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Decontamination of Multiple Casualties Who Are Chemically Contaminated: A Challenge for Acute Hospitals

Published online by Cambridge University Press:  28 June 2012

Simon F.J. Clarke*
Frimley Park National Health Service Foundation Trust, Frimley, Camberly, Surrey, UK Chemical Hazards and Poisons Division, Health Protection Agency, Chiltern, UK
Rob P. Chilcott
Chemical Hazards and Poisons Division, Health Protection Agency, Chiltern, UK
James C. Wilson
Chemical Hazards and Poisons Division, Health Protection Agency, Chiltern, UK
Robie Kamanyire
Chemical Hazards and Poisons Division, Health Protection Agency, Chiltern, UK
David J. Baker
Chemical Hazards and Poisons Division, Health Protection Agency, Chiltern, UK
Anthony Hallett
Guy's and St. Thomas' NHS Foundation Trust, London, UK
Consultant Emergency Physician Emergency, Department Frimley Park NHS Foundation Trust Portsmouth Road, Frimley, Camberley, Surrey, GU16 7UJ UK E-mail:


Patients who have been contaminated by chemical compounds present a number of difficulties to emergency departments, in particular, the risk of secondary contamination of healthcare staff and facilities. The Department of Health in the United Kingdom has provided equipment to decontaminate chemically contaminated casualties who present at emergency departments. The capacity of this equipment is limited, and although both the ambulance and fire services have equipment to cope with mass casualties at the scene of a chemical incident, there is still the possibility that acute hospitals will be overwhelmed by large numbers of self-presenting patients. The risks and potential consequences of this gap in resilience are discussed and a number of possible practical solutions are proposed.

Comprehensive Review
Copyright © World Association for Disaster and Emergency Medicine 2008

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1. Crawford, IWF, Mackway-Jones, K, Russell, DR, Carley, SD: Planning for chemical incidents by implementing a Delphi based consensus study. Emerg Med J 2004;21:2023.CrossRefGoogle ScholarPubMed
2. Crawford, IWF, Mackway-Jones, K, Russell, DR, Carley, SD: Delphi based consensus study into planning for chemical incidents. Emerg Med J 2004;21:2428.CrossRefGoogle ScholarPubMed
3. Home Office: The decontamination of people exposed to chemical, biological, radiological or nuclear (CBRN) substances or material. Strategic national guidance (2nd ed). 2004. Available at gencies/cbrn_docs/homeoffice/people/peoplecbrn.pdf.Google Scholar
4. Chemical Abstract Service. Available at Accessed 13 November 2006.Google Scholar
5. Baxter, PJ: Major chemical disasters. Br Med J 1991;302:6162.CrossRefGoogle ScholarPubMed
6. Han, KH, Walker, R, Kuhri, M: An integrated response to chemical incidents—The UK perspective. Resuscitation 1999;42:133140.CrossRefGoogle Scholar
7. Moles, TM: Emergency medical services systems and HAZMAT major incidents. Resuscitation 1999;42:103116.CrossRefGoogle ScholarPubMed
8. Control of Major Accident Hazards (Amendment) 2005. Available at Scholar
9. Maclean, AD: Chemical incidents by the United Kingdom public fire service in 1980. J Hazard Mat 1981;5:340.CrossRefGoogle Scholar
10. Burgess, JL, Kirk, M, Borron, SW, Cisek, J: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999;34:205212.CrossRefGoogle ScholarPubMed
