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Hazardous Material, Toxic,

and Industrial Events

Hoon Chin Lim and Tareg A. Bey

OVER V IEW

Hazardous material (HazMat) incidents are increasingly preva- lent due to the continuing rapid growth and globalization of the chemical industry. In a previous report, the World Health Orga- nization (WHO) noted that 100,000 industrial chemicals exist in the workplace. This number is increasing by an estimated 1,000 per year.1 In the United States alone, there are approximately 13,500 chemical manufacturing facilities, owned by more than 9,000 companies.2 When it comes to transportation of HazMats, the nation has nearly 1 million daily shipments by land, sea, and air.3 Globally, chemical production and use has also increased nearly 10-fold over the last 30 years, and this is particularly true in developing countries.4 The presence of such large quantities of toxic chemicals and hazardous substances among populations poses a significant threat to global health and the environment.

This chapter will focus on industrial HazMat events. Haz- ards of a biological nature or those with radioactive properties are discussed in Chapters 29 and 30. Harm can also result from deliberate release of hazardous materials from terrorism. Chem- ical emergencies related to the use of entities such as nerve agents are described further in a Chapter 28. Practical advice is provided based on best available evidence and any guidance is intended to undergo local interpretation.

Acute releases of hazardous materials are common and occur on a daily basis. As an example, a total of 7,744 acute HazMat emergency events were reported in 13 U.S. states alone in a 2004 annual report by the Hazardous Substances Emergency Events Surveillance (HSEES) system maintained by the Agency for Toxic Substances and Disease Registry.5 In England and Wales, a chem- ical surveillance system managed by the Environmental Health and Risk Assessment Unit of the Chemical Hazards and Poisons Division reported 1,978 chemical incidents in the years 2006 and 2007.6 The numbers from such databases will differ depending on surveillance methodology and the sources utilized that report such events. The WHO recognizes that as far as chemical emer- gencies are concerned, wide-scale major industrial accidents or attacks using chemical weapons give an incomplete picture when it comes to the disease burden from chemical incidents. The majority of exposure-related deaths and illnesses are attributable

to the many medium-sized and small-scale chemical incidents that take place every year around the world.7 One has to suspect that in some countries, these are the same incidents that go unre- ported due to poor or nonexistent injury surveillance systems. This may lead to an underestimation of disease burden.

Most acute HazMat events affect public health within the nation of its occurrence. Occasionally, these chemical incidents become events of international public health concern. In August 2002, the WHO initiated a pilot project sponsored by the Inter- national Programme on Chemical Safety (IPCS) to determine whether a system complementary to that for communicable dis- ease surveillance and response could be developed for chemi- cal incidents and related illnesses. Using several informal (e.g., Internet-based resources) and formal (e.g., various networks of organizations) sources, incidents were assessed against criteria for international public health emergencies using the then pro- posed revised International Health Regulations (IHR). During the 17 months of the project, from August 1, 2002 to December 31, 2003, 35 chemical incidents from 26 countries met one or more of the IHR criteria. The WHO European Region accounted for 43% (15 of 35) of reports.8 This was possibly the first global surveillance system for chemical incidents of potential interna- tional concern. It appears capable of providing early detection of important events as well as information on their magnitude and geographical distribution, thereby improving global public health preparedness.

Epidemiology of Acute Hazardous Material Events

The number of acute HazMat events is on the rise. Accord- ing to HSEES, the number of events per year increased from 5,785 in 1998 to 7,105 during 2001 even after excluding states that did not participate in their reporting program for the full period.9 It is uncommon for acute HazMat events to cause mass casualty scenarios. In 2004, 620 HSEES-reported emer- gency events (8% of all events) produced victims. Only one event resulted in more than 50 injured persons. In that event, 57 employees were injured due to improper mixing of a chemical that aerosolized a hydrochloride/phenol solution in a physician’s clinic.5

511 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 08:58:41.

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512 ■ HO O N CH I N LI M A N D TA R E G A. BEY

An industrial chemical disaster is defined as the release or spill of a toxic chemical that results in an abrupt and serious disruption of the functioning of a society, causing widespread human, material, or environmental losses that exceed the ability of the affected society to cope using only its own resources.10

Compared with daily small-scale HazMat emergencies, these incidents with high casualty counts are rare. One example, pos- sibly the worst incident in history, is the 1984 Bhopal disaster in which more than 2,500 persons were killed and an additional 200,000–300,000 individuals were affected.11 In contrast, most acute events do not result in patient injury. Furthermore, the majority of events that produce injuries result in only one or two victims.5 Even so, these incidents call for special planning and preparedness due to the challenges of managing a chemi- cally injured victim and the potential for HazMat incidents to harm emergency healthcare providers. Employees are most often injured (>50% of victims), followed by the general public.9,12

Within the group of first responders, police, career firefighters, and volunteer firefighters were the most frequent victims of both fixed facility and transportation-related events.9

Many factors can contribute to a chemical incident. They include poor maintenance of manufacturing and storage equip- ment, lack of regulation and poor enforcement of existing safety standards, motor vehicle collisions, and human error as well as meteorological and geological events such as heavy rain, earth- quakes, hurricanes, and floods, and terrorism.13 As a conse- quence of these factors, incidents could be associated with fires, explosions, spills and leaks, and structural collapse. Industrial accidents can also be described by the initiating event, which can be one or more of the following: human error, environmental conditions, and container or equipment failure.14 Between 1993 and 2001, most major acute chemical releases in the United States were due to equipment failure, followed by human/operator error. More than 75% of all events occurred in fixed facilities. Most events involved the release of only one substance.9,12 Of the 7,169 transportation-related events from 1998 to 2001, 85% occurred during ground transport; 9% during rail transport, and 6% during a combination of air, pipeline, water, or other types of transport. The 10 most frequently released chemicals were ammonia (5%), sulfur dioxide (5%), sulfuric acid (2%), hydrochloric acid (2%), carbon monoxide (2%), sodium hydrox- ide (2%), nitric oxide (2%), mercury (2%), paint or coating not otherwise specified (2%), and ethylene glycol (1%).9

Bhopal Cyanide Event: Classic Example of an Industrial Disaster

On December 2–3, 1984, approximately 41 tons of highly toxic gaseous methyl isocyanate was released into the air from a Union Carbide plant in the city of Bhopal, which is located in the Indian state of Madhya Pradhesh. Additionally, other substances such as CO2, CO, hydrogen cyanide, oxides of nitrogen, and phosgene were probably released within the gas cloud.15 At the time of the disaster, there were inadequate industrial safety programs in place at the Bhopal Union Carbide plant (Table 31.1).15–20 The infrastructure around the plant was deficient and included inef- fective roadways and streets, water supply, and medical treatment facilities. Poor to nonexistent urban planning was prevalent for people living extremely close to the industrial plant. Addition- ally, people in Bhopal were destitute and had little education or training on how to respond as a community to a chemical disaster. The health infrastructure was weak in Bhopal in 1984.

