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Chemical Agents. Chapter 6. Overview. History of chemical disasters / terrorism D-I-S-A-S-T-E-R Paradigm for chemical agents Specific Agents Nerve agents Choking / Irritant Gases Cyanide Blister / Vesicants Agents Incapacitating agents. Potential Chemical Agents. History: World War I.

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Chemical agents

Chemical Agents

Chapter 6


  • History of chemical disasters / terrorism

  • D-I-S-A-S-T-E-R Paradigm for chemical agents

  • Specific Agents

    • Nerve agents

    • Choking / Irritant Gases

    • Cyanide

    • Blister / Vesicants Agents

    • Incapacitating agents

Potential Chemical Agents

History world war i
History: World War I

First large-scale use

  • Ypres, Belgium

    • April 1915

    • Chlorine, 168 tons

    • 5,000 deaths

    • 5 mile front

Terrorist Attacks

Matsumoto, June 1994

  • 280 injured

  • 7 dead

  • Tokyo, March 1995

  • Tokyo hospital response
    Tokyo: Hospital Response

    • 5,500 victims

    • 11 Dead

    • 641- St. Luke’s International Hospital

    • No decon

    • No EMS involvement for most

    Bhopal India 1984

    • 40 Tons of Methyl Isocyanate

    • Population of 900,000

    • Estimates of affected

      • 6,000-10,000

      • ? Affected ~ 400,000

    • Lack of safety devices

    • Manuals in English

    • “Mini-Bhopals in US?”


    I: Incident Command

    S: Safety & Security

    A: Assess Hazards

    S: Support

    T: Triage & Treatment

    E: Evacuation

    R: Recovery

    D: Detection

    I: Incident Command

    S: Safety & Security

    A: Assess Hazards

    S: Support

    T: Triage & Treatment

    E: Evacuation

    R: Recovery


    Rapid onset

    little or no warning

    Common symptoms

    Low lying clouds or vapors

    Dying animals or insects

    Unexplained odors

    Concentrations of Dead, dying, or sick people at the scene



    • Likely based on symptoms

      • DUMBELS – Nerve Agent

      • Respiratory symptoms – irritant gases

      • Skin symptoms – vesicants

      • Altered mental status and anti-cholinergic syndrome – BZ

    D: Detection

    I:Incident Command

    S: Safety & Security

    A: Assess Hazards

    S: Support

    T: Triage & Treatment

    E: Evacuation

    R: Recovery

    Incident command
    Incident Command

    • Must supply the following information:

      • number and type of casualties

      • substances involved

      • estimated time of arrival to hospital

      • time of the incident and incident site

      • method of contamination (vapor or liquid)

      • necessary decontamination

      • hazards to health care providers

      • role of the health care facility in the incident

      • updated information

    D: Detection

    I:Incident Command

    S:Safety & Security

    A: Assess Hazards

    S: Support

    T: Triage & Treatment

    E: Evacuation

    R: Recovery

    Scene security1
    Scene Security

    • Scene must be secured to prevent more casualties

    • Most (4/5) victims will go to the hospital by private/ public transportation vehicle!!!


      • all personnel involved in decontamination must wear PPE

    Scene security2
    Scene Security

    Minimum Site BoundariesOpen Area Chemical Release



    Uphill if agent heavier than air, downhill or level iflighter than air


    300 ft



    60 ft




    Casualty Collection Point

    6,000 ft

    RS= Release Site

    Adapted from Illinois Emergency Management Agency Chem-Bio Handbook. April 2000


    6,000 ft

    Figure 5

    D: Detection

    I:Incident Command

    S: Safety & Security

    A:Assess Hazards

    S: Support

    T: Triage & Treatment

    E: Evacuation

    R: Recovery

    Assess hazards
    Assess Hazards

    • Ongoing threat of contamination to other individuals

      • contamination control must be continually assessed and enforced by safety officer

      • badges must be given to hospital personnel

      • guards must wear PPE at ingress points

      • law enforcement assist with crowds, traffic, and casualty flow

    • Secondary devices?