11. Keim, ME, Pesik, N, Twum-Danso, NAY: Lack of hospital preparedness for chemical terrorism in a major US city: 1996–2000. Prehospital Disast Med 2003;18:193199.CrossRefGoogle Scholar
12. Saunders, P, Jeffery, B: Chemical incidents in England and Wales, 2005. Health Protection Agency, 2007. Available at 2007/chemical_incident_05/chemical_incidents_05.pdf.Google Scholar
13. Herriott, N, Stuart, AJ, Leonardi, GS: Estimating the number of chemical incidents: Methodological approaches, needs and difficulties. Epidemiology 2004;15:s130s131.CrossRefGoogle Scholar
14. Mehta, PS, Mehta, AS, Mehta, SJ, Makhijani, AB: Bhopal tragedy's health effects. A review of methyl isocyanate toxicity. JAMA 1990;264:27812787.CrossRefGoogle ScholarPubMed
15: Murray, V: Mass casualty incidents. Chemical Incident Report. 2001;22:213. Available at Google Scholar
16. Claudio, L: Environmental aftermath. Environ Health Perspect 2001;109:A528–A536.CrossRefGoogle ScholarPubMed
17. Lioy, PJ, Weisel, CP, Millette, JR, Eisenreich, S, Vallero, D, Offenberg, J, Buckley, B, Turpin, B, Zhong, M, Cohen, MD, Prophete, C, Yang, I, Stiles, R, Chee, G, Johnson, W, Porcja, R, Alimokhtari, S, Hale, RC, Weschler, C, Chen, LC: Characterization of the dust/smoke aerosol that settled east of the World Trade Center (WTC) in lower Manhattan after the collapse of the WTC 11 September 2001. Environmental Health Perspectives 2002;110:703714.CrossRefGoogle Scholar
18. McGee, JK, Chen, LC, Cohen, MD, Chee, GR, Prophete, CM, Haykal-Coates, N, Wasson, SJ, Conner, TL, Costa, DL, Gavett, SH: Chemical analysis of World Trade Center fine particulate matter for use in toxicologic assessment. Environmental Health Perspectives 2003;111:972980.CrossRefGoogle ScholarPubMed
19. Landrigan, PJ, Lioy, PJ, Thurston, G, Berkowitz, G, Chen, LC, Chillrud, SN, Gavett, SH, Georgopoulos, PG, Geyh, AS, Levin, S, Perera, F, Rappaport, SM, Small, C, NIEHS World Trade Center Working Group: Health and environmental consequences of the World Trade Center disaster. Environ Health Perspectives 2004;112:731739.CrossRefGoogle Scholar
20. Morita, H, Yanagisawa, N, Nakajima, T, Shimizu, M, Hirabayashi, H, Okudera, H, Nohara, M, Midorikawa, Y, Mimura, S: Sarin poisoning in Matsumoto, Japan. Lancet 1995;346:290293.Google ScholarPubMed
21. Nakajima, T, Sato, S, Morita, H, Yanagisawa, N: Sarin poisoning of a rescue team in the Matsumoto sarin incident in Japan. Occup Environ Med 1997;54:697701.CrossRefGoogle ScholarPubMed
22. Nakajima, T, Ohta, S, Morita, H, Midorikawa, Y, Mimura, S, Yanagisawa, N: Epidemiological study of sarin poisoning in Matsumoto City, Matsumoto, Japan. J Epidemiol 1998;8:3341.CrossRefGoogle Scholar
23. Okumura, T, Ninomiya, N, Ohta, M: The chemical disaster response system in Japan. Prehospital Disast Med 2003;18:189192.CrossRefGoogle ScholarPubMed
24. Masuda, N, Takatsu, M, Morinari, H: Sarin poisoning in Tokyo subway. Lancet 1995;345:1446.CrossRefGoogle ScholarPubMed
25. Nozaki, H, Hori, S, Shinozawa, Y, Fujishima, S, Takuma, K, Sagoh, M, Kimura, H, Ohki, T, Suzuki, M, Aikawa, N: Secondary exposure of medical staff to sarin vapor in the emergency room. Intensive Care Med 1995;21:10321035.CrossRefGoogle ScholarPubMed
26. Okumura, T, Takasu, N, Ishimatsu, S, Miyanoki, S, Mitsuhashi, A, Kumada, K, Tanaka, K, Hinohara, S: Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med 1996;28:129135.CrossRefGoogle ScholarPubMed
