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Chemical Hazards
Topic Collection
February 7, 2022

Topic Collection: Chemical Hazards

An incident involving the accidental or intentional release of chemicals can lead to death or serious illness and injuries, hospital surge, and the need to protect responders, medical care providers, and community members. The resources in this Topic Collection are specific to chemical agent patient evaluation and treatment and can help emergency responders and healthcare workers identify chemical hazards and prepare for, respond to, and treat survivors of related incidents. Please note: While ASPR TRACIE works closely with subject matter experts to ensure we provide the most up-to-date information; this field and related treatment/antidote information is constantly evolving. If you are a clinician treating a patient, please check the U.S. Department of Health and Human Service’s Chemical Hazards and Emergency Medical Management (CHEMM) webpage, and/or your local poison control center.   

Related information can be found in the CBRN Resources page and the following Topic Collections (listed alphabetically): Hospital Patient DecontaminationMass Distribution and Dispensing of Medical Countermeasures, On-Scene Mass Casualty Triage and Trauma Care, Pediatric, Pre-Hospital Patient Decontamination, and Responder Safety and Health.  

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.  

Must Reads


This issue of The Exchange highlights planning, response, and lessons learned specific to chemical incidents.
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This website provides information for both the general public and for professionals about chemical emergencies. Links to case definitions, toxic syndrome descriptions, and medical management guidelines are included for professionals.
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Chilcott, R.P., Larner, J., and Matar, H. (Eds.). (2019). Primary Response Incident Scene Management: PRISM Guidance, Second Edition. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Biomedical Advanced Research and Development Authority.
The Primary Response Incident Scene Management (PRISM) series is comprised of three volumes that can help ensure that patients exposed to potentially hazardous chemicals receive the most effective treatment possible during the initial stages of an incident (after prompt decontamination). Updated in 2019, PRISM incorporates new scientific evidence on emergency self-decontamination, hair decontamination, the interactions of chemicals with hair, and the effects of a combined decontamination strategy referred to as the “triple protocol.” The clinical research showed that these three steps, taken together, remove 99.9 percent of chemical contamination.
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Ciottone, G. (2018). Toxidrome Recognition in Chemical Weapons Attacks. New England Journal of Medicine. 378(17): 1611-1620.
The author discusses deficiencies of existing triage systems for use with chemical agent attack casualties. He proposes a rapid-triage system for chemical warfare agents to “identify those classes of agents that require rapid treatment with antidotes, emergency airway support, and spot decontamination, and then further delineate within that group the class of agent that is present so that the correct antidote can be given.”
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Commonwealth of Massachusetts Department of Public Health -Office of Emergency Preparedness and Emergency Management (2014). Proposed Minimum Decontamination Capabilities for Hospitals in Massachusetts.
This resource was designed to assist hospitals and their response partners with addressing challenges in hospital-based decontamination during all four phases of the emergency management cycle. While each document can be used individually to facilitate improvement, the resources are most effective when used in combination
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DeLuca M.A., Chai P.R., Goralnick E., et al. (2020). Five Decades of Global Chemical Terror Attacks: Data Analysis to Inform Training and Preparedness. (Abstract only.) Disaster Medicine and Public Health Preparedness. 24:1-12.
Using the Global Terrorism Database, the authors conducted a retrospective analysis dating back five decades to assess trends in chemical agent attacks. Research results identified the specific agents used, the most common route of exposure, and target population, as well as trends that can be of value for future chemical emergency preparedness efforts
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This quick-reference cardset is intended for use by pre-hospital and hospital personnel and groups the exposure by class rather than agent (corrosives, asphyxiants, cholinergics) for easier initial assessment and treatment. It includes detailed descriptions of patient treatment steps (decontaminate and collect information; treat chemical exposure; collect blood and urine specimens) following hazardous materials exposure.
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This webpage can serve as the starting point for hospital decontamination planning and includes foundational information on personal protective equipment, training first responders/ receivers, response components (e.g., isolation, lockdown, decontamination, equipment), and recovery components (e.g., waste management). Though geared to hospitals, the document contains a great deal of valuable information about PPE and programs/training of relevance to first responders, particularly those that are not fire-based and may model their PPE and programs similarly in order to support warm-zone response support when appropriate. Templates and case studies are provided in appendices.
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Pipeline and Hazardous Materials Safety Administration. (2020). Emergency Response Guidebook (ERG). U.S. Department of Transportation.
This version of the guidebook can help first responders respond to hazardous materials incidents within the first 30 minutes.
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Schwartz, M., Sutter, M., Eisnor, D., and Kirk, M. (2018). Contingency Medical Countermeasures for Mass Nerve-Agent Exposure: Use of Pharmaceutical Alternatives to Community Stockpiled Antidotes. (Free registration required.) Disaster Medicine and Public Health Preparedness.
The authors share findings from a literature review and expert panel meeting on pharmaceutical alternatives for treating nerve agent toxicity. This information can help emergency planners, pharmacists, and emergency healthcare practitioners better understand the options they have in a mass exposure event that exhausts medical countermeasure supplies.
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U.S. Army Borden Institute. (2014). Medical Management of Chemical Casualties Handbook.
This webpage includes links to agent-specific chapters that include comprehensive descriptions of the effects of chemical agents on different organs and systems within the body by exposure type, as well as guidance for making a differential diagnosis, and medical management information for clinicians. Note: some of the decontamination techniques are not recommended for civilian use.
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U.S. Department of Defense, U.S. Department of Health and Human Services, U.S. Department of Transportation, et al. (2019). Fourth Generation Agents: Medical Management Guidelines.
This document was designed to educate and prepare fire, emergency medical services, and hospital staff and guide the medical management of patients exposed or potentially exposed to a fourth generation agent. This is one PDF document that is divided into two sections, one for pre-hospital care and one for in-hospital care.
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U.S. Department of Health and Human Services, National Library of Medicine, Specialized Information Services and the Office of the Assistant Secretary for Preparedness and Response. (2013). Wireless Information System for Emergency Responders (WISER).
The Wireless Information System for Emergency Responders (WISER) is a searchable database providers may use to quickly obtain response, treatment, and clean-up information for various weapons of mass destruction, including chemical agents. Users may access information via the online version or as stand-alone applications for PC, iOS & Android devices. WISER also contains the Chemical Hazards Emergency Medical Management (CHEMM) resource.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (n.d.). Chemical Hazards Emergency Medical Management (CHEMM). (Accessed 11/3/2021.)
This website provides a wide range of information on chemical hazards for first responders, healthcare providers, and incident command staff.
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U.S. Department of Health and Human Services. Chemical Hazards Emergency Medical Management (CHEMM). (2021). CHEMPACK.
CHEMPACKs contain nerve agent antidotes and are stored in secure locations across the country. More than 90 percent of the U.S. population is within one hour of a CHEMPACK location; most locations are in hospitals or fire stations.
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Van Sickle, D., Wenck, M., Belflower, A., et al. (2009). Acute Health Effects After Exposure to Chlorine Gas Released After a Train Derailment. The American Journal of Emergency Medicine.
The authors discuss findings from a review of medical records and autopsy reports to describe the clinical presentation, hospital course, and pathology observed in persons hospitalized or deceased as a result of chlorine gas exposure after a train derailment in 2005.
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Chemical Countermeasures


This position statement was issued to assist first responders and healthcare providers with caring for patients poisoned by acetylcholinesterase (AchE) inhibitor chemical warfare agents or pesticides when supplies of standard medical countermeasures are insufficient. Strategies discussed in this document include using expired medications and alternative countermeasures.
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Dart, R., Goldfrank, L., Erstad, B., et al. (2018). Expert Consensus Guidelines for Stocking of Antidotes in Hospitals That Provide Emergency Care. Annals of Emergency Medicine. 71(3): 314-325.
An expert panel representing diverse perspectives (including clinical pharmacology, medical toxicology, critical care medicine, hospital pharmacy, emergency medicine, emergency medical services, pediatric emergency medicine, pediatric critical care medicine, and poison centers) conducted a literature review and issued recommendations for stocking of antidotes used in emergency departments (EDs). They note which should be available immediately; within 1 hour; and after 1 hour to provide the greatest benefit to patients.
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* Organisation for the Prohibition of Chemical Weapons (OPCW). (2015). Blister Agents and Their Countermeasures. (Free registration required.)
This poster includes information on blister agents (i.e., sulfur mustard, nitrogen mustard, and Lewisite) and their countermeasures.
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* Organisation for the Prohibition of Chemical Weapons (OPCW). (2015). Blood Agents and Their Countermeasures.
This poster includes information on blood agents (e.g., hydrogen cyanide and sodium cyanide) and their countermeasures.
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* Organisation for the Prohibition of Chemical Weapons (OPCW). (2015). Choking Agents and Their Countermeasures.
This poster includes information on choking agents (i.e., chlorine and phosgene) and their countermeasures.
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* Organisation for the Prohibition of Chemical Weapons (OPCW). (2015). Organophosphorus Nerve Agents and Their Countermeasures.
This poster includes information on organophosphorus nerve agents (e.g., VX, Sarin, Tabun, and Soman) and their countermeasures.
