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Pre-Hospital Patient Decontamination
Topic Collection
June 27, 2022

Topic Collection: Pre-Hospital Patient Decontamination

Caring for patients on the scene of an incident who have been contaminated by a hazardous material calls for strict planning to protect both the patient and the responder. 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. In addition to these resources, providers are encouraged to contact local poison control centers during an event for real-time access to expertise and additional databases and information sources than are available in the field.

This Topic Collection was refreshed in 2022. Each resource in this 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


Chemical Hazard Emergency Medical Management. (2014). Chemical Decontamination Procedures. U.S. Department of Health and Human Services.
This webpage includes procedural information on decontaminating survivors of a mass casualty event before they report for medical care. It includes guidance on setting up decontamination corridors, safe areas, and medical triage areas and includes prehospital and emergency department medical guidance for specific chemical exposures.
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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., and Ignacio, J., et al. (2014). Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities. U.S. Department of Homeland Security and U.S. Department of Health and Human Services.
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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Cook, L. (2010). Teaching Hazmat Decontamination. Journal of Emergency Medical Services.
The author discusses contamination, the different types of decontamination typically performed on an incident scene, and special challenges that might arise (e.g., patient refusal of decontamination) and how to manage them.
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Office of Environmental Management. (2014). Pre-Hospital Practices for Handling a Radiologically Contaminated Patient. U.S Department of Energy.
The speakers share medical practices for caring for and managing patients potentially contaminated with radioactive material. Information on personal protective equipment, triage, patient transport, and other related issues is also included.
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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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Transportation Emergency Preparedness Program. (2014). Pre-Hospital Practices for Handling a Radiologically Contaminated Patient. U.S. Department of Energy.
This video highlights personal protective needs for responder safety; illustrates proper patient management, including transport; and shares strategies for returning responders and equipment to use after transporting a patient exposed to a radiological contamination hazard.
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U.S. Department of Health and Human Services. (2005). Decontamination of Children.
This video explains how children differ from adults physically and emotionally, and provides recommendations for pediatric decontamination.
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Books Available for Purchase


Beebe, R. (2012). Chapter 26: Hazardous Materials Operations. (Book available for purchase.) Professional Paramedic Vol. III Trauma Care and EMS Operations.
This chapter provides a general overview of emergency medical response principles and practices for decontaminating patients on the scene of a hazardous materials incident.
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Blackwell, T., Brenna, K., DeAtley, C., and Yee, A. (2015). Medical Support for Hazardous Materials Response. (Book available for purchase.) Emergency Medical Services: Clinical Practice and Systems Oversight, 2 Volume Set.
The authors review hazardous materials response planning through all aspects of response, including decontamination and medical monitoring of response personnel.
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Limmer, D., O'Keefe, M., and Dickinson, E.T. (2011). Chapter 39: Hazardous Materials, Multiple Casualty Incidents and Incident Management. (Book available for purchase.) Emergency Care, 12th Edition.
The authors of the chapter provide introductory information on hazardous material response (including decontamination) for emergency medical technicians.
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Education and Training


