The Role of
Emergency Physician
in Response to
CBRNE Attack
Dr. Chew Keng Sheng
Emergency Medicine
Universiti Sains Malaysia
Objectives
Definitions
Key criteria for determining a terrorist attack
Overview on selected terrorists’ attacks and WMDs
Major Lessons Learnt from Previous Disasters
Syndromic Surveillance
Defining roles of EPs in response to CRBNE Terrorist
Attacks – ―7Ds in Disasters‖
Q & A
Definitions of Disaster, Mass
Casualty Incidents and
Terrorism
Definitions
Disaster – defined as a sudden ecologic
phenomenon of sufficient magnitude to
require external assistance
In the Emergency Department, disaster exists
when the number of patients presenting in any
given space of time are such that even
minimal care cannot be offered without
external assistance.
Definitions
Disasters occur when normal, basic services of
a society become disrupted to such extent that
widespread human and environmental losses
exceed the community‟s management
capacity (SAEM Disaster Medicine White Paper
Subcommittee)
Disasters characterized by large numbers of
deaths and injuries are also referred to “Mass
Casualty Incidents”
Definitions
However, disasters are not defined only by a
given number of victims
Example: The arrival of one VIP guest with
severe medical or trauma emergency conditions
can completely disrupt normal operations of
even the most efficient emergency departments.
In short, the essence of the concept of disaster
is it has a “massive disruptive impact”
Definitions
Mass Casualty Incidents (MCI) – events resulting in a numbers of victims large enough to disrupt normal course of emergency and health care services of the affected community
Disasters result in MCIs, but encompass a broad range of calamities beyond just the high numbers of casualties
―All MCIs are disastrous, but not all disasters are due to MCIs‖
Definitions
Disasters can be divided into two:
Natural Disasters OR Man-made Disasters
External Disasters (events occurring outside the
hospital) OR Internal Disasters (events involving
the physical structures of hospital itself - e.g. fire,
lab accident involving radioactive materials)
Terrorism – man made, external disasters
Directive 20, National Security
Council
A Disaster is
1. an event that occurs suddenly.
2. complex in nature.
3. loss of lives.
4. destruction of property and/or environment.
5. disruption of the community daily activities
Three Levels According to Directive
20, NSC
Level 1
Localized, well-controlled, manageable by local authorities
Level 2
Well-controlled, management at state or national level
Level 3
Complete destruction, disruption of routine activities,
Directive 20, NSC
Disaster can be divided into 3 level
LEVEL 1
1. Localized major incident
2. Under controlled
3. Not complex
4. Small no. of casualties and property loss
5. Minor disruption of daily community activities
6. Manageable by the local authorities requiring
7. Multisectoral involvement.
Example: bus accident, train derailment, landslide.
Directive 20, NSC
LEVEL 2 Disaster
1. Widespread over a large area but under controlled
2. Complicated and complex
3. Large no. of casualties and property loss.
4. Affecting daily community activities
5. Not manageable by the local authorities requiring
6. Assistance from other states or National Authorities
7. Support required, Regional or National Support
Examples: Highland Towers Collapse, Greg Storm Sabah, Bright Sparklers.
Directive 20, NSC
LEVEL 3 Disaster
1. Involves a very large area.
2. Loss of many lives.
3. Total Destruction of infrastructure and public facility.
4. Complicated and complex.
5. High risk to rescue workers.
6. Complete disruption of daily community activities.
7. Major destruction of resources.
8. All local resources destroyed and assistance from external resources required.
e.g. Earthquake, typhoons, volcanoes, war.
Disasters Vs Emergencies
Routine Emergencies Disasters
Interaction with familiar
parties
Interaction with unfamiliar
parties
Familiar tasks/procedures Unfamiliar
tasks/procedures
Intra-organization
coordination
Intra- and inter-
organization coordination
Intact communications,
roads, etc.
Disrupted
communications, blocked
roads, etc
Disasters Vs Emergencies
Routine Emergencies Disasters
Familiar terminology Unfamiliar, organization-
specific terminology
Local press attention National/international
media attention
Resources adequate for
management
Resources overwhelmed for
management capacity
PRE-HOSPITAL MANAGEMENT ORGANIZATION
Hospital Director
INCIDENT SITE MEDICAL MANAGER
Red Team Leader
Medical Triage Officer
NGO ADVANCED MEDICAL POST
Yellow Team Leader
Evacuation Officer
Admin.
