Disaster. BSN Iv3

Guidelines
for Mass
Casualty
Decontamination During a Terrorist
Chemical Agent
Incident
Prepared by:
 ROSELYN JANE P. DAGO-OC
 FREZY S. HIPONIA
 SUSANA AWA
 JESAMIE FUENTES
 CHRISTINE ROSE FUENTES
 CINDYRELLA VINCE ELARDE
Disclaimer
The findings in this report are not to be construed as an official Department of the Army position unless so
designated by other authorizing documents.
REPORT DOCUMENTATION PAGE Form Approved

OMB No. 0704-0188
Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson
Davis Highway, Suite 1204, Arlington, VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project
(0704-0188), Washington, DC 20503.
1. AGENCY USE ONLY (Leave Blank) 2. REPORT DATE 3. REPORT TYPE AND DATES COVERED
January 2000 Final; Feb 1998 – January 2000
5. FUNDING NUMBERS
4. TITLE AND SUBTITLE
Guidelines for Mass Casualty Decontamination During a Terrorist Chemical

Agent Incident None
6. AUTHOR(S)
Lake, William A.; Fedele, Dr. Paul D.; Marshall, Stephen M.
7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING

ORGANIZATION
REPORT NUMBER
DIR, ECBC, ATTN: AMSSB-REN-HD-DI, APG, MD 21010-5424 ECBC–TR-125
9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING/MONITORING

AGENCY REPORT NUMBER
Commander, U.S. Army, ECBC
ATTN: AMSSB-REN-HD-DI
Building E5307, Hanlon Road
APG, MD 21010-5424
11. SUPPLEMENTARY NOTES
12a. DISTRIBUTION/AVAILABILITY STATEMENT 12b. DISTRIBUTION CODE
Approved for public release; distribution is unlimited.

The Mass Casualty Decontamination Research Team (MCDRT) collectively
13. ABSTRACT (Maximum 200 words)
addressed the issue of how to effectively decontaminate large numbers of people. Emphasis was placed on
decontamination methods that could be performed with equipment and expertise readily available to most
responder jurisdictions. The general principles identified to guide emergency responder policies, procedures,
and actions after a chemical agent incident were:
• Expect at least a 5:1 ratio of unaffected to affected casualties

• Decontaminate victims as soon as possible
• Disrobing is decontamination; head to toe, more removal is better
• Water flushing generally is the best mass decontamination method
• After a known exposure to liquid chemical agent, emergency responders should be
decontaminated as soon as possible to avoid serious effects.
14. SUBJECT TERMS 15. NUMBER OF

PAGES
Personal Decontamination Skin Decontamination Ladder Pipe Decontamination System
Mass Casualty Processing Ambulatory Casualties Non-Ambulatory Casualties 38
Triage Prioritizing Casualties Non-Aqueous Methods Fog Nozzle
16. PRICE CODE
17. SECURITY CLASSIFICATION 18. SECURITY CLASSIFICATION 19. SECURITY CLASSIFICATION 20. LIMITATION OF
OF REPORT OF THIS PAGE OF ABSTRACT ABSTRACT
UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UL

NSN 7540-01-280-5500 Standard Fo
PREFACE
The work described in this report was funded by the Domestic Preparedness
Program.
The use of trade names or manufacturers' names in this report does not constitute
an official endorsement of any commercial product. This report may not be cited for purposes of
advertisement.
This report has been approved for public release. Registered users should request
additional copies from the Defense Technical Information Center; unregistered users should
direct such requests to the National Technical Information Center.
II
TABLE OF CONTENTS
LIST OF FIGURES ........................................................................................................................

ii
EXECUTIVE SUMMARY ...........................................................................................................iii
1.0 INTRODUCTION ....................................................................................................................1
2.0 OBJECTIVE.............................................................................................................................1
3.0 TECHNICAL APPROACH .....................................................................................................1
4.0 RESULTS.................................................................................................................................4
4.1 Purposes of Decontamination.......................................................................................4
4.2 Methods of Mass Decontamination..............................................................................5
4.3 Decontamination Procedures........................................................................................6
4.4 Decontamination Approaches.......................................................................................7
4.5 Types of Chemical
Victims ........................................................................................14
4.6 Prioritizing Casualties for Decontamination...............................................................14
4.7 Casualty Processing....................................................................................................17
4.8 Additional
Considerations ..........................................................................................22
5.0 RECOMMENDATIONS........................................................................................................22
REFERENCES ..............................................................................................................................24
APPENDIX A LIST OF ACRONYMS............................................................................. A-

1 APPENDIX B NAAK MARK I – NERVE AGENT ANTIDOTE
KIT ............................B-1
APPENDIX C EVIRONMENTAL PROTECTION AGENCY (EPA) LETTER..............C-1
ii
LIST OF FIGURES
3-1 MCDRT’S Relationships and Process......................................................................................3
4-1 The Ladder Pipe Decontamination System..............................................................................8

4-2 Schematic for Mass Decontamination......................................................................................9
4-3 The Emergency Decontamination Corridor Decontamination System..................................10
4-4 Schematic for EDCDS............................................................................................................10
4-5 Proper Positioning of Salvage Covers Provides Adequate Privacy to Victims......................11
4-6 Alternative EDCS Configuration Using Ladder Truck..........................................................12
4-7 Example of Commercial Decontamination System Available to Emergency Responders....12
4-8 Definition of Ambulatory and Non-Ambulatory
Casualties ..................................................15 4-9 Factors in Decontamination Prioritization of
Ambulatory Victims .......................................16 4-10 START Medical Triage
System...........................................................................................16 4-11 Mass Casualty
Decontamination Algorithm.........................................................................18 4-12 Emergency
Decontamination Corridor System (1 Corridor) ...............................................19 4-13 Emergency
Decontamination Corridor System (2 Corridors)..............................................20 4-14
Administration of Atropine and Oxime (2-Pam CI) by Autoinjector ..................................21
EXECUTIVE SUMMARY
The fiscal year (FY) 1997 Defense Authorization Bill (P.L. 104-201, Sept 23, 1996),
commonly called the Nunn-Lugar-Domenici legislation, funded the U.S. Domestic Preparedness
initiative. Under this initiative, the Department of Defense (DoD) was charged with enhancing
the capability of federal, state, and local emergency responders in incidents involving nuclear,
biological, and chemical terrorism. The U.S. Army Soldier and Biological Chemical Command
(SBCCOM), Aberdeen Proving Ground, Maryland, was assigned the mission of developing an
Improved Response Program (IRP) to identify problems and develop solutions to the tasks
associated with responding to such incidents. The Chemical IRP was established to deal
specifically with terrorists using chemical weapons.
A Mass Casualty Decontamination Research Team (MCDRT) was formed by SBCCOM

under the Chemical IRP in February 1998 to address specific technical and operational issues
associated with the performance of mass casualty decontamination after a terrorist incident
involving chemical weapons of mass destruction (WMD). The MCDRT was assembled from
affected emergency response and technical disciplines. The research team included a broad
scientific and operational knowledge base, both with general experts and specialized staff,
including medical doctors with direct knowledge of the physiology and toxicological effects of
chemical agents, emergency responders drawn from government organizations at all levels, and
from contract research organizations.
Over several months, the MCDRT collectively addressed the issue of how to effectively
decontaminate large numbers of people. Emphasis was placed on decontamination methods that
could be performed with equipment and expertise readily available to most responder
ii
jurisdictions. Effective physical and medical approaches were identified by review of over 200
research papers, books, articles, manuals, and Internet sites. Through review and the experience
of the MCDRT team members, several basic decontamination principles were identified. Using
these principles as a basis, decontamination processes were developed to effectively address
operational decontamination of large numbers of people.
The general principles identified to guide emergency responder policies, procedures, and
actions after a chemical agent incident were:

To acquire a final consensus for the general principles identified, the MCDRT conducted
several meetings to discuss the findings and resolve any technical or operational concerns. A
panel of experts from the chemical defense and emergency response communities studied each
principle identified to ensure that they represented the best recommendations that provide the
most benefit to the largest number of victims in the shortest possible time.
Blank
iii
GUIDELINES FOR MASS CASUALTY DECONTAMINATION DURING A
TERRORIST CHEMICAL AGENT INCIDENT
1.0 INTRODUCTION
The FY97 Defense Authorization Bill (P.L. 104-201, Sept 23, 1996), commonly called
the Nunn-Lugar-Domenici legislation, funded the U.S. Domestic Preparedness initiative. Under
this initiative, the Department of Defense (DoD) was charged with enhancing the capability of
federal, state, and local emergency responders in incidents involving nuclear, biological, and
chemical terrorism. The U.S. Army Soldier and Biological Chemical Command (SBCCOM),
Aberdeen Proving Ground, Maryland, was assigned the mission of developing an Improved
Response Program (IRP) to identify problems and develop solutions to the tasks faced in
responding to such incidents. Under this authorization, the SBCCOM Domestic Preparedness
Office Chemical Team conducted this study to recommend methods for civilian mass casualty
decontamination after a chemical terrorist incident.
The Chemical IRP includes a broad cross-section of operational and technical experts
from local, state, and federal agencies. Emergency responders from the Baltimore-Washington
DC area, as well as experts from across the nation were included to ensure that solutions were
broad-based and usable by any jurisdiction. Chemical IRP members participated from fire
departments, emergency management offices, law enforcement agencies, and military test and
evaluation agencies, included legal experts, medical doctors, computer modelers, operations
researchers, and environmental scientists. The Chemical IRP formed specific “research teams”
to address issues that evolved from a series of tabletop exercises called BALTEX (Baltimore
Exercise).
This study addressed decontamination in mild temperatures only. Decontamination in

cold weather is the subject of another study.
For easy dissemination, this report is available at the following Web site:
http://www.ecbc.army.mil/hld/ip/reports.htm.
2.0 OBJECTIVE
The objective of this study is to identify technical and operational issues associated with
mass casualty decontamination after a terrorist incident involving chemical weapons of mass
destruction (WMD) and recommend the most efficient and effective techniques and procedures
to best cope with a large-scale decontamination effort.
3.0 TECHNICAL APPROACH
Through the BALTEX series, the IRP identified the need for methods of decontaminating
large numbers of people. Although hazardous materials (HAZMAT) teams have experience and
procedures for decontaminating small numbers of chemical victims, the emergency response
community has no formal procedures for decontaminating hundreds of victims. In February
1998, the Mass Casualty Decontamination Research Team (MCDRT) was formed to study the
1
decontamination process and recommend operational approaches for the effective
decontamination of large numbers of potential terrorist victims after a terrorist chemical incident.
The MCDRT’s focus was to ensure the technical merit, operational feasibility, and overall
consensus within the emergency responder and medical communities on the report
recommendations.
To address the decontamination process and develop decontamination recommendations,

the research team was composed of representatives from all affected emergency response and
technical disciplines with a broad scientific and operational knowledge base. The team’s staff
included scientists with expertise in chemical agent properties and dispersion processes, medical
doctors who have direct knowledge of the physiology and toxicological effects of chemical
agents, and emergency responders who are thoroughly familiar with emergency operations and
emergency response equipment. Team members were drawn from government and emergency
response organizations at all levels. Responder and emergency management organizations
participating with the Chemical Weapons IRP are from Maryland and the surrounding area, and
include Montgomery County Department of Fire and Rescue Services, Baltimore City Fire
Department, Baltimore County Fire Department, District of Columbia Fire and Emergency
Medical Services, Howard County Department/Office of Emergency Management, City of
Baltimore Health Department, and Baltimore Police Department.
The MCDRT had to deal with several constraints associated with mass decontamination.
Successful decontamination approaches must be executable with resources available in most
response jurisdictions, the approaches must save lives and preserve the health of chemically
contaminated victims, and they must reduce the chemical hazards faced by medical personnel
who subsequently treat chemical victims. To ensure that the developed recommendations satisfy
these constraints, the MCDRT applied the process shown in Figure 3-1. Through workshops,
tabletop exercises, and functional exercises with first responders and the Chemical Weapons
IRP, the problem of decontamination and its associated constraints were identified. Through
scientific and technical investigations, the MCDRT then developed operational approaches to
meet the decontamination needs. The developed approaches were reviewed and exercised by the
Chemical Weapons IRP, to ensure that they are executable by most responder jurisdictions, that
they do protect the lives and health of chemical victims, and that they will ensure the safety of
personnel who subsequently process the chemical victims.
2
Figure 3-1. MCDRT’s Relationships and Process
The effort of the MCDRT concentrated on:
• Providing technical solutions to specific issues on the efficacies and priorities of

decontaminating people contaminated with chemical agents.
• Identifying mass decontamination methods that can be readily applied, using existing
resources, and that are consistent with current emergency responder procedures,
training, logistic feasibility, and other potential considerations (human nature and
psychology) and constraints (resource limits, civil liberty, environment preservation).
Over several months, the MCDRT acquired data from multiple searches of 8 databases
containing medical, scientific, and operational test and evaluation findings. Information was
acquired and reviewed from over 200 research papers, books, articles, manuals, and Internet
sites. Through review and the experience of the MCDRT members, five basic decontamination
principles were identified.
The general principles identified to guide emergency responder policies, procedures, and
actions after a chemical agent incident were:

3
Using these principles as a guide and staying within the constraints associated with
emergency response equipment and operational considerations, recommendations for
decontamination procedures were established.
To acquire a final consensus on the recommended decontamination procedures, the

