To provide standardized recommendations for the emergency department (ED) response to chemical, biological, radiological, and nuclear (CBRN) events by combining the human factors/ergonomics method of hierarchical task analysis with the theoretical framework for Work as Imagined versus Work as Done.

Document analyses were used to represent CBRN response operational procedures. Semi-structured interviews using scenario cards were carried out with 57 first receivers (ED staff) to represent CBRN practice at 2 acute hospitals in England.

Variability existed in general organizational responsibilities associated with the CBRN response. Variability was further evident in top level CBRN tasks and CBRN phases at both EDs. Operational procedures focused on tasks such as documentation, checking, and timing. CBRN practice focused on patient needs through assessment, treatment, and diagnosis.

The findings provide top-down and bottom-up insights to enhance the ED CBRN response through standardization. The standardized CBRN action card template embeds the choice approach to standardization. The standardized CBRN framework implements the streamlined categorization of CBRN phases. Work as Imagined versus Work as Done is a useful theoretical framework to unpack a complex sociotechnical system, and hierarchical task analysis is an effective system mapping tool in health care.

Chemical, biological, radiological, and nuclear (CBRN) incidents are those that involve chemical or biological warfare agents or toxic radiological or nuclear materials. These agents can cause disasters intentionally or accidentally. Hospitals play a crucial role in handling CBRN disasters. This study aimed to assess the CBRN preparedness of government hospitals in Riyadh.

A descriptive cross-sectional study was conducted across government hospitals in Riyadh. All government hospitals with more than 100 inpatient beds and an emergency department met the inclusion criteria. Hospital preparedness was assessed using an adaptation of the CBRNE (chemical, biological, radiological, nuclear, or explosive event) Plan Checklist. This adaptation was chosen due to the inclusion of explosive events in hospital disaster readiness, and its structural composition of key clinical guidelines necessary for a comprehensive disaster and readiness plan. Results were described in frequencies across several domains such as foundational considerations and planning which are used to assess plan preparedness using readiness tools, training, and awareness among staff members in accordance to a pre-established emergency plan, placed procedures and their implementation, and modules for preparing for a biological incident, a chemical incident, and a radiological or nuclear incident.

Of the 11 eligible hospitals, 10 participated in the study. Furthermore, CBRN considerations were included in the disaster plans of 7 hospitals. Drills had been conducted in collaboration with local agencies in only 2 hospitals. The staff had been trained to recognize the signs and symptoms of exposure to class (A) biological agents in less than half of the hospitals. Eight of the hospitals had antidotes and prophylactics to manage chemical incidents, but only half of them had radiation detection instruments. Personal protective equipment was available in all hospitals, but rapid access to stockpiles of medications was available in only half of them.

Government hospitals in Riyadh demonstrated insufficient CBRN preparedness as per the CBRNE Plan Checklist. Overall, there was a lack of preemptive planning, application of pre-established policies and procedures, and adequate staff training. Furthermore, several hospitals had insufficient stockpiles of medications and in concrete plans on accessing government stockpiles in the case of an emergency. Therefore, their staffs should be trained to manage CBRN emergencies, and local drills should be conducted to improve their preparedness.

The survivability of mass casualties exposed to a chemical attack is dependent on clinical knowledge, evidence-based practice, as well as protection and decontamination capabilities. The aim of this systematic review was to identify the knowledge gaps that relate to an efficient extraction and care of mass casualties caused by exposure to chemicals.

This systematic review was conducted from November 2018 through September 2020 in compliance with Cochrane guidelines. Five databases were used (MEDLINE, Web of Science Core Collection, Embase, Cochrane, and CINAHL) to retrieve studies describing interventions performed to treat victims of chemical attacks (protection, decontamination, and treatment). The outcomes were patient’s health condition leading to his/her stabilization (primary) and death (secondary) due to interventions applied (medical, protection, and decontamination).

