Emergency Room Procedures in Chemical Hazard Emergencies: A Job Aid
1. Try to determine agent identity.
2. Break out personal protection equipment, decon supplies, antidotes, etc.
3. Is chemical hazard certain or very likely?
• Put on personal protective equipment.
• Set up hot line.
4. Clear and secure all areas which could become contaminated.
5. Prepare to or secure hospital entrances and grounds.
6. Notify local emergency management authorities if needed.
7. If chemical is a military agent and Army has not been informed, call them.
8. If an organophosphate is involved, notify hospital pharmacy that large amounts of atropine and 2-PAM may be needed.
When victim arrives
(Note: A contaminated patient may present at an emergency room without prior warning.)
9. Does chemical hazard exist?
- Known release/exposure (including late notification)
- Liquid on victim’s skin or clothing
- Symptoms in victim, EMTs, others
- Odor (H, L, phosgene, chlorine)
- M-8 paper, if appropriate
YES: Go to 10.
NO: Handle victim routinely.
10. Hold victim outside until preparations are completed (put on personal protective equipment to assist EMTs as necessary).
11. If patient is grossly contaminated (liquid on skin, positive M-8 paper) OR if there is any suspicion of contamination, decontaminate patient before entry into building.
Initial Treatment and Identification of the Chemical Agent
1. Establish airway if necessary.
2. Give artificial respiration if not breathing.
3. Control bleeding if hemorrhaging.
4. Symptoms of cholinesterase poisoning?
- Pinpoint pupils
- Difficulty breathing (wheezing, gasping, etc)
- Local or generalized sweating
- Copious secretions
- Nausea, vomiting, diarrhea
YES: Go to Nerve Agent Protocol
5. History of chlorine poisoning?
YES: Go to Chlorine Protocol
6. Burns that began within minutes of poisoning?
YES: Go to 7.
NO: Go to 8.
7. Thermal burn?
YES: Go to 9.
NO: Go to Lewisite Protocol
8. Burns or eye irritation beginning 2-12 hours after exposure?
YES: Go to Mustard Protocol
NO: Go to 9.
9. Is phosgene exposure possible?
- Known exposure to phosgene
- Known exposure to hot chlorinated hydrocarbons
- Respiratory discomfort beginning a few hours after exposure
YES: Go to Phosgene Protocol
10. Check other possible chemical exposures:
- Known exposure
- Decreased level of consciousness without head trauma.
- Odor on clothes or breath
- Specific signs or symptoms
1. Survey extent of injury.
2. Treat affected skin with British Anti-Lewisite
3. Treat affected eyes with BAL ophthalmic
4. Treat pulmonary/severe effects
5. Severe poisoning?
2. Treat other problems and reevaluate
3. Respiratory system OK?
4. Is phosgene poisoning possible?
YES: Go to Phosgene Protocol
5. Give supportive therapy; treat other problems
|1. Severe respiratory distress?
2. Major secondary symptoms?
|3. Repeat atropine as needed until secretions decrease and breathing easier
Adults: 2 mg IV or IM
4. Repeat 2-PAM C1 as needed
NO: Go to 6.
6. Reevaluate q 3-5 min.
Note: Warn the hospital pharmacy that unusual amounts of atropine and 2-PAM may be needed