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Schwartz, M., Sutter, M., Eisnor, D., and Kirk, M. (2018). Contingency Medical Countermeasures for Mass Nerve-Agent Exposure: Use of Pharmaceutical Alternatives to Community Stockpiled Antidotes. (Free registration required.) Disaster Medicine and Public Health Preparedness.
The authors share findings from a literature review and expert panel meeting on pharmaceutical alternatives for treating nerve agent toxicity. This information can help emergency planners, pharmacists, and emergency healthcare practitioners better understand the options they have in a mass exposure event that exhausts medical countermeasure supplies.
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U.S. Department of Health and Human Services. Chemical Hazards Emergency Medical Management (CHEMM). (2021). CHEMPACK.
CHEMPACKs contain nerve agent antidotes and are stored in secure locations across the country. More than 90 percent of the U.S. population is within one hour of a CHEMPACK location; most locations are in hospitals or fire stations.
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U.S. Food and Drug Administration. (2018). Products Approved for Chemical Emergencies.
The Food and Drug Administration lists products approved for cyanide, nerve agent and insecticide, and chemical decontamination on this webpage (nerve agent antidotes are stocked in the CHEMPACK program). Links to select resources are also provided.
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U.S. Food and Drug Administration. (2019). Medical Countermeasure Monitoring and Assessment.
This webpage is focused on the need to build and maintain a national capability to monitor and assess medical countermeasures (MCMs) after they are dispensed or administered in response to a chemical, biological, radiological, or nuclear threat or an emerging infectious disease. Links to “FDA Information about Past and Current MCM Monitoring and Assessment Projects” are included
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Considerations for Special Populations


ASPR TRACIE. (2018). Chemical Hazard Spills.
This ASPR TRACIE TA response includes resources specific to evacuation and shelter-in-place procedures for long-term care facilities and general chemical hazards spills. Related Topic Collections: the Long-Term Care Facilities and Chemical Hazards.
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ASPR TRACIE. (2019). Pediatric/Children. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response.
The resources in this Topic Collection can help healthcare facilities, healthcare coalitions, and other health and medical providers to consider the specialized care and resources needed for children prior to, during, and after an incident.
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Bartenfeld, M., Peacock, G., and Griese. S. (2014). Public Health Emergency Planning for Children in Chemical, Biological, Radiological and Nuclear (CBRN) Disasters. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 12(4).
This article discusses the distinct physical, developmental, and social traits and characteristics of children in the context of the science behind exposure to, health effects from, and treatment for the threat agents potentially present in CBRN incidents.
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Chung, S., Baum, C.R., and Nyqusit, A.C. (2020). Chemical-Biological Terrorism and Its Impact on Children. American Academy of Pediatrics. 145(1).
This policy statement addresses the steps that clinicians and policy makers can take to protect children and mitigate the effects of a chemical or biological attack. To access the technical report, copy and paste this link into a new browser: https://pediatrics.aappublications.org/content/early/2020/01/23/peds.2019-3750
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Freyburg, C., Arquilla, B., Fertel, B., et al. (2008). Disaster Preparedness: Hospital Decontamination and the Pediatric Patient. (Free registration required to access abstract and algorithm.) Prehospital Disaster Medicine. 23 (2)166-172.
The authors discuss the medical and psychological planning needs associated with children and chemical decontamination. They developed an algorithm that includes steps for ambulatory and non-ambulatory patients.
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Hamele, M., Poss, W.B., and Sweney, J. (2014). Disaster Preparedness, Pediatric Considerations in Primary Blast Injury, Chemical, and Biological Terrorism. World Journal of Critical Care Medicine. 3(1):15-23.
The authors review the presentation, pathophysiology, and treatment of pediatric victims of blast injury, chemical weapons, and biological weapons, with a focus on those injuries not commonly encountered in critical care practice.
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* Henretig, F., Kirk, M., and McKay, C. (2019). Hazardous Chemical Emergencies and Poisonings. (Free registration required.) New England Journal of Medicine. 380: 1638-1655.
This contemporary review article on management of chemical casualties in a hospital environment includes adult and pediatric considerations. The authors provide an overview of decontamination, toxidromes, patient presentation, and current clinical management strategies for both patient populations.
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Tennessee Emergency Medical Services for Children. (2012). Responding to Chemical Incidents.
This course teaches responders how to recognize signs and symptoms of pediatric contamination by chemical agent. It also shares information on pediatric decontamination procedures.
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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2012). Specific Populations.
This webpage describes the unique responses and/or needs of the following special populations during a chemical exposure event: seniors; infants and children; pregnant women and fetuses; persons with disabilities; and individuals with pre-existing disease(s)/altered metabolism.
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The U.S. Government Accountability Office was asked about efforts to address the needs of children in the event of a CBRN incident. This report examines: the percentage of CBRN medical countermeasures in the Strategic National Stockpile that are approved for pediatric use; how the U.S. Department of Health and Human Services (HHS) is addressing the challenges associated with developing and acquiring CBRN medical countermeasures for the pediatric population; and the ways HHS and state and local governments have addressed the dispensing of pediatric medical countermeasures in emergency response plans and guidance.
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Education and Training


Agency for Toxic Substances and Disease Registry (ATSDR) (2020). HazMat Emergency Preparedness Training and Tools for Responders.
This webpage provides information on training programs and tools developed by the Agency for Toxic Substances and Disease Registry (ATSDR) to help communities prepare for hazardous materials emergencies and disasters. It includes resources on how to manage hazardous materials incidents, emergency medical services, toxicological profiles, and risk communication
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Alabama Department of Public Health. (2019). Chemical Warfare: A Primer for First Responders & Receivers.
This hour-long webinar discusses “challenges in prevention and response for first responders and receivers in caring for victims of chemical exposure.” The target audience includes first responders, emergency medical services, emergency preparedness coordinators, emergency room nurses, public health professionals, social workers, and preventative medicine physicians and staff.
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American College of Medical Toxicology. (2021). Chemical & Radiological Agents of Opportunity for Terrorism. (Registration required for download.)
This free, two-day, virtual course provides an overview of the medical and psychological consequences of exposures. The course includes practical information regarding scene safety and provides content in two one-day segments: Radiological Emergency Medical Management and Chemical Agents of Opportunity for Terrorism.
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* ASPR TRACIE. (2020). Hospital Patient Decontamination. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response.
The resources in this Topic Collection highlight lessons learned, guidelines, plans, tools, and templates, and promising practices that can help emergency medical practitioners accomplish this goal.
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This document can help exercise designers set up a healthcare coalition chemical emergency surge tabletop exercise.
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This 25-minute online course provides a basic overview of CHEMPACK. Because the MCM that protects exposed persons from harmful effects of chemical exposure must often be administered within two hours of exposure, the CDC uses the CHEMPACK program to forward place significant caches of these assets within communities, at locations such as hospitals and fire stations.
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Participants will learn more about logistics and maintenance issues associated with CHEMPACK containers in this (Vermont-specific) 20-minute, on-line course. Other topics covered include different CHEMPACK configurations, storage requirements, and mobilization timing.
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Center for Domestic Preparedness. (2018). Hands-On Training for CBRNE Incidents. Federal Emergency Management Agency.
In this two-day course, students will learn about CBRNE response (e.g., triage, decontamination) and performing mass casualty triage while wearing the proper level of personal protective equipment.
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Center for Domestic Preparedness. (2021). Emergency Medical Operations for CBRNE Incidents. Federal Emergency Management Agency.
This four-day course teaches responders to effectively respond to a chemical, biological, radiological, nuclear, or explosive (CBRNE) or mass casualty incident using classroom lectures and hands-on training.
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Center for Domestic Preparedness. (2021). Hazardous Materials Operations. Federal Emergency Management Agency.
This five-day course is designed for emergency managers, emergency medical service providers, first responders, and any responders having operations-level response duties during a chemical, biological, radiological, nuclear, or explosive (CBRNE)/all-hazards incidents. Students will learn about these threats in the Nation's only toxic agent training facility, the Chemical, Ordnance, Biological and Radiological (COBRA) Training Facility.
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Centers for Disease Control and Prevention. (2015). Emergency Preparedness and Response: Training for Chemical Emergencies.
This webpage includes links to training resources to prepare healthcare providers for responding to chemical emergencies.
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Djalali, A., Della Corte, F., Segond, F., et al. (2016). TIER Competency-Based Training Course for the First Receivers of CBRN Casualties: A European Perspective. (Free registration required.) European Journal of Emergency Medicine. 24(5):371-376.
The authors developed a set of competencies under 10 domains to define the skills and knowledge necessary to respond to chemical, biological, radiological and nuclear (CBRN) emergencies. They created a training program based upon these competencies, and note that a blended training approach may allow clinicians the opportunity to participate in the same trainings, even in different time zones and locations.
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Eason, M. (2013). Sarin Exposure: A Simulation Case Scenario. (Free registration required.) Southern Medical Journal. 106(1):55-62. .
The author describes the successful use of simulation training to prepare healthcare workers to respond to a Sarin exposure incident. Details on the scenario, which reviews the presentation of nerve agent exposure and its management, and includes “a recipe for performing this simulation in a training exercise,” are included.