Table 31.1: Factors Contributing to the 1984 Bhopal Disaster

■ Multinational industrial producer of chemicals operates in a devel- oping nation and does not adhere to accepted international safety standards

■ Financial pressures supersede industrial safety regulations (violation of industrial zoning in the inner city, violation of limits for maximal production)

■ No enforcement of international safety operational standards ■ Lack of risk reduction in plant location ■ Poor public health infrastructure in the vicinity of a major industrial

operation ■ Poor public utility infrastructure such as drinking water, sewer, elec-

tricity, and telephone ■ Absence of an emergency response system for industrial accidents ■ Lack of infrastructure and technical expertise to manage an industrial

incident

Adapted after Broughton.20

No mass casualty emergency response system existed in the city and there was a lack of warning devices, shelter-in-place train- ing, public education on the dangers associated with the plant, and joint planning activities by public agencies and the Union Carbide plant.20

No consensus exists regarding how many people died, how many were actually exposed, or the numbers who suffered long- term disabilities.16 The literature describes different numbers of immediate and delayed fatalities as well as exposed individ- uals. Gupta and Broughton estimate that there were approxi- mately 3,800–4,000 immediate deaths and more than 200,000 injuries.17 In a report published in 2004, Sharma points out that Amnesty International estimated between 7,000 and 10,000 people lost their lives within the first 3 days of the Bhopal chem- ical release. Additionally, Amnesty International estimated that another 15,000–20,000 people succumbed to their exposures between the years of 1985 and 2003.16 Eckerman suggests that approximately 500,000 people were exposed.15 This makes the Bhopal incident the largest industrial disaster in history to date in terms of deaths and disabilities related to pulmonary, oph- thalmological, neurological, reproductive, gastrointestinal, and psychiatric effects.16

Numerous articles were published in the aftermath, analyzing the 1984 Bhopal event.16–20 Broughton points out that many safety measures and precautions that were normally in place in a highly industrialized country were absent in the Bhopal scenario. The Bhopal industrial disaster stands as a classic example of the consequences when pressure to expand industrialization in a developing nation leads to negligent enforcement of concurrent safety regulations.

The Bhopal disaster changed the chemical process industry permanently. Gupta emphasizes that improvements in the chem- ical process industry resulting from this event have saved lives and money by reducing accident damages.17 These improve- ments include

■ New legislation resulting in better enforcement and harsher sentencing

■ Enhancement in process safety ■ Development of safer industrial plants ■ Monitoring by the media, nongovernmental organizations,

and the public

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 08:58:41.

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HA ZA R D O U S MAT E R I A L, TOX I C, A N D IN D U S T R I A L EV E N TS ■ 513

■ Chemical process industry management’s willingness to invest in safety equipment, education and training

The Bhopal incident had a major effect on legislation and public political consciousness about chemical safety in the United States. It resulted in the formation of the American Institute of Chemical Engineers, the Center for Chemical Process Safety, and the Safety and Chemical Engineering program. These organi- zations resulted in a change in the practice and education of chemical engineers.18

Hazardous Wastes and the Environment

Hazardous wastes are dangerous substances intended for dis- posal. Their covert or deliberate release into the environment may not cause “disasters” that are immediately evident. However, being insidious and cumulative in effect, the damage they cause to the environment and subsequently public health is potentially great. Since the adoption of Agenda 21 at the United Nations Conference on Environment and Development, the attention of policy makers has been drawn to the links between health and the environment.21 Air pollution is just one example. At the global level, air pollution is estimated to be responsible for approximately 800,000 premature deaths each year, or 1.4% of all deaths worldwide and 6.4 million years of life lost, or 0.7% of the world’s total. This burden of disease is most important in developing countries, causing an estimated 39% reduction in years of life in southeast Asia (e.g., China, Malaysia, and Vietnam) and 20% in other Asian countries (e.g., India and Bangladesh).22 Another example was the disposal of hazardous waste into Minamata Bay. This case illustrates one of the worst chemical incidents and was characterized by the chronic release of hazardous materials into the environment, poisoning a large number of victims. Between 1932 and 1968, Chisso Corporation, a company located in Kumamoto Japan, dumped an estimated 27 tons of mercury compounds into Minamata Bay. It was not until the mid-1950s that people began to notice a “strange dis- ease.” Thousands of people whose normal diet included fish from the bay unexpectedly developed a neurological syndrome characterized by ataxia, numbness, muscle weakness, and visual problems. The illness became known as “Minamata disease.” The illness was ultimately diagnosed as methyl mercury poisoning. The public health impact was devastating. By 1974, 798 vic- tims had been officially recognized as having Minamata disease, although approximately 3,000 more people were awaiting verifi- cation from the board of physicians in Kumamoto Prefecture. In 1993, almost 40 years later, victims were still being compensated for damages.23

Chemical Incidents and Environmental Justice

A study in the United States investigating the relationship be- tween incidents at chemical facilities and characteristics of the surrounding communities revealed that larger facilities with higher risk for HazMat incidents are located in counties with larger African-American populations and higher levels of income disparity.24 The relationship between chemical facility risk and the demographics of the surrounding community is complex. Higher risk facilities are more frequently found in counties with sizeable poor and/or minority populations who disproportion- ately bear the collateral environmental, property, and health risks.24 In the light of such findings, environmental justice seeks

to redress the inequitable distribution of this burden. The U.S. Environmental Protection Agency defines environmental justice as the fair treatment and meaningful involvement of all peo- ple regardless of race, color, national origin, culture, education, or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and poli- cies.25 Legislation such as the Emergency Planning and Com- munity Right to Know Act (EPCRA) mandates the community be informed regarding the risks of chemical incidents that could arise from nearby facilities.26

STATE OF THE AR T

Hazardous Materials Classification and Identification

Hazard materials are substances that pose a potential risk to life, health, the environment, or property when not properly con- tained because of their chemical, physical, or biological proper- ties.27 Different government agencies may define HazMat differ- ently for operational reasons. Some use it loosely to describe specialized first responder teams equipped to handle on-site control and containment of hazardous chemicals. Apart from its inherent toxicity, the sheer quantity or concentration of the hazardous material in an acute release will also determine its ability to cause harm. These substances can be in solid, liquid, or gaseous form. Knowledge of a hazardous substance’s physical properties (e.g., water solubility) during an acute event is useful because it will help to determine the route of victim exposure, the likelihood of secondary contamination, and the most effective method of protection and decontamination.

Chemicals may be known by their common, generic, chemi- cal, or brand names. The Chemical Abstracts Service (CAS) of the American Chemical Society numbers chemicals to overcome the confusion regarding multiple names for a single chemical. The CAS assigns a unique CAS registry number (CAS#) to atoms, molecules, and mixtures. These numbers provide a unique iden- tification for chemicals and a means for cross-checking chemi- cal names. Identifying a chemical by name and CAS# is critical because one must be as specific as possible about the hazardous material in question. Trade or brand names can be mislead- ing.28,29 Another method for identifying hazardous substances is the globally recognized four-digit United Nations Substance Identification Number (UN SIN or UN Number), together with the United Nations Hazard Classification.

At the time of this writing, there is no universally adopted system of HazMat classification. Many different countries have their own standard for classification and communication. The presence of such inconsistent systems impacts both safety and economic interests. One positive step comes from the continuing development of a Globally Harmonized System for the Classifica- tion and Labelling of Chemicals (GHS).30 An internationally syn- chronized approach to classification and labeling would provide the foundation for national programs to ensure safe use, trans- port, and disposal of hazardous substances. It would also provide a basis for harmonization of rules and regulations on chemicals at national and international levels, which is an important step for trade facilitation and improvement of hazard risk manage- ment. Two objectives of the GHS include 1) harmonized criteria for classifying substances and mixtures according to their health, environmental, and physical hazards, and 2) harmonized hazard communication elements, including requirements for labeling and safety data sheets. Although country participation in this

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program is voluntary, at least 65 countries have agreed to imple- mentation. Many governments have either incorporated GHS into their existing regulations or established workgroups to rec- oncile existing legislation with the GHS. The UN released the second revised edition of the GHS in 2007.31

Various systems have been devised for the actual labeling of hazardous materials. Labels or placards contain information alerting people to the presence of dangerous materials by way of a pictogram or symbol. The placard may have words such as “flammable liquid” or “toxic gas,” a product identifier, hazard classification number, or an emergency assistance number to call. Some identification systems are permanent and cannot be modified once attached to a container. Others can be changed with fitted slots or interchangeable placards.

