Secondary exposure of medical staff to sarin vapor in the emergency room

A Call to Action: Why Anesthesiologists Must Train, Prepare, and Be at the Forefront of Disaster Response for Mass Casualty Incidents

Disasters, both natural and man-made, continue to increase. In Spring 2023, a 3-hour workshop on mass casualty incidents was conducted at the Society for Pediatric Anesthesia-American Academy of Pediatrics Annual conference. The workshop used multiple instructional strategies to maximize knowledge transfer and learner engagement including minididactic sessions, problem-based learning discussions in 3 tabletop exercises, and 2 30-minute disaster scenarios with actors in a simulated hospital environment. Three themes became evident: (1) disasters will continue to impact hospitals and preparation is imperative, (2) anesthesiologists are extensively and comprehensively trained and their value is often underestimated as mass casualty incident responders, and (3) a need exists for longitudinal disaster preparedness education and training over the course of a career. In this special article, we have sought to further define the problem and evidence, the capacity of anesthesiologists as leaders in disaster preparedness, and the rationale for preparation with current best practices to guide how best to move forward.

Organophosphorus Poisoning: Acute Respiratory Distress Syndrome (ARDS) and Cardiac Failure as Cause of Death in Hospitalized Patients

Industrial production of food for animals and humans needs increasing amounts of pesticides, especially of organophosphates, which are now easily available worldwide. More than 3 million cases of acute severe poisoning are estimated to occur worldwide every year, and even more cases remain unreported, while 200,000–350,000 incidentally or intentionally poisoned people die every year. Diagnostic and therapeutic procedures in organophosphate poisoning have, however, remained unchanged. In addition to several neurologic symptoms (miosis, fasciculations), hypersecretion of salivary, bronchial, and sweat glands, vomiting, diarrhea, and loss of urine rapidly induce dehydration, hypovolemia, loss of conscience and respiratory distress. Within hours, signs of acidosis due to systemic hypoxia can be observed at first laboratory investigation after hospitalization. While determination of serum-cholinesterase does not have any diagnostic value, it has been established that hypoalbuminemia alone or accompanied by an increase in creatinine, lactate, or C-reactive protein serum levels has negative prognostic value. Increased serum levels of C-reactive protein are a sign of systemic ischemia. Protective mechanical ventilation should be avoided, if possible. In fact, acute respiratory distress syndrome characterized by congestion and increased weight of the lung, accompanied by heart failure, may become the cause of death. As the excess of acetylcholine at the neuronal level can persist for weeks until enough newly, locally synthesized acetylcholinesterase becomes available (the value of oximes in reducing this time is still under debate), after atropine administration, intravenous albumin and fluid infusion should be the first therapeutic interventions to reestablish normal blood volume and normal tissue oxygenation, avoiding death by cardiac arrest.

Acute care for patients exposed to a chemical attack: protocol for an international multicentric observational study

INTRODUCTION

The use of weapons of mass destruction against civilian populations is of serious concern to public health authorities. Chemical weapons are of particular concern. A few studies have investigated medical responses in prehospital settings in the immediate aftermath of a chemical attack, and they were limited by the paucity of clinical data. This study aims to describe the acute management of patients exposed to a chemical attack from the incident site until their transfer to a medical facility.

METHODS AND ANALYSIS

This international multicentric observational study addresses the period from 1970 to 2036. An online electronic case report form was created to collect data; it will be hosted on the Biomedical Telematics Laboratory Platform of the Quebec Respiratory Health Research Network. Participating medical centres and their clinicians are being asked to provide contextual and clinical information, including the use of protective equipment and decontamination capabilities for the medical evacuation of the patient from the incident site of the chemical attack to the moment of admission at the medical facility. In brief, variables are categorised as follows: (1) chemical exposure (threat); (2) prehospital and hospital/medical facility capabilities (staffing, first aid, protection, decontamination, disaster plans and medical guidelines); (3) clinical interventions before hospital admission, including the use of protection and decontamination and (4) outcomes (survivability vs mortality rates). Judgement criteria focus on decontamination drills applied to any of the patient's conditions.

ETHICS AND DISSEMINATION

The Sainte-Justine Research Centre Ethics Committee approved this multicentric study and is acting as the main evaluating centre. Study results will be disseminated through various means, including conferences, indexed publications in medical databases and social media.

TRIAL REGISTRATION NUMBER

NCT05026645.

Gaps in Prehospital Care for Patients Exposed to a Chemical Attack - A Systematic Review

INTRODUCTION

The survivability of mass casualties exposed to a chemical attack is dependent on clinical knowledge, evidence-based practice, as well as protection and decontamination capabilities. The aim of this systematic review was to identify the knowledge gaps that relate to an efficient extraction and care of mass casualties caused by exposure to chemicals.

METHODS

This systematic review was conducted from November 2018 through September 2020 in compliance with Cochrane guidelines. Five databases were used (MEDLINE, Web of Science Core Collection, Embase, Cochrane, and CINAHL) to retrieve studies describing interventions performed to treat victims of chemical attacks (protection, decontamination, and treatment). The outcomes were patient's health condition leading to his/her stabilization (primary) and death (secondary) due to interventions applied (medical, protection, and decontamination).

RESULTS

Of the 2,301 papers found through the search strategy, only four publications met the eligibility criteria. According to these studies, the confirmed chemical poisoning cases in acute settings resulting from the attacks in Matsumoto (1994), Tokyo (1995), and Damascus (2014) accounted for 1,333 casualties including 11 deaths. No study reported comprehensive prehospital clinical data in acute settings. No mention was made of the integration of specialized capabilities in medical interventions such as personal protective equipment (PPE) and decontamination to prevent a secondary exposure. Unfortunately, it was not possible to perform the planned meta-analysis.

CONCLUSIONS

This study demonstrated gaps in clinical knowledge application regarding the medical extraction of casualties exposed during a chemical attack. Further research is required to optimize clinical practice integrating mixed capabilities (protection and decontamination) for the patient and medical staff.

Increasing Disaster Medical Assistance Teams' Intent to Engage with Specific Hazards

To ensure human resource availability for a smooth response during various types of disasters, there is a need to improve the intent of those involved in responding to each hazard type. However, Disaster Medical Assistance Team personnel’s intent to engage with specific hazards has yet to be clarified. This study therefore aimed to clarify the factors affecting Disaster Medical Assistance Team members’ (n = 178) intent to engage with each type of hazard through an anonymous web questionnaire survey containing 20 questions. Our results show that the intent to engage in disaster response activities was significantly lower for chemical (50), biological (47), radiological/nuclear (58), and explosive (52) incidents compared with natural (82) and man-made hazards (82) (p < 0.01). Multiple regression analysis showed that incentives were the most common factor affecting responders’ intent to engage with all hazard types, followed by self-confidence. Thus, creating a system that provides generous incentives could effectively improve disaster responders’ intent to engage with specific hazards. Another approach could be education and training to increase disaster responders’ confidence. We believe that the successful implementation of these measures would improve the intent of responders to engage with hazards and promote the recruitment of sufficient human resources.

Is secondary chemical exposure of hospital personnel of clinical importance?