* Ansari, A., and Caspary, K. (2015). Guide to Operating Public Shelters in a Radiation Emergency. Centers for Disease Control and Prevention, National Center for Environmental Health.
Chapter Three of this guidance document shares strategies for screening and decontamination (of people, service animals, pets, possessions, and vehicles) in shelters. Quick guides on decontamination are provided as appendices.
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Center for Domestic Preparedness. (n.d.). Framework for Healthcare Emergency Management. (Accessed 9/5/2024.) Federal Emergency Management Agency.
Emergency healthcare providers and planners can learn about development, implementation, maintenance, and administration of emergency management programs and plans for healthcare facilities. The course includes lectures and guided discussions on topics such as emergency management issues for healthcare, personal protective equipment, decontamination, and isolation and quarantine.
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Center for Domestic Preparedness. (n.d.). Hands on Training for CBRNE Incidents. (Accessed 5/18/2022.) Federal Emergency Management Agency.
This training is focused on personal protective equipment, survey and monitoring equipment, evidence collection and preservation, mass-casualty triage, and explosive devices/searches. It culminates in an in-person training exercise.
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Center for Domestic Preparedness. (n.d.). Technical Emergency Response Training for CBRNE Incidents. (Accessed 5/18/2022.) Federal Emergency Management Agency.
In this training, responders will learn about potential terrorist targets and chemical, biological, radiological, and explosive hazards that may be used in all emergency incidents. The training includes hands-on exercises in decontamination, mass-casualty triage, and survey and monitoring.
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Center for Domestic Preparedness. (2021). Emergency Medical Operations for CBRNE Incidents. Federal Emergency Management Agency.
This federally supported four-day course (usually offered in Anniston, AL) provides emergency medical personnel with hands-on training in the pre-hospital management of chemical, biological, radiological, nuclear, explosives and mass casualty incidents, as well as on-scene triage, and field treatment of victims exposed to chemical hazards, biological agents, radiological hazards and explosions. The course concludes with a multi-task, pre-hospital exercise.
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Chemical Stockpile Emergency Preparedness Program. (n.d.). First Responders' Training. (Accessed 5/18/2022.)
These courses provide a variety of hazardous materials training for responders, planners, public officials, and healthcare workers. Courses include: "Comprehensive Planning for Technological Emergencies," "Operations Level Training—A Refresher for Responders," and "Exposure and Contamination."
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Cook, L. (2010). Teaching Hazmat Decontamination. Journal of Emergency Medical Services.
The author discusses contamination, the different types of decontamination typically performed on an incident scene, and special challenges that might arise (e.g., patient refusal of decontamination) and how to manage them.
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Imamedjian, I., Maghraby, N., and Homier, V. (2017). A Hospital Mass Casualty Exercise using City Buses and a Tent as a Hybrid System for Patient Decontamination. Prehospital and Disaster Medicine, 32(S1).
This article discusses an exercise in Milan, Italy, in which buses and a tent were used by healthcare and emergency preparedness staff to simulate decontamination during a biological, chemical, or radiation incident. While the buses proved to be practical for several reasons, the authors listed challenges associated with limited capacity, non-ambulatory patients’ access to the buses, and other issues.
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* Oak Ridge Institute for Science and Education. (2015). Radiation Emergency Assistance Center/Training Site.
This webpage links to the Radiation Emergency Assistance Center/Training Site (REAC/TS), which offers several resources to prepare medical professionals to respond to radiological emergencies. There are links to books, live training courses, online trainings, and assessment and treatment guidance documents. REAC/TS staff are available for deployment to provide medical consultation during emergencies, upon request.
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Office of Environmental Management. (2014). Pre-Hospital Practices for Handling a Radiologically Contaminated Patient. U.S Department of Energy.
The speakers share medical practices for caring for and managing patients potentially contaminated with radioactive material. Information on personal protective equipment, triage, patient transport, and other related issues is also included.
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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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Transportation Emergency Preparedness Program. (2014). Pre-Hospital Practices for Handling a Radiologically Contaminated Patient. U.S. Department of Energy.
This video highlights personal protective needs for responder safety; illustrates proper patient management, including transport; and shares strategies for returning responders and equipment to use after transporting a patient exposed to a radiological contamination hazard.
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U.S. Department of Health and Human Services. (n.d.). Radiation and Emergency Medical Management (REMM). (Accessed 3/8/2024).
This webpage provides guidance on diagnosis and treatment for healthcare providers. It includes downloadable tools, templates, references, and contact lists.
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* U.S. Department of Health and Human Services. (2005). Decontamination of Children.
This video explains how children differ from adults physically and emotionally, and provides recommendations for pediatric decontamination.
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Event-Specific Lessons Learned


Egan, J., and Amlot, R. (2012). Modelling Mass Casualty Decontamination Systems Informed by Field Exercise Data. International Journal of Environmental Research and Public Health. 9(10):3685-710.
The authors reviewed field exercise data collected during a mass decontamination exercise. They found that the "bottleneck" in the process was the re-dressing or re-robing of patients after they had showered. They suggested strategies for addressing this challenge, including shorter showers and more people showering at one time. ASPR TRACIE subject matter expert reviewers suggest, however, that shorter showers may be less effective, and recommend additional space for re-dressing. This article does effectively convey that “real-world” decontamination will experience bottlenecks—some of which can be anticipated and some of which will require adaptation during the event. Availability of “dry decontamination” / redress kits for those with minimal/no symptoms may help prevent bottlenecks in the gross/technical decontamination process.
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Morimura, N., Asari, Y., Yamaguchi, Y., et al. (2013). Emergency/Disaster Medical Support in the Restoration Project for the Fukushima Nuclear Power Plant Accident. Emergency Medical Journal. 30: 997-1002.
The authors describe the medical response to the incident, including patient decontamination. Photos of the decontamination tent and tables illustrating diagnosis and patient outcome are included.
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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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Guidance