27. Ohbu, S, Yamashina, A Takasu, N, Yamaguchi, T, Murai, T Nakano, K, Matsui, Y, Mikami, R, Sakurai, K, Hinohara, S: Sarin poisoning on Tokyo subway. South Med J 1997;90:587593.CrossRefGoogle ScholarPubMed
28. Murakami, H: Underground. The Tokyo Gas Attack and the Japanese Psyche. London:Vintage Books, 2003.Google Scholar
29. Intelligence and Security Committee. Report into the London terrorist attacks on 7 July 2005. The Stationary Office. 2006. Available at http://www.cabinetoffice. Scholar
30. Murphy, P: Government's Response to the Intelligence and Security Committee's Report into the London Terrorist Attacks on 7 July 2005. London: The Stationary Office, 2005.Google Scholar
31. BCC News: Seven US soldiers killed in Iraq. BBC News, 20 May 2007. Available at May 2007.Google Scholar
32. Ensom, J: Terrorists target chlorine tankers.Available at http://www.globalcon Accessed May 2007.Google Scholar
33. Thanabalasingham, T, Beckett, MW, Murray, V: Hospital response to a chemical incident: Report on casualties of an ethyldichlorosilane spill. Br Med J 1991;302:101102.CrossRefGoogle ScholarPubMed
34. Burgess, JL: Hospital evacuations due to hazardous materials incidents. Am J Emerg Med 1999;17:5052.CrossRefGoogle ScholarPubMed
35. Armstrong, A: Chemical incident responded to by University Hospital Aintree. Chemical Incident Report 1999;13;1011.Google Scholar
36. Cook, G: Chemical incident responded to by Maidstone Hospital. Chemical Incident Report. 1999;13;1112. Available at reports/cir13_jul1999.pdf.Google Scholar
37. Geller, RJ Singleton, KL Tarantino, ML Drenzel, CL Toomey, KE:Nosocomial poisoning associated with emergency department treatment of organophosphate toxicity—Georgia, 2000. J Toxicol Clin Toxicol 2001;39:109111.CrossRefGoogle ScholarPubMed
38. Morcom, F. Report of a mass casualty incident dealt with by an accident and emergency department. Chemical Incident Report 2003;28;68.Google Scholar
39. Davey, A, Moppett, IK: Postoperative complications after CS spray exposure. Anaesthesia 2004;59:12191220.CrossRefGoogle ScholarPubMed
40. Harrison, H, Clarke, SFJ Wilson, A, Murray, V: Chemical contamination of healthcare facilities and staff. Chemical Incident Report 2002;25:25.Google Scholar
41. Stewart, A Whiteside, C Tyler-Jones, V, Ghebrehewet, S, Reid, J, McDonald, P Kennedy, C, Pennycock, A, Gent, N, Seddon, D: Phosphine suicide. Chemical Incident Report 2003;27:2325.Google Scholar
42. Horton, DK, Berkowitz, Z, Kaye, W: Secondary contamination of ED personnel from hazardous materials events, 1995–2001. Am J Emerg Med 2003;21:199204.CrossRefGoogle ScholarPubMed
43. Nakajima, T Ohta, S Fukushima, Y Yanagisawa, N:Sequelae of sarin toxicity at one and three years after exposure in Matsumoto, Japan. J Epidemiol 1999;9:337343.CrossRefGoogle ScholarPubMed
44. Tucker, JB: National health and medical services response to incidents of chemical and biological terrorism. JAMA 1997;278:362368.CrossRefGoogle ScholarPubMed
45. Li, Q, Hirata, Y, Piao, S, Minami, M: The by-products generated during sarin synthesis in the Tokyo sarin disaster induced inhibition of natural killer and cytotoxic T lymphocyte activity. Toxicol 2000;146: 209220.CrossRefGoogle ScholarPubMed
46. Li, Q, Hirata, Y, Kawada, T, Minami, M: Elevated frequency of sister chromatid exchanges of lymphocytes in sarin-exposed victims of the Tokyo sarin disaster 3 years after the event. Toxicol 2004;201:209217.CrossRefGoogle ScholarPubMed
