MEDICAL MANAGEMENT OF CHEMICAL CASUALTIES HANDBOOK

Appendix

 


A. Patient decontamination

B. Casualty receiving area

C. Personnel Decontamination Station

D. Toxicity Data

E. Physical-Chemical Data

F. Medical Equipment Set Contents

G. Summary Chart

H. Glossary of Terms


APPENDIX A

PATIENT DECONTAMINATION

OVERVIEW

Patient decontamination is personnel, time, and equipment intensive. Nevertheless, with a little ingenuity and attention to just a few basic principles, an effective litter decontamination procedure can be accomplished with minimal cost. The first part of this appendix briefly discusses considerations in establishing a decontamination site, and this is followed by step-by-step procedures.

The decontamination site is part of the medical treatment facility, and the same considerations for establishing the treatment facility apply to the decontamination area. The decontamination area is located about 50 yards downwind from the treatment area (i.e., wind blowing from the clean treatment area to the dirty decontamination area).

KEY PRINCIPLES

The important considerations of personnel and equipment requirements are discussed in other publications.

Wind Direction

Wind direction is important because a vapor hazard may be present downwind from a liquid contaminated area (i.e., patient arrival/triage area). Patient decontamination is always performed upwind, or at least not downwind, from the patient arrival area.

The decon site will initially be set up to take advantage of the prevailing wind; however, setup should be adaptable to allow for quick rearrangement when the wind comes from another direction.

If the wind changes direction by more than 45o the decontamination site will need to be adjusted accordingly. A wait of 15 to 20 minutes to determine if the change is permanent should preceed the move. When the site is moved, it must be moved at least 75 meters upwind from any contaminated area. Personnel working in the old "clean" area when the wind shifts must insure that all casualties remain masked. This scenario points out that the ideal decon setup should include two separate decon sites approximately 75 meters apart, when possible.

Security of Decon Site

When choosing a decontamination site, the same security considerations must be given as any other site chosen for medical operations. The decontamination site is at the same potential risk from attack as is the actual medical treatment facility.

Area Control of Decon Site

An entry control point (ECP) can be established to control movement of clean and contaminated vehicles to the Medical Treatment Facility (MTF) or the Decon Site. The ECP should be located at a distance far enough from the MTF to keep vapor hazard from contaminated vehicles to the minimum.

Traffic control at the decon site involves routing a clearly marked one-way course from the ECP to the decon site.

Control of personnel movement is necessary to ensure that contaminated walking personnel do not accidentally contaminate clean areas. The hot line must be secured. Concertina wire works well to keep personnel in the desired areas and a clearly marked one-way route helps to ensure that correct entry and exit points are used.

LITTER PATIENT DECONTAMINATION

Personnel

Two people are required per litter patient. These two augmentees will link up with one litter patient in the triage area and work with that same litter patient until hand-off at the "hot line." These two people conduct both clothing removal and any required skin decontamination. To assist these two augmentees, two other augmentees will be needed: one to assist the first two augmentees in picking up the patient from the clothing removal litter and the second to remove the contaminated clothing and litter and to replace it with a clean litter. These four augmentees will conduct all patient decontamination and movement of the patient while in MOPP level 4 and the Toxicological Agent Protective (TAP) apron.

Personnel working in the patient decon area will be at MOPP level 4 plus the Toxicological Agent Protective (TAP) apron. At least two people from this area will move to the triage area and carry the patient from this area to the first decontamination station.

Hypochlorite Solutions

Two different concentrations of chlorine solution are used in the patient decontamination procedure. A 0.5% chlorine solution is used for all patient washing procedures and for the mask decon. The 5% chlorine solution is used to decon the scissors, the TAP aprons and the gloves on personnel working in patient decon area, and the casualty's hood. The chlorine solutions are placed in buckets for use in this area. The buckets should be distinctly marked because it is very difficult to tell the difference between the 5% chlorine solution and the 0.5% solutions. These solutions may be made using the 6 ounce Calcium Hypochlorite (HTH) containers that come with the Chemical Agent Decon Set. The 0.5% solution can be made adding one (1) six (6) ounce container of calcium hypochlorite to 5 gallons of water. The 5% Cl solution can be made by adding eight (8)-six (6) ounce containers of calcium hypochlorite to 5 gallons of water. These solutions evaporate quickly at high temperatures so if they are made in advance they should be stored in closed containers.

