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Hazardous Materials HAZMAT Definition (USDOT)

“Any substance which may pose an unreasonable risk to health and safety of operating or emergency personnel, the public, and/or the environment if not properly controlled during handling, storage, manufacture, processing, packaging, use, disposal, or transportation.”

Medical Roles

Size up incidentEstablish commandActivate IMSAssess toxicological risksEvaluate decontamination methodsTreat, transport patientsSupport HAZMAT team members (medical monitoring, rehab)

Requirements and Standards

OSHA: CFR 1940.120EPA: 40 CFR 311NFPA: Standard 473 (Standard for Competencies of EMS Personnel Responding to Hazardous Materials Incidents)

EMS HAZMAT Training Levels

AwarenessLevel 1Level 2

Awareness

All responders who may arrive first on scene and discover hazardous substanceEMS, Fire, Law enforcementFocus

Recognition of HAZMAT incidentsBasic identification techniquesPersonal protection

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EMS Level I

Patient care in cold zone with NOsignificant 2o contamination riskFocus

Hazard assessmentAssessment, management of previouslycontaminated patients

EMS Level II

Patient care in warm zone with significant risk of 2o contaminationFocus

Personal protectionDecontamination proceduresAssessment, management during decon

Incident Size Up

Size-Up Priorities

SafetyIncident stability (Stable vs. Unstable)Property conservation

Exposures—people, propertyRun-off

Size-Up Special Considerations

Personal risk of exposure, contaminationDelayed product effectsScene topographyWind directionDecontamination corridor(s)Incident facility location contingency plans

Incident Awareness

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Transportation

Transport incidents = HAZMAT riskDo NOT rely on placards!Passenger vehicles transport HAZMATKnow, preplan rail lines

Fixed Facilities

ManufacturersWarehousesHardware storesAgricultural storesWater treatment plants

Loading docksPipelinesSilosBarnsGreenhouses

Know Your Community!

Terrorism

WeaponsChemicalBiologicalNuclear

Potential TargetsPublic buildingsMultinational HQsShopping centersWorkplacesPublic assembly placesPlaces of worshipSchools

Terrorism

Preplan potential targetsMultiple patients with similar signs, symptoms = High index of suspicionConsider secondary device, attack risk

HAZMAT Recognition

Clues

Occupancy, locationVehicle, container shapePlacards, other markingsLabelsScene appearanceOther sensory information

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Occupancy/Location

What do you know about the activities at this location?Are hazardous materials likely to be manufactured, stored, used there?Highway incidents are by definition a high risk situation!

Vehicle/Container Shape

External ring stiffeners frequently are present on vehicles transporting corrosives or poisons.

Vehicle/Container Shape

Rounded ends on highway transport vehicles suggest presence of pressurized contents.

Vehicle/Container ShapeDome covers on rail tank cars suggest that the contents are under pressure.

Tank cars with flat ends have been insulated to control product temperature changes.

Placards

DOT (transport vehicles)NFPA 704 (fixed facilities)

DOT Hazard Classes

Miscellaneous (ORMs)9Corrosives8Radioactive materials7Poisons, etiologic agents6Oxidizers, organic peroxides5Solids4Liquids3Gases2Explosives1HAZARD TYPEHAZARD CLASS

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Explosives

Explosives: Designed to function with instantaneous release of gas and heat (i.e., by exploding).

Blasting Agents: Designed to explode, but require a blasting cap to trigger the explosion

Gases

Anhydrous Ammonia is classified as a non-flammable gas However, it is flammable and highly toxic!

Chlorine gets its own placard because it is toxic, corrosive, and an oxidizer!

Poison A: Gases or liquids producing vapors highly hazardous to human health.

Liquids

Flammable Liquid: Flash point < 100oF

Combustible Liquid: Flash point > 100oF

Solids

Any solid material other than an explosive that is liable to cause fires through friction, through retained heat from manufacturing, or which can be ignited readily and when ignited burns vigorously and persistently.

Oxidizers

Liquid oxygen is an oxidizer and a cryogenic agent.

Oxidizers will readily give up oxygen and support combustion. Organic oxidizers will readily give up oxygen, support combustion, and will burn!

PoisonsClass B Poisons: Solids and liquids known to be so toxic as to afford a risk to human health or which, in the absence of adequate data are assumed to be toxic to man.

Irritants, substances that give off irritating fumes when heated or exposed to air, are included in Class 6, but are placarded only as DANGEROUS and only if >1000 pounds is present.

Etiologic agents are included in Class 6 but are not placarded.

