Let’s get to the OP
toxic agents for which effective antidotes are available. These should be implemented immediately at the site of the incident using autoinjectors, as any delay in administration will entail grave consequences. OP poisoning is characterised by a
violent cholinergic response, with a distinctive combination of clinical signs and symptoms, including miosis, hypersecretion, dyspnea and respiratory insufficiency, loss of consciousness and seizures (the mnemonics are SLUDGE or DUMBELLS & SMTWT), which can be diagnosed relatively easily given proper training. To increase the specificity of the OP poisoning clinical diagnosis, we suggest initiating the OP procedure only when at least three casualties are clinically diagnosed with poisoning, of whom at least one is moderately to severely injured. In the presence of mild casualties only, nerve agents should not be immediately considered.
Pre-hospital medical countermeasures Once an OP event is defined, antidotal treatment should be administered as quickly as possible, together with supportive care and resuscitation measures as necessary. The classical antidotes include atropine and oximes. In Israel we use autoinjectors in which the two are combined, for ease of use. In case of seizures or loss of consciousness, benzodiazepines and scopolamine should be administered as anticonvulsants and for their neuroprotective effect. We have also demonstrated that establishing an intraosseous line is a simple method for administration of antidotes and anticonvulsive drugs while wearing PPE. Due to the extreme importance of early antidotal administration, all ambulances in Israel carry several combined autoinjectors to allow for immediate medical response in case of an OP event. Other TICs prompt a primarily
respiratory response, in which oxygen supplementation, general resuscitation measures and supportive care are the key components of emergency treatment. Other important components include undressing the casualties and evacuating them as soon as possible. In Israel we do
The plastic tag lets hospital staff know exactly what medical treatment has been administered ©Eisenkraft
not perform casualty decontamination on site during a TMCE event, since it is too time consuming and probably will not improve the outcome. Moreover, the current capabilities of on site decontamination units are clearly insufficient for the immediate decontamination of possibly hundreds of people in a matter of minutes. Considering that every hospital in
Israel has the necessary infrastructure for wet decontamination, first responders are instructed to undress casualties on the way to hospital, while wearing their own full protective gear. Full decontamination should be performed by non-medical personnel before victims enter the hospital, using designated showers placed at the entrance to the facility. This ‘scoop and run’ philosophy is similar to trauma care, allowing for definitive medical care as quickly as possible. On the way, antidotal and resuscitative treatments are administered as necessary. This approach takes advantage of the relatively short evacuation distances in Israel.
Rescue and evacuation Israeli EMTs comprise physicians, paramedics, medics and volunteers. All EMT personnel receive CBRN medical training at least once a year, in which toxidromes, treatment protocols, and the importance of teamwork are emphasised. Moreover, we have
developed a unique simulation-based training for EMTs on managing CBRN casualties, which allows for evaluation of learning and performance over time. As stated earlier, EMT personnel wear level C protection, with identification labels indicating their roles. All rescue teams help with on site evacuation of victims in addition to their basic duties. EMT staff are taught to work in
groups and not individually, enabling rapid response by team members in case one of them is poisoned and/or contaminated. Immediately after an incident and before risk assessment is carried out, an automatic initial isolation perimeter is defined and enforced by the police, 100 metres from the margins of a building for an indoor event, and 200 metres from the source at an outdoor event. This perimeter defines the area in which every entrance is documented, and only rescue personnel in PPE are allowed to enter. The exact borders of the isolation area are defined more accurately later, by combining risk assessments with field detection. Upon reaching the scene, EMTs set
up an organised grid to search for casualties. They try to identify the offending agent by looking for typical clinical signs and symptoms, or toxidromes, and administer antidotes accordingly. If an antidote is administered, the victim is marked using a plastic tag around the neck.
CBRNe Convergence, Indianapolis Motor Speedway, Indiana, USA, 6 - 8 Nov 2017
www.cbrneworld.com/convergence2017 26 CBRNe WORLD June 2017
www.cbrneworld.com
CBRNeWORLD
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