Chemical Stockpile Emergency Preparedness Program CSEPP Integrated Response Course

1
Chemical Stockpile Emergency Preparedness Program
(CSEPP) Integrated Response Course

• Department of Homeland Security
• 2006

2
Chemical Stockpile Emergency Preparedness Program

• Initiated in 1988
• Joint FEMA - Army program
• Implemented in 10 states 41 counties
• Current agents include GB (sarin), VX (nerve
  agent) (HD) Mustard
• Goal of maximum public protection as mandated
  by Congress

3
Chemical Stockpile Emergency Preparedness Program

• Initiated in 1988
• Joint FEMA - Army program
• Implemented in 10 states 41 counties
• Current agents include GB (sarin), VX (nerve
  agent) (HD) Mustard
• Goal of maximum public protection as mandated
  by Congress
• Disposal completed at Aberdeen, MD

4
CSEPP Training

• Initiated in 1990 at CSEPP National Meeting
• Comprehensive needs assessment
• by job function
• by location
• Training Management Plan developed (1992,
  updated 1997 and 2005)
• Training divided into 3 development paths
• Technical, Public affairs, and Medical
• Use variety of delivery techniques
• http//emc.ornl.gov/CSEPPweb/FEMACSEPPHome.html

5
Purpose of This Course

• To present an integrated version of
• Chem Awareness
• ACT FAST (Agent Characteristics,Toxicology, First
  Aid, and Special Treatment )
• Personal Protective Equipment
• Decontamination
• Use of Auto Injector
• CSEPP Multi-Hazard Medical Course

6
Course Objectives

• Understand the history of CSEPP and composition
  of the stockpile
• Understand the potential hazards of nerve and
  mustard agents
• Understand the signs and symptoms of nerve and
  mustard agent exposure
• Understand the use of personal protective
  equipment (PPE)
• Understand the process of decontaminating exposed
  personnel
• Understand the medical treatment of nerve and
  mustard agent exposure

7
Chemical Stockpile

• Comprised of chemicals designed and produced for
  the sole purpose of warfare
• Nerve agents and blister agents

Deseret Chemical Disposal Facility
8
CHEMICAL STOCKPILE LOCATIONS
Umatilla Chemical Depot (UMCD) Hermiston, OR
Newport Chemical Depot (NECD) Newport, IN
WA
Edgewood Chemical Activity (ECA) Aberdeen Proving
Ground, MD (Stockpile Destroyed)
IL
Deseret Chemical Depot (DCD) Tooele, UT
Blue Grass ChemicalActivity (BGCA) Richmond, KY
Pueblo Chemical Depot (PUCD) Pueblo, CO
Pine Bluff Chemical Activity (PBCA) Pine Bluff, AR
Anniston Chemical Activity (ANCA) Anniston, AL
Storage Facilities States with Storage
Facilities Impacted States
9
Various Munitions Types
Land Mine
Projectile
Cartridge
500 lb Bomb
M-55 Rocket
Bulk Containers
10
TYPES OF AGENTS
CA20
11
Nerve Agents
GA
VX
GB
Blister Agents
H
HT
L
HD
12
Nerve Agents
GA
GB
VX

• Attack bodys nervous system
• Scientific classification Organophosphate
• organophosphates also include agricultural
  insecticides such as malathion and parathion

CA22
13
GB
14
VX
15
Specific Names

• Symbol Common name Referred to as
• VX VX VX
• GB Sarin GB or G-agent
• GA Tabun GA or G-agent
• Small amount is stored at Deseret Chemical Depot

16
Nerve AgentPhysical Properties

• Usually liquid in normal state
• Becomes volatile and generates vapors if heated
• Potential for release if in vapor or aerosol form
• All nerve agents currently in liquid form
• Most distinguishable factors are physical
  consistency and color

17
VXPhysical Properties

• Oily liquid resembles light weight oil
• Usually a pale amber color (colorless in pure
  form)
• Odorless
• Tasteless
• Persistent designed to cling to whatever it
  splatters on
• persistence is weather-dependent

18
G-AgentsPhysical Properties

• GB is usually colorless, watery in pure form
• GA may be pale to dark amber
• GB has almost no odor
• GB is tasteless
• GB volatilizes at lower temperature than VX
• GB evaporates more rapidly than VX but less than
  water

19
Blister Agents (Vesicants)
H
HD
HT
L

• Poisons that destroy individual cells
• Blisters most noticeable effect from exposure
• Includes sulfur mustard and Lewisite

20
Specific Names

• Symbol Common name Referred to as
• H, HD, HT Sulfur mustard H, HD, HT
• L Lewisite Lewisite
• Small amount was stored at Deseret Chemical
  Depot and now destroyed

21
HD
22
L
23
Sulfur MustardPhysical Properties

• Mustard-garlic-like smell
• Liquid or solid form in normal state
• Melting point about 57oF
• Becomes volatile and generates vapors if heated
• burns well once ignited
• Pale amber brown color in liquid form
• Colorless gas when vaporized

Laboratory bottle of sulfur mustard
24
Lewisite Physical Properties

• Amber to brown liquid
• colorless when pure
• About 10 times more volatile than sulfur mustard
• Irritating, fruity or geranium-like odor
• little odor when pure
• Persistent
• More dangerous as liquid than as vapor

25
Non-Stockpile Agents

• Cyanide (i.e., CK)
• Pulmonary agents (i.e., Phosgene)
• Riot Control agents (i.e., Mace)
• Incapacitating agents (i.e., BZ)

26
Non-Stockpile Agents

• Riot Control Agents (i.e., Mace)
• Incapacitating Agents (i.e., BZ)

27
Example of CSEPP Planning Zones

• Immediate Response Zone
• Protective Action Zone
• Precautionary Zone

28
Likelihood of Agent Release

• Most likely releases are small ones that do not
  pose a threat except to someone in very close
  proximity to the release site
• Large releases with source terms large enough to
  pose a threat to community have much lower
  probability of occurring
• Unlikely that a release will cause injury or
  death to anyone off-site