Procedure

1. Decontaminate the mask and hood: Sponge down front, sides, and top of hood with 5.0% calcium hypochlorite solution, or wipe off with the M258A1 or the M291 Decon Kit.

2. Remove hood

a. Dip scissors in 5% HTH solution.

b. Cut off hood.

(1) Release or cut hood shoulder straps.

(2) Cut/untie neck cord.

(3) Cut/remove zipper cord.

(4) Cut/remove drawstring under the voicemitter.

(5) Unzip the hood zipper.

(6) Cut the cord away from the mask.

(7) Cut the zipper below voicemitter.

(8) Proceed cutting upward, close to the inlet valve covers and eye lens outserts.

(9) Cut upward to top of eye lens outsert.

(10) Cut across forehead to the outer edge of the next eye lens outsert.

(11) Cut downward toward patient's shoulder staying close to the eye lens outsert inlet valve cover.

(12) Cut across the lower part of the voicemitter to the zipper.

(13) Dip scissors in HTH.

(14) Cut from center of forehead over the top of the head.

(15) Fold left and right sides of the hood to the side of the patient's head, laying sides on the litter.

c. The Quick Doff Hood is loosened and removed.

3. Decontaminate protective mask/face

a. Use M258A1, M291, or 0.5% hypochlorite.

b. Cover both inlet valve covers with gauze or hands.

c. Wipe external parts of mask.

d. Uncover inlet valve covers.

e. Wipe exposed areas of patient's face.

(1) Chin

(2) Neck

(3) Back of ears

4. Remove Field Medical Card

a. Cut FMC tie wire.

b. Allow FMC to fall into a plastic bag.

c. Seal plastic bag and wash with 0.5% hypochlorite.

d. Place plastic bag under back of mask head straps.

5. Remove all gross contamination from patient's overgarment.

a. Wipe all evident contamination spots with M258A1 Decon Kit, M291, or 5% hypochlorite.

b. Wipe external parts of mask with M258A1 Decon Kit, or M291.

c. Use wipe 1 then wipe 2, to clean exterior of mask; use wipe 2 then wipe 1 to clean interior.

6. Cut and remove overgarments. Cut clothing around tourniquets, bandages, and splints. Two persons will be cutting clothing at the same time. Dip scissors in 5% hypochlorite solution before doing each complete cut to avoid contaminating inner clothing.

a. Cut overgarment jacket.

(1) Unzip protective overgarment.

(2) Cut from wrist area of sleeves, up to armpits, and then to neck area.

(3) Roll chest sections to respective sides with inner surface outward.

(4) Tuck clothing between arm and chest.

(5) Repeat procedure for other side of jacket.

b. Cut overgarment trousers.

(1) Cut from cuff along inseam to waist on left leg.

(2) On right overgarment leg, cut from cuff to just below zipper and then go sideways into the first cut.

(3) Allow trouser halves to drop to litter with contamination away from patient.

(4) Tuck trouser halves to sides of body and roll the camouflage sides under between the legs.

7. Remove outer gloves. This procedure can be done with one aidman on each side of the patient working simultaneously. Do not remove inner gloves.

a. Lift the patient's arms by grasping his gloves.

b. Fold the glove away from the patient over the sides of the litter.

c. Grasp the fingers of the glove.

d. Roll the cuff over the finger, turning the glove inside out.

e. Carefully lower the arm(s) across the chest when the glove(s) is removed.

(Do not allow the arms to contact the exterior (camouflage side) of the overgarment.)

f. Dispose of contaminated gloves.

(1) Place in plastic bag.

(2) Deposit in contaminated dump.

g. Dip your own gloves in HTH.

8. Remove overboots.

a. Cut laces.

b. Fold lacing eyelets flat outward.

c. Hold heels with one hand.

d. Pull overboots downwards over the heels with other hand.

e. Pull towards you until removed.

f. Place overboots in contaminated disposal bag.

9. Remove personal articles from pockets.

a. Place in plastic bags.

b. Seal bags.

c. Place in contaminated holding area.

10. Remove combat boots without touching body surfaces.

a. Cut boot laces along the tongue.

b. Pull boots downward and toward you until removed.

c. Place boots in contaminated dump.

