3 cases of Secondary Contamination
EMS Village Staff
Nosocomial Poisoning Associated With Emergency Department Treatment of Organophosphate
Toxicity --- Georgia, 2000
Emergency department (ED) staff caring for patients contaminated with toxic
chemicals are at risk for developing toxicity from secondary contamination.
This report describes three cases of occupational illnesses associated with
organophosphate toxicity caused by exposure to a contaminated patient and underscores
the importance of using personal protection equipment (PPE) and establishing
and following decontamination procedures in EDs and other areas of acute care
On April 11, a 40-year-old man intentionally ingested approximately 110 g of
a veterinary insecticide concentrate. The insecticide contained 73% naphthalene,
xylene, and surfactant, and 11.6% phosmet. On clinical examination at a local
hospital ED approximately 20 minutes after the ingestion, the patient had profuse
oral and bronchial secretions, vomiting, bronchospasm, and respiratory distress.
He was intubated for airway management and ventilation. To control secretions,
he received 4 g pralidoxime and 22 mg atropine during the next 24 hours. The
patient improved over a 9-day period and was transferred to a psychiatric facility.
The patient was brought to the ED by a friend, not by emergency medical services,
and the friend developed symptoms that required treatment. ED personnel exposed
to the patient had symptoms within an hour of his arrival. The staff noted a
chemical odor in the ED and contacted the regional poison center, which recommended
decontaminating the patient's skin and placing gastric contents in a sealed
container to minimize evaporation; however, no decontamination was performed.
Health-Care Worker 1
A 45-year-old ED nursing assistant providing care to patient 1 developed respiratory
distress, profuse secretions, emesis, diaphoresis, and weakness. She had contact
with the patient's skin, respiratory secretions, and emesis. She was admitted
to the hospital and required intubation for 24 hours to support respiration.
After medical management and serial doses of atropine and pralidoxime for 7
days, her respiratory function improved, and she was discharged after 9 days
Health-Care Worker 2
A 32-year-old ED nurse had diaphoresis, confusion, hypersalivation, nausea,
and abdominal cramps while caring for patient 1. Although she did not have skin
contact with his secretions or emesis, she had shared his breathing space. After
treatment with 10 mg of atropine and pralidoxime over the next 12 hours, her
Health-Care Worker 3
A 56-year-old nurse providing care for patient 1 was admitted to the hospital
with dyspnea, confusion, and headache. Although she did not have skin contact
with secretions or emesis from patient 1, she had shared his breathing space.
She was given 6 mg of atropine without relief of the dyspnea. As a possible
result of excessive atropine, she experienced hallucinations. On recommendation
of the regional poison center, she received intravenous lorazepam and was observed
until the episode resolved. She improved overnight and was discharged.
Reported by: RJ Geller, MD, KL Singleton, MD, ML Tarantino, Georgia Poison
Center, Atlanta; CL Drenzek, DVM, KE Toomey, MD, State Epidemiologist, Georgia
Div of Public Health. Div of Surveillance, Hazard Evaluations, and Field Studies,
National Institute for Occupational Safety and Health; National Pharmaceutical
Stockpile Br, Div of Emergency and Environmental Health Svcs; Div of Environmental
Hazards and Health Effects; National Center for Environmental Health, CDC.
During the incident in this report, health-care workers were exposed to a patient
contaminated with an organophosphate insecticide. These health-care workers
were not wearing appropriate respiratory or skin protective equipment while
caring for the patient. As a result, three health-care workers developed symptoms
consistent with organophosphate intoxication and required treatment. This was
the third episode reported during 2000 to the Georgia Poison Center of nosocomial
poisoning of ED staff involved in the care of patients who had intentionally
ingested a concentrated organophosphate mixed with xylene and other hydrocarbon
solvents. Similar incidents have occurred elsewhere (1). During 1987--1998,
the National Institute for Occupational Safety and Health identified 46 health-care
workers who had acute pesticide-related illness after providing care to a pesticide-contaminated
patient (G. Calvert, CDC, personal communication, 2000).