In some countries, Material Safety Data Sheets (MSDSs) containing basic substance information are legally required to accompany each product supplied to an end user. MSDSs are not necessarily intended for emergency responders, but they can be used by professional staff to advise such individuals. MSDSs have existed for many years in a wide variety of formats, with a broad range of data quality and quantity. The IPCS and the Euro- pean community produce International Chemical Safety Cards (ICSC) containing this information that are translated into var- ious languages.32,33

The driver of a vehicle transporting hazardous materials may carry more detailed information on its contents. Within the European community, regulations require that written emer- gency instructions be carried in the vehicle cab. The European Chemical Industry Council has produced a series of instructions called TREMCARDS (transport emergency cards). These cards are written using internationally approved standard sentences with appropriate translations.32,34

First responders may also encounter other numerical codes such as the Emergency Action Codes and the Hazard Identifi- cation Number (also known as the Kemmler Code). Emergency Action Codes (commonly called Hazchem Codes) are designed to assist emergency services providers during the initial contact with a HazMat incident by instructing responders which actions they should perform. They are designed for responding to bulk product incidents. In contrast, the Hazard Identification Num- ber, which is usually found in the United Kingdom on vehicles traveling internationally, gives advice on the nature of the hazard presented by the substance in question, as opposed to the actions required when dealing with the material.35

In the United States, the Department of Transportation Pipeline and Hazardous Materials Safety Administration uses the Hazard Classification System in its guidebook.36 This system assigns a chemical to a hazard class based on its most danger- ous physical characteristic, such as corrosiveness, flammability, or radioactivity. It is primarily a guide to aid first responders in 1) quickly identifying the specific or generic classification of the material(s) involved in the incident, and 2) protecting themselves and the general public during the initial response phase of the incident.

In contrast, fixed facilities in the United States use a labeling system that is different from the vehicular placarding system. The National Fire Protection Association 704 system is used at most fixed facilities.37 This system uses a diamond-shaped sign (commonly referred to as the “fire diamond”) that is divided into color-coded quadrants: blue, red, yellow, and the 6 o’clock posi- tion which is assigned no special color. Blue color indicates the degree of health hazard, red for flammability, yellow for insta-

bility, and the last quadrant reserved for special hazards. These markings assist first responders to quickly and easily identify the risks posed by the HazMat, helping to determine what specialty equipment should be used, procedures followed, or precautions taken during the first moments at the site of the release. They do not identify the substance.

First responders need to rapidly and precisely identify the chemical or the components of a HazMat mixture. They must be familiar with the local labeling systems and where to seek further information regarding the chemical. One cannot always rely on the presence of a HazMat placard. Many HazMats may not be placarded because their quantity did not exceed a certain weight limit (e.g., 450 kg). Placards may also be damaged by fire or explosions during the event. Other sources of information that may aid identification include site of the HazMat incident and the type of business, laboratory, or vehicle involved. Safety data sheets, order invoices, shipping documents, inventory sheets, and verbal information from front-line employees and management are potential sources of information.28 The Internet provides up-to-date resources related to chemical classification and iden- tification (Table 31.2).

Identifying a Hazardous Material Incident

To recognize a HazMat event, emergency medical services and fire department personnel responding to a motor vehicle colli- sion or structure fire must have a high index of suspicion. They may not receive information on hazardous materials involve- ment prior to arriving on scene. The ability to recognize that an event has occurred is the key to responder safety. One approach is by performing a three-point incident site assessment of envi- ronment, containers, and materials (chemical and physical prop- erties) involved.38

This method builds a framework that enables the responder to see the overall picture and have a manageable span of control over the data, using it to develop and implement an incident action plan. Weather patterns in the immediate area, particularly the local wind direction and speed, are important considerations as these incidents are approached from uphill and upwind. Other weather factors, such as heat and humidity, can greatly affect the behavior of a HazMat. For example, anhydrous ammonia typically moves upward, but a cloud can interact with moisture in the atmosphere and hover along the ground on a humid day.38

Public Health Response Cycle in an Industrial Hazardous Material Incident

Comprehensive emergency management of industrial HazMat incidents involves addressing all the elements of the public health response cycle – preparedness, mitigation, response, and recov- ery. The aim is to improve prevention of HazMat incidents that might affect the general population and, should an event occur, to minimize adverse effects on human health. Organizations and officials having roles include, but may not be limited to, those working in the following areas39

■ Ministries of health, labor, industry, and transportation ■ Regional and local health authorities and inspectorates ■ Hospitals and other treatment facilities ■ Providers of toxicological/health information, such as poison

information centers and chemical emergency centers

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Table 31.2: Online Resources Related to Chemical Identification and Classification

Name Description and Internet Address

CHEMTREC R© Access a library of over 5 million Material Safety Data Sheets (MSDSs), has 24-h toxicology specialists, language translation services, and chemical industry experts. http://www.chemtrec.com/Chemtrec/

Chemical Abstracts Service, CAS A division of the American Chemical Society, this group provides the most comprehensive database of disclosed research in chemistry and related sciences, including the world’s largest collection of substance information, the CAS REGISTRYSM

http://www.cas.org/

MSDSOnline R© MSDSonline develops on-demand products and services to help environmental health and safety professionals around the globe to access, manage and deploy material safety data sheets (MSDS) and safety information. The database contains millions of original MSDS documents in an indexed electronic format. More than 10,000 new or updated MSDS documents are added to their database each week. http://www.msdsonline.com/

National Fire Protection Association. NFPA 704, Standard System for the Identification of the Hazards of Materials for Emergency Response, 2007 Edition

This standard addresses the health, flammability, instability, and related hazards that are presented by short-term, acute exposure to a material under conditions of fire, spill, or similar emergencies. http://www.nfpa.org/aboutthecodes/aboutthecodes.asp?docnum=704

Occupational Safety and Health Administration, OSHA: Chemical Sampling Information (CSI)

The Chemical Sampling Information pages present, in concise form, data on a large number of chemical substances that may be encountered in industrial hygiene investigations. It is intended as a basic reference for OSHA personnel. http://www.osha.gov/dts/chemicalsampling/toc/toc chemsamp.html

Toxicology Data Network, TOXNET Databases on toxicology, hazardous chemicals, environmental health, and toxic releases. For example IRIS (Integrated Risk Information System), which is a compilation of electronic reports on specific substances found in the environment and their potential to cause human health effects. The information in IRIS is intended for those without extensive training in toxicology, but with some knowledge of health sciences. http://toxnet.nlm.nih.gov/

U.S. Department of Transportation (DOT) Pipeline and Hazardous Materials Safety Administration (PHMSA), Emergency Response Guidebook (ERG 2008)

Developed jointly by the U.S. DOT, Transport Canada, and the Secretariat of Communications and Transportation of Mexico (SCT) for use by firefighters, police, and other emergency services personnel who may be the first to arrive at the scene of a transportation incident involving a HazMat. http://hazmat.dot.gov/pubs/erg/gydebook.htm

