SUPPLE

SUPP LEM
LE M E N T 11

EMS Sector Standard Operating Procedures

This supplement, EMS Sector Standard Operating Procedures, was originally published as part of the
Hazardous Materials Response Handbook (third edition). As with all the materials in the handbook, use of
this material is subject to the following Notices:

Copyright 1997
NFPA
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Quincy, Massachusetts 02269
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Standard for Professional Competence for Responders to Hazardous Materials Incidents; and NFPA 473, Standard for
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4611-&.&/5


EMS Sector Standard Operating

Procedures
Editors Note: This supplement contains
standard operating procedures for a
hazardous materials incident EMS sector
developed by the Montgomery County,
Maryland, Department of Fire and Rescue
Services along with sample medical protocols
developed by the state of Maryland. Thanks
to Chief Mary Beth Michos of Prince William
County, Virginia, previously the Deputy Chief
of the Montgomery County Department of
Fire and Rescue Services, for sharing this
plan with us.

MONTGOMERY COUNTY, MARYLAND,

STANDARD OPERATING PROCEDURES
General Information
On all hazardous materials incidents requiring levels A
or B protective clothing or specialized protective
clothing, an EMS sector officer (designated Haz Mat
EMS) shall be assigned by the Haz Mat sector officer.
Where possible, the EMS sector officer should be
trained to a minimum of the EMT-P level.
At the discretion of the Haz Mat sector officer, an
EMS sector officer may be assigned on other incidents
where conditions may subject personnel to severe stress.
Haz Mat EMS shall assume responsibility for the
medical care of all Haz Mat response personnel and
advise the EMS control officer (FRC ICS) on the care of
other emergency services personnel and civilian victims.

Page 1

Haz Mat EMS Functions

The Haz Mat EMS sector shall be conducted in
accordance with the following:
1. The health and emergency care of all Haz Mat
personnel shall be the prime mission of the Haz Mat
EMS sector.
2. At least one Advanced Life Support (ALS) unit
shall remain committed to provide advanced care
whenever Haz Mat personnel are engaged in entry
operations.
3. The Haz Mat EMS officer shall assign ALS
personnel to perform pre-entry and post-entry medical
evaluations of entry team personnel in accordance with
the sections Personnel Medical Evaluations and Physical
Signs of this procedure.
4. The Haz Mat EMS officer shall have the authority
to deny entry to any Haz Mat personnel for medical
reasons, after evaluation. The Haz Mat EMS officer shall
also retain the authority to order any Haz Mat personnel
to undergo medical evaluation and transport to a
hospital for further evaluation and/or treatment.
5. The Haz Mat EMS officer will coordinate with the
research officer on the acute, delayed, and chronic effects
of exposure and treatment for each hazardous material.
The Haz Mat EMS officer shall ensure that such
information is provided to the EMS control officer and
any receiving hospitals.
6. The Haz Mat EMS officer shall ensure that a
complete and accurate log is maintained of all EMS
functions including pre- and post-entry evaluations,
treatment of personnel, and communications with the
EMS control officer.
7. The Haz Mat EMS officer shall complete the
Hazardous Materials EMS Checklist, as appropriate, on
the following pages.
Haz Mat EMS Resources

Hazardous Materials EMS Checklist

ALS unit immediately available

BLS equipment, monitor and drug kit from Haz

Mat 7

Haz Mat medical evaluation forms

HIRT Internal Communications Capability

Note pad and pencil

Incident Operations Structure
The Haz Mat EMS officers shall be responsible for
maintaining the following lines of communications with
other sectors. This directive shall not preclude direct
communications with other sector officers where
necessary. (See Figure S11-1.)

Page 2

Haz mat sector officer

Operations officer

Safety

EMS

Figure S11-1 Incident operations structure.