29
Potential Types of Release and Associated
Hazards

• If a release is large enough to pose threat to
  public, the dominant hazard is from breathing air
  in which agent exists as vapor
• Paths for liquid chemical warfare agent to travel
  from release point to off-site are limited and
  relatively easy to block therefore people
  off-site unlikely to encounter liquid agent

30
Four Basic Typesof Potential Releases

• Spill
• Fire
• Explosion
• Complex

Simulated Chemical Explosion at Deseret, UT
31
Spill

• Onto ground or other surfaces
• Resulting puddle of agent (liquid deposition) can
  evaporate into vapor and drift downwind

(not to scale)
Example of a plume resulting from a spill
32
Explosion

• Causes droplets of agent to be formed
• Larger, heavier droplets quickly fall to ground
  (deposition)
• Releases vapors and aerosols (smaller droplets
  and particles) that can travel greater distances

(not to scale)
Example of a plume resulting from an explosion
33
Fire

• Both aerosols and vapors are formed
• Vapors and aerosols lifted higher into air
  because of heat from fire
• Hazard similar to those of an explosion

Example of a plume resulting from a fire
(not to scale)
34
Difference BetweenAerosols and Vapors

• Think of a chemical agent release in terms of
  hair spray coming from a spray can
• when spray is release, it is an aerosol
• larger particles and/or droplets are deposited
  near point of release
• particles quickly fall out of air onto hair and
  skin
• person across room can smell hair spray from
  breathing vapors released

35
What If a Release Occurs?(CSEPP)

• It is very unlikely the public would be exposed
  to droplets and aerosols
• Particles will mostly fall out of plume (via
  deposition) by time plume reaches installation
  boundary
• Coordinated response system implemented

36
Vapor Hazard

• For most releases, the primary health hazard
  comes from vapors when they are inhaled or come
  in contact with skin or eyes
• Agent vapors pose greatest hazard when inhaled
  because they are rapidly absorbed by lung tissues
• Skin exposure to agent vapors can be hazardous,
  but seldom life-threatening

37
Federal Response

• NIMS - may require integration of Incident
  Command System (ICS) as off-post event would
  likely be of National Interest
• DoD may send team to help communities with
  detection
• FBI would likely respond to civilian terrorist
  event - change of custody of samples then would
  be needed

38
Chemical Warfare Detection Capabilities (CSEPP)

• Armys detection capability consists of low-level
  and gross-level detectors
• Any vapor detection efforts off-site would be
  conducted by Army survey teams using appropriate
  equipment
• Civilian responders would monitor public for
  exposure in the hot zone using appropriate PPE

39
Module 2Potential Exposure Routes and Hazards
40
How Nerve Agents Work

• Nervous system controls normal functions through
  use of chemicals
• Chemicals act as instructions to nerves, muscles,
  and glands
• Two forms of instructions
• stimulate (move or work)
• relax (stop or rest)
• Nerve agent interferes with normal transmission
  of instructions

41
Leads to Destruction of System Control

• Over-stimulates nerve endings and central nervous
  system
• Causes muscles and certain glands to malfunction

42
Normal Nervous System Function
Nerve impulse transmitted along nerve
cells
Acetylcholine (a neurotransmitter) is
released
Target cell is stimulated
43
Normal Nervous System Function

• Once target cell is stimulated, acetycholine
• is deactivated by acetylcholinesterase
• Target cell relaxes

44
Nerve Agent Interference
Nerve agents inactivate acetylcholinesterase
Excess acytelcholine accumulates Muscle
action becomes uncontrolled and
twitchy Muscle can tire and
collapse Gland continues to secrete sweat,
tears, or mucus
45
Routes of Exposure
Inhalation Ingestion Direct contact
46
Inhalation

• Respiratory failure is the chief cause of death
  after severe exposure

47
Direct Contact

• Absorption through skin
• All agents can be absorbed
• VX persists longer
• GB evaporates quickly, but still a threat
• Scrape or cut in skin allows immediate entry
• Entry also through eyes

48
Direct Contact

• Absorption through skin
• All agents can be absorbed
• VX persists longer
• GB evaporates quickly, but still a threat
• Scrape or cut in skin allows immediate entry
• Entry also through eyes

49
Ingestion

• Access to bloodstream via digestive system
• Effects similar to inhalation, but at greater
  doses

50
Inhalation Exposure From Atmospheric Transport

• The critical route of exposure that you should be
  most concerned with is inhalation of agent vapors
  or aerosols

51
How Vesicant Agents Work

• Chemical burns to skin especially warm, moist
  surfaces
• Chemical burns to soft membranes
• eyes
• eye ball
• lung tissue
• mouth
• throat

52
Sulfur Mustard (HD) Agent Exposure

• Delayed reaction and little or no pain
• Blisters develop in 2 to 36 hours

53
Routes of Exposure
Inhalation Ingestion Direct contact
54
Inhalation

• Can destroy mucous membrane lining of
• nasal passages
• throat
• bronchial tubes

55
Direct contact With Liquid or Vapor

• Highly damaging to skin especially warm, moist
  areas
• Mucous membranes are very susceptible to effects
  of blister agents including
• lining around eyelids
• inside mouth and nose
• Sweat and moisture increase effect

56
Ingestion

• If deposited on or in food items, drink, etc
• Injures warm, moist tissues of mouth, throat and
  esophagus

57
Inhalation Exposure From Atmospheric Transport

• The critical route of exposure that you should be
  most concerned with is inhalation of agent vapors
  or aerosols

58
Module 3Toxicity
59
Toxicity Measures

• Ct is used to express the dose of a vapor or
  aerosol. C represents the concentration of the
  substance in air (in mg/m3) and t represents time
  (in minutes).
• The Ct value is the product of the concentration
  (C) to which an organism is exposed multiplied by
  the time (t) during which it remains exposed to
  that concentration. Ct does not express the
  amount retained within an organism thus, it is
  not an inhalational dose.
• LCt50 is used to denote the vapor or aerosol
  exposure (Ct) necessary to cause death in 50 of
  the population exposed.
• LD50 is used to denote the dose that is lethal
  for 50 of the population exposed by other routes
  of exposure (liquid, solid).