MCDRT conducted several meetings to discuss their recommendations and resolve any technical
or operational concerns. Experts from the chemical defense and emergency response
communities studied each recommendation to ensure that it represented the most beneficial
approach to decontaminating the largest number of victims in the shortest possible time.
4.0 RESULTS
4.1 Purposes of Decontamination
Research revealed that the three most important reasons for decontaminating exposed victims
are:
• Remove the agent from the victim’s skin and clothing, thereby reducing further
possible agent exposure and further effects among victims
• Protect emergency responders and medical personnel from secondary transfer
exposures
• Provide victims with psychological comfort at, or near, the incident site, so as to
prevent them from spreading contamination over greater areas.
Rapid physical removal of agent from the victim is the single most important action
associated with effective decontamination.1 Physical removal includes scraping or blotting off
visible agent from the skin, disrobing, using adsorbents to soak up the agent, and flushing or
showering with large quantities of water.
After a chemical agent attack, vapor or aerosol hazards still may be present, especially if
the agent was disseminated within an enclosed structure. Furthermore, potentially toxic levels of
chemical agent vapor may be trapped inside clothes and could continue to affect people, even
after they leave the incident site.
Since the most important aspect of decontamination is the timely and effective removal
of the agent, the precise methods used to remove the agent are not nearly as important as the
speed by which the agent is removed. From scientific literature showing the effectiveness of
different types of solutions in preventing chemical effects and the wide-spread, ready,
availability of large quantities of water that can be rapidly used in decontaminating large
numbers of people, the MCDRT determined that mass decontamination can be most readily and
effectively accomplished with a water shower system.
First responders may become contaminated during the conduct of decontamination

operations. It is recommended that all responders participating in these procedures to follow
1 Medical Management of Chemical Casualties Handbook; Sept 1995, Second Edition; United States Army Medical
Research Institute of Chemical Defense, Aberdeen Proving Ground, MD 21010.
4
guidance outlined in National Fire Protection Administration (NFPA) 471 “Recommended
Practices for Response to Hazardous Materials Incidents”.
WARNING
Even small amounts (several droplets) of liquid nerve agent contacting the unprotected skin can
be severely incapacitating or lethal if the victim or responder is not decontaminated rapidly
(within minutes) and treated medically.
4.2 Methods of Mass Decontamination
Decontamination must be conducted as soon as possible to save lives. Firefighters should

use resources that are immediately available and start decontamination as soon as possible.
Since they can bring large amounts of water to bear, the most expedient approach is to use
currently available equipment to provide an emergency low-pressure deluge.
The following forms of water-based decontamination were considered:
• Water alone. Flushing or showering uses shear force and dilution to physically
remove chemical agent from skin. Water alone is an excellent decontamination
solution.
• Soap and water. By adding soap, a marginal improvement in results can be achieved
by ionic degradation of the chemical agent. Soap aids in dissolving oily substances
like mustard or blister agent. Liquid soaps are quicker to use than solids, and reduce
the need for mechanical scrubbing; however, when scrubbing, potential victims
should not abrade the skin.
A disadvantage of soap is the need to have an adequate supply on hand. Additionally,

extra time may be spent employing it, and using soap may hydrate the skin, possibly
increasing damage by blister agents.
• Bleach and water. Bleach (sodium hypochlorite) and water solutions remove,
hydrolyze, and neutralize most chemical agents. However, this approach is not
recommended in a mass decontamination situation where speed is the paramount
consideration for the following reasons:
− Commercial bleach must be diluted and applied with equipment not generally
available to firefighters.
− Skin contact time is excessive. Laboratory studies show that chemical agents and
relatively nontoxic, aqueous decontaminants may need to be in contact for
durations longer than expected shower durations for significant reaction to occur.
5
− Laboratory studies suggest that bleach solutions at the 0.5% level may not be better
than flushing with water alone.2, 3
− Medically, bleach solutions are not recommended for use near eyes or mucous
membranes, or for those with abdominal, thoracic, or neural wounds.4
In summary, the issues associated with the use of soap and bleach solutions include time
delay, dilution and application, medical contraindications, and its efficacy compared to water.
These limitations make the use of soap or bleach solutions less desirable than using water alone.
The MCDRT recommends rapid use of water, with or without soap, for
decontamination. However, the process should never be delayed to add soap or any other
additive.
4.3 Decontamination Procedures
Decontamination by removing clothes and flushing or showering with water is the most
expedient and the most practical method for mass casualty decontamination. Disrobing and
showering meets all the purposes and principles of decontamination. Showering is
recommended whenever liquid transfer from clothing to skin is suspected.5 Disrobing should
occur prior to showering for chemical agents; however, the decision to disrobe should be made
by the Incident Commander based upon the situation. Wetting down casualties as they start to
disrobe speeds up the decontamination process and is recommended for decontaminating
biological or radiological casualties. However, this process may:
• Force chemical agents through the clothing if water pressure is too high
• Decrease the potential efficacy of directly showering skin afforded by shear forces
and dilution
• Relocate chemical agent within the actual showering area, thereby increasing the
chance of contamination spread through personal contact and shower water runoff.
The MCDRT recommends that victims remove clothing at least down to their
undergarments prior to showering. Victims should be encouraged to remove as much clothing as
possible, proceeding from head to toe. Victims unwilling to disrobe should shower clothed
before leaving the decontamination area. It is also recommended that emergency responders use
a high volume of water delivered at a minimum of 60 pounds per square inch (psi) water pressure
2 Hypochlorite Solution as a Decontaminant in Sulfur Mustard Contaminated Skin Defects in the Euthymic
Hairless Guinea Pig; 1994; Gold, M.B., Woodard, Jr., C.L., Bongiovanni, R., Schraf, B.A., and Gresham, V.C.;
Drug and Chemical Toxicology 17(4), 499-527.
3 Evaluation of the Effects of Hypochlorite Solutions in the Decontamination of Wounds Exposed to Either the
Organophosphonate Chemical Surety Material VX or to the Vesicant Chemical Surety Material HD (1992); Hobson,
D.W. and Snider, T.H.; Final Report for Contract DAMD17-89-C-9050, Task 89-04; Battelle.
4 Decontamination, Chapter 15 in Medical Aspects of Chemical and Biological Warfare; 1997; Hurst, Charles G.;
in Textbook of Military Medicine, Part 1: Warfare, Weaponry, and the Casualty; Specialty editors: Sidell, F.R.,
Takafugi, E.T., and Franz, D.R.
5 Personnel Decontamination Station, AD HOC Study team report, U.S. Army Armament Research and
Development Command, DITC-AD041888, 1979.
6
(standard household shower pressures usually average between 60-90 psi) to ensure the
showering process physically removes viscous agent. The actual showering time will be an
incident-specific decision but may be as long as two to three minutes per individual under ideal
situations. When large numbers of potential casualties are involved and queued for
decontamination, showering time may be significantly shortened. This may also be dependent
upon the volume of water available in the showering facilities.
In the course of deconning victims, first responders may inadvertently become

contaminated. High-pressure, low-volume decontamination showers are recommended primarily
for wet decontamination of emergency responders in Level A suits after a HAZMAT incident.
This gross decontamination procedure forcibly removes the contaminant from the personal
protective equipment (PPE) worn by the emergency responders while conserving water. Often a
secondary wash, and possible a tertiary wash, and rinse station are used. However, for
decontaminating potential victims, a consensus exists among the MCDRT medical experts that
high pressure could force chemical agent through the victim’s clothing onto the skin. Therefore,
the Occupational Safety & Health Administration (OSHA) standard for a chemical accident
(high-volume, low-pressure) is the recommended “default standard”.
4.4 Decontamination Approaches
4.4.1 Ladder Pipe Decontamination System. To provide a large capacity shower of

highvolume, low-pressure water spray, one proposed method is to employ a Ladder Pipe
Decontamination System (LDS). Ladder pipes, wagon pipes, monitor nozzles, and 22” fog
nozzles attached to pump dischargers and other fire apparatus (i.e., fire engines or trucks) are
positioned strategically to create decon corridors for large quantities of exposed people to travel
through. Once the decon corridor has been formed, the objective is to spray water from every
feasible direction. The Howard County, MD Fire Department demonstrated the LDS, shown in
Figure 4-1, during the BALTEX V exercise. A single ladder pipe decontamination system is
comprised of two engines (also creating the corridor) that provide water spray from both sides
using hoselines and deck guns, while the ladder pipe provides a high-volume, low-pressure flow
from above. Multiple ladder pipe decontamination systems employ more than one ladder pipe in
order to increase the decon corridor length to accommodate extremely large groups of victims.
Multiple corridors can be established for ambulatory or non-ambulatory victims; victims are
woven through multiple overhead sprays.
7
Figure 4-1. The Ladder Pipe Decontamination System
The Washington, DC Department of Fire and Emergency Medical Services developed

similar internal guidelines:
…Position two engine companies approximately 20 feet apart to form a

decontamination corridor between the apparatus. Two and one-half inch fog
nozzles, set at a wide fog pattern, are attached to the pump discharges. Position a
truck company in line with one of the engine companies with a fog nozzle placed
on the ladder pipe. The ladder is slightly elevated and rotated to provide a
downward fog pattern in the corridor created by the placement of the two engine
companies. Hydrant pressure alone may be enough to provide a high volume, low-
pressure shower. Care should be exercised to prevent injuries from over
pressurization.6
Figure 4-2 shows a schematic for mass decontamination developed by the Baltimore
County, MD, Fire Department. It is modeled after the Washington, DC, model; however,
firefighters with hoses have been positioned at the end of the shower area to apply the final wash.
Victims are decontaminated between two engines, shown as E-1 and E-2, with nozzles on the
rear and side discharges. Deck guns and a ladder pipe is also used. At the end of the line, two
firefighters using hose lines complete a gross decontamination of the victims. All victims should
wait in the shower area until hosed off. This serves the additional critical functions of
controlling traffic flow, lengthening the duration of the wash, and increasing the efficiency of the
decontamination process.
6 Washington, DC Department of Fire and Emergency Medical Services Internal Operating Procedure.
8
Holding Holding
Area Area
for Clothes,for Clothes,
Effects Effects
Disrobin Disrobin
g g
Figure 4-2. Schematic for Mass Decontamination
4.4.2 Emergency Decontamination Corridor System. Another field-expedient approach to

mass casualty decontamination developed by Montgomery County, MD, Fire and Rescue Service
is to use available equipment and responding fire and emergency units. The Emergency
Decontamination Corridor System (EDCS) (Figures 4-3 and 4-4) uses fire apparatus, ladders,
and salvage covers to create a privacy barrier and corridors for decontaminating victims. Two
pumpers are positioned approximately 20 feet apart and parallel to each other. Three ladders (or
ropes) are placed across and secured to the top of each pumper. Another ladder is centered atop
and perpendicular to the three ladders and secured. Two nozzles are secured to this ladder and
allowed to hang into the corridors. Salvage covers are attached to or draped over the ladders (or
ropes) to provide two separate corridors as shown in Figure 4-5. It may be noted that although
ropes serve the purpose, it is difficult to tie them with enough tension to hold up the covers
without sagging. Water from the two nozzles is used to shower victims as they pass through the
corridors. Plastic cable ties may be used to secure the covers and nozzles to the ladders.
9
Figure 4-3. The Emergency Decontamination Corridor System
Ladder or Rope
Entry Exit
Shower Shower
Area Area
Water
Nozzle
Engine 1 Engine 2
Undress Redress
Area Area
Shower Shower
Area Area
Water
Nozzle
Undress Redress
Area Area
Entry Exit
Additional Covers for Privacy
Figure 4-4. Schematic for EDCS
10
Figure 4-5. Proper Positioning of Salvage Covers Provides Adequate Privacy to Victims
Inside the corridor, two covers can be suspended from the ladder, one on each side of the
nozzle. These covers provide additional privacy to the person who is showering and allow other
people to prepare for showering in the corridor. A salvage cover (or other translucent or opaque
material) is placed on top of the two corridors to provide privacy from building tops and news
media helicopters. To prevent excessive noise and carbon monoxide buildup in the proximity of
the corridors, both pumpers might be shut down. A third pumper can be used to supply water to
the two nozzles. To conserve water, remote shutoff valves may be used to control water flow
from each open nozzle. With proper planning and practice, the EDCS could be set up within 15
minutes of arrival at an incident site.
A variation to the EDCS uses an aerial ladder or tower that is extended horizontally 20 to
30 feet and is enclosed by covers as shown in Figure 4-6. Draping or suspending covers from
both beams of the ladder forms a single EDCS. End covers (covers placed at the two ends of the
corridor) are attached to provide additional privacy. Additional covers are draped over the ladder
as needed to provide victim privacy as needed.
Irrespective of the system used, the system should be located upwind and uphill. Where
practical, efforts should be made to control runoff water.
11
Figure 4-6. Alternative EDCS Configuration Using Ladder Truck
4.4.3 Commercially Available Decontamination Systems. An example of a commercially

available system is shown in Figure 4-7.
Figure 4-7. Example of Commercial Decontamination System Available to Emergency

Responders
Most of these systems are mounted to, or are carried on, special trailers that require
transportation and setup at the incident site. The use of trailer-mounted systems may cause
unreasonable delays in physically removing agent from the victims as soon as possible. If these
systems can be centrally pre-positioned or immediately on hand, they may offer an advantage
over the identified field-expedient systems. Potential advantages include:
• Heated showers may reduce the chance of hypothermia among victims
12
• Covered areas provide privacy that may encourage more complete disrobing and more
thorough showering
• Methods to control contamination runoff.
Potential disadvantages over the field-expedient systems include:
• Systems cannot be employed as rapidly

• Systems with household showerheads for each victim will likely have lower throughput
rates.
4.4.4 Other Field-Expedient Water Decontamination Methods. Emergency responders