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Radioactive MaterialsVehicles transporting radioactive materials are placarded ONLY if the packages contains material measures >50 millirem/hr on the entire package surface or >3 millirem/hr at 3 feet. (Radioactive III package labeling)

Defense material being moved under authority of the Department of Energy or Department of Defense is NOT placarded.

Corrosives

Materials that attack and destroy living tissue or that produce severe corrosion of steel.

Frequently are also toxic and reactive.

DangerousClass C Explosives

Irritants

Mixed motor vehicle loads of >1000 but <5000 pounds of all HAZMAT except Poison A, Poison B, Solid Dangerous when Wet, Explosive A, Explosive B, and Radioactive

UN Numbers

DOT Placard Limitations

ALL product hazards NOT indicatedIncorrect placardsAbsent placards

DOT Placard Limitations

Some products NOT placardedRail flat car containers, motor vehicles, freight containers containing <1000 pounds of:

Nonflammable gasesChlorineFluorineLiquid oxygenFlammable gasesFlammable liquids

Combustible liquidsFlammable solidsOxidizers, organic peroxidesPoison BCorrosivesIrritating materials

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DOT Placard Limitations

“DANGEROUS”Rail flat car containers, motor vehicles, freight containers containing >1000, but <5000 pounds of:

Nonflammable gasesChlorine, FluorineLiquid oxygenFlammable gasesFlammable liquids

Combustible liquidsFlammable solidsOxidizers, organic peroxidesPoison BCorrosives

DOT Placard Limitations

“DANGEROUS”IrritantsClass C Explosives

NFPA 704

Used at fixed facilities

Health

Fire

Reactivity

SpecificHazard

NFPA 704HEALTH

4 = Too dangerous to enter

3 = Extreme danger—Full protective clothing

2 = Hazardous—Breathing apparatus

1 = Slight hazard

0 = No hazard FIRE

4 = Extremely flammable

3 = Ignites at normal temperatures

2 = Ignites when moderately heated

1 = Must be preheated to burn

0 = Will not burn

NFPA 704REACTIVITY

4 = May detonate—Evacuate area if fire present

3 = Shock, heat may detonate—Take cover

2 = Violent chemical change possible

1 = Unstable if heated

0 = Normally stable SPECIFIC HAZARD

OX = Oxidizer

ACID = Acid

ALK = Alkali (Base)

COR = Corrosive

W = Use NO Water

NFPA 704

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DOT Labels

Placed on packages/containers

Other Sensory Information

What do you see? Hear? Smell?Is there a vapor cloud?Is there a fire?Can you hear escape of a pressurized product?Any unusual odors?Are your eyes watering, burning?Are there dead animals, birds, fish observable?

HAZMAT Identification

HAZMAT Identification

Often most difficult part of incidentALWAYS use at least TWO concurring sources

HAZMAT References

Emergency Response GuidebookContainer MarkingsShipping PapersMaterial Safety Data SheetsMonitors/Chemical TestsComputer Databases

Telephone HotlinesPoison CentersChemistsToxicologistsReference Books

Emergency Response Guidebook

U.S., Canada, MexicoLists >1000 products with placards, UN numbers, chemical namesCross references emergency, evacuation procedures

Medical information is limited, very genericMultiple chemicals share UN numbers

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Container Markings Container Markings

“Candystriper”HCN Tank Car

Shipping Papers

List specific substancesIndicate quantities carried

Operators may not take papers with themScene may be too unstable to retrievePapers may be incomplete, inaccurate

Material Safety Data Sheets

Present at fixed facilitiesAvailable for ALLhazards on siteCover wide range of common, simple products

Typically list:Material nameCharacteristicsManufacturerHealth, fire, reactivity dangersSafe handling considerationsEmergency procedures

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Monitors and Testing

RadioactivityCombustibilityOxygen availabilitypH (Corrosiveness)Carbon monoxideHydrogen sulfideOrganic vapors

Computer Databases

CAMEO®ALOHA®MARPLOT®OHMTADS®

Telephone Hotlines

Chemical Transportation Emergency Center (CHEMTREC)Sponsored by Chemical Manufacturer’s Association (CMA)

CHEMTREC Services

Emergency response informationAccess to manufacturer’s representativesActivation of specialized teams to deal with chlorine, phosphorus, vinyl chloride, HCN, HF, and LPGActivation of CHEMNET response teams

CHEMTREC Limitations

Communicators NOT technical personnelWill NOT interpret data or go beyond what information sheets sayMust have product trade or chemical name to provide assistanceCannot provide information on effects of mixing of several products

CHEMTREC Information Needed

What has happened?Where?When?Chemical(s) involvedContainer type conditionShipper/originCarrier