47. Nishiwaki, Y Maekawa, K Ogawa, Y Asukai, N Minami, M and Omae, K: Effects of sarin on the nervous system in rescue team staff members and police officers 3 years after the Tokyo subway sarin attack. Environmental Health Perspectives 2001;109:11691173.CrossRefGoogle ScholarPubMed
48. Miyaki, K, Nishiwaki, Y, Maekawa, K, Ogawa, Y, Asukai, N, Yoshimura, K Etoh, N, Matsumoto, Y, Kikuchi, Y, Kumagai, N, Omae, K: Effects of sarin on the nervous system of subway workers seven years after the Tokyo subway sarin attacks. J Occup Health 2005;47:299304.CrossRefGoogle Scholar
49. Okumura, T, Suzuki, K, Ishimatsu, S, Takasu, N, Fuiji, C, Kohama, A: Lessons learned from the Tokyo subway sarin attack. Prehospital Disast Med 2000;15:s30.Google Scholar
50. Cox, RD: Decontamination and management of hazardous materials exposure victims in the emergency department. Ann Emerg Med 1994;23:761770.CrossRefGoogle ScholarPubMed
51. Brennan, RJ, Waerckerle, JF, Sharp, TW, Lillibridge, SR: Chemical warfare agents: Emergency medical and emergency public health issues. Ann Emerg Med 1999;34:191204.CrossRefGoogle ScholarPubMed
52. Moles, TM, Baker, DJ: Clinical analogies for the management of toxic trauma. Resuscitation 1999;42:117124.CrossRefGoogle ScholarPubMed
53. Baker, DJ: Management of respiratory failure in toxic disasters. Resuscitation 1999;42:125131.CrossRefGoogle ScholarPubMed
54. Laurent, JF, Richter, F, Michel, A: Management of victims of urban chemical attack: The French approach. Resuscitation 1999;42:141149.Google ScholarPubMed
55. Renshaw, B: Observations on the role of water in the susceptibility of human skin to injury by vesicants. J Invest Dermatol 1947;9:7585.CrossRefGoogle Scholar
56. Suchard, JR: Chemical and biological weapons. In: LR, Goldfrank Flomenbaum, NE, Lewin, NA, Howland, MA, Hoffman, RS, Nelson, LS (eds). Goldfrank's Toxicological Emergencies (7th Ed). McGraw-Hill, 2002.Google Scholar
57. Chemical agents. In: A, Dwyer, Eldridge, J, Kernan, M: Jane's Chem-Bio Handbook. Surrey: Jane's Information Group, 2003.Google Scholar
58. Lapierre, D, Moro, J: Five Past Midnight in Bhopal. New York: Scribner, 2002.Google Scholar
59. The NHS Emergency Planning Guidance 2005—Underpinning Materials for Acute Trusts and Foundation Trusts section 8.2. Available at Scholar
60. Fullerton, CS, Ursano, RJ: Behavioural and psychological responses to chemical and biological warfare. Mil Med 1990;155:5459.CrossRefGoogle ScholarPubMed
61. DiGiovanni, C: Domestic terrorism with chemical or biological agents: Psychiatric aspects. Am J Psychiat 1999;156:15001505.CrossRefGoogle ScholarPubMed
62. Karsenty, E, Alshech, I, Cojocaru, B, Moscovitz, M: Medical aspects of the Iraqi missile attacks on Israel. Isr J Med Sci 1991;27:603607.Google ScholarPubMed
63. Al-Damouk, M, Bleetman, A: Impact of the Department of Health initiative to equip and train acute trusts to manage chemically contaminated casualties. Emerg Med J 2005;22:347350.CrossRefGoogle ScholarPubMed
64. Chilcott, RP: Dermal effects of chemical warfare agents. In: TC, Marrs Maynard, RL, Sidell, FR. Chemical Warfare Agents: Toxicology and Treatment (2nd Ed.) West Sussex: J Wiley & Sons, 2007.Google Scholar
65. Heptonstall, J, Gent, N: CBRN Incidents: Clinical Management and Health Protection. Health Protection Agency, 2005.Available at rgency/pdfs/generic.pdf.Google Scholar