should not overlook existing facilities when identifying means for rapid decontamination
methods. For example, although water damage to a facility might ensue, the necessity of saving
victims’ lives would justify the activation of overhead fire sprinklers for use as showers.
Similarly, having victims wade and wash in water sources, such as public fountains, chlorinated
swimming pools, swimming areas, etc., provides an effective, high-volume decontamination
technique.
4.4.5 Non-Aqueous Methods. The use of dry, gelled, or powdered decontaminating materials
that adsorb the chemical agent are appropriate if their use is expedient. Commonly available
absorbents include dirt, flour, Fuller’s earth, baking powder, sawdust, charcoal, ashes, activated
carbon, alumina, silica gels, zeolites, clay materials, and tetracalcium aluminate. Although these
absorbents may be expedient means of decontamination, their efficacy has not been determined.
The M291 and M295 Skin Decontamination Kits, which employ a charcoal-based resin
as a sorbent, are used in the U.S. military and may be purchased commercially. However, while
these kits are effective in removing spots of liquid chemical agent contamination, they may not
be suitable for treating mass casualties due to potentially limited availability, relatively high
labor requirements, and the need to use these kits quickly after the victim is contaminated.
Reactive foams are often polymeric materials with reactive sites that can readily
decontaminate chemical warfare agents. Oxidants, nucleophiles, and/or enzymes are bound to
the polymeric backbone of the foams or gels, and when the chemical warfare agents contact the
foam or gel, they encounter the reactive site and are detoxified. Bacterial organophosphorus acid
anhydrases have been placed in firefighting foam to increase decontamination efficiency within
30 minutes with low residual contact hazard (~1 g/cm2). They have also been placed into the
firefighting spray ColdFireϑ and have shown >99% decontamination efficiency within 15
minutes with the same low residual contact hazard as in firefighting foam. Enzyme samples
have been provided to the U.S. Army Technical Escort Unit (TEU) for use in firefighting foams.
Enzymes were also used by TEU in support of the 1997 G7 summit in Denver. The foams can
be mixed with water and various co-solvents to aid in their deployment. Foams can be
engineered to use limited amounts of solvent in order to reduce their dependency upon solvent
volume and to aid in the cleanup after deployment. After the solvent evaporates, the foams
collapse and turn into a powder, allowing for a simplified, final clean-up operation. However,
since researchers have not identified a single enzyme that is effective on all classes of chemical
agents, several enzymes would have to be used simultaneously.
13
4.5 Types of Chemical Victims
Three recent, large-scale casualty events provide insight into the operational issues
associated with casualty distribution and subsequent assessment that may be encountered during
a response to a chemical terrorist incident. During Operation Desert Storm, 39 Iraqi Scud
missiles reached the ground, with some landing in or around Tel Aviv, Israel. The attacks
resulted in approximately 1,000 treated casualties with only two deaths. Even though it was
never demonstrated that any of the Scuds contained chemical agents, the well known possibility
that the Scuds might contain chemical agents stimulated 544 anxiety attacks and 230 atropine
overdoses. Approximately 75% of the overall casualties resulted from fears and reactions of the
victims.
The second event occurred in Bhopal, India on 2-3 December 1984. During the night,
several thousand gallons of highly volatile methylisocyanate was accidentally released over a
three-hour period. This release was caused by the introduction of water into a methylisocyanate
storage tank. The release resulted in over 200,000 people being exposed to the deadly gas. As
many as 5,000 died and over 60,000 were seriously and/or permanently injured.
The third event was the Japanese subway incident where a reported 5,510 victims sought
medical treatment in 278 different hospitals and health clinics. Of the 5,510 victims, 12 were
casualties that died, 17 were casualties that were considered critically ill, 37 were casualties that
were considered seriously ill, and 984 were casualties that were considered moderately ill.
Approximately 4,000 of the 5,510 victims were deemed to have not been exposed to any
significant amount of the chemical agent, yet they sought medical treatment.
Although these incidents contain many of the elements that might typify an attack within
our nation, without a history of directly related incidents, a realistic characterization of potential
casualty distribution after a chemical agent terrorist incident is difficult to assess. However, to
provide on-scene commanders a perspective on the probable types of and range of victims, the
MCDRT suggests anticipating at least a 5:1 ratio of victims to actual casualties as a guideline.
For every casualty that actually is exposed to chemical agent, more than five victims who are not
exposed to the chemical agent will be evaluated. While this ratio may typify an outside open-air
incident, a realistic casualty assessment is incident-dependent.
4.6 Prioritizing Casualties for Decontamination
The consensus from emergency responders and medical practitioners associated with the
MCDRT is that the term “decontamination prioritization” be used to describe the process of
deciding the need for and order of victim decontamination. Triage is the medical process of
prioritizing treatment urgency within a large group of victims. Both processes may be executed
at the same time. The number of apparent victims from a chemical agent terrorist incident may
exceed emergency responders’ capabilities to effectively rescue, decontaminate, and treat
victims, whether or not they have been exposed to chemical agent. Responders, therefore, must
prioritize victims for receiving decontamination, treatment, and medical evacuation, while
providing the greatest benefit for the greatest number. Although many emergency response
services prepare for such incidents, few are currently capable of treating victims inside the Hot
Zone. Therefore, whenever large numbers of victims are involved, it is recommended that they
14
be sorted into ambulatory and non-ambulatory triage categories as defined in Figure 4-8.
Prioritization for decontamination can effectively be performed in a manner that will maximize
treatment while minimizing the number of emergency responders exposed to chemical agent.
Triage Definitions
•
Ambulatory Casualties: Victims able to understand
directions, talk, and walk unassisted. Most ambulatory
victims are triaged as minimal (green tag/ribbon or Priority 3)
unless severe signs/symptoms are present.
Non-Ambulatory Casualties: Victims who are unconscious,
•
unresponsive, or unable to move unassisted.
Figure 4-8. Definition of Ambulatory and Non-Ambulatory Casualties
4.6.1 Ambulatory Casualties. Ambulatory casualties are those victims who are able to
understand directions, talk and walk unassisted, and are triaged as minimal (i.e., green tag, green
ribbon, or priority 3), unless severe signs and symptoms are present. These casualties should be
directed to move upwind into an assembly area within the Warm Zone where they can be
prioritized for decontamination by on-site medical personnel. Factors that are recommended for
determining the highest priority for ambulatory victim decontamination are highlighted in Figure
4-9. The highest priority for ambulatory decontamination are those casualties who were closest
to the point of release and report they were exposed to an aerosol or mist, have some evidence of
liquid deposition on clothing or skin or have serious medical symptoms (e.g., shortness of breath,
chest tightness, etc). The next priority are those ambulatory casualties who were not as close to
the point of release, and may not have evidence of liquid deposition on clothing or skin, but who
are clinically symptomatic. Victims suffering conventional injuries, especially open wounds,
should be considered next. The lowest decontamination priority goes to ambulatory casualties
who were far away from the point of release and who are asymptomatic. Emergency responders
should direct ambulatory victims in a prioritized fashion into the Warm Zone for
decontamination. Care must be taken to ensure that the victims do not traverse contaminated
areas in the Hot Zone or transfer contamination to the decontamination area.
Factors That Determine Highest Priority for Ambulatory

Victim Decontamination
15
• Casualties closest to the point of release
• Casualties reporting exposure to vapor or aerosol
• Casualties with evidence of liquid deposition on clothing or

skin
• Casualties with serious medical symptoms (shortness of

breath, chest tightness, etc)
• Casualties with conventional injuries
Figure 4-9. Factors in Decontamination Prioritization of Ambulatory Victims
4.6.2 Non-Ambulatory Casualties. Non-ambulatory casualties are victims who are

unconscious, unresponsive, or unable to move unassisted. These victims may be more seriously
injured than ambulatory victims and will remain in place while further prioritization for
decontamination occurs. It is recommended that prioritization of non-ambulatory victims for
decontamination should be done using medical triage systems, such as START (Simple Triage
and Rapid Treatment/Transport), as described in Figure 4-10.
Four S.T.A.R.T. Categories
S.T.A.R.T. Decon Classic Observations Chemical Agent Observations

Category Priority
1
IMMEDIATE Respiration is present only after • Serious signs/symptoms
Red Tag repositioning the airway. Applies • Known liquid agent contaminaiton
to victims with respiratory rate
>30. Capillary refill delayed more
than 2 seconds. Significantly
altered level of consciousness.
2
DELAYED Victim displaying injuries that can • Moderate to minimal signs/symptoms
Yellow Tag be controlled/treated for a limited • Known or suspected liquid agent
time in the field. contamination
• Known aerosol contamination
• Close to point of release
3
MINOR Ambulatory, with or without minor • Minimal signs/symptoms
Green Tag traumatic injuries that do not • No known or suspected exposure to
require immediate or significant liquid, aerosol, or vapor
treatment.
4
DECEASED/ No spontaneous effective • Very serious signs/symptoms
• EXPECTANT respiration present after an • Grossly contaminated with liquid
Black Tag attempt to reposition the airway. nerve agent
Unresponsive to autoinjections
Figure 4-10. START Medical Triage System

The highest priority for overall decontamination will be those casualties who are
medically triaged as immediate (i.e., red tag, red ribbon, or priority 1) and are in need of
immediate life-saving medical procedures that can be done quickly with the medical resources
available on-site. Usually these casualties have breathing or circulatory problems but might also
include those victims with severe nerve agent poisoning whom need antidote or ventilation
immediately. Severely intoxicated nerve agent casualties may be the highest priority for
decontamination within this category; for these casualties, decontamination completed as soon as
possible after the exposure may be lifesaving.
16
Depending on local protocols, responders in the Hot Zone may perform some treatments,
such as Mark I antidote injections. Responders may need to recategorize victims in a chemical
terrorist event. Those victims who are non-ambulatory priority 1 red might need to be tagged as
black priority 4 non-viable victims (Figure 4-10). If these victims have not received Mark I kit
treatment or decontamination within 5 minutes of exposure and if they are suffering from severe
agent symptoms, they will die regardless of what type of medical intervention is provided.
The next priority for non-ambulatory decontamination will be those casualties medically
triaged as delayed (i.e., yellow tag, yellow ribbon or priority 2). These are casualties who may
have serious injuries and require definitive care but can wait for a short period of time without
compromising the outcome (for example, a victim with a fractured lower leg). These victims
may also have mild exposure to chemical agent vapor or liquid but not a life-threatening dose.
Priority 3 victims, those with no known or suspected exposure to any chemical

contamination, follow treatment of priority 2 victims. The lowest priority for overall
decontamination will be those casualties medically triaged as expectant (i.e., black tag, black
ribbon, or priority 4) as discussed above.
4.7 Casualty Processing
The Incident Commander must quickly assess the scene and assign personnel to
coordinate and manage both the medical triage and decontamination functions. If sufficient
resources exist, two mass casualty decontamination systems (e.g., LDS, EDCS, commercial
system) should be established: one for ambulatory victims and one for non-ambulatory victims.
If available resources are only sufficient for a single system, non-ambulatory victims triaged as
immediate are higher priority than the ambulatory victims triaged as immediate; therefore, they
may be decontaminated as depicted in Figure 4-11. It is recommended that the remaining
casualties should be processed in the same manner, with non-ambulatory victims being
decontaminated before ambulatory victims. Due to the complex nature of some of these
casualties (i.e., mixed chemical and conventional casualties), the medical triage and
decontamination sectors should work closely together to maximize their collective sorting and
management of casualties.
Respiratory Effort Position Airway / No
No RED Circulatory System
Intact?
Respiratory EffPresent? ort?
Yes Ambulatory
Yes
Immediate Decon Respirations Compromised (<12 RED
Respirations/min or >26/min) and Interventions Rapid Decon an
(Highest Priority) compromised(>30/min)? Yes
No
17
Serious signs/symptoms, Treatment (High Priority, chemical, BLACK
Yes
medical Non-ambulatory 1st)
No YELLOW Yes
Moderate signs/symptoms Treatment (Medium -Delayed Non - Ambulatory
Decon and or liquid exposure/close High Priority,

Serious signs/symptoms,
Non- chemical or medical
Yes No
proximity to release point ambulatory 1st)
Moderate signs/symptoms
or liquid exposure/close
proximity to release point
No YELLOW Yes
Expectant (Priority 4)
No
Lowest Decon Priority
Minimal signs/symptoms or
Min imal signs/symptoms or vapor exposure/close
vapor exposure/close Yes Delayed Decon and proximity to release point
proximity to release point Treatment (Medium -
Low Priority, Non-
ambulatory 1st) No
No
GREEN Minimal signs/symptoms, no

Low Priority Decon vapor or liquid exposure and
Minimal signs/symptoms, no
Treatment
vapor or liquid exposure (Non-ambulatory 1st)
Figure 4-10. Mass Casualty Decontamination Algorithm

Notes: Immediate decontamination may only involve removal of clothing unless victim is grossly contaminated with liquid
agent. Once initial triage and/or decontamination prioritization is performed and adequately trained responders are available,
ambulatory victims should be placed in a separate collection area in the upwind area of the Hot Zone for secondary triage.
Should a second decontamination system be placed in operation at the same site, ambulatory victims may be assigned to the
second station, leaving the initial station for the non-ambulatory victims. It is recommended that all non-ambulatory victims
recognizes that some of these victims will not survive, and decontamination resources would be better spent on other victims.
who are exhibiting serious chemical signs and symptoms receive highest priority for decontamination. However, the MCDRT
18
Figure 4-11. Mass Casualty Decontamination Al gorithm
In some circumstances, a severely injured, non-chemically exposed casualty cannot wait

for the ideal treatment of showering or flushing with water to occur before departing the Hot
Zone. Clothing removal may be the only field-expedient decontamination before the victim is
removed to the support area. Additionally, severely intoxicated nerve agent casualties with
extreme respiratory distress may require antidote administration and definitive airway
intervention prior to showering or flushing with water. The reality is that medical triage and
decontamination prioritization are often performed simultaneously and are both
resourcedependent field measures. Figures 4-12 and 4-13 demonstrate the layout of EDCS’s for
ambulatory and non-ambulatory victims.
INCIDENT SITE V WIND DIRECTION

A
DECONTAMINATION P
AREA O
R
AMBULATORY H
PATIENT ASSEMBLY C A
L CLEAN T
AREA (SECONDARY BOTH Z
O TREATMENT
TRIAGE) A R
T AMBULATORY + R AREA
H NON-AMBULATORY A
D
I N
TRIAGED NON-
N S
G
AMBULATORY P
PATIENTS R O
E
M
R
PATIENT
O DECONTAMINATION Z
RAPID T
IMMEDIATE PATIENTS V O TREATMENT
A N
L E
HOT ZONE WARM ZONE COLD ZONE
Figure 4-12. Emergency Decontamination Corridor System (1 Corridor)
19
INCIDENT SITE V
WIND DIRECTION
DECONTAMINATION A
AMBULATORY AREA P
PATIENT ASSEMBLY O
AREA (SECONDARY R
TRIAGE)
C T
L R
O H CLEAN
T AMBULATORY A A
TREATMENT
H Z N
AREA
I A S
N R
TRIAGED NON- D P
G NON-AMBULATORY
AMBULATORY O
PATIENTS R
E
R
M T
O RAPID
IMMEDIATE PATIENTS V Z TREATMENT
A O
L N
E
HOT ZONE WARM ZONE COLD ZONE
Figure 4-13. Emergency Decontamination Corridor System (2 Corridors)
If victims can walk, responders should have the victims remove their contaminated
clothing and then lead them out of the Hot Zone to the Warm (decontamination) Zone. These
victims should be instructed to remove contact lenses, if present, and flush skin, eyes, and hair
with water. If victims are unable to walk, the rescuers should assist the victims with the removal
of their contaminated clothing before transporting them on a backboard, gurney, etc. If there is
no other means of transport, the victims should be carefully carried or dragged to safety;
however, responders need to ensure that they do not drag victims through a contaminated area or
transfer visually identifiable contamination on clothing or personal items from the Hot Zone to
the Warm Zone. The contaminated items, such as clothing and personal belongings, must be left
in the Hot Zone.
If responders do not have sufficient resources to decontaminate all potential victims,

priority 3 victims may not need to be showered. They may be transferred immediately to the
Cold (support) Zone. Doing this introduces the risk that a contaminated victim might pass
through the decontamination process and contaminate others in the Cold Zone. However, when
situations are severe enough, some risks may be accepted in attempts to expedite the
decontamination process so that more lives can be saved. However, in any situation, victims that
present physical/clinical signs and symptoms of chemical agent exposure must be
decontaminated before removal from the Warm Zone.
The triage personnel positioned at the entrance of the Cold (support) Zone must be
certain that victims have either undergone basic decontamination or are not suspected of having
been contaminated, before leaving the Warm Zone. It is recommended that triage personnel
question all people leaving the site that have not showered. If possible, the first 25 meters of the
Cold Zone should be treated as a vapor hazard zone where only victims and responders in transit
should be allowed in the area.
20
Victims who have undergone proper decontamination, or have no more than one physical
sign and indicate verbally no known exposure, pose less risk of causing secondary
contamination. These victims should be retained at the site in a safe area for observation for up
to several hours if possible. Cold Zone emergency response personnel require no specialized
respiratory protective gear when treating these people, provided they are properly positioned
outside of the Hot and Warm Zones.
The triage of non-ambulatory victims in a Hot Zone may be difficult to perform and may
be highly incident-specific. These victims are the only group that should receive medical
treatment within the Hot Zone; however, timely removal of the victims from the contaminated
area is essential for their survival. They may need to receive an autoinjection of atropine and
Oxime (2-Pam C1) (Figure 4-14) prior to their removal or decontamination. For additional
information on Mask I kits, see Appendix B. Immediate decontamination may need to occur
within the Hot Zone, and responders must remove visible contamination from the victim prior to
medical treatment within the Cold Zone.
There may also be victims that have expired by the time triage personnel arrive. Expired
victims and those who are black tagged are the last concern for emergency responders, and they
may choose not to address these victims at all, leaving these victims to be handled later, during
site cleanup and remediation.
Figure 4-14. Administration of Atropine and Oxime (2-Pam CI) by Autoinjector

