The terrible toxins chemical terrorism
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The Terrible Toxins: Chemical Terrorism. Cynthia Aaron MD FACMT FACEP Medical Director, Michigan Regional Poison Control Center. It’s a beautiful spring day. The Spartans had a great victory. People disperse home

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The terrible toxins chemical terrorism

The Terrible Toxins: Chemical Terrorism

Cynthia Aaron MD FACMT FACEP

Medical Director, Michigan Regional Poison Control Center


The terrible toxins chemical terrorism

  • It’s a beautiful spring day. The Spartans had a great victory. People disperse home

  • That evening, local EDs note a larger number of people than normal with URI complaint

    • Mild cough, nasal irritation, sneezing, husky voice, runny nose, sore throat

    • Conjunctivitis, itchy eyes

    • Itching in the groin, under arms, under neck with faint red rash

    • Fatigue


Terrorism

Terrorism

  • “Terrorism is an intentional and rational act of violence to cause fear in the target audience for the purpose of changing behavior”

    • It is a political act

  • Three kinds of attacks

    • Weapons of mass destruction

      • Systems or structures of society

    • Weapons of mass casualty

      • Biological and chemical agents to injure or kill

    • Weapons of mass disruption

      • Social, political or economic damage to society

http://cjc.delaware.gov/terrorism/nature.shtml


Weapons of mass casualty

Weapons of mass casualty

  • Indiscriminate and indirect targeting

    • Targets are chosen for desired impact

      • Not who dies but the fact that they do die

    • Perceived random nature  fear, impotence, anxiety

    • Utilization of scarce resources

      • Death versus injury


Toxic terrorism

Toxic Terrorism

  • Clear history of use separate from warfare

    • Syria 2013 Sarin

    • Afghanistan 2013 Pesticides

    • England 2006Polonium

    • Iraq 2006Chlorine

    • Ukraine 2004Dioxin

    • Maine 2003Arsenic

    • Russia 2002Fentanyl and other agents

    • 2001 US MailAnthrax

    • 1995 Tokyo Sarin

    • 1994 Matsumoto Sarin

    • 1988 Halabja IraqSarin, mustard, CN

      and the list goes on

http://www.ncfpd.umn.edu/Ncfpd/assets/File/pdf/GlobalChron.pdf


Toxic chemicals

Toxic chemicals

  • Characteristics

    • Ease of acquisition

      • Synthesis and production

      • Readily available

      • Purchased

    • Public health impact

      • Morbidity, mortality and public health strain

      • Mass confusion, panic, social disruption

    • Resistance to medical treatment

      • Is prophylaxis or treatment available?

    • Ease of dissemination

      • Dispersal, vapor pressure (temperature), water solubility, local reactivity, persistence

    • Weaponized

Shea DA, Gottron F. CRS Report: Small-scale terrorist attacks using chemical and biologic agents: An assessment framework and preliminary comparisons. May 2004 RL32391


Toxic weapons

Biological

Infective agents

Bacteria, Rickettsia, Virus

Toxins

Botulinum toxins, Staph enterotoxin B, Ricin, Tricothecene mycotoxins

Chemical

Nerve agents

Vesicants

Chemical asphyxiants

Pulmonary toxins

Toxic industrial chemicals

Radiologic

Thallium, cesium, polonium, uranium, radium

Toxic weapons


The terrible toxins chemical terrorism

http://www.frontmed.co.nz/products/product-details/_cat2_/120/Military-Tactical/Emergency--Medical-Training/_prod_/Mass-Destruction-Casualty-Simulation-Kit?productlistPCMID=226


Ticcs and tims

TICCs and TIMs

NATO ITF-25: High Hazard TICs

• Tissue Irritants

– ammonia

– boron trichloride

– chlorine

– fluorine

– formaldehyde

– hydrogen bromide

– hydrogen chloride

– phosgene

– phosphorus trichloride

– nitric acid

– sulfur dioxide

– sulfuric acid

• Systemic Poisons

– arsine

– boron trifluoride

– carbon disulfide

– cyanide

– diborane

– ethylene oxide

– hydrogen fluoride

– hydrogen sulfide

– tungsten hexafluoride


Chemicals used by terrorists

Chemicals used by terrorists

  • Corrosives-alkali/acids

  • Metals (arsenic, mercury, thallium)

  • Cyanide

  • Rodenticides

  • Pesticides

  • “Poison gas”

Montery Institute database 2002


Methods to disperse agents

Casual or direct contact

Aerosol or spray

Food or drink

Unknown

Product tampering

Exposives

Water supply

Jug/jar/canister

Mail or letter

Reaction device

Injection or projectile

Methods to disperse agents

Montery Institute Database 2000


Methods to disperse agents1

Injection or projectile

Reaction device

Mail or letter

Jug/jar/canister

Explosives

Product tampering

Small number individuals

Resources

Effective but requires highly purified stable compound

More likely for explosive (Boston Marathon)

Resources, thermal degradation

High potential (Tyenol, Chilean grapes)

Methods to disperse agents

Montery Institute Database 2000


Water supply

Botulsim: 7 ng (0.0000007 mg)

