The first wave of minimally exposed victims arrives within 30 min of the incident, overwhelming the ED and impeding the care of patients who will arrive later. 14 ED triage must be efficient and should occur outdoors. First and foremost, the patient should not be allowed to enter the ED. Second, those personnel who are not in an appropriate level of protective gear should not be allowed in the triage/decontamination area. The incoming ambulance or ambulatory patients should be met by a triage officer, an individual in appropriate level of personal protective gear, to determine whether decontamination has been performed and, if so, its adequacy. The most difficult situations involve those victims who are seriously injured and who have bypassed the field decontamination procedure. A management dilemma is created between immediate medical treatment and decontamination. While the appropriate response varies depending on the chemical(s) involved, many situations involve unknown chemicals and therefore unknown risk to personnel. It is always prudent to err on the side of decontamination before treatment in unknown situations. Examples of those substances with little or no risk of secondary contamination include gases, vapors, and substances with no serious toxicity or skin absorption. Patients exposed to gases or vapors only, with no symptoms other than respiratory irritation and no signs of condensation of vapor on the clothing, do not require decontamination beyond clothing removal. This may not hold true, however, for large numbers of victims exposed to nerve agent vapor or for those in confined spaces. Substances with high risk of secondary contamination include highly toxic substances that are readily absorbed dermally, radioactive agents, and certain biologic agents.
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