4.8 Additional Considerations
21
4.8.1 Environmental Concerns. The Environmental Protection Agency (EPA) has addressed
the issues of acceptable levels of contamination in runoff and first responder liability for the
spread of contamination caused by efforts to save lives; EPA website is provided at Appendix C.7
Regarding the liability issue, the EPA’s interpretation of The Comprehensive Environmental
Response, Compensation, and Liability Act (CERCLA) indicates that “no person shall be
liable… for costs or damages as a result of actions taken or omitted in the course of rendering
care, assistance or advice in accordance with the National Contingency Plan (NCP) or at the
direction of an On-Scene Coordinator appointed under such plan…”
On the subject of accepted runoff, the EPA recognizes that any level of contamination
represents a threat to the environment. The threat is also dependent on many variables, including
the involved chemicals, their concentrations, and the runoff watershed. However, life and health
considerations are again paramount. “… first responders should undertake any necessary
emergency actions to save lives and protect the public and themselves. Once any imminent
threats to human health and lives are addressed, first responders should immediately take
all reasonable efforts to contain the contamination and avoid or mitigate environmental
consequences.”I The EPA allows that the highest priority be given to responder actions taken to
save lives and preserve health during a chemical terrorist incident. The EPA indicates that, when
taking federally recommended actions in response to a chemical terrorist incident, responders are
protected under the law.
4.8.2 Legal Concerns. The BALTEX exercises highlighted that laws and the body of legal
findings that may govern the actions and liability of the emergency responder community after a
chemical terrorist incident are sometimes poorly defined. Ultimately, each local jurisdiction
should tailor their policies, plans, training, and procedures based on local interpretation of
applicable regulations, statutes, and laws.
5.0 RECOMMENDATIONS
The efforts of the MCDRT during this study resulted in the consensus development of
several general guidelines for emergency responder mass casualty decontamination policies,
procedures, and actions after a chemical agent incident. The most imperative principle of mass
casualty decontamination is the timely physical removal of the agent from the skin of the victim.
To support this, the following should be conducted:

• Consider disrobing as part of decontamination; head to toe, more removal is better
• Flushing with water generally is the best mass decontamination method.
Decontamination approaches most readily available to first responders involve the use of
water-pumping capability to create showers for decontamination. Several equipment
configurations are possible and have been described. The fundamental goal is to use pumping
capability to set up showers as quickly as possible and get people disrobed, into, and through the
showers, before further chemical agent effects can occur. It is not advised to delay the
decontamination process, while obtaining soaps or other decontamination materials. If
7 EPA website: http://www.epa.gov/swercepp/pubs/onepage.pdf, subject: First Responders’ Environmental
Liability Due to Mass Decontamination Runoff.
22
immediately available, such materials may be of benefit, but it is more important to begin
decontamination as soon as possible.
Decontamination prioritization helps ensure the maximum benefit for the maximum
number of victims. Decontamination prioritization should be performed using medical triage
systems, such as START. Prioritizing casualties for decontamination becomes more important
when the number of victims overwhelms the available resources. Procedures should be
implemented to assist in preventing triage personnel from becoming overwhelmed. In such
situations, the Incident Commander must often decide how to best adjust the prioritization to
maximize the benefit.
Decontamination prior to leaving the Hot and Warm Zones is essential for protecting
people in the Cold Zone. However, during the response to a chemical agent terrorist incident, the
MCDRT notes that emergency responders should expect at least a 5:1 ratio of unaffected to
affected casualties expecting emergency care and decontamination. Therefore, when the
situation is severe enough and resources are overwhelmed, individuals who show no chemical
agent contamination or symptoms, and who are not otherwise suspected of being contaminated,
may be allowed to proceed to the Cold Zone. The Incident Commander may make this
allowance, if it is believed that such action will speed the decontamination process for genuinely
contaminated and symptomatic people, and ultimately result in more lives saved.
Finally, after a known exposure to liquid chemical agent, emergency responders wearing
firefighter PPE should be prepared to self-decontaminate using procedures discussed in NPFA
471, Recommended Practices for Response to Hazardous Materials Incidents.
REFERENCES
All references below were consulted during this study. Several web sites have changed
addresses or servers since the research began, and may not be current.
CHEMICAL DEFENSE/CHEMICAL BIOLOGICAL INFORMATION

ANALYSIS CENTER (CBIAC)
Listed below are the search queries used by CBIAC personnel from which output was received
for review.
CBIAC's Database
Personal Decontamination
Terror* and Decon*
Disaster Preparedness
Casualty Decon*
Skin Decontamination
DTIC's DROLS Database

$cwa , $bwa AND $first aid
$cwa, $bwa, AND ?00%DECON AND emergencies
$cwa, $bwa, AND %civil defense
23
$CHEMICAL WARFARE AGENTS, $BIOLOGICAL WARFARE AGENTS AND
%DISASTER
$CHEMICAL WARFARE AGENTS, $BIOLOGICAL WARFARE AGENTS AND
EMERGENCY CONTROL, EMERGENCY FEEDING AND LODGING, EMERGENCY
MEDICAL CARE, EMERGENCY MEDICAL CARE SUBSYSTEMS, EMERGENCY
MEDICAL CARE SYSTEMS, EMERGENCY NETWORK, EMERGENCY OPERATING
CENTERS, EMERGENCY OPERATIONS, EMERGENCY OPERATIONS CENTERS,
EMERGENCY OPERATIONS PLANNING, EMERGENCY PREPARATION, EMERGENCY
PREPAREDNESS PLANNING,
EMERGENCY PREPAREDNESS PROGRAM, EMERGENCY PREPAREDNESS (NS/EP),
EMERGENCY PROCEDURES, EMERGENCY PROCESSES
(TPS - CBIAC Searches.doc 9/15/03)
National Library of Medicine: search terms were decontamination, chemical or biological

warfare, terrorism
Medline, 1965-1997, Toxline, Sulfur (W) Mustard and Skin and (Protect? Or Barrier? Or
Penetrate?)
AGRICOLA 1970-1997,Sulfur (W) Mustard or Soman or organophosphonate and Percutaneous

and Analgesic? Or Anesthetic? Or Animal Model? Or Pain? Or Animal Test? Or Alternative?
Or Drug Therapy? Or Analytical Method?
CAB Abstracts, 1972-1977, Sulfur (W) Mustard or Soman or organophosphonate and

Percutaneous; and Analgesic? Or Anesthetic? Or Animal Model? Or Pain? Or Animal Test? Or
Alternative? Or Drug Therapy? Or Analytical Method?
Medline, 1966-1977, Sulfur(W)Mustard or Soman or organophosphonate and Percutaneous; and

Analgesic? Or Anesthetic? Or Animal Model? Or Pain? Or Animal Test? Or Alternative? Or
Drug Therapy? Or Analytical Method?
Toxline, 1965-1997, Sulfur(W)Mustard or Soman or organophosphonate and Percutaneous; and

Analgesic? Or Anesthetic? Or Animal Model? Or Pain? Or Animal Test? Or Alternative? Or
Drug Therapy? Or Analytical Method?
EMBASE, 1974-1997, Sulfur(W)Mustard or Soman or organophosphonate and Percutaneous;

and Analgesic? Or Anesthetic? Or Animal Model? Or Pain? Or Animal Test? Or Alternative?
Or Drug Therapy? Or Analytical Method?
OUTPUT FROM CBIAC SEARCHES
General References
1. Hazardous Materials: Managing the Incident; 1995; Noll, G.G., Hilderbrand, M.S., and
Yvorra, J.G.; Stillwater, OK; Fire Protection Publications.
24
2. Studies on Skin Decontamination. Part I. Protective Ointments M5, Water and Bleaches on
Skin Decontaminants for GB; 1953; Zvirblis, P. and Kondritzer, A.A.; Medical Laboratories
Research Report No. 193, Army Chemical Center, MD.
3. Studies on Skin Decontamination. Part II. Bleaching Powder and Related Items as
Decontaminants for Liquid GB; 1954; Zvirblis, P., Mayer, W.H., and Kondritzer, A.A.;
Medical Laboratories Research Report No. 307; Army Chemical Center, MD.; DITC No.
AD-043038.
4. 1996 Annual Report of PG.31 (NATO ARMY ARMAMENTS GROUP), 11 November

1996; DTIC CB-100671.02.
5. Sulfur-Mustard: Its Continuing Threat as a Chemical Warfare Agent, the Cutaneous Lesions
Induced, Progress in Understanding the Mechanism of Action, Long-term Health Effects, and
New Developments for Protection and Therapy; 1995; Smith, K.J., Hurst, C.G., Moeller,
R.B., and Sidell, F.R.; J. Amer. Acad. of Dermatology 32, 767-776.
6. Chemical Warfare Agents: II.. Nerve Agents; 1992; Sidell, F.R., Borak, J.; Annuals of
Emergency Medicine 21(7), 865-871.
7. Clinical Considerations in Mustard Poisoning; 1992; Sidell, F.R., and Hurst, C.G.; In
Chemical Warfare Agents (ed. Somani, S.M.), 52-67, Acad. Press, Inc.: New York.
8. Progress in Medical Defense Against Nerve Agents; 1989; Dunn, M.A. and Sidell, F.R.;
JAMA 262: 649-52.
9. Civil Emergencies Involving Chemical Warfare Agents: Medical Considerations; 1992; In

Chemical Warfare Agents (ed. Somani, S.M.), 341-356, Acad. Press, Inc.: New York.
10. Methodology for Mass Casualty Characterization, Extracted From a Document Prepared by
District Chief Rick Long and Captain Barry Reid (Montgomery County, Maryland, Fire and
Rescue and Provided by Deputy Chief Ted Jarboe).
11. Mustard Agent Poisoning: Pathophysiology and Nursing Implications; 1993; Moore, D.W.,
and Keeler, J.R.; Critical Care Nurse 139(6), 62-68.
12. Medical Defense Against Blistering Chemical Warfare Agents; 1991; Smith, W.J., and Dunn,
M.A.; Arch. Of Dermatology 127, 1207-1213.
13. Surgeon General of the Army and Director of Military Support EXERCISE TERMINAL
BREEZE After Action Report; CB101631-01; Oct 1996.
14. Environmental Temperature and the Percutaneous Absorption of a Cholinesterase Inhibitor,

VX; 1977; Craig, F.N., Cummings, E.G., and Sim, V.M.; J. of Invest. Dermatol. 68: 357-361.
25
15. Studies on Skin Decontamination, Part 1; MLRR 193, June 1953; Zvirbles, P., and
Kondritzer, A.A.
16. Aqueous Sodium Hypochlorite and Protective Ointment M-5 as Skin Decontaminants for V
Agents; CWLR 2303, Aug 1957; Mayer, W.M., and Kondritzer, A.A.
17. National Health and Medical Services Response to Incidents of Chemical and Biological
Terrorism, Policy Perspectives; Aug 1997; Tucker, J.B.; J. Amer. Med. Assoc. 278 (5),
362368; From the Center for Nonproliferation Studies, Monterey Institute of International
Studies.
18. The Threat of Biological Terrorism – Prophylaxis and Mitigation of Psychological and Social
Consequences; Aug 1997; Hollaway, H.C., Norwood, A.E., Fullerton, C.S., Engel, C.C., and
Ursano, R.J.
19. Medical Management of Biological Casualties Handbook; Aug 1996, Second Edition; United
States Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD
21702
20. North American Emergency Response Guidebook: A Guidebook for First Responders
During the Initial Phase of a Hazardous Materials Incident; 1996; Response and Special
Programs Administration, Washington, DC, United States Dept. of Transportation.
21. International Hazardous Materials Response Teams Conference: Nuclear, Biological, and
Chemical Problems as They Relate to Terrorism; 1997; International Association of Fire
Chiefs, Fairfax, VA; United States Dept of Transportation.
22. Chemical and Biological Terrorism; Aug 1996; Briefing in Jane’s Defense Weekly
23. Control of Communicable Disease Manual; 1995, Sixteenth edition; Beneson, Abram S.,
Editor; An Official Report of the American Public Health Association.
24. Personal Decontamination Station Standing Operating Procedures; 1994; United States Army
Technical Escort Unit; Aberdeen Proving Ground, MD 21010
25. Evaporation of Agents from Saudi Soil Arabian Soils 1. Mustard; 1992; Penski, E.C.,
Walker, H.M., Ellzy, M.W., Mitchell, P.C., and Janes, L.G.; DTIC AD-B168 071.
26. Evaporation of Agents from Saudi Soil Arabian Soils II. G-Agents; 1992; Penski, E.C.,
Walker, H.M., Szafraniec, L.L., Ellzy, M.W., Mitchell, P.C., and Janes, L.G.; CRDEC-
TR378; DTIC AD-B168 627.
27. Technical Escort Operations; 1988; United States Army Technical Escort Unit;
Headquarters, Dept. of the Army, Washington, DC.
28. Task 4C08-02-023-04, CWL Notebook 879, Toxicology Division, Field Toxicology Branch;
Feb 1957; U.S. Army Chemical Research and Development Laboratories.
26
29. Casualty Decontamination – Training for Chemical and Medical Personnel; 1990; Russell,
R., SFC; Army Clinical Review, PB 3-90-1; DTIC CB 014025, Pg. 12-16.
30. Technical Options for Protecting Civilians from Toxic Vapors and Gases; 1988; Chester,
C.V.; ORNL/TM-10423, Oak Ridge National laboratory, Oak Ridge, Tenn.
31. Compressed Air Breathing Apparatus. Firefighter Escape Sets. Manufactures Brochure,
Siebe Gorman and Company, Ltd.; Siebe Gorman and Company, Ltd.; 1985; Avondale,
Way, Gwent, United Kingdom.
32. Defense Against Toxin Weapons; 1994; Franz, D.R.; DTIC AD286301, CB-027310.03.
33. Efficacy of the Proposed Reactive Skin Decontaminant Lotion Against Challenge by GD,
VX, and HD; Suffield Report No. 516; Mar 1989; Bide, R.W., Sawyer, T.W., and Parker, D.;
Defense Research Establishment Suffield, Ralston, Alberta Canada; DTIC AD-B132 575
34. Development of a Safe and Effective Skin Decontamination System: Demonstration and
Validation; Feb 1987; Rohm and Haas Company; USAMRDC Contract DAMD17-85-
C5200; Borenstein, N., Horsey, D.W., MacDuff, J.H., Steigerwalt, R.B., and Miller, H.H.;
DITC AD-B134 687.
35. Comparison of Three Skin Decontamination Systems for Activity Against G and H Agents;
May 1989; Suffield Memorandum No. 1265 Project No. 0513Q-12T, Task DNBCC 007,
DRDHP 11; Defense Research Establishment Suffield, Ralston, Alberta Canada; Bide, R.W.,
Armour, S.J., Sawyer, T.W., Parker, D., and Risk, D.
36. Civilian-Military Health Services Contingency Program for a Mass Casualty Situation and
Wartime in Israel; 1991; Shemer, J., Heller, O., Danon, Y.L.; Israel J. of Medsci, Nov,
27(11-12):613-615.
37. Field Expedient Dermal Decontamination of Low Molecular Weight Toxins (T-2
Mycotoxin); DTIC CB014066.01, D751 481; Bunner, B.L., Pace, J.G., and Wannemacher,
Jr., R.W.
38. Primary Dermal Irritation Potential of Components of the M258A1 Decontamination Kit;
Apr. 1982; Fruin, J.T., and Haynes, M.A.; Letterman Army Institute of Research Report No.
120; DTIC AD-A114 803, AD 105 977 (Study 1); 107-382 (Study 4).
39. NBC Decontamination; 1993; U.S. Army Field Manual (FM) 3-5; CB 025412.03
40. Chemical Casualty Treatment Protocol Development – Treatment Approaches (HSD-TR-

