Hot Medicine: CBRN Medical Capabilities in the Trenches


By Frank Rando

Frank Rando outlines the most important aspects of medical countermeasure care in a live CBRN battlefield.

From the time of the Napoleonic surgeon and military doctor Dominique Jean Larrey and his ambulance volante to current standards and practices, the objective of CBRN medical countermeasures has always been to bring rapid and lifesaving medical care to the wounded or sick before transporting them to a higher echelon of care, with the goal being the expedient return of combatants to the battlefield.

In the traditional battlespace, traumatic injuries caused by conventional munitions and weaponry are addressed by self-care, buddy care, combat lifesaver care, and the combat medic or corpsman. These individuals are trained in Tactical Combat Casualty Care (TCCC). TCCC provides evidence-based, life-saving techniques, tactics, and strategies for delivering high-quality battlefield trauma care, and reducing combat deaths without undermining mission completion.

TCCC was originally designed and developed in the mid-90s for the special operations medical community, and its objectives remain the same. These are to treat injured combatants, limit the risk of further casualties, and achieve mission success. To these ends, TCCC emphasizes the phases of care as care-under-fire, tactical field care, and tactical evacuation care.

As asymmetric warfare, political violence, and terrorism have evolved to use threat agents such as militarized chemical warfare agents, improvised chemical devices, and toxic industrial chemicals and materials, the principles, concepts, and implementation of TCCC had to be modified to meet the challenges of injured and exposed casualties.

Operators must be able to apply TCCC principles to medical treatment of exposed casualties utilizing a hybrid approach. Medical readiness in support of CBRN responses requires extensive preventive medicine, post-exposure, and downrange trauma threat assessment and preparedness. 

TCCC training integrated in the NATO SOF Combat Medical Course in Staten, Germany, in May 2019, © U.S. Department of Defense

Tactical Emergency Casualty Care (TECC) is the civilian equivalent of TCCC and is extrapolated and adapted to civilian tactical medical response, such as Joint Rescue Task Forces. These integrate law enforcement for threat neutralization and force protection with emergency medical and fire service personnel to conduct rapid assessments, lifesaving interventions, and extractions in tactical operations.

In a CBRN hot zone, both military and civilian medical responders can provide medical reconnaissance, rapid assessment and triage, life-saving trauma interventions such as hemorrhage control and tourniquet application, and antidotes.

Training and equipping Special Operations Forces (SOF) and other assets to execute CBRN missions with medical treatment skills and mission-specific material requires threat-specific planning. These threats might include the likes of anthrax, organophosphate neurotoxicants, ionizing radiation, and contaminated traumatic injuries.

SOF-CBRN Direct Action Mission

In the U.S., for example, as part of a non-combatant evacuation operation, SOF elements can be sent to evacuate civilians from a remote location in the vicinity of a chemical plant set ablaze by criminals. This fire then spreads toxicants over the area, possibly contaminating civilians. The Joint Special Operations Task Force Commander must contend with complications presented by toxic industrial material contamination, SOF aircraft entering contaminated areas to pick up civilians without PPE, and resultant casualties.

Three Types of Casualties

Casualties in a CBRN battlefield can broadly be grouped into any one of three categories. These are standard battlefield traumatic injuries, poisoning or toxicity, or a combination of both. In any case, to provide the most appropriate care, one must ask what is killing the patient now.

For example, a casualty bleeding from the femoral artery can exsanguinate in three minutes, while some chemical warfare agents, and especially biological warfare agents and radiological exposures, have a delayed onset depending on agent characteristics, toxicity, virulence, exposure time and rate, airborne concentration, PPE, and other factors. However, it must be noted that nerve agents and cyanide can kill a casualty quickly and antidote administration is essential.

If feasible, it is critical to remove casualties from the contaminated environment to terminate further exposure to toxicants or to fires or explosions. Active shooters and enemy combatants create a direct threat or care-under-fire situation, thereby hindering medical and rescue operations. Fire superiority and threat suppression takes priority over medical treatment or rescue operations. It is important to remember the adage “good medicine may be bad tactics”. 

Decontamination is Critical

Immediate decontamination can mean the difference between minor and major health effects from agent exposure. Where liquid, droplet, and aerosolized contaminants are concerned, a critical intervention must rapidly commence decontamination to limit absorption into the skin and prevent cross-contamination. 

Ocular decontamination utilizing rapid and continuous flushing of the eyes is also important as contaminants can be absorbed via eyes and associated mucous membranes.

Vapor exposures do not require skin decontamination, but vapors may be entrapped in clothing. In such cases, a rapid cut-out procedure should be used to remove contaminated clothing. This will reduce the risk posed by entrapped vapors, which can off-gas in ambient air. For example, sarin has a volatility of 21,900 mg/cubic meter at 25°C (volatile).