Clerk
Transport Officer
Ambulance Drivers
Acute Treatment Manager
Admin.
Clerk Doctors & Paramedics
•JPA 3
•MRCS.
•SJAM
Medical/Health Officer
COMMAND POST Temporary
Morgue
Green Team Leader
Know Your Role!
Key Criteria Defining a Terrorist
Attack
Violence "the only general characteristic [of terrorism] generally agreed
upon is that terrorism involves violence and the threat of violence" -Walter Laqueur of the Center for Strategic and International Studies
Psychological Impact and Fear attack was carried out in such a way as to maximize the
severity and length of the psychological impact.
Perpetrated for a Political Goal This is often the key difference between an act of terrorism
and a hate crime or lone-wolf "madman" attack
The political change is desired so badly that failure is seen as a worse outcome than the deaths of civilians.
Key Criteria Defining a Terrorist
Attack
Targeting of non-combatants
It is commonly held that the distinctive nature of terrorism lies in its deliberate and specific selection of civilians as direct targets.
Much of the time, the victims of terrorism are targeted not because they are threats, but because they are specific "symbols, tools, or corrupt beings" that tie into a specific view of the world that the terrorist possess.
Their suffering accomplishes the terrorists' goals of instilling fear, getting a message out to an audience, or otherwise accomplishing their political end.
(en.wikipedia.org)
Overview of Selected Terrorist
Incidents
Bombing of WTC New York City 1993
Sarin Gas Attack by Aum Shinrikyo in Matsumoto, Japan, 1994
Truck Bomb explosion of Alfred P. Murrah Building in Oklahoma, 1995
Sarin Gas Attack by Aum Shinrikyo in five subway train stations simultaneously in Tokyo, 1995
WTC Bombing, New York, September 11, 2001
US Anthrax Incident, 2001
Bombing in Bali, Indonesia 2002
Major Lessons Learnt
Incident Confirmation
At time of incident (whether biological, chemical or even
high explosive incidents), most people at the scene and even
the initial responders did not recognize the event as a terrorist
attack
E.g. during the Sarin Gas Attack in Matsumoto, Japan,
emergency responders initially thought that the first victims
were ill from food poisoning, contaminated water, or natural
gas
To improve early detection, a process called Syndromic
Surveillance is employed
Syndromic Surveillance
A method to aid the early detection of bioterrorism events
This is to respond to bioterrorism attack – time is essential
This type of surveillance involves collecting and analyzing statistical data on health trends – such as symptoms reported by people seeking care in emergency rooms or other health care setting – or even sales of flu medicines.
Syndromic Surveillance
Because bioterrorist agents such as anthrax, plague, and smallpox initially present ―flu-like‖ symptoms, a sudden increase of individuals with fever, headache, or muscle pain could be evidence of a bioterrorist attack.
By focusing on symptoms rather than confirmed diagnoses, syndromic surveillance aims to detect bioterror events earlier than would be possible with traditional disease surveillance systems.
Syndromic Surveillance
In other words, the term syndromic surveillance
refers to methods relying on detection of clinical
case features that are discernable before
confirmed diagnoses are made
Syndromic Surveillance
Recommended Website
Centers for Disease Control and Prevention –
Emergency Preparedness & Response (http://www.bt.cdc.gov/)
Major Lessons Learnt
Command and Control
Unlike smaller emergencies where one single Incident Commander in charge, in a terrorist attack, numerous agencies and organizations involved
The need to speedily establish a secure perimter around the incident. Failure to do so during the Oklahoma bombing
Communications
Communications failure
Overloaded land lines and cell phones with calls from public trying to obtain info about their loved ones
Major Lessons Learnt
Initial Responders
Traditionally initial responders are defined as the local police, firefighters, EMDs, paramedics. Well trained, part of daily routine
In overwhelming terrorist attacks, other professionals were needed at the scene – NGOs, volunteers, mental health workers
These individuals thrust into new roles – without proper training.
Safety of these responders – 1993 WTC bombing, 124 emergency responders injured; in Oklahoma bombing, one nurse killed from falling debris.
