Outside portable decontamination systems include portable showers, large inflatable heated tents, or a series of kiddy pools with privacy screens. Effluent must be contained, and disposable equipment should be used wherever feasible. Suggested equipment for outdoor hospital decontamination is listed in IabIeJ.81-.2.. Decontamination inside the hospital should only be done in a designated room with a separate entrance, separate ventilation, and separate water drainage systems.

TABLE 181-2 Suggested Equipment for Outdoor Hospital Decontamination

The goal of decontamination is to decrease the absorbed dose for the victim and prevent secondary contamination of health care providers. Clothing should be removed quickly because this is thought to accomplish 80 percent of the decontamination. Those covered with particulate or radioactive matter should remove clothing very carefully by the roll-down method. Further particulate matter should be brushed away prior to showering, since interaction of some dry chemicals with water may produce heat. All clothing should be double bagged and treated as toxic waste. All patients' belongings and waste must be accounted for by a tracking log. Jewelry and valuables should be bagged separately from clothing, which may require disposal.

While undergoing decontamination, the nonambulatory patient should have a patent airway ensured, the cervical spine immobilized, oxygen administered, ventilation assisted, and pressure maintained on arterial bleeding. Further medical care, such as intubation or intravenous line insertion, is delayed until gross decontamination has been completed and the patient has been transferred to the cold zone. Ocular exposures take precedence and should be treated first with immediate eye irrigation. Ideally, this should have begun in the prehospital phase. Wounds are the next decontamination priority and should be irrigated, debrided of gross contaminants, and then covered with a water-occlusive dressing to prevent recontamination during subsequent showering. Whole-body decontamination should begin with the head and proceed downward. Along with the hands, the face and head generally are the most heavily contaminated areas and should be washed or shampooed in the head-back position to avoid runoff onto other body parts and incorporation of toxic material. This may best be accomplished initially in the sitting position, prior to showering. Most agents are readily removed with copious amounts of water and a mild soap, shampoo, or detergent. Tincture of green soap has been recommended by some based on its small concentration of ethanol that enhances dissolution of certain agents such as hydrocarbons. Typically, 3 to 5 min of showering is recommended, although 15 min may be required for concentrated, strongly alkaline materials or oily, adherent substances. The use of abrasives, such as corn meal or scrub brushes, is generally not advised, since abrading the skin may increase toxin absorption. New amphoteric decontamination solutions, such as Diphoterine, for specific acid, base, solvent, oxidizer, and reducing agent exposures are under investigation. Water temperature should be tepid, since heat potentially will increase dermal absorption of some toxins.

Certain agents may be removed more effectively with the use of specific decontamination solutions. Dilute household bleach solutions (9 parts water to 1 part bleach) will inactivate nerve agents and most biologic agents. The use of neutralizing solutions for acid or alkaline corrosives is controversial. Other agents requiring targeted decontamination solutions include phenol and hydrofluoric acid and are discussed below. One should not delay decontamination if such solutions are not readily available but rather begin washing with deluge volumes of water in an attempt to prevent toxin absorption through massive dilution.

Certain metals such as sodium, lithium, and potassium react violently with water, releasing heat, hydroxide ion, and hydrogen gas and potentially causing thermal burns. Proper treatment of alkali metal burns involves clothing removal, covering the affected area with mineral or cooking oil, followed by removal of any remaining metal with dry forceps. Only then can wounds be copiously irrigated with water. Burning fragments should be extinguished by smothering or with a class D fire extinguisher. Again, in the absence of proper solutions, decontamination with deluge volumes of water may be considered. Other water-reactive chemicals are listed in Table 181-3.. In contrast to water-reactive chemicals, white phosphorus ignites spontaneously on exposure to air. Burns from this agent must be kept continuously moist with water or saline dressings until adequate debridement is accomplished. Each phosphorus particle must be removed. The application of copper sulfate solution blackens the phosphorus, aids in visualization, and provides neutralization. Alternatively, a Wood's lamp may be used. Some adherent toxins are extremely difficult to remove from the skin. Epoxy resins and cyanoacrylates (glues) may be removed by swabbing with acetone. Use of vegetable or mineral oil or saline-soaked gauze pads for the eyes and mucous membranes is safe. Hot tar, typically inflicting burns to the face and upper extremities, should be allowed to cool prior to removal. Effective tar removal has then been reported using Neosporin cream, Tween 80, plain Vaseline, Shur Clens, Desolv-It, or mayonnaise. No attempt should be made to remove tar by mechanical means, since this may increase tissue destruction and result in hair follicle loss.

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