Consignee/destinationNature/extent casualtiesNature/extent property damagePrevailing weatherNature of incident areaCaller name/locationCall-back number

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Federal, State, Local Resources

FederalUS EPACoast Guard

StateTNRCCTDHRailroad CommissionParks & WildlifeAgriculture Department

LocalPoison ControlHealth DepartmentColleges, Universities

Reference Books

NIOSH Pocket Guide to Chemical HazardsFarm Chemical HandbookChemical Hazards Response Information System(CHRIS)NFPA Fire Protection Guide on Hazardous MaterialsAmerican Association of Railroads Emergency Action Guides

Reference Books

Condensed Chemical DictionaryDangerous Properties of Industrial Chemicals (Sax)Chemical Synonyms and Trade NamesMerck Index

HAZMAT Terms

HAZMAT ZonesHot Zone

Contamination PresentAppropriate PPELimited number of personnel

Everything inside considered contaminatedWarm Zone

Contamination Control ZoneAppropriate PPEDecon CorridorLife-Saving Emergency Care

Cold ZoneCP LocationTreatment/Transport AreasStagingMedical Monitoring/Rehab

Boiling Point

Temperature at which a liquid becomes a gasMore technically, temperature at which a substance’s vapor pressure equals atmospheric pressure

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Flammable/Explosive Limits

Lower Explosive Limit = Lowest concentration of chemical that burns in airUpper Explosive Limit = Highest concentration of chemical that burns in air

Flash Point

Lowest temperature at which a liquid will give off enough vapors to ignite

Ignition Temperature

Lowest temperature at which a liquid will give off enough vapors to support ongoing combustionSlightly higher than flash point

Specific Gravity

Density of a liquid compared to water (water = 1)Specific gravity >1 = Liquid sinks in waterSpecific gravity <1 = Liquid floats on water

Vapor Density

Density of a vapor or gas compared to air (air = 1)Vapor Density >1 = Gas sinksVapor Density <1 = Gas rises

Vapor Pressure

Pressure of vapor against container wallsIndicates how fast a liquid evaporatesHigher vapor pressures = Rapid evaporation

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Parts per million/Parts per billion

ppmppbConcentration of substance expressed in number of units of substance per 106 or 109 units of air or solution

Threshold Limit Value/ Time Weighted Average

TLV/TWAMaximum concentration of toxin a person can be exposed to 8 hours a day, 40 hours per week without suffering adverse effectsLower TLV/TWA = Higher toxicity

Threshold Limit Value/ Short-Term Exposure Limit

TLV/STELMaximum concentration of toxin a person can be exposed to for 15 minutes without suffering adverse effectsNot to be exceeded or repeated >4x daily with 60 minute rests between each exposure

Threshold Limit Value/Ceiling Level

TLV/CLMaximum concentration of a toxin that should NEVER be exceeded, even for a moment

Lethal Concentration/Lethal Dose

Concentration or dose of toxin that results in death of a defined % of test subjects

LCt50 = Concentration in air that kills 50% of test subjectsLD50 = Ingested, injected, absorbed dose that kills 50% of test subjects

Immediately Dangerous to Life and Health

IDLHConcentration of toxin that causes immediate threat to lifeMay cause delayed or irreversible effectsMay interfere with person’s ability to self-rescue

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Contamination and Toxicology

Contamination Types

Primary = Direct exposureSecondary = Indirect exposure via a contaminated person or object

Liquids, solids are most likely to produce secondary contamination.

Exposure Routes

Inhalation (most common)AbsorptionInjection, including entry via open woundsIngestion (least common)

Poison Actions

Acute Effects = Appear rapidly following exposureDelayed Effects = May not develop for hours, days, weeks, months, years

Poison Actions

Local Effects = Involve areas immediately around exposure siteSystemic Effects = Occur throughout body as toxin is distributed by bloodstream

Poison Actions

Major organs for handling toxinsLiver, metabolizes (biotransforms) toxinsKidney, excretes toxins

Since liver, kidney must concentrate toxins to manage them, damage frequently occurs

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Poison Actions

Synergism = Interaction of substances to produce greatly enhanced effects. (2+2 =40)Medications given to poisoned patients may produce unanticipated effectsTry to confirm medication safety with at least two independent sources

Common Exposures

Corrosives

Acids, alkalisCan be inhaled, ingested, absorbed, injectedSevere skin burns, respiratory burns with pulmonary edemaSome have systemic effects