Assume community 10,000 people with 1.8 billion gallons

Drink 1 qt water per day per person

Requires 7 billion lethal doses needed

Would require 7 kg of pure toxin

Botox: 100 unit vial equivalent to 4.9 ng approximately 2 million vials

CN well water Zimbabwe

Small volume

Filtration system

Activated Charcoal

Chlorination and disinfection process

Water Supply

15 billon gallons


Dissemination

Dissemination


Targeted group

Smaller numbers

Dispersal

Ventilation system

Trucks, loaded drums

Food, beverages

Fluoroacetate

10 lb bag of coffee + 35 ml fluoroacetate in 35 cup urn = 1 LD50/cup

Larger numbers

Dispersal methods

Aerosolize without explosion

Ventilation system

Confined space

Subway, domed sports stadium, convention center, large public building

Outdoors

Lower ground

Targeted group


The terrible toxins chemical terrorism

Source: This table was prepared from compiled open source data. Congressional Research Service, 2002 (Updated 2004). See Appendix B for detailed data used to generate rating.

http://www.fas.org/irp/crs/RL32391.pdf


Sarin tokyo

7:55-5 subway cars release 30% sarin-plastic bags

8:16 Gas explosion reported in subway

8:28 first patients arriving by foot

8:43 first ambulances arrive

8:43 first cardiac arrest arrives by car

9:00 500 patients arrive at St. Lukes

9:00 Routine hospital operations shut down

9:00 triage assembled at site and subway access blocked

9:40 cholinesterase levels return extremely low

Specific therapy started

10:00 substance identified as acetonitrile

11:00 substance re-identified as Sarin

Hospitals notified by TV

Sarin-Tokyo


Tokyo

Miosis99%

HA75%

Dypsnea 63%

Nausea60%

Eye pain45%

Blurred 40%

Vision dark38%

Vomiting37%

Easy fatigue37%

Cough34%

Agitation33%

Fasciculations23%

Convulsions2.7%

Tokyo


Points of comparison

Organophosphates

Any route

SLUDGE

Miosis

Bradycardia, hypotension

Large amounts of atropine

May be delayed response

Nerve Agents

Most likely inhaled

Skin if VX

Tachycardia, transient hypertension

Miosis

Minimal SLUDGE

Respiratory distress

Bronchospasm

Respiratory weakness

Seizures

Atropine usually < 30 mg

Points of comparison


Tokyo1

Tokyo

  • St Lukes

    • 174 arrived on foot

    • 120 arrived by taxi

    • 67 by passing car (2/3 cardiac arrest pts)

    • 64 by Tokyo Metro Fire Department car

    • 35 by ambulance

    • 7 by police car

    • 31 by “other”


Tokyo2

Tokyo

  • 1363 EMTs

    • 135 (9%) developed secondary poisoning

  • 472 staff at St. Lukes

    • 110 (23%)

      • Chapel 46%

      • ICU 39%

      • OPD 32%

      • Ward 18%

      • ED 17%

Eye symptoms 14%

HA11%

Throat pain8%

Dypsnea5%

Nausea3%

Dizziness2.5%

Nose pain2%


Tokyo lessons learned

Tokyo-Lessons learned

  • PPE

  • Decontamination

    • Weather

      • > 65°, 36-64°, and < 36°

      • http://www.ecbc.army.mil/hld/ip/reports.htm, MIRP

      • https://www.ecbc.army.mil/downloads/publications/ECBC_SP_024_Lake.pdf?DocID=59

  • Detection

  • Treatment

  • Poison information management

  • Chronic effects


Sulfur mustard

Sulfur mustard

  • Transparent yellow liquid

    • Impurities give it odor

    • Volatile

    • Persistent (days/weeks)

    • Lipophilic

    • Alkylating agent


Sulfur mustard1

Sulfur mustard

  • Local tissue damaging effects

    • Mucous membranes, lungs, eyes, skin

  • Systemic distribution

    • Systemic effects

      • Liver, kidneys, intestines, brain, hematopoietic


Sulfur mustard2

Sulfur mustard

  • Symptom-free interval

    • Interval duration inversely correlates with absorbed dose

  • Onset

    • URI

      • Eye discomfort, conjunctivitis, rhinorrhea, sore throat, cough

      • Chest discomfort

      • Reddened itchy skin in warm moist areas


Sulfur mustard3

Sulfur mustard

  • Decontaminate early-patient

    • Copious amounts water

      • Water soluble-can spread

    • Dry agents

  • Decontaminate late-caretakers


Toxic terrors

Toxic Terrors

  • Identification

    • Simultaneous large amount of people at one site

      • EASY

    • Delayed onset

      • HARD

  • Syndromic surveillance


What to do

Resources

Meddrun

120 Mark I

30 Atropen 1 mg

30 Atropen 2 mg

250 Atropine 1mg vial

100 Midazolam 1 mg

50 Cyanide treatment

Chempack

EMSHospital

Mark 1 480

Atropine 900

Pralidoxime 2760

600 CANA 650

What to do


Toxic terrors1

Toxic Terrors

  • Poison Center

    • We’ve seen these poisonings

    • We’ve treated them

      • Not just read about them

    • We have had the CBRNE training

    • We have the guidelines


Toxic terrors2

Toxic Terrors

  • We will help you

    • Differential

    • Alternatives

    • Treatment guidelines

      • Follow patient-through

    • Discharge guidelines and follow-up recommendations

    • Resource allocation

    • Data collection

    • Required reporting

    • PPE and Cleanup recommendations

    • Workforce screening and surveillance recommendations


Poison center

Poison Center

  • 1-800-222-1222

  • Physician available 24/7

  • Multiple resources

  • AHLS training

  • Education


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