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Federal Emergency Management Agency. (n.d.). Emergency Medical Response Awareness for CBRNE Incidents. (Accessed 1/30/2022.)
This course teaches practical experience in the triage and treatment of CBRNE mass casualty victims. It reviews chemical threats, associated symptoms of exposure and contamination, as well as on-site and hospital-based triage and treatment practices.
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In this 10-hour independent study, on-line course, hospital personnel will learn how to analyze hazardous materials situations and identify decontamination and medical care resources. This course does not provide HAZWOPER training certification but covers many relevant and included materials.
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Federal Emergency Management Agency. (2013). IS-5.A: An Introduction to Hazardous Materials.
This 10-hour independent study, online course provides a general overview of hazardous materials under five units; Unit 4 focuses on human health and hazardous materials. This course does not provide HAZWOPER training certification.
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Federal Emergency Management Agency (FEMA), Center for Domestic Preparedness (2022). Disaster Related Exposure Assessment and Monitoring.
This 4-day course addresses how to assess, monitor and track the health effects of a CBRN emergency on responders and community members before, during, and after an incident. It also includes information on how to use epidemiologic tools such as Assessment of Chemical Exposure (ACE), and Epi CASE (Case Assessment Symptom and Exposure)
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Leary, A., Schwartz, M., Kirk, M., et al. (2014). Evidence-Based Patient Decontamination: An Integral Component of Mass Exposure Chemical Incident Planning and Response. (Free registration required.) Disaster Medicine and Public Health Preparedness. 8(3): 260-266.
The authors summarize the science behind the national planning guidance prepared by the U.S. Department of Health and Human Services and Department of Homeland Security specific to mass patient decontamination in a chemical incident.
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While written for the state of Connecticut, and reflective of its specific procedures, this 40-minute course includes information on what responders should do when they recognize a potential nerve agent incident, and when to request deployment of CHEMPACK assets.
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Masden, J. (2007). Chemical Warfare Agents: An Overview. National Institutes of Health (U.S.). Emergency Preparedness and Biodefense Interest Group.
In this webinar, the speaker provides an overview of high-threat chemicals, lessons learned, features of chemical attacks, and strategies for recognizing chemical attacks. He also shares a pneumonic for patient assessment.
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McInerney, J. and Richter, A. (2011). Strengthening Hospital Preparedness for Chemical, Biological, Radiological, Nuclear, and Explosive Events: Clinicians' Opinions Regarding Physician/Physician Assistant Response and Training. (Abstract only; free registration required to request full text.) American Journal of Disaster Medicine. 6(2):73-87.
Physicians and physician assistants from 21 specialties were surveyed to examine their perceptions related to roles and responsibilities of clinicians in a disaster; barriers to participation; implementation of chemical, biological, radiological, nuclear, and explosive training; and training preferences. Respondents indicated that concerns about risk and malpractice, the cost of training, the time involved in training, and the cost for the time in training were all barriers to training. There were no clear preferences for training strategies.
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Montachusett Regional Planning Commission (n.d.). Chemical Safety & Climate Change Preparedness Training: Chemical Incident Response. (Accessed 1/30/2022)
These local training slides addresses how to plan for chemical emergency response activities and includes templates and frameworks for assessing a chemical incident. It discusses different tools and strategies to improve disaster management, and provides charts, graphics, and slides to be used during training exercises
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Monteith, R. and Pearce, L. (2015). Self-care Decontamination within a Chemical Exposure Mass-casualty Incident. Prehospital and Disaster Medicine. 30(3): 288-296.
The self-care decontamination protocols recommended here present a viable option to ensure decontamination is completed in the field, at the incident scene, and that casualties are cared for more quickly and less traumatically than they would be otherwise.
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* National Library of Medicine. (n.d.). ToxTutor. (Accessed 1/30/2022.)
This tutorial covers the primary principles of toxicology and includes information on dose and response, risk assessment, exposure standards and guidelines, absorption, distribution, cellular toxicology, and the like.
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Occupational Safety and Health Administration. (n.d.). Hazardous Waste Operations and Emergency Response. (Accessed 11/3/2021.) U.S. Department of Labor.
This guidance document provides information that can help employers assure compliance during decontamination and hazardous materials training and responses. It includes the section "Provisions of HAZWOPER for Emergency Response Operations" which highlights the importance of plans, response procedures, training, medical surveillance, and personal protective equipment.
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This webpage can serve as the starting point for hospital decontamination planning and includes foundational information on personal protective equipment, training first responders/ receivers, response components (e.g., isolation, lockdown, decontamination, equipment), and recovery components (e.g., waste management). Though geared to hospitals, the document contains a great deal of valuable information about PPE and programs/training of relevance to first responders, particularly those that are not fire-based and may model their PPE and programs similarly in order to support warm-zone response support when appropriate. Templates and case studies are provided in appendices.
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Tennessee Emergency Medical Services for Children. (2012). Responding to Chemical Incidents.
This course teaches responders how to recognize signs and symptoms of pediatric contamination by chemical agent. It also shares information on pediatric decontamination procedures.
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Texas A&M Engineering. (n.d.). WMD/Terrorism Awareness for Emergency Responders. (Prerequisite: IS-700.) (Accessed 6/27/2019.)
This online course teaches students how to recognize hazardous materials, protect themselves, notify others, and secure the scene.
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* United States Army Medical Research Institute of Chemical Defense, Chemical Casualty Care Division. (n.d.). Chemical Casualty Care Division. (Accessed 1/30/2022.)
Medical professionals can access links to a variety of tools, products, and courses on chemical casualty care from this web page.
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University of Nebraska Medical Center. (n.d.). Videos - Chemical Preparedness and Response. (Accessed 7/15/2019.)
This webpage includes links to a series of videos (published between 2007-2018) that demonstrate the correct procedures for donning and doffing personal protective equipment (PPE) for interacting with casualties contaminated by chemical agents.
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Guidance and Guidelines


* Albanese, J., Burich, D., Smith, D. et al. (2014). Clinical Guidelines for Responding to Chemical, Biological, Radiological, Nuclear and Trauma/Burn Mass Casualty Incidents: Quick Reference Guides for Emergency Department Staff. (Free registration required.) Journal of Business Continuity & Emergency Planning 8(2):122-33.
The authors describe a quick reference for a hospital’s first response to chemical emergencies. Steps based on the word "DISASTER" can help staff quickly assess and respond to an incident (Detection, ICS, Safety/Security, Assessment, Support, Triage and Treatment, Evacuate, Recovery).
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This issue of The Exchange highlights planning, response, and lessons learned specific to chemical incidents.
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* ASPR TRACIE. (2020). Hospital Patient Decontamination. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response.
The resources in this Topic Collection highlight lessons learned, guidelines, plans, tools, and templates, and promising practices that can help emergency medical practitioners accomplish this goal.
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ASPR TRACIE. (2020). Pre-Hospital Patient Decontamination. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response.
The resources in this Topic Collection include guidelines, courses, exercises, and lessons learned from past events that can help emergency healthcare providers better plan for, and respond to, hazardous materials incidents.
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Berry, L., and Perera, T. B. (2021). EMS Hazardous Waste Response. (Book excerpt.) StatPearls Publishing.
This book reviews the elements of an effective response to a hazardous waste incident highlighting preparedness and disaster management challenges. Content also outlines proper planning and policy development and emphasizes safety and protection of first responders
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Busl K. and Bleck, T. (2012). Treatment of Neuroterrorism. Neurotherapeutics. 9(1):139-57.
The authors discuss the neurological effects of biological and chemical agents/toxins that may be used for terrorism, and the role that neurologists must play in identifying and treating them. This includes how to determine when observed neurological effects are the result of exposure to biological or chemical terrorism, or the result of naturally-occurring disease.
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Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences. (2017). Psychological and Behavioral Issues Healthcare Providers Need to Know When Managing a Chemical, Biological, Radiological or Nuclear (CBRN) Event.
This document discusses the management of acute psychological and behavioral responses following widespread exposure to a chemical, biological, radiological, or nuclear (CBRN) event, which will be as important as the treatment of any CBRN-related injuries and illnesses. It provides guidance on administering psychological first aid, health care, patient education, public health, and mental health.
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This website provides information for both the general public and for professionals about chemical emergencies. Links to case definitions, toxic syndrome descriptions, and medical management guidelines are included for professionals.
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The authors evaluated the clinical and operational effectiveness of PRISM through an exercise and found that the triple combination of dry, ladder pipe system, and technical decontamination attained an average decontamination efficiency of approximately 100% on exposed hair and skin sites.
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Chilcott, R.P., Larner, J., and Matar, H. (Eds.). (2019). Primary Response Incident Scene Management: PRISM Guidance, Second Edition. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Biomedical Advanced Research and Development Authority.
The Primary Response Incident Scene Management (PRISM) series is comprised of three volumes that can help ensure that patients exposed to potentially hazardous chemicals receive the most effective treatment possible during the initial stages of an incident (after prompt decontamination). Updated in 2019, PRISM incorporates new scientific evidence on emergency self-decontamination, hair decontamination, the interactions of chemicals with hair, and the effects of a combined decontamination strategy referred to as the “triple protocol.” The clinical research showed that these three steps, taken together, remove 99.9 percent of chemical contamination.