The Joint Commission on Accreditation of Healthcare Organizations requires
hospitals to have a plan to manage contaminated patients (2); however,
these recommendations do not include a plan to protect health-care workers caring
for contaminated patients. During 1996--1998, surveys of hospitals in Georgia
and at level 1 trauma centers nationally indicated that few acute care hospitals
had trained staff, equipment, and procedures to safely care for contaminated
Depending on the extent of the contamination, health-care workers caring for
chemically contaminated patients should use level C protection (i.e., full face
mask and powered/nonpowered canister/cartridge filtration respirator) or level
B protection (i.e., supplied air respirator or self-contained breathing apparatus)
(6). The type of canister/cartridge should be appropriate to the agent;
if the agent cannot be identified, an organic vapor/HEPA filter is recommended
(6). To prevent dermal absorption, chemical barrier protection appropriate
to the contaminant is needed; latex medical gloves are of little protection
against many chemicals. In addition to the need for surface decontamination
of patients, body fluids also must be contained to prevent dermal and inhalational
exposure. To limit distant spread of the contaminant, the EDs ventilation exhaust
should be directed away from the hospital's main ventilation system.
EDs may have to care for persons contaminated with chemicals resulting from
self-inflicted contamination, industrial incidents, and terrorist events (7).
To protect health-care workers caring for these patients, EDs should adhere
to existing guidelines (6,8,9) and decontamination protocols, train staff
in the use of PPE, and maintain adequate quantities of antidotes (10).
If sufficient quantities of antidote are not available, the National Pharmaceutical
Stockpile at CDC maintains a mechanism to procure and deliver large quantities
of pharmaceuticals to state health departments within 12 hours. Coordination
among health-care facilities, poison centers, and state and local health departments
could provide surveillance of a chemical agent release, facilitate the expeditious
procurement of supplies from outside sources, protect health-care workers, and
inform the public about contaminants.
While this Call Review focuses on Emergency Department reports from the "Morbidity
and Mortality Weekly Report" (MMWR) from the CDC, I can think of several
instances where EMS providers have been contaminated and fallen ill, have failed
to recognize dangers, or were simply taken completely by surprise by a hazardous
material situation. What
do you think?
- Burgess JL. Hospital evacuations due to hazardous materials incidents. Am
J Emerg Med 1999;17:50--2.
- Joint Commission on Accreditation of Healthcare Organizations. Accreditation
standards for hospitals, 2000. Oakbrook Terrace, Illinois: Joint Commission
on Accreditation of Healthcare Organizations, 2000; sections EC1.5e,
EC1.5i, and EC1.6l.
- Sharp TW, Brennan RJ, Keim M, Williams RJ, Eitzen E, Lillibridge S. Medical
preparedness for a terrorist incident involving chemical or biological agents
during the 1996 Atlanta Olympic games. Ann Emerg Med 1998;32:214--23.
- Meehan P, Toomey KE, Drinnon J, Cunningham S, Anderson N, Baker E. Public
health response for the 1996 Olympic games. JAMA 1998;279:1469--73.
- Ghilarducci D, Pirallo R, Hegmann K. Hazardous materials readiness of United
States level 1 trauma centers. J Emerg Med 2000;42:683--92.
- Macintyre A, Christopher G, Eitzen E, et al. Weapons of mass destruction
events with contaminated casualties. JAMA 2000;283:242--9.
- Okumura T, Takasu N, Ishimatsu S, et al. Report on 640 victims of the Tokyo
subway sarin attack. Ann Emerg Med 1996;28:129--35.
- Burgess JL, Kirk M, Borron SW, Cisek J. Emergency department hazardous materials
protocol for contaminated patients. Ann Emerg Med 1999;34:205--12.
- Pons P, Dart RC. Chemical incidents in the emergency department: if and
when. Ann Emerg Med 1999;34:223--5.
- Dart RC, Goldfrank LR, Chyka PA, et al. Combined evidence based literature
analysis and consensus guidelines for stocking of emergency antidotes in the
United States. Ann Emerg Med 2000;36:126--32.