Of the 2,301 papers found through the search strategy, only four publications met the eligibility criteria. According to these studies, the confirmed chemical poisoning cases in acute settings resulting from the attacks in Matsumoto (1994), Tokyo (1995), and Damascus (2014) accounted for 1,333 casualties including 11 deaths. No study reported comprehensive prehospital clinical data in acute settings. No mention was made of the integration of specialized capabilities in medical interventions such as personal protective equipment (PPE) and decontamination to prevent a secondary exposure. Unfortunately, it was not possible to perform the planned meta-analysis.

This study demonstrated gaps in clinical knowledge application regarding the medical extraction of casualties exposed during a chemical attack. Further research is required to optimize clinical practice integrating mixed capabilities (protection and decontamination) for the patient and medical staff.

Chemical, biological, and radiological (CBR) terrorism continues to be a global threat. Studies examining global and historical toxicological characteristics of CBR terrorism are lacking.

Global Terrorism Database (GTD) and RAND Database of Worldwide Terrorism Incidents (RDWTI) were searched for CBR terrorist attacks from 1970 through 2017. Events fulfilling terrorism and poisoning definitions were included. Variables of event date and location, event realization, poisonous agent type, poisoning agent, exposure route, targets, connected events, additional means of harm, disguise methods, poisonings, and casualties were analyzed along with time trends and data gaps.

A total of 446 events of CBR terrorism were included from all world regions. A trend for increased number of events over time was observed (R2 = 0.727; coefficient = 0.511). In these attacks, 4,093 people lost their lives and 31,903 were injured. Chemicals were the most commonly used type of poison (63.5%). The most commonly used poisonous agents were acids (12.3%), chlorine or chlorine compounds (11.2%), riot control agents (10.8%), cyanides (5.8%), and Bacillus anthracis (4.9%). Occurrence of poisoning was confirmed in 208 events (46.6%). Most common exposure routes were skin, mucosa, or eye (57.2%) and inhalation (47.5%). Poison was delivered with additional means of harm in 151 events (33.9%) and in a disguised way in 214 events (48.0%), respectively.

This study showed that CBR terrorism is an on-going and increasingly recorded global threat involving diverse groups of poisons with additional harmful mechanisms and disguise. Industrial chemicals were used in chemical attacks. Vigilance and preparedness are needed for future CBR threats.

The objective of this study was to assess the impact of chemical, biological, radiological, nuclear personal protective equipment (CBRN-PPE) on the ability to secure an endotracheal tube (ETT) with either the Thomas Tube Holder™ or cotton tape tied in a knot.

Seventy-five clinicians secured an ETT in a previously intubated manikin with the Thomas Tube Holder™ and cotton tape. A mixed quantitative and qualitative research design was used to gauge actual performance times and perceptions of difficulties. Following completion of the study, 25 clinicians were interviewed to gauge their experiences of securing the ETT with both devices while wearing CBRN-PPE.

The mean time to apply the Thomas Tube Holder was 29.02 seconds, compared with tape which took a mean of 58 seconds (p = 0.001). Clinicians rated the Thomas Tube Holder as easier to use than tape (Mann-Whitney z = 9.934; p <0.001), which was confirmed during interviews. Of the clinicians interviewed, 92% perceived that the Thomas Tube Holder provided the better method for securing an ETT, none of the clinicians identified the tape as the best method for securing the endotracheal tube while wearing CBRN-PPE. Clinicians identified that the design of the Thomas Tube Holder facilitated the gross motor movement required for application.

The Thomas Tube Holder is easier and faster to apply when wearing CBRN-PPE when compared with cotton, and the Thomas Tube Holder is perceived by the participants as being more effective at preventing accidential extubation

The medical system has an important role in response to a radiological emergency. Although the Radiation Emergency Medical Preparedness and Assistance Network (REMPAN) exists, every country must provide elements of preparedness of a national medical system for managing radiological emergencies.

A research group consisting of experts reviewed the literature and related plans; International Atomic Energy Agency (IAEA) standards also were considered. Based on a three-level approach, preparedness elements of the national medical system were determined.