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Cibulsky, S., Kirk, M., Ignacio, J., et al. (2014). Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This guidance can help emergency planners prepare for mass patient decontamination from initial assessment to evaluation of process effectiveness. The authors emphasize the importance of communication and coordination between on-scene and health care facility-based staff.
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Commonwealth of Massachusetts Department of Public Health -Office of Emergency Preparedness and Emergency Management (2014). Proposed Minimum Decontamination Capabilities for Hospitals in Massachusetts.
This resource was designed to assist hospitals and their response partners with addressing challenges in hospital-based decontamination during all four phases of the emergency management cycle. While each document can be used individually to facilitate improvement, the resources are most effective when used in combination
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* County of Los Angeles, Department of Public Health. (2012). Terrorism Agent Information and Treatment Guidelines for Clinicians and Hospitals.
Healthcare providers can use this handbook to learn more about: bioterrorism agents (e.g., smallpox, tularemia, and ricin); treatments for select chemical agents (e.g., sarin, sulfur mustard, and cyanide); and treatments for radiological and nuclear incidents.
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* Culley, J., Svendsen, E., Craig, J., and Tavakoli, A. (2014). A Validation Study of 5 Triage Systems Using Data from the 2005 Graniteville, South Carolina, Chlorine Spill. Journal of Emergency Nursing. 40(5):453-60.
The authors used data from the 2005 Graniteville, SC chlorine spill to evaluate the appropriateness of 5 commonly used triage systems for assessing casualties from chemical events. They found that the five triage systems did not agree with the actual injury severity from a chemical exposure and that “oxygen saturation measured by pulse oximetry provides early indications and is very predictive of outcome severity in incidents involving irritant chemical exposures such as chlorine.” The article emphasizes the notion that trauma-derived mass casualty triage criteria may not apply well to chemical incidents.
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This federal document provides state, local, tribal, and territorial officials with information and resources to improve resilience to hazardous materials incidents. Content provides an overview of hazardous materials, incident planning and response guidelines, and specific policy, communication, and training practices
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Ganesan, K., Raza, S., and Vijayaraghavan, R. (2010). Chemical Warfare Agents. Journal of Pharmacy & BioAllied Sciences. 2(3): 166–178.
The authors provide a comprehensive review of chemical warfare agents, including their effects, and related treatment.
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Gum, R. and Hoyle, J. (2015). CBRNE - Chemical Warfare Mass Casualty Management. Medscape.
The authors discuss specific procedures for a chemical weapons response for hospital leaders and emergency response planners, as well as for hospital-based healthcare providers. Triage, decontamination, and treatment considerations are included.
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Gupta, R. (2015). Handbook of Toxicology of Chemical Warfare Agents (Second Edition). (Book available for e-purchase.)
This comprehensive resource includes information on “every aspect of deadly toxic chemicals used in conflicts, warfare and terrorism.” It covers the effects of toxic chemicals on humans, as well as decontamination and countermeasures.
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Koenig, K.L. and Schultz, C.H. (2016). Koenig and Schultz's Disaster Medicine: Comprehensive Principles and Practices, 2nd edition. (Book available for purchase.) Cambridge University Press.
This book is written for emergency physicians and nurses. Chapter 31 discusses “Clinical aspects of large-scale chemical events.”
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This quick-reference cardset is intended for use by pre-hospital and hospital personnel and groups the exposure by class rather than agent (corrosives, asphyxiants, cholinergics) for easier initial assessment and treatment. It includes detailed descriptions of patient treatment steps (decontaminate and collect information; treat chemical exposure; collect blood and urine specimens) following hazardous materials exposure.
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National Institute for Occupational Health and Safety. (2018). Chemical, Biological, Radiological, and Nuclear (CBRN) Respiratory Protection Handbook. Atlanta, GA: The Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Injury Response.
This document provides technical information on use of NIOSH respiratory protective devices (RPD) during a nuclear or radiological emergency. Guidance includes information on respiratory program requirements, fit testing methods, and user training.
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National Vital Statistics System. (2017). A Reference Guide for Certification of Deaths in the Event of a Natural, Human-induced, or Chemical/Radiological Disaster. Centers for Disease Control and Prevention.
This guide provides recommendations and examples for recording the name and type of disaster on death certificates to ensure consistency and accuracy and help jurisdictions promote a common framework for measuring "disaster relatedness."
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* Pipeline and Hazardous Materials Safety Administration. (2020). Emergency Response Guidebook (ERG). U.S. Department of Transportation.
This version of the guidebook can help first responders respond to hazardous materials incidents within the first 30 minutes.
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Rubin, G.J., Chowdhury, A., and Amlôt, R. (2012). How to Communicate with the Public About Chemical, Biological, Radiological, or Nuclear Terrorism: A Systematic Review of the Literature. Biosecurity and Bioterrorism. 10(4):383-95.
The authors reviewed 33 peer-reviewed studies that assessed communication strategies or information needs using hypothetical CBRN scenarios or in actual CBRN incidents to identify in advance what people would want to know, where they would get information from, and how messages should be presented. These strategies are critical for ensuring that affected individuals get to the right place at the right time to receive assessment and interventions.
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U.S Department of Homeland Security, American College of Medical Toxicology. (2012). Report on the Toxic Chemical Syndrome. Definitions and Nomenclature Workshop.
The proceedings from this workshop highlight how participants reached consensus on a list of syndromes, their definitions, and designated syndrome names to establish a common language for chemical defense planners, policy makers, first responders, first receivers, and hazardous materials stakeholders.
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* U.S. Army Borden Institute. (2014). Medical Management of Chemical Casualties Handbook.
This webpage includes links to agent-specific chapters that include comprehensive descriptions of the effects of chemical agents on different organs and systems within the body by exposure type, as well as guidance for making a differential diagnosis, and medical management information for clinicians. Note: some of the decontamination techniques are not recommended for civilian use.
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This webpage includes links to agent-specific chapters that include comprehensive descriptions of the effects of chemical and biological agents on different organs and systems within the body by exposure type, as well as treatment guidance for clinicians.
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U.S. Army Soldier and Biological Chemical Command. (2001). Guidelines for Responding to a Chemical Weapons Incident.
This guidebook was designed to assist response personnel in dealing with critical incident management decisions consistent with an actual chemical weapons (CW) emergency response. It provides specific information on initial response activities, incident command structures, decontamination needs, and differing roles across the law enforcement, healthcare, and emergency response sectors.
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* U.S. Department of Defense, U.S. Department of Health and Human Services, U.S. Department of Transportation, et al. (2019). Fourth Generation Agents: Medical Management Guidelines.
This document was designed to educate and prepare fire, emergency medical services, and hospital staff and guide the medical management of patients exposed or potentially exposed to a fourth generation agent. This is one PDF document that is divided into two sections, one for pre-hospital care and one for in-hospital care.
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U.S. Department of Defense, U.S. Department of Health and Human Services, U.S. Department of Transportation, et al. (2019). Fourth Generation Agents: Reference Guide.
This guide was designed to educate and prepare hazardous materials response teams, and includes information on: chemical and physical properties of fourth generation agents; detection, firefighting, personal protective equipment; and decontamination recommendations for situations when responding to a known or suspected fourth generation nerve agent incident. This guide will assist hazardous materials response teams develop specific guidance and training to enhance overall preparedness efforts.
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U.S. Department of Defense, U.S. Department of Health and Human Services, U.S. Department of Transportation, et al. (2019). Fourth Generation Agents: Safety Awareness for First On-Scene Responders.
This resource was designed to educate and prepare first responders (e.g., law enforcement, fire, and emergency medical services personnel) who may be exposed to a fourth generation nerve agent during a response. It includes sections on agent identification, rescuer protection, and decontamination
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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2017). Acute Patient Care Guidelines.
Emergency medical service and hospital-based healthcare providers can use the information on this webpage to prepare to care for patients exposed to select chemicals. Guidelines are split into prehospital and hospital management and are currently available for ammonia, chlorine, hydrogen cyanide, mustard agents, nerve agents, and phosgene. Once users select the hazard, information is provided by zone (e.g., hot zone, decontamination zone, and support zone).
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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2021). Information for the Hospital Providers.
This webpage includes links to resources to assist hospital providers with receiving, triaging, assessing, and treating chemical agent casualties.
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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2021). Strategy for Developing a Community Chemical Response Plan.
This webpage includes information to assist emergency response planners with developing a chemical response plan for their community.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (n.d.). Chemical Hazards Emergency Medical Management (CHEMM). (Accessed 11/3/2021.)
This website provides a wide range of information on chemical hazards for first responders, healthcare providers, and incident command staff.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2018). Contingency Medical Countermeasures for Treating Nerve Agent Poisoning.
This document provides guidance to medical personnel and first responders to include information on contingency medical countermeasures for treating nerve agent-exposed patients in the case that standard medical countermeasures are in short supply. It includes flow charts for both adult and pediatric patient nerve agent medical countermeasure treatment protocols.
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* U.S. Department of Health and Human Services, U.S. Department of Transportation, and U.S. Department of Homeland Security. (2018). Nerve Agent Information for Emergency Medical Services and Hospitals.
