Page 94 - 2022 Ranger Medic Handbook

CBRN – Pulmonary Agents
Lung-damaging agents are not commonly mentioned as major chemical threats. However, troops may be exposed to
these threats through enemy actions or mitigating side effects such as explosions/fires involving vehicles or manufactur-
ing areas, industrial hazards or accidents, or various burning materials.
The 4-hour rule states that if a patient shows breathing difficulty within 4 hours of exposure, prognosis is poor, versus
patients who do not become symptomatic until after 4 hours.
SECTION 2 24 hours is the minimum time for observation and no physical exertion after an exposure to a pulmonary agent.
Agents that are liquids at room tend to give off vapors that can become trapped in clothing. Thus, the agent then begins
to “off-gas,” which could affect personnel without respiratory protection. Therefore, decontaminating a patient with
exposure to one of these agents is still needed. Always wear multiple pairs of nitrile gloves when conducting decontami-
nation. DECON with either RSDL or soap and water. Use the DRY-WET-DRY technique for DECON.
Irrigate the patient’s eyes to a pH 7.0 and provide tetracaine for pain relief.
Treat respiratory symptoms with nebulized albuterol 3mL 0.083% and solumedrol 125mg IV × 1. Consider nebulized
racemic epinephrine for no respiratory improvement. Aggressive airway and respiratory support with PPV and suction-
ing may be required.

Ammonia (NH 3 )
S/Sx: Mild exposure: eye complaints, hoarseness, strider, cough, SOB, chest pain, wheezing; moderate-severe expo-
sure: hypoxia, chemical pneumonia, hemorrhage
MANAGEMENT: Remove from exposure, decontaminate, and consider advanced airway protocol
DISPOSITION: Refer to chemical casualty triage table

Sulfur Mustard (HD)
S/Sx: Mild exposure: eye complaints, hoarseness, strider, cough, SOB, chest pain, wheezing; moderate-severe expo-
sure: hypoxia, chemical pneumonia, hemorrhage
MANAGEMENT: British anti-Lewisite 3mg/kg IM × 1 for vesicant exposure and immediate pain. Respiratory treatments.
DISPOSITION: Refer to chemical casualty triage table
Chlorine
S/Sx: Mild-suffocation, choking sensation, ocular and/or nasal irritation, chest tightness, cough, exertional dyspnea;
moderate: aforementioned S/Sx plus hoarseness, stridor, pulmonary edema within 2–4 hours; severe: dyspnea at rest,
can cause pulmonary edema in 30–60 seconds, copious airway secretions, sudden death may occur with laryngospasms
MANAGEMENT: Remove from exposure, decontaminate, and respiratory treatments.
DISPOSITION: Refer to chemical casualty triage table.

Peripheral Acting Agents
(Phosgene or CG, Perfluoroisobutylene or PFIB, HC Smoke, Nitrogen Oxides)
S/Sx: Mild: cough, SOB, chest tightness; moderate: ocular irritation and aforementioned; severe: dyspnea at rest, on-
set of pulmonary edema in 30 seconds to 4 hours, copious upper airway secretions, sudden death may occur with
laryngospasms
MANAGEMENT: Remove from exposure, decontaminate, respiratory/airway treatments.
DISPOSITION: Refer to chemical casualty triage table.
SPECIAL CONSIDERATIONS: Phosgene can be found in foam plastics, herbicides, pesticides, and dyes. It can be pres-
ent in the burning objects like plastics, degreasers, and paint strippers. PFIB can be found in “Teflon” or burning military
vehicles. Nitrogen oxides can be found in arc welding areas specifically with enclosed areas and diesel engine exhaust.

80 SECTION 2 PRIMARY TRAUMA PROTOCOLS