11. Remove inner clothing.

a. Unbuckle belt.

b. Cut BDU pants following same procedures as for overgarment trousers.

c. Cut fatigue jacket following same procedures as for overgarment jacket.

12. Remove undergarments following same procedure as for fatigues. If patient is wearing a brassiere, it is cut between cups. Both shoulder straps are cut where they attach to cups and laid back off shoulders.

13. Clothing removal to skin decontamination: Transfer the patient to a decontamination litter. After the patient's clothing has been cut away, he is transferred to a decontamination litter or a canvas litter with a plastic sheeting cover. Three decontamination team members decontaminate their gloves and apron with the 5% hypochlorite solution. One member places his hands under the small of the patient's legs and thigh; a second member places his arms under the patient's back and buttocks; and the third member places his arms under the patient's shoulders and supports the head and neck. They carefully lift the patient using their knees, not their backs to minimize back strain. While the patient is elevated, another decon team member removes the litter from the litter stands and another member replaces it with a decontamination (clean) litter. The patient is carefully lowered onto the clean litter. Two decon members carry the litter to the skin decontamination station. The contaminated clothing and overgarments are placed in bags and moved to the decontaminated waste dump. The dirty litter is rinsed with the 5% decontamination solution and placed in a litter storage area. Decontaminated litters are returned by ambulance to the maneuver units.

14. Skin decontamination: The areas of potential contamination should be spot decontaminated using the M258A1 kit, the M291 kit, or 0.5% hypochlorite. These areas include the neck, wrists, lower face, and skin under tears or holes in the protective ensemble. After the patient is deconned his dressings and tourniquet are changed. Superficial (not body cavities, eyes or nervous tissue) wounds are flushed with the 0.5% Cl solution and new dressings applied as needed. Cover massive wounds with plastic or plastic bags. New tourniquets are placed 0.5 to 1 inch proximal to the original tourniquet, then the old tourniquets are removed. Splints are not removed but saturated to the skin with 0.5% Cl solution. If the splint cannot be saturated (air-splint or canvas splint) it must be removed sufficiently so that everything below the splint can be saturated with the 0.5% Cl solution. The patient, his wounds, and the decontaminable stretcher have now been completely deconned.

15. Final monitoring and movement to treatment area: The patient is monitored for contamination using the CAM, the M8 paper or M9 paper. The contents of the M258A1 kit (pad 1 and pad 2 when used separately or together) and hypochlorite on the skin do not affect the CAM. However, pad 1 of the M258A1 kit causes M8 paper to turn dark green (V agent), pad 2 causes no color change, and the pads used together cause M8 paper to turn yellow (G agent). Each pad causes the M9 paper to react (turn red). Once the casualty is confirmed clean of chemical agent he is transferred via a shuffle pit over the hot line. The shuffle pit is composed of two parts Super Tropical Bleach (STB) and 3 parts earth or sand. The shuffle pit should be deep enough to cover the bottom of the protective overboots. The buddy system wash of the TAP apron and gloves in 5.0% hypochlorite solution precedes the transfer of the patient to a new clean canvas litter if the decontaminable stretchers are in limited supply. A three-person patient lift is again used as the litter is switched. If the litter as well as the patient was checked both patient and the same litter can be placed over the hot line.

AMBULATORY PATIENT DECON

Casualties who are decontaminated in an ambulatory area are those who (a) require treatment that can be supplied in the emergency treatment area, or (b) require resupply of their protective overgarments in the clean area before return to duty. Those who require clothing removal use the litter decontamination procedure as removal of clothing is not done in this area.

Personnel

Personnel from the decontamination station might assist the casualty, or the casualties might assist each other during this process under close supervision.

Procedure

Decontamination of ambulatory patients follows the same principles as for litter patients. The major difference is the sequence of clothing removal, listed below, to lessen the chance of patient contaminating himself and others.

The first five steps are the same as in litter patient decontamination and are not described in detail.

1. Remove load bearing equipment

2. Decontaminate mask and hood and remove hood

3. Decontaminate skin around mask

4. Remove Field Medical Card and put it into a plastic bag

5. Remove gross contamination from the outergarment

a. Removal and bag personal effects from overgarment

6. Overgarment Jacket Removal

a. Instruct patient to:

(1) Clench his fist.

(2) Stand with arms held straight down.