66. Lavoie, FW, Coomes, T, Cisek, JE Fulkerson, L: Emergency department external decontamination for hazardous chemical exposures. Vet Hum Toxicol 1992;34:6164.Google Scholar
67. Schultz, M, Cisek, J, Wabeke, R: Simulated exposure of hospital emergency personnel to solvent vapors and respirable dust during decontamination of chemically exposed patients. Ann Emerg Med 1995;26:324329.CrossRefGoogle ScholarPubMed
68. Marrs, TC, Maynard, RL, Sidell, FR: Chemical Warfare Agents: Toxicology and Treatment (2nd ed). West Sussex: J Wiley & Sons, 2007.CrossRefGoogle Scholar
69. Black, J: Exercise Alex. Chemical Incident Report. 2003;28:1619. Available at Scholar
70. BBC News: The ricin case timeline.Available at 4433459.stm. Accessed May 2007.Google Scholar
71. Kirk, MA, Cisek, J, Rose, SR: Emergency department response to hazardous materials incidents. Emerg Med Clin N Am 1994;12:461481.Google ScholarPubMed
72. Goldsmith, MF: Preparing for medical consequences of terrorism. JAMA 1996;275:17131714.CrossRefGoogle ScholarPubMed
73. Horby, P, Murray, V, Cummins, A, Mackway-Jones, K, Euripidou, R: The capability of accident and emergency departments to safely decontaminate victims of chemical incidents. J Accident Emerg Med 2000;17:344347.CrossRefGoogle ScholarPubMed
74. Treat, KN Williams, JM Furbee, PM, Manley, WG Russell, FK, Stamper, CD: Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Ann Emerg Med 2001;38:562565.CrossRefGoogle Scholar
75. Advanced Life Support Group: The Structured Approach to Chemical Casualties (2nd ed). London: BMJ Publishing Group, 2002.Google Scholar
76. Crawford, I, Mackway-Jones, K: The delivery of the structured approach to chemical casualties (SACC) course to emergency departments in England. Chemical Incident Report 2003;28:32.Google Scholar
77. Morcom, F: Silent Weapons. Chemical Incident Report 2003;28:31.Available at Scholar
78. George, G, Ramsay, K, Rochester, M, Seah, R, Spencer, H, Vijayasankar, D Vasicuro, L: Facilities for chemical decontamination in accident and emergency departments in the United Kingdom. Emerg Med J 2002;19:453457.CrossRefGoogle ScholarPubMed
79. National Audit Office: Facing the challenge: NHS emergency planning in England. 2002. The Stationary Office. Available at blications/nao_reports/02-03/020336.pdf.Google Scholar
80. Malpass, T, Blunden, M: Deployment of PPE in the event of a chemical incident. The importance of pre-planning and estimating capacity. Chemical Hazards and Poisons Report 2003;1:2324.Google Scholar
81. Kreuger, GP: Psychological and performance effects of chemical-biological protective clothing and equipment. Mil Med 2001;166 (Suppl 2):4143.CrossRefGoogle Scholar
82. Levitin, HW, Siegelson, HJ, Dickinson, S, Halpern, P, Haraguchi, Y Nocera, A Turineck, D: Decontamination of mass casualties—Re-evaluating existing dogma. Prehospital Disast Med 2003;18:200207.CrossRefGoogle ScholarPubMed
83. Civil Contingencies Act 2004. Available at acts2004/20040036.htmGoogle Scholar
84. New Dimension: Equipping the fire and rescue service. Available at Scholar
85. Woodall, J: Tokyo subway gas attack. Lancet 1997;350:296.CrossRefGoogle ScholarPubMed
86. The Royal Society. Making the UK safer: Detecting and decontaminating chemical and biological agents. Policy document 06/04/2004. Available at Scholar
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