60
Toxicity Values for Nerve Agents

• LD50 of VX is 5 mg/70-kg human (liquid on skin)
• LCt50 of VX is 15 mg-min/m3 (vapor inhalation)
• LD50 of GB is 1.7 gr/70-kg human (liquid on skin)
• LCt50 of GB is 35 mg-min/m3 (vapor inhalation)
• 1 kg 2.2046 pounds

61
VX Liquid Exposure

• An potentially lethal exposure is a drop about
  the size of the Lincolns head on the back of a
  penny.

62
Toxicity Values for Sulfur Mustard Agents H and HD

• LD50 (liquid on skin) is 1.4g/70-kg human
• Between 4 and 32 micrograms/70-kg man can cause
  blistering
• LCt50 (vapor) is 1000 mg-min/m3

63
Airborne Exposure Standards

• Occupational exposure values for workers
• Threshold Limit Values (TLV's) (chronic)
• Short-Term Exposure Limits (STELs) (acute)
• Permissible Exposure Limits (PELs) (chronic)
• General Population Limit (GPL) for civilians

64
Immediately Dangerous to Life and Health (IDLH)

• Immediately Dangerous to Life and Health (IDLH)
  initially based on 30 minutes
• Values adapted for first response work and based
  on air monitoring results were used for decision
  making for PPE
• Described as an art or a balancing act
• Not truly the best course for emergency response
• Not designed for the type of exposure encountered
  at a HAZMAT release
• At IDLH level, elderly, respiratory impaired, and
  children could experience severe health problems
  yet people in good health may not.
• IDLH values used to select appropriate
  respiratory protection

65
Evolution to 1/10 IDLH for Level of Concern (LOC)

• Over time it became obvious that an exposure
  level below the IDLH was needed
• EPA, FEMA, and DOT recommended use of 1/10 IDLH
  as the new level of concern (LOC) in which to
  base evacuation decisions

66
Emergency Response Planning Guidelines (ERPGs)

• ERPG's were developed for planning purposes based
  on an anticipated one-hour exposure
• Uses a three-tiered system based on severity of
  effects with ERPG-1 the least severe and ERPG-3
  the most severe
• AIHA strongly advises against extrapolating ERPG
  values to longer duration exposures

67
Response Process

• First Responders
• Determine product and amount
• Use NAERG 2000
• ERPG
• First 30 minutes
• Minimal downwind hazard prediction ability

68
Response Process

• Next tier of response
• Confirm product and amount
• Gather data through monitoring and modeling
• Develop and implement response strategy
• Determine protective actions
• Key question how long will it take to solve
  the problem?

69
Acute Exposure Guideline Levels (AEGLs)
70
AEGLs

• Concentration of a chemical in air, above which,
  specific categories of health effects could begin
  to occur in an unprotected civilian population.
• AEGLs are expressed as the concentration of a
  chemical an individual is exposed to over a given
  period of time.

71
AEGLs

• Represent threshold exposure limits
• Three levels - 1, 2, and 3
• Based on 5 reference times ranging from 10
  minutes to 8 hours
• Used to trigger emergency actions including event
  notification and protective action decisions

72
AEGLs Five Exposure Periods

• 10 minutes
• 30 minutes
• 1 hour
• 4 hours
• 8 hours

73
AEGL-1

• AEGL-1 is the airborne concentration (expressed
  as ppm or mg/m3) of a substance at or above which
  it is predicted that the general population,
  including susceptible individuals, could
  experience notable discomfort, irritation, or
  certain subclinical, non-sensory effects.
  However, the effects are not disabling and are
  transient and reversible upon cessation or
  exposure
• May trigger a precautionary alert

74
AEGL-2

• AEGL-2 is the airborne concentration (expressed
  as ppm or mg/m3) of a substance at or above which
  it is predicted that the general population,
  including susceptible individuals, could
  experience irreversible or other serious,
  long-lasting effects or impaired ability to
  escape.
• Exposed people may need to evacuate or
  shelter-in-place above AEGL-2. May become a mass
  casualty event.

75
AEGL-3

• AEGL-3 is the airborne concentration (expressed
  as ppm or mg/m3) of a substance at or above which
  it is predicted that the general population,
  including susceptible individuals, could
  experience life-threatening effects or death.
• People must not be exposed to these levels. This
  is likely a mass casualty event.

76
AEGL Summary
Severe adverse effects
Above AEGL-3 effects become increasingly severe
and could be fatal.
AEGL-3
Significant adverse effects
Above AEGL-2 effects become increasingly more
significant, and may cause impairment, be longer
lasting, or permanent.
AEGL-2
No significant adverse effects
Above AEGL-1 there may be some discomfort, odor,
or irritation. Effects, if any, are not impairing
and only temporary.
AEGL-1
No adverse effects
No Exposure
77
AEGL Values for GB
78
Comparison of AEGLs CTs for HD and GB
79
Airborne Health Criteria Continuum Based on
Nerve Agent GB Concentration
AEGLs - 30 min. exposure
AEGL-1 (0.004 mg/m3)
AEGL-2 (0.05 mg/m3)
AEGL-3 (0.38 mg/m3)
Lower Concentration
Higher Concentration
TLV (0.00001 mg/m3)
GPL (0.000001 mg/m3)
IDLH (0.1 mg/m3)
STEL (0.0001 mg/m3)
LOC (0.01 mg/m3)
Chronic Exposure
Acute Exposure
Source Adapted from Hauschild,2000.
80
AEGLs as Response Tools

• Analyze other potential threats/events to develop
  MCEs
• Work with responders to determine how long it
  will take to solve problem
• Time determines exposure level to use and drives
• planning-phase modeling

81
Module 4Signs and Symptoms
82
Situation Assessment

• Known information regarding the chemical release
• Recognition of the event based on signs and
  symptoms

83
Not All Signs and Symptoms May Appear Immediately

• Manifestation based on
• dose,
• duration, and
• route of entry

84
Nerve Agent Exposure
85
Signs and Symptoms Nerve Agent Vapor Exposure

• Affects organs directly contacted by agent
• Affects other organs as agent is absorbed into
  body systems
• Signs and symptoms appear in seconds to minutes
• Peak effects within 15 to 25 minutes after
  exposure stops