(3) Extend arms backward at about a 30 degree angle.

(4) Place feet shoulder width apart.

b. Stand in front of patient.

(1) Untie drawstring

(2) Unsnap jacket front flap.

(3) Unzip jacket front.

c. Move to the rear of the patient.

(1) Grasp jacket collar at sides of the neck.

(2) Peel jacket off shoulders at a 30 degree angle down and away from the patient.

(3) Smoothly pull the inside of sleeves over the patient's wrists and hands.

d. Cut to aid removal if necessary.

7. Removal of Butyl Rubber Gloves

a. Patient's arms are still extended backward at a 30 degree angle.

(1) Dip your gloved hands in 5% hypochorite solution.

(2) Use thumbs and forefingers of both hands.

(a) Grasp the heel of patient's glove at top and bottom of forearm.

(b) Peel gloves off with a smooth downward motion. This procedure can easily be done with one person or with one person on each side of the patient working simultaneously.

(c) Place gloves in contaminated disposal bag.

b. Tell the patient to reposition his arms, but not to touch his trousers.

8. Remove patient's overboots

a. Cut overboot laces with scissors dipped in 5% hypochlorite.

b. Fold lacing eyelets flat on ground.

c. Step on the toe and heel eyelet to hold eyelets on the ground.

d. Instruct patient to step out of the overboot onto clean area. If in good condition, the overboot can be decontaminated and reissued.

9. Remove overgarment trousers

a. Unfasten or cut all ties, buttons, or zippers.

b. Grasp trousers at waist.

c. Peel trousers down over the patient's boots.

d. Cut trousers to aid removal if necessary.

(1) Cut around all bandages and tourniquets.

(2) Cut from inside pant leg ankle to groin.

(3) Cut up both sides of the zipper to the waist.

(4) Allow the narrow strip with zipper to drop between the legs.

(5) Peel or allow trouser halves to drop to the ground.

e. Tell patient to step out of trouser legs one at a time.

f. Place trousers into contaminated disposal bag.

10. Remove glove inner liners. Patient should remove the liners since this will reduce the possibility of spreading contamination.

a. Tell patient to remove white glove liners.

(1) Grasp heel of glove without touching exposed skin.

(2) Peel liner downward and off.

(3) Drop in contaminated disposal.

(4) Remove the remaining liner in the same manner.

(5) Place liners into contaminated disposal bag.

11. Final monitoring and decontamination

a. Monitor/test with M8 Detection Paper or CAM.

b. Check all areas of patient's clothing.

c. Give particular attention to

(a) Discolored areas

(b) Damp spots

(c) Tears in clothing

(d) Neck

(e) Wrist

(f) Around dressings

d. Decontaminate all contamination on clothing or skin by cutting away areas of clothing or using 5% hypochlorite, the M291, or the M258A1 for clothing or 0.5% hypochlorite and the M291, or the M258A1 for skin

12. The medical corpsman should remove bandages and tourniquets and decontaminate splints, using the procedures described in the decontamination of a litter patient, during overgarment removal.

13. The patient is decontaminated and ready to be moved inside the hot line. Instruct patient to shuffle his feet to dust his boots thoroughly as he walks through the shuffle pit.

In the clean treatment area the patient can now be re-triaged, treated, evacuated, etc. In a hot climate the patient will probably be significantly dehydrated and the rehydration process should start.

Comments

The clean area is the resupply point for the patient decontamination site. Water is needed for rehydration of persons working in the decon area. The resupply section should have an adequate stock of canteens with the chemical cap.

A location is needed in each decon area (75 meters from the working decon site) to allow workers, after they have deconned their TAP aprons, to remove their masks and rehydrate. There are generally not enough BDOs available to allow workers to remove them during the rest cycle and don new gear before going back to work. If these clean/shaded rest areas are not provided, the workers must remain in MOPP 4 even during rest periods, and water must be drunk through the mask via the drinking port. If all water consumption is by mask there must be a canteen refill area adjacent to the vapor/clean line in which empty canteens can be deconned and placed for refill and clean full canteens are present for rehydration.

(The above procedures were adapted from FM 8-10-4 and FM 8-10-7.)

Appendix B
Casualty Receiving Area

The diagram (not yet available) shows a setup for casualty reception in a contaminated environment. The chapter on casualty management describes the stations.

