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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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overview
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
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
slide6

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
slide9

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?”
slide10
D:Detection

I: Incident Command

S: Safety & Security

A: Assess Hazards

S: Support

T: Triage & Treatment

E: Evacuation

R: Recovery

slide11
D: Detection

I: Incident Command

S: Safety & Security

A: Assess Hazards

S: Support

T: Triage & Treatment

E: Evacuation

R: Recovery

detection
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

Detection
detection1
Detection
  • Likely based on symptoms
    • DUMBELS – Nerve Agent
    • Respiratory symptoms – irritant gases
    • Skin symptoms – vesicants
    • Altered mental status and anti-cholinergic syndrome – BZ
slide14
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
slide16
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!!!
  • PREVENT THE HOSPITAL FROM BECOMING CONTAMINATED
    • all personnel involved in decontamination must wear PPE
scene security2
Scene Security

Minimum Site BoundariesOpen Area Chemical Release

COLD ZONE

CCP

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

WARM ZONE

300 ft

WIND DIRECTION

HOT ZONE

60 ft

WARM ZONE

RS

COLD ZONE

Casualty Collection Point

6,000 ft

RS= Release Site

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

HOT ZONE

6,000 ft

Figure 5

slide20
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?
slide22
D: Detection

I:Incident Command

S: Safety & Security

A: Assess Hazards

S:Support

T: Triage & Treatment

E: Evacuation

R: Recovery

support
Public health organizations

Poison control centers

Health care providers

Medical research centers

Medical examiners

Emergency response units and first responder organizations

DMAT’s

State Disaster Teams

Safety and medical equipment manufacturers

Federal agencies

FBI

Hazardous Materials Response Unit

Local law enforcement

Support
support health care providers
Use primary care clinics and urgent care centers

Volunteers

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
slide26
D: Detection

I:Incident Command

S: Safety & Security

A: Assess Hazards

S: Support

T:Triage &Treatment

E: Evacuation

R: Recovery

slide27
D: Detection

I:Incident Command

S: Safety & Security

A: Assess Hazards

S: Support

T: Triage &Treatment

E:Evacuation

R: Recovery

evacuation
Evacuation
  • Most victims will self transport
  • Consider school buses for minimal pts
  • Caution
    • Contaminated pts
    • Off-gassing
    • Open windows
    • Use vents
slide29
D: Detection

I:Incident Command

S: Safety & Security

A: Assess Hazards

S: Support

T: Triage & Treatment

E: Evacuation

R:Recovery

recovery
Recovery
  • 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
slide32

Nerve Agents

  • Organophosphates
  • Are similar to insecticides:
    • Malathion
    • Diazinon
    • Chlorpyrifos

Sarin

VX

Soman

Tabun

slide33

Nerve Agents

G-agents

Volatile

Nonpersistent

vapor and liquid threat

  • Nerve agents
    • liquids ambient temperatures
    • Vapor heavier than air
  • VX
    • Nonvolatile
    • Persistent
    • liquid threat
slide34

Agent

Tabun (GA)

Sarin (GB)

Soman (GD)

VX

LCt50

Mg(min)/m3

400

100

50

10

Vapor Density

(air = 1)

5.63

4.86

6.33

9.20

Topical LD50 mg

1000

1700

100

10

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
nerve agent symptoms
Nerve Agent Symptoms
  • Diarrhea
  • Urination
  • Miosis
  • Bradycardia, Bronchoconstriction, Bronchorrhea
  • Emesis
  • Lacrimation
  • Salivations, Secretions,Sweating

(dumbells)

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

Fasiculations

No miosis

Moderate amount (<LD50) (18 hrs)

GI effects

Miosis uncommon

Large amount (LD50) (<30 minutes)

Sudden loss of consciousness

Seizures

Apnea

Flaccid paralysis

Death

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?
slide45

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
slide48

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 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)
slide63

O2

O2

CN-

O2

O2 + H+

Cyt a cyt a3 Cu

Cyt c

O2

H20

ADP

ATP

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
slide69

rbc

CN-

Fe2+-Hb

Cyt a3

Amyl nitrite

Sodium nitrite

Fe3+-Hb

Fe3+-Hb

MetHb

CN-

Sodium thiosulfate

thiocyanate

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
slide73

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
  • KEEP VICTIM COOL
  • 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

Decontamination

Nerve Agents

DUMBELS

Treatment: atropine/ 2PAM

Irritant Gases

Sx’s based on water solubility

Aggressive airway management

Cyanide

Amyl nitrite/ sodium nitrite

Sodium thiosulfate

Vessicants

Decon a must

Supportive care

BAL for lewisite

BZ

AMS, red and hot

Physostigmine

Summary: Chemical Agents
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