Decontamination is the physical process of removing the chemicals, biological agents, or radioactive materials from people, equipment, and eventually the environment. Residual hazardous materials covering those who have been exposed directly are themselves a source of ongoing exposure to others. These residuals pose a risk of secondary exposure to first responders and healthcare personnel. Immediate decontamination is a major treatment priority for those with chemical weapon agent exposure.
Initial decontamination involves removing all contaminated clothes and items from the affected person and then washing the body thoroughly with warm water and soap. Be aware that hot water and vigorous scrubbing may worsen the effects by increasing chemical absorption into the skin.
Vapor exposure alone may not require decontamination. If it is not known whether the exposure was to a vapor or an aerosolized liquid, decontamination is recommended.
Make sure victims are able to breathe, as respiratory effects are common with the majority of chemical warfare agents. Ideally, decontamination will take place as close as possible to the site of exposure to minimize the duration of exposure and prevent further spread. Hospitals receiving contaminated people may establish an area outside the Emergency Department in which to perform initial decontamination. Portable decontamination equipment with showers and run-off water collection systems are commercially available. All hospitals should have the capacity to decontaminate at least one person at a time safely.
Immediate decontamination within 2 minutes of exposure is the most critical intervention for people who have skin exposure to mustard agents. Any effects on living tissue caused by chemical mustard will result in irreversible cell damage to that tissue. If an exposure takes place and a person shows no obvious signs or symptoms, decontamination is still urgent. If exposure is suspected, immediately remove clothing and wash the skin with soap and water. Eye exposure requires immediate irrigation with copious amounts of saline or water. Even delayed decontamination serves a purpose as it prevents spread of the chemical to other parts of the body as well as protecting emergency care personnel from further contact exposure. Liquid blister agent contamination poses a high risk for emergency care personnel. The use of PPE (personal protective equipment) that is impervious to the highly soluble agents is necessary.
The presence of radiological contamination can be readily confirmed by passing a radiation detector (radiac dosimetry device or Geiger counter) over a person’s body. The need for radiological decontamination should not interfere with emergent medical care. Unlike chemical weapon agents, the presence of radioactive particles will not cause acute injury to caregivers. Decontamination measures that are sufficient to remove chemical agents are more than suffi¬cient to remove superficial radiological contamination.23
That said, please be aware that it is important to initiate decontamination of victims exposed to a radiation weapon as soon as possible, and usually, this will be done prior to arrival at a medical facility. Decontamination of multiple casualties resulting from a radiological weapon is an enormous task. Be aware that the process will require a considerable amount of time. Therefore initial life-sustaining medical interventions such as intubation for respiratory distress, emergent control of bleeding, or the initiation of intravenous access should be done prior to full decontamination efforts.
Open wounds should be carefully covered prior to decontamination, as radioactive particles may move onto the exposed tissue, especially when there is blood or serous fluid to adhere to. Contaminated clothing, all jewelry, and other items should be carefully removed, placed in sealed, labeled plastic bags and re-moved to a secure location clearly marked as a contaminated holding area. Bare skin and hair should be thoroughly washed with soap, and if at all possible, all of the fluid and soilage from the washing process should be gathered, contained and labeled. It should then be stored in an area clearly marked as contaminated and later disposed of in an appropriate manner.
Should the seriousness of injuries mandate decontamination be delayed, the simple removal of outer clothing and shoes along with a rapid washing of exposed skin and hair will, in most instances, effect a significant reduction in the patient’s contamination. Anti-contamination protective clothing, such as coveralls, should be worn by the provider prior to the patient's initial decontamination, but standard universal precautions are adequate for those treating limited numbers of radiologically contaminated patients. After treating and decontaminating the patient, providers themselves should undergo decontamination.
Special care must be taken not to irritate the skin. Experience with victims of radiological contamination has shown that should the skin become erythematous, small particles of radionuclides may be absorbed directly through it. Standard surgical irrigation solutions should be used in liberal amounts in all open wounds including the abdomen and the chest as al¬pha and beta-emitting particles left in wounds will continue to cause extensive local damage and may even be absorbed into the systemic circu¬lation where they become redistributed as internal contaminants. If at all possible, all irrigation solutions should be removed by suction instead of sponging and wiping, with the contained solution being saved, labeled and moved to an area clearly marked as contaminated. Copious amounts of water, normal sa¬line, or eye solutions are recommended for suspected eye contamination.
Frequently a second, more deliberate decontamination will be conducted on arrival of victims to a medical care facility. A second decontamination is initiated to prevent the transfer of any residual radiological particulate to areas of the body pre¬viously uncontaminated, as well as to limit possible particulate contamination of personnel. During this second, less emergent decontamination, it is common to obtain moist cotton swabs of the nasal mucosa from both sides of the nose. These should be carefully labeled with an emphasis on documentation of exact time the sample was obtained, and sealed in separate bags for later determination of radioactive particle inhalation.
Be aware that if decontamination wash-water and soilage cannot be contained and collected, local water and sanitation authorities must be notified so that appropriate action can be taken.
All wound dressings, tourniquets, and pressure pads initially applied must be replaced with clean ones after general decontamination is complete. The original items were placed prior to the body wash process for protection of open wounds, and must now be bagged, labeled, and stored in an area marked as contaminated.
Walking wounded are arriving at your facility from the Conference Center explosion, having made their way around street closures and points set up for triage processing, decontamination, and transport. Emergency Command has notified all care centers of the risk that biologic contaminants were released using an explosive blast as a spread mechanism. Instructions are to decontaminate all leaving the blast scene and quarantine them pending further instructions.
No patients were supposed to arrive without processing! Yet here they are, limping in, holding makeshift dressings to lacerations and injuries, covered with debris from the blast and who knows what weaponized organism. Worse yet, all mobile decontamination units have already been rushed to the edge of the hot zone where decontamination and triage were supposed to occur. What to do?
Following written protocols, staff members quickly establish a facility specific triage area in a parking garage using plastic sheeting retrieved from storage and water lines ran to provide warm water for decontamination. More water lines serve to remove used water runoff into a makeshift holding pond. Folding privacy screens are set outside the quickly established decontamination corridor, and staff in waterproof PPE and N-95 masks assist patients to place all of their clothing and personal possessions into sealed, clearly marked bags for storage in a clearly marked area. Wounds are covered, and soap with plenty of warm water is used to decontaminate skin and hair. Nasal swabs are taken as a part of the process and carefully conveyed to laboratory services. After drying, clean clothing is provided. Processed patients are escorted to quarantine or further treatment as warranted.
|After Action Notes: |
- Routine “pinch-nose” surgical masks are designed to be sneeze and droplet guards, not infection barriers. N-95 face contoured masks are designed to filter out 95% of all air-borne contaminants such as smoke, dust, bacteria and virus particles; they are not oil resistant, so use around oily aerosols will require another type of PPE.
- Experience working with people in during disasters has shown that alert citizens always find ways around help stations! Always anticipate some “walking wounded” to arrive from a near disaster and have a fallback plan for dealing with the possible surge of individuals arriving.
- Past decontamination, incident debriefings reveal that a small number of individuals unwilling to part with sentimental jewelry or completely disrobe can create a full stop to the time sensitive process. Have a plan for bringing time requiring discussions out away from the decontamination line. Often “can’t part with” jewelry can be sealed into a rip-proof plastic bag and kept “in hand” during decontamination, then opened and cleaned under controlled conditions later. Same-sex staff can accompany bashful individuals, or reliable family members can be enlisted to assist. However, if personnel resources are tight, defer dilemmas to the last of the line so those willing to be aided can progress through without delay.