Major Lessons Learnt
The Volunteers
Volunteers, though well intentioned, often created problems
Most not familiar with the emergency command and control system
The Victims
At most disasters, victims left the scene and sought medical help on their own
Need for rapid establishment of a centralized database containing identification victims from all responding medical sites. E.g. in Bali Bombing – internet database used extensively
Major Lessons Learnt
Psychological Effects
PTSD – Example 11 months after 9/11 incident, 1277 stress related illnesses reported
Need for debriefing and de-stressing; short briefings prior to change of shift for responders
Tokyo Sarin Attack and Anthrax threat – created unique psychological fear – the healthy but anxious lots taxed the health services at a time when others needed care.
Need for proper public education
Major Lessons Learnt
Mortuary Affairs
Temporary morgues, body bags
Body decay
Rapid identification of victims – for family members, law, insurance companies, etc; the need for DNA analysis
Example – Oklahoma bombing – unavoidable delays in official death notifications added emotional trauma to the already bereaved families
The need for religious sensitivity in handling bodies
Major Lessons Learnt
Duration of event
Prolonged duration – strained the human and material
resources; depletion of stocks
Need for regular work shifts
Criminal Investigations
One of the main difference between natural disaster and
man-made disaster
The concern to preserve the evidence
Medical emergency responders help protect the evidence by
only touching and removing items when necessary
Major Lessons Learnt
Media
Mixed blessings
Disseminate information
Yet, in an effort to provide information ASAP, sometimes
media give false and confusing information
VIP Visits
Politicians, celebrities, etc
Timing of these visits sometimes interfered with ongoing
recovery efforts
Overview
Chemical Weapons Nerve Agents – G series (GA,
GB, GD), V series
Blood Agents - cyanides
Blistering Agents
Biological Weapons Biological Agents – viruses (e.g
Ebola), bacteria (Yersenia pestis, anthrax)
Biological Toxins – botulism, ricin, Staphylococcal Enterotoxin B
Radiation α radiation
β radiation
γ radiation
Nuclear A bomb (Atomic)
H bomb (Hydrogen)
Explosives Large scale - Incendiary
bombs, Napalm-B, Mark 77
Smaller scale - Molotov Cocktail (Poor man’s hand grenades)
Explosives
(Reference: en.wikipedia.org) Molotov Cocktail
The use of Napalm-B in
Vietnam in 1966
How Prepared are the ED?
In 1997, Burgess et al. reported that only 44.2% of
hospital EDs had the ability to handle any chemically
contaminated patients from HAZMAT
41.1% - no designated decontamination facilities
Greenberg et al. in June 2000, conducted a survey to
assess the level of preparedness of hospital EDs in a
large metropolitan area to evaluate and treat victims of
a terrorist biological or chemical agent release
44 out of 62 ED directors responded to the questionnaire
How Prepared Are the EDs?
(Figures given in percentage) Yes No DK
Decon facilities 90.7 9.3 0
Ability to decon:
a. < 10/Hr 83.3 - -
b. 10-19/Hr 7.4 - -
c. 20-50/Hr 5.6 - -
d. >50/Hr 3.7 - -
Written plan for handling post-decon waste water 63 18.5 18.5
Written plan for handling contaminated clothings 42.6 29.6 27.8
Presence of detection equipment in ED 14.9 68.5 16.7
Personal Protective Clothing 87 13 0
(Greenberg et al., 2000)
Suggested Criteria for Minimum Preparedness of
EDs to Evaluate and Treat Victims of Biological or
Chemical Agent Release
1. At least one EP who has completed formal training regarding biological and chemical WMD
2. Ability to decon ≥10 patients/Hr
3. Written policies addressing the evaluation and treatment of biological and chemical casualties
4. Written cooperative agreements with local agencies addressing issues of biological and chemical terrorism
5. Participation in a disaster exercise involving biological or chemical agents within the past 12 months
6. Self characterized adequate supplies of appropriate antidotes
Antidotes
Atropine and oxide
(2 PAM CI)
injection auto-
injector
Roles of Emergency Physician in
DISASTERS –EIGHT „D‟s Detection and Diagnosis
Rapid Recognition
Declaration and Activation Activate contingency plans
Establish intra-hospital, inter-hospital, inter-agencies, inter-states, international communications
Defense Self-protection
Decontamination
Delegations
Drugs
Disposition Delivering right patients to right place and right time
Debriefing and De-stressing
The Main Problem with Biological
Weapon
Biological weapons can be divided into two categories
Overt (Announced)
First responders (fire fighters or law enforcement) are most likely to
respond to the announced release, or more likely the hoax
Covert (Unannounced)
First responders would probably be the GPs, family doctors, EPs, etc.