Corrosives

ManagementBrush off dry particulatesFlush with large amounts of waterOphthalmic anesthetics to facilitate eye irrigationTincture of green soap for skin contaminationAlbuterol for bronchospasmDo NOT induce vomiting in ingestionsIf patient can swallow/is not drooling, dilute with 5cc/kg up to 200cc

Pulmonary Irritants

Include chlorine, ammoniaGases react with water in respiratory secretions to form acids, alkalisTissue damage, pulmonary edema may result

Pulmonary Irritants

ManagementRemoval of clothingFlushing of skin, eyesHigh concentration oxygenAlbuterol for bronchospasmsPossible intubation to protect airwayPEEP for non-cardiogenic pulmonary edema

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Pesticides

OrganophosphatesCarbamates

Acetylcholinesterase (AChE) Inhibitors

AChE Inhibitor Pesticides

SalivationLacrimationUrinationDefecationGI CrampingEmesis

BradycardiaBronchospasmIncreased respiratory secretionsSweatingPinpoint pupilsMuscle fasiculationsParalysis

AChE Inhibitor Pesticides

ManagementSupport ABCsRemove all clothing, jewelryDecontaminate with H2O, tincture of green soapAtropine to reverse SLUDGEPralidoxime for organophosphates, but NOT carbamatesDiazepam to control seizuresDo NOT induce vomiting if ingested

Chemical Asphyxiants

Carbon monoxideCyanide

Carbon monoxide

MechanismBinds to hemoglobinAffinity 200x > O2

Reduces oxygen transport capacity

ManagementHigh concentration O2

Hyperbaric oxygen therapy

Cyanide

SourcesHCNKCNSodium nitroprussideBitter almond oilWild cherry syrup

MechanismInhibits cytochrome oxidaseStops electron transport, ATP production

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Oxidative Phosphorylation

NAD NADH2

2H

FAD FADH2

Ox. Cyt. b Red. Cyt. b

Ox. Cyt. c Red. Cyt. c

Ox. Cyt. a Red. Cyt. a

Red. Cyt. a3Ox. Cyt. a3

1/2O2

2H+

H2O

ADP + Pi

ADP + Pi

ADP + Pi ATP

ATP

ATP

Cytochrome Oxidase

Fe2+Fe3+ 2H+

2e-

2e-

1/2 O2

H2O

Cytochrome a

Cyanide Toxicity

Fe2+Fe3+ 2H+

2e-

2e-

1/2 O2

H2O

Cytochrome a

CN-

Cyanide

ManagementHigh concentration oxygenCyanide kit

Amyl nitriteSodium nitriteSodium thiosulfate

CN-

Cyanide Antidote

Fe3+ Fe2+ 2H+

2e-

2e-

1/2 O2

H2O

Cytochrome a Fe2+ Fe3+CN-NO2 -

SCN-Hydrocarbon Solvents

ExamplesXyleneTolueneMethylene chlorideGasolineKeroseneNaptha

EffectsPulmonary edemaRespiratory failureArrhythmiasCNS depressionSeizuresLiver, kidney damageSkin irritation

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Hydrocarbon Solvents

ManagementSupport ABC’sHigh concentration oxygenWash skin with water, tincture of green soapGenerally, do NOT induce vomiting if ingestedDiazepam for seizuresGlucose for hypoglycemia 2o to liver damageUse caution with all catecholamines; ventricular arrhythmias may occur

Decontamination

Decon Purposes

Reduce patient exposure/doseReduce secondary contamination risk

Decon Types

PhysicalChemical

Decon Methods

DilutionAbsorptionNeutralizationIsolation

Dilution

Washing with large amounts of waterLowers chemical concentration to non-hazardous levelMay be aided by use of a soapSome chemicals should NOT be mixed with water

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Absorption

Use of pads/towels to “blot” up materialUsually absorbed after washingNot used as primary method of deconCommonly used to clean environment

Neutralization

Chemical decontamination methodReaction with another substance neutralizes hazardSeldom used

Difficult to select proper neutralizerDifficult to apply in correct amountReactions frequently generate heat

Isolation/Disposal

Separating people, equipment from hazardous substanceRemoval of clothing, jewelry, etc.

Decon Decision Making

Fast BreakLong Term

Fast Break

Quick decisions to prevent rescuer, equipment contaminationUsed on incidents with:

Patients who have self-rescuedCritical patients out of hot zone needing immediate careUnknown materialsPotentially life-threatening materials

Fast Break

Do NOT expose yourselfContain, isolate patientsRemove clothing, if possible by having them undress themselvesWash with large amounts of waterWrap completely in blankets (human burrito)

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Fast Break

What are the risks associated with immediate care?What are the benefits of the patient receiving immediate care?

