Chemical, Biological, Radiological and Nuclear (CBRN) Injury Part 1: Initial Response to CBRN Events

SUMMARY OF CHANGES

1. Updated CRESS findings for select chemical agents based on latest available information from US Department of Health and Human Services
2. Condensed and clarified information
3. Updated hot/warm/cold zone responses based on most updated TCCC Guidelines from January 2024

INTRODUCTION

This Role 1 (including Point of Injury [POI]) through Role 4 Clinical Practice Guideline (CPG) is intended for use in conjunction with Tactical Combat Casualty Care (TCCC) Guidelines. This CPG is meant to provide medical professionals who encounter CBRN exposures with evidence-based guidance where it exists or consensus opinion when evidence is lacking. Additional information and resources for decontamination, medical management, and overall management during a CBRN exposure are available at https://chemm.hhs.gov. JTS CBRN CPGs include four separate parts:

1. Response to CBRN events (an approach to all CBRN casualties)
2. Medical management of chemical agent exposure
3. Medical management of radiation exposure and nuclear events
4. Medical management of biologic agent exposure

While encountering conventional casualties on the battlefield is more likely, it is important to remain vigilant in identifying any unusual scenarios that may indicate a CBRN incident occurred. Initial suspicion of a CBRN attack will often rest solely on clinical signs and symptoms when environmental sampling and rapid point-of-care testing for agent identification is unavailable. Figure 1 provides a breakdown of different toxidromes and syndromes for an ease of use and an integrated approach. Note that some chemical agents traditionally considered chemical warfare agents are being moved to the Inhalational Injury and Toxic Industrial Chemicals (TICs) CPG as they are more likely to be encountered via other occupational exposures.

This CPG Part I guideline is intended to provide an approach to casualty assessment and treatment from POI to established medical facilities.

Figure 1. Toxidromes and syndromes by CPG location for ease of reference

Note: Edits to the CBRN CPG 2 and TICS CPG are currently in update to reflect the above figure of toxidromes and syndromes.