Ricin: Control Measures Overview for Clinicians
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Protecting Emergency/First Responders
- Always use Standard Precautions.
- Responders should be trained and attired in appropriate personal protective equipment (PPE) before entering the incident site (hot zone).
- If rescuers have not been trained in use of appropriate PPE, call for assistance in accordance with local Emergency Operational Guides.
- Sources include local HAZMAT teams, the closest metropolitan strike system (MMRS), and the U.S. Soldier and Biological Chemical Command (SBCCOM)-Edgewood Research Development and Engineering Center.
- Incident Commander assigns personal protective equipment (PPE) levels based on a hazard assessment and site conditions, including the mechanism of dispersal and whether or not dispersal is continuing.
- Incident site (hot zone) PPE may include:
- Chemical protective clothing
- NIOSH-approved pressure-demand, self-contained breathing apparatus (SCBA CBRN, if available) is recommended in response to non-routine emergency situations
- In other situations, two types of full facepiece, tight-fitting masks may be used: 1) Powered air Purifying respirator (PAPR) with HEPA filters; or 2) Air Purifying respirator (APR) with P100 filters
- For guidance on selection criteria, see: Interim Recommendations for the Selection and Use of Protective Clothing and Respirators Against Biological Agents
- Eyes should be protected when possible (full face-piece respirator provides eye protection)
- Support Zone (Post-Decontamination)
- Use Standard Precautions.
- PPE disposal:
- Decontaminate any reusable PPE by thoroughly rinsing with soap and water, soaking in a 0.1% sodium hypochlorite solution for 15 minutes, and then rinsing with water and allowing to air dry
- Dispose single-use PPE hazardous waste.
- Identify person(s) assigned to coordinate communication (e.g., with medical examiner, investigators, law enforcement).
- Identify person(s) assigned to managing fatalities (e.g., to set up temporary morgue, provide security, provide victims’ identities, protect victims’ personal effects, and maintain and protect records).
- Heighten awareness of and be suspicious for injuries and exposures beyond a release of ricin (e.g., another biological or chemical agent, blast injury, and trauma).
- If a ricin release is suspected or known:
- Determine if evacuation or “shelter in place” inside a building to avoid further exposure is necessary.
- Sort victims by urgency, need for stabilization, need for decontamination, number of victims, and healthcare resources.
- Base triage on walking feasibility, respiratory status, and additional injuries.
- Category (Priority) for triage of casualties:
- Immediate (Priority 1) Unconscious, talking but not walking, or moderate to severe effects in two or more body organ systems; seizing, post-ictal, severe respiratory distress, apneic, recent cardiac arrest.
- Delayed (Priority 2): Recovering from agent exposure/improving respiration.
- Minimal (Priority 3): Walking and talking.
- Expectant (Priority 4): Unconscious; cardiac/respiratory arrest of long duration.
- Direct ambulatory victim(s) from incident site/hot zone to decontamination zone.
- Shift to doing the most good for the most people when resources are exceeded.
- Evaluate and support airway, breathing, and circulation.
- When assisted ventilation is required, use bag-valve-mask device with canister or air filter, if available.
- Apply direct pressure to stop bleeding, if present.
- Remove from incident site/hot zone as quickly as possible.
- Persons suspected to be contaminated with ricin should receive gross decontamination to the extent possible at the site of release, prior to transport to the hospital, unless medical condition of a victim dictates immediate transport to the hospital.
- Remove, bag, seal, and dispose of clothes, and wash body.
- See Healthcare Facility Management, Decontamination/Infection Control, Decontamination.
- Emergency response personnel, local or state health department representative(s) arrange for disposal of clothing.
- When responding to victims at agent release site, depending upon timing, duration, and circumstances of exposure (e.g., suspected/known release, release of another chemical agent or a biological agent, etc) and availability of resources (e.g., medical personnel, antidote):
- Identify potentially exposed and evaluate each for evidence of exposure and for ricin poisoning symptoms.
- Transport exposed persons to a temporary field location, or to a healthcare facility.
- Notify exposed persons who are not transported to a healthcare facility of ricin poisoning symptoms, and to seek immediate medical attention if symptoms develop. Record names, addresses, and telephone numbers.
- Be prepared for victim(s) who may present to an emergency department without prior warning
- Direct the emergency department ventilation exhaust away from the hospital’s main ventilation system to limit distant spread of any airborne biological agent chemical agent contaminant through off-gassing vapor from victims who present to and enter the emergency department.
- Comply with healthcare facility’s Emergency Response Plan.
- Prepare for mass casualties by establishing patient triage, registration, decontamination, treatment, transportation, and stabilization zones/areas for hospital admission(s).
- Perform hazard vulnerability analysis to determine if hospital can manage the anticipated number of victims.
- Determine if lockdown (shelter-in-place) is necessary, and secure area to control access and contain contamination.
- Prepare for public health surge capacity and cooperate with other healthcare facilities, local, state, and federal authorities when:
- It is determined that healthcare facility cannot manage anticipated number of victims.
