Basic Principles of CBRN Casualty Management

Initial care of the CBRN casualty should be approached in the same manner as other casualties. However, there are additional layers of personal protection, decontamination and medical countermeasures that need to be applied. Life threatening conditions require prompt recognition and intervention, while non-life-threatening sequelae can be addressed when clinically appropriate. Early recognition and categorization of CBRN-exposed patients is key for initiating patient treatment and preventing contamination of medical personnel, equipment, and facilities. Thorough and appropriate decontamination is a core skill that requires planning and practice. Attention to detail such as preventing hypothermia and clinical reassessment at each stage of the process will reduce unnecessary morbidity. Hypothermia is highly likely to occur in patients not only due to the decontamination processes but also due to agent exposure itself. Furthermore, easy access to reference materials to guide advanced therapy should be a part of every provider’s armamentarium. These basic principles will be discussed in more detail in the following sections. Understanding the difference between exposure and contamination is critical. Contamination occurs when a material/agent is somewhere undesirable. If intact Personal Protective Equipment (PPE) is contaminated and the contaminated PPE is safely removed there is no longer contamination, i.e., the patient has been decontaminated. If contamination is present on the skin and the skin is properly decontaminated the patient is clean and poses no threat to caregivers.

Critical Task List

The critical task list applies to medical and non-medical personnel and addresses core competencies that can be adjusted based on the medical skill level of the responder. All personnel should be trained on the concepts and principles identified in the critical task list to respond to CBRN casualties. These tasks should be taught according to service-specific publications and recognized standards of medical care and are outlined below.

- Recognize CBRN exposure
- Don personal protective equipment (PPE) to prevent self-exposure and assist others with PPE (Tables 1 and 2)
- Egress from the threat
  - Move upwind, uphill, and upstream from threat
  - Utilize time, distance, and shielding for protection
- Utilize CRESS and clinical toxidromes and syndromes to build a differential diagnosis (Figure 4)
  - Utilize the CRESS acronym (Consciousness, Respirations, Eyes, Secretions, Skin) (Table 3) for the rapid identification of signs/symptoms of CBRN exposure (Table 4) that prompt immediate self-treatment or treatment of others (i.e. nerve agent and cyanide exposure)
  - Clinical toxidromes and syndromes can be used to broaden the differential diagnosis

- Apply TCCC integrated with CBRN response: TCCC + CBRN = (MARCHE)2
  - (MARCHE)2: Massive hemorrhage/mask, airway/antidote, respiration/rapid focused decontamination, circulation/countermeasure, hypothermia/head injury, extraction/evacuation
- Apply airway management skills in a CBRN setting (positioning, suction, manual/mechanical ventilation, placement of definitive airway)
- Perform Rapid Focused Decontamination
- Identify and establish Hot/Warm/Cold Zones (Appendix A)
- Establish a dirty casualty collection point (CCP) in the hot zone (Figure 7)
- Understand decontamination principles and casualty procedures for partial or complete removal of PPE, clothing, and equipment
- Understand cross-contamination and take appropriate measures to prevent it