    D: Detection

    I:Incident Command

    S: Safety & Security

    A: Assess Hazards


    T: Triage & Treatment

    E: Evacuation

    R: Recovery


    Public health organizations

    Poison control centers

    Health care providers

    Medical research centers

    Medical examiners

    Emergency response units and first responder organizations


    State Disaster Teams

    Safety and medical equipment manufacturers

    Federal agencies


    Hazardous Materials Response Unit

    Local law enforcement


    Support health care providers

    Use primary care clinics and urgent care centers


    All individuals should be oriented to the disaster plan

    Support:Health care providers

    Support supplies pharmaceuticals
    Support:Supplies / Pharmaceuticals

    • Vendor Agreements

      • ventilators

      • other equipment

    • Essential pharmaceuticals

    • Atropine can be stockpiled

      • powder form

    D: Detection

    I:Incident Command

    S: Safety & Security

    A: Assess Hazards

    S: Support

    T:Triage &Treatment

    E: Evacuation

    R: Recovery

    D: Detection

    I:Incident Command

    S: Safety & Security

    A: Assess Hazards

    S: Support

    T: Triage &Treatment


    R: Recovery


    • Most victims will self transport

    • Consider school buses for minimal pts

    • Caution

      • Contaminated pts

      • Off-gassing

      • Open windows

      • Use vents

    D: Detection

    I:Incident Command

    S: Safety & Security

    A: Assess Hazards

    S: Support

    T: Triage & Treatment

    E: Evacuation



    • Most difficult aspect of a chemical event

    • All areas of the hospital, buses, ambulances, equipment checked for persistence of chemicals

    • Law enforcement investigate human remains for evidence

    • Psychological sequelae

    Nerve Agents

    • Organophosphates

    • Are similar to insecticides:

      • Malathion

      • Diazinon

      • Chlorpyrifos





    Nerve Agents




    vapor and liquid threat

    • Nerve agents

      • liquids ambient temperatures

      • Vapor heavier than air

    • VX

      • Nonvolatile

      • Persistent

      • liquid threat


    Tabun (GA)

    Sarin (GB)

    Soman (GD)








    Vapor Density

    (air = 1)





    Topical LD50 mg





    Aging half-life

    14 hours

    5 hours

    2-6 minutes

    48 hours

    Nerve Agent Properties

    Nerve agent pathophysiology
    Nerve Agent Pathophysiology

    • Acetylcholine

      • Neurotransmitter parasympathetic nervous system

      • neuromuscular endplate

      • Ganglia

        • Sympathetic

        • parasympathetic

    Cholinergic Nerve Function



    Cholinergic Nerve Function




    Nerve agent symptoms
    Nerve Agent Symptoms

    • Diarrhea

    • Urination

    • Miosis

    • Bradycardia, Bronchoconstriction, Bronchorrhea

    • Emesis

    • Lacrimation

    • Salivations, Secretions,Sweating


    Nerve agent symptoms nicotinic
    Nerve Agent Symptoms: Nicotinic

    • Mnemonic for the days of the week

      • M: mydriasis (pupil dilation)

      • T: tachycardia

      • W: weakness

      • tH: hypertension

      • F: fasciculations

    Nerve agent exposure vapor
    Nerve agent exposure - Vapor

    • Low exposure

      • Meiosis (dim vision, eye pain)

      • Rhinorrhea

      • Dyspnea

    • High exposure

      • Immediate loss of consciousness

      • Seizures

      • Apnea

      • Flaccid paralysis

    • Vapor effects occur within second, peak within minutes: no late onset

    Nerve agents liquid

    Small amount (up to 18 hrs)

    Localized sweating


    No miosis

    Moderate amount (<LD50) (18 hrs)

    GI effects

    Miosis uncommon

    Large amount (LD50) (<30 minutes)

    Sudden loss of consciousness



    Flaccid paralysis


    Nerve Agents: Liquid

    Nerve agent triage
    Nerve Agent-Triage

    • Tokyo Sarin

      • 3/6 victims in cardiac arrest resuscitated

      • Majority were worried well

    • Consider cardiac arrest as immediate?

    Nerve Agents: Treatment

    • ABC’s, supportive care

    • Antidotes

      • Atropine 2 mg IV/IM/ET

        • Repeat doses as necessary

        • End point is dry secretions, easier ventilation

      • 2-PAMCl

        • 1 gram slow IV or Mark I kit IM (600 mg)

      • Benzodiazepines, PRN for seizures

    Nerve agent treatment
    Nerve agent: Treatment

    • Atropine Starting dose - 2 mg

    • Maximum cumulative dose - 20 mg

      • Insecticide poisoning requires much more

    • Side effects in normal people

      • Mydriasis

      • Blurred vision

      • Tachycardia

      • Decreased secretions and sweating

    Nerve agent treatment1
    Nerve Agent Treatment

    • Atropine – How much to give?

