Kitipong Banomyong MD.,GP, MHSc (OHS), PM ( Occ. Med.) Occupational and Environmental Medicine Center Nopparat Rajathanee Hospital

1. Emergency Chemical Response Decontamination Principles and Patient Management Kitipong Banomyong MD.,GP, MHSc (OHS), PM ( Occ. Med.) Occupational and Environmental Medicine Center Nopparat Rajathanee Hospital

2. Reasonable ≠ Adequate Best possible care for victims while not compromising the safety hospital staff and current patients

3. Lessons Learned From Mass Casualty Incidents

4. Emergency Management Consequence Timelines

5. Timeline For Medical Intervention of Terrorist / Warfare Agents 10 min 20 min 40 min 1 hr 2 hr 4 hr 8 hr 1 day 2 days 4 days 8 days 16 days Saxitoxin Tetrodotoxin Conotoxin Batrachotoxin Tricothecene Aflatoxin Ricin Perfringens Verotoxin Botulism SEB Toxins Elapsed Time From: Greenwood, D. P., A Relative Assessment of Putative Biological-Warfare Agents: Technical Report 1040 , (Lexington, Massachusetts: Lincoln Laboratory, Massachusetts Institute of Technology, 17 July 1997). Chemical Agents T=0 threat first reaches victims Overt Encephalitis (various) Hantaan Congo-Crimean Chikungunya Rift Valley Dengue Yellow Ebola/Marburg Lassa Smallpox Viruses Cryptococcosis Coccidioidomycosis Histoplasmosis Fungi Anthrax Plague Shigellosis Cholera Salmonella Tularemia Legionnaire’s Glanders Melioidosis Brucellosis Typhoid Nocardiosis Bacteria RMSF Typhus Psittacosis Q fever Rickettsiae, Chlamydiae Covert 1 st Responders Arrive (1) 2 nd Responders Arrive (1) Civil Support Teams Arrive (1) Follow-up Federal Resources & Supplies Arrive (1) (1) After Notification

6. Summary Comparison SUMMARY CHARACTERISTICS Low Local to Global CHEM RAD BIO AGENTS Days to Weeks City Blocks City to Region Potential Impact High Medium Availability Seconds to Hours Minutes to Hours Time To Effects

7. Chem-Agent Dose Note: A barrel holds 44 gallons; tanker trucks carry 1,000 to 12,000 gallons; rail cars carry in excess of 20,000 gallons. Lethal doses vary among different Chem-agents 100% Lethal Air Dose Quantity 5.3 Quarts 21 Gallons 1820 Gallons Riot-Control 1.5 Quarts 6 Gallons 520 Gallons Blood 2.3 Quarts 9 Gallons 780 Gallons Choking 1 Quart 4 Gallons 338 Gallons Blister 1.3 ounces 2 ½ Cups 13 Gallons Nerve Boeing 747-400 Movie Theater Domed Stadium Chemical Agent

8. Bhopal Disaster 3 Dec.1984 8,000 died 300,000 injured

20. Vapor Pressure(VP) VP = 3877 mm VCM Chlorine VP = 7600 mm X VP = 60 mm

21. Boiling point(BP) VCM BP = -13.88 C H2O BP = 100 C BP = 50.55 C Chlorine BP = -34.6 C HCl

22. Vapor Density(VD) VD of dry air = 1

23. Specific gravity (SG) SG of Water = 1

24. The process of removing or neutralizing surface contaminants that have accumulated on personnel and equipment. What is Decontamination?

30. Urgency for decontamination Triage High risk for secondary contamination Mild or no illness Decontamination before treatment Low risk for secondary contamination Mild or no illness Decontamination not needed High risk for secondary contamination Critically ill Simultaneous decontamination and treatment Low risk for secondary contamination Critically ill Focus on Treatment Urgency for Medical Care

32. Layout of Hospital Decontamination Zone

33. Decontamination Station 2 lines

34. Decontamination Station 3 lines

36. Isolation Zones WARM INCIDENT SITE HOT **SAFE REFUGE AREA DECONTAMINATION CORRIDOR ACCESS CORRIDOR COLD COMMAND POST WIND DIRECTION **

42. Hospital Decontamination Immediate Treatment Triage Arrival Point Hospital & Secondary Treatment Facility Dry Decon litter Wet Decon (Non-Ambulatory) Wet Ambulatory Decon

44. Suggested Cut-Out Procedures (Non-ambulatory Patient’s Clothing)

54. Mass Decon Fire Department / Haz Mat Team

60. Mass Decon Hospital Based

67. VICTIM DECONTAMINATION FACILITY

68. Entrance to Emergency Department Site of Decon Unit

69. Site of Decon Unit Circular Drive at Front of Med Ctr

70. Routinely used as break area. During emergency, site of decon unit.

71. Deploying the shower curtains

72. Curtain separates male/female ambulatory decon lines

73. Drop down sprayers help with final rinse of ambulatory and decon of non-ambulatory victims.

75. Off/on box and mixing unit for shower

76. Deluge shower head – five on each line

77. Fully deployed shower Entrance for ambulatory victims Shower lines for ambulatory victims Disrobing area for ambulatory victims

79. Looking down the ambulatory men’s shower line

80. Assisting an ambulatory victim (drill)

81. Decon’ing a non-ambulatory victim

94. Medical Management Medical Treatment Protocol available from US Dept. of Health and Human Services Agency for Toxic Substances and Disease Registry http://www.atsdr.cdc.gov/mmg.html

95. ตัวอย่างไอระเหย / ก๊าซพิษที่เกิดจากการเผาไหม้พลาสติก

96. Chemicals Can Often Be Recognized by the Clusters of Symptoms That They Cause (Toxidromes)

106. Irritant Gas Moderately Water Soluble

109. Vapor Density(VD) VD of dry air = 1

142. Carbon Monoxide “The Silent Killer”

190. Explosives… Decon??? Madrid, 11 March 2004