Note: Casualty Flow moves from top to bottom in this diagram. Triage flows immediate to delayed from left to right in the hot zone diagram. Medical personnel, at least one provider designated clean and one provider designated dirty

Decontamination and treatment should be a synchronous process. Medical personnel need to clearly communicate with non-medical personnel responsible for decontamination. “Expose to treat” is used by decontamination personnel when the provider deems it in the best interest of the casualty to remove PPE to provide life-saving medical intervention. For example, the mask may be removed and the head, face, and chest quickly decontaminated for the provider to ventilate the casualty and insert a sternal IO if parenteral antidotes, blood product, or fluid resuscitation are immediately indicated. It may also be appropriate to prioritize decontamination of an extremity to establish an IV or IO access, should a sternal IO not be an option.

Circulation should be assessed to identify external hemorrhage and shock. Per TCCC guidelines, fluid resuscitation is only indicated for altered mental status in the absence of brain injury and/or a weak or absent radial pulse. The provider can also assess the effects of both CBRN agents and antidotes on the patient’s circulatory status. As decontamination ensues, dirty treatments are replaced with clean. Due to cold water and the need to fully expose the casualty in order to conduct thorough decontamination, hypothermia is a significant risk. Added to the hypothermia risk is the fact that exposure to many of the chemical warfare agents will themselves cause hypothermia of the casualty. Ensure rapid transit through the decontamination line with careful attention to hypothermia mitigation to prevent iatrogenic injury from the decontamination process due to exposure. Additionally, it is important to recognize that personnel working within the warm zone in full protective gear are at risk of heat injury and stressors associated with operating in PPE.