      • Until secretions are drying or dry

      • Until ventilation is easy

      • If conscious or the patient is comfortable

      • Do not rely on heart rate or pupil size

    Nerve Agents:Treatment summary

    • Vapor exposure

      • Symptoms develop suddenly

      • Most ambulatory victims require minimal intervention

      • Risk of secondary contamination, which is minimized by removing the victim’s clothing

      • Requires immediate access to antidotes

    • Liquid exposure

      • Symptoms delayed minutes to hours

      • Greater need for decontamination

      • High risk of secondary contamination; victims require decontamination (clothing removal & washdown)

      • Requires immediate access to antidotes

    Irritant gases choking agents
    Irritant Gases (Choking Agents)

    Irritant agents
    Irritant Agents

    • Irritate respiratory tract or damage lung tissue

      • Combine with moisture to form acids or bases

    • Three groups based on water solubility

      • Highly water soluble

      • Moderately water soluble

      • Low water solubility

    • Examples:

      • Ammonia, chlorine, phosgene

    Irritant gas symptoms
    Irritant Gas Symptoms

    Highly water soluble - ammonia

    Moderately water soluble - chlorine

    Poorly water soluble - phosgene

    Irritant gas symptoms1
    Irritant Gas - Symptoms

    • Mucous membrane irritation and excess mucous production

    • Conjunctivitis

    • Coughing

    • Dysphonia (hoarseness)

    • Stridor and aphonia

    • Bronchospasm

    • Shortness of breath

    • Non- cardiogenic pulmonary edema

    Highly water soluble irritant gases
    Highly Water Soluble Irritant Gases

    • Ammonia

    • Formaldehyde

    • Hydrogen Chloride

    • Sulfur Dioxide

    • Mostly upper airway to vocal cords

      • laryngospasm

    Moderately water soluble irritant gases
    Moderately Water Soluble Irritant Gases

    • Chlorine

      • Hydrochloric acid

      • Hypochlorus acid

      • Greenish-yellow gas

    • Slightly slower to combine with water

    • Affects upper airway

    • Affects lower airways

    Poorly water soluble irritant gases
    Poorly Water Soluble Irritant Gases

    • Phosgene (COCl2)

      • Forms hydrochloric acid

    • Nitrogen dioxide (NO2)

      • Forms nitric acid

    • Inhaled into alveoli before combining with water

    • Results in pulmonary edema (20 min to 24 hrs)

    Phosgene cg
    Phosgene (CG)

    • Most dangerous of pulmonary agents

    • Use in WWI

    • Developed as warfare agent, first use 1917

    • U.S. Produces > 1 billion pounds/yr for industrial uses

    • Odor of New Mown Hay

    • Poor Warning Properties

      • odor may not be detected

      • accumulates in low areas (trenches)

    Phosgene cg1
    Phosgene (CG)

    • Low concentrations

      • mild cough, chest tightness, shortness of breath

    • Moderate concentrations

      • lacrimation

    • High concentrations

      • pulmonary edema (2-6 hours)

      • death (24-48 hours)

    • Initial presence/absence of symptoms do not predict severity of exposure

    Irritant gases triage
    Irritant Gases: Triage

    • Majority – Worried well?

    • Airway compromise – immediate

    • Severe shortness of breath- immediate

    • Mild SOB, No airway compromise – delayed

    • Mild mucous membrane symptoms – minimal

    • Respiratory arrest – expectant

    Irritant gases treatment
    Irritant Gases: Treatment

    • Dry decontamination usually adequate

    • Water for mucous membrane irritation

    • ABC’s

    • Oxygen PRN

    • Early airway management

      • highly and moderately water soluble exposures

    • Inhaled beta agonist PRN wheezing

    • Observation and support

      • phosgene 12- 24 hrs?

    Irritant gas summary
    Irritant Gas - Summary

    • Solubility determines physiologic effect

    • Dry decon is usually all that is needed

    • Incident Command and treatment areas– upwind

    • Treatment is supportive

      • Early airway management critical

      • Consider intubation for stridor

      • Be prepared for surgical airway

    • Transport contaminated separate from decontaminated

    Cyanide ac ck
    Cyanide (AC, CK)

    • Formerly referred to as “blood agents”

    • Hydrogen Cyanide AC

    • Cyanogen Chloride CK

    • Odor “bitter almonds”? – “musty” smell

    • Odor not a reliable indicator (genetic)

    • Combines with Cytochrome a3 and Inhibits Oxygen Utilization (bright red venous blood)