This tip sheet can serve as a refresher on standard protocols for recognizing, treating, and protecting emergency responders and medical practitioners from nerve agent exposures. This document also compares and contrasts the clinical effects of nerve agents and opioids as an aid to distinguishing nerve agent exposure from opioid overdose cases.
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U.S. Environmental Protection Agency (n.d.). Emergency Planning and Community Right-to-Know Act. (Accessed 1/30/2022.)
This agency website provides information on the Emergency Planning and Community Right-to-Know Act (EPCRA) and how it pertains to community planning for chemical emergencies
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This short one-page resource can be used as a quick reference guide to the Emergency Planning and Community Right-to-Know Act (EPCRA). It summarizes its purpose, requirements, and impacts on emergency planning and reporting needs
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U.S. Environmental Protection Agency. (2016). Chemical Emergency Preparedness and Prevention on Tribal Lands.
This factsheet provides information for Tribal leaders to become familiar with Emergency Planning and Community Right-to-Know Act (EPCRA) and the Clean Air Act (CAA). It explains how these chemical accident prevention provisions apply to tribal lands and their role under these acts
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* United States Army Medical Research Institute of Chemical Defense, Chemical Casualty Care Division. (n.d.). Chemical Casualty Care Division. (Accessed 1/30/2022.)
Medical professionals can access links to a variety of tools, products, and courses on chemical casualty care from this web page.
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Veenema, T.G. (2018). Disaster Nursing and Emergency Preparedness: For Chemical, Biological, and Radiological Terrorism and Other Hazards, 4th Edition. (Book available for purchase.) Springer Publishing.
This book provides information to prepare nurses to respond to disasters and public health emergencies. This latest edition includes information on hospital and emergency department preparedness, as well as a digital teacher's guide containing critical thinking questions and exercises.
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Wanner, G.K., Atti, S., Jasper, E. (2019). Chemical Disaster Preparedness for Hospitals and Emergency Departments. Jefferson Digital Commons, Thomas Jefferson University, Department of Emergency Medicine Faculty Papers. 95.
This document provides an overview of the requirements and guidelines needed to respond to a chemical disaster incident from a healthcare perspective. It includes resources for training, evaluation of chemically contaminated patients, and pre-hospital and hospital-based decontamination procedures of ambulatory and non-ambulatory at-risk patients
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This manual provides a comprehensive overview of the principles and roles of public health agencies in the management of chemical incidents and emergencies. It provides information for each phase of the emergency cycle, including prevention, planning and preparedness, detection and alert, response, and recovery
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This report highlights the risks and prevention and response strategies associated with flood-, earthquake-, and cyclone-related chemical releases.
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Lessons Learned


Al-Hajj, S., Dhaini, H.R., Mondello, S., et al. (2021). Beirut Ammonium Nitrate Blast: Analysis, Review, and Recommendations. Frontiers in Public Health. 9:657996.
This review provides detailed analysis of the 2020 Beirut chemical disaster in the Port of Beirut, Lebanon. It details the health and environmental implications and makes recommendations to improve chemical safety measures and emergency preparedness efforts
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This issue of The Exchange highlights planning, response, and lessons learned specific to chemical incidents.
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ASPR TRACIE interviewed Susan Cibulsky, PhD, a Senior Policy Analyst with ASPR and Mark Sutter, MD, with the Department of Homeland Security’s / Countering Weapons of Mass Destruction Office, who have both studied the incident and met with some of the responders and clinicians responsible for treating these patients. Together with other federal and non-governmental partners, they have worked to develop scientific and clinical materials to help responders and providers prepare for, recognize, and treat FGA-exposed patients.
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A massive leak of liquefied chlorine gas created a dangerous cloud over the city of Henderson, NV, in the early morning hours of May 6, 1991. Over 200 people (including firefighters) were examined at a local hospital for respiratory distress caused by inhalation of the chlorine and approximately 30 were admitted for treatment. ASPR TRACIE interviewed Chief Bruce Evans (who was a firefighter-paramedic at the time of the incident), asking him to share his experiences and highlight how the fire and emergency response to chemical incidents has changed over the years.
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At 2:39 a.m., on January 6, 2005, Graniteville, SC was the scene of a deadly train derailment. Three chlorine tankers derailed and one ruptured, releasing between 46 and 90 tons of chlorine. In this interview with ASPR TRACIE, Dr. Stephen Grant described the initial chaos in the emergency department and how the medical response was managed in this incident that led to 9 fatalities, 554 people receiving treatment at hospitals, and 75 admissions.
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Chemical incidents can significantly affect community health. The speakers in this webinar shared information on potential effects, recent guidance, and lessons learned, including considerations for novel nerve agents.
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* ASPR TRACIE. (2020). Hospital Patient Decontamination. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response.
The resources in this Topic Collection highlight lessons learned, guidelines, plans, tools, and templates, and promising practices that can help emergency medical practitioners accomplish this goal.
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Cairns, B.A.,Stiffler, A.,Price, F. et al. (2005). Managing a Combined Burn Trauma Disaster in the Post-9/11 World: Lessons Learned From the 2003 West Pharmaceutical Plant Explosion. The Journal of Burn Care and Rehabilitation. 26(2):144-50.
The authors share lessons learned from a January 2003 chemical plant fire and describe the challenges associated with managing patients with combined burn and trauma injuries. Recommendations for future disaster responses are included.
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Chemical Emergency Preparedness and Prevention Office. (2000). First Responders’ Environmental Liability Due To Mass Decontamination Runoff. U.S. Environmental Protection Agency.
This report summarizes a multi-agency drill based on a simulated nerve-agent attack. The authors explain how workers set up the scene to decontaminate victims, including challenges that arose, how they dealt with them, and lessons to incorporate into future planning.
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Clarke, S. A., Weir, A.G. (2020). UK Resilience to a Chemical Incident. (Abstract only.) British Medical Journal Military Health. 166(2):95–98.
This review discusses the impacts of a wide range of chemical incidents to include intentional chemical attacks, terrorism, and accidental events in the United Kingdom. It reviews their effects on infrastructure, economics, public health, and medical care to assess the efficacy of the national health system emergency preparedness and resilience framework
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* Culley, J., Svendsen, E., Craig, J., and Tavakoli, A. (2014). A Validation Study of 5 Triage Systems Using Data from the 2005 Graniteville, South Carolina, Chlorine Spill. Journal of Emergency Nursing. 40(5):453-60.
The authors used data from the 2005 Graniteville, SC chlorine spill to evaluate the appropriateness of 5 commonly used triage systems for assessing casualties from chemical events. They found that the five triage systems did not agree with the actual injury severity from a chemical exposure and that “oxygen saturation measured by pulse oximetry provides early indications and is very predictive of outcome severity in incidents involving irritant chemical exposures such as chlorine.” The article emphasizes the notion that trauma-derived mass casualty triage criteria may not apply well to chemical incidents.
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DeAtley, C. (2012). Hospital Preparedness for “Chemical/Detergent” Suicides. Domestic Preparedness. 8(3): 13-14.
The author explains the trend in chemicals being ingested by suicidal patients, how these chemicals may make the scene and patients' bodies dangerous to caregivers, and strategies for protecting medical staff from these hazards.
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DeLuca M.A., Chai P.R., Goralnick E., et al. (2020). Five Decades of Global Chemical Terror Attacks: Data Analysis to Inform Training and Preparedness. (Abstract only.) Disaster Medicine and Public Health Preparedness. 24:1-12.
Using the Global Terrorism Database, the authors conducted a retrospective analysis dating back five decades to assess trends in chemical agent attacks. Research results identified the specific agents used, the most common route of exposure, and target population, as well as trends that can be of value for future chemical emergency preparedness efforts
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Hardison, L. Jr., Wright, E., and Pizon, A. (2014). Phosgene Exposure: A Case of Accidental Industrial Exposure. Journal of Medical Toxicology. 10(1):51-6.
The authors present their experiences with a case of accidental phosgene exposure, and present treatment recommendations based on lessons learned.
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Lee, E. (2003). Clinical Manifestations of Sarin Nerve Gas Exposure. (Abstract only.) Journal of the American Medical Association. 290(5): 659-662.
The author explains the toxicology, toxicity, and other variables as they relate to sarin gas exposure. Lessons learned from the Tokyo subway attack in 1995 are also discussed.
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Markham, P., Gianato, J., and Hoyer, J. (2015). After Action Review: Emergency Response to January 9, 2014 Freedom Industries Chemical Leak. U.S. Department of Health and Human Services.
Several local health departments participated in a review of the response to the 2014 methanol spill. Interagency communications and public risk communications were listed as challenges, and participants shared that, for example, flushing recommendations were not practical for hospitals (they suggested that in future incidents, hospitals be treated as separate from the business community.)
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Okumura, T., Suzuki, K., Fukuda, A., et al. (1998). The Tokyo Subway Sarin Attack: Disaster Management, Part 1: Community Emergency Response. Academic Emergency Medicine. 5(6):613-7.