INTRODUCTION

There is increasing concern among hospital personnel about potential secondary exposure when treating chemically contaminated patients.

OBJECTIVE

To assess which circumstances and chemicals require the use of Level C Personal Protective Equipment (chemical splash suit and air-purifying respirator), to prevent secondary contamination of hospital personnel treating a chemically contaminated patient.

METHODS

The US National Library of Medicine PubMed database was searched for the years 1985 to 2020 utilizing combinations of relevant search terms. This yielded 557 papers which were reviewed by title and abstract. After excluding papers on biological or radiological agents, or those not related to hospital personnel, 38 papers on chemicals remained. After a full-text review, 13 papers without an in-depth discussion on the risk for secondary contamination were omitted, leaving 25 papers for review. The references of these papers were searched and this yielded another seven additional citations, bringing the total to 32 papers.

INCIDENCE OF SECONDARY TOXICITY

Secondary toxicity in hospital personnel is rare: a large-scale inventory of 120,000 chemical incidents identified only nine cases, an occurrence of 0.0075%.

SKIN CONTACT AS A SECONDARY EXPOSURE ROUTE

Skin exposure is rare under normal hygienic working conditions, reflected by the very small number of cases reported in the literature: two cases with corrosive effects due to unprotected contact and one case of presumed skin absorption.

INHALATION AS A SECONDARY EXPOSURE ROUTE

Most case reports described secondary toxicity as a result of inhalation. The chemicals involved were irritating solid particles (capsaicin spray/CS), toxic gases formed in the stomach of patients (arsine/hydrazoic acid/phosphine) and vapours from volatile liquids (solvents).

FEATURES OF SECONDARY TOXICITY

Reported symptoms after secondary inhalation were generally mild and reversible (mostly irritation of eyes and respiratory tract, nausea, headache, dizziness/light-headedness) and did not require treatment. In many cases, special circumstances increased exposure: treatment/decontamination of multiple patients, regurgitation of the chemical agent from the stomach, or inadequate room ventilation.

USE OF MORE THAN STANDARD PERSONAL PROTECTIVE EQUIPMENT

Normal hygienic precautions prevent direct skin contact from exposure to common chemical agents. When solid particle contamination is extensive, a mask and eye protection should be applied. Splash proof outer clothing (splash suit) and eye protection is preferred if (partial) wet decontamination is performed on single patients. Adequate ventilation, careful removal of clothing in case of solid particles contamination and adequate disposal of gastric content reduces exposure. Hospital staff can be rotated if symptoms occur, which can be odour-mediated. The use of more elaborate personal protective equipment with an air-purifying respirator (Level C) is only necessary in exceptional cases of contamination with highly toxic volatile chemicals (e.g., sarin). It should also be considered when decontaminating a large number of patients.

CONCLUSIONS

The risk of secondary contamination and subsequent toxicity in hospital personnel decontaminating or treating chemically contaminated patients is small. Normal hygienic precautions (gloves and water-resistant gown) will adequately protect hospital staff when treating the majority of chemically contaminated patients. More extensive protection is only necessary infrequently and there is no reason to delay critical care, even if more elaborate protection is not immediately available.

Impact of personal protective equipment on prehospital endotracheal intubation performance in simulated manikin

Background

Tracheal intubation in COVID-19 patients is a potentially high-risk procedure for healthcare professionals. Personal protective equipment (PPE) is recommended to minimize contact with critical patients with COVID-19 infection. This study aimed to primarily examine the effect of PPE use on intubation time and success rate among prehospital healthcare professionals; additionally, we compared intubation times among prehospital health care professionals using PPE with direct laryngoscopy and video laryngoscopy assistance.

Methods

In this prospective simulation study, we compared the intubation times and success rates among prehospital healthcare professionals who were or were not using PPE. Furthermore, demographic data, previous intubation experience, and previous intubation experience with PPE were recorded.

Results

Overall time to intubation with PPE use was 51.28 ± 3.89 s, which was significantly higher than that without PPE use (33.03 ± 2.65 s; p < 0.001). In addition, the overall success rate with PPE use was 74.4%, which was significantly lower than that without PPE use (93%;p < 0.001). PPE use increased the average intubation time by 19.73 ± 2.59 s with direct laryngoscopy and by 16.81 ± 2.86 s with video laryngoscopy (p < 0.001).

Conclusions

PPE use is associated with increased intubation time and decreased success rate. Video laryngoscopy assistance in cases where PPE use is required facilitates faster endotracheal intubation than does direct laryngoscopy assistance.

Translating COVID-19 Pandemic Surge Theory to Practice in the Emergency Department: How to Expand Structure

Multiple professional societies, nongovernment and government agencies have studied the science of sudden onset disaster mass casualty incidents to create and promote surge response guidelines. The COVID-19 pandemic has presented the health-care system with challenges that have limited science to guide the staff, stuff, and structure surge response.This study reviewed the available surge science literature specifically to guide an emergency department's surge structural response using a translational science approach to answer the question: How does the concept of sudden onset mass casualty incident surge capability apply to the process to expand COVID-19 pandemic surge structure response?The available surge structural science literature was reviewed to determine the application to a pandemic response. The on-line ahead of print and print COVID-19 scientific publications, as well as gray literature were studied to learn the best available COVID-19 surge structural response science. A checklist was created to guide the emergency department team's COVID-19 surge structural response.

Broad Spectrum Treatment for Ocular Insult Induced by Organophosphate Chemical Warfare Agents

Warfare organophosphates nerve agents constitute one of the prime threats to mankind on the battlefield and in the scenario of civilian terror. Exposure to organophosphate (OP) nerve agents dose-dependently result in incapacitation. They affect multiple organs, but the eye is one of the first and most frequently affected. Ocular OP insult may result in long-term miosis, impaired visual function, and ocular pain thus inducing functional incapacitation. The currently recommended military medical doctrine of using 1% atropine eye drops is far from being the optimal treatment. Although effective in reducing ocular pain and the miotic response, this treatment induces long-term mydriasis and cycloplegia promoting photophobia and restricted accommodation, which may result in further impairment in visual function. An optimal treatment must ameliorate the long-term ocular insult enabling rapid return of normal visual function, while avoiding the induction of mydriasis and cycloplegia side effects, which could possibly worsen the visual performance. Optimal treatment should also keep effects of misuse to a minimum. Work done in recent years examined treatments with various anticholinergic drugs alone or used in combination with oxime treatments and may offer improved efficacy in ameliorating the ocular insult. This review is a summary of the applied research in animals and will discuss clinical implications and possible alterations in treatment protocols following OP exposure. Taken together the data points toward the use of topical low concentrations of potent anticholinergic ophthalmic drops such as atropine or homatropine, which rapidly ameliorate the long-term OP-induced ocular insult.

Identification of S419 on human serum albumin as a novel biomarker for sarin and cyclosarin exposure

RATIONALE

Organophosphorus nerve agents are highly toxic because they inhibit acetylcholinesterase activity, thereby causing a series of symptomatic poisoning. Upon entering the body, nerve agents bind active amino acid residues to form phosphonylated adducts. A potentially beneficial method for specific verification of exposure of nerve agents is based on albumin adducts, which have a half-life of 18 days. This appears to be more effective than the fluoride reactivation method, based on acetylcholinesterase.

