Ann. Medit. Burns Club - vol. VIII - n. 3 - September 1995


Rosenberg L., Shabshin U.

Department of Plastic and Reconstructive Surgery,
Soroka Medical Center and the Center for Research and Development in Plastic Surgery,
Ben Gurion University of the Negev, Beer Sheva, Israel

SUMMARY. This paper considers accidents caused by the spillage of dangerous chemicals and how they could be prevented, in the light of direct experience gained in Israel and of the findings of researchers in other parts of the world, as reported in the literature. The procedure followed in Israel in the event of such accidents is described and general guidelines are suggested for the stockpiling and transport of these potentially lethal substances. It is important to be prepared and there must be specific protocols for all possible forms of chemical poisoning. Hospitals must be well equipped and medical and paramedical staff properly trained. These accidents can happen anywhere at any time, and it is stressed that the best protection is prevention.


The need for chemicals in our daily life and the fast expansion of the human population oblige us to locate chemical plants near heavily populated areas. The use, transportation and storage of these chemicals pose the constant threat of a potential spillage disaster. Each chemical substance has its own environment contamination potentials.

These are defined by a number of criteria:

1. Mass (m).
2. Toxicity - defined by the National Institute for Occupational Safety and Health (NIOSH) as Immediate Danger to Life and Health (IDLH).' This value relates to the maximum concentration of the chemical substance in the air that a healthy employee can be exposed to at least for 30 minutes without any irreversible adverse effects.
3. Volatility - defined by the vapour pressure (VP) of the substance (in mm/hg) at room temperature.

The potential environment contamination (PEC) = m x VP x I/IDLH.
Some chemical plants stockpile compounds with a high poisoning capacity and high PEC, which means that evacuation has to be completed in less than 30 minutes after spillage occurs.
Israel, a small country with a population of 5,000,000, has had several cases of chemical spillage accidents. To mention the last two: in 1992 a loaded truck full of bromide skidded on an open road, far away from any urban area. The tank was crushed and the highly volatile liquid spilled out, creating a gas cloud that spread all over the area. Before dying, the driver radioed the security service at his chemical company and the police quickly blocked the road. The cloud of suffocating and corrosive gases dispersed, the driver being the only casualty. In another chemical factory situated in a huge industrial zone near a heavily urbanized area there was a chemical spillage caused by the accidental bursting of a tank. As it was Friday evening the factory and the whole industrial zone were practically deserted. There was no wind and the only victim was a guard who suffered moderate injuries and was evacuated to the nearest hospital for successful treatment. These accidents fortunately caused only a limited number of casualties, but things would have gone differently if in the first case the truck had crashed in a heavily populated urban area or if in the second case the industrial zone and the factory had been full of employees during regular daily working hours. Such accidents may happen any time, anywhere.
There have been chemical disasters in all parts of the world, e.g. Bhopal, India, in 1984 ;3, 4, 5, 6 the Hinton train disaster in Canada in 1986;1 and the Bashkirian train disaster in the USSR in 1989.1 Thousands of people were killed or injured in these accidents. Nor do the problems end after acute exposure to the chemical cloud: every year after the Bhopal disaster at least 15 people exposed to the cloud have died every month.
A number of national and international control organizations have been established for these toxicological disasters, e.g. CIMAH (Control of Major Accident Hazards, UK), PEC (Pittsburgh Emergency Poison Center, Pittsburgh, USA) and UNEP (United Nations Environment Program, UN).9, " However, even with these organizations, is our society ready to deal with such disasters? Is the medical establishment prepared?
In this paper we will consider the position of the medical establishment and its role in preparedness for chemical disasters. Our aim is to establish a comprehensive protocol to guide the various authorities during a chemical disaster.

Materials and methods

In Israel the management of chemical spillage basically follows the management of chemical warfare activities (i.e. with mustard gas, sarin, etc. as the contaminants).
On detection of a chemical spillage, the police, security forces and the army take control of the situation. A control group is established to coordinate all the teams and forces that may be involved, including communication and the media.
The police are responsible for sealing off the contaminated area and organizing evacuation, if necessary. Medical and paramedical troops such as NIDA (Red Magen David), reinforced by well-protected trained rescue teams capable of functioning in contaminated areas, providing first aid and evacuating casualties, are sent to the scene.
When a spillage accident has been announced, a mobile unit of the Ministry of the Environment arrives on the site to test and diagnose the nature of the contaminant and to inform the control group. Information about the contaminant is also provided by one or more security mobile units of the company involved in the spillage. The country should be divided into areas, each with its own mobile spillage control unit. The control group distributes the information to the rest of the forces, including medical staff (field level and hospitals).
Evacuation should be performed by trained and specially protected teams in order to prevent spreading of the contaminant.
In the hospitals evacuated patients are treated according to a specific chemical poisoning protocol which is in two main phases:

