What would the nurse do first when assisting in decontaminating a client who was recently involved in a chemical exposure event?

Health services should have management systems in place for dealing with blood and body substance spills. Protocols should be included in procedural manuals, and emphasised in ongoing education or training programs.

The basic principles of blood and body fluid/substance spills management are:

• standard precautions apply, including use of personal protective equipment (PPE), as applicable
• spills should be cleared up before the area is cleaned (adding cleaning liquids to spills increases the size of the spill and should be avoided)
• generation of aerosols from spilled material should be avoided.

Using these basic principles, the management of spills should be flexible enough to cope with different types of spills, taking into account the following factors:

• the nature (type) of the spill (for example, sputum, vomit, faeces, urine, blood or laboratory culture)
• the pathogens most likely to be involved in these different types of spills – for example, stool samples may contain viruses, bacteria or protozoan pathogens, whereas sputum may contain Mycobacterium tuberculosis
• the size of the spill – for example, spot (few drops), small (10cm) 10>
• the type of surface – for example, carpet or impervious flooring
• the location involved – that is, whether the spill occurs in a contained area (such as a microbiology laboratory), or in a public or clinical area of a health service, in a public location or within a community premises
• whether there is any likelihood of bare skin contact with the soiled (contaminated) surface.

Cleaning spills – equipment

Standard cleaning equipment, including a mop, cleaning bucket and cleaning agents, should be readily available for spills management. It should also be stored in an area known to all. This is particularly important in clinical areas.

To help manage spills in areas where cleaning materials may not be readily available, a disposable ‘spills kit’ could be used, containing a large (10 L) reusable plastic container or bucket with fitted lid, containing the following items:

• appropriate leak-proof bags and containers for disposal of waste material
• a designated, sturdy scraper and pan for spills (similar to a ‘pooper scooper’)
• about five sachets of a granular formulation containing 10,000 ppm available chlorine or equivalent (each sachet should contain sufficient granules to cover a 10-cm diameter spill)
• disposable rubber gloves suitable for cleaning (vinyl gloves are not recommended for handling blood)
• eye protection (disposable or reusable)
• a plastic apron
• a respiratory protection device, for protection against inhalation of powder from the disinfectant granules or aerosols (which may be generated from high-risk spills during the cleaning process).
• destroyed by incineration
• immersed in sodium hydroxide or sodium hypochlorite for 1 hour, rinsed and placed in a pan of clean water, and sterilised on an 18-minute cycle.

Single-use items in the spills kit should be replaced after each use of the spills kit.

With all spills management protocols, it is essential that the affected area is left clean and dry.

Sodium hydroxide (caustic soda) spills kits should be available for areas at risk for higher-risk Creutzfeldt–Jakob disease (CJD) spills, such as in neurosurgery units, mortuaries and laboratories.

Cleaning spills – procedures

In clinical areas, blood and body fluid/substance spills should be dealt with as soon as possible. In operating rooms, or in circumstances where medical procedures are under way, spills should be attended to as soon as it is safe to do so.

Care should be taken to thoroughly clean and dry areas where there is any possibility of bare skin contact with the surface (for example, on an examination couch).

PPE should be used for all cleaning procedures, and disposed of or sent for cleaning after use. Hands should be washed and dried after cleaning.

Where a spill occurs on a carpet, shampoo as soon as possible. Do not use disinfectant. Steam cleaning may be used instead.

Wash hands thoroughly after cleaning is completed.

Cleaning spots or small spills

Spots or drops of blood or other small spills (up to 10 cm) can easily be managed by wiping the area immediately with paper towels, and then cleaning with warm water and detergent, followed by rinsing and drying the area. Dry the area, as wet areas attract contaminants.

A hospital-grade disinfectant can be used on the spill area after cleaning.

Cleaning large spills

Where large spills (more than 10 cm) have occurred in a ‘wet’ area, such as a bathroom or toilet area, the spill should be carefully washed off into the sewerage system using copious amounts of water and the area flushed with warm water and detergent.

Large blood spills that have occurred in ‘dry’ areas (such as clinical areas) should be contained and generation of aerosols should be avoided.