The authors summarize the emergency medical services response to the attack, including challenges and strengths. They recommend that responders have access to mobile decontamination facilities in similar events. Chemical effects on responders were significant. Though many effects were psychogenic in nature, the mere perception of harm rendered responders less effective (another reason why responder access to personal protective equipment for chemical events is so important).
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O'Neill, T.B., Rawlins, J., Rea, S., et al. (2012). Complex Chemical Burns Following a Mass Casualty Chemical Plant Incident: How Optimal Planning and Organisation Can Make a Difference. (Abstract only.) Burns. 38(5):713-718.
The authors reviewed patient case notes and surgery logs to identify lessons learned in the management of four severely burned patients injured in a sulphuric acid pipeline rupture.
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Razavi, S., Salamati, P., Harandi, A., and Ghanei, M. (2013). Prevention and Treatment of Respiratory Consequences Induced by Sulfur Mustard in Iranian Casualties. International Journal of Preventive Medicine. 4(4): 383–389.
The authors conducted a literature review of 50 articles related to prevention and treatment of respiratory problems induced by sulfur mustard. They found that most treatments were directed at symptom alleviation, and that oxygen supplementation, tracheostomy in laryngospasm, use of moist air, respiratory physical therapy, mucolytic agents and bronchodilators used in the acute phase led to improved lung injury outcomes.
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U.S. Chemical Safety Board (2021). Investigations.
This independent, non-federal agency, website provides summaries on investigations into the causes and impacts of major chemical incidents across the U.S. Additional information includes safety recommendations, advocacy and policy initiatives, and statistics on chemical incidents
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This planning aid can help multijurisdictional urban area planners manage the recovery from a biological, chemical, or radiological event. Developed from lessons learned during events in Seattle (WA) and Denver (CO), the document provides a recovery planning template along with corresponding planning support annexes for each of the three hazards.
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Van Sickle, D., Wenck, M., Belflower, A., et al. (2009). Acute Health Effects After Exposure to Chlorine Gas Released After a Train Derailment. The American Journal of Emergency Medicine.
The authors discuss findings from a review of medical records and autopsy reports to describe the clinical presentation, hospital course, and pathology observed in persons hospitalized or deceased as a result of chlorine gas exposure after a train derailment in 2005.
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Medical Response to Chemical Hazards


Agency for Toxic Substances and Disease Registry (ATSDR) (2021). Toxic Substances Portal.
This agency website provides comprehensive information on health effects of exposure to toxic chemicals, information on medical response for health professionals and emergency responders, as well as a toxicological resource list of chemical classifications, profiles, and summary FAQs on known hazardous substances
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Chemical incidents can significantly affect community health. The speakers in this webinar shared information on potential effects, recent guidance, and lessons learned, including considerations for novel nerve agents.
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Bevelacqua, A., Stilp, R. (2019). Florida Special Incident Hazardous Materials Medical Protocols. East Central Florida Local Emergency Planning Committee.
These protocols were developed to guide EMS in the treatment of chemically exposed individuals during a hazardous materials incident response. They were intended to be used by local medical leaders, or for individual jurisdictions. Information focuses on toxidromes and their associated protocols, with a special section for treatment and management of exposed K-9 service animals
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Buckley, N., Eddleston, M., and Szinicz, L. (2005). Oximes for Acute Organophosphate Pesticide Poisoning. (Abstract only.) The Cochrane Database of Systemic Reviews. 25(1).
While the traditional treatment for this type of poisoning has been intravenous atropine and oxime (e.g., pralidoxime and obidoxime), the practicality of oximes has been disputed by physicians across the globe. Based on literature reviews, the authors conclude there is not enough evidence either way and emphasize the need for further research.
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This website provides information for both the general public and for professionals about chemical emergencies. Links to case definitions, toxic syndrome descriptions, and medical management guidelines are included for professionals.
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Ciottone, G. (2018). Toxidrome Recognition in Chemical Weapons Attacks. New England Journal of Medicine. 378(17): 1611-1620.
The author discusses deficiencies of existing triage systems for use with chemical agent attack casualties. He proposes a rapid-triage system for chemical warfare agents to “identify those classes of agents that require rapid treatment with antidotes, emergency airway support, and spot decontamination, and then further delineate within that group the class of agent that is present so that the correct antidote can be given.”
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Cone, D., MacMillan, D., Parwani, V., and Van Gelder, C. (2008). Pilot Test of a Proposed Chemical/Biological/Radiation/Nuclear-Capable Mass Casualty Triage System. (Abstract only.) Prehospital Emergency Care. 12(2):236-40.
The authors share results of a pilot test that measured a triage system for patients exposed to chemical, biological, radiological, or nuclear contamination. They found that while the algorithm could be applied by trained paramedics, there was a significant under-triage rate and more research needs to be conducted.
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The authors used patient data from a chemical incident to describe, categorize, and validate symptoms and signs of irritant gas syndrome agent exposures. They grouped signs/symptoms into three clusters: respiratory, chest discomfort, and eye, nose, and/or throat pain.
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Dotson, G., Hudson, N., and Maier, A. (2016). A Decision Support Framework for Characterizing and Managing Dermal Exposures to Chemicals during Emergency Management and Operations. Journal of Emergency Management. 13(4): 359-380.
The authors reviewed literature and developed a conceptual framework for a decision support system that can help emergency responders assess and manage chemical emergencies involving dermal exposures. Additional checklists and figures are included.
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* Henretig, F., Kirk, M., and McKay, C. (2019). Hazardous Chemical Emergencies and Poisonings. (Free registration required.) New England Journal of Medicine. 380: 1638-1655.
This contemporary review article on management of chemical casualties in a hospital environment includes adult and pediatric considerations. The authors provide an overview of decontamination, toxidromes, patient presentation, and current clinical management strategies for both patient populations.
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Hulse, E., Davies, J., Simpson, A. et al. (2014). Respiratory Complications of Organophosphorus Nerve Agent and Insecticide Poisoning. Implications for Respiratory and Critical Care. American Journal of Respiratory and Critical Care Medicine. 190(12):1342-54.
This review article discusses the clinical effects of exposure to organophosphorus nerve agents (e.g., Sarin, Soman, and Tabun), and includes a comprehensive summary of treatment approaches from respiratory and critical care perspectives.
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Jones, T., Craig, A., Hoy, D., et al. (2000). Mass Psychogenic Illness Attributed to Toxic Exposure at a High School. The New England Journal of Medicine. 342: 96-100.
The authors review a case from 1998, where a teacher noticed a smell resembling gasoline, the school was evacuated, 38 people were hospitalized at first, and another 71 reported to the emergency room (after the school reopened). No medical or environmental explanation was found, and the authors describe the symptoms, investigation, and outcome of the event.
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Kovarik, Z. (2016). Workshop on Chemical Warfare Agents: Toxicity, Emergency Response and Medical Countermeasures. Organisation for the Prohibition of Chemical Weapons (OPCW).
This presentation summarizes information on chemical weapon toxicity and mechanisms of action; emergency response to a chemical terrorist attack; and medical countermeasures and decontamination for chemical weapons.
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Kozak, R., Siegel, S., and Kuzma, J. (2003). Rapid Atropine Synthesis for the Treatment of Massive Nerve Agent Exposure. (Abstract only.) Annals of Emergency Medicine. 41: 685-688.
The authors developed and tested a protocol for compounding a large volume of injectable atropine from powder; this low-cost, quick turnaround protocol could be used by hospitals in a timely manner during a chemical emergency.
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Madsen J. (2019). Chemical Terrorism: Rapid Recognition and Initial Medical Management. (Abstract only; linked reference list available.)
The author shares guidance on “rapid recognition and initial management of patients exposed to the chemical agents that are most likely to be used in warfare or by terrorists” based on an ongoing literature review.
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Markel, G., Krivoy, A., Rotman, E., et al. (2008). Medical Management of Toxicological Mass Casualty Events. The Israel Medical Association Journal. 10(11): 761-766.
This response algorithm provides guidelines for healthcare responders in toxic mass casualty incidents. The authors emphasize early recognition of the incident, communication with command and control, responder self-protection, and regular training and exercises.
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Mishra R., Geiling J. (2019). Chemical Agents in Disaster: Care and Management in the Intensive Care Unit. (Abstract only.) Critical Care Clinics. 35(4):633-645.
This resource provides information on the medical care of chemically exposed patients in a hospital intensive care unit. It differentiates between lung agents, blood agents, vesicants, and nerve agents to help intensivists become familiar with the clinical presentation and management of individuals affected during a chemical attack
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Moshiri, M., Darchini-Maragheh, E., and Balali-Mood, M. (2012). Advances in Toxicology and Medical Treatment of Chemical Warfare Nerve Agents. Daru. 20(1): 81.
The authors list and discuss therapies (in addition to the traditional atropine/oxime combination) for patients exposed to nerve agents.
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Naughton S.X., Terry A.V. Jr. (2018). Neurotoxicity in Acute and Repeated Organophosphate Exposure. Toxicology. 408:101-112.
This review describes the uses for organophosphates globally, risks associated with exposure to organophosphates, mechanisms of toxicity, and potential therapeutics. It details the neurologic impacts and psychiatric symptoms connected to long-term exposure to include aerotoxic syndrome, Gulf war illness, and other neurodegenerative diseases
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New York State Department of Health. (2005). Chemical Terrorism Preparedness and Response Card.
