title: Lessons learned from chlorine intoxications in swimming pools: the challenge of pediatric mass toxicological events.
abstract: BACKGROUND
  The classical doctrine of mass toxicological events provides general guidelines for the management of a wide range of "chemical" events. The guidelines include provisions for the: (1) protection of medical staff with personal protective equipment; (2) simple triage of casualties; (3) airway protection and early intubation; (4) undressing and decontamination at the hospital gates; and (5) medical treatment with antidotes, as necessary. A number of toxicological incidents in Israel during the summer of 2005 involved chlorine exposure in swimming pools. In the largest event, 40 children were affected. This study analyzes its medical management, in view of the Israeli Guidelines for Mass Toxicological Events.
  
  
  METHODS
  Data were collected from debriefings by the Israeli Home Front Command, emergency medical services (EMS), participating hospitals, and hospital chart reviews. The timetable of the event, the number and severity of casualties evacuated to each hospital, and the major medical and logistical problems encountered were analyzed according to the recently described methodology of Disastrous Incident Systematic Analysis Through-Components, Interactions, Results (DISAST-CIR).
  
  
  RESULTS
  The first ambulance arrived on-scene seven minutes after the first call. Emergency medical services personnel provided supplemental oxygen to the victims at the scene and en route when required. Forty casualties were evacuated to four nearby hospitals. Emergency medical services classified 26 patients as mildly injured, 13 as mild-moderate, and one as moderate, suffering from pulmonary edema. Most children received bronchodilators and steroids in the emergency room; 20 were hospitalized. All were treated in pediatric emergency rooms. None of the hospitals deployed their decontamination sites.
  
  
  CONCLUSIONS
  Event management differed from the standard Israeli toxicological doctrine. It involved EMS triage of casualties to a number of medical centers, treatment in pediatric emergency departments, lack of use of protective gear, and omission of decontamination prior to emergency department entrance. Guidelines for mass toxicological events must be tailored to unique scenarios, such as chlorine intoxications at swimming pools, and for specific patient populations, such as children. All adult emergency departments always should be prepared and equipped for taking care of pediatric patients.
authors.affiliation: Tel-Aviv Sourasky Medical Center,Tel Aviv, Israel.
authors.forename: Ofer
authors.initials: O
authors.lastname: Lehavi
authors.forename: Adi
authors.initials: A
authors.lastname: Leiba
authors.forename: Yehudit
authors.initials: Y
authors.lastname: Dahan
authors.forename: Dagan
authors.initials: D
authors.lastname: Schwartz
authors.forename: Odeda
authors.initials: O
authors.lastname: Benin-Goren
authors.forename: Rama
authors.initials: R
authors.lastname: Schwartz
authors.forename: Arie
authors.initials: A
authors.lastname: Augarten
authors.forename: Josef
authors.initials: J
authors.lastname: Ben-Ari
authors.forename: Yoram
authors.initials: Y
authors.lastname: Ben-Yehuda
authors.forename: Gali
authors.initials: G
authors.lastname: Weiss
authors.forename: Yeheskel
authors.initials: Y
authors.lastname: Levi
authors.forename: Yaron
authors.initials: Y
authors.lastname: Bar-Dayan
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002648:Child; D002669:Child Welfare; D002675:Child, Preschool; D017606:Chlorine Compounds / Q000633:toxicity*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D004781:Environmental Exposure / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007557:Israel; D008297:Male; D054527:Mass Casualty Incidents; D013551:Swimming Pools; D014218:Triage
chemical_list: D017606:Chlorine Compounds