87007); Sept 1986; Augerson, W.S., Sival, A., and Marley, W.S.; CB-000001-03, B112 914;
Prepared by Arthur D. Little, Inc. for HQ Human Systems Division, Chemical Defense SPO
(HSD/YA), Air Force Systems Command, Brooks AFB, TX 78235-5000.
27
41. NBC Defense – An Overview; Part 2: Detection and Decontamination; 1984; Benz, K.G.;
International Defense Review, 159-164
42. Assessment of Capability of Special Operations Forces (SOF) to Handle Chemical Warfare
Casualties; Jun 1990; Metz, G.G., Hutton, M., and Llewelly, C.; DTIC No. AD-B146 109.
43. The Economic Impact of a Bioterrorist Attack: Are Prevention and Postattack Intervention
Programs Justifiable; Kaufmann, A.F., Meltzer, M.I., and Schmid, G.P.; Emerging Infectious
Diseases 3 (2): Apr-Jun 1997.
44. Chemical Biological Incident Response Force Handbook Decontamination Element Proposed
Operational Requirements Document (ORD) for Chemical and Biological Incident Response
force (CIBRF) Capability.
45. The Detoxification and Natural Degradation of Chemical Warfare Agents; 1985; Trapp, R.;
Stockholm International Peace Research Institute.
46. D’Agostino, P.A.; Provost, L.R., The Identification of Compounds in Mustard Hydrolysate
(U), DRES Suffield Report 412, Ralston, Alberta, Canada, 1985; DTIC AD-A156381.
47. Rosenblatt, D.A.; Miller, T.A.; Dacre, J.C.; Muul, I.; Cogley, D.R., Problem Definition
Studies on Potential Environmental Pollutants II. Physical, Chemical, and Biological
Properties of Sixteen Substances, Technical Report 7509, U.S. Army Medical Research and
Development Command, Washington, DC, 1975, AD-A020428, pp. B-6, B-7.
48. Price, C. C.; von Limbach, B., Further Data on the Toxicity of Various CW Agents to Fish,
OSRD No. 5528, Division 9, National Defense Research Committee of the Office of
Scientific Research and Development, 1945.
49. Hazardous Materials: Managing the Incident, 2nd edition; 1995; Noll, G.G., Hildebrand,
M.S., and Yvorra, J.G.; Fire Protection Publications, Oklahoma State University, Stillwater,
OK 74078
50. Managing Hazardous Materials Incidents; Vol. 2; Hospital Emergency Departments: A

Planning Guide for the Management of Contaminated Patients; U.S. Dept. of Human
Services, Public health Service, Agency for Toxic Substances and Disease Registry.
51. Managing Hazardous Materials Incidents; Vol. 3; Medical Management Guidelines for Acute
Chemical Exposures; U.S. Dept. of Human Services, Public health Service, Agency for
Toxic Substances and Disease Registry
52. EPA Solid Waste 846, method 8260B.
53. Gordon, J. J.; Leadbeater, L., Toxicol. Appl. Pharmacol., 1977, 40, 109.
54. Chemical Agent Data Sheets, Vol. I, EO-SR-74001, Edgewood Arsenal, 1974.
28
55. Chem. Eng. News, 1953, 31, 4676-4678.
56. The King Has No Clothes: The Role of the Military in Responding to a Terrorist
Chemical/Biological Attack; Jun 1996; Osterman, J.L., Naval War College.
57. Individual and Group Behavior in Toxic and Contained Environments; Dec. 1986; Ursano,
R.J. (ed); Department of psychiatry, F. Edward Hebert School of Medicine, Uniformed
Services University of the Health Sciences; DTIC No. AD-A203 267.
58. Treatment of Chemical and Biological Warfare Injuries: Insights Derived from the 1984 Iraqi
Attack on Majnoon Island; 1991; Kadivar, H., and Adams, S.C.; Military Medicine Apr,
156(4):171-177.
59. Managing Hazardous Materials Incidents; Vol. 1; Emergency Medical Services: A Planning
Guide for the Management of Contaminated Patients; U.S. Dept. of Human Services, Public
health Service, Agency for Toxic Substances and Disease Registry.
60. Chemistry and Toxicology of Water Treated With Hypochlorite to Detoxify Chemical Agent
VX; 1987; Kalkwarf, D.R., Zangar, R.C., and Springer, D.L.; Battelle Pacific Northwest Lab,
Richland, WA.; ADA 194559.
61. JAMA 278(5): 362368; Aug 6, 1997
62. The Effect of Time and Removal of Contaminated Clothing on the Prevention of Death from
VX Poisoning; CRDLR 3028, SEPT 1960, Vande Wal, Jr., A, and Wiles, J.S.
63. Toxicity of Certain G and V Agents Through Clothing; CWLR 2295, Aug 1955; Wiles, J.S.,
Alexander, J.B.
64. Proceedings of the Seminar on Responding to the Consequences of Chemical and Biological
Terrorism, July 11-14, 1995; Sponsored by the U.S. Public Health Service Office of
Emergency Preparedness; NTIS PB97-121248.
66. Validation of an In Vitro Model Used to Characterize the Evaporative, Penetrative and
Fixative Properties of 14C-Labeled Sulfur Mustard, Lewisite, and VX Applied Topically to Fresh
Pig Skin (1987); Joiner, R.L., Harroff, H.H., Jr., Feder, P.I., and Snider, T.H.; Final Report on
Contract No. DAMD17-83-C-3129, Task 84-3, Battelle.
67. Personal communication with Scott Wright, Emergency Response Coordinator, Agency for
Toxic Substances and Disease Registry (ATSDR), Atlanta Georgia (1-404-639-6360) on 28
April 1998.
Additional References Supporting-High Volume Low-Pressure Showers
1. 29 CFR 1910.151, Medical Services and First Aid
29
2. American National Standard for Emergency Eyewash and Shower Equipment, Section
4.5.1(4)
3. ANSI Z358.1-1990, Lawrence Livermore National Laboratory Health & Safety Manual,
Chapter 6
4. 40 CFR 165.10(c)(4)
5. MIL-HDBK-1028/8, Pest Management Facilities

Internet Resources
http:/www.cdc.gov/wonder/prevguid: Medical Management Guidelines for Acute Chemical

Exposures; U.S. Department of Health and Human Services, Public Health Service, Agency for
Toxic Substance and Disease Registry; Recommendations from their web site entitled
Unidentified Chemical Pre-hospital Management
www.apgea.army.mil ERDEC Safety Office MSDSs
www.cdc.gov BMBL-Section VII-Agent Summary Statements, Bacterial Agents
http://atsdr1.atsdr.cdc.gov:8080/hazdat.html Agency for Toxic Substances and Disease Registry,

Hazardous Substance Release/Health Effects Database
www.apgea.army.mil SBCCOM Web Site Home page
http://www.ecbc.army.mil/hld/ip/reports.htm SBCCOM/Homeland Defense website
www.nbc-med.org Field Manual 8-285
www.emergency.com Hazmat
http://www.emergency.com/hzmtpage.htm Hazardous Materials Operations Page
www.nbc-med.org The Nuclear, Biological, and Chemical Medical Web Page
www.cbiac.apgea.army.mil CBIAC Home Page
http://www.epa.gov/chemfact/ Chemicals in the Environment: OPPT Chemical Fact Sheets
http://www.cdc.gov/ CDC Home page
http://www.os.dhhs.gov/ USAD Health and Human Services Home Page
http://research.nwfsc.noaa.gov/ Northwest Fisheries Science Center: Material Safety Data Sheet

Searches
30
http://www.disasters.org/emgold/Terrism.html Disaster Management Central resource
http://ww.disastercenter.com/medical.html NBC Medical Defense Library
http://www.usamriid.army.mil Biological Agent Information Papers, USAMRIID
www.emergency.com Emergency Response and Research Institute
http://ccc.apgea.army.mil/ USAMRICD open literature publications and books, 1981-1996

www.opcw.org/chemhaz/decon.htm: Website from the Organization for the Prohibition of
Chemical Weapons (OPCW) in The Hague, the Netherlands. OPWC is responsible for
implementing the Chemical Weapons Convention (CWC); Decontamination of Chemical
Warfare Agents: An Introduction to Methods and Chemicals for Decontamination.
Medical Publications
Field Manuals | Government Documents | Department of Defense Reports | Case Studies | Other |
National Academy Press | Newsletters | Periodicals
Field Manuals
1. FM 3-5; NBC Decontamination
2. FM 3-21; Chemical Accident Contamination Control
3. FM 8-9; Handbook on the Medical Aspects Of NBC Defensive Operations
4. FM 8-10-7; Health Service Support in a Nuclear, Biological, and Chemical Environment
5. FM 8-285; Treatment Of Chemical Agent Casualties And Conventional Military Chemical

Injuries
6. FM 21-10; Field Hygiene And Sanitation
7. FM 21-10-1; Unit Field Sanitation Team
8. FM 21-11; First Aid for Soldiers-See Chapter 7 for NBC First Aid
Other Government Documents
1. Biological Information Papers; U.S. Army Medical Research Institute of Infectious Diseases
2. Medical Products for Supporting Military Readiness (GO BOOK); U.S. Army Medical
Research and Materiel Command-Medical Biological Defense and Medical Chemical
Defense
31
3. Medical Management of Biological Casualties Handbook; U.S. Army Medical Research
Institute of Infectious Diseases
4. Medical Management of Chemical Casualties Handbook; U.S. Army Medical Research

Institute of Chemical Defense
5. The Defense Against Toxin Weapons Manual provides basic information on biological
toxins for military leaders and health care providers.
6. Joint Doctrine for Nuclear, Biological, and Chemical (NBC) Defense (10 July 1995) Joint
Publication 3-11
7. TB MED 296; Assay Techniques for Detection of Exposure to Sulfur Mustard,

Cholinesterase Inhibitors, Sarin, Soman, GF, and Cyanide
8. "Chemical Facts Sheets", U.S. Army Center for Health Promotion & Preventive Medicine
Chemical Facts Sheets
Department Of Defense Reports
1. Domestic Preparedness in the Defense Against Weapons of Mass Destruction, May 1, 1997.
2. NBC Defense Annual Report To Congress, March 1997
3. Proliferation: Threat and Response, Nov 25, 1997
4. Quadrennial Defense Review, May 1997
5. Report on Activities and Programs for Countering Proliferation and NBC Terrorism, May
1997.
6. Decontamination Systems for the Skin; AD Number: ADA193370 and ADA194133
7. A Survey and Evaluation of Chemical Warfare Agent-Decontaminants and Decontamination:

AD Number: ADA202525
8. Decontamination of Casualties from Battlefield Under CW and BW Attack, AD Number:

ADA211477
9. Formulation of Topical Protectants/Decontaminants; AD Number: ADA213246
10. Full Scale Development and Initial Production of the Personnel/Casualty Decontamination
System Skin Decontamination Kit (PCDS SDK),
AD Number: ADA244438
32
11. Reactive Skin Decontaminant Reactivity Studies: The Effect of O-Acetyl 2,3-Butanedione
Monooxime on the Stability of 2,3-butanedione monooximate, AD Number: ADA251165
12. Decontamination of Chemical Warfare Agents; AD Number: ADA261882
13. Enzyme Decontamination of O-P Toxins; AD Number: ADA275937
14. Development of a Safe and Effective Skin Decontamination System: Demonstration and
Validation.; AD Number: ADB134687
15. Chemical Warfare Agent Decontaminant Solution Using Quaternary Ammonium

Complexes. AD Number: ADD017924
16. CW Agents and the Skin Penetration and Decontamination; AD Number: ADD750392
17. Simple Methods for the Removal of Chemical Agents from the Skin; AD Number:
ADD750394
18. Decontamination and Detection by Grafted Polymer Films and Powdered Clays; AD
Number: ADD750496
19. Microemulsions Containing Reactive Decontaminants: Formulation, Efficacy, and

Optimization; AD Number: ADD750529
20. A Multi-Component Decontamination System: Studies of Component Compatibility and

Effectiveness; AD Number: ADD750565
21. The Detoxification and Natural Degradation of Chemical Warfare Agents; AD Number:
ADD750632
22. Knowing Agents and Decons - An NBC NCO Shares His Knowledge, AD Number:
ADD751327
23. Decontamination of Agents of Biological Origin: A Potential Shipboard System; AD

Number: ADD751477
24. Field Expedient Dermal Decontamination of Low Molecular Weight Toxins (T-2
Mycotoxin); AD Number: ADD751481
25. The Immediate Decontamination of the Skin; AD Number: ADD751488
26. The Development of a Mass Decontamination Unit for Air Base Operations; AD Number:
ADD751587
27. Hydrolysis of 1,2,2-trimethylpropyl methylfluorophosphonate (Soman) By Some Reactive

Tenzides; AD Number: ADD752641
33
28. Use of the Sorption-,Mechanical Principle in the Personal Skin Decontamination; AD
Number: ADD753165
29. Development of Chemically Reactive Fibers and Films for Decontamination; AD Number:
ADD753384
30. Evaluation of Candidate Decontaminants Against Percutaneous Sulfur Mustard and

Thickened Soman Challenges.; AD Number: ADP008788
31. Skin Decontamination of G, V, H & L Agents by Canadian Reactive Skin Decontaminant

Lotion.; AD Number: ADP008793
32. Domestic Preparedness Training Manual - Train the Trainer; 1997; Chemical and Biological
Defense Command; Aberdeen Proving Ground, MD.
Case Studies
1. Accidental Leakage of Cesium-137 in Goiania, Brazil, in 1987
2. Sverdlovsk Anthrax Outbreak of 1979
Other
1. Chemical Agent Terrorism, Frederick R. Sidell, M.D.