Furthermore, patients exposed to biologic agents
usually present with vague symptoms associated with
flulike illnesses (latency period).
Overt Attack
First responders (trained fire fighters or law enforcement) are most likely to respond to the announced release, or more likely the hoax
In recent anthrax attack, an example would be the letter received and opened in a Senator’s office in the Hart Senate Office Building.
The envelope contain a letter stating that it contained anthrax spores and the opener was going to die.
First responders called, the presence of spores of Bacillus anthracis confirmed.
Exposed individuals given prophylaxis. To date, none in the Senate Building has developed anthrax
Covert Attack
Current NO REAL TIME environmental monitoring for a covert release of biological weapon
A covert attack would probably go unnoticed, with those exposed leaving the area long before the act of terrorism became evident
Furthermore, because of the incubation period, the first signs of the biological agent released not be recognized until days or weeks later.
Thus those first responders would probably be the family doctors, GPs, EPs, etc
Factors indicative of a Potential
Bioterrorism Event Multiple simultaneous patients with similar clinical syndrome
Severe illnesses, especially among the young and otherwise healthy
Predominantly respiratory symptoms
Unusual (non-endemic) organisms
Unusual antibiotics resistance
Atypical clinical presentation of disease
Unusual patterns of disease such as geographic co-location of victims
Intelligent information – tips from law enforcement, discovery of delivery devices, etc
Reports of sick or dead animals or plants (Richards et al., 1999)
ON SITE MANAGEMENT
YELLOW ZONE
OSC
(POLICE )
COMMAND POST
F.F.C. - BOMBA
SAR TEAM
RED ZONE
WORK MATRIX
P.K.T.K.
O.M.C. BOMBA
MEDICAL BASE
CRTICAL
S.CRITICAL
N.CRITICAL
DEAD
RESCUERS
FORENSIC M.E.L.O.
QUARTER
MASTER
M.E.S.A.R.O. SAR
SAR
SPECIALISTS SJAM MRCS JPA 3 BOMBA S.B.
ON SITE MANAGEMENT – TRIAGE SYSTEM
TO NEAREST APPROPRIATE HOSPITAL
GREEN
Victims Collecting Point
COLLECTING POINT
Working Area
Impact Zone
Advance Medical Post
Simple Triage and Rapid Treatment
* Victims who can
walk are first identified
and be diverted to one
designated area
START Triage System
Disaster Operation and the SAVE
Concept
Basic/Simple Advanced Medical Post
RED YELLOW
GREEN WHITE TRIAGE AREA
EVACUATION
Standard Advanced Medical Post
RED YELLOW
GREEN WHITE
TRIAGE AREA
EVACUATION
NON-ACUTE
ACUTE
NON-ACUTE
ACUTE
Disaster Zoning
VICTIM FLOW
―Conveyor Belt‖ Management
Transport Resource Flow Victim Flow
TRANSFER ADVANCE
MEDICAL POST
Triage
Impact
Zone
Collecting
Point
Triage
Treatment Treatment
HOSPITAL
Evacuation
Initiating Isolation
Ideally be decontaminated outside the hospital Approach from upwind direction
Isolate at least 100 m radius (initial isolation) for hot zone
If large spill, 500 m; and if on fire (flammable substances), 800 m
Establish three zones Hot zone
where the spill/contamination occurred
Only trained personnel with proper attire to enter
Only the most immediate life threats addressed here – like opening up airway, cervical spine immobilization, bleeding control
Warm zone
area for thorough decontamination
Theoretically no risk of primary contamination but secondary contamination still possible
Initiating Isolation
Initiating Isolation
Initial Isolation
Protective
Action Zone
Principles of Decontamination
Removal of clothings most important step
(accomplishes 80-90% of decon)
From top to bottom
The more the better
Privacy is an issue
Water flushing the best Typically shower 3 – 5min
Decon ASAP
Expect a 5:1 of unaffected: affected casualties ratio
First responders must self-decon too
Decontamination
Emergency Decontamination
Summary
Terrorist Attacks are disastrous – but that does
not mean that there is nothing we can do.
