Module 3 of 10 ~30 minutes

Clinical Recognition & Management

PPE Selection, START Triage, and Decontamination Protocols

Learning Objectives

1

Recognize syndromic patterns suggesting biological agent exposure

2

Select appropriate PPE based on suspected agent and transmission route

3

Apply the START triage algorithm in mass casualty situations

4

Implement decontamination protocols for chemical and radiological contamination

Syndromic Recognition

Most Category A agents initially present with influenza-like illness (ILI), making pattern recognition critical for early detection.

Syndrome Suspect Agents Red Flags
Febrile RespiratoryAnthrax, Plague, TularemiaRapid progression, widened mediastinum, hemoptysis
Vesicular/Pustular RashSmallpoxCentrifugal distribution, synchronous lesions
Hemorrhagic FeverVHFs (Ebola, Marburg)Bleeding from multiple sites, shock
Flaccid ParalysisBotulismDescending paralysis, alert patient
GI SyndromeAnthrax (GI), RicinBloody diarrhea, severe abdominal pain

PPE Selection

Standard Precautions

Gloves, hand hygiene

Use for: Anthrax, Botulism, Tularemia

Droplet Precautions

Standard + surgical mask within 6 ft

Use for: Pneumonic Plague

Airborne Precautions

N95/PAPR + negative pressure room

Use for: Smallpox

Enhanced/Full Barrier

Fluid-impermeable suit, double gloves, PAPR

Use for: Ebola, Marburg (VHFs)

CRITICAL WARNING

Standard hospital PPE is INADEQUATE for chemical nerve agents! Sarin/VX exposure requires specialized chemical-resistant suits. Contaminated patients must be decontaminated BEFORE entering the ED.

START Triage Algorithm

Video: START Triage in Action

Simple Triage and Rapid Treatment (START) allows rapid categorization of patients in under 60 seconds each.

🔴

IMMEDIATE

Life-threatening, survivable with immediate care

🟡

DELAYED

Serious but can wait 4-6 hours

🟢

MINOR

Walking wounded, minor injuries

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EXPECTANT

Deceased or unsurvivable injuries

START Algorithm Steps

Step 1:
Can they walk? YES → MINOR (Green)
Step 2:
Breathing? NO after airway opening → DECEASED (Black)
YES but >30/min → IMMEDIATE (Red)
Step 3:
Perfusion (Cap Refill)? >2 seconds OR no radial pulse → IMMEDIATE (Red)
Step 4:
Mental Status? Cannot follow commands → IMMEDIATE (Red)
CAN follow commands → DELAYED (Yellow)

Decontamination Protocols

Key Principle

Removing clothing eliminates 80-90% of external contamination

Chemical Agents

  • CRITICAL life-saving intervention
  • Must occur in Hot Zone OUTSIDE hospital
  • Remove ALL clothing immediately
  • Flush with copious water, wash with soap
  • Protect staff with chemical-resistant PPE
  • Control runoff as hazardous waste

Radiological

  • Remove clothing, bag separately
  • Survey with Geiger counter
  • Wash with soap and water
  • Flush contaminated wounds first
  • Patient is NOT radioactive once decontaminated

Key Takeaways

Most bioterrorism agents present initially with flu-like symptoms

PPE selection depends on transmission route

START triage: Immediate (Red), Delayed (Yellow), Minor (Green), Expectant (Black)

Removing clothing eliminates 80-90% of contamination

Module 2 Module 4