86
Signs and SymptomsMild Vapor Exposure

• Pinpoint pupils (w/ or w/o redness, pain)
• Dim or blurred vision
• Runny nose
• Slight chest tightness
• Slight difficulty breathing
• Secretions (tears, nasal fluids, saliva, sweat,
  phlegm)
• Nausea and vomiting

87
Signs and SymptomsModerate Vapor Exposure

• Pinpoint pupils (w/ or w/o redness, pain)
• Dim or blurred vision
• Excessively runny nose
• Pronounced chest tightness
• Plentiful secretions
• Moderate to severe breathing difficulty
• Nausea and vomiting
• Diarrhea
• General muscle weakness

88
Signs and SymptomsSevere Vapor Exposure

• Same as for moderate exposure, plus
• Loss of consciousness
• Convulsions
• Generalized rippling of muscles under skin
• Flaccid paralysis
• Cessation of breathing
• Involuntary urination or defecation

89
Signs and SymptomsLiquid Nerve Agent on Skin

• Effects differ from vapor exposure
• Different signs and symptoms
• Different timing of appearance
• General rule the more severe the exposure, the
  quicker effects appear

90
Signs and SymptomsMild Liquid on Skin Exposure

• Sweating at site of exposure
• Rippling of muscles under skin at site of
  exposure
• Effects appear in 10 min to 18 hrs, depending on
  dose

91
Signs and SymptomsModerate Liquid/Skin Exposure

• Same as for Mild exposure, plus
• Nausea, vomiting, and diarrhea
• Generalized sweating
• Generalized weakness, tiredness, or ill feeling
• Effects appear in 10 min to 18 hrs, depending on
  dose

92
Signs and SymptomsSevere Liquid on Skin Exposure

• Same as for Moderate exposure, plus
• Collapse
• Loss of consciousness
• Convulsions
• Severe respiratory difficulty
• Flaccid paralysis
• Cessation of breathing
• Involuntary urination or defecation
• Effects appear suddenly in 2-30 min

93
Differential Diagnosis

• Refers to distinguishing one disease from another
  when they produce similar signs and symptoms

94
Diseases Producing Symptoms Similar to Nerve
Agent Exposure

• Epilepsy
• Gastroenteritis
• Exposure to agricultural insecticides
  (organophosphates and carbamates)

• Heat illness
• Emphysema
• Stroke
• Head trauma
• Drug overdose

95
VESICANT AGENT EXPOSURE
96
Signs and Symptoms by Route of Exposure

• Agent vapor affects eyes, skin, and airways
• Agent liquid on skin or eyes
• Produces more severe effects than vapor
• Does not normally affect airways
• Large exposures via either route can affect
  internal body systems

97
Signs and Symptoms of Exposure to Mustard Agent
Vapor

• Agent contacts skin and eyes
• Causes surface damage
• Absorbed into body
• Agent is inhaled into respiratory tract
• Damages mucous membranes
• Absorbed into body

98
Signs and Symptoms ofVapor Exposure on Eyes

• Mild exposure
• Tearing, itching, burning, gritty feeling,
  sensitivity to light
• Effects appear in 4-12 hrs
• Moderate exposure
• Same as for Mild exposure, plus reddening,
  swelling of lids, moderate pain
• Effects appear in 3-6 hrs
• Severe exposure
• Same as for Moderate, plus marked swelling of
  lids, possible damage to cornea, severe pain
• Effects appear in 1-2 hrs

99
Signs and Symptoms of Vapor Exposure on Skin

• Mild exposure
• Reddening of skin with itching, burning, and
  stinging
• Severe exposure
• Same as for Mild exposure, plus blisters
• Effects appear in 2-24 hrs

100
Signs and Symptoms of Vapor Exposure on Airways

• Mild exposure
• Runny nose pain in throat, nostrils, sinus
  sneezing nose bleed hoarseness hacking cough
• Effects appear in 6-24 hrs
• Moderate exposure
• Same as for Mild exposure, plus, loss of voice,
  productive cough
• Severe exposure
• Same as for Moderate exposure, plus
  mild-to-severe breathing difficulty
• Effects appear in 2-6 hrs

101
Signs and Symptoms ofVapor Exposure on GI Tract

• Nausea and vomiting
• Effects appear a few hrs to 24 hrs after exposure

102
Signs and Symptoms of Liquid Exposure on Skin or
Eye

• Effects similar to those for vapor exposure but
  more severe and appear sooner
• Eyestearing, itching, burning, gritty feeling,
  sensitivity to light, swelling of lids, damage to
  cornea, pain
• Skinreddening, itching, burning, stinging,
  blisters
• Effects most apparent at exposure site

103
Signs and Symptoms of Liquid Exposure on Eyes

• Effects same as for vapor exposure, but more
  severe
• For severe exposure
• Symptoms can appear within minutes
• Can result in severe damage to cornea, loss of
  vision, or loss of eye

104
Signs and Symptoms of Liquid Exposure on Skin

• Effects similar to those for vapor exposure, but
  more severe
• Tissue damage is deeper
• Tissue death may occur at exposure site
• Injury comparable to third-degree burn

105
How Sulfur Mustard Agent Blisters Skin
Normal skin
Reddened skin
Blistered skin
106
Sulfur Mustard Blisters
107
Other Possible Causes of Signs and Symptoms

• Blister agent signs and symptoms could also apply
  to
• hay fever
• chemical or thermal burns
• heavy tear gas exposure
• poison ivy, poison oak, and other contact
  allergies

108
Summary Pop QuizMatch signs symptoms on the
left with the correct cause on the right

• Miosis
• Blisters on skin
• Breathing difficulty
• Extreme sore throat
• Runny nose
• Hearing loss
• Rippling muscles
• Swollen eyelids

• Nerve Agent
• Mustard Agent
• Either
• Neither

109
Summary Pop QuizAnswers

• MiosisNerve agent
• Blisters on skinMustard agent
• Breathing difficultyEither
• Extreme sore throatMustard agent
• Runny noseNerve agent
• Hearing lossNeither
• Rippling musclesNerve agent
• Swollen eyelidsMustard agent

110
Module 5Personal Protective Equipment
111
CSEPP Approach to PPE

• Current CSEPP policy does not provide for
  deployment of civilian emergency workers into
  areas which are known or suspected to be
  contaminated with chemical weapon agent until
  monitoring and sampling confirms that
  concentrations are within range for which PPE
  provides protection.
• To provide protection in event of entry into
  contaminated areas, individuals identified in
  state and local plans as initial off-site
  emergency workers will be issued PPE appropriate
  for prescribed job functions.