CAMEO (Computer-aided Management of Emergency Operations) Chemicals

CAMEO Chemicals is developed jointly by three U.S. Federal agencies: the National Oceanic and Atmospheric Administration (NOAA), the Environmental Protection Agency (EPA), and the Coast Guard. CAMEO Chemicals is an online version of part of the CAMEO A suite of software programs developed by NOAA and EPA. CAMEO supports a number of information management functions, such as retrieval of chemical specific information to support emergency response activities, threat zone calculation and plotting for risk assessment, organization and management of EPCRA information, and storage and computer display of area maps. http://cameochemicals.noaa.gov/

■ Facilities handling, storing, or producing hazardous materi- als

■ Occupational health centers ■ Suppliers of pharmaceuticals and medical equipment

Mitigation, Prevention, and Risk Management

Measures to mitigate, prevent, and manage toxic HazMat inci- dents are closely interconnected and can be similar in both execution and goals. For example, global positioning system (GPS) satellite-based technology that tracks ground transporta- tion vehicles carrying hazardous substances provides their exact locations in the event of an acute release. The system can mitigate damage by reducing response time of emergency services to the scene. It also provides surveillance and early warning of any devi- ation from predetermined routes, be it accidental or deliberate,

as in a hijacking by terrorists. With improved situational aware- ness by drivers, route planning can be optimized and include consideration of hazards such as the weather. In this way, it is also assists with disaster prevention.

Plans for mitigation should incorporate an all-hazard approach, be location specific, and flexible to circumstances sur- rounding an event. Mitigation planning commonly includes the following areas,40,41 which can be considered in the context of HazMat incidents.

■ Business continuity plans ■ Building design, for example drainage systems for decon-

tamination run-off ■ National and local regulation on land use, locating buildings

outside hazard zones ■ Essential building utilities

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■ Protection of building contents ■ Mechanisms and instruments for spreading risk and/or risk

transfer (insurance and safety reserves) ■ Education, such as training the population and local and

national institutions on the causes, impacts, and means of disaster prevention

■ Surveillance ■ Warning and evacuation

Table 31.3: Items to Be Considered When Undertaking a Risk Assessment in a Catchment Area43

■ What are the use and storage arrangements for chemicals for all industrial sites?

■ What are the on-site capabilities of local industrial sites? ■ What are the transport arrangements for hazardous substances? ■ What are the historical patterns of local chemical incidents? ■ What is the population density, taking into consideration the size

and position of the major population centers? ■ Are all sites accessible within 20 minutes? ■ What and where are the local bodies of water? ■ What is the potential for deliberate release of industrial chemicals or

chemical warfare agents? ■ What is the overall risk?

Other areas of risk assessment include40

■ Records of past disasters ■ Specific geological, climatic, and other hazards in the local/regional

area ■ Drafting and updating hazard maps and vulnerability profiles with

maximal participation ■ Surveys of vulnerable populations ■ Surveys of buildings, production activities, roads, vehicles, persons

per households

Mitigation measures need not duplicate resources. For exam- ple, public warning systems for disaster evacuation are all-hazard and are not only used in chemical releases. Special considerations concerning population protection measures arise from chemi- cals released as vapor or gas. Shelter-in-place contingencies may be useful when there is insufficient time for evacuation following release, when remaining indoors is safer due to the presence of an outdoor chemical plume. To be effective, public awareness, education, and communication are crucial. The process of sus- tainable hazards mitigation requires 1) nonjudgmental debate, 2) full public participation, 3) a willingness to experiment, learn, fine-tune, and alter approaches, and 4) a consensus among stakeholders to stand behind their shared commitment to the goal.42

For any community, complete prevention of HazMat inci- dents is unrealistic. There will always be a risk of events in the presence of hazards. The approach should be that of manag- ing and reducing risks causing disaster. Risks can be assessed by investigating the cause–effect matrix between hazards and vul- nerability (hazard vulnerability assessment [HVA]). Risk man- agement is part of disaster mitigation and prevention. The main vulnerability factors are political-institutional, economic, and sociocultural.40 They include issues such as fragile infrastruc- ture, absent or poorly developed safety policies, low levels of political and social organization, absence of early warning sys- tems, and an increase in population density, especially around

chemical facilities. Table 31.3 contains items to be considered when undertaking a risk assessment in a catchment area.43

Integrated response plans involving both specialized plant HazMat teams and local community first responders can be devised by following each stage of the chemical life cycle: 1) research and development, 2) site of manufacture, 3) storage at site of manufacture, 4) transportation, 5) storage at site of use, 6) site of use, and 7) disposal of waste products.44 Reducing human error and equipment failure in each stage will yield the high- est return. It is much more efficient to implement effective risk management strategies and avoid the costs of chemical industrial events than to respond to actual incidents. There is reluctance when approaching the topic, however, due to issues such as cost, poor awareness, resistance to reforms, and minimizing the like- lihood of events.40

Preparedness

A systems approach to seamlessly integrate capability is needed for all-hazard incident planning. The same approach should be undertaken with special considerations to the intricacies of a HazMat incident. The 3-S Surge System (staff, stuff, and struc- ture – see Chapter 3) is a reminder of what plans should include in order to develop optimized and sustainable capability.45

Planning and Systems Healthcare authorities, local communities, and hospitals

need to plan for acute chemical incidents. At any time, hospitals must safely and rapidly decontaminate, evaluate, and treat at least two chemically injured victims. This is the premise for develop- ment of further response capabilities for mass casualty incidents involving chemical or radiological weapons of mass destruction. In a study comparing 1996 and 2000 measures of preparedness among hospitals of a major U.S. metropolitan area, the hospitals were poorly prepared to manage chemical emergency incidents, including terrorism. This lack of hospital preparedness did not change significantly between 1996 and 2000, despite increased funds allocated to bioterrorism preparedness at the local level.46

In some countries such as the United States, extensive legis- lation, regulations, and standards exist mandating and assisting hospitals to plan for chemical incidents.

1) Occupational safety regulations from the Occupational Safety and Health Administration (OSHA) protect health- care providers during a HazMat response as a worker safety issue.47

2) The Emergency Medical Treatment and Active Labor Act requires hospitals to provide a medical screening examina- tion and stabilization (consistent with their capabilities) to anyone presenting to their grounds for treatment regardless of citizenship, legal status or ability to pay.48 It does not make exceptions for contaminated patients.

3) The Emergency Planning and Community Right-to-Know Act is a section of the Superfund Amendments and Reauthoriza- tion Act, otherwise known as SARA Title III.26 It states that facilities manufacturing or storing hazardous chemicals must report inventories and every HazMat release to public offi- cials and emergency health agencies. The Act also requires the establishment of state emergency response commissions and local emergency planning committees.

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4) Healthcare accreditation organizations such as the Joint Commission have requirements relating to HazMats.49

Planning for toxic incidents involves modification within the framework of existing emergency response plans and inci- dent command systems, rather than creating entirely new pro- tocols. Plans should be established before a HazMat incident occurs. Separate prehospital and hospital plans are needed for first responders and first receivers, respectively, to manage vic- tims. Both plans must be integrated and harmonized.

