Hazardous Area Response Teams: the clinical aspects

1
Hazardous Area Response Teams the clinical
aspects

• David Baker DM FRCA
• Chemical Hazards and Poisons Division (London)
• Health Protection Agency (UK)

2
Objectives

• Introduction to Hazardous Area Response Team
  (HART) project
• Why HART is needed
• What can and should be done for casualties from
  chemical release
• Problems in providing care
• Basis and development of the HART clinical
  standard operating procedures (SOP)
• Provision of pre - hospital emergency care the
  case for a combined paramedical medical
  response in HART and USAR

3
Toxic hazards and threats in civil life

• Deliberate or accidental release of toxic
  chemical agents is an established hazard
• Hazards may be established agents of chemical
  warfare (CW) or toxic industrial chemicals (TIC)
• Some TIC are also CW agents
• CW agents classed as part of Chemical,
  Biological, Radiological and Nuclear (CBRN)
  releases
• Not an appropriate classification in terms of
  emergency medical responses

4
Properties of toxic agents

• Toxicity
• Latency of onset of signs and symptoms
• Persistency
• Transmissibility
• In chemical releases toxicity and latency
  determine the management of the patient but
  persistency and transmissibility determine the
  management of the incident and the health risks
  to others

5
Specific Chemical Hazards

• Nerve agents (eg sarin)
• High toxicity, short latency, variable
  persistency, high transmissibility
• Cyanide agents (eg hydrogen cyanide
• High toxicity, short latency, limited
  persistency and transmissibility
• Lung damaging agents (eg phosgene, methyl
  isocyanate)
• Toxic after a variable latency period
• Vesicant agents (eg mustard gas)
• Relatively long latency period to clinical
  manifestation but early lung damage occurs in
  high temperatures

6
Somatic systemic attack by chemical agents

• CNS
• PNS
• Autonomic
• voluntary
• Epithelial and cellular
• Gastrointestinal
• Urinary
• Circulatory
• Haemopoeitic
• Respiratory
• Control, mechanics, airways (large and small),
  alveoli

7
Chemical incidents the civil Hazmat response
AE
WIND
Loading Point
Inner Cordon
Decon Shower
Triage Sieve
Triage Sort
Casualties
Decon Shower
HOT ZONE
WARM ZONE
COLD ZONE
8
Chemical agent medical response realities

• HAZMAT protocols confine victims to the warm zone
  prior to decontamination
• Requirement in certain cases for early and
  continuing medical care before decontamination
• Antidotes alone may not enough for patient
  support
• Life support required in a contaminated zone by
  trained and protected personnel

9
Problems of working in a contaminated zone

• Need for personal protection
• Loss of contact with patient
• Difficulties in physical examination
• Normal emergency medical procedures for airway,
  ventilation and vascular access are all made more
  difficult

10
What care must be given in the contaminated zone?

• Triage (P1 P4)
• Airway management
• Artificial ventilation
• Vascular access
• Control of haemorrhage from associated physical
  injury

11
What primary care is feasible in the contaminated
zone?

• Application of skills used in normal emergency
  practice
• Triage primary triage sieve
• Recognition of key signs and symptoms
• Airway management position, suction, airway
  insertion
• Ventilation use of specially designed equipment
• Vascular access intraosseous approach
• Early administration of antidotes

12
Contaminated zone care a Cold War view
13
TOXALS Protocol (1996) for advanced life
support in a contaminated zone or
decontamination area

• Assessment (patient and site)
• Airway
• Breathing
• Artificial ventilation
• Circulatory
• - control of haemorrhage and cardiac
  abnormalities
• Disability (AVPU scale)
• Drugs and antidotes
• Decontamination
• Evacuation

14
Hazardous Area Response Teams (HART) origins
Department of Health Emergency
Preparedness Division project Two-year
investigation into Hot Zone Working Final
report submitted in Jan 05 Ministerial approval
in Aug 05
15
HART Development of Standard Operating
Procedures SOP define the following and provide
the bibliography for the project Tactical Role
and Responsibilities Health and Safety Risk
Assessment Team Structures, Concept of
Operations, Objectives and Roles Vehicles
Areas of Operation PPE, Deployment Criteria
Communications Clinical procedures
16
HART - clinical objectives

• Provision of essential immediate care for
  chemical casualties before and during
  decontamination
• Provision of continued care from point of
  chemical release to A and E and beyond
  treatment protocols, decontamination, life
  support equipment and antidote stockpiles
• To train and equip paramedical personnel to
  operate safely in a contaminated zone
• Integration with other dangerous environment
  responses urban search and rescue (USAR)

17
HART the paramedic challenge

• Extension of current clinical skills
• Special training to operate safely inside a
  contaminated zone
• To provide essential early life support before
  and during decontamination and to deliver the
  patient quickly to definitive hospital treatment

18
HART clinical sub group

• Input from specialists in
• Accident and emergency medicine
• Anesthesiology
• Medical Toxicology
• Paramedic Training

19
Clinical Rationale Triage Advanced clinical life
support with early intervention Airway and
ventilation management. Infusion control of major
haemorrhage Antidotes Support drug
administration
20
Hart Clinical Subgroup basis for warm zone
treatment protocols

• Findings of the DH Expert Group on the Management
  of Chemical Casualties Caused by Terrorist
  Activity (Blain Committee) report 2003
• Existing JRCALC paramedic training protocols
• Medical and paramedical experience