Granular formulations that produce high available chlorine concentrations can contain the spilled material and are useful for preventing aerosols. A scraper and pan should be used to remove the absorbed material. The area of the spill should then be cleaned with a mop, and bucket of warm water and detergent. The bucket and mop should be thoroughly cleaned after use and stored dry.

Sodium hypochlorite (bleach)

It is generally unnecessary to use sodium hypochlorite for managing spills, but it may be used in specific circumstances. It is recognised, however, that some healthcare workers and members of the public may feel more reassured that the risk of infection is reduced if sodium hypochlorite is used. Healthcare workers and members of the public should be aware that there is no evidence of benefit from an infection control perspective.

Hypochlorites are corrosive to metals and must be rinsed off after 10 minutes and the area dried.

Cleaning spills that contain Creutzfeldt–Jakob disease prions

If a spill of tissue that is definitely or potentially infected with CJD prions occurs (for example, brain tissue), the contaminated item should either be:

The items should then be cleaned following routine cleaning and sterilisation procedures.

Surface spills should be cleaned up using paper towels before the surface is wiped with either sodium hydroxide or sodium hypochlorite, left for 1 hour (if possible, or as long as possible, with the area cordoned off), the solution wiped off and the surface cleaned by following routine cleaning procedures.

Most standard sources recommend that water rinsing/flushing following skin or eye contact with a chemical should continue for 15 or 20 minutes. However, all chemicals do not cause the same degree of effects (some are non-irritants while others can cause severe corrosive injury). At the present time, there is insufficient scientific evidence available to properly address the question of how long flushing should continue. However, it makes sense to tailor the duration of flushing to the known effects of the chemical or product, as follows:

• 5-minutes for non-irritants or mild irritants
• 15-20 minutes for moderate to severe irritants and chemicals that cause acute toxicity if absorbed through the skin
• 30 minutes for most corrosives
• 60 minutes for strong alkalis (e.g., sodium, potassium or calcium hydroxide)

It is very important that water flushing start immediately following skin or eye contact with a chemical. It is better if complete water flushing occurs on-site. However, moving the exposed person to an emergency care facility earlier may be necessary depending on their condition (e.g., compromised airways, breathing, or circulation) and/or the availability of a suitable water supply. If it is necessary to transport the person before completing flushing on-site, flushing should continue during emergency transport, taking proper precautions to protect emergency services personnel.

Note that the manufacturer/supplier may also specify a cleansing agent (e.g., non-abrasive soap) if appropriate, or may recommend an alternative agent in exceptional cases if water is clearly inappropriate.

OSH Answers has more information on emergency eyewash and shower equipment.

If an employer opts to offer additional first aid measures (including over-the-counter medications, administration of oxygen, use of epinephrine auto-injectors, naloxone, etc.), it is suggested that they first seek legal counsel so that they are aware of any liability issues, and to check with your local jurisdiction responsible for health and safety. For example, in some jurisdictions, distribution of over-the-counter medications is not recommended (although an individual who can purchase using a vending machine may be permissible). In other jurisdictions, distribution of over-the-counter medications may be permitted under specific circumstances (including the appropriate training of first aid personnel).

In the past, emergency oxygen was commonly recommended as a first aid procedure for almost any chemical inhalation exposure. Later, concern was expressed that the administration of oxygen itself may be harmful if carried out improperly or in the wrong circumstances. In particular, there was concern that administering oxygen to people with chronic obstructive lung diseases, such as chronic bronchitis or emphysema, could cause the person to stop breathing. However, recent reviews have concluded that, during an emergency situation, the lack of oxygen is the most critical issue and there should be little concern over worsening the condition of people with chronic obstructive pulmonary disease.

The presence of oxygen cylinders in the workplace can introduce additional hazards. For example, since oxygen supports combustion, the presence of oxygen cylinders could contribute to a fire hazard in the workplace. Also, since oxygen is stored under high pressure, the cylinder can behave like a missile if the valve breaks or the tank is punctured. Therefore, the risks and benefits of storing and maintaining an emergency oxygen supply in the workplace must be weighed.