This tool summarizes: how to recognize and diagnose health effects of chemical agents; decontamination and treatment considerations; antidote recommendations by agent type; and personal protective equipment for health professionals
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Oregon Health Authority (n.d.). Chemical Preparedness. (Accessed 1/30/2022.)
This webpage contains a compilation of chemical preparedness information for laboratories that include lab response protocol, flow charts, specimen collection forms, and chemical exposure information
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* Organisation for the Prohibition of Chemical Weapons (OPCW). (2015). Blister Agents and Their Countermeasures. (Free registration required.)
This poster includes information on blister agents (i.e., sulfur mustard, nitrogen mustard, and Lewisite) and their countermeasures.
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* Organisation for the Prohibition of Chemical Weapons (OPCW). (2015). Blood Agents and Their Countermeasures.
This poster includes information on blood agents (e.g., hydrogen cyanide and sodium cyanide) and their countermeasures.
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* Organisation for the Prohibition of Chemical Weapons (OPCW). (2015). Choking Agents and Their Countermeasures.
This poster includes information on choking agents (i.e., chlorine and phosgene) and their countermeasures.
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* Organisation for the Prohibition of Chemical Weapons (OPCW). (2015). Organophosphorus Nerve Agents and Their Countermeasures.
This poster includes information on organophosphorus nerve agents (e.g., VX, Sarin, Tabun, and Soman) and their countermeasures.
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Organisation for the Prohibition of Chemical Weapons (OPCW) (2019). Practical Guide for Medical Management of Chemical Warfare Casualties.
This resource contains information, guidelines, diagrams, and other materials to be used by medical practitioners treating casualties of a chemical weapons attack. Chapters are divided according to chemical agent type and include vesicants, nerve agents, blood agents, and riot control agents to name a few. Individual chapters further discuss the chemical and toxicological properties of each agent as well as clinical manifestations, triage, pre-hospital management, and hospital management
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Page, L., Kesheshian, C., Leonardi, G., et al. (2010). Frequency and Predictors of Mass Psychogenic Illness. (Abstract only.) Epidemiology. 21(5): 744-747.
The authors reviewed a random sample of 280 chemical incidents and found that 19 “were probable episodes of mass psychogenic illness.” They shared that odor was a strong predictor of this phenomenon and suggest that “a substantial minority” of chemical incidents may be a result of mass psychogenic illness.
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Thiermann, H., Worek, F., and Kehe, K. (2013). Limitations and Challenges in Treatment of Acute Chemical Warfare Agent Poisoning. (Abstract only.) Chemico-Biological Interac.
The authors explain that traditional treatment with autoinjectors (filled with a combination of atropine and an oxime) is not effective against all nerve agents. They list considerations for treatment, including broad spectrum oximes or a combination of oximes and further research into the use of stem cells.
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This resource provides information from the Scientific Advisory Board of the OPCW on best practices for preventing and treating acute, prolonged, and repeated organophosphorus nerve agent exposure. It includes pre- and post-exposure treatment practices, new developments on decontaminants and absorbing materials as well as recommendations for medical countermeasures research
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* U.S. Department of Defense, U.S. Department of Health and Human Services, U.S. Department of Transportation, et al. (2019). Fourth Generation Agents: Medical Management Guidelines.
This document was designed to educate and prepare fire, emergency medical services, and hospital staff and guide the medical management of patients exposed or potentially exposed to a fourth generation agent. This is one PDF document that is divided into two sections, one for pre-hospital care and one for in-hospital care.
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* U.S. Department of Health and Human Services, U.S. Department of Transportation, and U.S. Department of Homeland Security. (2018). Nerve Agent Information for Emergency Medical Services and Hospitals.
This tip sheet can serve as a refresher on standard protocols for recognizing, treating, and protecting emergency responders and medical practitioners from nerve agent exposures. This document also compares and contrasts the clinical effects of nerve agents and opioids as an aid to distinguishing nerve agent exposure from opioid overdose cases.
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Plans, Tools, and Templates


Agency for Toxic Substances and Disease Registry. (2020). ATSDR Toolkits.
This website contains information on and links to several ATSDR toolkits including the Assessment of Chemical Exposure (ACE) Toolkit that contains surveys, consent forms, training materials, and Epi Info 7 database material to be used after a chemical incident; the Epi Contact Assessment Symptom Exposure (EpiCASE) toolkit that is can help public health and disaster response organizations rapidly assess affected or exposed persons; the Rapid Response Registry that aids state and local response agencies quickly register exposed, or potentially exposed, individuals during a chemical emergency; and the Community Disaster Resilience Tool (CDRT) that is a map-based tool used to facilitate community assessment of their specific vulnerabilities.
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* Albanese, J., Burich, D., Smith, D. et al. (2014). Clinical Guidelines for Responding to Chemical, Biological, Radiological, Nuclear and Trauma/Burn Mass Casualty Incidents: Quick Reference Guides for Emergency Department Staff. (Free registration required.) Journal of Business Continuity & Emergency Planning 8(2):122-33.
The authors describe a quick reference for a hospital’s first response to chemical emergencies. Steps based on the word "DISASTER" can help staff quickly assess and respond to an incident (Detection, ICS, Safety/Security, Assessment, Support, Triage and Treatment, Evacuate, Recovery).
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ASPR TRACIE interviewed federal staff to discuss tools and resources that can help emergency responders and healthcare providers learn more about and respond to chemical incidents involving industrial chemicals, chemical warfare agents, and emerging threats.
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* ASPR TRACIE. (2020). Hospital Patient Decontamination. U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response.
The resources in this Topic Collection highlight lessons learned, guidelines, plans, tools, and templates, and promising practices that can help emergency medical practitioners accomplish this goal.
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The 2019-2023 HPP Funding Opportunity Announcement (FOA) requires healthcare coalitions (HCCs) to develop a complementary coalition-level chemical emergency surge annex to their base medical surge/trauma mass casualty response plan. This annex aims to improve capacity and capabilities to manage exposed or potentially exposed patients during a chemical emergency.
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Association of American Railroads. (2018). AskRail. (Registration required.)
This app can give first responders real-time data regarding the type of hazardous materials a railcar is carrying, providing for a more informed response in the event of an emergency.
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This screening tool was developed to help determine and prioritize public health risk associated with intentional or accidental release of chemicals into the atmosphere.
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This report details the cognitive tool, developed by the Paris Fire Brigade, that outlines the exact order of response activities to be used as a framework for improving health system preparedness and limiting contamination, exposures, and death.
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California Emergency Medical Services Authority (2017). Incident Planning Guide: Chemical Incident.
This incident planning guide was intended to help responders plan for, and address, chemical incidents and exposures such as chlorine, nerve agent, blister agent, and toxic industrial chemical. Hospitals can tailor this incident planning guide for their specific facility requirements
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California Office of Emergency Services (2014). Hazardous Materials Toolkit.
This toolkit is comprised of four major components common to hazardous materials incident planning needs. They include an introduction with objectives of the plan; concept of operations with subsections on preparedness and planning; roles and responsibilities; and appendices for additional resources
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Connecticut Department of Public Health Environmental and Occupational Health Assessment Program (2018). Hazardous Materials Response: A Guide to Aid Local Health Directors and Staff in Planning for and Responding to Hazardous Materials Releases.
This plan was designed for state and local health departments to be used during a hazardous material emergency. It focuses on an intentional release or a terror-related event with checklists and templates for each phase of a response
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* County of Los Angeles, Department of Public Health. (2012). Terrorism Agent Information and Treatment Guidelines for Clinicians and Hospitals.
Healthcare providers can use this handbook to learn more about: bioterrorism agents (e.g., smallpox, tularemia, and ricin); treatments for select chemical agents (e.g., sarin, sulfur mustard, and cyanide); and treatments for radiological and nuclear incidents.
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Department of Health Services, County of Los Angeles. (2017). Chempack Deployment for Nerve Agent Release.
Los Angeles County shares jurisdiction-specific guidelines and roles and responsibilities for the release of CHEMPACK in this document, which may be adapted for planning purposes by other jurisdictions.
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Environmental Protection Agency, Chemical Emergency Preparedness and Prevention Office, Office of Emergency Management (2015). Chemical Emergency Preparedness and Prevention Documents – Compilation.
This resource is a compilation of documents created by several agency offices that includes hazardous materials planning guidance, hazard communication standards, hazardous waste regulations, and chemical safety, among others. Each document is linked with date of publication and agency specific information
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Federal Emergency Management Agency (FEMA) (n.d.). CBRNResponder. (Accessed 1/30/2022.)
This FEMA sponsored chemical, biological, radiological, and nuclear platform was developed to support CBRN incident data sharing and multi-hazard event management efforts. The tool integrates federal guidance, policy, planning, preparedness, and operational resources as a free service to all state, local, tribal, and territorial emergency response organizations
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Federal Emergency Management Agency (FEMA) (n.d.). ChemResponder. (Accessed 1/30/2022.)
