To protect providers, decontamination sometimes comes before treatment

After a powerful explosion ripped through a Texas fertilizer plant in April 2013, nearby hospitals treated hundreds of people for blast injuries. Many were also treated for exposure to anhydrous ammonia, which can severely damage the skin, eyes and lungs, and is especially toxic for children. The standard treatment is decontamination, maintaining an open airway and respiration support.

Although the Texas tragedy was an unusual event, exposure to a variety of toxic substances and particularly to spilled fuel in motor vehicle crashes is increasingly common and requires proper decontamination procedures to ensure the safety of both patients and providers.

John B. Osborn, M.Sc., is operations manager for general and trauma surgery in the Department of Surgery at Mayo Clinic in Minnesota and lead administrator for mass casualty incident planning and response for Mayo Clinic operations. He says Mayo's Emergency Department (ED) has a robust set of guidelines detailing when to perform specific types of decontamination and in what order.

"Some agents are more dangerous than others, so although in many cases you want to treat the injury first, in others, you decontaminate first because the threat to responders is so great. With any kind of chemical, gas or ammonia, you decontaminate first. The same is true of radiological contamination," he says.

Mayo also has specific protocols for handling various types of contaminated items. For example, gasoline-soaked clothing is sealed in plastic bags and deposited in 55-gallon drums, which are then disposed of by waste management companies.

In standard decontamination, soiled clothing is removed and ambulatory patients wash thoroughly with soap and water in special showers in the ED. For nonambulatory patients who arrive on a cart or backboard, a provider team does the cleansing, taking special care to protect the airway.

Instances of mass contamination are relatively rare, but when they occur, hospitals often use tents and an assembly-line process to treat as many patients at a time as possible. Decontamination usually begins in the field, though. "Fire departments do a lot of hazardous response in the field, and patients would usually be decontaminated before leaving the hot zone," Osborn says. "That's a good first step, and it's essential so responders aren't placed at risk."

For the same reason, patients should be decontaminated before transfer to a higher level of care. "Transferring a patient in gasoline-soaked clothes is a bad deal. You don't want an ambulance full of fumes so the ambulance crew gets lightheaded and suddenly they're victims, too," Osborn points out.

The problem can be compounded by olfactory fatigue — the inability to distinguish a particular odor after prolonged exposure. Osborn explains, "We all know what gas smells like. But we can get used to it fairly quickly, so we have to maintain a level of suspicion, especially if there are multiple patients. There may be contamination without a discernible odor, or we may become sensitized to it. Providers have to remain vigilant and take precautions like wearing a face shield or mask."

Decon for kids

Children add a special element to the decontamination process. Their small size means they can be decontaminated more quickly and easily than adults, but it also means toxic substances they've absorbed may be more concentrated. More important, children don't have an adult's ability to cope with stress and anxiety.

"It's hard enough for well-adjusted adults with strong coping skills to deal with accident and injury," Osborn says. "Imagine how much harder that is for a child — separated from parents, surrounded by strangers in suits. Kids have different stressors and different coping mechanisms, and we always have to be aware of that."