Introduction
Chemical Warfare Agents
Nerve Agents
Vesicants
Cyanide
Pulmonary Agents
Incapacitating Agents
Medical Response
Summary
2. National Academy Press: An Evaluation of Radiation Exposure Guidance for Military

Operations: Interim Report (1997); Committee on Battlefield Radiation Exposure Criteria
3. The Nuclear Weapons Complex: Management for Health, Safety, and the Environment
4. Management and Disposition of Excess Weapons: Plutonium: Reactor-Related Options
5. Management and Disposition of Excess Weapons: Plutonium
6. Alternative Technologies for the Destruction of Chemical Agents and Munitions
34
7. Proliferation Concerns: Assessing U.S. Efforts to Help Contain Nuclear and Other
Dangerous Materials and Technologies in the Former Soviet Union
8. Post-Cold War Conflict Deterrence
9. Dual-Use Technologies and Export Administration in the Post-Cold War Era
Newsletters
1. The ASA NEWSLETTER published six times a year by Applied Science and Analysis, Inc.
2. The CBIAC Newsletter - a quarterly publication of the Chemical Warfare/Chemical and

Biological Defense Information Analysis Center
3. The CBW Chronicle- a periodic newsletter from The Henry L. Stimson Center.
4. Chemical/Biological Arms Control Dispatch - a bi-monthly report from Chemical and

Biological Arms Control Institute
5. HTIS BULLETIN - a publication of the Hazardous Technical Information Services
Periodicals
1. Journal of the American Medical Association (August 6, 1997); Biological Warfare - JAMA
Theme Issue
2. Scientific American (12/96); The Specter of Biological Weapons
Products
1. CANADIAN REACTIVE SKIN LOTION – Patent information provided by Nancy McBean,

Licensing Associate for University Technologies, Inc. per my phone request for additional
information concerning scientific literature for their product. She provided me “patent”
information, which did contain some additional in vivo animal study data.
2. Reference CB-019399; MedicleanR 1000 and 2000; Produced by American Kleaner Mfg.
Co., Inc; Mobile Systems for Military and Special Clients; High pressure Cleaning Systems
3. Electro-Chemical Activated Solution (ECASOL) presently under evaluation by Battelle,

MREF.
4. Canadian Reactive Skin Decontaminant Lotion – RSD - (2,3-butanedione monoximate in

polyethyleneglycol monomethylether ); reduced vesicant damage if applied within 60
seconds post application of agent; as the dose is decreased the decon time post application of
agent can be increased (out to 300 seconds).
35
5. Canadian Decontaminating Mitt (Mitt) was compared to the US Personnel / Casualty
Decontamination System: Skin Decontamination Kit (SKD) and the Canadian Reactive Skin
Decontamination Kit (RSD) and all showed some efficacy against G and H agents.
6. Germany: Karcher – decontaminating equipment using high pressure steam spray
7. MODEC Mobile Decontamination Systems
Hazardous Incidents Reviewed
1. 1915, WW1; Germans released 150 tons of chlorine form 6000 cylinders, +800 dead
casualties; 2500-3000 incapacitated, Approximately 95% of the soldiers injured by chemical
agents survived; WW1, US suffered 250,000 casualties; 13%KIA, 87% wounded and 30% of
these 225,000 casualties were due to gas; British experienced 180,000 casualties with similar
death ratio – 11% in the Russian Army because of the lack of gas masks
2. Saturday, November 10, 1979, 11:54 PM, Mississauga, Ontario, Canada, Series of tank cars
including one with 90 tons of chlorine, 4 cars filled with caustic soda, a string of cars
containing propane, and three cars carrying styrene derailed; propane cars ruptured creating
explosions which punctured the chlorine car, and the contents of the styrene and caustic soda
poured onto the tracks, No deaths or major injuries; 250,000 people evacuated; eye
irritations, respiratory problems, chest pains, psychosomatic illnesses, food poisoning,
aggravated existing illnesses, bruises, pain, sprains, broken bones
3. Saturday, April 11, 12:29 PM, Pittsburgh, PA, Two trains sideswiped each other, 4 derailed
tank cars containing hazardous materials – phosphorous oxychloride, fire but no explosion
4. Wednesday, May 6, 4:10 AM, train derailment in Confluence PA, cars carrying only residue
of hazardous materials, no deaths or major illness.
5. Reston, VA (Ebola) 1990
6. NY, World Trade Center
7. Oklahoma Federal Bldg.
8. Tokyo and Matsumota, Japan
9. Russian Biological Warfare Program
10. Operation Desert Storm, 18 Jan – 28 Feb 1991; 39 scud missiles reached Israel – most off
target or malfunctioned – some landed in or around Tel Aviv resulting in approximately 1000
treated casualties; 2 deaths, 544 anxiety attacks, 230 Atropine overdoses; 75% of the
casualties resulted from inappropriate actions or reactions on the part of the victims.
36
11. Studies on Disaster Medicine in India. Poison Gas Accident in Bhopal, 2-3 December 1984;
DTIC ADA317495; (Swedish text); Internet site: (www.connect.net/dreggie/Methyl)
Ken’s Ph.D. Thesis, Biochemical Studies on the Toxicity of Isocyanates, From a Ph.D.
Thesis submitted to the University College Cork, (Ireland), May 1996; 2 AM, 3 Dec
1984, Bhopal, India; gas of methyisocyanate (mixture of phosgene and methylamine) over 3
hour period; release caused by the introduction of water into a methylisocyanate storage tank;
over 60,000 casualties of which 2500-5000 died, 60,000 seriously injured, 200,000 exposed;
follow-up studies indicated that 43% of the pregnant women did not carry a live child to
birth.
12. MATSUMOTO, JAPAN: Population 200,000 (Denver, CO.); 27 June, 1994, Last evening;
first complaints around 11:00 PM; 7 deaths due to undetermined toxic gas release (less than
20 liters) – later determined to be an evaporated/aerosol Sarin release estimated to have been
released 80 meters downwind; 54 admitted to hospital; 028 people went to outpatient clinics;
via inquiry of residents it was estimated that 277 people exhibited symptoms but did not
consult with physicians; people who opened their windows during the night died and no
victims on the ground level died, first responders did not wear any PPE and only the
policemen wore gloves, 52 people responded formed into 18 teams from 5 fire departments;
8 first responders, 15%, complained of symptoms with one hospital admission. Sarin
identified in air, pond water, tissues and blood samples of deceased casualties.
13. Kamakuishiki, Japan, July, 1994; Toxic fumes on a train in Yokohama; accidental release in
an attempt to get the plant (capable of producing THOUSANDS OF KILO’S of Sarin and
other agents) up and running; this was a dedicated Sarin production plant
14. TOKYO, JAPAN, March 20, 1995, 7:50 AM, Victims came to the hospital by taxi,
ambulance, car, walked, etc.; widespread panic; Sarin identified 3 hours post attack and later
determined to have been diluted; 5510 casualties; 12 deaths, 17 critical casualties, 37 severe
casualties, 984 moderate casualties; roughly 4,000+ casualties showed no signs of
intoxication – psychological 278 hospitals and clinics received casualties
15. Ref. JAMA 278(5): 362368; Aug 6, 1997; Tokyo fire department sent 1364 personnel to the
16 incident sites and other locations; 135 first responders (about 10%) were themselves
injured by direct or indirect exposure to the Sarin.
16. Ann Emerg Med. 1996, 28:129-135; “One of the difficulties in the Sarin attack was
undressing patients and disposing of their clothing.”
17. ARRESTED CULT MEMBERS ACKNOWLEDGED MAKING VX, TABUN (GB),

MUSTARD, AND CLOSTRIDIUM BOTULINUM
18. Sarin degradation products found in sheep carcasses in Australia
19. JAMA 278 (5): 362368; Aug 6, 1997; CBIRF – 1996 OLYMPICS – casualties would be
medically stabilized, deconned with warm water, sponged off with 0.5% bleach solution, and
then rinsed under showers. Decontaminated patients would be dried off, clothed in hospital
37
garb and blankets, and evacuated in buses along with a sufficient supply of antidotes to
ensure continued medical stabilization.
38
A-1
APPENDIX A
ACRONYMS
BALTEX Baltimore Exercise
DoD Department of Defense
EDCS Emergency Decontamination Corridor System
FY Fiscal year
HAZMAT Hazardous materials
IRP Improved Response Program
LDS Ladder Pipe Decontamination System
MCDRT Mass Casualty Decontamination Research Team
OSHA Occupational Safety & Health Administration
PPE Personal protective equipment

PSI Pounds per square inch
SBCCOM Soldier and Biological Chemical Command
TEU Technical Escort Unit
USAMRICD U.S. Army Medical Research Institute of Chemical Defense
WMD Weapons of mass destruction

Nurses and disaster risk reduction, response,
and recovery
Disasters have a devasting effect on individuals, populations and economies, and

they significantly impede progress towards sustainable development. According to the
United Nations, a disaster is an event that seriously disrupts the functioning of a
community or society and causes widespread human, material, or environmental losses
and impacts that exceed the affected community’s ability to cope with those negative
impacts. Nurses remain an underused resource in disaster risk reduction, response and
recovery for communities around the world. The International Council of Nurses (ICN)
believes that the involvement of nurses is essential to prevent new and reduce existing
disaster risk. According to the Sendai Framework for Disaster Risk Reduction 2015-
2030, adopted by the UN General Assembly, this will be achieved by preventing and
reducing hazard exposure and vulnerability to disaster, and by increasing preparedness
for effective response and recovery, thereby strengthening resilience.
A nation’s capacity to undertake this role will depend, in part, on the abilities of its
health workforce.
Disasters are exacerbated by global climate change, rapid population growth,
unplanned urbanisation and environmental degradation. Disasters occur when a
vulnerable community or society is exposed to hazards and has an insufficient capacity
to prepare for and respond effectively to mitigate the impact of the hazard(s). Hazards
may be natural: geophysical (earthquake, volcano eruption), hydrological (tsunami),
climatological (extreme temperatures, drought), meteorological (cyclone, tornado) or
biological (disease epidemic). They may also be technological or human-induced as the
result of armed conflict, famine, environmental degradation or chemical and radiological
incidents.
Regardless of the source, disasters can erode essential services, such as the infrastructure
for the provision of healthcare, electricity, water, sewage/garbage removal, transport and
communications, seriously affecting the economic, physical, social, cultural and
environmental assets of individuals and communities. Disaster can lead to loss in lives,
livelihoods and health, and severely impact the economic, physical, social, cultural and
environmental assets of persons, businesses, communities and countries. Developing
nations are particularly vulnerable to disasters as they may not have disaster
preparedness systems in place and may have higher levels of poverty, poor governance,
inequalities and reduced access to resources and assets. Vulnerable groups of
individuals, including children, older people, indigenous people, and people with
disabilities, require special attention during and after a disaster, as the impact of
disasters can reinforce, perpetuate, and increase existing inequalities. It is important to
note that nurses and their families are disproportionately affected because of the need for
nurses to form part of the first response and recovery groups. The daily physical and
psychological needs of nurses may be greater due to frequent and first-hand exposure to
human tragedy, as they often provide care with scarce resources, and they often work in
unsafe environments.
Disaster(s) may negatively impact the physical and mental health of those affected
by creating conditions such as lack of security and safety; gender-based violence; lack of
access to basic goods and services, including health services; family separation; abuse,
neglect, and exploitation of vulnerable persons, and discrimination. Furthermore, these
conditions may represent a violation of human rights, with some individuals
experiencing obstacles to defend and claim their rights. Social challenges posed by
disasters put individuals at great risk of experiencing mental health and psychosocial
problems, and support in this regard is crucial.
There is, therefore, a need for qualified individuals to engage in the implementation of
local, national, regional, and global risk reduction plans and strategies, to enable them to
bring their expertise and pragmatic guidance. Nurses have a vital role to play in all
phases of disaster(s). Their knowledge of community resources, their understanding of
the needs of vulnerable populations, health workforce planning and clinical knowledge
and skills, allow them to play a strategic role in promoting cooperation of health and
social sectors, governmental agencies and non-governmental organizations, including
humanitarian organizations and community groups, and make them of immense value
during disaster risk prevention, response, and recovery.
ICN Position and Recommendations

As the global voice of nursing the ICN:
1. Strongly believes that nurses must be involved in the development and implementation
of disaster risk reduction, response and recovery policies at the international level.
2. Advocates for adoption of disaster risk reduction, response and recovery strategies by
governments together with private sector, and other stakeholders, to prevent the loss of
lives, livelihoods and health.
3. Believes that disaster risk reduction, response and recovery planning must include
strategies to support the resilience of nurses. This involves ensuring nurses’ personal
safety and physical and psychological health and wellbeing in the short and long term.
4. Furthermore, ICN believes that support to nurses’ families and dependents should be
provided if they are involved in the recovery phase, as this may be extended and
undefined.
5. Promotes strategies that support social justice and equity of access to needed healthcare
and social services, and calls on governments and disaster risk management
organizations to establish the support systems required to address the health needs of
people affected by disaster.
6. Strongly believes that community participation is fundamental to successfully align

national policies with local disaster risk reduction needs.8 As such, it is vital to
advocate for the critical involvement of women, children and youth, persons with
disabilities, older persons, indigenous peoples and migrants. In addition, that people
with life-threatening and chronic diseases, and those who are isolated, should be
included in the design of policies to manage their risks before, during and after
disasters.
7. Strongly believes that there must be a link between relief and development planning.
Furthermore, that relief operations must develop and adhere to credible accountability
systems to ensure appropriate, effective use of financial, technical, and human
resources.
8. Supports and encourages education and training of nurses in disaster risk reduction,
response and recovery, which is guided by the ICN Framework of Disaster Nursing
Competencies.
9. Strongly advocates for the inclusion of mental health and psychosocial support for
responders and survivors, and for their families, as part of the health response to
disaster and disaster recovery.
10. Supports the Sendai Framework, including the following guiding principles and
priorities for action
11. Disaster risk reduction requires an all-of-society engagement and partnership,
empowerment, and inclusive, accessible and non-discriminatory participation.
12. Disaster risk management is aimed at protecting individuals and their health,
livelihoods, property and productive assets, as well as cultural and environmental
assets, while promoting and protecting all human rights.
13. The responsibility to reduce disaster risk primarily lies with the State, but it is shared
with local government, the private sector and other stakeholders across relevant sectors.
14. Action must be focused on: understanding disaster risk; strengthening disaster risk
governance to manage disaster risk; investing in disaster risk reduction for resilience;
enhancing disaster preparedness for effective response and on ‘Building Back Better’ in
recovery, rehabilitation and reconstruction.
15. ICN encourages national nurses’ associations (NNAs), in collaboration with their
respective government to:
16. Actively participate in supporting institutions and governments to prepare in advance