21
Patients in hot and warm zones levels of care

• Level 1 ambulant and asymptomatic
• Level 2 ambulant and symptomatic
• Level 3 non ambulant, conscious
• Level 4 Unconscious
• Level 5 physically trapped
• Level 4 and 5 patients are vulnerable but
  salvageable and in need of expert clinical care.
  TOXALS essential to avoid fatality from toxic
  respiratory failure

22
HART primary toxic triage
Is patient able to walk?
YES P3
NO
Is patient conscious? (able to obey commands)
YES P2
NO
Signs of Life? (open airway respiratory effort)
YES P1
NO P4
Unconscious patients and those with obvious
signs of respiratory distress must be prioritised
for immediate assessment and emergency treatment
(P1)
23
HART provision of TOXALS and antidotes
Point of injury/poisoning (Hot Zone) The
Casualty Collection Point (Warm Zone) , Casualty
Decontamination Area The Casualty Clearing
Station
24
Spectrum of HART Clinical Care at toxic primary
Incident site
25
HART airway and ventilation management

• Hot zone simple positioning lateral
• Airway clearance suction
• Warm zone
• Laryngeal mask airway as desired option
• ETT as alternative option
• Ventilation using VR1 portable gas powered CBRN
  ventilator
• Oxygen from multi outlet supply

26
HART ventilation capability in a contaminated
zone
27
Multiple outlet oxygen provision
28
HART Life support logistics
29
HART Logistic Unit
30
Treatment protocols

• Simple and straightforward to allow for
  difficulties of working in PPE in a contaminated
  zone.
• Based upon previous DH consensus for primary
  treatment of chemical victims
• (EXPERT GROUP ON THE MANAGEMENT OF CHEMICAL
  CASUALTIES CAUSED BY TERRORIST ACTIVITY, 2003)

31

• Patient group directions (PGDs)
• Patient Group Directions (PGDs) are documents
  which allow medicines to be given to groups of
  patients - for example in a mass casualty
  situation - without individual prescriptions
  having to be written for each patient.
• They empower staff other than doctors (for
  example paramedics and nurses) to give the
  medicine in question legally

32
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33
UK National Reserve Stocks 2002

• POD 1
• - Modesty Clothing
• POD 2
• - Nerve Agent antidote
• POD 3
• - Equipment Ventilators etc.
• POD 4
• - Ciprofloxacin
• POD 5
• - Doxycycline

POD 1
POD 4
POD 3
34
Drug Equipment Pods revision 2007
Replacement of original PODS and transfer of
control to ambulance services -
ongoing Strategic supplies to be placed on
underground and national main line stations
Upgrading of equipment and drug scales
35
2006 REVISED PODS/HART response drugs
Combopens (P2S, Atropine, Avisophone) Atropine
(2mgs/ml) 50 mls Diazemuls (1mg/ml) 10
mls (Amyl Nitrite ampoules) Dicobolt Edetate
300mgs ampoules 50 glucose - 50mls Salbutamol
Inhalers 100ugs Beclomethasone inhalers
100ugs Salbutamol 5mgs (for nebuliser) Dexamethaso
ne 8mgs Naloxone 400ugs Flumazanil 500ugs
36
Urban Search And Rescue Emergency medical teams
working alongside the Fire Service to deliver
clinical support to trapped injured persons New
skills must be learned ranging from working
underground, in confined spaces and working at
height Wide range of incidents in abnormal
environments
37
USAR Clinical SOP

• USAR SOP requirements different from HART
• No SOP have yet been drafted
• USAR clinical sub committee not yet formed
• Early consultations with clinical expertise
  taking place
• Training to JRCALC standards before USAR training
• Issues
• Consensus on early management of crush syndrome
• Division of crushed tissues for release
• Use of chest drains
• Airway management in confined spaces
• Training and governance for use of ketamine and
  midazolam

38
2006 REVISED PODS/USAR response drugs

• Etomidate
• Suxamethonium
• Ketamine
• Midazolam
• Morphine
• Propafol
• Cyclizine
• Lignocaine 1
• 50 glucose

39
The requirement for a joint paramedical medical
entry team in HART and USAR

• Difficult triage decisions can be taken by
  medical personnel on site (the question of P4
  triage)
• Antidotes and life support drugs can be given
  without the need to use patient group directions
  and dose protocols
• Difficult airway ventilation cases can be
  managed with a team approach
• General anaesthesia can be given for extraction

40
Joint paramedical medical emergency care

• Proven value in conventional attacks
• HEMS and BASICS are integrated already into EMS
  response in UK
• Problems
• No official recognition or funding of existing
  arrangements
• Lack of co ordinated policy and structure

41
HART commissioning London, December 2006
42
HART clinical policy problems identified

• Training issues regarding new procedures
  regional variations eg LMA
• Administration of essential antidotes and support
  drugs (PGD)
• Clinical SOP still being adjusted with user
  feedback
• USAR clinical SOP have yet to be determined but
  raise questions about medical presence

43
Conclusions

• HART project now active in London
• Expansion of project to other cities projected
  for 2007 -8
• Special skills have been taught to paramedics and
  technicians to enable provision of essential life
  support in a contaminated zone
• USAR has been linked in with HART by DH EP
  Division
• Both initiatives increase the ability of the
  ambulance services to respond to circumstances
  outside the remit of usual practice.