This tool, created as a complement to the RadResponder Network, aims to provide real-time data collection, management, and sharing capabilities to hazmat community stakeholders in the event of a chemical incident. It provides users the ability to manage equipment, personnel, and interagency partnerships during a response effort via the web, smartphones, or tablets
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Federal Emergency Management Agency (FEMA) (n.d.). Interagency Modeling and Atmospheric Assessment Center (IMAAC). (Accessed 1/30/2022.)
This federally supported center coordinates and disseminates atmospheric dispersion modeling and hazard prediction products to be used by emergency responders during a hazardous material release. Specifically, the center provides plume modeling analysis to aid in decision-making, as well as access to a digital media toolkit to facilitate communication during a chemical emergency, national and local training information, and links to partner sites and resources
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Good, K., Winkel, D., VonNiederhausern, M. et al. (2013). Medical Mitigation Model: Quantifying the Benefits of the Public Health Response to a Chemical Terrorism Attack. Journal of Medical Toxicology. 9(2):125-32.
This article describes the Chemical Terrorism Risk Assessment (CTRA) and Chemical Infrastructure Risk Assessment (CIRA) Medical Mitigation Model, which was developed to simulate the medical response that would be employed following a chemical attack on the general public. The authors note that this model “can be used to inform first-responder actions/training, guide policy decisions, justify resource allocation, and direct knowledge-gap studies.”
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This incident planning guide uses a chlorine tank explosion scenario as the basis for developing a chemical emergency management plan. The resource is formatted as template with questions to be used during an exercise or planning session
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Hospital Incident Command System. (2006). Chemical Attack-Nerve Agent. Incident Planning Guide.
This planning guide is based on a terror attack involving sarin gas. It can be used as is, or tailored to specific jurisdictions.
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This plan provides a systematic approach to effective response measures in the event of a hazardous chemical release or incident. The plan outlines the responsibilities and functions between local governmental entities, industry, and partners supporting incident response
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This quick-reference cardset is intended for use by pre-hospital and hospital personnel and groups the exposure by class rather than agent (corrosives, asphyxiants, cholinergics) for easier initial assessment and treatment. It includes detailed descriptions of patient treatment steps (decontaminate and collect information; treat chemical exposure; collect blood and urine specimens) following hazardous materials exposure.
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National Institute for Occupational Safety and Health. (2010). NIOSH Pocket Guide to Chemical Hazards (NPG). Centers for Disease Control and Prevention.
This guide provides information on hundreds of chemicals/classes for workers, employers, and occupational health professionals. Information on medical treatment, personal protective equipment, respirator selection, and first aid is also included.
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National Institute for Occupational Safety and Health (NIOSH) (2011). Emergency Response Safety and Health Database (ERSH-DB).
This occupational health and safety database contains information on high-priority chemical, biological and radiological agents that could be encountered by emergency response personnel during a terrorist event. It includes a search capability that details the agent name, properties, characteristics, and occupational exposure limits
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National Institute for Occupational Safety and Health (NIOSH) (2016). Dermal Exposure Risk Management and Logic (DERMaL eToolkit).
This tool provides emergency preparedness responders, incident commanders, and other emergency management professionals direct access to a resource library of references and information related to dermal (skin) exposure to chemicals
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* National Library of Medicine. (n.d.). ToxTutor. (Accessed 1/30/2022.)
This tutorial covers the primary principles of toxicology and includes information on dose and response, risk assessment, exposure standards and guidelines, absorption, distribution, cellular toxicology, and the like.
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National Library of Medicine. (2019). ASPIRE, a Decision-Aided Tool for PRISM.
This webpage links to ASPIRE (Algorithm Suggesting Proportionate Incident Response Engagement), a decision aiding tool developed by experts in medicine and emergency response to help identify the need for patients exposed to chemical agents to undertake wet decontamination.
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This template helps responders and emergency planners prepare for a possible hazardous material incident using their local emergency planning committee framework. It outlines the types of materials communities should be aware and the procedures and capabilities within that jurisdiction that are available during a response
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New York State Department of Health. (2005). Chemical Terrorism.
This wall chart for healthcare providers contains information on recognizing, diagnosing, and treating health effects caused by exposure to major classes of chemical agents, and describes methods to assist healthcare workers with protecting themselves against exposure during a chemical incident.
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This webpage can serve as the starting point for hospital decontamination planning and includes foundational information on personal protective equipment, training first responders/ receivers, response components (e.g., isolation, lockdown, decontamination, equipment), and recovery components (e.g., waste management). Though geared to hospitals, the document contains a great deal of valuable information about PPE and programs/training of relevance to first responders, particularly those that are not fire-based and may model their PPE and programs similarly in order to support warm-zone response support when appropriate. Templates and case studies are provided in appendices.
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* Pipeline and Hazardous Materials Safety Administration. (2020). Emergency Response Guidebook (ERG). U.S. Department of Transportation.
This version of the guidebook can help first responders respond to hazardous materials incidents within the first 30 minutes.
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* U.S. Army Borden Institute. (2014). Medical Management of Chemical Casualties Handbook.
This webpage includes links to agent-specific chapters that include comprehensive descriptions of the effects of chemical agents on different organs and systems within the body by exposure type, as well as guidance for making a differential diagnosis, and medical management information for clinicians. Note: some of the decontamination techniques are not recommended for civilian use.
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This webpage includes links to agent-specific chapters that include comprehensive descriptions of the effects of chemical and biological agents on different organs and systems within the body by exposure type, as well as treatment guidance for clinicians.
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U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (n.d.). Hospital Surge Model, Version 1.3. (Accessed 10/1/2018.) Office of the Assistant Secretary for Preparedness and Response.
The AHRQ Hospital Surge Model estimates the resources needed in your hospital(s) to treat casualties resulting from specific biological, chemical, nuclear, or radiological scenarios. For the selected scenario, the model estimates the number of casualties and the required hospital resources to treat the casualties. NOTE: The Hospital Surge Model went out of existence when its support contract ended on September 30, 2011 but the assumptions for the different threats may be helpful.
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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2018). CHEMM Intelligent Syndromes Tool (CHEMM-IST 2.0) - Beta.
A prototype decision support tool developed by experts in medicine and emergency response as an aid for identifying the chemical a patient was exposed to in a mass casualty incident. The tool assumes chemical inhalation only and is currently being tested and validated. Emergency care providers can review it as a potential tool for use by basic and advanced life support providers and “hospital first receivers.”
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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2021). CHEMM Toxidrome Cards.
These cards include user-friendly guidance that can help first responders understand main considerations associated with specific chemical toxidromes.
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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2021). Medical Countermeasures Database.
This webpage includes links to information on countermeasures for chemical agent exposure, including mechanism of action; pharmacokinetics and toxicokinetics; approved indications, available formulations and their shelf-life, adverse effects, and contraindications.
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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2021). Types and Categories of Hazardous Chemicals and Related Toxidromes.
Users can click on nearly every chemical listed for links to resources related to medical care.
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U.S. Department of Health and Human Services, National Library of Medicine, Specialized Information Services and the Office of the Assistant Secretary for Preparedness and Response. (2013). Wireless Information System for Emergency Responders (WISER).
The Wireless Information System for Emergency Responders (WISER) is a searchable database providers may use to quickly obtain response, treatment, and clean-up information for various weapons of mass destruction, including chemical agents. Users may access information via the online version or as stand-alone applications for PC, iOS & Android devices. WISER also contains the Chemical Hazards Emergency Medical Management (CHEMM) resource.
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U.S. Department of Labor, Occupational Safety and Health Administration (n.d.). Chemical Reactivity Hazards. (Accessed 1/31/2022.)
This agency website details types of chemical reactions that can occur when exposed to other chemicals, hazardous materials, or certain physical conditions. It describes specific dangers associated with chemical reactions when not properly managed and provides additional information on standards, hazard recognition, and hazard evaluation. This resource can be used when supporting a chemical emergency response to ensure safety of individuals and responders
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Agencies and Organizations


Agency for Toxic Substances and Disease Registry. Homepage.
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American Association of Poison Control Centers. American Association of Poison Control Centers.
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American College of Emergency Physicians Disaster Medicine Section Chemical Disasters.
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Centers for Disease Control and Prevention Laboratory Response Network for Chemical Threats (LRN-C).
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Centers for Disease Control and Prevention. Emergency Preparedness and Response: Chemical Emergencies.
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Cybersecurity and Infrastructure Security Agency Chemical Security.
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International Association of Fire Chiefs Topics and Tools: HAZMAT.
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National Chemical Emergency Centre Chemical Emergency Response.
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National Institute for Occupational Safety and Health. Emergency Response Resources: Chemical Hazards.
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National Oceanic and Atmospheric Administration, Office of Response and Restoration Oil and Chemical Spills.
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U.S. Chemical Safety Board Homepage.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. 2017-2018 PHEMCE Strategy and Implementation Plan.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, and the National Library of Medicine, Specialized Information Services. Chemical Hazards Emergency Medical Management (CHEMM).
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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. BARDA. Chemical, Biological, Radiological, and Nuclear (CBRN) Threat Programs.
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U.S. Department of Homeland Security. Hazardous Materials Release.
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U.S. Department of Labor, Occupational Safety and Health Administration Emergency Preparedness and Response.
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