Personnel Medical Evaluations

Medical evaluations of physical condition are to be
conducted on all personnel prior to suiting up and
engaging in activities while wearing chemical protective
clothing.
Assessment of the following physical signs shall be
conducted and recorded for a pre-entry baseline. The
pre-entry baseline should be compared to the medical
data carried on board Haz Mat 7. Any significant
deviations may, in the opinion of the Haz Mat EMS
officer, preclude an individual from operating as part of
an entry team.
An assessment of the same physical signs shall be
conducted and recorded for all personnel immediately
upon leaving decon. Any significant changes from the
pre-entry baseline may, in the opinion of the Haz Mat
EMS officer, preclude an individual from participating in
another entry.
If, in the opinion of the Haz Mat EMS officer,
personnel require further evaluation at a medical facility,
personnel shall be transported without delay and shall
not deny transport.
Physical Signs
1. Blood Pressure. Entry shall be denied to
personnel with a blood pressure exceeding 150 systolic
or 100 diastolic where there is 20 or more points
deviation from their normal resting pressure.
2. Pulse. Entry shall be denied to personnel with a
pulse greater than 110 or irregular without prior history.
3. Respirations. Entry shall be denied to personnel
with a respiratory rate greater than 24.
4. Temperature. Entry shall be denied to personnel
with an oral temperature greater than 99.2.
5. EKG. All personnel shall have a minimum 10
second rhythm strip obtained.
6. Weight. Re-entry shall be denied personnel who
show a loss of more than 2 percent pre-hydration weight.
Prior to entry, all personnel are to hydrate with AT
LEAST 1 PINT of water. Weight should be taken prior to
hydration to prevent false fluid loss readings.
(See Figures S11-2 through S11-7.)

Page 3

EMS Sector Officer Checklist

Nature of incident:

Location:
EMS sector officer:

EMS sector officer identified by EMS vest

EMS sector personnel / assignments:
1.

2.

3.

4.

Command
Haz mat sector officer:
Haz mat safety officer:
Haz mat operations officer:
Decon officer:
EMS control officer:
Command post location:

Figure S11-2 EMS sector officer checklist.

Site Set-up
Treatment and Triage Site Set-up (patients)
Location (describe area, should be close to decon):

Medical Evaluation Site Set-up (pre- and post-entry evaluations)

Location (describe area, should be close to haz mat units):

Command, Entry, Safety, and Decon Officers Notified

of Location
Medical Evaluation and Treatment Supplies and Equipment
Available

Transport Vehicle Available (one must be an ALS unit)

Unit number

ALS [

Unit number

ALS [

BLS [

Unit number

ALS [

BLS [

Unit number

ALS [

BLS [

Other (bus, helicopter, etc.)

Protective Clothing for EMS Personnel Determined

Level of protection:

Type of clothing:

Primary Receiving Hospital Defined

(Check with EMS control officer.)
Receiving Hospital Notified of Decontamination Procedures
(Consult decon officer for recommendations.)

Figure S11-3 Site set-up form.

Page 4

Chemical Information
Name(s) of Chemicals Involved (obtained from research)
1.
2.
3.
4.
5.
6.

Signs / Symptoms of Exposure and Onset

Chem

Acute

Delayed . . . . . Time:

1.
2.
3.
4.
5.
6.

Additional Chemicals Listed in Notes Section

Figure S11-4 Chemical information form.

Medical Treatment
Exposure Treatment
Physician contacted

Protocol

By case

Who:

Time:

1.
2.
3.
4.

Antidotes
1.

3.

2.

4.

Contraindications
1.

3.

2.

4.

Facility Contacted for Treatment / Antidote Information

Poison control center

Phone number:

Other:
Facility:

Phone number:

Contact person:
Facility:

Phone number:

Contact person:
Availability of Drugs / Antidotes Established
Locations:

Figure S11-5 Medical treatment form.

