Guidelines for poison control
II. Technical guidance - 6. Response to major emergencies involving chemicals1
The accidental discharge of chemicals during industrial operations, as well as during transport by land, sea, and inland waterways, is a growing problem throughout the world. Chemical accidents do not always involve cases of poisoning. However, people exposed to a major release of chemicals may, in some instances, be seriously contaminated and require emergency treatment. Chemical discharge may pollute the environment and give rise to poisoning in populations some distance from the accident itself. Major incidents involving many cases of poisoning may also be caused by the accidental or deliberate contamination of food, water, medicines, or consumer goods by synthetic chemicals or natural toxins. In some cases, these incidents may not be immediately associated with chemical contamination but are identified through the toxicovigilance activities of poison information centres.
Many countries have emergency plans covering the fullest possible range of natural and technological disasters. The fire and rescue services, together with the police, are usually the first to be involved in the response to a major chemical accident. By providing appropriate information, poison information centres have an important contribution to make to the handling of major incidents involving chemicals, and clinical toxicology services may also be involved in the treatment of victims. Centres should take an active part in contingency planning, education, and training for chemical accidents. They should also initiate research and follow-up studies when appropriate. A poison information centre often has the advantage of being the only centre of its kind in a country or a region providing a 24-hours-a-day service and may therefore play a central role in chemical emergencies.
The staff of the poison information centre should receive specific instructions on how to act in the case of a chemical disaster. They should be prepared to provide relevant information on the chemicals involved to those responsible for handling the emergency or alert procedures, as well as to decision-makers and the mass media. They should know how to recognize the magnitude or level of the accident (whether it is operational, local, regional, or international) and should alert the centre's director, other staff, and health and other authorities, according to established procedures.
1See also: Health aspects of chemical accidents. Guidance on chemical accident awareness, preparedness and response for health professionals and emergency responders. Paris, Organisation for Economic Co-operation and Development, 1994 (OCDE/GD (94)1).
Staff must also be trained to deal with the general public, either directly or, preferably, through the mass media. They should be instructed on how to avoid creating panic and how to communicate calmly with others involved in responding to the disaster and also with the community, providing reassurance and a clear message. Retrospective studies of chemical incidents that have occurred in the area or examination of hypothetical disaster situations may form a good basis for the training of staff and for contingency planning with other concerned bodies.
The poison information centre may act as the focal point for action in case of chemical accidents and should be prepared to provide adequate information rapidly in the acute phases. When building up toxicological data banks, centres should therefore include information on all chemicals likely to be involved in accidents in the region, not forgetting the less frequently used industrial chemicals and reactive intermediates. It is important to have information on:
*toxic chemicals and their effects
*high-risk areas and processes and/or activities involving risk
*which chemical(s) might be released, in what forms and quantities
*possible protective and remedial measures.
The exact location, capabilities, and capacities of treatment and toxicological analytical services and of facilities for emergency transport must be known. Centres must also be aware of the responsibilities and roles of all bodies involved in contingency planning, and establish close communication links with rescue services and the police. The information may have to be gathered by the poison information centre itself if emergency contingency planning has not yet been organized in the country or may be requested from the authorities when such plans exist and are operative. There is often a legal requirement for authorities to be notified of highly hazardous activities involving the use of chemicals and of the location of stored chemicals; such information could valuably be made available to poison information centres as well. In some countries, poison information centres, identified as focal points for chemical disasters, are informed when dangerous cargoes are being transported or high-risk manoeuvres involving toxic chemicals are to be undertaken in the areas they serve.
Experience with industrial accidents involving chemicals is often available at the plants concerned but not always elsewhere. It is of vital importance for poison information centres to have access to this experience, and for activities that encourage exchanges of information and experience between different occupational health services and poison information centres to be established.
In the event of a major chemical accident, poison information centres may expect a flood of telephone calls. They should be prepared to deal with this type of situation, avoiding panic and providing advice rapidly to all concerned parties.
Staff at clinical toxicology services may be involved in the treatment of victims of chemical incidents or disasters. They need to provide guidance to the medical rescue teams on the triage of poisoned patients, on their initial treatment procedures before they reach hospital, and on decontamination at the site of the incident. Any hospital that treats patients may need to provide decontamination facilities outside its emergency admission area in order to prevent contamination of the hospital by toxic chemicals.
Poison information centres should cooperate with other agencies in contingency planning for chemical accidents. Some countries, especially the more highly industrialized, have coordinated contingency plans in which a number of specific activities are demanded of poison information centres. In the many countries that lack an established emergency response system the responsibility of poison information centres may be even greater: they may suddenly be obliged to assume responsibility for the handling of an emergency. If contingency plans have already been established, a poison information centre may become an emergency control centre in the event of a chemical disaster. New centres should therefore have the foresight to consider what chemical disasters could occur within their region and be prepared to provide fast, accurate advice and orientation.
Emergency medical plans must be extended to cover chemical accidents, and close collaboration should be established between the planners and the poison information centre. The centre should provide the planners with guidelines on: measures for risk assessment; decontamination in situ and within hospitals; first-aid measures; general and specific therapy; and measures to ensure the availability of antidotes. At the medical level, poison information centres should also be aware of the facilities available for dealing with large numbers of victims in terms of number of beds, pharmaceutical supplies, and availability of specific antidotes.
Education and training
Poison information centres should play an active role in the education and training of all members of rescue teams for their role in the event of chemical accidents. This education and training should be geared to the educational level of each group being trained (e.g. firemen, field commanders, supervisors, telephone and radio operators, doctors). Training should cover decontamination techniques and protective measures for medical staff treating contaminated patients, as well as triage techniques.
Close follow-up studies of both major and minor chemical accidents may yield much valuable information on their handling. In the event of a major incident involving chemicals, poison information centres should be ready to mobilize competent personnel. Appropriate data on the accident should be collected to enable exposure to be related to clinical features of poisoning. This requires preparation in advance. A staff member from the centre may need to go to the scene of the incident, or to the place where the patients are being treated, in order to take an active part in evaluation and risk assessment, coordinate advice to health care personnel on site, and organize analytical tests. This would also provide an opportunity to collect human toxicological data, valuable for advice on future occasions and for further planning in respect of chemical accidents.
If poison information centres are to respond adequately to major incidents involving chemicals, financial support may be required from the government. Personnel from the centres should have the opportunity to participate in educational activities and visit the sites of accidents outside their own areas in order to gather relevant information and experience. This is important not only during the acute phase of an incident but also at later stages when conclusions can be drawn from the incident and recommendations made.
Collaboration between centres
The need for close national and international collaboration between poison information centres is recognized. The hazards arising from the manufacture, storage, and transport of chemicals are sometimes shared by neighbouring countries, in which case concerted action should be taken to prevent or reduce the likelihood and impact of chemical accidents. Poison information centres should therefore undertake periodic exchanges of information on high-risk circumstances for chemical accidents, and be consulted concerning relevant international or intergovernmental agreements.
To assist in the identification of chemicals to which an individual may have been exposed, it is essential for a poison information centre to build up a database of relevant information on commercial and other local products found in the area it serves. A simple card file can be used for this purpose. Alternatively, if a centre is contemplating computerization of its database, the IPCS INTOX format for standardizing product information is recommended.