CSEPP.ORG

Introduction

Most agencies have either "Standard Operating Procedures" or "Policies and Procedures" that dictate the manners in which both day-to-day operations are handled as well as emergency situations. This document serves as a reference and guide to assist agencies in the proper Chemical Stockpile Emergency Preparedness Program (CSEPP) guidelines that have been created to operate in a chemical weapons environment.

Threat Assessment

The threat in the area of the Umatilla Chemical Depot is two-fold. Both are directly related to the storage and on-going destruction of the chemical agents. One threat is the direct consequence of exposure to chemical warfare agents. The second is collateral injuries and illness associated with the stress of an event and traffic accidents that occur during evacuation.

In the UMCD communities, there are approximately 30,000+ residents in or adjacent to the IRZ. This does not include the transient population associated with two Interstate Freeways, a major East-West rail line, and a Commercially Navigable waterway. All of which run directly through the IRZ. Based on these numbers alone, there could be as many as 40,000+ people at risk.

Assumptions of Chemical Exposure

If an affected person is within the plume and does not receive an incapacitating dose and they are able to drive to a hospital or decontamination site, the following assumptions can GENERALLY be made as to the cross contamination threat to first responders posed by the exposed person.

 The patients clothing should still be removed and they should be de-contaminated with soap and water to ensure any quantity of agent has been removed from the clothing, hair or skin of the patients.

If a patient was potentially contaminated, may or may not be exhibiting signs and symptoms of exposure before or after decontamination, they should be treated in accordance with the treatment protocols.

If a patient has traveled by means of an enclosed motor vehicle, and passed through a chemical plume, the exposure may be limited. Whether they arrive at a treatment facility or at a de-contamination site, they should be handled the same way. Since the vehicle itself could be contaminated, it should be parked as far away as practical. The occupants should be coached to get out of the vehicle without touching the exterior. They should then be sent through the decontamination process while being observed further for signs and/or symptoms of chemical agent exposure. If after completing the decontamination process, the people are still not exhibiting signs or symptoms, they may be sent on to an Assistance Center. If the people are exhibiting signs and/or symptoms, they should be transported to a medical facility for further treatment and observation.

The patients clothing and external portions of any vehicle become even more of a concern with HD due to its persistence.

In dealing with HD exposure, it is important to realize that the signs and symptoms may not manifest themselves for hours. For this reason everyone who traveled in the vicinity of, or came from the area of the protective wedge has to be considered as exposed. They should be decontaminated and then observed to confirm that they are asymptomatic. Treatment of HD exposed patients is currently limited to supportive care as there are no antidotes for this agent.

Concept of Operations, Fire and EMS

After the initial notification phase of a chemical incident, all of the local agencies will respond to their assigned duty stations.

The Umatilla, Hermiston, Heppner and Boardman fire departments all have mobile de-contamination units that will be deployed by the Incident Command Post. The deployment locations are predetermined but can be changed by the Operations Sections Chief based upon the available information (See Annex D of the CSEPP Plan)

Concept of Operations, Hospitals

After the initial notification of a chemical agent incident, Pioneer Memorial, St. Anthony and Good Shepherd hospitals should activate their respective Mass Casualty Plans which should include decontamination operations for a chemical event. Under certain chemical circumstances, Good Shepherd Hospital may be forced to over-pressurize instead of deploying their decontamination trailer. St. Anthony and Pioneer Memorial hospitals will then have to carry the load for receiving all patients related to a chemical incident.

In accordance with the Centers for Disease Control and Prevention (CDC) regulations, 40 patients will give blood and urine samples to be tested. Hospitals will follow CDC protocol to send samples to a certified regional laboratory. 

There are 4 blood and urine sampling kits available (each kit contains materials and specific CDC collection and labeling instructions for the collection of blood and urine specimens from 40 cases or patients): there are 3 kits in the CSEPP area -- Good Shepherd Hospital Laboratory in Hermiston; St Anthony Hospital La-boratory in Pendleton; and Morrow County Public Health; plus 1 kit in the PHEP Mobile Environmental Lab. Note that all hospital laboratories would also have the proper specimen collection equipment and supplies on hand(these are routine blood and urine specimen collection supplies used daily in hospital labs). The specific CDC collection and labeling instructions can also be found at http://www.oregon.gov/DHS/ph/lrn/index.shtml --> Chemical Preparedness or Chemical Event Response or Google "Oregon LRN"). The OSPHL is responsible to always have supplies available for the collection of blood and urine for 500 patients or cases (note: the blood collection tubes have a shelf-life of approximately 6-8 months depending on what out-date the distributer provides).