METHODS

After the exposure of human serum albumin to nine nerve agents, human serum albumin was denatured, reduced, alkylated and digested with trypsin according to standard mass spectrometry-based proteomics procedures. The phosphonylated peptides of human serum albumin were identified using positive ion electrospray ionization with a quadrupole orbitrap mass spectrometer.

RESULTS

The peptide KVPQVSTPTLVESR showed a good mass spectrometric response to the nine nerve agents. The tendency of sarin and cyclosarin was to bind to S419 on the peptide, while the other nerve agents (tabun, soman and V-type nerve agents) were shown to bind more readily to K414 on the peptide.

CONCLUSIONS

This research revealed a new site, S419, of the tryptic peptide KVPQVSTPTLVEVSR on human albumin to be a valuable biomarker for sarin/cyclosarin exposure, helping to further distinguish sarin and cyclosarin poisoning from that of other nerve agents and providing an important tool for the identification of sarin or cyclosarin in terrorist attacks.

Efficacy of Different Hair and Skin Decontamination Strategies with Identification of Associated Hazards to First Responders

Background: Established procedures for mass casualty decontamination involve the deployment of equipment for showering with water (such as the ladder pipe system [LPS] and technical decontamination [TD]). This necessarily introduces a short, but critical delay. The incorporation of dry decontamination to the incident response process offers the potential to establish a more rapid and timely intervention. Objectives: To investigate the effectiveness of various dry (DD) and wet decontamination strategies for removing a chemical warfare simulant (methyl salicylate; MS) from the hair and skin of human volunteers. Methods: The simulant was applied to volunteers via whole body exposure to an aerosol. Three decontamination protocols (dry, LPS and technical decontamination) were applied, singly and in various combinations. The efficacy of the protocols was evaluated by fluorescent photography and analysis of residual MS from skin/hair swabs, decontamination materials and air samples. Results: Dry decontamination was effective, with the greatest reduction in skin and hair contamination arising from the "Triple Protocol" (DD+LPS+TD). Secondary hazards associated with contaminated individuals and equipment decreased as the number of decontamination procedures increased. In particular, dry decontamination reduced the potential contact and inhalation hazard arising from used washcloths, towels and vapor within the TD units. Discussion: The introduction of dry decontamination prior to wet forms of decontamination offers a simple strategy to initiate treatment at a much earlier opportunity, with a corresponding improvement in clinical outcomes and substantial reduction of secondary hazards associated with operational processes.

Tuning Butyrylcholinesterase Inactivation and Reactivation by Polymer-Based Protein Engineering

Organophosphate nerve agents rapidly inhibit cholinesterases thereby destroying the ability to sustain life. Strong nucleophiles, such as oximes, have been used as therapeutic reactivators of cholinesterase-organophosphate complexes, but suffer from short half-lives and limited efficacy across the broad spectrum of organophosphate nerve agents. Cholinesterases have been used as long-lived therapeutic bioscavengers for unreacted organophosphates with limited success because they react with organophosphate nerve agents with one-to-one stoichiometries. The chemical power of nucleophilic reactivators is coupled to long-lived bioscavengers by designing and synthesizing cholinesterase-polymer-oxime conjugates using atom transfer radical polymerization and azide-alkyne "click" chemistry. Detailed kinetic studies show that butyrylcholinesterase-polymer-oxime activity is dependent on the electrostatic properties of the polymers and the amount of oxime within the conjugate. The covalent coupling of oxime-containing polymers to the surface of butyrylcholinesterase slows the rate of inactivation of paraoxon, a model nerve agent. Furthermore, when the enzyme is covalently inhibited by paraoxon, the covalently attached oxime induced inter- and intramolecular reactivation. Intramolecular reactivation will open the door to the generation of a new class of nerve agent scavengers that couple the speed and selectivity of biology to the ruggedness and simplicity of synthetic chemicals.

Proposal for Reforming Prehospital Response to Chemical Terrorism Disasters in Japan: Going Back to the Basics of Saving the Lives of the Injured by Securing the Safety of the Rescue Team

INTRODUCTION

Having experienced the Tokyo subway sarin attack in 1995, Japan has established extremely strict rules on handling injured victims before they are sent to a hospital. As a result, it takes a long time before rescue actions are taken. This report aims to propose a reform to change the system that focuses on saving lives.

METHODS

First, the issues in firefighting on sites that currently present problems in Japan were identified. Then, Japanese guidelines were compared with those that were considered in other countries. Based on this, an ideal way of running rescue operations was examined, and a proposal to save many lives was made. This research was conducted with funding from the Ministry of Health, Labour, and Welfare of Japan (MHLW; Chiyoda, Tokyo, Japan).

RESULTS

In addition to preventing secondary injuries, the temporal aspect of rescuing people early with the clear goal of saving many lives was emphasized. Priority was given to measures against nerve agents to prevent secondary injuries, which put the rescuers' lives at risk. Possible decontamination methods were pursued before choosing the one that was most appropriate. A linear algorithm was used to determine which decontamination method could be started immediately, and then the gradual use of equipment was recommended. Even if Level A personal protective equipment (PPE) and other dedicated equipment and materials cannot be procured, the possibility of starting rescue activities under certain condition using regular equipment was pointed out. The need for a system for possible victims who would require support, such as foreigners, the handicapped, and elderly people, was also identified. Japan limits the scope of activities that can be undertaken by emergency medical technicians (EMTs) on-site. The way in which on-site medical care can be provided with future legal revisions in mind was also discussed.

CONCLUSION

There is an urgent need to build a framework in which rescue activities can take place so that the number of deaths would not rise, even if sarin and other poisons are scattered.

Validating a model of benzodiazepine refractory nerve agent-induced status epilepticus by evaluating the anticonvulsant and neuroprotective effects of scopolamine, memantine, and phenobarbital

INTRODUCTION

Organophosphorus nerve agents (OPNAs) irreversibly block acetylcholinesterase activity, resulting in accumulation of excess acetylcholine at neural synapses, which can lead to a state of prolonged seizures known as status epilepticus (SE). Benzodiazepines, the current standard of care for SE, become less effective as latency to treatment increases. In a mass civilian OPNA exposure, concurrent trauma and limited resources would likely cause a delay in first response time. To address this issue, we have developed a rat model to test novel anticonvulsant/ neuroprotectant adjuncts at delayed time points.

METHODS

For model development, adult male rats with cortical electroencephalographic (EEG) electrodes were exposed to soman and administered saline along with atropine, 2-PAM, and midazolam 5, 20, or 40 min after SE onset. We validated our model using three drugs: scopolamine, memantine, and phenobarbital. Using the same procedure outlined above, rats were given atropine, 2-PAM, midazolam and test treatment 20 min after SE onset.

RESULTS

Using gamma power, delta power, and spike rate to quantify EEG activity, we found that scopolamine was effective, memantine was minimally effective, and phenobarbital had a delayed effect on terminating SE. Fluoro-Jade B staining was used to assess neuroprotection in five brain regions. Each treatment provided significant protection compared to saline + midazolam in at least two brain regions.

