Putting It All Together, Integrating CRESS and (MARCHE) 2

Step 1: Hot Zone/Care Under Fire

During “hot zone” care, the agent itself is similar to enemy fire. As such, the priorities are protection from and egress away from the threat (CBRN agent) for both casualty and provider. Both casualty and provider should don protective mask. If the casualty is incapacitated, the provider must ensure the casualty’s protective gear is applied and functional.

Only rapid interventions for immediate life-threats should be addressed. Massive hemorrhage, if present, may be the most immediate life threat and control of hemorrhage supersedes other interventions. Massive hemorrhage, if compressible, should be treated according to TCCC guidelines with limb tourniquets.

Perform a rapid assessment of the airway and respirations. Excessive secretions and increased respirations may indicate nerve agent exposure. Completion of the CRESS assessment will help determine if the symptoms are due to trauma or chemical agent exposure. Most airway and respiration interventions should be deferred. Occasionally, such interventions may take priority over mask application, but the decision to unmask a casualty in order to provide the intervention needs to be weighed against the risk of the contaminated environment.

Some CBRN agents are rapid killers. The CRESS assessment will quickly determine whether immediate antidotes are required. If nerve agent exposure is suspected (decreased level of consciousness, increased respirations, constricted pupils, increased secretions, diaphoretic skin) then the provider should direct self-administration of Antidote Treatment Nerve Agent Auto-injector (ATNAA) and Convulsant Antidote for Nerve Agent (CANA) or administer the antidotes for an incapacitated casualty.

Rapid spot decontamination of skin or wounds is indicated when there is gross contamination on the skin or wounds or when protective gear is breached. If wound contamination with chemical agent is suspected, immediately expose the wound to perform rapid spot decontamination. This step is necessary even in a contaminated environment and may be lifesaving.

Treatment for cyanide can be considered in the hot zone, but the need to establish IV/IO access to administer hydroxocobalamin makes this a judgment call weighed against the time needed to reach the warm zone and the ongoing threat in the hot zone location. Naloxone 2 mg intramuscular or intranasal for opioid incapacitating agents may also be considered for life-threatening respiratory depression. As in TCCC, non-essential interventions should be deferred until the next phase of care.