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Chemical Hazards
Topic Collection
July 16, 2019

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.   

Related information can be found in 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 awareness-level series of 12 webinars discusses the medical and psychological impact of industrial chemicals (e.g., gases, agricultural chemicals, cyanide, fumigants, and neurotoxins) used as terrorist weapons. Major health effects, assessment and treatment modalities, and public health management strategies are covered.
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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. and Amlot, R. (Eds.). (2019). Decontamination Guidance for Chemical Incidents. 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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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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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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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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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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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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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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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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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. (2017). 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 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). (2017). 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). (2017). 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). (2017). 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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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2017). 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, 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 6/29/2019.)
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, 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. Department of Health and Human Services. Chemical Hazards Emergency Medical Management (CHEMM). (2017). 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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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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Yale New Haven Health System Center for Emergency Preparedness and Disaster. (2013). Chemical Clinical Guidelines: A Quick Guide for the Management of Chemical Disasters for Emergency Department Personnel.
This guide serves as 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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Chemical Countermeasures


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). (2017). 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). (2017). 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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Considerations for Special Populations


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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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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U.S. Department of Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2017). 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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Education and Training


This awareness-level series of 12 webinars discusses the medical and psychological impact of industrial chemicals (e.g., gases, agricultural chemicals, cyanide, fumigants, and neurotoxins) used as terrorist weapons. Major health effects, assessment and treatment modalities, and public health management strategies are covered.
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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). 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. (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. (2018). 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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Columbia University School of Nursing. (2005). Emergency! Chemical Incidents.
This scenario-based training module, while slightly dated, provides an overview of key emergency preparedness issues that may be faced by a hospital clinician in a chemical incident. Chemical warfare agents, hospital emergency command, and roles and tasks are covered. Links to related resources are provided at the bottom of the page.
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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. 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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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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Geyer, B. (2016). Chapter 112 – Nerve Agent Mass Casualty Incidents. (First page only.) Ciottone's Disaster Medicine (Second Edition).
The author explains how nerve agents affect the body, and how they can be weaponized. Pre- and post-incident considerations for healthcare providers are also listed.
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Harvard T.H. Chan School of Public Health. (2015). Hazardous Material Exercise Evaluation Form.
Emergency planners can use this checklist to assess their capabilities related to a hazardous material incident. It includes measures specific to CHEMPACK, and decontamination, and the like.
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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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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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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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Occupational Safety and Health Administration. (2008). Hazardous Waste Operations and Emergency Response. 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 presentation identifies common nerve agents, lists signs and symptoms of exposure, provides casualty estimates, and provides an overview antidotes and the CHEMPACK program.
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Tarrant County Advanced Practice Center. (2005). Responding to Chemical/Radiological Terrorism: Training Manual. National Association of County and City Health Officials.
These training materials are geared towards public health staff, medical emergency department staff, and first responders. Participants will learn how to respond to incidents involving nuclear, radiological, or chemical weapons of mass destruction.
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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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Guidance and Guidelines


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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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. and Amlot, R. (Eds.). (2019). Decontamination Guidance for Chemical Incidents. 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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* 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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Disaster Information Management Research Center, National Library of Medicine/ National Institute of Health. (2018). Chemical Emergencies.
This webpage includes links to information on preparedness, response, and recovery from chemical emergencies. Resources include CBRNE/Hazmat guidelines and training for the main classes of chemical agents, for healthcare providers, emergency managers and the public health workforce.
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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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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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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 Borden Institute. (2017). 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 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). (2017). 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). (2017). 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 6/29/2019.)
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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United States Army Medical Research Institute of Chemical Defense, Chemical Casualty Care Division. (2015). Chemical Casualty Care Division.
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. (2012). Disaster Nursing and Emergency Preparedness: For Chemical, Biological, and Radiological Terrorism and Other Hazards, 3rd 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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* Yale New Haven Health System Center for Emergency Preparedness and Disaster. (2013). Chemical Clinical Guidelines: A Quick Guide for the Management of Chemical Disasters for Emergency Department Personnel.
This guide serves as 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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Lessons Learned


* 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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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. 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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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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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


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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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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This presentation is based loosely on the 2007 article “Bringing Order Out of Chaos: Effective Strategies for Medical Response to Mass Chemical Exposure.” The speaker lists three primary elements of an effective response strategy: quickly recognizing a hazard exists; “closing the silent gap” (creating a community-related assessment to try to predict the most likely chemicals, using a tiered response strategy, and establishing a communications network); and prioritizing care and allocating resources to maximize effect.
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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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Lansdowne, K., Scully, C., Galeotti, L., et al. (2015). Recent Advances in Medical Device Triage Technologies for Chemical, Biological, Radiological, and Nuclear Events. (Abstract only.) Prehospital and Disaster Medicine. 30(3): 320-323.
The authors provide an overview of chemical, biological, radiological, or nuclear triage technology (e.g., apps, electronic triage tags, diagnostic field devices, and decision support systems, such as the Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool [CHEMM-IST]).
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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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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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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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Subbarao, I., Johnson, C., Bond, W., et al. (2005). Symptom-Based, Algorithmic Approach for Handling the Initial Encounter with Victims of a Potential Terrorist Attack. Prehospital Disaster Medicine. 20(5):301-30.
The authors create and illustrate six inter-connected symptom-based algorithms that can help healthcare responders identify and treat chemical attack victims.
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Tuorinsky, S., Caneva, D., and Sidell, F. (2008). Triage of Chemical Casualties. Chapter 15 of Medical Aspects of Chemical Warfare. U.S. Army.
This chapter covers chemical warfare agent classes and existing triage systems to be used in chemical agent mass casualties.
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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


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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* 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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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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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 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 Library of Medicine. (n.d.). ToxTutor. (Accessed 7/16/2019.)
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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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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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 Borden Institute. (2017). 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 Health and Human Services, Chemical Hazards Emergency Medical Management (CHEMM). (2017). 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). (2017). 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). (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). (2018). 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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* Yale New Haven Health System Center for Emergency Preparedness and Disaster. (2013). Chemical Clinical Guidelines: A Quick Guide for the Management of Chemical Disasters for Emergency Department Personnel.
This guide serves as 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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Agencies and Organizations


Agency for Toxic Substances and Disease Registry. Toxic Substances Portal.
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Centers for Disease Control and Prevention. Emergency Preparedness and Response: Chemical Emergencies.
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National Institute for Occupational Safety and Health. Emergency Response Resources: Chemical Hazards.
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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. Biomedical Advanced Research and Development Authority (BARDA).
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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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