An emergency medical services (EMS) team for each district is to be trained. The competence of the team members, requisite equipment, procedures for rapidly preparing an ambulance, triage, and decontamination procedures were compiled. For each province, a prepared general hospital and its teams should develop: (1) radiological assessment capability; (2) triage; and (3) decontamination preparedness intervention. A radiation emergency receiving area, equipment list, personal protective equipment, and cooperation with specialized centers were considered. Each country must have a specialized hospital for medical management, training, and connection with REMPAN. All specialized departments, unique instruments, specific drugs, and'necessary procedures were defined. Also, tlie development of a mobile medical support team that could be accessed from the region.

Although radiological emergencies are rare, a national medical system must provide a comprehensive emergency management plan and be prepared for incidents.

Although 15 years have passed since the Tokyo subway attack, it was the preparations for the Kyushu-Okinawa G8 summit (2000) five years thereafter that catalyzed the development of countermeasures and policy against chemical, biological, radioactive, nuclear, or explosive (CBRNE) threats in Japan.

Report: No substantial progress was made for five years after the subway attack. Preparedness for the Kyushu-Okinawa G8 Summit included promulgation of the Civil Protection Law (2004), which codified the responses to CBRNE terrorist attacks, and consequendy, the effectiveness with which the countermeasures against CBRNE terrorism acts could be deployed at a national level. Countermeasures included the establishment of a CBRNE task force, syndromie surveillance programs, and the stockpiling of antidotes, antitoxins, and antibiotics. Decontamination facilities were introduced throughout Japan.

Preparedness for the summit facilitated recognition of the need for medical countermeasures against CBRNE threats to protect healthcare providers in Japan. In the 15 years since the Tokyo Subway Attack, the measures implemented in the last five years have been most effective. However, future challenges include the promotion of civilian awareness, inter-agency collaboration, and increasing the mutual-aid capacity of local communities.

The response to hazardous materials or chemical, biological, radiological, nuclear (CBRN) incidents typically consists of: (1) cordons regulating access into and egress from designated zones; and (2) use of appropriate personal protective equipment. In most systems emergency medical services (EMS) will stay outside of the “hot zone”. The patient will be rescued by the fire service and, after some gross decontamination, handed over. As mass gatherings are regarded as high-risk events, this system was used in Vienna during the Euro08 and augmented by: (1) casualty decontamination units (seven parallel lines for stretcher decontamination, located before triage); (2) a rapid intervention group for medical care in the hot zone (25 medical personnel), responsible for triage, life support (airway, breathing, bleeding), and antidote therapy; and (3) a joint CBRN incident command for close cooperation with detection units.

After a review of the available open-source literature, a risk analysis was performed and the tactical concept described above was developed with cooperation of all involved services. Special training was performed for all members of the aforementioned units.

As the concept was not tested by an actual emergency, the following observations can be made: (1) readiness of the units could be successfully maintained during the EURO08; (2) me chosen equipment was experienced as appropriate; (3) several minor cases corroborated the risk analysis; and (4) manpower and training requirements were considerable.

While it is possible to perform medical care within the hot zone, concepts are rarely tested in reality and the necessary efforts raise the question of proportionality.

Accidental or voluntary chemical incidents create many health and environmental problems. According to the physico-chemical proprieties of the released agent, risks are present for all involved persons (victims, rescuers), either by primary contamination (contact with skin or mucosal surfaces, respiratory tract inhalation), or by secondary contamination from close contact with exposed victims. Recent descriptions of mass-chemical accidents with numerous spontaneous evacuations from the contaminated zone to nearby hospitals represent an important risk for secondary contamination to these hospitals.

The use of an easy-to-set-up decontamination gate to protect or preserve hospitals from contamination of their site and personnel following a massive influx of contaminated patients was evaluated. A multi-disciplinary team equipped six regional hospitals with mass-decontamination gates without mobilizing excessive human or material resources.

Basic formation of hospital personnel took two hours; attaching the gate to a local fire hydrant took <10 minutes.

This decontamination gate has several advantages and limitatins that will be discussed. However, it does have merit as an autonomous protection for non-specialized and equipped hospitals to prevent secondary contamination.