Introduction

Hazardous waste, hazardous material, and hazardous chemicals are synonymous terms that refer to agents that can cause injury or death to those exposed. This includes chemical, biological, and nuclear materials. Although the media often highlights hazmat (hazardous material) events as "bioterrorism," hazmat exposures are more commonly due to accidental or natural chemical spills. Luckily, these events are relatively rare and on a small scale. In all cases, preparation is critical. Appropriate disaster management must take into account direct injury due to the release of the agent, as well as the chaos and confusion associated with exposures. Preparation must also be made for secondary injuries such as trauma and burns. During the incident, victims often flee the scene and seek out the nearest hospital for medical care with no regard for that institution’s capabilities. To optimally handle these events, preparedness requires planning, procedure development, policy creation, hazard analysis, and the availability of appropriate protective equipment. Safety should remain the priority when an emergency occurs, including the safety of the first responders, the exposed, and the public, including downstream personnel such as hospital providers.[1][2][3][4][5]

Issues of Concern

Epidemiology

Data from the United States Department of Transportation Office of Hazardous Material Safety report that approximately 12,000 to 18,000 events are classified as hazmat events yearly. These include spills on roadways, industrial leaks, lab chemical exposures, naturally occurring toxic exposures, and rarely events intended for harm (bioterrorism). Many spills and exposures are taken care of on a local level and never reported, so there is underreporting of these events. In 2012, an analysis of prehospital responses to hazmat events was released. The authors studied public data from the National Emergency Medical Services (EMS) Information System and concluded that hazmat events are a rare cause of EMS activation in the United States. They further explain that most events involving 2 or fewer patients occurred in nonindustrial venues. In patients with reported exposure, cardiac arrest occurred in one-fifth of the patients, supporting the seriousness of these exposures. Mortality rates were not calculated due to the number of possible agents and their effects on humans.

On-Scene Hazmat Response

As mentioned, EMS and other emergency personnel must be prepared to handle hazmat exposure adequately, regardless of size. The prehospital response to hazmat is typically complicated by factors such as a potentially dangerous environment, multiple victims, the need to ensure adequate decontamination for both the patient and the responder, and arrival-to-scene delays. The Emergency Planning and Community Right-to-Know Act (EPCRA) was passed in 1986 in response to concerns about the environmental and safety hazards of storing and handling toxic chemicals. This act requires local governments to prepare chemical emergency response plans overseen by state governments. Even so, many hazardous chemicals are stored at various sites, and it is unreasonable to expect a detailed plan for each chemical or toxic agent. Instead, there are general principles by which hazmat response is guided. These include community assessment, recognition, identification of the substance in question, scene control and isolation, decontamination, and stabilization.

Community assessment involves state and local government response and other available resources such as EMS, fire departments, and local organizations. In addition, the EPCRA mentioned above requires response plans to be practiced once a year. Once community plans are in place, a hazmat event must be recognized. Industrial facilities are typically well-equipped, with monitors and systems to detect leaks and possible exposures. Outside of industrial facilities, most hazmat exposures are recognized by the effects of the chemical itself. These include but are not limited to noxious stimuli causing coughing, burning of the eyes, airway irritation, headaches, and, in some cases, quick asphyxiation and death. This also includes subtle clues such as crops, other plants, and even animals discovered dead in large quantities or certain geographical patterns.

After a hazmat event is recognized, the next goal is to attempt to recognize the inciting agent. There are numerous resources for identification; however, unless the chemical is known, it is most important to recognize the clinical syndrome expected. This way, the providers may be able to intervene and treat appropriately. The identification should be questioned if the symptoms do not fit the initial chemical agent identified.

Decontamination and Stabilization

It is of paramount importance to remember that safety is the number one priority. First responder safety should be kept at the forefront of the operation and should often guide the management plan. Once an incident is identified, the EMS response team must establish an incident command system. This is an organized approach to control and manage operations at an emergency incident. For a hazmat incident, this means the designation of a hot, warm, and cold zone, an isolation process, and many other layers of operations, commands, and communications roles.

Hot zone

The suspected hazmat and victims are immediately located in the hot or exclusion zone. The hot zone should be carefully controlled for safety and contamination purposes. Only trained personnel in full personal protective equipment (PPM) should be allowed to enter to remove the victims from further exposure. There is a substantial risk of contamination for a rescuer or a bystander who happens to be within the zone. Great care should be taken to control the hot zone, and the area designated hot may range from 75 to 3000 feet or more, depending on the hazmat agent involved. It is also important to note that anything, including vehicles, equipment, clothing, and other items in the hot zone, is considered contaminated and should not be removed until decontaminated.

Warm zone

A warm zone is created outside the hot zone where the decontamination occurs. Each patient is taken to the warm zone where initial medical management may occur simultaneously. These include things such as basic airway management or other life-saving procedures. However, it is important to decontaminate thoroughly. The first and most effective decontamination method is removing the victim’s clothes, brushing off solid particles, and washing and toweling the face. Water is the universal decontamination agent. Most sources recommend a decontamination method in a linear or "assembly-line" fashion, with those involved performing each step in a line. First, affected people take their clothes off, and then warm water is used to rinse them, paying close attention to the face and areas where fluid can hide (axilla, groin, toes, skin folds). In general, 5 minutes of thorough decontamination is adequate for patients. Next, patients are covered to protect them from the environment and moved to the cold zone. It is also important to note that providers who are helping to decontaminate the patients should be wearing personal protective equipment, and they require decontamination afterward.

Cold zone

The cold zone is designated outside the warm zone where an emergency can be directed and supported. Ideally, the cold zone should be upwind, uphill if necessary, and out of danger. Once decontaminates, patients can be taken to the cold zone for further triage and stabilization. Primary stabilization focuses on the airway and breathing. Administering oxygen and breathing treatments with bronchodilators can occur rapidly and with little training. Further, if the appropriate personnel is available, intravenous access can be considered for fluid resuscitation and medications. From the cold zone, patients are triaged to the appropriate setting, including transfer to a hospital. This underscores the importance of decontamination because the patients encounter many people while navigating the incident command system.

Clinical Significance

The scale of a hazmat incident is unpredictable, and many factors affecting the scene must be considered. Factors such as wind direction, weather, and available resources such as a water supply or electricity can make hazmat scenes difficult to control. On some occasions, decontamination inside warehouses or make-shift shelters may be considered. If decontamination occurs outside in a very cold climate, the incidence command system must implement a way to combat hypothermia. Factors such as these can add many layers to a hazmat incident, adding to the already unpredictable nature of hazmat incidents.[6][7][8][9]

Further, there is often a delay in providing care for hazmat victims. It takes time to adequately set up an incident command system responding to a hazmat call. Even in a well-equipped, resource-rich environment, time to decontamination is often delayed. One study recommended a "self-decontamination" protocol for large-scale hazmat exposures. This would help relieve the burden of a large patient load overcrowding a decontamination protocol; however, it would require better community education. Despite the best planned and rehearsed chemical response plan, most individuals self-rescue and head toward the nearest hospital or healthcare facility. For this reason, healthcare facilities should also have decontamination procedures in place. Audits must be routinely done to ensure workers comply with the safety features.