In addition to areas addressed in general emergency man- agement programs, specific areas to consider when planning for a hospital’s HazMat response include

■ Hazards and vulnerabilities identified in a HVA ■ Estimated time before arrival based on location of hazard ■ Casualty care areas ■ Decontamination procedures and protocols ■ Secondary contamination and containment of contaminated

equipment and run-off water ■ Safety: personal protection equipment (PPE) ■ Communications at decontamination area ■ Heating, ventilating, and air conditioning and in-place pro-

tection ■ Medical management – antidotes ■ Interfacility transfers – patients with special needs, burn

patients ■ Knowledge resources for hazardous materials

Local authorities that develop such plans should consider the following50

■ Identify local facilities using hazardous substances ■ Designate community and industrial coordinators ■ Establish mechanisms for emergency notification ■ Establish procedures for determining the occurrence of a

release and an estimation of the affected population (location and numbers)

■ Identify community emergency equipment facilities ■ Establish evacuation plans ■ Establish and schedule training programs for emergency per-

sonnel

Staff The hospital’s incident command center is responsible for

optimal use of staffing resources. It should coordinate medical and auxiliary personnel, direct activities at the various treatment sites, organize equipment and supplies, and maintain contact with outside authorities.51 Standard operating procedures indi- cating roles and responsibilities of personnel must be established before and event occurs.

Education and training are important aspects of planning because of specialized procedures and equipment used by pre- hospital providers and hospital personnel. First responders and first receivers must acquire necessary knowledge, skills, and abil- ities to respond safely to incidents involving hazardous materials. Because of different work environments and PPE requirements, education and training should be tailored to address their specific needs. It should be structured and standardized, locally relevant to hazards and equipment used, continually revised and updated,

and delivered multiple times and across all work shifts to enhance retention.

In a study of paramedic students, retention of proper don- ning and doffing techniques for PPE was poor at 6 months after initial training. Critical errors were common even in individuals with previous HazMat, firefighter, and emergency medical ser- vices training.52 It appears unrealistic to retrain hospital decon- tamination teams composed of staff nurses and allied health personnel every 6 months; however, annual refresher courses are achievable.

The training courses may consist of practical approaches to the management of HazMat casualties, common toxicological agents, triaging contaminated victims, computer searches for information on toxic materials, wearing PPE, and assembling a portable decontamination shower.53 Hospitals can video record and review drills to critique and refresh the knowledge of their participating staff.

Frequently planned drills are essential for effective imple- mentation of disaster plans. Joint training and education are important ingredients in producing a multidisciplinary team functioning optimally under stressful circumstances. Training must include 1) communication exercises, 2) small-scale (hos- pital and emergency service) response exercises, and 3) full-scale simulations involving industry, health professionals, emergency services, and others with responsibilities in the area, such as civil defense services and military authorities.54 A cost-effective five-level scale for hospital preparedness in accordance with the existing threat has been suggested (Table 31.4).51

Stuff and Structure HazMat medical response involves mobilization and utiliza-

tion of equipment and treatment areas that are rarely encoun- tered in the course of routine hospital work. “Structure” can mean physical infrastructure such as a fixed facility for decon- tamination, assembly, triage and evaluation, and patient care, all of which must be determined pre-event. Decontamination can be conducted in fixed, semifixed, or mobile facilities like tents, inflatable structures, and mass decontamination vehicles.

Some of the challenges facing hospitals on the safe treatment of HazMat exposures may be mitigated by engineering controls. Examples include46,55

■ Controlled access points to prevent contaminated patients from entering the facility prior to decontamination

■ Designing decontamination shower facilities that can accom- modate placement of warm water lines

■ Situating shower nozzles on the building exterior ■ Collection system to control for contaminated water run-off ■ Access fittings for medical gases on the building exterior that

will facilitate use by emergency responders when utilizing supplied-air respirators

■ Design of hospital ventilation systems that takes into account the potential need to isolate the internal hospital environ- ment

Procurement and acquisition of PPE and decontamination items need to complement the hospital’s role and HVA outcomes. Further elaboration on both topics can be found in Chapters 13 and 14. “Stuff” also includes knowledge resources that are needed for medical management of victims. A vast amount of informa- tive resources are web based, thus underscoring the need for maintenance of Internet access during a crisis. Other resources

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Table 31.4: Five-Level Scale for Hospital Preparedness According to Existing Threat51

Level of Preparation∗ Action Required

I No Threat 1. Prepare a hospital deployment plan for a chemical incident (e.g., due to a motor vehicle collision)

II Minimal Threat 1. Instruction of the hospital plan and principles of chemical agent diagnosis and treatment once a year 2. Assign specific tasks in the deployment plan to hospital personnel 3. Partial practice drill once in 3 years 4. Consider the need for medical equipment, supplies, and communication systems, and examine their

maintenance once a year

III Existing Threat 1. Full practice drill once in 3–5 years, instruction every year 2. Prepare appropriate medical equipment, supplies and communication systems, and examine their maintenance

every half year

IV Increased Threat 1. Organize appropriate shifts of hospital personnel to increase their availability and an emergency calling system for the staff and auxiliary personnel according to their assigned tasks

2. Full practice drill once in 1–2 years, instruction and smaller scale review drills on receiving the new threat level and as often as possible

3. Examine maintenance of equipment, protective gear, and communication systems every few months. Increase their availability by storage at or near the sites

4. Prepare arrangements for shifting of patients inside the hospital

V Maximal Threat 1. Be prepared to receive and treat chemical casualties within minutes or hours 2. Organize equipment, protective gear, and communication systems at all sites 3. Arrange patient transfer and discharge when possible 4. Maintain continuous contact with authorities outside the hospital

∗ Each level should also include the required actions of the previous levels

include poison information centers, ad-hoc toxicological advi- sory teams, in-hospital toxicologists, or textbooks.

Medical field teams deployed from hospitals to the scene of a HazMat mass casualty incident usually conduct their work in the “cold” zone. Nevertheless, they will need to carry PPE that is commensurate with the hazard’s risk, in case the zone turns suddenly “warm” without the opportunity for timely evacuation. In addition to general items, an inventory of antidotes and burn care items should be considered (Figure 31.1).

Antidote stockpiling is a critical component of comprehen- sive medical preparedness in chemical emergencies.56 A national

Figure 31.1. Boxes of equipment on trolleys packed pre-event for rapid deployment with medical field teams located next to the exit. See color plate.

program for distribution of antidotes from a central stockpile plays a fundamental role; however, demographic, geographical, and economic factors often obstruct the rapid disbursement of antidotes. Any system of antidote distribution must provide poi- soned patients with empirical antidotes based on toxidromic assessment or specific antidotes based on substance identifica- tion in appropriate quantities and within the time required for treatment. Local stockpiles of antidotes are limited by factors such as infrequent use, cost, and short shelf life. A push system can be adopted to supplement local stockpiles with antidotes to common poisonings, which can be based on local HVA. This is important in the initial phase when the substance is unidentified. Larger quantities of specific items or antidotes can follow as the situation becomes clearer. Most toxins do not have specific anti- dotes (Table 31.5).56 Time-sensitive antidotes such as diazepam,

Table 31.5: Available Life-saving Antidotes for HazMat and Chemical Weapons56

Antidote Chemical

Calcium Hydrofluoric acid or fluoride

Hydroxocobalamin Cyanides

Atropine Organophosphates, carbamates, nerve agents

Amyl nitrite Cyanides, nitriles, sulfides

Methylene blue Methemoglobin-forming compounds

Oxygen Simple asphyxiants, systemic asphyxiants, methemoglobin-forming compounds, carbon monoxide, cyanides, azides and hydrazoic acid, hydrogen sulfide and sulfides

Oximes Organophosphates, nerve agents

Pyridoxine Hydrazones

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Figure 31.2. Incident site control zones.60

cyanide antidote kits, atropine, and pralidoxime are the most important drugs to stockpile locally for the potential treatment of mass casualties of a chemical emergency.57,58

Response

When responding to an acute HazMat incident, the protocols and procedures that are planned during the preparation phase are followed and executed. The command structure and responsi- bilities should follow the same approach as that for a major inci- dent.43 Early recognition that a HazMat situation exists, effec- tive risk communication, administration of basic or advanced resuscitation measures, rapid decontamination, and timely evac- uation and transport to hospitals that can provide appropri- ate treatment are crucial factors for improving outcomes. The response phase is usually staged in two locations: the prehospital environment and the hospital site.