The actual setup of this area may vary depending on the assets and circumstances.


Appendix C
Personnel Decontamination Station

The following foldout (not yet available) is a diagram of the Personnel Decontamination Station. This is a decontamination procedure for non-casualty personnel. It is not a medical specific procedure, but a procedure that all units in the military--including medical units--employ.

Using this procedure, contaminated non-casualty personnel can move from the contaminated (dirty) area across the hot line to the non-contaminated (clean) area. In a medical unit this procedure would be followed by those working in the dirty area (such as the triage officer, the decontamination team) to move to the clean area.

A related procedure (not shown) is the MOPP exchange station. In this station personnel who have been wearing contaminated MOPP gear longer than the recommended time can exchange their dirty protective garments for clean garments.

(Taken from FM 3-5.)


Appendix D
Toxicity Data

The following tables provide estimated human toxicity data on the agents discussed in this Handbook.


  Effect Ct50 (mg-min/m3) Liquid on skin
GA Miosis ~2-3  
  Death 200-400  
GB Miosis ~3  
  Death 100-200  
GD Miosis ~2-3  
  Death 50-70  
VX Death 10-50  
HD Eye 12-200  
  Pulmonary 100-200  
  Erythema 200-1000 10 g
  Death 1500 inhalation

10,000 skin

100 mg/kg
L Erythema >1500 10-15 :g
  Death ~1500 inhalation 40-50 mg/kg
CX Eye 200?  
  Erythema 2500?  
  Death 3200?  
  Effect Ct50 (mg-min/m3)
CG Pulmonary effects >1600
  Death 3200
AC Death 2500-5000
CK Death 11,000
CN Irritation 10-20
  Death 14,000
CS Irritation 5-10
  Death >50,000

Appendix E
Physical-Chemical Data

The following tables provide physical-chemical data on the agents discussed in this Handbook.



  GA GB GD GF VX
  Tabun Sarin Soman    
Mole.

Wt.

162 140 182 180 267
Vapor

Density

5.63 4.86 6.33 6.2 9.2
Liquid

Density

1.07 @

25oC

1.09@

25oC

1.02@

25oC

1.17@

20o

1.01@

20oC

Freez/

Melt

Point

(oC)

-5 -56 -42 -30 <-51
Boil

Point

(oC)

240 158 198 239 298
Vapor

press.

0.037 2.9 0.4 0.04 0.007
Volatility 610 22,000 3,900 438 10.5
  HD L CX
  Distilled

Mustard

Lewisite Phosgene

Oxime

Mole.Wt. 159 207 114
Vapor

Density

5.4 7.1 3/9
Liquid density 1.27@

25oC

1.89@

20oC

--
Freez/

Melt.

Point

(oC)

14 -18 35-40
Boiling

Point

(oC)

217 190 53-54
Vapor

Pressure

0.07@

20oC

0.39@

20oC

11.2@

25oC

Volatility 610@

20oC

4480@

20oC

1800@

20oC

  AC CK   CG
  Hydrogen

Cyanide

Cyanogen Chloride   Phosgene
Mole.

Weight

27 61   99
Vapor

Density

0.99 2.1   3.4
Liquid

Density

0.69 1.18   1.37
Freez.

Melt.

Point

(oC)

-13.3 -6.9   -128
Boil.

Point

(o)C

25.7 12.8   7.6
Vapor

Pressure

742@

25oC

1000@

25oC

  1.17@

20oC

Volatility 1,080,000

@25oC

2,600,000

@12.8oC

  4,300,000

@7.6oC

  CN CS
  Mace  
Mole.

Weight

155 189
Vapor

Density

5.3 --
Liquid

Density

1.32 (solid)

@20oC

1.04

@20oC

Freez/

Melt.