Page 5

Entry Team Safety

Entry Team Briefed on Effects of Chemical(s)
Safety Officer Briefed on Effects of Chemical(s)
EMS Personnel
Briefed:

on effects of chemical(s)
treatment procedures
medical monitoring procedures
review procedures sheet

Pre-entry Physicals Conducted (see attached sheet)

Protective Clothing for EMS Determined
Level of Protection

Post-entry Physicals Conducted (see attached sheet)

Post-transport Decon Required for:
Rescuers

Vehicles

Equipment

Receiving Hospital Notified of Decon Requirements and

Procedures:
Personnel

isolated area required?

Equipment

isolated area required?

Notes:
(Include significant observations such as time in suit, inappropriate
behaviors, intuitive feelings, etc.)

Figure S11-6 Entry team safety form.

Medical Evaluation Form Entry Team No.

Pre-entry Evaluation
Name

B/P

Pulse

Resp. Temp. Weight EKG

B/P

Pulse

Resp. Temp. Weight EKG

B/P

Pulse

Resp. Temp. Weight EKG

Post-entry Evaluation
Name

5 Minutes Post-entry
Name

Figure S11-7 Medical evaluation form.

Page 6

Maryland Medical Protocols for Hazardous Materials Exposure

This protocol assumes that the ambulance is the first and
only unit to arrive on the scene. Should there already be
other units on the scene, the Incident Commanders
instructions should be strictly adhered to in conjunction
with this protocol.
En Route to and Approaching the Incident Scene
If hazardous material involved in the incident is known
while responding to the scene, begin to research the
hazardous material using appropriate reference material
[e.g., manufacturer safety data sheets (MSDS), North
American Emergency Response Guidebook, pre-incident
plans]. Become familiar with the following:
1. Potential health hazards
2. Proper level of personal protection equipment
indicated by the hazardous material
3. Other potential hazards
4. Safe distance (the distance from the incident that is
considered to be free from hazards)
If at all possible, approach the incident from uphill and
upwind
While nearing the scene, be observant for
environmental clues (e.g., the lean of the trees may
indicate wind direction; unusual odors or vapor clouds
may indicate a hazardous condition).
Begin to don the proper level of protective clothing
and equipment if available and trained in its use.
Arrival at the Incident Scene
Position the ambulance vehicle outside the hot zone at
a safe distance.
Immediately establish a hot zone and deny access
by anyone into that area. Upon arrival of additional
units, stage as necessary and establish warm and
cold zones as appropriate.
Evaluate the magnitude of the incident and gather as
much specific information as possible on the hazardous
material involved without endangering personnel.
Call for appropriate assistance.
Coordinate closely with other responding units
and/or agencies. Confirm hazardous material involved,
advise best route of travel, etc.
Advise potential receiving hospitals of hazardous
material involved and possible number of patients
involved.
Contact appropriate poison control center to receive
detailed health implications of hazardous material
involved and product-specific treatment protocols. The
following may be required when calling the designated
poison control center:

The chemical name of the hazardous material

Length of exposure
Page 7

 State (i.e., gas, solid, or liquid) of hazardous

material
Route of introduction
Complete the donning of personal protective
clothing and equipment if available and trained in its
use.
Gain Access to the Patient(s)
When dealing with ambulatory patients (persons able to
remove themselves from the hot zone), assume that
anyone leaving the hot zone is contaminated. They should
be treated as such until properly assessed and
decontaminated.
1. Move these patients to, and contain them in, a
controlled area at the perimeter of the hot zone.
2. Do not make physical contact with these persons
until the proper level of personal protective clothing and
equipment has been donned.
3. Move these personnel to the decontamination
area in an organized fashion.
When dealing with non-ambulatory patients proceed as
follows.
1. Attempt to remove these patients from the hot
zone if the proper level of personal protection and
personnel trained in their use are available.
2. Treatment in the hot zone should be limited to
gross
airway
management,
cervical
spine
immobilization, and control of obvious hemorrhage. No
invasive procedures should be performed, as this would
provide a direct route of introduction of the hazardous
material into the patient.
3. Move patient to the decontaminated area.
Decontamination Procedures
1. Remove gross contaminants.
2. Remove all the contaminated clothing. Articles
that remain on the patient and cannot be removed
should be isolated from the environment.
3. Further decontamination should be completed
based upon the patients condition, environmental
conditions, and resources available.
4. Take care not to introduce contaminants into
open wounds.
5. Contain all runoff from
procedures for proper disposal.

decontamination

6. Isolate patient from the environment to prevent

the spread of any remaining contaminants.
7. Transfer patient to a clean, protected crew for
transport if resources are available.