Fast Break

As incident evolves:Can/should runoff be contained?Controlled decon facilities?Patient privacy?Reclothing patients? (scrub suits)

Long Term

Occurs when patients remain in hot zoneRescue performed by hazmat teamIMS, decon corridor will have to be established before rescue is attemptedSet-up can take up to 60 minutes

Long Term

Allows for:More complete decontaminationBetter PPELess risk of secondary contaminationGreater environmental considerationFewer opportunities for error

Access/Decon Corridor

ColdWarm

Hot

Access Corridor

Decon Corridor

Access/Decon Corridor

Access

Responder Decon

Patient Decon

Medical Monitoring

Rehab

Treatment Area

Command Post

Transport Area

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Decon Agents

WaterTincture of Green SoapIsopropyl Alcohol (isocyanates)Vegetable Oil (water-reactive substances)

Two Step Decon Process

Gross decontaminationUsed for “fast-break” situationsProcedure

Remove all clothing, jewelryWash, rinse with soap/water x 2Be sure patients do not stay in runoffWrap in blanket

Eight Step Decon Process

More thoroughRequires complete decon corridor

Eight Step Process

Rescuers enter deconcorridor; mechanically remove victim contaminantsRescuers drop equipment in tool-drop; remove outer gloves

Decon personnel shower, scrub all victims/rescuersRescuers remove, isolate SCBA

Eight Step Process

Rescuers remove protective clothingRescuer, victim personal clothing removed

Rescuers, victims receive full-body wash with soft brushes, water, mild soapPatients assessed, treated before transport; Rescuers medically monitored

Difficult Contamination Areas

Scalp, hairEarsNostrilsAxillaFingernailsNavel

GenitalsGroinButtocksBehind kneesBetween toesToenails

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Transport Considerations

Patients field decontaminated are only semi-decontaminatedMay harbor latent contaminants, may outgas contaminants in body fluidsLimit number of ambulances used in transportRemove non-essential equipmentWrap patient in plastic sheeting, blanketsCover floor with plastic sheeting

Transport Considerations

Better Dirty and Alive than Clean and Dead!

Transport Considerations

Do NOT assume your hospitals are equipped to

handle contaminated patients

Transport Considerations

Preplan transport of contaminated patients to hospitals

Hospitals may want contaminated patients delivered to location other than usual ER entranceHospitals need adequate warning to prepare to receive these patients. Alert should come when first EMS unit arrives at the scene.

Protective Equipment and Medical Monitoring

Protective Equipment Types

Level ALevel BLevel CLevel D

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Level A

Highest level of respiratory/skin protectionSuit fully encapsulates rescuer, SCBAUsed in hot zone with:

Unknown substancesSubstances with potential for respiratory and skin absorption hazards

Level A

Level B

Full respiratory protectionLower skin protection levelSuit non-encapsulating, but chemically resistantSCBA worn outside of suitTypically worn in warm zone by decon team

Level C

Non-permeable suit, boots, hand, eye protectionAir-purifying respirator with cartridges for specific substancesWorn during transport of patients with 2o

contamination risk

Level D

Firefighter turnout gearNOT suitable for HAZMAT incidents

Selection of PPE

Based on chemical involvedNO single suit material is appropriate for all chemicalsPermeability charts should be consulted to determine breakthrough times for suit material

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Selection of PPE

Latex gloves are NOT chemically resistantNitrile gloves have high resistance to most chemicalsLeather boots will absorb chemicals permanently

Medical Monitoring & Rehab

A primary role of EMSEntry team personnel should have annual physicals with baseline vitals on file

Entry Readiness

MonitorBPPulseRespiratory rateTemperatureBody weightECGMental/neurological status

Abnormal findings prohibit entryPre-hydrate with 8 to 16 oz of water or diluted sports drink

After-Exit Rehab

MonitorBPPulseRespiratory rateTemperatureBody weightECGMental/neurological status

Use weight loss to estimate hydration statusRehydrateDo NOT permit reentry unless:

AlertNon-tachycardicNormotensiveNormothermicWithin reasonable percentage of normal body weight

Hazardous materials questions:

1. List five indicators Hazardous Materials may be present.

2. The D.O.T. Placarding system is to transportation as the ____________________ is to fixed facilities.

3. The three categories of exposure reduction to Hazardous Materials are:

4. The four types of decontamination are:

5. List three of the six considerations to keep in mind prior to transporting Hazardous materials contaminated patients.

Contact:

Renee Anderson601 W. First AvenueSpokane, WA 99201509-232-8155 (d) 509-232-8344 (f)andersr@inhs.org