There are some situations where the benefits of emergency oxygen outweigh the potential risks associated with maintaining and storing oxygen cylinders in the workplace. Emergency oxygen may be beneficial following exposure to chemicals that interfere with the body getting the necessary levels of oxygen to sustain life and health, including chemicals that:

• Displace oxygen in the air, reducing the amount of oxygen available for breathing (e.g., helium, argon, methane, carbon dioxide or nitrogen).
• Reduce the ability of blood to transport oxygen (e.g., carbon monoxide poisoning, or methemoglobinemia – presence of an oxidized form of hemoglobin in the blood that does not transport oxygen).
• Compromise the use of oxygen by body tissue, as with cyanide or hydrogen sulfide toxicity.
• Interfere with the ability of oxygen to cross through the lungs to the blood stream, as occurs with pulmonary edema, a potentially fatal accumulation of fluid in the lungs. Ammonia, phosgene and chlorine are examples of chemicals that can cause pulmonary edema.
• Provoke a severe asthma attack (e.g., toluene diisocyanate).

Additional training of first aid providers is required since basic first aid training courses do not include oxygen administration. First aid providers must be familiar with the laws that govern the use of oxygen administration in their workplace.

Vomiting should NOT be induced following ingestion of a chemical in an occupational setting unless advised by a Poison Centre or doctor. Some of the arguments against inducing vomiting are:

• The amount of chemical accidentally ingested by an adult is generally estimated to be very small (14-21 mL or about 0.5-0.75 oz).
• There is no conclusive evidence that people who swallow a chemical and who do have their stomachs emptied have more successful outcomes than people who do not.
• There can be significant risks associated with inducing vomiting especially in emergency situations.
• There does not seem to be a reliable and safe first aid procedure for inducing vomiting in adults.
• Medical attention is usually available quite quickly in most situations.

In the event of a chemical ingestion, the best course of action is to call your local Poison Control Centre or a doctor and follow their advice. They will ask you specific questions, such as the name of the product swallowed, the amount swallowed and the condition of the person who swallowed the chemical. This information will assist them in determining the best course of action.

Much of what we know about the benefits of diluting an ingested chemical with water or milk is based on in vitro (test tube) and ex vivo (using harvested rat esophagi) studies.

Based on their evaluation of the evidence for dilution with milk or water, the American Heart Association and American Red Cross recommend that people should not take anything by mouth for an ingested poison unless specifically told to do so by a doctor or the Poison Control Centre.

It is a common misperception that antidotes are available for most chemical poisonings. True antidotes are the exception rather than the rule.

Activated charcoal is sometimes considered to be an antidote. Activated charcoal works by binding the chemical in the stomach so it cannot be absorbed through the stomach. According to the American Academy of Clinical Toxicology and the European Association of Poisons Centres "the administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to 1 hour previously...". In general, the administration of activated charcoal is NOT considered a first aid procedure. Activated charcoal may be administered in the emergency department or under medical supervision.

Some chemical classes do have true antidotes - cyanides and organophosphate pesticides are good examples. You can determine which chemicals used in your workplace have antidotes by consulting with a doctor with certification in medical toxicology or occupational medicine, or the manufacturer/supplier of your product. These specialists can advise you on situations where it may be appropriate to store an antidote onsite. Special training of first aid providers will be required. In some cases, it may be appropriate to request your local hospital to stock an antidote that must be administered by a medical professional.

In order to know what first aid procedures to follow, it is essential that you know what chemicals are present in your workplace. Consult your chemical inventory and the First-aid measures section on the Safety Data Sheets (SDSs) for those products. Create a list of chemicals, their properties and their corresponding first aid requirements. Be sure that the emergency first aid providers in your workplace have the appropriate training and authority (if necessary) to respond to the effects of chemicals used at your workplace.

Finally, make sure your local hospital is aware of any chemicals on your site that may require special first aid procedures, antidotes or medical follow-up.

CCOHS staff prepared the publication The Safety Data Sheet - A Guide to First-Aid Recommendations as a source of information for people interested in developing or evaluating first aid recommendations for Safety Data Sheets. It is also useful for developing first aid programs for responding to chemical exposures in workplaces.

Document last updated on July 26, 2018

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