedures in decontamination area or triage.

Determine toxicity and
appropriate treatment,
including need for
decontamination.
Assess chemical toxicity and determine appropriate treatment
through identification of specific chemical (if known),
form of material, and routes and duration of exposure.
Decontamination is required for toxic solid and liquid exposures,
but usually is not necessary for noncorrosive gas and vapor
exposures.
Contact the poison center or consultants, such as Chemtrec,
ATSDR, or local industry for additional information.
Material Safety Data Sheets (MSDS) help identify the chemical,
but may not have correct treatment information.

Protect staff If possible, allow the patient to decontaminate himself or
herself, or use a specially trained and equipped decontami-
nation team. Otherwise, wear personal protective equipment
(PPE) when assisting the contaminated victim. Gloves, goggles,
mask, and disposable gowns provide some degree of protection.
Select additional PPE, including chemical-resistant gloves and
clothing, based on the chemical hazard.
Local fire departments may be recruited to assist in
decontamination.
Sources of additional information on appropriate PPE include
hazardous materials teams, industrial hygienists, medical
toxicologists, chemical manufacturers, and retail PPE outlets.

Patient decontamination Remove patient’s clothing and place in plastic bags. If stable, Double-bag contaminated clothing, linens, and gloves in red
have patient remove clothes and shower with soap and biohazard bags, then seal and label.
water in decontamination shower.

If victim must sit or lie down, place chair (washable surface) or Take special precaution with exposures to concentrated acids,
stretcher in shower area. Wash from victim’s head to feet. caustics, or oily or lipid-soluble liquids (pesticides).
Decontaminate open wounds first, and avoid contamination of
unexposed skin. Surgical drapes may help protect For special circumstances, staff should consider additional or
unexposed skin. different PPE (for preplanning consider possible sources
of contamination from nearby industry).
Decontaminate exposed area
•Flush exposed areas with soap and water for 10 to 15 minutes Patient ingestion of toxic materials warrants special care in
with gentle sponging (surgical sponge) to avoid skin breakdown. gastric decontamination (if indicated) and staff protection.
•Irrigate exposed eyes with saline 10 to 15 minutes
•Clean under nails with scrub brush or plastic nail cleaner
•Gently irrigate contaminated open wounds with water or saline
solution an additional 5 to 10 minutes.

Supportive care Provide supportive care and supplemental oxygen as indicated.

(Continued)

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HAZARDOUS MATERIALS PROTOCOL FOR CONTAMINATED PATIENTS
Burgess et al
Appendix (continued).
Objective
Antidotal treatment
Staff decontamination
Large exposures
Reestablish normal operations
Decontaminate facility
Chemical monitoring
Authorize reentry
Communication
Debriefing
2 1 2
Plan of Action
Determine if antidotal treatment would be effective and
available. Administer as indicated.
Decontaminate personnel with direct skin contact with
the chemical contaminant.
Move other symptomatic staff to fresh air.
For significant and very large exposures, or if staff are untrained
in use of protective equipment, or if protective equipment is
unavailable, contact local fire department for assistance.
Ventilate the contaminated area with large fans if available,
moving air outside and away from occupied areas.
Clean spills with soap and water after removing gross
particulates. Use existing hazardous materials spill protocols.
Consider chemical-specific monitoring if indicated and
appropriate equipment available.
Obtain appropriate agency clearance before reentry, if required or
if adequacy of hospital decontamination is uncertain.
Contact all individuals and sites contacted previously at initiation
of incident to provide notification of reopening.
Debrief staff regarding signs and symptoms from the specific
chemical exposure, and risks posed to them, if any. Discuss
incident. Revise protocol as needed.
Comments
Anticipate need for antidotes based on chemicals used in local
industry.
Staff without direct dermal contact with the contaminated patient
or clothing do not require decontamination
EDs should use chemical exposure scenarios for drills with local
fire departments.
Fire departments may assist in facility decontamination.
For significant contamination, use an environmental clean-up
service (available 24 hours, pre-established contract) if
hospital resources are limited or fire department
assistance is not practical.
Usually not necessary, fire department may provide.
Determine agency and 24-hour contact number before incident.
Involve hospital administration and public information officer.
Consider how to better identify chemical contamination.
ANNALS OF EMERGENCY MEDICINE 34:2 AUGUST 1999