1. Cleansing and detoxification

2. Medical treatment

The cleansing and triage posts in the hospital should if possible be located in an open place (e.g. a parking lot). The posts should have cleansing facilities (showers, shower stretches, cleansing agents, etc.) and protected, well-trained personnel. Triage should be performed according to a casualty scale by well-trained and experienced physicians, protected if necessary.
Treatment posts should be set up in the entrance of the hospital beyond the cleansing posts. Treatment posts should be divided for different levels of casualty severity, and treatment must start as soon as possible.
In the front position, besides cleansing and diagnosis of the toxic agent, treatment should be only supportive, with particular attention for respiratory tract symptoms.
Antidotes for some well-defined toxic agents (such as 4-damp, amyl nitrite and sodium thiosulphate for cyanide, BAL or other chelators for arsine, and calcium gluconate for fluorides) should be kept in a regularly refreshed store. Local hospitals, with their normal facilities, are the natural and logical centre for the medical care of the victims.
Chemical spillage accidents, unlike wartime incidents, occur without any forewarning. The number of casualties is often higher than predicted and is determined by the toxic properties of the chemical substance and the circumstances of the accident.
In many cases, following individual or badly organized evacuation, patients may reach the hospital even before the medical staff have been informed and specific facilities prepared. In such cases, the cause of the accident and the number and severity of the patients are unknown.
For each potential chemical poisoning a specific protocol including toxicology (early and late) and treatment is prepared. All these protocols are compiled in sets for chemical disasters.
These sets of protocols should be supplied to every hospital that may be involved in chemical disasters (e.g. because of its vicinity to a chemical factory, chemical depot or transport routes).
All hospitals should obtain a list of chemical substances in general use in their area. The protocols should be available at all times.
Each hospital should prepare its own trained medical and paramedical staff, with representatives of all disciplines (i.e. intensive care, plastic surgery, toxicology, internal and paediatric physicians, etc.).The training of these teams should include refresher courses and the checking of techniques and equipment, including antidotes. An emergency communications network system to contact teams in the event of an emergency should be prepared and practised. There should be reserve personnel for each discipline. National and international toxicology staff should also be included in this network. The contaminated zone is defined by a clearly visible perimeter established by the chemical factory rescue and intervention vehicle (from chemical factory* manuals). A. Chemical tanker B. Spilled chemicals C. Lights D. Electrical generator E. Wind direction F. Rescue and intervention vehicle G. Perimeters of the contaminated zone


Chemical spillage can happen at any moment. Dangerous chemicals are very often stored in the vicinity of populated areas and when transported they pass along heavily congested routes exposing thousands of people to deadly hazards.

In Israel, owing to the threat of chemical warfare such as in the recent "desert storm" war, a system for treating civilian chemical victims at field level and in hospital had to be organized and implemented. The same system could be used for chemical spillage accidents (Fig. 2).

The success of handling accidents and victims depends basically on:

  1. decisions taken by the control group
  2. early detection of the chemical substance
  3. distribution of clear and effective information and orders
  4. the ability to detoxify the substance
  5. the handling of the evacuation of casualties
  6. the functioning of the medical team at field level and in hospital
  7. correct use of media and communication systems

The arrival of patients at the hospitals should be coordinated and the cause of the accident and the number of patients and their severity determined.
Experience from past incidents (such as Bhopal) shows that the number of casualties in the population at risk will be 25% in the contaminated area, of whom 5% will be dead or badly injured, 15% will have intermediate injuries and 80% mild injuries.
The most frequent injuries will be in the respiratory tract, mucous membranes and skin. Respiratory tract symptomatology ranges from mucous membrane irritation to severe chemical pneumonitis.  Eye symptomatology ranges from conjunctival irritation to orbital oedema, infeclions and even blindness.` Skin symptomatology ranges from mild irritation to severe chemical bums.
In mild injuries the problem of diagnosis may be much more difficult to resolve as the symptomatology may be obscure and mixed. Many symptoms can be unspecific, such as tachycardia, tachypnoea, chest pain, sweating, confusion, ete. All such patients should be kept under supervision and appropriate adjusted supportive treatment.
Many chemical substances have long-lasting effects. The morbidity and mortality rates among residents in con~ taminated areas rise significantly, especially with regard to chronic respiratory, liver and kidney disease. Genetic malformations may occur in the future (12).
Because of the complexity of the problem and the lethal risk to large populations, it is imperative to establish a comprehensive system to tackle chemical spillage.