112
Federal PPE Requirements

• U.S. Government requires that employer provide
  workers with PPE if it is required on your job
• Code of Federal Regulations (CFR) 29 CFR 1910.120
  and 1910.134 and 40 CFR 311 prescribe guidelines
  for training, protective clothing and equipment
• Other State and local regulations may specify
  types of PPE for specific positions or tasks in
  dealing with range of hazardous materials
• Workers should be familiar with local and
  job-specific requirements as well as federal
  regulations

113
Who Needs PPE and Training

• All persons (including volunteers) designated as
  part of the emergency response (e.g., police,
  medics, paramedics, firefighters, medical
  personnel) to a chemical agent release
• All persons who anticipate being active in
  potentially hazardous environments as part of a
  CSEPP emergency response plan
• Before training, a medical evaluation must be
  performed
• Regular drills and training sessions designed to
  maintain familiarity with equipment should be
  incorporated into emergency response protocols

114
What is PPE?

• Personal Protective Equipment (PPE) is defined as
  articles worn or equipment used in order to
  protect wearer from harmful contaminants in
  environment
• Main function of PPE is to providea shield
  between worker and agent contaminating
  environment
• To be effective it must prevent worker from being
  contaminated by airborneor surface agents

115
4 Levels of PPE

• Level A
• Level B
• Level C
• - used in CSEPP
• - includes PAPR
• Level D
• work uniform

A
B
116
Levels of PPE

• Level A
• Level B
• Level C
• - used in CSEPP
• - includes PAPR
• Level D
• work uniform

C
D
117
Proper Use Critical

• If PPE is used it must be used correctly
• It is not possible to be partially protected from
  nerve or blister agents
• You are either protected or not protected

118
Recommended PPE(for CSEPP)

• Potential nerve and blister agent contamination
  requires respiratory protection and protective
  covering for all parts of the body. PPE
  includes
• powered air-purifying respirator (PAPR)
• hood
• protective suit
• overshoes
• gloves
• This type of protection guards against skin,
  respiratory tract, and eye exposures

119
CSEPP Protective Clothing

• CSEPP, in conjunction with the Centers for
  Disease Control and Prevention/National Center
  for Environmental Health, have conducted several
  studies and tests on PPE to select the
  appropriate PPE for CSEPP

120
Protective Suit

• 4 suits approved for CSEPP use
• Only 2 suits initially used by CSEPP communities
• DuPont Responder
• DuPont CPF3

121
DuPont Responder and CPF 3 Suits

• One-piece coverall suits for wear over street
  clothes or long underwear
• Multiple layer, composite material provides
  protection
• Responder weighs less CPF 3 is tougher
• Do not protect from heat and cold

122
Storage and Shelf Life

• Store on hangers or in shipping bag
• Shelf life of 5 years
• Not repairable discard if damaged, punctured or
  worn out
• Discard after exposure to chemical agent

123
Gloves

• Outer glove for protection and inner glove for
  perspiration absorption
• Outer gloves impermeable, black, butyl rubber
• Inner gloves thin, white cotton
• Protect against liquid chemicalagents and vapor
  hazards
• If become contaminated,replace within 24 hours
• Replace if exposed to anypetroleum-based
  products

124
Boots

• Military-issue vinyl overshoes with elastic
  fasteners
• Protect feet from contamination by all known
  agents for up to 24 hours following
  contamination for up to 14 days if not
  contaminated
• Alternative is commercial HAZMAT boot

125
Ready Bag

• Canvas bag designed to carry all the protective
  equipment - protective suit, hood, gloves,
  overshoes, and PAPR

126
Respiratory Equipment

• Prevents airborne contaminants from being inhaled
• Protects facial skin from exposure
• Must be only used in context of complete
  respirator program as described in OSHA
  regulations and NIOSH publications

127
Powered Air-Purifying Respirator (PAPR)

• Protects against
• particulates
• gases and vapors
• Typically uses organic Vapor/HE particulate filter

128
PAPR Components

• 2 types of PAPR are approved for CSEPP
• Tight-fitting PAPR
• Loose-fitting PAPR
• Tight-fitting PAPR provides better respiratory
  protection
• Loose-fitting PAPR is easier to use accommodates
  facial hair and eyeglasses
• Tight-fitting provides protection if batteries
  fail, while loose-fitting must be removed

129
PAPR Components

• Both types of PAPRs consist of
• full face piece
• butyl rubber-covered hood
• breathing tube
• motor-blower unit with filter cartridges
• battery

130
Powered Air-Purifying Respirator (PAPR)

• Draws outside air through filters which remove
  contaminants and delivers the cleaned air through
  corrugated breathing tube into facepiece assembly
  on face of wearer
• Battery-operated blower delivers decontaminated
  air at slight positive pressure into face piece
• if leak occurs, air will flow from inside
  facepiece to outside air
• Air flow also provides wearer comfort

131
Why the PAPR Was Selected

• Civilian air-purifying respirators approved by
  CDC/NCEH
• NIOSH confirmed cartridge tests were conducted in
  valid scientific manner
• Data support conclusion that commercial
  cartridges tested will remove up to 0.5 milligram
  per cubic meter of nerve agent GB for up to 16
  hours
• Concentration chosen because it is the maximum
  predicted concentration to which emergency worker
  would be exposed
• U.S. Army data on military gas masks indicate
  that nerve agent GB wears out filters more
  quickly than other agents

132
Spectacle Kit

• Proper seal with tight-fitting PAPR cannot be
  established if the temple bars of eyeglasses
  extend through sealing edge of full facepiece
• 3M has developed spectacle kits that mount
  corrective lenses inside full facepieces
• Personnel who wear eyeglasses should use a
  spectacle kit or wear a loose-fitting PAPR

