Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities
The US Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) and the US Department of Homeland Security (DHS) Office of Health Affairs published the nation’s first evidence-based guidance for mass decontamination. The guidance, titled “Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities”, informs planning and response for a wide variety of situations, from local chemical plant accidents to terrorism incidents, and covers mass casualties, chemical release, external contamination, and decontamination of people. Certain details related to children are included. HHS and DHS have started developing a companion guidance document focused on decontaminating pediatric patients.
Decontamination of Children
Whether as a result of an accidental release at a chemical plant, a transportation accident, or an intentional terrorist action, the threat of exposure of the public to hazardous chemicals is real. Children are particularly vulnerable to aerosolized biologic or chemical agents because they normally breathe more times per minute than adults, and they would be exposed to larger doses than adults in the same period of time. Children are also more vulnerable to agents that act on or through the skin because their skin is thinner and they have a larger skin surface-to-body mass ratio than adults. Children will require different advanced planning and supplies for decontamination. For example, children, especially young children, are more at risk of hypothermia and therefore require heated water or decontamination conducted in a site more protected from cold environments. Each hospital must have its own system or plan for decontamination, with protocols specific to children.
Need for Decontamination
Decontamination is the removal or reduction of harmful substances from a patient's body. The goal of decontamination is to ensure that a toxic substance, whether chemical, biological, or radiological, is no longer in direct contact with the patient. This prevents further absorption by the patient and will decrease the possibility of transfer of the toxic substance to health care workers.
Important Processes for Decontaminating Children
The following are tips and suggestions for decontaminating children:
- Staff helping with decontamination should receive training on the vulnerabilities of children and how to address these.
- Children should be prioritized before adults within the same decontamination priority group.
- Unless strictly contraindicated due to medical needs, families should undergo decontamination together. Children and parents may become upset if separated from family members during decontamination. Keeping children with their parents or caregivers may reduce psychological stress for all family members and decrease the need for additional assistance from responders or health care personnel.
- Children will take more time to disrobe and prepare (emotionally) for the decontamination. Parents may fear that the privacy, safety, and welfare of their children are not protected if they are cared for by responders of the opposite gender. Children of certain ages may become more anxious when asked to disrobe, and it is recommended to have both male and female personnel to assist children. A study sponsored by the HHS revealed that 99% of chemical contamination can be eliminated by carefully removing clothes and wiping skin with a paper towel or dry wipe.
- The risk of adverse consequences of water-based decontamination may be greater in children; warming measures will be necessary. The water temperature should be 98◦ to 110◦ F out of tap, and foil/metallic blankets should be used post decontamination for ease of use and disposal.
- Hospital personnel should take care to ensure each child's airway remains open and protected during decontamination.
- Low pressure shower systems should be used to decontaminate children.
- Infants and young children can be slippery when wet and will require a system to ensure their safety (eg, hand spraying while on a stretcher, in a bassinet, or laundry basket with holes).
- When children are exposed to circumstances that are beyond the usual scope of human experience, they may have difficulty understanding and coping with the events and may need support from adults. See additional information on Promoting Adjustment and Helping Children Cope.
- For unaccompanied minors, psychosocial support should be provided in a pre-designated child safe area with age appropriate activities.
- When appropriate, self -care decontamination (actions that a patient can perform for him/herself) can have a positive impact on children following a chemical exposure. Consider developing standard protocols and kits to support self-care decontamination.
To ensure that the unique physical and emotional needs of children are met during times of disaster, the pediatrician should be involved in community preparedness planning in advance of a disaster. Clinicians can talk to parents about the need to develop a family disaster plan and encourage them to talk to their children about what to do in various emergency situations. See the Family Readiness Kit. See additional information from the Pediatric Preparedness Resource Kit or The Youngest Victims: Disaster Preparedness to Meet Children's Needs.
Biological Terrorism and Agents (AAP)
Chemical Terrorism and Agents (AAP)
Decontamination of Children (HHS)
Decontamination of Poisoned Children (UpToDate)
Domain 4 of the EMSC Pediatric Disaster Checklist for Hospitals (EMSC)
Dropbox of Pediatric Decontamination Resources
Essential Pediatric Domains and Considerations for Every Hospital's Disaster Preparedness Policies - Domain 4 (EMSC)
Principles of Pediatric Decontamination Article (Clinical Pediatric Emergency Medicine)
Radiologic or Nuclear Terrorism and Agents (AAP)
Talking to Children About Disasters (AAP)
Decontamination Decoded: Disrobing, Dry Wiping Removes 99% of Chemical Contaminants (ASPR Blog)