The different levels of such a system are as follows:

  1. a front control group responsible for coordination of all matters involved in the incident (i.e. personnel, equipment, cooperation between teams, gathering and documenting information)
  2. diagnosis of the chemical agent and its toxic effect
  3. safe evacuation of the endangered population and civilian management
  4. prevention of expansion of the spillage
  5. detoxification
  6. fast and safe transportation of patients to hospital
  7. comprehensive and well-adjusted medical treatment
  8. dealing with the media

The levels of hospital facilities are:

  1. evacuation, cleansing and triage of casualties (as performed in chemical warfare)
  2. reinforced task teams and medical staff during the emergency, all with adequate equipment and personnel
  3. preparation and implementation of protocols for the medical staff (chemical substances, exposure, toxic signs and symptoms, antidotes and supportive treatment)
  4. training in various scenarios of chemical spillage incidents

It must be borne in mind that no operative plan can give full protection to the population. Emergency plans can reduce the number of casualties and damage in the short and long term. But the best protection is prevention, which is provided by:

  1. better and safer management of chemical depots
  2. better protection for equipment and personnel
  3. better insulation of chemical substances
  4. removal of chemical plants and depots from populated areas
  5. construction of safe by-pass routes for chemical transportation in populated areas and cities

The vital questions that arise and must be answered by all concerned are:

Do we have all these set-ups?
Do we have similar or alternative means to handle cases of chemical spillage?
Are we prepared?

RESUME. Les auteurs, à la lumière de leurs expériences directes en Israël et des observations présentées par les chercheurs dans les autres pays du monde, considèrent les accidents causés par le renversement des produits chimiques dangereux et comment les prévenir. Ils décrivent la procédure suivie en Israël quand ces accidents se produisent et ils proposent des suggestions pratiques pour ce qui concerne l'emmagasinage et le transport de ces substances potentiellement mortelles. Il est important d'être préparé et il faut donc formuler des protocoles spécifiques pour toutes les formes possibles d'intoxication chimique. Les hôpitaux doivent être bien équipés et le personnel médical et paramédical très qualifié. Ces accidents peuvent survenir partout et dans tous les moments, et les auteurs concluent en soulignant que la meilleure protection est la prévention.


  1. National Research Council: Criteria and Methods for Preparing Emergency Exposure Guidance Level (EEGL) Documents. May, 1985; Appendix D.

  2. Personal communication: Toxicological and Clinical Pharmacology Department, Cheim Sheba Medical Center, Tel Hashomer, Israel.

  3. Koplan P.J., Falk H., Green G.: Public health lessons from the Bhopal chemical disaster. JAMA, 264: 2795-6, 1990.

  4. Jasanoff S.: The Bhopal disaster and the right to know. J. Sci. Med., 27: 1113-23, 1988.

  5. Lepkowski W.: Bhopal. Chem. Engin. News, 23: Dec. 2,1985.

  6. Bhandari A.: Aspects of the Bhopal tragedy. In: "Bhopal Industrial Genocide?", 104, Arena Press, Hong Kong, 1985.

  7. Smiley A.M.: The Hinton train disaster. Accid. Anal. and Prev., 22:443-55, 1990.

  8. Kulyapin A.V., Sakhahtdinov V.G., Temerbulatov V. M., Becker W.K., Waymack J.P.: The Bashhkiria train / gas pipeline disaster, June 1989 Bashkirian Republic. Burns, 16: 339-42, 1990.

  9. Baxter P.J.: Responding to major toxic releases. Ann. Occup. Hyg.,34: 615-20, 1990.

  10. Mrvos R., Dean S.B., Krenzelok P.E. In: Vet. Hum. Toxicol., 30:138-40, 1988.

  11. World Health Organization, Geneva, Switzerland: "Emergency Preparedness and Response: Rapid Health Assessment in Chemical Emergencies", Pub. ERO/EPR/90.1.9, Emergency Relief Operations, Jan., 1990.

  12. Mehra P. S., Mehta A. S., Mehta S.J., Makhijani A.B.: The Bhopal tragedy's health effects: a review of methyl isocyanate toxicity. JAMA, 264: 27 81-7, 1990.

  13. Baxter P.J., Kapila M., Mfonfu D.: Lake Nyos disaster, Cameroon, 1986: the medical effects of large scale emission of carbon dioxide. Br. Med. J., 298: 1437-41, 1986.

  14. Marshall V.C.: The predictions of human mortality from chemical accidents with especial reference to the lethal toxicity of chlorine. J. Hazardous Mater., 22: 13-56, 1989.

  15. Baxter P.J.: Review of major chemical incidents and their medical management. In: "Major chemical disasters - medical aspects of management", Royal Society of Medicine, London, 1990.

  16. Naik S.R., Acharya V.N., Bhalerao R.A. et al.: Medical survey of methyl isocyanate gas - affected population of Bhopal, 11: pulmonary effects in Bhopal victims as seen 15 weeks after MIC exposure. J. Postgrad. Med., 32: 185-91, 1986.

  17. Maskati Q.B.: Ophthalmic survey of Bhopal victims 104 days after the tragedy. J. Postgrad. Med., 32: 199-202, 1986.


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