133
Limitations of PAPRS

• Do NOT use in atmospheres immediately dangerous
  to life or health (IDLH)
• Do NOT use in atmospheres containing less than
  19.5 oxygen (confined spaces)
• Do NOT use the respirators in a flammable or
  explosive atmosphere
• Do NOT use air-purifying elements beyond useful
  life
• Use only fully charged battery packs when
  respirator is donned
• Protect batteries/battery packs from fire and
  heat at all times

134
Air-Purifying Cartridges

• Most common filtration method for airborne
  particulates and vapors
• Often referred to as filter or canister
• Always read cartridge labels
• All cartridges in blower unit must be identical
  and must be replaced at same time
• Follow good industrial hygiene practices when
  replacing and disposing of cartridges

135
Cartridges

• Identify cartridge by properly worded labels and
  color code
• Correct color code for organic vapor is black
• Each ready bag should have 3 sets of 3 cartridges
• 1 set for chemical accident/incident
• 1 set for backup
• 1 set for training marked For Training Purposes
  Only

136
Respirator Fit Testing

• Shall be done while wearing all protective
  equipment that could interfere with fit and/or
  wearer acceptance
• Must be based upon 29 CFR 1910.134 Appendix A
• Must be repeated at least annually based on 29
  CFR 1910.134(f)
• Medical evaluation required for wearer
• Wearer should be familiar with all State and
  local requirements as well as federal regulations

137
Respirator Storage

• Before storing facepiece should be inspected,
  repaired if needed, cleaned, and dried
• While in storage, facepiece should be protected
  from distortion from weight or pressure of
  surrounding objects or being placed in too small
  a place
• Never store PPE equipment in car or truck because
  of potential for heat damage but keep in a
  location easily accessible
• Fully charged battery pack should be stored in
  closed plastic bag in dry, cool, uncontaminated
  place
• Remember - when sold, batteries not charged

138
Respirator Storage (cont.)

• Use battery charger and AC/DC adapter to charge
  and recharge battery pack
• All parts in plastic bag should be connected
  together in manner of assembled respirator
• Facepiece and its subparts should be stored
  separately from remainder of PAPR
• Only fully operable facepieces should be stored

139
Storage of Protective Clothing

• DuPont Responder and CPF3 protective suits come
  sealed in a shipping bag
• The protective suit may be stored in the open
  shipping bag inside the Ready Bag along with,
  gloves, hood, overshoes
• Alternatively, the suits can be stored on hangers
  
• Store
• away from sunlight and direct heat
• in a clean, dry, cool place that is free from
  contaminating vapors, gases and particulates
• storage temperatures must not exceed 120F (49C)
  

140
Basis and Timing for Working in PPE

• Emergency workers who enter an area where PPE is
  required must limit their activities so that
  protection from contamination and excessive
  exposure is assured

141
Basis and Timing for Working in PPE

• Emergency worker requirements
• Not be sent into environments which are known or
  suspected to be immediately dangerous to life or
  health (IDLH)
• Not remain in potentially contaminated area long
  enough to receive agent dosage sufficient to
  affect health or ability to execute assigned
  tasks
• Not remain in potentially contaminated area long
  enough to exceed agent absorption capacity of
  canisters used in PAPR
• Not be exposed to agent deposition density levels
  exceeding maximum capability of protective suit

142
Airborne Agent ConcentrationsImmediately
Dangerous to Life or Health (IDLH)
IDLH
Agent Concentration (mg/m3)
GA/GB 0.1 VX 0.003 HD 0.7
Dept. of Health and Human Services (DHHS)
Centers for Disease Control and Prevention (CDC).
Interim recommendations for airborne exposure
limits for chemical warfare agents H and HD
(Sulfur Mustard). Federal Register 69 (85),
24164-24168 (3 May 2004).
143
Exposure Limits

• Simplest, most effective work rule to assure that
  respirator cartridges are used within capacity is
  to avoid sending emergency workers into areas
  where a plume containing airborne chemical agent
  may be present
• Activity of off-site emergency workers in areas
  where airborne chemical agent may be present must
  be limited
• To ensure that workers are not exposed to average
  airborne agent concentrations greater than those
  established for agent workers, even when using
  respiratory protection
• To ensure that agent absorption capacity of
  respirator cartridges is not exceeded

144
Respirator Cartridge Limits

• Have been determined to provide at least 16 hours
  of protection when exposed to an agent vapor
  concentration of 0.5 mg/m3
• Possible that under certain release and
  atmospheric conditions this dosage may be
  exceeded outside boundaries of several storage
  installations

145
Respirator Cartridge Limits

• Work rules must avoid possibility that emergency
  workers can be exposed to conditions in excess of
  cartridges absorption capacity
• Once airborne agent concentration level has
  declined below IDLH level, combination of limited
  stay times and use of chemical detector kits can
  assist emergency workers in using PPE within its
  capabilities

146
PAPR-Limited Stay Times

• Depend on
• Concentration of chemical agent in the air
• Exposure limit for the chemical agent
• The protection factor for the respirator
• The dosage capacity of the filter cartridges

147
Work Intensity

• Along with ambient temperature, work intensity is
  major contributing factor to heat stress
• Work/rest cycles should be instituted to control
  heat stress. Cycles need to be flexible because
  of
• variability in work intensity
• differences in an individuals susceptibility to
  heat stress
• unique demands of each emergency situation

148
Clothing-Limited Stay Times

• COOL TEMPERATURES
• 50 70F (10 21C) Wet Bulb/Globe Temperature
  (WBGT)
• Work 30 45 minutes
• Followed by 10 15 minutes rest
• WARM TEMPERATURES
• 70 85F (21 29C) Wet Bulb/Globe Temperature
  (WBGT)
• Work 20 30 minutes
• Followed by 40 60 minutes rest
• HOT TEMPERATURES
• 85 100F (29 38C) Wet Bulb/Globe
  Temperature (WBGT)
• Work 15 20 minutes
• Followed by indefinite rest

149
Heat Stress Factors

• PPE restricts heat loss mechanisms because of low
  permeability to water vapor
• Amount of heat accumulation depends upon
• amount of physical activity
• level of hydration
• clothing worn
• load carried
• state of heat acclimatization
• physical fitness and fatigue
• terrain and climatic conditions