Though we are probably helpless in preventing
them from coming, yet our preparedness would
hopefully be able to lessen the magnitude of
severity of the attack
Sarin Gas Attack on Tokyo Subway
Attack on 20th March 1995 was the second attack – 12 people died. First attack 1994 – 7 died.
How many perpetrators were involved and how many train stations were contaminated?
How did they do it?
Shoko Asahara –
Founder of AUM
Shinrikyo
Ikuo Hayashi
– one of the
perpetrators
The Attack
Attack at approximately 7:55 AM on March 20, 1995.
8:16 AM - the St Luke's ED was alerted
520-bed tertiary care
located near the affected subway stations (within 3 km)
received the largest number of victims from the subway attack.
services comparable to those of any medical center within the United States.
Within hours of the terrorist incident, St Luke's emergency department received 640 patients.
The Attack
8:28 AM - the first subway victim arrived at the St Luke's ED. This patient was ambulatory and arrived without assistance from ambulance personnel. The patient's only complaints were of eye pain and dim vision.
8:43 AM – arrival of first ambulance arrived
During the next hour, approximately 500 additional subway victims, including 3 patients who were in cardiopulmonary arrest on arrival, presented to the ED
Five of the female patients were pregnant.
The Attack
9:20 AM - hospital directors activated the hospital's disaster plan.
This resulted in the cancellation of all routine surgeries and outpatient activity.
More than 100 doctors and 300 nurses and volunteers were immediately called to care for victims
Victims into three clinical groups - mild, moderate and severe
The Attack
Mild cases (528, or 82.5%) - only eye signs or symptoms (eg, miosis, eye pain, dim vision, decreased visual acuity) on presentation
released after a maximum of 12 hours of ED observation
Moderate cases (107, or 16.7%) - systemic signs and symptoms (eg, weakness, difficult breathing, fasciculations, convulsions) BUT not require mechanical ventilation
Severe cases (5, 0.78%) - emergency respiratory support (eg, intubation and ventilation support)
Outcomes of Patients Admitted to St.
Luke‟s Hospital ED, Tokyo
Lessons Learnt
Delay in confirming the nature of the toxin
Delay in organizing an effective mass casualty strategy
Poor ventilation in patient reception area
Secondary exposure by medical staffs treating the patients
Inadequate provision of privacy to remove contaminted clothings
Inadequate shower facilities
Treatment
Three drugs are the mainstay treatment Atropine
Counteract primarily the muscarinic effect
Administer doses of 2 mg every 5 – 10 min to minimize dyspnea, airway resistance or respiratory secretions
Pralidoxime To reactivate acetylcholinesterase and counteract the nicotinic effect
Over time, OP-acetylcholinesterase bond becomes irreversibly covalent and resistant to reactivation by pralidoxime (―aging‖ process)
But still, Pralidoxime should never be withheld.
Diazepam The only effective anticonvulsant drugs for nerve gas poisoning
patients with seizure
Nerve Gas Agents
Are organophosphates Inhibits acetylcholinesterase, block degradation of Ach at postsynaptic
membrane.
Two main classes G series
―G‖ because accidentally first discovered by German scientist, Dr. Gerhard Schrader
GA (Tabun), GB (Sarin), GD (Soman) and GF (cyclosarin). Why no GC?
SARIN (most toxic of the four in G series) named in honor of its discoverers: Gerhard Schrader, Ambros, Rüdiger and Van der LINde.
V series V stands for ―venomous‖. Examples: VX, VR
All G series – watery, high volatility, serious vapor hazard; VX – oily, less vapor hazard, but poses a greater environmental hazard over time.
