Early Patient Management after Chemical and Biological Warfare Agent Release

If the released hazard is persistent and transmissible, decontamination is essential in the decontamination zone. In some countries, level C-protected medical staff or paramedics can operate in this area and work alongside fire personnel in providing triage in terms of whether the patient requires decontamination, assessing the medical status, providing advanced life support for acute toxic injury (TOXALS), and offering immediate antidote and other pharmacologic support.

Figure 64-11 shows a medically operated chemical warfare casualty reception facility in a Parisian hospital. The importance of early life support measures in the decontamination zone has been recognized by many emergency services over the past decade.^[90] The concept of TOXALS, introduced in 1996 by the International Trauma Anesthesia and Critical Care Society, expands the familiar ABCs (airway, breathing, and circulation) of life support to relate to toxic releases (ABCDDEE) as follows:

Airway: The airway of the casualty must be maintained at all times. In the unconscious casualty, this may involve simple basic airway maneuvers plus suction of the copious secretions associated with chemical poisoning. Occasionally, there may be a requirement for advanced airway management, such as tracheal intubation, to protect the airway from the excessive secretions and to prevent aspiration of regurgitated stomach contents.

Breathing: The patient's breathing must be carefully observed until full decontamination and recovery have occurred. Supplemental oxygen speeds the recovery from volatile chemical poisoning. If breathing becomes compromised, it must be supported by artificial ventilation with supplemental oxygen using self-inflating bag-valve-mask resuscitation or an automatic ventilator. Entrained air must be filtered when ventilating casualties in a contaminated environment.

Circulation: The victim's circulation must be carefully observed and monitored. Noninvasive blood pressure, pulse oximetry, and cardiac monitoring are all useful indicators of circulatory function. Early establishment of intravenous access aids the administration of fluids and drugs.

Disability: The level of consciousness should be assessed using the simple AVPU scale (i.e., alert, responds to voice, responds to pain, or unresponsive). This assessment should be repeated at frequent intervals to assess the progress of the casualty.

Drugs: Medications, especially the specific antidotes, should be administered when a specific agent has been identified.

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Exposure: The casualty must be exposed to assess physical damage and remove all clothes that have been contaminated by the chemical.

Environment: The primary management described previously may be severely limited by the need of the rescuer to wear protective clothing. Only those skilled in these techniques and trained in the use of protective clothing should enter and treat casualties in a contaminated area. All others should await the casualties' arrival in the cold or clean zone after decontamination.

Figure 64-11 Special triage, decontamination, and resuscitation center set up in a Parisian teaching hospital. (Courtesy of Service d'Aide Médicale Urgente [SAMU] de Paris, France.)

Identification of the chemical and its specific antidote may take some time. However, this must not delay the basic medical management of the casualty.

Somatic Systems Affected by Toxic Hazards

Early patient management is based on identification information and the presenting signs and symptoms. Usually, information is available to help with identification of the agent used. However, on the basis of presenting signs and symptoms, it is useful to consider attacks on the various systems as a guide to the agent used ( Table 64-14 ).

A wide range of chemical agents affect the respiratory system. These are summarized in Table 64-15 .