150
Dehydration

• Because of higher body temperatures, individuals
  in PPE sweat considerably more than usual, often
  more than 1.5 quarts of water every hour during
  work
• Water must be consumed to replace lost fluids or
  dehydration will follow
• Inability to drink in full PPE increases
  likelihood of dehydration
• Dehydration and need for regular and timely fluid
  replacement in workers is limiting factor on stay
  time in full PPE

151
Psychological Factors

• Wearing full PPE reduces ability to see and hear
  clearly
• Makes it more difficult to recognize and
  communicate with others
• Creates or increases feelings of isolation and
  confusion
• Causes frustration in many, and claustrophobia in
  others
• Experience in wearing and exercising in PPE can
  reduce these factors

152
Effects of Heat Stress on Performance in PPE

• Workers wearing PPE will take about 1.5 times
  longer to perform most tasks
• Performance is affected by stress in a variety of
  ways
• reaction and decision times are longer
• routine tasks are completed more slowly
• errors of omission are more common
• Use the buddy system whenever possible a buddy
  can check for signs of stress and fatigue
• Critical jobs should be shared and work should be
  double-checked

153
Cold Stress Factors

• Can directly affect an individuals health and
  performance while wearing PPE
• Can lower body temperature, resulting in cold
  injuries and impaired performance
• Often accompanied by wind, rain, snow and ice,
  which can worsen the effects of cold
• Cold weather clothing and PPE may be difficult to
  integrate

154
Buddy System Recommended

• Good industrial hygiene practice recommends buddy
  system be used if resources permit
• Can assist other workers in dressing out in PPE
• Can ensure that all workers are regularly checked
  for signs of stress and agent exposure
• Pair an experienced worker with inexperienced
  buddy whenever possible

155
Work Rules SummaryPlan Ahead

• Follow guidance for working in PPE
• Ensure serviceability of equipment through
  regular inspections of PPE equipment
• Plan work/rest cycles appropriate to environment
  and situation
• Use standard operating procedures to reduce
  command, control, and communication tasks
• Keep plans and operations simple

156
Work Rules Summary Think Teamwork

• Use methods of individual identification
• Encourage small talk while wearing PPE
• If resources permit, use the buddy system to
  ensure that all workers are regularly checked for
  signs of stress, dehydration, and agent exposure
• Pair experienced worker with inexperienced
  buddy whenever possible

157
Work Rules SummaryGood Practices

• Provide relief from PPE outside hazard area as
  soon as situation allows
• Use work/rest ratios, slow work rate, and
  minimize work intensity
• Work in the shade whenever possible
• Rotate jobs and people during long periods of
  relative inactivity
• Provide relief from extreme temperatures (hot or
  cold) as soon as possible
• Remember that even short breaks from total
  encapsulation are effective in sustaining
  performance
• Enforce drinking of water to reduce dehydration
  and heat casualties

158
Module 6Decontamination
159
Decontamination

• Reduction or removal of agents by physical means
  or by chemical neutralization
• Physical means flushing, scraping, and powders
• Neutralization soap, bleach, and special
  solutions

160
Purposes of Decontamination

• Prevent further damage from chemical exposure
• Prevent secondary or cross contamination

161
Module Organization

• Overview of decontamination concepts
• Current practices
• 3 case studies
• Special considerations

162
Basic Concepts

• Must be done immediately
• Must be done effectively
• Clothes must be removed to eliminate possible
  contamination

163
Three Decontamination Types

• Personal
• self
• buddy
• Casualty
• non-ambulatory
• Personnel
• non-exposed
• ambulatory

164
Liquid versus Vapor

• Decontamination is needed for both liquid and
  vapor exposure
• Vapor is absorbed by clothing and hair
• Rigorous decontamination is needed for liquid
  exposure
• Less rigorous decontamination is needed for vapor
  exposure

165
Decontamination Solution

• Soap and water is the preferred solution
• as effective as diluted bleach solution
• less caustic
• takes less time than diluted bleach solution
• Do NOT delay decontamination if only water is
  readily available

166
Secondary Contamination

• Case Study Tokyo Sarin
• Case Study New York HAZMAT
• Case Study Louisiana Mustard Exposure
• Lessons learned
• need appropriate PPE and training
• need to isolate persons exposed
• need to follow standardized protocols and
  procedures

167
Tokyo Subway Sarin Incident

• 3 subway lines attacked in morning rush hour
• Estimated 5,500 persons exposed
• No on-scene decontamination
• Decontamination initiated at medical facilities 3
  hours after exposure
• Secondary contamination at hospitals was a major
  problem

168
Tokyo Subway Sarin Incident

• Decontamination initiated at medical facilities 3
  hours after exposure
• Hospitals lacked space and equipment to handle
  large number of victims
• Secondary contamination at hospitals was a major
  problem

169
NY State HAZMAT Event

• Dimethoate (systemic insecticide) overheated and
  released fumes
• Quickly resulted in respiratory problems
• Eleven workers self-reported to hospital ED
• ED staff become ill HAZMAT called
• Evacuated ED and decontaminated victims and ED
  staff (1 hour)

170
NY State HAZMAT Event

• ED washed down by hospital staff and reopened 2
  hours later
• No testing conducted or reentry criteria used

171
NY State HAZMAT Event

• No screening
• No training of ED staff in signs and symptoms
• Lack of communication and info on chemicals
• No containment area for victims
• Separate facilities unavailable
• No testing conducted or reentry criteria used

172
Mustard Exposure in Vinyl Chloride Plant

• Inadvertently produce nitrogen and sulfur mustard
  in Louisiana chemical facility
• Over 150 workers exposed during hydro-blasting
  operation, 3 seriously
• Latent symptoms

173
Mustard Exposure in Vinyl Chloride Plant

• 150 people report symptoms 2 days later
• OSHA involved after 3rd hospitalization
• Over a week to determine mustard involved
• Considerable secondary contamination from
  workers clothing to spouses