Page 8

Assessment of Patient(s)
1. Complete primary and secondary surveys as
conditions allow. Bear in mind the product-specific
information received from the designated poison control
center.
2. In multiple patient situations, begin proper triage
procedures.
Treatment Procedures
1. Treat presenting signs and symptoms
appropriate and when conditions allow.

as

2. Administer orders of on-line medical direction.

3. IV therapy should be administered only with
physician direction.
4. Invasive procedures should be performed only in
fully decontaminated areas where conditions permit.
These procedures may create a direct route for
introduction of the hazardous material into the patient.
5. Reassess the patient frequently, as many
hazardous materials have latent physiological effects.
Transport to Hospital
1. Recontact receiving hospital.
2. Update on treatment provided and any other
information received from appropriate poison control center.
3. Obtain specific instructions regarding entering the
hospital.
4. Transport patient.
(a) Land
transportProtect
vehicle
equipment from contaminants.
(b) Air
transportIs
inappropriate
contaminated patients.

and
for

Transferring Responsibility for Patient to Hospital

Personnel
1. Await direction from hospital personnel before
entering hospital.
2. Assist
hospital
personnel
with
decontamination and treatment as requested.

patient

3. Arrange for personal decontamination.

Decontamination Procedures
Arrange for decontamination of the following in
accordance with information received from expert
resources.

Personnel
Emergency care equipment
Vehicles

Page 9

Medical Follow-up of Personnel

All public safety personnel who came into close contact
with the hazardous material should receive an
appropriate medical examination, post incident, based
upon information from the designated poison control
center. This should be completed within 48 hours of the
incident and compared with the findings of any recent,
pre-incident examination. Personnel who routinely
respond to hazardous materials emergencies should
have periodic pre-incident examinations. Personnel
should be advised of possible latent symptoms at the
time of their exam.

Maryland Medical Toxic Gas (Smoke Inhalation)

Field Protocol
A
specialty
referral
program
for
carbon
monoxide/cyanide inhalation has been developed by the
MIEMSS Department of Hyperbaric Medicine. Exposure
to these gases may be related to a fire scene and smoke
inhalation or inhalation of exhaust fumes or some paint
solvents.
It is not feasible to list the absolute triage for every
possible toxic gas inhalation patient, nor to define on a
statewide basis which patients should go directly from
the field to the department of hyperbaric medicine at
MIEMSS or to go first to a closer facility. Time, distance,
weather, and proximity to MIEMSS are all factors that
must be considered in making an individual patient
decision based upon the patient assessment and
mechanism of exposure.
The following guidelines are intended to aid in the
decision making, with the understanding that
appropriate consultation should be obtained if there is
any question regarding appropriate referral, treatment,
and/or transport. Consultation is particularly important
if the nature of the toxic gas is known, e.g., carbon
monoxide (CO), general smoke inhalation, cyanide gas,
hydrogen sulfide (H2S), or methylene chloride (CH2Cl2dichloromethane), because exposure to these substances
can be treated with hyperbaric oxygen therapy.
Candidates for Hyperbaric Medicine Referral

Toxic gas inhalation only

Unconscious patients
Incoherent, does not follow verbal commands
Combative, does not follow verbal commands*
Burn patients with toxic gas inhalation
*NOTE: All combative patients are to be transported via
ambulance.