DISCUSSION

Because our data agree with previously published studies on the efficacy of these compounds, we conclude that this model is a valid way to test novel anticonvulsants/ neuroprotectants for controlling benzodiazepine-resistant OPNA-induced SE and subsequent neuropathology.

Benzodiazepine-refractory status epilepticus, neuroinflammation, and interneuron neurodegeneration after acute organophosphate intoxication

Nerve agents and some pesticides such as diisopropylfluorophosphate (DFP) cause neurotoxic manifestations that include seizures and status epilepticus (SE), which are potentially lethal and carry long-term neurological morbidity. Current antidotes for organophosphate (OP) intoxication include atropine, 2-PAM and diazepam (a benzodiazepine for treating seizures and SE). There is some evidence for partial or complete loss of diazepam anticonvulsant efficacy when given 30 min or later after exposure to an OP; this condition is known as refractory SE. Effective therapies for OP-induced SE are lacking and it is unclear why current therapies do not work. In this study, we investigated the time-dependent efficacy of diazepam in the nerve agent surrogate DFP model of OP intoxication on seizure suppression and neuroprotection in rats, following an early and late therapy. Diazepam (5 mg/kg, IM) controlled seizures when given 10 min after DFP exposure ("early"), but it was completely ineffective at 60 or 120 min ("late") after DFP. DFP-induced neuronal injury, neuroinflammation, and neurodegeneration of principal cells and GABAergic interneurons were significantly reduced by early but not late therapy. These findings demonstrate that diazepam failed to control seizures, SE and neuronal injury when given 60 min or later after DFP exposure, confirming the benzodiazepine-refractory SE and brain damage after OP intoxication. In addition, this study indicates that degeneration of inhibitory interneurons and inflammatory glial activation are potential mechanisms underlying these morbid outcomes of OP intoxication. Therefore, novel anticonvulsant and neuroprotectant antidotes, superior to benzodiazepines, are desperately needed for controlling nerve agent-induced SE and brain injury.

EHAC medical working group best practice advice on the role of air rescue and pre hospital critical care at major incidents

BACKGROUND

Helicopter EMS (HEMS) teams may perform a variety of clinical, managerial and transport functions during major incident management. Despite national and international variations in HEMS systems, the rapid delivery of HEMS personnel with advanced skills in major incident management and clinical scene leadership has been crucial to the delivery of an effective medical response at previous incidents. This document outlines the Best Practice Advice of the European HEMS and Air Ambulance Committee (EHAC) Medical Working Group on how HEMS and Pre Hospital Critical Care teams may maximise the positive impact of their resources in the event of Major Incidents.

METHODS

Narrative literature review and expert consensus.

RESULTS

To ensure a safe, coordinated and effective response, HEMS teams require suitable, proportionate and up to date major incident plans that are integrated into the major incident plans of other regional emergency and healthcare services. Role specific protocols, training and equipment should be adapted to the expected HEMS role in the major incident plan and likely regional threats. System and incident factors will influence HEMS utilisation during the major incident response and can include patient and staff transfer, equipment resupply, aerial assessment, search and rescue, clinical leadership and advanced care. During the recovery phase of a major incident there is a need to ensure restoration of conventional service and address the welfare of involved HEMS personnel. Standardised reporting of major incidents is strongly recommended for clinical governance, legal and research reasons.

CONCLUSIONS

The rapid delivery of HEMS personnel with advanced skills in Major Incident management and clinical scene leadership is crucial to the delivery of an effective medical response at Major Incidents.

Desorption of sulphur mustard simulants methyl salicylate and 2-chloroethyl ethyl sulphide from contaminated scalp hair after vapour exposure

Chemical warfare agents have been used to incapacitate, injure or kill people, in a context of war or terrorist attack. It has previously been shown that hair could trap the sulphur mustard simulants methyl salicylate and 2-chloroethyl ethyl sulphide. In order to investigate simulants persistency in hair after intense vapour exposure, their desorption kinetics were studied by using two complementary methods: hair residual content measurement and desorbed vapour monitoring. Results showed that both simulants were detected in air and could be recovered from hair 2 h after the end of exposure. Longer experiments with methyl salicylate showed that it could still be recovered from hair after 24 h. Our data were fitted with several kinetic models and best correlation was obtained with a bimodal first-order equation, suggesting a 2-step desorption kinetics model: initial fast regime followed by a slower desorption. 2-chloroethyl ethyl sulphide was also detected in the immediate environment after hair exposure for 2 h, and hair simulant content decreased by more than 80%. Our results showed that hair ability to release formerly trapped chemical toxics could lead to health hazard. Their persistency however confirmed the potentiality of hair analysis as a tool for chemical exposure assessment.

A Review Article on Nerve Agents

The incidence of Tokyo subway attack by the Aum Shinrikyo cult in 1995 had raised the concern of the use of nerve agent as a weapon in terrorist attack. The recent event in World Trade Centre in New York city had further brought our attention to the possibility of terrorist attacks using these agents. In view of the high possibility of nerve agents being used as chemical weapon, medical personnel should have a clear knowledge of these agents. This article aim to provide a detailed discussion of these agents.

Essential Lessons in a Potential Sarin Attack Disaster Plan for a Resource-Constrained Environment

Sarin is a potent nerve agent chemical weapon that was originally designed for military purposes as a fast-acting anti-personnel weapon that would kill or disable large numbers of enemy troops. Its potent toxicity, ease of deployment, and rapid degradation allow for rapid deployment by an attacking force, who can safely enter the area of deployment a short while after its release. Sarin has been produced and stockpiled by a number of countries, and large quantities of it still exist despite collective agreements to cease manufacture and destroy stockpiles. Sarin's ease of synthesis, which is easily disseminated across the Internet, increases the risk that terrorist organizations may use sarin to attack civilians. Sarin has been used in a number of terrorist attacks in Japan, and more recently in attacks in the Middle East, where nonmilitary organizations have led much of the disaster relief and provision of medical care. In the present article, we examine and discuss the available literature on sarin's historical use, delivery methods, chemical properties, mechanism of action, decontamination process, and treatment. We present a management guideline to assist with the recognition of an attack and management of victims by medical professionals and disaster relief organizations, specifically in resource-constrained and austere environments. (Disaster Med Public Health Preparedness. 2018;12:249-256).

Airway Management in Disaster Response: A Manikin Study Comparing Direct and Video Laryngoscopy for Endotracheal Intubation by Prehospital Providers in Level C Personal Protective Equipment

Introduction Airway management is one of many challenges that medical providers face in disaster response operations. The use of personal protective equipment (PPE), in particular, was found to be associated with higher failure rates and a prolonged time to achieve airway control. Hypothesis/Problem The objective of this study was to determine whether video laryngoscopy could facilitate the performance of endotracheal intubation by disaster responders wearing Level C PPE.

