Triage of Chemical Casualties

REVIEW OF CHEMICAL AGENT EFFECTS Nerve Agents Cyanide Vesicants Phosgene 

CATEGORIES FOR TRIAGE OF CHEMICAL CASUALTIES Immediate Delayed Minimal Expectant 

CASUALTIES WITH COMBINED INJURIES Nerve Agents Mustard Phosgene Cyanide 

Formerly, Chief, Chemical Casualty Care Office, and Director, Medical Management of Chemical Casualties Course, U.S. Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland 21010-5425 currently, Chemical Casualty Consultant, 14 Brooks Road, Bel Air, Maryland 21014 

The intent of triage is to provide immediate help to those who need it to delay care for those who have less threatening injuries and to set aside, at least temporarily, both those who need care beyond the capabilities of the available medical assets (personnel, equipment, and facilities) and those who require such extensive care that the time and assets spent would delay or prevent care for those more likely to recover. 

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An important activity in the medical operation of the exercise was Triage of chemical casualties, the Iranian Medical team used an standard procedure for triage (primary and secondary) in the EMT point and field hospital as well. 

As discussed in greater detail in Chapter 14, Triage of Chemical Casualties, the triage officer must know the natural history of the injuries he faces, including chemical injuries. He must also have knowledge of evacuation capabilities and the facilities at higher echelons of care as well as his own decontamination capabilities and assets for medical care. 

Locate the Web site for the United States Army Medical Research Institute for Chemical Defense. Locate the TLiage of Chemical Casualties chapter. Describe each of the triage categories and how they would be used in a mass chemical exposure event. 

At the first echelon of medical care, the chemical casualty is contaminated and both he and the triage officer are in protective clothing. Furthermore, the first medical care given to the casualty is in a contaminated area, on the hot or dirty side of the hotline at the emergency treatment station (see Figure 13-1 in Chapter 13, Field Management of Chemical Casualties). This is unlike the clean side of the hotline at any echelon of care where casualties are decontaminated before they enter, or un-... 

Before discussing the triage groups and the types of chemical casualties that might be placed in each, a brief review of the type of casualty seen with each chemical agent is presented. Under the best of circumstances, a casualty probably will not reach a medical treatment area until at least 15 minutes after exposure (or after onset of effects, if onset immediately follows exposure). Moreover, a casualty will not seek medical attention until effects are apparent an appreciable amount of time, therefore, may elapse before the casualty is seen. 

The categories of triage for chemical casualties and the types of chemical casualties that might be placed in each group (Exhibit 14-2) follow. 

Triage of casualties of chemical agents is based on the same principles as the triage of conventional casualties. The triage officer tries to provide immediate care to those who need it to survive he sets aside temporarily or delays treatment of those who... 

Triage for chemical casualties follows similar principles as stated by general MIMMS guidance and should initially take place at the scene of the incident in order that the most serious casualties are decontaminated first so that clinical management can be initiated. 

More critically, in cases of large numbers of serious chemical casualties, it may reach the point that limitations of personnel, time, equipment, and space do not permit the degree of medical intervention usually called for on any other given day. Most modern health care settings are not used to making very difficult triage decisions, where some casualties must be allowed to deteriorate or even die so that others can be saved. 

Figure 6. Interaction of the red and white plans for the evacuation of casualties following a disaster. The fire service are responsible for rescue and primary evacuation of casualties as far as the advanced medical post. Here, casualties are triaged and receive primary treatment. The hospital white plan for the management of mass casualties is extended to this point using medically manned mobile intensive care units which can carry out extensive early care before transporting the patient to the most appropriate hospital facility. In the case of a toxic release, this will be to a special reference hospital, manned and equipped to deal with casualties from a chemical-biological release...

Medical facilities treating chemical casualties must divide their operations into two categories contaminated (dirty) and uncontaminated (clean). Contaminated operations include triage, emergency treatment, and patient decontamination. Uncontaminated operations include treatment and final disposition. All activities conducted in the Casualty Decontamination Center (CDC) and not inside a collective protection shelter must be conducted at MOPP 4. Operational flexibility is essential. Therefore, the number and arrangement of functional areas will be adapted to both medical and tactical situations. 

TRIAGE CATEGORIES FOR CASUALTIES OF CHEMICAL WARFARE AGENTS... 

It must be remembered that triage refers to priority for medical or surgical care, not priority for decontamination. All chemical casualties require decontamination. One might argue that a casualty exposed to vapor from a volatile agent, such as cyanide or phosgene, or from some of the volatile nerve agents does not need to be decontaminated. However, one can seldom be certain that in a situation in which vapor and liquid both exist, some liquid is not also present on the casualty. 

Early decontainination may be the only treatment required following chemical agent e>q>osure. Only life-saving interventions (LSIs) should be imdertaken in die hot zone in order to reduce further exposure of the casualty to the chemical agent involved and minimise contamination of emergency personnel. These interventions are summarised in Box 5.7. Casualties should be extracted to specific treatment areas within the cold zone as rapidly as possible according to triage priorities. 

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