Step 3: Cold Zone/Tactical Evacuation Care/Prolonged Field Care

Once the decontaminated casualty has passed into the cold zone, they should be re-evaluated and receive needed interventions to include tactical evacuation or prolonged field care. The decontamination process alone can result in significant change in the casualty’s condition, so re-triage and reassessment are the first priority. If a secondary survey has not been performed, it should be done immediately after re-assessment of the primary survey. Documentation throughout the phases of care is vital to facilitate information transfer as the patient transits from one phase to another. The CBRN casualty card (Appendix B) is a useful tool to ensure comprehensive documentation relevant to the CBRN casualty. In the absence of a CBRN casualty card, the TCCC casualty card is sufficient if duration of care before transfer is short and patient is relatively stable. If handoff to higher echelon of care is delayed or patient is unstable, PFC documentation will likely be necessary. (Loos 2018)

It is important to take into consideration that receiving providers at all roles of care may have minimal to no experience with CBRN patients. Communication is crucial to ensure receiving providers understand previous decontamination and care and exposures that may be suspected. This can prevent delays in patient care caused by unnecessary repetitive decontamination or redundant treatments.

Casualties that reach the cold zone have been decontaminated and are now suitable for the full spectrum of care appropriate to the clinical environment and capabilities. There are however, some unique concerns to address in a combination CBRN/trauma casualty. While thorough decontamination and complete removal of a casualty’s clothing eliminates almost all debris, it is possible the casualty may have retained foreign material or contaminated dressings in wounds. Such material may pose risk to treating personnel from off-gassing or secondary contamination. Additionally, this residual contamination may represent a continuing source of exposure to the patient via a route that bypasses the normal barriers of the skin resulting in rapid systemic distribution of the agent. Larger fragments should be removed from the wound using a “no touch” technique with surgical instruments, followed by placing the material and instrument in a sealed container with hypochlorite solution, minimizing the risk to providers. When possible, the contaminated wound should be further irrigated with clean water. Providers dealing with contaminated foreign material or dressings can wear 3 pairs of nitrile gloves. The outer glove should be discarded every 20 minutes. In the absence of suspected retained debris, the fully decontaminated patient in the cold zone can be treated as all other patients at that level of care. The extent of wound care provided will depend on prehospital resources available and transport time to surgical care.