Agency for Toxic Substances & Disease Registry. (2014). ToxFAQs™. Centers for Disease Control and Prevention.
This webpage contains links to two-page summaries of the most commonly asked questions about specific chemicals.
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Agency for Toxic Substances & Disease Registry. (2015). Toxicological Profiles. Centers for Disease Control and Prevention.
This series of 150 peer-reviewed publications details the known adverse health effects of specific chemicals and includes public health talking points on the harmful potential and properties of each, as well as more technical information. ToxFAQs links are also provided when available.
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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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This article discusses public behavior during events requiring mass decontamination, strategies for communicating with the public, and issues when privacy is not possible during decontamination. The authors also describe additional research needed regarding mass decontamination.
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Centers for Disease Control and Prevention. (2001). Managing Hazardous Materials Incidents (MHMIs), Version 2001. Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry.
This three-volume set of guidance documents and a video provide recommendations for on-scene and hospital medical management for patients exposed to hazardous materials.
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Chemical Hazard Emergency Medical Management. (2014). Chemical Decontamination Procedures. U.S. Department of Health and Human Services.
This webpage includes procedural information on decontaminating survivors of a mass casualty event before they report for medical care. It includes guidance on setting up decontamination corridors, safe areas, and medical triage areas and includes prehospital and emergency department medical guidance for specific chemical exposures.
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Chiang, C., Kashetsky, N., Feschuk, A., et al. (2021). Efficacy of Water-Only or Soap and Water Skin Decontamination of Chemical Warfare Agents or Simulants Using In Vitro Human Models: A Systematic Review. (Abstract only.) Journal of Applied Toxicology.
This literature review examined the extent to which soap and water are sufficient decontamination procedures for chemical exposures, based on in vitro models. The authors found that this method achieved partial decontamination of chemical war agents, and in some cases increased their absorption rates. The authors called for continued research to determine more effective methods
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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., and Ignacio, J., et al. (2014). Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities. U.S. Department of Homeland Security and U.S. Department of Health and Human Services.
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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Collins, S., James, T., Carter, H., et al. (2021). Mass Casualty Decontamination for Chemical Incidents: Research Outcomes and Future Priorities. International Journal of Environmental Research and Public Health. 18(6):3079.
The authors reviewed the literature on chemical decontamination in a mass casualty scenario, based on research in vitro and in human volunteers. The authors emphasize the importance of beginning decontamination immediately/removing contaminated clothing and examine the effectiveness of wet and dry decontamination interventions. They also suggest several areas for future research, including chemical vapors, determining safe chemicals to use with human volunteers, and improving assessment of exposure and risk communication.
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Department of Defense, U.S. Army Edgewood Chemical Biological Center. (2013). Guidelines for Mass Casualty Decontamination During a HAZMAT/Weapon of Mass Destruction Incident, Volumes I and II.
These guidelines can be tailored by first responders and emergency planners responsible for designing mass casualty decontamination plans following a hazardous material or weapons of mass destruction attack.
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This (very detailed, yet somewhat dated) guidance can help emergency responders learn more about chemical, biological, radiological, and nuclear decontamination equipment. It includes information on delivery systems, containment devices and accessories, shelters, showers, commercial decontaminants (foams, solutions, gaseous, nonaqueous), and decontamination systems and trailers.
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Jagminas, L. (2013). CBRNE-Chemical Decontamination. Medscape.
On this webpage, the author defines and shares strategies for recognizing chemical contamination; provides an overview on personal protective equipment (and additional links to resources); information on pre-hospital decontamination; and considerations for evacuating the emergency department.
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Johnston, G.M. and Wills, B.K. (2022). Chemical Decontamination. StatPearls.
This free book excerpt addresses chemical decontamination before and after patient arrival at a healthcare facility. The authors explain how dosage and time before treatment affect injury severity.
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Kumar, V., Goel, R., Chawla, R., et al. (2010). Chemical, Biological, Radiological, and Nuclear Decontamination: Recent Trends and Future Perspective. Journal of Pharmacy and BioAllied Sciences. 2(3): 220-238.
The authors present the general principles of decontamination with a focus on radiodecontamination.
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Larner, J., Durrant, A., Hughes, P., et al. (2020). Efficacy of Different Hair and Skin Decontamination Strategies with Identification of Associated Hazards to First Responders. (Abstract only.) Prehospital Emergency Care. 24(3):355-368.
This article evaluated a variety of wet and dry decontamination methods for removing a chemical contaminant from volunteer’s skin and hair. The authors found that dry decontamination and a “Triple Protocol” of dry, ladder pipe system, and technical decontamination were effective. Dry decontamination conducted earlier was found to improve effectiveness.
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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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Magnano, G.C., Rui, F., and Larese Filon, F. (2021). Skin Decontamination Procedures Against Potential Hazards Substances Exposure. (Comprehensive abstract only.) Chemico-Biological Interactions. 344.
This review examines old and new literature on how to decontaminate skin after exposure to hazardous substances, including flushing with soap and water, other liquid decontamination methods, adsorbent powders, and chelation therapy.
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* Oak Ridge Institute for Science and Education. (2015). Radiation Emergency Assistance Center/Training Site.
This webpage links to the Radiation Emergency Assistance Center/Training Site (REAC/TS), which offers several resources to prepare medical professionals to respond to radiological emergencies. There are links to books, live training courses, online trainings, and assessment and treatment guidance documents. REAC/TS staff are available for deployment to provide medical consultation during emergencies, upon request.
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Occupational Safety and Health Administration. (n.d.). Frequently Asked Questions: HAZWOPER. (Accessed 5/18/2022.) U.S. Department of Labor.
The Hazardous Waste Operations and Emergency Response (HAZWOPER) standard applies to five distinct groups of employers and their employees who may be exposed hazardous substances, including emergency operations planners. This document provides answers to frequently asked questions (e.g., HAZWOPER training, incidental vs. accidental spills).
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Occupational Safety and Health Administration. (2009). Best Practices for Protecting EMS Responders during Treatment and Transport of Victims of Hazardous Substance Releases. U.S. Department of Labor.
This document contains guidance for the emergency medical response to a hazardous material incident. It includes information on the role of responders in the community, the Occupational Health and Safety Administration's response principles, and practical recommendations and best practices on a variety of topics, including pre-transport patient decontamination.
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Occupational Safety and Health Administration. (2019). Hazardous Waste Operations and Emergency Response (HAZWOPER). U.S. Department of Labor.
This document provides emergency planners with the official federal requirements of the HAZWOPER standards (CFR 1910.120) surrounding HAZMAT responses including team training, definitions, and requirements. This resource can help responders interpret regulations and can illustrate the origin of the requirements for those who are not familiar with HAZMAT regulations. States may have additional regulations, and letters of interpretation from OSHA may provide clarification and/or create additional expectations in addition to these regulations.
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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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Weingart, S.D. (2018). CBRNE - Nuclear and Radiologic Decontamination. (Abstract only; free registration required to access full article.) Medscape.
The author discusses decontamination to reduce morbidity and mortality after a radiological emergency, including accidents or nuclear attack. Sections on personal protective equipment and external and internal decontamination can help healthcare emergency managers and workers plan accordingly for these incidents.
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Lessons Learned and Research