Prehospital Response First responders may immediately suspect a HazMat incident

when confronted with a truck rollover and leakage of unknown substances. In the absence of such obvious clues, general indica- tors of possible HazMat event include53

■ Unusual occurrence of dead or dying animals (such as dead birds)

■ Unexplained casualties (multiple victims with the similar signs and symptoms such as skin, respiratory system, vision, and nervous system involvement)

■ Increase in the frequency of those with the aforementioned signs and symptoms in the direction of prevailing winds

■ Unusual liquid or vapor clouds (droplets, unexplained odor, or taste)

■ Mass casualties without any conventional injuries

Binoculars are helpful for ascertaining visible information from a safe distance.

Once a HazMat incident has been declared, all noncontam- inated, nonprotected personnel should be evacuated from the scene. The area is then cordoned off, with limited access. When full decontamination is needed, it occurs along a corridor in the

“warm zone.” This is the area between the contaminated area (the hot zone) and the safe area (the cold zone).59 The cold zone is uphill and upwind from the hot zone (Figure 31.2).60

Information from the scene should be widely communi- cated as soon as possible to receiving hospitals to optimize their preparation. If available, the following data should be transmit- ted: number and type of casualties, chemical substance involved, estimated time of arrival of first casualties (realizing that some patients may bypass the prehospital system and self-present), time of the incident and location of the incident site, method of contamination (vapor or liquid), and potential hazards to health- care providers.60 The development of state-of-the-art computer- based communication and information networks designed espe- cially for mass casualty incident management have provided the means for a more coordinated and effective response by facil- itating information flow. Through these systems, first respon- ders can activate web-based cameras to provide live streaming videos of selected incident areas (e.g., casualty clearing stations) to improve situational awareness at the hospitals.61

Identification of the hazardous substance is useful and poten- tial sources of information have been discussed earlier in this chapter. Equipment exists, including chemical detection paper and the Improved Chemical Agent Monitor that allows trained personnel to detect chemicals.

Depending on the scale of the chemical incident and local emergency planning, physicians and nurses from hospitals or organized response teams may be mobilized to provide forward medical care to victims on scene. They usually perform their duties in the cold zone, where it is uncontaminated and safe. HazMat victims may, however, have acute life-threatening respi- ratory and cardiovascular problems that require aggressive and early definitive care. The problem is amplified should the sub- stance have high persistence in the surroundings. To withhold care until decontamination is completed may lead to unaccept- able delays in treatment. Given this situation, many emergency medical services teams are trained to work with full protective equipment and provide early, enhanced basic or advanced life support inside the contaminated hot zone.62 Medical response personnel who enter the contaminated zone need to be ade- quately trained and equipped with appropriate PPE. Safety is the first and foremost consideration. Special knowledge on med- ical and operational aspects of managing victims in a hostile, contaminated environment is required for the best results.63 In the situation when decontamination can be conducted quickly, limiting medical attention to opening the airway with spinal pre- cautions, controlling hemorrhage, and terminating seizures can expedite a victim’s transport to definitive care.

Triage When decontamination facilities are saturated, two factors

should help to decide patient priority – the principles of field medical triage and the severity of contamination.59 Casualties who require immediate treatment with antidotes should receive early intervention and be reevaluated at intervals. Triage at this point will also help to identify which patients need immediate, life-saving care before and during decontamination.

Whichever triage system is used in a HazMat incident, it should be familiar to those responsible for the activity. Phys- iological methods such as the modified triage sieve have been described for use in the warm zone, although there is some question as to its efficacy.43,64,65 Other triage methods have fac- tored in aspects such as organ system involvement, area of skin

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Figure 31.3. Trauma and chemical triage.66

injury, and response to antidotes.60 Although such criteria may improve triage precision, application of these algorithms may be restricted by their complexity in a situation in which time is lim- ited. One chemical algorithm triage method proposed by Cone et al. considers the latency period of some hazardous chemicals like phosgene and uses “breathing” as a simple subjective assess- ment of patient’s overall respiratory status (Figure 31.3).66 This system will need further refinement and testing.

Decontamination and Personal Protection Equipment Decontamination of chemically contaminated casualties

should be viewed as part of the initial treatment, not as an addi- tional process, and should occur as soon as possible.43 It also prevents secondary contamination of personnel and equipment. Removal of outer layers of clothing may reduce contamination by up to 85%.59

If the exposure is from a vapor or gas, then nearly all of the contaminants will be eliminated when the victim is evac- uated and the clothing is removed.67–69 Gas or vapor releases can expose victims to toxic concentrations, but tend to dissipate quickly. Arriving victims who were only exposed to HazMats in the gaseous or vapor state, or who undergo proper decontami- nation at the scene, are not likely to pose a secondary contami- nation risk to hospital personnel. However, victims whose hair, skin, or clothing is grossly contaminated with solid or liquid material, including condensed vapor, can endanger emergency personnel by direct contact or by off-gassing of the toxic sub- stance.70 Nonetheless, it is unlikely that a living victim could cre- ate an “immediately dangerous to life or health” environment at a receiving hospital if contaminated clothing is quickly removed and isolated, and the victim is treated and decontaminated in an area with adequate ventilation.71 Failure to perform these actions, however, can generate an immediately dangerous to life

or health situation during treatment of a viable victim within the hospital, resulting in significant medical consequences for healthcare providers.72

In a mass casualty situation with limited resources, skin decontamination is not needed and removal of clothing may be sufficient if it has been confirmed that the exposure is due only to vapor or gas and no gross contamination of the hair or skin by condensation exists.27,71,73 Special consideration should be made for highly soluble irritant gases such as ammonia. Ammo- nia dissolves in the moisture of mucous membranes to form ammonium hydroxide, a strong base. It produces a local toxic effect of irritation and burning on mucous membranes. If vic- tims feel skin burning, decontamination should be conducted. All clothing should ideally be removed on scene and double bagged.

Decontamination should be conducted with consideration for privacy. Equipment for medical care including bag-mask- valve devices, oxygen tanks, airway devices, and wound care items must be prepared and mobilized to the warm zone. Further detailed discussion on decontamination and PPE can be found in their relevant chapters.

Transportation and Evacuation Prioritizing the transportation of victims from the casualty

clearing station to hospitals requires further triage. Transport vehicles should be well ventilated with the windows open if nec- essary. The importance of improving ventilation in the confined space of a transport vehicle was underscored by the Tokyo sarin attack in 1995, when it was observed that 9.9% of 1,364 emer- gency medical technicians showed acute symptoms and received medical treatment at hospitals. Most of them experienced the onset of symptoms during transportation, and it is suspected that they were exposed to the vaporized sarin from the victims’

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clothes in ambulances. The ventilation in ambulances and mini- vans was poor because the windows were shut.74 Additionally patients were not undressed and decontaminated before trans- port to healthcare facilities.

Hospital-based Response DECONTAMINATION AGAIN?