174
Mustard Exposure in Vinyl Chloride Plant

• Findings
• Personnel decontamination not performed
• No control of contaminated personnel or
  clothing
• Secondary contamination at unknown levels
• Local physicians do not know how to treat victims
• Agents were not initially identified
• Commercial laboratory analysis inadequate
• PPE not used or used improperly

175
Mustard Exposure in Vinyl Chloride Plant

• Follow-up 6 years later

176
Current Practices

• Self- and buddy-decontamination
• Decontamination station
• Ambulatory decontamination
• Non-ambulatory decontamination
• Mass decontamination
• Animal decontamination

177
Self- and Buddy-Decontamination

• Insufficient time to set up decontamination
  station
• Need to instruct public to do it themselves
• Self Do it on your own
• Buddy Help others to do it
• Followed by technical decontamination

178
Self- and Buddy-Decontamination

• Anticipate that not all people will follow
  instructions

179
Field and Hospital Decontamination

• Siting the facility
• upwind, uphill, and upstream
• allow for security to control scene
• Establish reception area for initial screening
• Establish triage area for rapid medical
  evaluation and classification
• Simple Triage and Rapid Treatment (START)

180
Decontamination Station2 lines
181
Decontamination Station 3 lines
182
Important Considerations

• Deployment
• portable for field use
• permanent facilities at HCFs
• At least two lines, ideally 3
• ambulatory (mixed or male only)
• non-ambulatory
• female ambulatory
• Warm water supply
• Privacy
• Run-off control

183
Decontamination Priorities

• People who are known or suspected of being
  contaminated and who require prompt medical
  attention due to agent exposure or other severe
  injury
• People who are exhibiting signs/symptoms of agent
  exposure
• People who are known to be contaminated but are
  not exhibiting signs/symptoms and don't urgently
  require medical attention
• People who are suspected of being contaminated
  but show no signs of agent toxicity
• Animals that provide critical support to humans
  (e.g., seeing eye dogs) that are known or
  suspected to be contaminated

184
Ambulatory Decontamination

• Receive, triage and tag
• Treat wounds (optional)
• Remove and bag all effects
• Thoroughly shower with soap and water

185
Ambulatory Decontamination

• Rinse and dry
• Don clean clothes and tag
• Remove to clean zone

186
Non-Ambulatory Decontamination

• Receive, triage and tag
• Send through line on backboard
• Clothing cut away and bagged

187
Non-ambulatory cont.

• Flushed with soap solution, scrubbed, rinsed with
  clean water and dried
• Tagged and covered
• Transferred to clean zone for treatment

188
Mass Decontamination

• Used to process large number of people
• Water only is recommended
• Several options

Ladder and Truck
Over-head Shower
189
Mass Decontamination

• Run-off water and EPA

190
Animal Decontamination

• PETS Act (2006)
• Pets, livestock, and service animals can be
  contaminated in a variety of disasters
• Need plan to set up decontamination facility for
  animals
• Scrub with liquid soap and water and dry

191
Animal Decontamination

• Need plan to set up decontamination facility for
  animals
• Scrub with liquid soap and water and dry

192
Animal Decontamination

• Animals evaluated for treatment
• Handling issues of owner/animal separation

193
Special Considerations

• Infants, children and elderly
• People with disabilities

194
Special Considerations

• Cold weather
• Psychological effects

195
Special Considerations

• Considerations for biological contamination

196
Special Considerations

• Considerations for radiological contamination

197
Module 7Medical Treatment
198
Nerve Agent
199
Treatment - No Signs and Symptoms

• Reassure
• Observe
• Vapor 1 hour
• Liquid Up to 18 hours

200
Basic Nerve Agent Exposure Treatment

• Airway/ventilation
• High resistance positive pressure of gt 50-70
  cm/H20 or higher is needed
• Oxygen
• Antidotes
• Atropine
• Pralidoxime Chloride
• (2-PAM Cl)
• Diazepam

201
Nerve Agent Effects

• Nerve agent overstimulates the
• nervous system muscles and
• glands over-react and organs
• malfunction
• Initial treatment involves 2-part antidote
• Atropine stops the effect of nerve agent
• 2-PAM Cl restores normal muscle function by
  reactivating cholinesterase

202
Atropine

• Atropine blocks effects of over-stimulation
• Relieves smooth muscle constriction
• Dries up respiratory secretions

203
2-PAM Cl Effect

• Removes organophospate from acetylcholinesterase
  which can then deactivate acetylchline
• Re-establishes normal skeletal muscle contraction
• Relieves twitching and paralysis of respiratory
  muscles

204
Diazepam

• Administer to patients experiencing convulsions
• Consider for patients with severe signs and
  symptoms
• Dosage depends on patients age

205
Administration of Antidotes

• Dosage varies depending on age and weight of
  patient and severity of signs and symptoms
• Dosages may need to be repeated at specified
  intervals
• repeat atropine until patient is atropinized
• repeat 2-PAM Cl until maximum dose per body
  weight is reached

206
Signs of Atropinization

• Secretions dry up
• Less labored breathing

207
Two Common Problems

• Underdosage
• administering too little antidote to relieve
  agent effects
• most serious problem failing to administer
  atropine when needed
• Administering antidote to patients not exposed to
  nerve agent

208
Guideline for Administering Antidotes

• Make sure atropine warranted
• Administer dosages of antidotes as recommended in
  treatment tables
• Continue administering atropine as recommended in
  treatment tables until atropinization is achieved
• If needed, repeat dosage of 2-PAM Cl as
  recommended in treatment tables until maximum
  total dose is given

209
Potential Problems With Atropine

• Exercise caution in administering atropine
• For non-life-threatening exposures, use extreme
  caution if patient has existing medical problems
• Administer to pregnant woman only if clearly
  needed
• Administer to nursing woman with caution
• Start at low end of dosing range when treating
  elderly

210
Potential Problems with 2-Pam Cl

• Exercise caution in administering 2-PAM Cl
• Reduce dosage if patient has renal insufficiency
• Give to pregnant woman only if clearly needed
• Give to nursing woman with caution

211
Adverse Reactions

• Atropine
• pain at injection site, dry mouth, blurred
  vision, photophobia, confusion, headache,
  dizziness, fast heart beat, palpitations,
  flushing, urinary hesitancy, con