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decontamination of an arm to establish IV access. Circulation outer glove can be discarded after ensuring there is no residual
should be assessed. The provider must factor in the effect of contamination. A nitrile glove liner under a butyl rubber glove
both CBRN agents and antidotes on patient circulatory status. is recommended but variations may be necessary depending
It is at this phase that dirty treatments are replaced with clean on resources and the need for dexterity. In the absence of sus-
8
as decontamination ensues. Due to the need to fully expose the pected retained debris, the fully decontaminated patient in the
casualty in order to conduct thorough decontamination, hy- cold zone can be treated as all other patients at that level of care.
pothermia is a significant risk. Medical treatment should not
slow down the decontamination process. Interventions should Available resources will dictate treatment within the cold
be limited to what is necessary to preserve life. Ensuring rapid zone. Additional triage may be necessary to properly distrib-
transit through the decontamination with careful attention to ute patients. For example, patients with radiologic exposure
hypothermia mitigation is necessary to prevent iatrogenic in- should have a complete blood count or other biodosimetry to
jury from the decontamination process. Attention should be determine priority of ongoing care. As mentioned in the intro-
made to mitigating the risk of heat injury and stressors associ- duction, there are multiple resources for specific agent man-
ated with PPE because personnel working within the warm agement. Once the casualty reaches the cold zone, it is likely
zone are operating in full protective gear. that the combination of patient presentation and intelligence
will guide a more specific response.
Much like trauma team protocols, where each individual has
assigned tasks and responsibilities, simple and rehearsed TTPs Conclusion
(tactics, techniques, and procedures) for rapid decontamina-
tion and cutout of casualties is important. A warm zone team Care of the CBRN-exposed patient can be daunting even to
needs clearly defined roles. The operations of the warm zone experienced providers. Establishing processes that align with
team are outside the scope of this report; however, it is nec- existing protocols could help relieve provider anxiety and pro-
essary to note the importance of having a well-thought-out mote standardized care that facilitates best practice within the
and well-rehearsed approach to how your particular unit or chaotic CBRN environment. Given the unprecedented suc-
element is going to approach this problem. In order to facili- cess of TCCC protocols in positively influencing outcomes of
tate quick and efficacious assistance for medical providers, combat casualties, it only makes sense to incorporate CBRN
performing casualty cutout and decontamination is everyone’s treatment with existing TCCC protocols to facilitate care of the
responsibility in a CBRN environment. CBRN casualty who may also be a simultaneous trauma casu-
alty. The (MARCHE) approach to the CBRN exposed patient
2
provides a structured approach that integrates with TCCC
Cold Zone/Tactical Evacuation Care/
Prolonged Field Care guidelines leading to a conceptual TCCC + CBRN framework
that is amenable to implementation in our current environment
Once the decontaminated casualties are passed into the cold where CBRN exposure is both a potential and realized threat.
zone, they are amenable to treatments that are typical in the
tactical evacuation phase or even those of a prolonged field Funding
care situation. Reassessment cannot be overemphasized as the This work did not receive funding support.
decontamination process alone can result in significant change
in the casualty’s condition. Documentation throughout the Disclosures
phases of care is vital to facilitate information transfer as the The authors have nothing to disclose.
patient transits. The CBRN Casualty Card (Figure 3) is a use-
ful tool to ensure comprehensive documentation relevant to Author Contributions
the CBRN casualty. In the absence of a CBRN Casualty Card, DRD provided the concepts contained in the manuscript.
the TCCC Casualty Card is sufficient. MLG wrote the manuscript. Both DRD and MLG edited the
manuscript and approved the final version.
It is important to take into consideration that receiving pro-
viders at higher echelons of care may have minimal to no expe- References
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