It is not easy for first receivers at healthcare facilities to accurately determine whether prehospital decontamination of casualties has been adequately conducted. Casualties can be symptomatic but “clean.” Checking individually with chemi- cal detection devices will require too much time. Some hospitals may subject these casualties to a second decontamination pro- cedure. This method is debatable as it delays treatment. Local health authorities, experts, and first responders and receivers should discuss the options and arrive at a consensus.

Wounds should be irrigated and covered with waterproof dressing during decontamination. Following that, attention should be paid to decontamination of the eyes, nose, ears, and oral cavity as necessary. The eyes can be irrigated with the help of a Morgan lens or an improvised device using a nasal cannula placed across the nasal bridge and attached to a one liter bag of normal saline.

Medical Treatment Initial medical attention should be focused on providing

basic resuscitation measures by addressing airway (with cervi- cal spine control), breathing, circulation, disability (nervous sys- tem), and exposure (decontamination, examination for injuries): the ABCDEs in a primary survey. The possibility of concomitant physical trauma, burns, and smoke inhalation injuries should be considered because many of these incidents involve fires and explosions. Supportive care is more important than specific anti- dotes. In a seizing victim, opening the airway, providing oxygena- tion, and aborting the seizure with a benzodiazepine will confer more benefit than any antidote.

Obtaining a concise history can be guided by using the AMPLE mnemonic, which stands for Allergies, Medications, Past medical history, Last meal, and Events leading up to the incident.75 Any past respiratory condition is significant because inhalation is the most common route of exposure at HazMat incidents. Victims with cardiac conditions may be at greater risk in asphyxiant (e.g., carbon monoxide) or hydrocarbon (e.g., propane) poisoning due to ischemia and cardiac irritability, respectively. With regard to “Events leading up to the incident,” helpful information includes: route of exposure; location of the incident; whether the incident occurred in a confined space; elapsed time since exposure; duration of exposure (entrapment); the presence of fire, explosion, or blast; and whether loss of con- sciousness occurred.

After the primary survey and resuscitation, HazMat patient assessment involves a secondary survey that focuses on75

■ Identifying complications of poisoning ■ Recognizing existing medical problems with potential for

exacerbation ■ Assessing for accompanying trauma or burns ■ Recognizing HazMat toxic syndromes (toxidromes)

Toxidromes are collective sets of signs and symptoms that indicate poisoning with a specific class of agents. They help to simply the approach to treatment and have both practical and

medical relevance. Table 31.6 summarizes the features and treat- ment of five toxidromes: irritant gases, asphyxiants, cholinergics, corrosives, and hydrocarbons and halogenated hydrocarbons.75

The use of PPE in the warm and hot zones limits dexterity, so antidotes are given via autoinjectors that deliver fixed incremen- tal doses of drugs such as atropine. At the first aid post or hospital setting, a dose–response regime via intravenous route should be adopted. In patients with shock and peripheral vasoconstriction, absorption of drugs via intramuscular injection is unpredictable and erratic.

Victims with seizures should be examined for intracranial pathology, including traumatic hemorrhage. Attributing such phenomenon simply to central nervous system injury from toxins is not suggested. The common approach to differential diagnosis for clinical symptoms and signs still applies.

The toxic effect of chemicals may be seen acutely or only become apparent after a period of latency. One such example is phosgene. This agent is a gas at room temperature, is slightly sol- uble in water, and has an odor threshold that is five times higher than the OSHA permissive exposure level.47 Its odor provides insufficient warning of hazardous concentration, thus prolong- ing exposure of victims to the chemical. This allows the chemical to enter the lower airways due to a lack of avoidance behav- ior by victims. It may initially cause no signs or symptoms, or symptoms may be due only to mild irritation of the airways. These symptoms (dryness and burning of the throat and cough) may cease when the patient is removed from exposure. After an asymptomatic interval of 30 minutes–8 hours, however, res- piratory damage becomes evident.76 This effects the period of observation that may be needed for victims of such exposures. There is an inverse relationship between the dose of most agents and their latent periods, i.e., a higher dose results in a shorter latency period.

While difficult to measure precisely, in mass casualty inci- dents, it is thought that there is often a 5:1 or larger ratio of persons who are symptomatic because they think they have been exposed to those who have actually been exposed. Those who are only psychologically affected assert an extra burden on a health- care system that must attend to the physically and physiologi- cally injured victims first. It is difficult to identify psychological casualties initially and decontamination will be needed before further clinical assessment can be made. Trained counselors are an important part of the management team and provide needed psychological support.

Recovery The recovery phase involves decontamination of the facil-

ity and certification that it is safe to resume normal operations. Patients, visitors, hospital staff, and the media should be kept informed during this process. Documentation created during the incident is collected for the purposes of archiving, creation of after-action reports, and development of corrective action plans.77 In some countries, such documents are crucial for finan- cial reimbursement procedures.

Equipment and contaminated areas must be decontami- nated. PPE such as chemical suits, gloves, and boots may require disposal. It is often difficult to ensure safe reuse due to limi- tations in the ability to assess the degree that chemicals have penetrated the equipment. Safe disposal of contaminated run- off water and other hazardous waste is necessary, usually with assistance from local fire, health, and environmental authorities. Disposition of the victims’ contaminated personal belongings

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Table 31.6: Features of Five Toxidromes (Table constructed with information from Advanced HazMat Life Support/AHLS)75

Hydrocarbon and Irritant gas Asphyxiant Cholinergic Corrosive Halogenated Hydrocarbon

Common agents. Some may present with characteristics of more than one toxidrome

Ammonia, sulphur dioxide, hydrogen chloride, chlorine, phosgene

Simple: Carbon dioxide, methane, propane

Systematic: Carbon monoxide, cyanides, hydrogen sulphide

Organophosphates, carbamates pesticides

Acids (sulphuric, hydrochloric, hydrofluoric acid), bases (sodium hydroxide), oxidizers (hydrogen peroxide), phosphorus

Methane, ethane, propane, butane, benzene, phenol, chloroform, chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFCs)

Industry Chemical synthesis, bleaching, disinfectant, and dye production

Byproduct of in/complete combustion, chemical synthesis, liquefied petroleum gas (LPG), dye production, fumigant, sewer gas

Pesticide Chemical synthesis, food production, petroleum refining, disinfectant, propellant, fireworks

Natural gas, chemical synthesis, LPG, dye production, preservatives, refrigerants

Routes of exposure Inhalation, skin, and mucous membranes

Inhalation, skin, and mucous membranes, ingestion

Classification. If prolonged exposure or high concentration occurs, the lower airway can also be affected

Water solubility: High (e.g., ammonia, sulphur dioxide): upper airway affected Low (e.g., phosgene): lower airway affected

Simple: displace oxygen from surrounding atmosphere

Systematic: affects oxygen transport via hemoglobin, or aerobic metabolism

Organophosphates, carbamates

Aliphatic, aromatic, halogenated Flammability

Characteristic presentation (signs and symptoms)

Upper airway: Coughing and stridor, laryngeal edema, laryngospasm, dysphonia, rhinorrhea

Lower airway: Bronchospasm, noncardiogenic pulmonary edema

Others: Lacrimation, conjunctival injection

Simple asphyxiant: Headache, fatigue, anxiety, giddiness, nausea, dyspnea, palpitations, altered mental status, coma, seizure, cardiac ischemia

In addition, systematic asphyxiant: Cyanosis and reliable pulse oximetry readings can be due to methemoglobinemia “arterialization” of venous blood