for disaster(s) by assessing potential hazards and vulnerabilities, and by increasing their
ability to predict, warn of and respond to disaster, for example through a national
disaster plan and emergency funds.
17. Develop and/or support a regulatory framework that helps nurses meet regulatory
requirements in a timely manner when deployment is needed to provide nursing care in
an affected jurisdiction.
18. Actively engage with governments so that they develop a binding strategy which is
intended to fulfil the four priorities set out in the Sendai Framework for Disaster Risk
Reduction.
19. Encourage governments to plan for responding to the basic needs of nurses in the event
of a disaster, ensuring a system is in place that aims to provide food, water and shelter,
as well as continued compensation and incentives that are normally provided for time
worked.
20. Actively participate in strategic planning and implementing of disaster plans to ensure
nursing input.
21. Ensure a register of nurses who are trained and able to respond to a disaster, and who
are linked to an organization or agency participating in the coordination of disaster
response and recovery in the country.
22. Incorporate disaster risk reduction, response and recovery in educational programmers
according to local needs and provide opportunities for continuing education to ensure a
sound knowledge base, skill development, and ethical framework for practice.
23. In the response phase of a disaster, assist in the efforts to mobilize the necessary
resources, including access to food, water, sanitation, shelter and medicines, and
support the coordination of care, giving special attention to vulnerable groups.
24. In the recovery phase, work with the community to plan for long-term needs, including
psycho-social, economic, and legal needs – for example through counselling,
resettlement and documentation.
25. Advocate for the continued care needs of those with injuries, disabilities, non-
communicable and communicable diseases and mental health needs, paying particular
attention to more vulnerable groups.
26. Partner with other health professional organizations, independent, local and national
branches of government, international agencies and nongovernmental organizations to
implement all aspects of the Sendai Framework and evaluate performance on an
ongoing basis.
27. ICN calls on individual nurses in their role as clinicians, educators, researchers, policy
influencers, or executives to:
28. Actively engage in disaster risk committees and policymaking for disaster risk
reduction, response and recovery.
29. Seek continuing professional development opportunities in disaster risk reduction,

response and recovery.
30. Be competent to provide disaster relief and meet the health needs according to the type
of disaster and the given situation.
31. Be informed of diseases, such as cholera, and changes in social behavior’s, such as
theft, that may be associated with disasters and which may be exacerbated by a
deterioration in living conditions, and of associated physical and mental health, socio-
economic, and nursing or care needs of individuals and communities, and identify
mechanisms to deal with these situations.
32. Be familiar with and raise public awareness of those disasters that their region and
country are most likely to experience.
33. Work closely with other healthcare and allied professionals in establishing
comprehensive and collaborative disaster risk reduction plans.
What Does a Disaster Relief Nurse Do?

A disaster relief nurse provides the
necessary care and treatment during an
emergency, such as a natural disaster,
terrorist attack, or other crises that
require an immediate medical response
for the community. In this position,
you typically work with a relief group
and travel to locations in need of your
services. Your primary responsibilities
are to assist first responders and other
health care providers with treating
injuries and illnesses. Your duties may also include helping to stabilize an area and
create a safe environment so you can provide medical care to patients. This job requires
excellent interpersonal, communication, and critical thinking skills, as well as the ability
to act quickly and remain calm in high-stress situations.
Disasters not only significantly affect healthcare institutions and providers but also
impact the lives of people and
economies worldwide. For instance, in
the last 10 years, more than 2.6 billion
people were affected by disasters.1 There
are three important things to know about
how disasters relate to health. First,
disaster is defined by the World Health
Organization (WHO) as any incident
that could end human life or cause
health-related harm and requires
immediate response with sufficient
manpower and resources, preparedness,
planning, response, and recovery by
many agencies, including healthcare
institutions.2 Second, hospitals must
increase their capacity in order to
effectively respond to disasters; large-
scale disasters have very negative
impacts on hospitals.3 Third, as the
largest healthcare provider group, nurses
play critical roles in holistically caring
for injured people and their families throughout the four phases of disaster management.
A lack of proper disaster management processes creates a chaotic and ineffective

response and care measures. Disaster management processes begin with identifying risks
that might impact communities, families, individuals, and hospitals. Even though
identifying disaster risks is very challenging and requires great effort from governments
and related agencies, it is a fundamental and essential step in disaster management. 4 The
second step is preparedness, which involves education and training, as well as
conducting drills and developing plans and policies.5–9 Involved parties include
caregivers, community members, and healthcare providers, including nurses and
organizations.5–9 The third step—disaster response—starts after a disaster begins. The
codes of response are announced in hospitals and include notifying hospital staff that
there is a disaster, activating the disaster plan, increasing the surge capacity, receiving
injured people and providing care to them, and communicating and coordinating with
other agencies.10–12 The final step is disaster recovery, where the main focus is returning
back to normal daily routines. All healthcare providers must follow these processes,
including nurses, who are on the frontline in such situations. Furthermore, all hospitals
must have plans and policies to ensure that disaster management is holistic and includes
all phases, not only response.
During a disaster, hospitals receive victims and their families within a very specific
period. Therefore, hospital managers and decision-makers must prepare nurses to be
ready to respond rapidly and effectively to disasters. For holistic disaster preparedness,
nurses must be involved in preparing and activating the plan and educated in disaster
management, including intensive training on all issues expected to arise before, during,
and after the response and drill simulations of different types of disaster scenarios (e.g.,
natural, eternal, external, biological, chemical, and radiological disasters). 3,15 Also, it is
very important for hospital mangers and leaders to understand the disaster management
barriers faced by healthcare providers. As one of the largest groups of healthcare
providers, nurses play critical and significant roles in all aspects of providing healthcare
to patients and their families. In disaster management, nurses work with other healthcare
providers to identify and plan for risks, participate in preparedness education and
training, respond efficiently and effectively in a timely manner, and participate in the
recovery process with other disaster management teams.14,15 In the nursing
literature,23 based on available evidences from published studies, several studies aimed
to explore the barriers faced by nurses in terms of disaster management, but the findings
have not been integrated together and summarized and discussed as a whole. To close
this gap, all barriers for nurses during disaster must be understood clearly. Therefore,
understanding the barriers nurses face in all disaster management phases will help
increase their awareness, help decision-makers create new plans and policies, and
improve quality of care during disasters. This knowledge will also help shape nursing
response to disasters; improve disaster management preparedness measures, such as
education, training, planning, and management; and allow nurses to respond to any type
of disaster rapidly and effectively. Therefore, the aim of this scoping review is to
synthesize and discuss the barriers of disaster nursing.
A disaster relief nurse needs to be ready for it all. This type of nursing is collaborative
and physical. Many volunteers do additional tasks like distributing clothing, providing
emotional support, or sweeping floors. In disaster response, nurses aren’t afraid to get
dirty — literally.
Professional preparation of nurses to manage disasters is critical to safe and effective

rescue and response. Nurses working in disaster settings must have clear leadership, and
disaster rescue policies to ensure they can react to disaster situations (Li et al., 2017).
Many nurses who have reported being a part of disaster response teams experience
psychological distress—exacerbated by lack of effective management, communication
mechanisms and resources (Mao, Fung, Hu, & Loke, 2018). In 2019, the International
Nursing Council (ICN) and the World Health Organization (WHO) jointly proposed a
framework for disaster care offering statements on diagnoses, outcomes and
interventions appropriate to disaster response (ICN, 2019). These capture the
physiological, psychological social and environmental needs of patients and their
families. However, there is limited information to evaluate how nurses cope with
disasters. There are also calls for us to look more closely at how nurse experiences can
be used to inform training strategies and curricula which may be specifically designed to
prepare nurses to work effectively in disaster settings.
Professional nursing skills in disaster response are critical. In a time of significant
global warming (Schenk, 2019), natural disasters are increasing and earthquakes,
tsunami, volcanic activity, floods and landslides more commonplace. In just one decade
(2007 to 2017), human deaths from natural disasters are estimated at 60,000. During the
more recent coronavirus (COVID-19) outbreak, nurses have been key to the disaster
response teams, relying on their clinical skills and on heuristics so that they could
adequately manage complex clinical demands in highly complex and volatile situations.
All nurses have to be responsive and they must be able to provide effective
disaster relief (Alpert et al., 2018).
Disaster nursing started with

Florence Nightingale (the founder of
nursing science) during the Crimean
War. She used environmental
resources to treat victims and was the
first healthcare practitioner to
activate a triage system by sorting
patients depending on their needs.
Disaster nursing gained importance
during WWI due to nurses’ pivotal
role. After the events of September
11, 2001, the world changed,
including the disaster management
field, which received more
attention.27 However, it is still
considered a new specialty as the
concepts and standards have not been
fully developed globally,14,19 despite many efforts from educators and researchers around
the world to define disaster nursing concepts, characteristics, scope of practice, and core
competencies. Some universities started teaching disaster nursing to undergraduate and
postgraduate students, which was recommended several times in the literature. 28 Since
the newness of the disaster nursing specialty is considered a challenge for nurses, more
effort must be made in the academic and clinical fields to enhance the development of
this specialty.
There is a general agreement in the literature about the qualifications and formal
education needed for disaster nursing. This is supported by the findings of this scoping
review, which indicated that formal disaster nursing education is one of the biggest
challenges for disaster nursing. As identified in an integrated literature review, 29 the
efforts made by researchers and educators to establish formal disaster nursing education
included (1) developing and implementing teaching methods; (2) developing and
implementing curriculum content; (3) determining the effectiveness of the education
initiatives; (4) evaluating students’ knowledge, skills, and confidence; (5) evaluating
disaster drill simulations; and (6) developing undergraduate education and training
courses. As reported in some studies, nurses are not willing to respond to disasters as
they have no experience or formal education in this area.14Therefore, more effort is
needed to develop disaster nursing education and a curriculum to enhance nurses’
competencies, confidence, and response.
The concept of disaster preparedness is very broad and includes the actions taken
before a disaster occurs to ensure readiness. This involves identifying risks; creating
plans and policies; developing education and training programs, including drills and
exercises for readiness; preparing the healthcare system for a disaster response; and
increasing disaster knowledge and awareness among healthcare providers, including
nurses. This scoping review found that attaining a level of preparedness for nurses to
work effectively is one of the biggest challenges in responding to a disaster. One of the
related factors is a prehospital system that is not fully developed or coordinated with
other healthcare institutions, such as hospitals. This issue was reported several times in
the literature. For instance, Roy et al 30 confirmed the lack of organization of the
prehospital system in India, while Feizolahzadeh et al17indicated that the most common
related issues in Iran were insufficient risk communication, weak prehospital measures,
and inappropriate distribution of patients to hospitals. A prehospital system in which all
first responders, such as police officers, firefighters, and paramedics, work together is
essential. Therefore, more effort must be made to improve this area and ensure that
nurses and other healthcare providers coordinate and work effectively. Furthermore, it is
recommended that nurses participate in creating disaster policies, procedures, and
planning measures at the regional level. However, it is important to note that this issue
might not apply to all countries, as some of them might have strong prehospital systems
that work effectively in daily routines and disaster situations.
It is also very important to prepare hospitals; the literature reported this as one of the
challenges in nursing disaster management. Therefore, it is recommended that all
hospitals develop disaster plans that address surge capacity in terms of staffing and
resources, decontamination, communication, the safety index, and survivor
support.15 The last point in disaster preparedness is the readiness of the healthcare
providers themselves. Several studies indicated that nurses are not fully prepared for
disasters, including that of Said and Chiang, 31which summarized the evidence using
systematic approaches. Therefore, more effort to enhance nurses’ preparedness is
essential.
During disasters, ethical and legal challenges for nurses are especially significant. The
differences from the challenges of everyday practice are mainly related to the allocation
of resources, the lack of privacy and confidentiality, dealing with the scope and scale of
a disaster situation, appropriate triage, treatment priorities, working autonomously,
informed consent, documentation, and conflicts with colleagues.21In addition, as
emphasized by Alpert et al,18nurses might face ethical challenges when they have a large
influx of patients during a disaster response and limited resources. Some performance
objectives for healthcare providers, including nurses, which were identified by Schultz
et al,32 include listing ethical principles related to the emergency or disaster, being
familiar with approaches for allocating resources during a disaster response, and being
able to deal with an ethical dilemma. It is recommended that ethical issues be included
in the disaster education priorities at the undergraduate and master’s degree levels.
Continuing education for nursing staff on ethical and legal issues is also recommended.
In addition, since research in this area is very limited, more effort and contributions
from experts and researchers will enhance nurses’ ability to work confidently in an
ethical manner during a disaster.
As nurses are the largest group of healthcare providers, they play significant roles in
preparing for disasters, including identifying risks, analyzing identified risks, creating
plans, conducting drills, participating in education and training activities, and identifying
areas for development and improvement.33–35 During response—the most important
phase of disaster management—nurses activate the disaster plan in their hospitals, triage
cases, provide emergency treatment for injured people, and help coordinate evacuations
and the transportation of patients to other medical facilities. In terms of recovery, nurses
participate in restoring the normal pre-disaster routine. However, according to the
nursing literature,5 nurses are confused about their roles in disasters, which creates a
significant challenge for disaster management overall. To tackle this problem, managers
and decision-makers across countries, cultures, and healthcare systems must work hard
to create a scope of practice, policies, and procedures with clear responsibilities and
accountability for all healthcare providers of the disaster management team.
Chemical Agents of Concern

Abstract
Exposure to hazardous chemical agents can occur in the home, workplace, and in the
community and may arise accidentally or through the intentional acts of terrorists. A variety of
toxic chemicals may be used as chemical warfare agents (CWAs). An emergency response
incident that involves the release of any chemicals or toxic materials will typically be referred
to as a HAZMAT incident. These first responders are the individuals responsible for
determining whether the HAZMAT team should be called for assistance. Rapid diagnosis of
patients who have been exposed to a chemical agent is critical to saving lives and preventing
further injury. The signs and symptoms of the patient provide the most important information
on which to base treatment decisions. Nerve agents are among the most potent and deadly of
the chemical weapons. They are rapidly lethal, and hazardous by any route of exposure.
Chemicals are part of our daily life. All living and inanimate matter is made up of chemicals
and virtually every manufactured product involves the use of chemicals. Many chemicals can,
when properly used, significantly contribute to the improvement of our quality of life, health
and well-being. But other chemicals are highly hazardous and can negatively affect our health
and environment when improperly managed.
The production and use of chemicals continues to grow worldwide, particularly in developing
countries. This is likely to result in greater negative effect on health if sound chemicals
management is not ensured. Multisectoral action is urgently needed to protect human health
from the harmful effects of improperly managed chemicals. WHO provides scientific evidence
and risk management recommendations for 10 chemicals or groups of chemicals of major
public health concern.
Hazardous chemicals can be found in the air, in consumers products, at the

workplace, in water, or in the soil, and can cause a large variety of diseases.
The health effects of chemicals are determined by a process of assessment

which aims to provide a consensus scientific description of the risks of chemical
exposures. These descriptions are published in assessment reports and other
related documents so that governments and international and national
organizations can use them as the basis for taking preventive actions against
adverse health and environmental impacts. Information is also provided for
chemicals used in the workplace, and may also be provided in a concise format.
The substances covered include chemicals or groups of chemical.
WHO works cooperatively with other international organizations, such as the