METHODS

In this prospective, randomized, crossover study, a convenience sample of practicing prehospital providers were recruited. Following standardized training in PPE use and specific training in the use of airway devices, subjects in Level C PPE were observed while performing endotracheal intubation on a stock airway in a Laerdal Resusci-Anne manikin system (Laerdal Medical; Stavanger, Norway) using one of three laryngoscopic devices in randomized order: a Macintosh direct laryngoscope (Welch Allyn Inc.; New York USA), a GlideScope Ranger video laryngoscope (Verathon Medical; Bothell, Washington USA), and a King Vision video laryngoscope (King Systems; Noblesville, Indiana USA). The primary outcome was time to intubation (TTI), and the secondary outcome was participant perception of the ease of use for each device.

RESULTS

A total of 20 prehospital providers participated in the study: 18 (90%) paramedics and two (10%) Emergency Medical Technicians-Cardiac. Participants took significantly longer when using the GlideScope Ranger [35.82 seconds (95% CI, 32.24-39.80)] to achieve successful intubation than with the Macintosh laryngoscope [25.69 seconds (95% CI, 22.42-29.42); adj. P<.0001] or the King Vision [29.87 seconds (95% CI, 26.08-34.21); adj. P=.033], which did not significantly differ from each other (adj. P=.1017). Self-reported measures of satisfaction evaluated on a 0% to 100% visual analog scale (VAS) identified marginally greater subject satisfaction with the King Vision [86.7% (SD=76.4-92.9%)] over the GlideScope Ranger [73.0% (SD=61.9-81.8%); P=.04] and the Macintosh laryngoscope [69.9% (SD=57.9-79.7%); P=.05] prior to adjustment for multiplicity. The GlideScope Ranger and the Macintosh laryngoscope did not differ themselves (P=.65), and the differences were not statistically significant after adjustment for multiplicity (adj. P=.12 for both comparisons).

CONCLUSION

Use of video laryngoscopes by prehospital providers in Level C PPE did not result in faster endotracheal intubation than use of a Macintosh laryngoscope. The King Vision video laryngoscope, in particular, performed at least as well as the Macintosh laryngoscope and was reported to be easier to use. Yousif S , Machan JT , Alaska Y , Suner S . Airway management in disaster response: a manikin study comparing direct and video laryngoscopy for endotracheal intubation by prehospital providers in Level C personal protective equipment. Prehosp Disaster Med. 2017;32(4):352-356.

Testing the Use of Symptom-Based Terrorism Triage Algorithms with Hospital-Based Providers

Introduction: A set of symptom-based, all-hazards, decision-making algorithms was designed to aid the first-contact provider during early patient presentations after a terrorist incident.

Objective: The primary objective was to assess the usability of these algorithms. A secondary objective was to assess the psychometric properties of the testing scenarios.

Methods: This was a written, usability assessment of the algorithms employing a convenience sample of hospital-based, healthcare providers who had not taken any specific training in the use of the algorithms. A series of 26 paragraph-length, moderately difficult scenarios was created to reflect possible agents, means of attack, and types of patients. Each of the 26 scenarios requires that one make a triage choice on the “attack” algorithm (the trunk algorithm), then proceed to one of four other branch algorithms (dirty resuscitation, chemical agents, biological agents, bomb/blast/radiation dispersal device) to make a final triage choice. Conditional scores based on getting both the attack and final card correct were calculated for each algorithm.

Results: Nineteen attending physicians, 50 emergency medicine residents, and 41 nurses took the assessment. The total score was 45% correct for all participants. The score on the attack algorithm was 66% correct. Dirty resuscitation, biological, chemical, and bomb/blast scores were 46%, 54%, 46%, and 51% respectively. The probability of guessing the correct answer on the attack algorithm was 1/7 or 14%. The conditional probability of guessing both the attack algorithm and the final card correct ranged from 4.7% for the biological, chemical, and bomb/blast algorithms to 2.4% for the dirty resuscitation algorithm. Item discrimination, item difficulty, and Cronbach's alpha were acceptable for the overall test. Certain individual items had item difficulty levels suggesting they were too difficult and should be replaced in future versions of the test.

Conclusions: Performance on the test suggests that participants did substantially better than would have been expected by chance alone. Future efforts will revise the algorithms with the goal of simplification. Revision of the testing instrument and testing algorithm use after instruction also are needed.

Efficacy of scalp hair decontamination following exposure to vapours of sulphur mustard simulants 2-chloroethyl ethyl sulphide and methyl salicylate

Chemical warfare agents are an actual threat and victims' decontamination is a main concern when mass exposure occurs. Skin decontamination with current protocols has been widely documented, as well as surface decontamination. However, considering hair ability to trap chemicals in vapour phase, we investigated hair decontamination after exposure to sulphur mustard simulants methyl salicylate and 2-chloroethyl ethyl sulphide. Four decontamination protocols were tested on hair, combining showering and emergency decontamination (use of Fuller's earth or Reactive Skin Decontamination Lotion RSDL^®). Both simulants were recovered from hair after treatment, but contents were significantly reduced (42-85% content allowance). Showering alone was the least efficient protocol. Concerning 2-chloroethyl ethyl sulphide, protocols did not display significant differences in decontamination efficacy. For MeS, use of emergency decontaminants significantly increased showering efficacy (10-20% rise), underlining their usefulness before thorough decontamination. Our results highlighted the need to extensively decontaminate hair after chemical exposure. Residual amounts after decontamination are challenging, as their release from hair could lead to health issues.

Intubation Efficiency and Perceived Ease of Use of Video Laryngoscopy vs Direct Laryngoscopy While Wearing HazMat PPE: A Preliminary High-fidelity Mannequin Study

INTRODUCTION

Management of contaminated patients in the decontamination corridor requires the use of hazardous material (HazMat) personal protective equipment (PPE). Previous studies have demonstrated that HazMat PPE may increase the difficulty of airway management. This study compared the efficiency of video laryngoscopy (VL) with traditional direct laryngoscopy (DL) during endotracheal intubation (ETI) while wearing HazMat PPE.

METHODS

Post-graduate year (PGY) 1-3 Emergency Medicine residents were randomized to VL or DL while wearing encapsulating PPE. Video laryngoscopy was performed using the GlideScope Cobalt AVL video laryngoscope. The primary outcome measure was time to successful ETI in a high-fidelity simulation mannequin. Three time points were utilized in the analysis: Time 0 (blade at lips), Time 1 (blade removed from lips after endotracheal tube placement), and Time 2 (bag valve mask [BVM] attached to endotracheal tube). Secondary outcome measures were perceived ease of use and feasibility of VL and DL ETI modalities.

RESULTS

Twenty-one of 23 (91.3%) eligible residents participated. Mean time to ETI was 10.0 seconds (SD=5.3 seconds) in the DL group and 7.8 seconds (SD=3.0 seconds) in the VL group (P=.081). Mean times from blade insertion until BVM attachment were 17.4 seconds (SD=6.0 seconds) and 15.6 seconds (SD=4.6 seconds), respectively (P=.30). There were no unsuccessful intubation attempts. Seventeen out of 20 participants (85.0%) perceived VL to be easier to use when performing ETI in PPE. Twelve out of 20 participants (60%) perceived DL to be more feasible in an actual HazMat scenario.

