CS in a Confined Space
A barricaded subject refuses to exit a 4-by-5-meter apartment. After 90 minutes, the team deploys three CS canisters through a window. The wind is blowing toward the command post. When entry is made, three people are exposed: the subject, who is handcuffed prone and shouting; an officer with a history of asthma who is wheezing and using accessory muscles; and a second officer with eye pain and skin burning. You establish a decontamination area in the yard. The subject's pulse is 150, he is sweating heavily, and he suddenly goes quiet. The asthmatic officer has SpO2 89 percent, RR 32, and can speak only in short phrases. The second officer is uncomfortable but has normal vital signs. Your supplies include oxygen, albuterol, ipratropium, ketamine, and large volumes of water.
1. Set triage priorities and the decontamination sequence. Explain how you manage the asthmatic officer and what you avoid.
Read the worked answer
I triage the asthmatic officer first: he has a real airway and breathing threat, with SpO2 89 percent, RR 32, accessory muscle use, and only short phrases. I move him to fresh air, remove his contaminated clothing and gear, and irrigate his skin and eyes with copious water; I do not scrub or use bleach. I give oxygen, albuterol, and ipratropium by nebulizer or metered-dose inhaler with a spacer, and I consider early advanced airway if he tires or cannot speak. Then I assess the subject, because he is restrained, tachycardic, and has just gone quiet; then the second officer, who has normal vitals and can wait for decon. The decon sequence is removal from the agent first, then clothing removal, then water irrigation. I keep the asthmatic officer out of the contaminated area and do not let him return to the scene. For the subject I use the same decon but maintain custody and watch the restraint.
2. The subject goes quiet while prone and restrained. Walk through your assessment and interventions, including positional asphyxia and the decision to sedate.
Read the worked answer
A restrained patient who goes quiet is an emergency until proven otherwise. I check responsiveness, airway, breathing, and pulse immediately. If he is unresponsive or pulseless, I start CPR and remove him from the prone position at once. If he is breathing but altered, I roll him to a recovery position, remove the handcuffs or reposition them to the front with continuous custody, and give oxygen. Prone restraint plus weight on the back causes positional asphyxia; I never allow a knee or body weight on his back or neck. I check a glucose and monitor the rhythm. If he is agitated again and a danger to himself or the team, ketamine 3-5 mg/kg IM is my preferred sedation because it preserves respiratory drive better than a large benzodiazepine dose, but I only sedate after securing the airway and with monitoring. The quiet period may be exhaustion, hypoxia, or arrest, not compliance.
3. What command-level recommendations do you make about the CS cloud, PPE, and secondary contamination?
Read the worked answer
My command recommendations are to establish an upwind exclusion zone, move the command post and nonessential personnel upwind and uphill, and ventilate the apartment before entry teams spend more time inside. CS persists on clothing and gear, so I set up a decon corridor before anyone else goes in, with clothing removal and bagging, and I keep contaminated officers out of vehicles and medical areas. I recommend respirators and eye protection for anyone entering, and I document exposure times. I tell the commander that the second officer's symptoms should resolve with fresh air and irrigation, but persistent chest pain, wheezing, or hypoxemia requires transport. I also warn that secondary contamination can injure medics and that the CS cloud will drift; the scene is not safe just because the subject is in custody.