    O2 + H+

    Cyt a cyt a3 Cu

    Cyt c





    Cyanide sources
    Cyanide - Sources

    • Pits of many plants

      • Cherries, peaches, almonds, lima beans

      • Cassava plant root

    • Combustion of carbon -> cyanide

      • Plastics- acrylonitriles

    • U.S. sources manufacture 300,000 tons of hydrogen cyanide annually

    Terrorist use of cyanide
    Terrorist Use of Cyanide

    • Tylenol – 1982 – Killed 7

    • Rev Jim Jones – 1978 – Killed 900

    • 1995 Aum Shinrikyo

      • Several subway restrooms after attack

      • Found acid and cyanide salt

      • cyanide salt + acid cyanide gas

    Cyanide triage
    Cyanide Triage

    • M-A-S-S Triage

    • Likely few critical victims

      • Most either dead

      • Others with minor exposure

    • Good supportive care may save many in absence of antidote

    Cyanide treatment
    Cyanide Treatment

    • Remove to Fresh Air

    • Oxygen, supportive care

    • Pasadena Kit (Was Lilly Kit)

    Cyanide treatment1
    Cyanide Treatment

    • Step 1

      • amyl nitrite

        • inhale 30 sec/min until IV)

    • Step 2

      • Sodium nitrite

        • 10 ml of 3% IV over 5-10 minutes

    • Step 3

      • Sodium thiosulfate

        • 50ml of 25% IV over 20 minutes




    Cyt a3

    Amyl nitrite

    Sodium nitrite





    Sodium thiosulfate


    Excreted in urine

    Cyanide treatment summary
    Cyanide Treatment Summary

    • Induce methemoglobinemia

      • Amyl nitrite, Sodium nitrite

  • Create thiocyante

    • Sodium thiosulfate

  • Good supportive care even in absence of antidote

  • Blister agents vesicants
    Blister Agents/Vesicants

    • Sulfur mustard

    • Phosgene Oxime CX

    • Nitrogen mustard

    • Lewisite L

    Mustard physical characteristics
    Mustard Physical Characteristics

    • Oily liquid so poorly volatile

    • Light Yellow in Color

    • Garlic odor

    • Freezes at 57 F

    • Penetrates rubber gloves

    Lewisite Characteristics

    • Organic arsenical with vesicant properties

    • Colorless, oily liquid

    • Odor of geraniums

    Vesicant mechanism
    Vesicant Mechanism

    • RAPIDLY penetrates cells and generates toxic intermediate

    • Alkylates DNA, RNA, protein-->disrupts cell function-->cell death

    • Rapidly dividing cells most susceptible

    Vesicant symptoms
    Vesicant Symptoms

    • Binds Irreversibly within minutes “Fixing”.

    • Onset of symptoms 4-8 hours

    • Tissue Damage Within Minutes Without Symptoms for Hours

    • Topical – Eyes, Airway, Skin

    • Systemic – Bone Marrow, GI, CNS

    Mustard skin
    Mustard - Skin

    • Erythema 2-24 hours

    • Small vesicles may coalesce to form bullae

    • High dose exposure – central zone of coagulationnecrosis

    Vesicant treatment
    Vesicant Treatment

    • Immediate decontamination (2 minutes)

    • Victim may not undergo decontamination since symptoms delayed

    • Remove clothes and wash skin with soap and water

    • Avoid overhydration; fluid losses less than with thermal burns

    Lewisite treatment
    Lewisite Treatment

    • British Anti-Lewisite (BAL)

      • chelating agent

      • only administer to victims with shock or severe pulmonary injury in consultation with the poison center

      • 3-5 mg/kg IM every 4 hours x 4 doses

      • Side effects: nausea/vomiting, headache, burning sensation of lips, chest pain, anxiety

    Incapacitating agents
    Incapacitating Agents

    • Not meant to be lethal

    • “inability to perform one’s mission”

    Incapacitating agents bz
    Incapacitating Agents:BZ

    • BZ--3-quinuclidinyl benzilate

    • Anticholinergic Agent

    • 25-times more potent than atropine

    Bz symptoms
    BZ: Symptoms

    • “Mad as a Hatter”

    • “Dry as a Bone”

    • “Blind as a Bat”

    • “Hot as a Hare”

    • “Red as a Beet”

    Bz treatment
    BZ: Treatment

    • Control patient


    • Physostigmine

      • 1-2 mg IV

      • atropine at bedside

      • seizures and cardiac arrhythmias rare

    Bz summary
    BZ: Summary

    • Sx:

      • Red, Hot, AMS, Tachycardia

    • Not all chemical exposures are nerve agents

    • Supportive care / cooling

    • Physostigmine

    Summary chemical agents

    ABC’s & supportive


    Nerve Agents


    Treatment: atropine/ 2PAM

    Irritant Gases

    Sx’s based on water solubility

    Aggressive airway management


    Amyl nitrite/ sodium nitrite

    Sodium thiosulfate


    Decon a must

    Supportive care

    BAL for lewisite


    AMS, red and hot


    Summary: Chemical Agents