CONCLUSION

The time to successful ETI was not significantly different between VL and DL. Video laryngoscopy had a greater perceived ease of use, but DL was perceived to be more feasible for use in actual HazMat situations. These findings suggest that both DL and VL are reasonable modalities for use in HazMat situations, and the choice of modality could be based on the clinical situation and provider experience.

Survey of UK Health Care First Responders' Knowledge of Personal Protective Equipment Requirements

INTRODUCTION

An adequate level of personal protective equipment (PPE) is necessary when treating patients with highly infectious diseases or those contaminated with hazardous substances.

METHODS

Following National Institute for Health Research's Research Centre (London, United Kingdom) approval, the authors of this study conducted a survey of specialist registrars' knowledge of the respiratory and skin protection requirements needed during a resuscitation scenario with Advanced Life Support. Participant responses were compared to UK national recommendations and to a previous survey in 2009.

RESULTS

A total of 98 specialist registrars (in Anesthesiology, n=51; in Emergency Medicine (EM), n=21; and in Intensive Care Medicine (ICM) n=26) completed hand-delivered surveys. The best knowledge of PPE requirements (76%) was found for severe acute respiratory syndrome (SARS), with less knowledge about PPE requirements for anthrax, plague, Ebola virus disease (EVD), and smallpox (60%). The results show limited knowledge of PPE requirements (20%-30%) for various chemical warfare agents. Personal protective equipment knowledge regarding treatment of sarin-contaminated casualties was over-rated by 80%, and for patients with EVD, it was over-rated by up to 67% of participants.

CONCLUSION

The results of the tested cohort indicate that current knowledge regarding PPE for chemical warfare agents remains very limited.

Risks to emergency medical responders at terrorist incidents: a narrative review of the medical literature

As the threat of international terrorism rises, there is an increasing requirement to provide evidence-based information and training for the emergency personnel who will respond to terrorist incidents. Current major incident training advises that emergency responders prioritize their own personal safety above that of the 'scene and survivors'. However, there is limited information available on the nature of these threats and how they may be accurately evaluated. This study reviews the published medical literature to identify the hazards experienced by emergency responders who have attended previous terrorist incidents. A PubMed literature search identified 10,894 articles on the subject of 'terrorism', and there was a dramatic increase in publications after the 9/11 attacks in 2001. There is heterogeneity in the focus and quality of this literature, and 307 articles addressing the subject of scene safety were assessed for information regarding the threats encountered at terrorist incidents. These articles demonstrate that emergency responders have been exposed to both direct terrorist threats and environmental scene hazards, including airborne particles, structural collapse, fire, and psychological stress. The emphasis of training and preparedness for terrorist incidents has been primarily on the direct threats, but the published literature suggests that the dominant causes of mortality and morbidity in responders after such incidents are the indirect environmental hazards. If the medical response to terrorist incidents is to be based on evidence rather than anecdote, analysis of the current literature should be incorporated into major incident training, and consistent collection of key data from future incidents is required.

Being prepared: emergency treatment following a nerve agent release

Nerve agents are extremely toxic and are some of the most lethal substances on earth. This group of chemicals consists of sarin, cyclosarin, soman, tabun, VX, and VR. It is currently unknown how many countries possess these chemicals and in what quantities. These agents work through altering the transmission and breakdown of acetylcholine by binding to, and inactivating, acetylcholinesterase. This results in an uncontrolled and overwhelming stimulation of both muscarinic and nicotinic receptors. Receptor activation at these sites can lead to a wide variety of clinical symptoms, with death frequently resulting from pulmonary edema. Antidotal therapy in this setting largely consists of atropine, pralidoxime, and benzodiazepines, all of which must be administered emergently to limit the progression of symptoms and prevent the enzyme inactivation from becoming permanent. This article reviews the mechanism of action of the nerve agents and their effects on the human body, the currently available therapies to mitigate their impact, and important therapeutic considerations for health care practitioners in the emergency department.

Secondary Contamination of Medical Personnel, Equipment, and Facilities Resulting From Hazardous Materials Events, 2003–2006

Background: When not managed properly, a hazardous material event can quickly extend beyond the boundaries of the initial release, creating the potential for secondary contamination of medical personnel, equipment, and facilities. Secondary contamination generally occurs when primary victims are not decontaminated or are inadequately decontaminated before receiving medical attention. This article examines the secondary contamination events reported to the Agency for Toxic Substances and Disease Registry (ATSDR) and offers suggestions for preventing such events.

Methods: Data from the ATSDR Hazardous Substances Emergency Events Surveillance system were used to conduct a retrospective analysis of hazardous material events occurring in 17 states during 2003 through 2006 involving secondary contamination of medical personnel, equipment, and facilities.

Results: Fifteen (0.05%) Hazardous Substances Emergency Events Surveillance events were identified in which secondary contamination occurred. At least 17 medical personnel were injured as a result of secondary contamination while they were treating contaminated victims. Of the medical personnel injured, 12 were emergency medical technicians and 5 were hospital personnel. Respiratory irritation was the most common injury sustained.

Conclusions: Adequate preplanning and drills, proper decontamination procedures, good field-to-hospital communication, appropriate use of personal protective equipment, and effective training can help prevent injuries of medical personnel and contamination of transport vehicles and medical facilities. (Disaster Med Public Health Preparedness. 2008;2:104–113)

Mobile decontamination units-room for improvement?

INTRODUCTION

Mobile decontamination units are intended to be used at the accident site to decontaminate persons contaminated by toxic substances. A test program was carried out to evaluate the efficacy of mobile decontamination units.

OBJECTIVE

The tests included functionality, methodology, inside environment, effects of wind direction, and decontamination efficacy.

METHODS

Three different types of units were tested during summer and winter conditions. Up to 15 test-persons per trial were contaminated with the imitation substances Purasolve ethyl lactate (PEL) and methyl salicylate (MES). Decontamination was carried out according to standardized procedures. During the decontamination trials, the concentrations of the substances inside the units were measured. After decontamination, substances evaporating from test-persons and blankets as well as remaining amounts in the units were measured.

RESULTS

The air concentrations of PEL and MES inside the units during decontamination in some cases exceeded short-term exposure limits for most toxic industrial chemicals. This was a problem, especially during harmful wind conditions, i.e., wind blowing in the same direction as persons moving through the decontamination units. Although decontamination removed a greater part of the substances from the skin, the concentrations evaporating from some test-persons occasionally were high and potentially harmful if the substances had been toxic. The study also showed that blankets placed in the units absorbed chemicals and that the units still were contaminated five hours after the end of operations.

CONCLUSIONS

After decontamination, the imitation substances still were present and evaporating from the contaminated persons, blankets, and units. These results indicate a need for improvements in technical solutions, procedures, and training.

