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 including tactical evacuation or prolonged field care. The decontamination process can result in significant change in the casualty’s condition, so re-triage and reassessment are the first priority. A secondary survey 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 transitions from one phase to another. The CBRN casualty card (Appendix C) 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. If handoff of care is delayed, PFC documentation will likely be necessary.⁹

It is important to consider that receiving providers at all roles of care may have limited experience with CBRN patients. Communication is crucial to ensure receiving providers understand previous decontamination, care, and exposures that may be suspected as to prevent 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. Consider the casualty may have retained foreign material or contaminated dressings in wounds. Such material may pose a risk to treating personnel from off-gassing or secondary contamination. Additionally, this residual contamination may represent a source of exposure to the patient via a route that bypasses the normal skin barriers resulting in rapid systemic distribution of the agent. Larger fragments should be removed from the wound using a “no touch” technique with surgical instruments and placed in a sealed container with hypochlorite solution, minimizing the risk to providers. 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 gloves 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.