Medical Supply Caches

In the event there is a mass casualty incident during a CSEPP incident, medical cashes have been distributed throughout each county to allow for the rapid distribution of the supplies. The medical supplies are grouped in a paramedic jump kit which includes a trauma bag, intravenous start bag, bandage/trauma bag, and bulk dressing bags. The bags are distributed as follows:
 

	Paramedic Jump Kit
		# of Trauma Bags	# of IV Bags	# of Bandage Bags	# of Bulk Dressing Bags	# of Oxygen Kits
	Hermiston Fire	6	6	6	1	4
	Umatilla Fire	6	6	6	1
	Pendleton Fire	3	3	3	1	3
	Boardman Fire	1	1	1	0
	Heppner Fire	1	1	1	0
	Heppner EMS	1	1	1	1
	Irrigon EMS	3	3	3	0
	Boardman EMS	3	3	3	2	3
	MC Health	1	1	1	0	0

Note: Umatilla Fire does have oxygen but it is stored in bulk on Rescue 92 with bags of O2 masks, bottles and regulators. There are also large supplies of backboard, C collars, straps, blankets etc.

Treatment Protocols

Treatment of Chemical casualties is a continually evolving process. The protocols listed are current as of the writing of this document. They may change as new information or procedures are developed.

1. GENERAL INFORMATION: Sulfur mustard is extremely toxic and may damage the eyes, skin, and respiratory tract and suppress the immune system. Although sulfur mustard causes cellular changes within minutes of contact, the onset of pain and other symptoms is delayed. Thus, pa-tients/victims arriving immediately from the scene of sulfur mustard exposure are not likely to have signs and symptoms. The sooner after exposure that symptoms occur, the more likely they are to progress and become severe. Initial treatment is primarily supportive.
2. ANTIDOTE: There is no antidote for sulfur mustard toxicity. Decontamination of all potentially exposed areas within minutes after exposure is the only effective means of decreasing tissue damage.
3. EYE:
   
   1. Immediately remove the patient/victim from the source of exposure.
   2. Immediately wash eyes with large amounts of tepid water for at least 15 minutes.
   3. Eyes must be decontaminated within minutes after exposure to limit injury.
   4. Do not cover eyes with bandages.
   5. Seek medical attention immediately.
4. INGESTION:
   
   1. Immediately remove the patient/victim from the source of exposure.
   2. Ensure that the patient/victim has an unobstructed airway.
   3. Do not induce vomiting (emesis).
   4. Administer nothing by mouth (NPO).
   5. Seek medical attention immediately.
5. INHALATION:
   
   1. Immediately remove the patient/victim from the source of exposure.
   2. Evaluate respiratory function and pulse.
   3. Ensure that the patient/victim has an unobstructed airway.
   4. If shortness of breath occurs or breathing is difficult (dyspnea), administer oxygen.
   5. Assist ventilation as required. Always use a barrier or bag-valve-mask device.
   6. If breathing has ceased (apnea), provide artificial respiration.
   7. Monitor for and treat spasmodic narrowing of the large airways (bronchospasm), if it occurs.
   8. Seek medical attention immediately.
6. SKIN:
   
   1. Immediately remove the patient/victim from the source of exposure.
   2. See the decontamination section for patient/victim decontamination procedures.
   3. Skin must be decontaminated within minutes after exposure to limit injury.
   4. Persons exposed to sulfur mustard will seldom be received for medical treatment in time to prevent tissue damage.
   5. Seek medical attention immediately.

Triage Procedures

START Triage System - Many jurisdictions across the U.S. are using the Simple Triage and Rapid Treatment (START) system. The advantage of START is its simplicity and its ease of use by individuals with very little medical training. START merely requires an understanding of basic first aid. Under START, all victims who are able to walk on their own ("walking wounded") are directed by the first emergency personnel on the scene to a designated area upwind of the hazard area and are labeled as minimal (green tag). This reduces the number of victims to be evaluated. These victims will require supervision and might be detained for further assessment and possible decontamination.

The remaining victims will be evaluated using the START triage system. This should take no longer than 1 minute per patient and will focus on three primary areas:

• Respiratory status
• Perfusion and pulse
• Mental status.

As the responder moves through each level of assessment, any condition that is deemed immediate (red tag) stops the evaluation process. Life-threatening injuries will be addressed, if necessary, during primary triage. The patient is tagged, and the responder moves on to the next patient.

Ventilation - If the patient is adequately ventilating (breathing), the triage officer moves on to the next step. If, however, ventilation is inadequate, the triage officer attempts to clear the airway by either repositioning the victim or clearing debris from the patient's mouth. If these attempts are unsuccessful, the victim is classified as follows:

• No respiratory effort - Expectant (black tag)
• Respirations greater than 30 or unstable airway - Immediate
• Normal respirations - Go to next step.

Perfusion - Initial evaluation is made by measuring capillary refill. [If the casualty has normal capillary refill (less than 2 seconds), proceed to the next step.] If the patient's blood return is delayed (greater than 2 seconds) or appears cyanotic, then the patient is classified as immediate. If the triage officer is unable to obtain capillary refill due to either the patient's color or poor lighting conditions, then the radial pulse is checked. If the radial pulse is not detected, the patient is classified as immediate. If present, the pressure is assumed to be adequate (80mm Hg), proceed to the next step.

Mental Status - The third and final level of assessment is the patient's mental status. Depending on the level of consciousness, the following classification is made:

• Unconscious - Immediate
• Altered level of consciousness - Immediate
• Change in mental status - Immediate
• Normal mental responses - Delayed, then move to next victim.