Advances in toxicology and medical treatment of chemical warfare nerve agents

Organophosphorous (OP) Nerve agents (NAs) are known as the deadliest chemical warfare agents. They are divided into two classes of G and V agents. Most of them are liquid at room temperature. NAs chemical structures and mechanisms of actions are similar to OP pesticides, but their toxicities are higher than these compounds. The main mechanism of action is irreversible inhibition of Acetyl Choline Esterase (AChE) resulting in accumulation of toxic levels of acetylcholine (ACh) at the synaptic junctions and thus induces muscarinic and nicotinic receptors stimulation. However, other mechanisms have recently been described. Central nervous system (CNS) depression particularly on respiratory and vasomotor centers may induce respiratory failure and cardiac arrest. Intermediate syndrome after NAs exposure is less common than OP pesticides poisoning. There are four approaches to detect exposure to NAs in biological samples: (I) AChE activity measurement, (II) Determination of hydrolysis products in plasma and urine, (III) Fluoride reactivation of phosphylated binding sites and (IV) Mass spectrometric determination of cholinesterase adducts. The clinical manifestations are similar to OP pesticides poisoning, but with more severity and fatalities. The management should be started as soon as possible. The victims should immediately be removed from the field and treatment is commenced with auto-injector antidotes (atropine and oximes) such as MARK I kit. A 0.5% hypochlorite solution as well as novel products like M291 Resin kit, G117H and Phosphotriesterase isolated from soil bacterias, are now available for decontamination of NAs. Atropine and oximes are the well known antidotes that should be infused as clinically indicated. However, some new adjuvant and additional treatment such as magnesium sulfate, sodium bicarbonate, gacyclidine, benactyzine, tezampanel, hemoperfusion, antioxidants and bioscavengers have recently been used for OP NAs poisoning.

Personal Protection during Resuscitation of Casualties Contaminated with Chemical or Biological Warfare Agents—A Survey of Medical First Receivers

Introduction:

The threat of mass casualties caused by an unconventional terrorist attack is a challenge for the public health system, with special implications for emergency medicine, anesthesia, and intensive care. Advanced life support of patients injured by chemical or biological warfare agents requires an adequate level of personal protection. The aim of this study was to evaluate the personal protection knowledge of emergency physicians and anesthetists who would be at the frontline of the initial health response to a chemical/biological warfare agent incident.

Methods:

After institutional review board approval, knowledge of personal protection measures among emergency medicine (n = 28) and anesthetics (n = 47) specialty registrars in the South Thames Region of the United Kingdom was surveyed using a standardized questionnaire. Participants were asked for the recommended level of personal protection if a chemical/biological warfare agent(s) casualty required advanced life support in the designated hospital resuscitation area.

Results:

The best awareness within both groups was regarding severe acute respiratory syndrome, and fair knowledge was found regarding anthrax, plague, Ebola, and smallpox. In both groups, knowledge about personal protection requirements against chemical warfare agents was limited. Knowledge about personal protection measures for biological agents was acceptable, but was limited for chemical warfare agents.

Conclusions:

The results highlight the need to improve training and education regarding personal protection measures for medical first receivers.

Hospital Responses to Acute-Onset Disasters: A Review

Introduction:

Hospitals the world over have been involved in disasters, both internal and external. These two types of disasters are independent, but not mutually exclusive. Internal disasters are isolated to the hospital and occur more frequently than do external disasters. External disasters affect the community as well as the hospital. This paper first focuses on common problems encountered during acute-onset disasters, with regards to hospital operations and caring for victims. Specific injury patterns commonly seen during natural disasters are reviewed. Second, lessons learned from these common problems and their application to hospital disaster plans are reviewed.

Methods:

An extensive review of the available literature was conducted using the computerized databases Medline and Healthstar from 1977 through March 1999. Articles were selected if they contained information pertaining to a hospital response to a disaster situation or data on specific disaster injury patterns. Selected articles were read, abstracted, analyzed, and compiled.

Results:

Hospitals continually have difficulties and failures in several major areas of operation during a disaster. Common problem areas identified include communication and power failures, water shortage and contamination, physical damage, hazardous material exposure, unorganized evacuations, and resource allocation shortages.

Conclusions::

Lessons learned from past disaster-related operational failures are compiled and reviewed. The importance and types of disaster planning are reviewed.

Disaster Preparedness: Hospital Decontamination and the Pediatric Patient— Guidelines for Hospitals and Emergency Planners

In recent years, attention has been given to disaster preparedness for first responders and first receivers (hospitals). One such focus involves the decontamination of individuals who have fallen victim to a chemical agent from an attack or an accident involving hazardous materials. Children often are overlooked in disaster planning. Children are vulnerable and have specific medical and psychological requirements. There is a need to develop specific protocols to address pediatric patients who require decontamination at the entrance of hospital emergency departments. Currently, there are no published resources that meet this need. An expert panel convened by the New York City Department of Health and Mental Hygiene developed policies and procedures for the decontamination of pediatric patients.The panel was comprised of experts from a variety of medical and psychosocial areas.Using an iterative process, the panel created guidelines that were approved by the stakeholders and are presented in this paper.These guidelines must be utilized, studied, and modified to increase the likelihood that they will work during an emergency situation.

Recommended Modifications and Applications of the Hospital Emergency Incident Command System for Hospital Emergency Management

The Hospital Emergency Incident Command System (Hospital Emergency Incident Command System), nowin its third edition, has emerged asa popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the Hospital Emergency Incident Command System in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (Severe Acute Respiratory Syndrome) outbreaks in eastern Asia and Toronto, Canada.

Several modifications of the Hospital Emergency Incident Command System are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the Hospital Emergency Incident Command System to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in chemical, biological, radiological, nuclear emergencies; (3) new unit leaders in theOperations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, anddependents in terrorismrelated emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types ofpatients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems.

New uses of the Hospital Emergency Incident Command System in hospital emergency management also are recommended, including: (1) the adoption of the Hospital Emergency Incident Command System as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the Hospital Emergency Incident Command System not only to healthcare facilities, but also to healthcare systems.

Finally, three levels of healthcare worker competencies in the Hospital Emergency Incident Command Systemare suggested: (1) basic understanding of the Hospital Emergency Incident Command System for all hospital healthcare workers; (2) advanced understanding and proficiency in the Hospital Emergency Incident Command Systemfor hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the Hospital Emergency Incident Command System ad hoc from existing healthcare workers in resource-deficient settings. The Hospital Emergency Incident Command System should be viewed asa work in progress that will mature as additional challenges arise and ashospitals gain further experience with its use.

Symptom-Based, Algorithmic Approach for Handling the Initial Encounter with Victims of a Potential Terrorist Attack

Objectives:

This study intended to create symptom-based triage algorithms for the initial encounter with terror-attack victims. The goals of the triage algorithms include: (1) early recognition; (2) avoiding contamination; (3) early use of antidotes; (4) appropriate handling of unstable, contaminated victims; and (5) provisions of force protection. The algorithms also address industrial accidents and emerging infections, which have similar clinical presentations and risks for contamination as weapons of mass destruction (WMD).

Methods:

The algorithms were developed using references from military and civilian sources. They were tested and adjusted using a series of theoretical patients from a CD-ROM chemical, biological, radiological/nuclear, and explosive victim simulator. Then, the algorithms were placed into a card format and sent to experts in relevant fields for academic review.