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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Power, S., Symons, C., Carter, H., et al. (2016). Mass Casualty Decontamination in the United States: An Online Survey of Current Practice. Health Security. 14(4): 226-236.
The authors conducted an online survey to understand U.S. fire departments' decontamination practices and related preparedness for responding to incidents involving mass casualty decontamination. Significant variance in decontamination plans and practices was uncovered, leading the authors to emphasize the need for national guidelines.
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Wenck, M., Van Sickle, D., and Drociuk, D., et al. (2007). Rapid Assessment of Exposure to Chlorine Released from a Train Derailment and Resulting Health Impact. Public Health Reports. 122(6): 784–792.
In 2005, in Graniteville, South Carolina, a train carrying three tanker cars of liquid chlorine under pressure derailed and released nearly 60 tons of chlorine until a patch could be applied. The authors describe patient characteristics, how they were transported (and where), symptoms, and components for planners to consider incorporating.
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Pediatric Considerations


* 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. (2005). Decontamination of Children.
This video explains how children differ from adults physically and emotionally, and provides recommendations for pediatric decontamination.
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Plans, Tools, and Templates


* Ansari, A., and Caspary, K. (2015). Guide to Operating Public Shelters in a Radiation Emergency. Centers for Disease Control and Prevention, National Center for Environmental Health.
Chapter Three of this guidance document shares strategies for screening and decontamination (of people, service animals, pets, possessions, and vehicles) in shelters. Quick guides on decontamination are provided as appendices.
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Occupational Safety and Health Administration. (n.d.). Decontamination. (Accessed 5/19/2022). United States Department of Labor.
This webpage discusses decontamination required due to materials workers may encounter at hazardous waste sites. It lays out decontamination planning, contamination prevention, and decontamination methods. Though geared toward site response, this resource includes valuable information for hospitals to consider.
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SOP Center. (n.d.). Emergency Decontamination. (Accessed 5/18/22)
This standard operating procedure document can be used as a template for emergency decontamination preparedness. It also contains information on decontamination precautions and procedures.
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Agencies and Organizations


Centers for Disease Control and Prevention. Emergency Preparedness and Response. Radiation Emergencies.
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Federal Emergency Management Agency. Center for Domestic Preparedness.
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Oak Ridge Institute for Science and Education (ORISE). Radiation Emergency Assistance Center/Training Site (REAC/TS). (Accessed 7/12/2018.)
This webpage links to the Radiation Emergency Assistance Center/Training Site (REAC/TS), which offers several resources to prepare medical professionals to respond to radiological emergencies. There are links to books, live training courses, online trainings, and assessment and treatment guidance documents. REAC/TS staff are available for deployment to provide medical consultation during emergencies, upon request.
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Texas A&M Engineering Extension Service. Various Courses.
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U.S. Department of Health and Human Services. Radiation and Emergency Medical Management.
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U.S. Department of Health and Human Services. Radiation Emergency Medical Management. Decontamination Procedures.
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