Page 10

Adult:
(a) Patient 50 years of age or less who is unconscious,
combative, and/or incoherent and who does not
follow verbal commands with:
1. 20 percent BSA burns or less (second and third
degree)
2. Above 20 percent BSA burns (second and third
degree) should be referred to the appropriate
burn center
(b) Patients over 50 years of age with burns (second and
third degree) over greater than 10 percent BSA
should also be referred to the appropriate burn
center.
Pediatric:
(a) Patient unconscious, combative, and/or incoherent,
who does not follow verbal commands with:
1. 10 percent BSA burns or less (second and third
degree) if 10 years of age or younger
2. 20 percent BSA burns or less (second and third
degree) if over 10 years of age
(b) All other patients should be referred to the
appropriate facility after consultation with the
appropriate pediatric trauma center and the
appropriate burn center.
Clinical Data and Referral
Prior to obtaining consultation, have as much of the
following data as possible collected:
1. Age, race, and sex of the patient
2. Vital signs: pulse, BP, respiration, and breath sounds
3. Nature of the injury: toxic gas inhalation or toxic gas
inhalation with burns and/or other associated
injuries
4. Specifics to the exposure
(a) Type of fire, namely the combustible involved, e.g.,
PVC, acrylics, styrofoams, urethanes, wood,
petroleum products
(b) In cases other than fire-related, the type of gas
involved
(c) Type of occupancy (e.g., dwelling, vehicle)
(d) Duration of exposure, when possible
(e) Level of consciousness (utilize Glasgow coma
scale) with clinical signs and symptoms
(f) Prehospital care rendered
Note: Once as much of the above information as possible has
been obtained, radio contact with MIEMSS systems
communication (SYSCOM) or other appropriate facility should be
made and the information passed on. A copy of the ambulance
report form should be transported with the patient if at all possible.

Page 11

Advanced Life Support (ALS) Unit Responses

1. An ALS unit should be dispatched to all
suspected toxic gas inhalation incidents and immediately
requested when not dispatched initially.
2. Upon arrival of the ALS unit, blood samples are
to be collected via closed vacutainer technique prior to
starting the IV.
3. For conscious patients, informed consent must be
obtained prior to drawing blood samples. In the case of
unconscious patients, blood samples may be obtained at
the time the IV infusion is started.
4. The blood sample will be placed in one 5-ml
purple-top tube to be transported with the patient. The
tube containing the blood sample should also contain the
patients name along with the date and time the sample
was obtained.
5. SYSCOM will be notified whenever any
unconscious toxic gas inhalation patient is taken to a
facility other than the MIEMSS Department of
Hyperbaric Medicine.
Note: Some concern has been expressed regarding the type of
tube in which to place the blood sample. The main concern of
blood analyzing facilities is that the blood remain uncoagulated.
Therefore, if purple-top tubes are not immediately available, any
tube (e.g., gray tops) containing an anticoagulant would suffice.

Treatment
Toxic gas inhalation only.
1.
2.
3.
4.
5.

Remove patient from toxic environment

Obtain vital signs every 5 minutes
Administer oxygen, 50100 percent
Initiate cardiac monitoring
IV
(a) For symptomatic or unconscious adult patients,
D5W KVO (2030 ml/hr).
(b) For pediatric patients, if an IV is indicated, the
infusion should be lactated Ringers solution
titrated to a systolic BP of 80 mmHg.
(c) For adult patients with burns or associated trauma,
the IV should be lactated Ringers solution titrated
to a systolic BP of 100 mmHg.
(d) For pediatric patients with burns, the IV solution
shall be lactated Ringers solution KVO unless
medical direction specifies otherwise.
6. MAST as indicated
Note: Patients with respiratory burns should not have an
esophageal airway inserted.

Due to the extreme toxicity and cumulative effects of

certain by-products of combustion and/or incomplete
combustion, any person suspected of toxic gas exposure
who refuses treatment shall be advised of the possible
consequences and advised against returning to the toxic
environment. The necessary signature on the ambulance
report form shall be obtained.

Page 12