The protective M40 mask or other respiratory protection should not be removed in the hot zone, but should be one of the last items to be removed in decontamination operations. 

Rapid assessment and life-saving interventions, such as tourniquet application for severe hemorrhage and antidote administration, should commence in the hot zone. Casualties should then be rapidly extracted and brought to the warm zone for decontamination, further medical assessment and treatment, and then moved to the cold zone and medical treatment facility.

Soldiers from the U.S. Army Civil Affairs and Psychological Operations Command participate in a bridge Combat Support Training Exercise in 2018, © U.S. Department of Defense


In the event of contamination, certain toxic agents will cause certain toxic syndromes, or toxidromes. Irritant gases such as ammonia, chlorine, and phosgene will cause airway and breathing effects, obstruction, or non-cardiogenic pulmonary edema.

Inert gases such as argon can displace atmospheric oxygen, while carbon monoxide can interfere or inhibit oxygen transport. Meanwhile, cyanide, azides, and hydrogen sulfide can interfere or inhibit cellular and mitochondrial oxygen utilization. These agents are known as simple or systemic asphyxiants.

Vesicants – also known as corrosive or “blister” agents – cause chemical burns, and liquefactive or coagulative necrosis. Examples include sulfur mustard, lewisite, and strong acids.

Finally, cholinergic toxidromes such as severe bradycardia, bronchorrhea, bronchoconstriction, seizures, and miosis can be caused by organophosphate pesticides. These include malathion and militarized nerve-agents such as sarin, soman, tabun, VX, and novichok.


In a CBRN event with trauma, the priorities are to limit and minimize exposure and contamination, treat the immediate life threat, and to administer appropriate antidotes and countermeasures by using the mnemonic MARCHE.

At the point of injury or in the hot zone, one must conduct a check both on their mask and for a massive hemorrhage, as well as checking their airway and administering antidotes. One must also check for respiratory anomalies and conduct rapid spot decontamination.

At the emergency patient decontamination station – or “dirty” casualty collection point – one must assess the patient’s circulation and administer countermeasures such as IV drips. Next would be addressing hypothermia or head wounds, before conducting extraction or evacuation. 

The NATO CBRN CRESS mnemonic for CBRN casualty assessment developed by British SOF toxicology and CBRN medical experts enables the tactical medic to quickly determine the agent of concern, conduct triage, and recognize symptoms. CRESS stands for consciousness, respirations, eyes, secretions, and skin.

Meanwhile, wounds must be decontaminated and treated surgically using standard irrigation and debridement. In extremis, the medic can wipe a wound with Kerlix or similar material, then perform wound packing and bandaging.

Continuum of Care is Essential

Emergency medical providers, tactical and military medics, and health care professionals may have to render care for CBRN exposure and traumatic injuries in austere, hostile, and front-line operational settings due to non-conventional threats or a mixed casualty load.

Traditionally in a battlespace, a military CBRN or HAZMAT casualty would undergo immediate decontamination in the hot zone or its periphery. Immediate decontamination can mean the difference between minor and significant health effects from agent exposure.

Certain assets of the international military special operations community are often tasked with sensitive site exploitation missions  and other activities associated with countering weapons of mass destruction and counterproliferation. Specialized CBRN reconnaissance, decommissioning, threat neutralization, and non-proliferation teams may also be involved in various military and related operations, such as the OPCW’s treaty verification activities.

In addition, both special operations and conventional military forces may be engaged during a tactical or strategic strike utilizing some form of CBRN weapon. In such an event, they may venture into a technological disaster zone involving chemical or radiological materials being released due to a conventional military strike or industrial accident, from a hazardous waste facility, or from a clandestine laboratory or facility storing, processing, manufacturing or fabricating CBRN materials and weapons.

As many rogue nation-states and terrorist factions have the capabilities to acquire, develop, deploy, and use CBRN agents as well as inflict injuries with conventional armaments and munitions, medical and healthcare assets must be prepared to provide rapid clinical interventions at the point of exposure and injury, and provide healthcare support throughout the continuum of care.

Frank Rando currently serves as an allied health programs educator, lead instructor, healthcare emergency preparedness, medical readiness, public health preparedness and tactical, operational, disaster medicine and homeland security subject matter expert, educator, instructor, and curriculum designer. He has served in instructional, guest speaker, and consultative roles for DHS-FEMA, various components of the National Domestic Preparedness Consortium, Department of Defense, industry, academia, health, safety and regulatory entities, emergency services organizations, and healthcare.

Related articles

Recent articles