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Abstract
During a multiple casualty chemical, biological, radiological and nuclear incident it is imperative that triage is accurately undertaken to use resources effectively and give the greatest chance of survival to those who need it. This reflection explores an option to assist in this matter by proposing a colorimetric breathing detection system, while remembering that this it is untested, may be a useful aid.
- Mass casualty
- chemical hazard release
- chemical warfare agents
- chemical terrorism
- triage
- resuscitation
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Background
After a review of the Health Protection Agency and Joint Royal Colleges Ambulance Liaison Committee Chemical, Biological, Radiological and Nuclear (CBRN) initial triage guidelines,1 2 it became apparent that these triage systems rely heavily on apnoea recognition to identify dead patients. During Hazardous Area Response Team (HART) multiple-casualty CBRN exercises it become evident to the author that it is difficult to recognise apnoea while wearing the NHS powered respirator protective suit (PRPS) (Respirex, Redhill, UK). The Health Protection Agency and Joint Royal Colleges Ambulance Liaison Committee CBRN initial triage guidelines do not recommend a means of respiratory assessment that can be effectively undertaken while wearing the PRPS.1 2 One possible method was the use of the Resuscitation Council (UK) look, listen and feel method for immediate respiratory assessment,3 but this has proved difficult during a number of different exercises. The difficulty in seeing chest movement arises from deformities in the visor, internal condensation from perspiration, and external water distorting and hindering vision. Further, noisy material around the ears, external precipitation, filter unit noise and air turbulence affect the ability to hear. Finally, thick rubber gloves hinder tactile sensation, making it difficult to feel chest wall movement. Allowing a casualty to exhale on the PRPS visor while kneeling on possibly contaminated ground may compromise the integrity of the protective suit and is therefore not recommended.
Discussion
As dead casualties only receive resuscitation attempts if there are enough resources available,2 it is imperative that these patients are triaged accurately to allow limited personnel to be used effectively. Hot and cold debriefs after exercises did not lead to suggestions of alternative means of detecting respiratory effect but did stimulate discussion. Consequently the author undertook a brief literature search using NHS Health Information Resources (http://www.library.nhs.uk) accessing the British Nursing Index (BMI), CINAHL and MEDLINE. This identified research recommending capnography as a rapid assessment and triage tool for chemical terrorism incidents.4 5 These papers suggest that capnography can provide a direct assessment of ventilation status, allowing rapid appraisal of the effects of chemical agents by monitoring end tidal waveforms. An alternative to electronic end tidal carbon dioxide (ETCO2) monitoring may be the use of a disposable colorimetric ETCO2 device attached to a disposable translucent mask (figure 1). This has the advantage of not needing to take heavy, bulky, non-intrinsically safe battery powered equipment into the contaminated ‘hot zone’, which would subsequently require decontamination. The mask/colorimetric ETCO2 monitor combination appears to offer an effective, cheap, disposable and easy to use means of detecting respiration. It has the additional benefit of being visually recordable by a rescuer-worn head mounted camera.
Disposable colorimetric end tidal carbon dioxide device attached to a disposable translucent mask.
Action plan
Further work is required to validate the proposed colorimetric breathing detection system, which may also be useful while wearing other types of personal protective equipment, such as the Swift Responder 3 protective suit (Remploy, Wallasey, UK) and Gas Tight Suit (Respirex, Redhill, UK). This will include determining the susceptibility of these devices to degradation from contact with chemical agents, which could result in false readings. A further literature search will be undertaken and the device will be assessed during training exercises.
Footnotes
Competing interests None.
Provenance and peer review Not commissioned; not externally peer reviewed.
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