SLUDGE mnemonic (muscarinic): salivation, lacrimation, urination, defecation, gastrointestinal cramping, emesis

MTWHF mnemonic (nicotinic): mydriasis, tachycardia, weakness, hypertension, fasciculation

Coughing, dyspnea, dysphonia, stridor, laryngeal edema, nausea and vomiting, bronchospasm, noncardiogenic pulmonary edema, cyanosis, skin burns

Others: Lacrimation, conjunctival injection, blindness

Present like simple asphyxiant. Sensitization of the heart to endogenous catecholamines, arrhythmias

Central nervous system depression, narcosis, coma

Skin irritation, defatting dermatitis and chemical burns

Main systems affected Airway and breathing Cardiovascular and nervous system

Nervous system Airway, cardiovascular, nervous system

White phosphorus - consider renal system

Breathing, cardiovascular and nervous system

Treatment summary Consider latency of chemical affecting lower airway

Supportive management include: oxygenation, bronchodilators, corticosteroids

Provide oxygen support

Cyanide: antidotes include amyl nitrite (inhaled), sodium nitrite, sodium thiosulfate, hydroxocobalamin

Hydrogen sulphate: sodium nitrite Consider hyperbaric oxygen treatment

Atropine, oximes (e.g., pralidoxime), benzodiazepine (for seizure)

Rapid decontamination, water irrigation of eyes and skin, burns management

Hydrofluoric acid: local or parenteral calcium replacement

Supportive management include: oxygenation, control seizures, wound care

Avoid sympathomimetics due to cardiac irritability

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must also be addressed. In some cases, all such items must be retained as evidence for law enforcement investigations of a crime scene.

A separate morgue must be established to prevent cross con- tamination between the victims’ dead bodies and those who died of other causes. The burial process will require special arrangements with environmental and public health consider- ations. First receivers may need further follow-up if radiological activity is present in the hazard. Behavioral health (acute and long term) services must also be provided for staff and patients.

RECOMMENDATIONS FOR FUR THER RESEARCH

Develop Surveillance and Early Warning Systems

The development of surveillance and early warning systems is based on a transition from a culture of reaction to one of being proactive, preventive, and prepared. As part of the revised IHR 2005, the WHO has been developing a system to rapidly iden- tify, verify, and alert nations to the occurrence of incidents of (potential) international public health concern, including those involving environmental health hazards. This system is a tech- nical collaboration among existing institutions and networks including the Global Outbreak Alert and Response Network, the Global Public Health Information Network, and the WHO/IPCS Global Chemical Incident Alert and Response System.

The WHO/IPCS Global Chemical Incident Alert and Response System consist of two components.

■ ChemiNet: This network pools human and technical resources for detecting, verifying, and responding to chemi- cal incidents of international public health concern.

■ ChemiTeam: WHO/IPCS staff who, on a daily basis, iden- tify and assess chemical events of (potential) international concern and determine appropriate response.

Strengthen Both Regional and Global Public Health Responses

Public health responses must be integrated globally as well as locally. Chemicals released into the environment can spread beyond the local vicinity and, in some cases, cross national borders. Therefore, it is also necessary to coordinate interna- tional preparedness and response. Some international agree- ments already exist, such as the United Nations Economic Com- mission for Europe’s Convention on the Transboundary Effects of Industrial Accidents.7,78 The aim of the Convention is to help its parties prevent, prepare, and respond to industrial acci- dents that can have international impacts. The Convention also encourages its parties to assist each other in the event of such an accident, to cooperate on research and development, and to share information and technology.

Environmental Justice

Developing nations struggle with the lack of technical capacities and regulatory infrastructure to ensure safe chemical manage- ment. In some countries with good technical capacity, the rapid pace of industrialization is outstripping the implementation of effective control measures. Increasing urbanization in such coun- tries is exposing growing numbers of people to the risk of chemi-

Table 31.7: Future Disaster Research Goals and Objectives for Industrial and HazMat Incidents

■ Epidemiological research and improved data collection before, dur- ing, and after disasters

■ Strengthening of the research agenda for technology, meteorology, engineering, and the environment. Alignment and synthesis of these activities with the medical and public health research agenda

■ Development of best practices for public warning ■ Urban and city planning research focusing on the locations of indus-

trial and HazMat facilities and transportation corridors ■ Support for infrastructure research and high-technology modeling

for preparedness, mitigation, response, and recovery for industrial and HazMat disasters

■ Strengthening of the toxicology and occupational medicine research agenda

■ Continuous HVA to improve surge capacity based on the latest data for the facility, staff, and current equipment

■ Funding for dedicated research staff with existing protocols deployed to incidents as a part of disaster management teams

■ Technology research for prevention and monitoring of industrial accidents. Examples: video cameras, surveillance satellites and aerial reconnaissance, and fixed and mobile monitoring units similar to “black boxes” in airplanes. Enhanced medical and technological monitoring of staff and environment

■ After events, implementation of improved, harmonized, and syn- chronized data collection on long-term effects of industrial incidents

■ Economic research examining the risk/benefit ratio for operation of industrial and HazMat facilities and transports

■ Sociological research to study behavioral and psychological patterns during disasters

■ Educational goals and objectives research agenda ■ Investigate strategies to optimize collaboration among different spe-

cialties such as chemists, meteorologists, physicians, and managers

cal incidents as they settle in proximity to hazardous installations. This particularly affects the poorer segments of society who have little choice about where to live.7

Future Research in Hazardous Material, Toxic, and Industrial Events

The performance of disaster research is often difficult. For eco- nomical and ethical reasons, it is not possible to “create disasters” for scientific study purposes. As such, investigators must usually wait for actual events to occur, and so the ability to conduct meaningful research is often limited. Nonetheless, opportunities do exist (see Table 31.7).

Fundamentally, research in disaster medicine should have a strong public health and epidemiological approach and should be outcomes oriented. At the same time, disaster research should be fiscally responsible and based on the best scientific evi- dence. Newer technologies such as computer-based programs and teaching methods such as simulations have greatly expanded the possibilities for facilitating problem-based research and find- ing solutions in disaster management.

One of the biggest challenges in disaster medicine is accurate data collection before, during, and after an actual event. One of the obstacles to collecting accurate data is the lack of dedicated research staff. When managing disasters, most personnel are usu- ally engaged in disaster response activities and not available for independent academic research. Additionally, disaster research

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for complex events such as industrial incidents must be multi- disciplinary and use an all-hazard approach. One possibility to increase data collection during and after industrial accidents is the use of newer monitoring technology such as closed-circuit video cameras, aerial and satellite observation, and “black boxes” on fixed structures that collect data and monitor all events sim- ilar to those used on aircraft. A high-quality HVA and subse- quently designed disaster management plan can only be based on accurate and sufficient data from previous experiences and events. Safety and security protocols for industrial facilities and HazMats should be based on the best scientific evidence and less on financial interests.

Decision makers and disaster managers who are responsible for development and implementation of protocols face a special challenge. They are caught in a conflict between the scientific data depicting the correct approaches and the financial realities of what they can afford. Many of the existing disaster protocols and much of the equipment have not been scientifically tested under the actual conditions for which they were designed. Often the- oretical models, policies, and equipment are simply transferred from one disaster scenario to another. In general, there should be more funding from unbiased sources to support independent and sound scientific research. There should be more collabora- tion among academic institutions with respect to the collection of research data in a central repository to prevent duplication. A well-developed research agenda will provide the evidence-based science to guide community risk management and enforcement of high safety standards in the chemical industry.

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