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Critical Care Management of Chemical Exposures

This complimentary chapter from Fundamental Disaster Management aims to: review measures of preparedness and planning and describe the purpose of decontamination 

The term chemical agent has traditionally been defined as a substance intended for use in military operations to kill, seriously injure, or incapacitate humans (or animals) through its toxicological effects. These agents
have been used in warfare for thousands of years but came to the forefront of modern warfare during World War I. German forces released 150 tons of chlorine gas from 6,000 cylinders on the afternoon of April 15,
1915, near Ypres, Belgium, in an attempt to help end the trench warfare. This release resulted in 800 deaths and caused the retreat of 15,000 Allied troops, largely due to the psychological terror it produced.
Two years later, on July 12, 1917, again near Ypres, German forces used weapons containing a new agent, sulfur mustard, which resulted in 20,000 casualties. Although less than 5% of the casualties
died as a result of the attack, many had debilitating injuries. 

Since then, chemical agents have been used intermittently in skirmishes and in warfare between nations, such as in the Iran-Iraq war of the 1980s, when both mustard and nerve agents were employed. In 1997, the Chemical Weapons Convention, which had the goal of eliminating state production, storage, and use of chemical weapons, was ratified by more than 160 nations. However, a new development, the use of chemical weapons by independent terrorist organizations, appeared on June 27, 1994, in Matsumoto, Japan, when the Aum Shinrikyo Cult released the nerve agent sarin, resulting in 600 people exposed, 58 admitted to the hospital, and 7 deaths. Their more famous and destructive release on March 20, 1995, in the Tokyo subway
system resulted in 5,500 people exposed and 3,227 seeking care at hospitals, with 550 transported via emergency medical services. The closest hospital to the largest concentration of casualties, St. Luke’s International Hospital, received 641 casualties in a short time: 5 critically ill, 106 with mild to moderate injuries, 530 with mild injuries, and eventually 2 deaths. Essentially none of the patients were decontaminated prior to arriving at the hospital. Consequently, 20% of ED personnel, including 11 physicians, were affected by off-gassing of the victims. Once the problem was recognized, the removal of victims’ clothing prevented further effects on the ED staff.

Owing to the local potential for earthquakes, St. Luke’s International Hospital had previously conducted exercises in disaster response. In managing this chemical event, hospital staff learned the following lessons, among others:
1. A chemical incident requires quick recognition.
2. A pre-event disaster plan helps both preparation and response.
3. A moderately well-prepared hospital can save most patients.
4. Even under ideal conditions for the use of chemical agents, most victims of nerve gas may be only mildly to moderately affected.
5. If no attempt is made to decontaminate patients before they enter the hospital, staff and the facility will be contaminated.

In short, to properly plan for the decontamination and care of victims of chemical exposure, the
presence of such agents and other toxins, such as biological agents, must be recognized.
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