Results:

Six inter-connected algorithms were created, described, and presented in figure form. The “attack” algorithm, for example, begins by differentiating between overt and covert attack victims (A covert attack is defined by epidemiological criteria adapted from the Centers for Disease Control and Prevention (CDC) recommendations). The attack algorithm then categorizes patients either as stable or unstable. Unstable patients flow to the “Dirty Resuscitation” algorithm, whereas, stable patients flow to the “Chemical Agent” and “Biological Agent” algorithms. The two remaining algorithms include the “Suicide Bomb/Blast/Explosion” and the “Radiation Dispersal Device” algorithms, which are inter-connected through the overt pathway in the “Attack” algorithm.

Conclusion:

A civilian, symptom-based, algorithmic approach to the initial encounter with victims of terrorist attacks, industrial accidents, or emerging infections was created. Future studies will address the usability of the algorithms with theoretical cases and utility in prospective, announced and unannounced, field drills. Additionally, future studies will assess the effectiveness of teaching modalities used to reinforce the algorithmic approach.

Decontamination of Multiple Casualties Who Are Chemically Contaminated: A Challenge for Acute Hospitals

Patients who have been contaminated by chemical compounds present a number of difficulties to emergency departments, in particular, the risk of secondary contamination of healthcare staff and facilities. The Department of Health in the United Kingdom has provided equipment to decontaminate chemically contaminated casualties who present at emergency departments. The capacity of this equipment is limited, and although both the ambulance and fire services have equipment to cope with mass casualties at the scene of a chemical incident, there is still the possibility that acute hospitals will be overwhelmed by large numbers of self-presenting patients. The risks and potential consequences of this gap in resilience are discussed and a number of possible practical solutions are proposed.

Principles of Emergency Department facility design for optimal management of mass-casualty incidents

INTRODUCTION

The Emergency Department (ED) is the triage, stabilization and disposition unit of the hospital during a mass-casualty incident (MCI). With most EDs already functioning at or over capacity, efficient management of an MCI requires optimization of all ED components. While the operational aspects of MCI management have been well described, the architectural/structural principles have not. Further, there are limited reports of the testing of ED design components in actual MCI events. The objective of this study is to outline the important infrastructural design components for optimization of ED response to an MCI, as developed, implemented, and repeatedly tested in one urban medical center.

REPORT

In the authors' experience, the most important aspects of ED design for MCI have included external infrastructure and promoting rapid lockdown of the facility for security purposes; an ambulance bay permitting efficient vehicle flow and casualty discharge; strategic placement of the triage location; patient tracking techniques; planning adequate surge capacity for both patients and staff; sufficient command, control, communications, computers, and information; well-positioned and functional decontamination facilities; adequate, well-located and easily distributed medical supplies; and appropriately built and functioning essential services.

DISCUSSION

Designing the ED to cope well with a large casualty surge during a disaster is not easy, and it may not be feasible for all EDs to implement all the necessary components. However, many of the components of an appropriate infrastructural design add minimal cost to the normal expenditures of building an ED.

CONCLUSION

This study highlights the role of design and infrastructure in MCI preparedness in order to assist planners in improving their ED capabilities. Structural optimization calls for a paradigm shift in the concept of structural and operational ED design, but may be necessary in order to maximize surge capacity, department resilience, and patient and staff safety.

New structural scaffolds for centrally acting oxime reactivators of phosphylated cholinesterases

We describe here the synthesis and activity of a new series of oxime reactivators of cholinesterases (ChEs) that contain tertiary amine or imidazole protonatable functional groups. Equilibration between the neutral and protonated species at physiological pH enables the reactivators to cross the blood-brain barrier and distribute in the CNS aqueous space as dictated by interstitial and cellular pH values. Our structure-activity analysis of 134 novel compounds considers primarily imidazole aldoximes and N-substituted 2-hydroxyiminoacetamides. Reactivation capacities of novel oximes are rank ordered by their relative reactivation rate constants at 0.67 mm compared with 2-pyridinealdoxime methiodide for reactivation of four organophosphate (sarin, cyclosarin, VX, and paraoxon) conjugates of human acetylcholinesterase (hAChE). Rank order of the rates differs for reactivation of human butyrylcholinesterase (hBChE) conjugates. The 10 best reactivating oximes, predominantly hydroxyimino acetamide derivatives (for hAChE) and imidazole-containing aldoximes (for hBChE) also exhibited reasonable activity in the reactivation of tabun conjugates. Reactivation kinetics of the lead hydroxyimino acetamide reactivator of hAChE, when analyzed in terms of apparent affinity (1/K(ox)) and maximum reactivation rate (k(2)), is superior to the reference uncharged reactivators monoisonitrosoacetone and 2,3-butanedione monoxime and shows potential for further refinement. The disparate pH dependences for reactivation of ChE and the general base-catalyzed oximolysis of acetylthiocholine reveal that distinct reactivator ionization states are involved in the reactivation of ChE conjugates and in conferring nucleophilic reactivity of the oxime group.

Comparison of techniques for securing the endotracheal tube while wearing chemical, biological, radiological, or nuclear protection: a manikin study

OBJECTIVE

The objective of this study was to assess the impact of chemical, biological, radiological, nuclear personal protective equipment (CBRN-PPE) on the ability to secure an endotracheal tube (ETT) with either the Thomas Tube Holder™ or cotton tape tied in a knot.

METHODS

Seventy-five clinicians secured an ETT in a previously intubated manikin with the Thomas Tube Holder™ and cotton tape. A mixed quantitative and qualitative research design was used to gauge actual performance times and perceptions of difficulties. Following completion of the study, 25 clinicians were interviewed to gauge their experiences of securing the ETT with both devices while wearing CBRN-PPE.

RESULTS

The mean time to apply the Thomas Tube Holder was 29.02 seconds, compared with tape which took a mean of 58 seconds (p=0.001). Clinicians rated the Thomas Tube Holder as easier to use than tape (Mann-Whitney z=9.934; p<0.001), which was confirmed during interviews. Of the clinicians interviewed, 92% perceived that the Thomas Tube Holder provided the better method for securing an ETT, none of the clinicians identified the tape as the best method for securing the endotracheal tube while wearing CBRN-PPE. Clinicians identified that the design of the Thomas Tube Holder facilitated the gross motor movement required for application.

CONCLUSIONS

The Thomas Tube Holder is easier and faster to apply when wearing CBRN-PPE when compared with cotton, and the Thomas Tube Holder is perceived by the participants as being more effective at preventing accidential extubation.

Psychosocial considerations for mass decontamination

Mass exposure to explosions, infectious agents, foodborne illnesses, chemicals or radiological materials may require mass decontamination that have critical psychosocial implications for the public and for both traditional and non-traditional responders in terms of impact and of response. Five main issues are common to mass decontamination events: (i) perception, (ii) somatisation, (iii) media role and communication, (iv) information sharing, (v) behavioural guidance and (vi) organisational issues. Empirical evidence is drawn from a number of cases, including Chernobyl; Goiania, Brazil; the sarin gas attack in Tokyo; the anthrax attacks in the USA; Three Mile Island; and by features of the 2003 severe acute respiratory syndrome pandemic. In this paper, a common platform for mass casualty management is explored and suggestions for mass interventions are proposed across the complete event timeline, from pre-event threat and warning stages through to the impact and reconstruction phases. Implication for responders, healthcare and emergency infrastructure, public behaviour, screening processes, risk communication and media management are described.