Point (oC)

54 ~94
Boiling

Point (oC)

249 ~310 (with

decomposition

Vapor

pressure

0.0041

@20oC

0.00034

@20oC

Volatility 34.3 @20oC 0.71 @25oC


APPENDIX F
MEDICAL EQUIPMENT SET

CHEMICAL AGENT PATIENT TREATMENT

NOMENCLATURE / NSN AMOUNT
Atropine Inj. 0.70L 6505-00-926-9083 500 ea
Pralidoxime Chloride 6505-01-125-3248 100 ea
Boric Acid 5% 6505-01-153-3012 36 tu
Sodium Nitrite 6505-01-206-6009 12 pg
Sodium Thiosulfate 6505-01-206-6010 12 pg
Diazepam 6505-01-274-0951 3 pg
Atropine Sulfate 6505-01-332-1281 1 pg
Infusion Set Size:2 6515-00-089-2791 60 ea
Airway Pharyn LGE 6515-00-300-2900 6 ea
Airway Pharyn SM 6515-00-300-2910 6 ea
NOMENCLATURE / NSN AMOUNT
Syringe Hypo 10ml 6515-00-754-0412 .6 pg
Needle Hypo 18ga 6515-00-754-2834 1.2 bx
Suction Apparatus 6515-01-076-3577 4 ea
Resuscitator Hand 6515-01-338-6602 4 ea
Syringe Hypo 50ml 6515-01-280-2320 1 pg
Chest No. 4 6545-00-914-3490 3 ea
Gloves Chem 8415-01-138-2502 2 pr
Gloves Chem. 8415-01-138-2503 2 pr
Bag Chem Cas. 8465-01-079-9875 12 ea


MEDICAL EQUIPMENT SET

CHEMICAL AGENT PATIENT DECONTAMINATION

NOMENCLATURE / NSN AMOUNT
M291 SDK 4230-01-276-1905 2 bx
Bandage Scissors 6515-00-935-7138 6 ea
Syringe Hypo 6515-01-280-2320 .6 pg
Litter Support 6530-00-660-0034 4 pr
Chest No. 4 6545-00-914-3490 1 ea
Chest No. 6 6545-00-914-3510 1 ea
M9 Chem Agt Paper 6665-01-049-8982 1 ro
Calcium Hypo 6810-00-255-0471 48 bo
12 qt Pail 7240-00-773-0975 10 ea
Sponge Cellulose 7920-00-884-1115 6 ea
Bag Plastic 8105-00-191-3902 2 ro
Plastic Sheet 8135-00-618-1783 2 ro
Work Gloves MED 8415-00-268-8353 25 pr
Work Gloves SM 8415-00-258-8354 25 pr
Black Pencils 7510-00-240-1526 2 dz
NOMENCLATURE / NSN AMOUNT
TAP Apron SM 8415-00-281-7813 2 ea
TAP Apron MED 8415-00-281-7814 4 ea
TAP Apron LRG 8415-00-281-7815 2 ea
Chem Prot Glove 8415-01-033-3517 2 ea
Chem Prot Glove 8415-01-033-3518 4 ea
Chem Prot Glove 8415-01-033-3519 2 ea
Decon Litter 6530-01-290-9964 4 ea


Appendix G

Fold out chart (not yet available)

The enclosed chart is intended to serve as a reminder of the agents, their effects, first aid measures, detection, and skin decontamination

It is in no way complete, nor is it intended to be complete. Consult the appropriate chapter for further details.


Appendix H
Glossary of Terms

ACAA: Automatic Chemical Agent Alarm

AMEDD: Army Medical Department

BDO: Battle Dress Overgarment

BDU: Battle Dress Uniform

CAM: Chemical Agent Monitor

CANA: Convulsive Antidote, Nerve Agent

CARC: Chemical Agent Resistant Coating

C/B: Chemical/Biological

CDC: Chemical Decontamination Center

CBPS: Chemical and Biological Protective Shelter

CPS: Chemical Protective Shelter

DBDO: Desert Battle Dress Overgarment

DTD: Detailed Troop Decontamination

ECP: Entry Control Point

FMC: Field Medical Card

GREGG: Graves Registration

HTH: High Test Hypochlorite

KPH: Kilometer Per Hour

LBE: Load Bearing Equipment

LCL: Liquid Control Line

MES: Medical Equipment Set

MOPP: Mission Oriented Protective Posture

MTF: Medical Treatment Facility

MTO&E: Modified Table of Organization and Equipment

NAAK: Nerve Agent Antidote Kit

NATO: North American Treaty Organization

NCO: Non-Commissioned Officer

NCOIC: Non-Commissioned Officer-in-Charge

OIC: Officer-in-Charge

SDK: Skin Decontamination Kit

TAP: Toxicological Agent Protective, e.g., TAP apron

TC: Training Circular

VCL: Vapor Control Line