Organization for Economic Cooperation and Development (OECD), under the
auspices of the Inter-Organizational Programmer for the Sound Management of
Chemicals (IOMC) avoiding duplication and thereby optimizing the use of
assessment resources.
Radiological Incident and Emergencies
Abstract
In industrialized countries, high energy trauma represents the leading cause of death
and disability among people under 35 years of age. The two leading causes of mortality
are neurological injuries and bleeding. Clinical evaluation is often unreliable in
determining if, when and where injuries should be treated. Traditionally, surgery was the
mainstay for assessment of injuries but advances in imaging techniques, particularly in
computed tomography (CT), have contributed to progressively changing the classic
clinical paradigm for major traumas, better defining the indications for surgery. The vast
majority of traumas are now treated nonoperatively with a significant reduction in
morbidity and mortality compared to the past. In this sense, another crucial point is the
advent of interventional radiology (IR) in the treatment of vascular injuries after blunt
trauma. IR enables the most effective nonoperative treatment of all vascular injuries.
Indications for IR depend on the CT evidence of vascular injuries and, therefore, a
robust CT protocol and the radiologist’s expertise are crucial. Emergency and IR
radiologists form an integral part of the trauma team and are crucial for tailored
management of traumatic injuries.
Keywords: motor vehicle crash; trauma; major trauma; high speed; energy trauma
1. Introduction
Major trauma is defined as an injury or a combination of injuries that are life-
threatening and could be life changing because they may result in long-term disability.
Different conditions may cause major trauma, particularly high energy trauma, which is
determined by deceleration, sudden impact or compression injuries at speeds above 65
km/h in motor vehicle accidents (>45 km/h in motorcycle accidents) , following a fall
from a height greater than 3 m or after sustaining crush injury between heavy objects
Major trauma may produce unstable injuries, particularly vascular, which when
becoming clinically apparent, may be so severe that treatment options are limited. This
is the reason why an early and complete imaging approach is of paramount importance.
In unstable patients undergoing major trauma, imaging approaches consists of FAST
(Focused Assisted Sonography for Trauma) or, even better, the more comprehensive
E(Extended)-FAST, as well as performing chest and pelvic X-rays. In stable or
stabilized patients, whole-body CT (WBCT) has a pivotal role in the diagnosis of
traumatic injuries showing high sensitivity and specificity in their detection and grading
(Figure 1) as many guidelines, from North America and Europe, underline, it is
proposed as first line comprehensive examination.
Ijerph 19 00539 g001 550
Figure 1. US (A) and enhanced-CT (B, venous phase) of a 32-year-old male who
sustained major trauma. US scans of the liver shows a subtle hypoechoic area (A,
arrow). Enhanced-CT allows exhaustive evaluation of the suspected liver injury,
depicting the whole extension of the liver laceration (B, arrow) and excluding the
presence of vascular injuries, thus allowing safe conservative management of the
patient.
We hereby examine the crucial points regarding the indication, modality, and role of CT
in major trauma patients.
2. Indications
The main issue is to properly select patients that require CT evaluation after trauma
to avoid imaging overutilization. The optimal identification of the patient cohort for CT
scanning remains a challenge, and up to 39–47% of patients undergoing a scan may
have no injuries. The choice is simpler when there is a combination of compromised
vital parameters, severe trauma mechanisms and clinical examination findings in
keeping with severe injuries. More difficult, though, is the decision to perform a CT
after high energy impact when physical examination is normal. Debate continues about
the risk-benefit ratio of systematic WBCT when no injuries are clinically suspected. In
this cohort of patients, WBCT does not seem to change patient management and hence
should not be performed routinely. On the other hand, there is a progressive increase in
technology utilization due to its greater availability, and an increase in the number of
emergency department admissions for trauma. This promotes the adoption of CT scans,
considering the importance of the negative predictive value in shortening the patient’s
hospital stay and increasing the physician’s level of certainty to manage and discharge
patients.
3. CT Equipment
Nowadays, CT technology consists of a multi slice-spiral CT between 4- and 320-
slice CT; tomography starting from 64-slices are preferred in trauma centres offering
higher quality examinations. Furthermore, in new technology development, efforts are
made to reduce radiation exposure while maintaining good image quality i.e., through
iterative reconstruction or tube current modulation. With iterative reconstruction
techniques, radiation exposure can be reduced significantly, with an effective dose
occasionally under 10 mSv for a WBCT scan]. Another option to reduce the radiation
dose is the adoption of dual-energy CT, allowing the possibility of virtual noncontrast
(VNC) images.
4. Timing of CT
The improvement in speed and accuracy of multidetector CT (MDCT) and increased
availability of CT scanners in or near the trauma room have made immediate total-body
CT feasible as a diagnostic tool in the initial assessment of trauma patients in several
institutions, thus reducing time to reaching a diagnosis in life-threatening injuries .
Furthermore, in institutions where CT scanners have been introduced in trauma
resuscitation rooms, a reduction in patient transportation time for CT examination was
observed with ultimate reduction in time to control bleeding and a total decrease in
mortality from exsanguination
5. CT Protocol
The CT protocol to be adopted in polytrauma patients is still not standardized across
institutions. Following the acquisition of an unenhanced scan of the head [15], a variety
of protocols can be found in the available literature for body imaging, which differ in
timing acquisition and the number of phases. The monophasic protocol consists of a
single CT acquisition after intravenous (IV) administration of contrast medium (CM)
from neck to pelvis and preceded by an unenhanced scan of the head. Multiphasic CT
protocol includes a noncontrast scan of the head, followed by arterial and venous phases
extending from the neck to the pelvis, with a single bolus and two separate acquisitions.
The split-bolus CT protocol consists of a single pass through the CT gantry after IV
injection of two or three boluses (arterial and portal venous) of CM given sequentially,
with a time delay or saline bolus in between. The sequential contrast boluses result in a
single acquisition, reflecting the combination of arterial and portal venous phases (and
potentially a urinary excretory phase).
Among the above, a multiphasic protocol should be considered the “optimal” CT
protocol to be adopted initially and in follow up of high-energy trauma. The goal would
be early detection and detailed characterization of injuries that may affect the patient’s
treatment and prognosis, with a high degree of sensitivity and specificity, especially in
vascular injuries which may require immediate intervention]. As drawbacks multiphasic
protocols have a higher radiation dose compared with others and a wide series of images
that need to be interpreted in a short time, thus with a major risk of error. Monophasic
and split-bolus CT protocols may not allow adequate identification and characterization
of vascular injuries such as pseudoaneurysms, arterial injuries and dissections, which
may be masked by the timing of acquisition. Furthermore, the acquisition of only one
post contrast phase does not allow accurate estimation of the volume of active bleeding
present, neither does it precisely define the arterial or venous origin of injury. The
acquired volume of the CT examination in polytraumatized patients usually extends
from head to pelvis. However, if vascular injury is suspected, such as in open or distal
limb fractures, the entire upper or lower limb maybe included in the study and it is
usually easier to include both lower limbs in the CT examination. On the contrary, when
imaging upper limbs, one of the arms should be selected and positioned in full adduction
to the trunk. A multiphasic CT protocol is also suggested for limb examination to
properly detect and characterize vascular injuries. Even if it has been proven that the
maintenance of a standard protocol for whole-body CT after polytrauma increases the
probability of survival, there is the impression that the number of patients with minor
injuries who undergo WBCT has increased [44]. In an attempt to limit the excessive
dose exposure, the European Society of Emergency Radiology (ESER), made a recent
proposal to consider at least two different WBCT protocols: the Time/Precision Protocol
(multiphasic CT study) that should be preferred for polytrauma patients with life-
threatening injuries or hemodynamically unstable conditions, and the Dose Protocol
(split bolus) which is preferred for polytrauma patients who do not have obvious life-
threatening injuries or are hemodynamically unstable.
6. Injury Classifications
To standardize the description and the communication of traumatic injuries, the
American Association for the Surgery of Trauma (AAST) produced several lists of
organ injury scaling that are constantly updated and online available.
7. Importance of Detection of Vascular Injuries

Acute vascular injuries are the second most common cause of fatality in patients with
multiple traumatic injuries. Thus, prompt identification and management are essential
for patient survival. CT has replaced catheter angiography as the primary screening
study due to its high sensitivity in detecting], characterizing and grading vascular
injuries and, therefore, only selected patients with specific indications for treatment are
managed by IR. Their prompt detection is crucial as nonbleeding injuries may also cause
problems that become manifest hours, days, or years after trauma. For example, arterial
thrombosis may lead to organ ischemia, liver arterio-portal fistulas may lead to portal
hypertension, and splenic arteriovenous fistulas may result in “spontaneous” splenic
rupture (The detection and characterization of active bleeding assume importance in
terms of management, as not all active bleeding injuries require operative management
in an emergency setting. Indeed, minor active bleeding, especially if intraparenchymal
and of venous origin, may be self-limiting and managed conservatively on the other
hand, it is necessary in single or multiple arterial injuries to recognize and point out the
urgency of the injury and feasibility of intervention in order to guarantee proper patient
management. In a recent study examining the effect of early door-to-CT time and door-
to-control of bleeding time on mortality in patients with severe blunt trauma, the authors
concluded that earlier time to hemostasis, including surgery and angioembolization, was
independently associated with a decrease in mortality. This suggests that “time is blood”
could be proposed as a standard for trauma management and designed to shorten time to
control life threatening bleeding and reduce mortality in patients with severe trauma.
8. Thoraco-Abdominal Parenchymal Injuries

Pulmonary and intra-abdominal parenchymal injuries are exhaustively identified and
graded using contrast enhanced CT. A detailed grading system helps in patient risk
stratification and proper management; preferably non-operative. Indeed, surgical
treatment as the commonest therapeutic strategy for solid organ injuries due to blunt
trauma has evolved, and it is currently considered a better option to adopt conservative
treatment aiming to preserve the injured organ as much as possible, with increasingly
satisfactory results. Nonoperative treatment is now the first adopted strategy in
hemodynamically stable patients with blunt trauma.
9. The Role of the Radiologist within the Trauma Team

In the emergency department (ED), complex trauma care requires strong inter-
professional teamwork and resource management. Emergency radiologists have an
active role in the emergency medical team interacting closely with emergency
physicians and surgeons for management of critically ill patients. The technological
improvement of MDCT has led to a greater applicability of CT in trauma setting,
reducing the time taken for CT scanning and promising high diagnostic accuracy even in
subtle but significant injuries; thus, improving patient management.
In view of the increasing evidence of potential benefits in performing immediate total-
body CT, several institutions have installed CT scanners in their trauma resuscitation
rooms to eliminate transportation time and reduce diagnostic time to a minimum.
Furthermore, considering that rapid control of bleeding is pivotal in the management of
the polytraumatized patient, and recent advances in IR have led to fast and minimal
invasive treatment of vascular injuries, the most recent novel approach suggests a hybrid
emergency room system in which prompt surgical management for both head and trunk
injuries is also feasible.
10. Conclusions
In conclusion, the latest innovations in radiological systems have drastically changed
the management of polytraumatized patients and led to prompt diagnosis, enabling
speedy and timely treatment to reduce patient mortality.

Disaster. BSN Iv3

Uploaded by

Copyright:

Available Formats

You might also like

Disaster. BSN Iv3

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Disaster. BSN Iv3

Uploaded by

Copyright:

Available Formats

Guidelines

REPORT DOCUMENTATION PAGE Form Approved

4. TITLE AND SUBTITLE

Guidelines for Mass Casualty Decontamination During a Terrorist Chemical

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING

DIR, ECBC, ATTN: AMSSB-REN-HD-DI, APG, MD 21010-5424 ECBC–TR-125

9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING/MONITORING

11. SUPPLEMENTARY NOTES

12a. DISTRIBUTION/AVAILABILITY STATEMENT 12b. DISTRIBUTION CODE

Approved for public release; distribution is unlimited.

• Expect at least a 5:1 ratio of unaffected to affected casualties

14. SUBJECT TERMS 15. NUMBER OF

UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED UL

LIST OF FIGURES ........................................................................................................................

EXECUTIVE SUMMARY ...........................................................................................................iii

1.0 INTRODUCTION ....................................................................................................................1

3.0 TECHNICAL APPROACH .....................................................................................................1

APPENDIX A LIST OF ACRONYMS............................................................................. A-

3-1 MCDRT’S Relationships and Process......................................................................................3

4-1 The Ladder Pipe Decontamination System..............................................................................8

A Mass Casualty Decontamination Research Team (MCDRT) was formed by SBCCOM

• Expect at least a 5:1 ratio of unaffected to affected casualties

This study addressed decontamination in mild temperatures only. Decontamination in

3.0 TECHNICAL APPROACH

To address the decontamination process and develop decontamination recommendations,

The effort of the MCDRT concentrated on:

• Providing technical solutions to specific issues on the efficacies and priorities of

• Expect at least a 5:1 ratio of unaffected to affected casualties

To acquire a final consensus on the recommended decontamination procedures, the

4.1 Purposes of Decontamination

First responders may become contaminated during the conduct of decontamination

4.2 Methods of Mass Decontamination

Decontamination must be conducted as soon as possible to save lives. Firefighters should

The following forms of water-based decontamination were considered:

A disadvantage of soap is the need to have an adequate supply on hand. Additionally,

4.3 Decontamination Procedures

In the course of deconning victims, first responders may inadvertently become

4.4 Decontamination Approaches

4.4.1 Ladder Pipe Decontamination System. To provide a large capacity shower of

The Washington, DC Department of Fire and Emergency Medical Services developed

…Position two engine companies approximately 20 feet apart to form a

Figure 4-2. Schematic for Mass Decontamination

4.4.2 Emergency Decontamination Corridor System. Another field-expedient approach to

4.4.3 Commercially Available Decontamination Systems. An example of a commercially

Figure 4-7. Example of Commercial Decontamination System Available to Emergency

• Heated showers may reduce the chance of hypothermia among victims

Potential disadvantages over the field-expedient systems include:

• Systems cannot be employed as rapidly

4.4.4 Other Field-Expedient Water Decontamination Methods. Emergency responders

4.6 Prioritizing Casualties for Decontamination

Figure 4-8. Definition of Ambulatory and Non-Ambulatory Casualties

Factors That Determine Highest Priority for Ambulatory

• Casualties reporting exposure to vapor or aerosol

• Casualties with evidence of liquid deposition on clothing or

• Casualties with serious medical symptoms (shortness of

• Casualties with conventional injuries

Figure 4-9. Factors in Decontamination Prioritization of Ambulatory Victims