Nerve Gas
Different from organophosphate insecticides
Much more toxic
VX – most toxic substance synthesized de novo
(botulinism toxin – biological)
Unlike typical OP, no association with urination
Bradycardia is rare
Its miosis effect does not respond to systemic
therapy
Actions of Cholineseterase Inhibitors
Muscarinic Effects
SLUDGE
Salivation, Lacrimation,
Urination, Diarrhea, GI
pain, Emesis
DUMBELS
Diarrhea, Urination,
Miosis, Bronchorrhea,
Emesis, Lacrimations,
Salivation
Clinical Features
There is no delay effects
Symptoms of sarin gas occur within seconds of inhalation and peak at 5 minutes.
If patients remaining asymptomatic 1 hour after possible exposure, have not been contaminated.
In vapor exposed – miosis first appeared but in liquid exposed – miosis usually last sign
Unlike botulinism toxin, flaccid paralysis never on initial presentation.
Differences between Nerve Agents
and Cyanide
Characteristics Nerve Agent Cyanide
Odor None Bitter Almond
Eyes Miosis (unresponsive
to nalaxone), dim
vision, pain and
lacrimation
Pupils normal or
dilated
Oral, nasal and
respiratory system
Copious secretions Relatively few
secretions
Skin Profuse sweating,
cyanosis likely
Profuse sweating,
sometimes also
cyanosis
Differences between Nerve Agents
and Cyanide
Characteristics Nerve Agent Cyanide
Initial CVS response HPT, tachycardia Often hypotension
Muscle Weakness,
generalized
fasciculations,
eventually paralysis
Twitching of body
parts (but not
fasciculation)
Arterial Blood Gas
and Acid Base
Balance
Resp alkalosis or
hypoxemia with
respiratory acidosis
High AG, above
normal venous
oxygenation
Vesicants
Cause blistering and irritations to eyes, skin and airway (example – Mustard)
Ophthalmic effect – conjunctivitis, corneal damage, temporal or permanent visual loss
Skin effect – blistering like 2nd degree burn
Systemic toxicity – BM suppression, leukopenia
Indicators of fatal exposure
Airway burn within 6 hours
Burn >25%
Absolute WBC <200/mm3
Blood Agents
Blood agents such as cyanide Bind to cytochromes within mitochondria and inhibit cellular oxygen use
Low-dose exposures result in tachypnea, headache, dizziness, vomiting, and anxiety.
Symptoms subside when the patient is removed from the source
In higher doses the symptoms progress to seizures, respiratory arrest, and asystole within minutes of exposure.
Victims should be removed from the area, should have their clothing discarded, and should receive oxygen (100%).
If no improvement occurs, the cyanide antidote is given (amyl nitrate, sodium nitrite, sodium thiosulfate)
Anthrax
Current assessment suggests that three biologic agents—anthrax, plague, and smallpox—represent the greatest threat
Bacillus anthracis a gram-positive spore-forming bacterium, is the causative agent of
anthrax
the spores are extremely hardy
survive for years in the environment
the disease is caused by exposure to the spores
normally a disease of sheep, cattle, and horses and is rarely seen in developed countries because of animal and human vaccination programs
disease in humans can occur when spores are inhaled, ingested, or inoculated into the skin
spores germinate into bacilli inside macrophages
bacteria then produce disease by releasing toxins that cause edema and cell death.
Nuclear and Radiation Attack
Terrorists selecting radiation as a means to inflict
casualties are unlikely to employ nuclear weapons
are heavily guarded
difficult to move due to their size and weight
easy to detect
Sabotage at nuclear power stations is possible, but
given tight security, multiple safety systems, and thick
concrete housings surrounding the reactors, the threat
is probably low
Nuclear and Radiation Attack
Instead, simple radiologic devices, such as those used by hospitals for radiation therapy, are thought to be the source of choice.
These sources are plentiful and usually unguarded
The only wartime use of atomic and nuclear energy was the detonation of atomic bombs over Hiroshima and Nagasaki in 1945.
However, with the dissemination of technical information and raw materials, many nations now have nuclear weapons in their arsenals. The real possibility of terrorist groups obtaining and using such weapons also exists.
Bombings of Hiroshima and
Nagasaki The first event occurred on
the morning of August 6, 1945, when the US dropped a uranium gun-type device code-named "Little Boy" on the Japanese city of Hiroshima.