- Services expand beyond normal from large scale event.
- Sort victims by urgency, need for stabilization, need for decontamination (e.g., simultaneous release of multiple agents), number of patients, and healthcare resources.
- Treat, or hold for observation, previously decontaminated patients.
- Shift to doing the most good for the most people when resources exceeded.
- Decontaminate persons whose skin or clothing was suspected or known to be exposed to ricin.
- If it has not been done at incident site, decontaminate exposed person prior to entry into the healthcare facility, outside the main emergency department (Decontamination Area).
- For the comfort of the victim and to improve cooperation, attention should be given to explaining the procedure to the victim, and providing privacy, security of personal belongings, and water at a comfortable temperature, if possible.
- Remove clothing, as quickly as possible,
- Any clothing that has to be pulled over the head should be cut off the body instead.
- Remove jewelry and watches.
- Double bag and seal contaminated clothing and all personal belongings in plastic bags:
- Wear gloves, use plastic bag turned inside out, or use tongs or similar objects to avoid touching contaminated areas of clothing.
- Place clothing inside one plastic bag, then seal the bag.
- Place the sealed bag inside another plastic bag and seal it.
- Label bag as contaminated and secure it in a safe location until it can be safely disposed.
- Avoid touching any contaminated areas if assisting an exposed person remove clothing.
- Prevent droplets from contacting broken skin or mucosal membranes when decontaminating someone or cleaning up body fluids that may contain ricin toxin. Airborne dispersal of ricin during decontamination is an unlikely hazard.
- Rapidly wash off any obvious contamination with soap and copious amounts of water.
- Shower entire body, including head and hair, with large amounts of liquid soap and warm water, this is the most effective and preferred method for removing remaining hazardous substances from skin.
- Irrigate exposed eyes with plain water for 10 to 15 minutes:
- Remove contact lenses if contact lenses are present and are easily removable without additional trauma to eyes.
- Do not put contact lenses back in eyes, even if they are not disposable contact lenses.
- Wash eyeglasses with soap and water.
- Eyeglasses may be put back on after they have been washed.
Isolation and Exposure Prevention
- Use standard precautions.
- Prior to decontamination, healthcare workers caring for chemically contaminated patients should:
- Put on full chemical resistant suit with gloves, surgical mask, and eye/face protection such as face shield and goggles.
- If a person’s skin or clothes have been contaminated with ricin, and the victim has not already undergone decontamination, decontaminate the ricin-exposed victim(s) before entry into healthcare facility.
- During and after decontamination tasks, healthcare personnel should refrain from any hand-to-mouth activities.
- After completing decontamination tasks, healthcare personnel should:
- Carefully remove all PPE, place in sealed plastic bag(s) for either decontamination or disposal
- Perform hand hygiene and shower.
- When caring for ricin-exposed victims who do not require decontamination or victim’s post-decontamination, healthcare workers should follow Standard Precautions and perform hand hygiene.
- Standard laboratory precautions should be observed and precautions taken to avoid aerosolization and exposure of laboratory personnel (See Ricin: Diagnosis and Laboratory Guidance for Clinician).
- Aerosol-generating sawing associated with surgery should be avoided.
- Use standard precautions when handling bodies of ricin-exposed patients who have died. Aerosol-generating procedures (e.g., bone-sawing associated with post-mortem examinations) should be avoided.
- Healthcare personnel or laboratory workers sustaining exposure via sharps injury, cuts, or abrasions should immediately wash the exposed site with a soap and water.
- Potentially exposed healthcare personnel should be advised to remove all PPE carefully, wash hands thoroughly with soap and water, refrain from any hand-to-mouth activities, and shower.
- When exposure to eyes occurs, flush eyes with copious amounts of water or eye wash solution for at least 15 minutes.
- Follow standard facility policy regarding workplace exposure.
- Environmental surfaces or equipment, such as in a transport vehicle (e.g., ambulance) can be cleaned with soap and water, then disinfected in a 0.1% sodium hypochlorite solution or cleaned and disinfected with an EPA-registered hospital disinfectant following conventional protocols.
- In the healthcare facility, disinfect environmental surfaces with EPA-registered hospital disinfectant following conventional healthcare facility policies and procedures.
- In case of a spill of materials potentially contaminated with ricin, immediately cover spill with absorbent materials, then disinfect the area with an EPA-registered hospital disinfectant or EPA-registered chlorine bleach solution following healthcare/laboratory facility policies and procedures.
Infection Control Professionals should:
- Maintain heightened awareness for evidence of ricin-exposed patients and collaborate with clinicians and laboratory to ensure immediate notification of local and state public health department officials when nerve agent poisoning is suspected
- Ensure that telephone numbers for notification of appropriate healthcare facility and public health agencies are current and distributed to the appropriate healthcare facility departments and personnel
- Communicate with the laboratories that receive specimens for testing.
- Page last reviewed February 29, 2008
- Page last updated April 17, 2006
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