The second event occurred three days later when a plutonium implosion-type device code-named "Fat Man" was dropped on the city of Nagasaki.
(en.wikipedia.org)
Being Exposed or Being
Contaminated? Being exposed to heat; or being
burned (external and internal
burn)?
The first step of recognizing contamination is to understand the difference between exposure to and contamination by radiologic agents.
Exposure is defined by an individual's proximity to material emitting ionizing radiation.
Actual touching, inhaling, or swallowing that material is contamination.
Personal Protection Equipment
(PPE)
PPEs are respiratory equipment, garments, and barrier materials used to protect rescuers and medical personnel from exposure to biological, chemical, and radioactive hazards.
The goal of PPE is to prevent the transfer of hazardous material from patients or the environment to health care workers.
Different types of PPE may be used depending on the hazard present
PPE can be divided into Civilian PPE – especially those working in hot zone (IDLH)
Military PPE
(www.emedicine.com)
SCBA
SCBA: Self Containing Breathing Apparatus
Vs SCUBA: Self Containing Underwater Breathing
consists of a full face piece connected by a hose to a portable source of compressed air.
the open-circuit, positive-pressure SCBA is the most common type
this SCBA provides clean air under positive pressure from a cylinder; the air then is exhaled into the environment.
(www.emedicine.com)
Civilian PPE
Self-contained breathing apparatus
Supplied-air respirator
Air-purifying respirator
High-efficiency particulate air filter
HEPA filters 0.3-15 micron
efficiency of 98-100%
exclude aerosolized BWA particles in the highly infectious 1- to 5-mm range
Surgical mask
Protective Clothing (www.emedicine.com)
Levels of Civilian PPE
Level A
SCBA and a totally encapsulating chemical-protective (TECP) suit
highest level of respiratory, eye, mucous membrane, skin protection
Level B
positive-pressure respirator (SCBA or SAR)
nonencapsulated chemical-resistant garments, gloves, and boots, which guard against chemical splash exposures.
highest level of respiratory protection with a lower level of dermal protection.
(www.emedicine.com)
Levels of Civilian PPE
Level C
APR and nonencapsulated chemical-resistant clothing, gloves, and boots.
same level of skin protection as Level B, with a lower level of respiratory protection.
used when the type of airborne exposure is known to be guarded against adequately by an APR.
Level D
standard work clothes without a respirator.
In hospitals, it consists of surgical gown, mask, & latex gloves (universal precautions).
no respiratory protection and only minimal skin protection
(www.emedicine.com)
Decontamination
Extenal Decontamination
Gross Decontamination Removal of clothings; done before reaching hospital
Secondary Decontamination Designated site at ED; with advice from Radiation Safety Officer;
head to toe survey
Internal Decontamination
Blockade of enteral absorption Gastric lavage
Use emetic agents – Barium sulphate
Blockade of end organ uptake Potassium Iodide
References
Kales, S. N. & Christisni, D. C. (2004) Acute Chemical
Emergencies. NEJM, 350, 800-8.
Greenberg, M. I., Sherri, M. J. & Gracely, E. J. (2002)
Emergency Department Preparedness For The
Evaluation And Treatment of Victims of Biological or
Chemical Terrorist Attack. Journal of Emergency Medicine,
22, 273-78.
Roy, M. J. (Ed.) (2004) Physician's Guide to Terrorist
Attack, Totowa, New Jersey, Humana Press.
References
Schultz, C. H., Koenig, K. L. & Noji, E. K. (1996) Current Concepts - A Medical Disaster Response To Reduce Immediate Mortality After An Earthquake. NEJM, 334, 438-44.
Richards, C. F., Burnstein, J. L., Waeckerie, J. F. & Hutson., H. R. (1999) Emergency Physician and Biological Terrorism. Annals of Emergency Medicine, 34, 183-190.
Mandl, K. D., Overhage, J. M., Wagner, M. M., Lober, W. B., Sebastiani, P., Mostashari, F., Pavlin, J. A., Gesteland, P., Treadwell, T., Koski, E., Hutwagner, L., Buckeridge, D. L., Raymond, D. A. & Grannis, S. (2004) Implementing Syndromic Surveillance: A Practical Guide Informed by the Early Experience. Journal of the American Medical Informatics Association, 11, 141-150