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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


  • 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 victory. People disperse home

  • “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 victory. People disperse home

  • 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 victory. People disperse home

  • Clear history of use separate from warfare

    • Syria 2013 Sarin

    • Afghanistan 2013 Pesticides

    • England 2006 Polonium

    • Iraq 2006 Chlorine

    • Ukraine 2004 Dioxin

    • Maine 2003 Arsenic

    • Russia 2002 Fentanyl and other agents

    • 2001 US Mail Anthrax

    • 1995 Tokyo Sarin

    • 1994 Matsumoto Sarin

    • 1988 Halabja Iraq Sarin, mustard, CN

      and the list goes on

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


Toxic chemicals
Toxic chemicals victory. People disperse home

  • 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 victory. People disperse home

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


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

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

  • Corrosives-alkali/acids

  • Metals (arsenic, mercury, thallium)

  • Cyanide

  • Rodenticides

  • Pesticides

  • “Poison gas”

Montery Institute database 2002


Methods to disperse agents

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

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

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

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


Targeted group

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

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


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

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

Miosis 99%http://www.frontmed.co.nz/products/product-details/_cat2_/120/Military-Tactical/Emergency--Medical-Training/_prod_/Mass-Destruction-Casualty-Simulation-Kit?productlistPCMID=226

HA 75%

Dypsnea 63%

Nausea 60%

Eye pain 45%

Blurred 40%

Vision dark 38%

Vomiting 37%

Easy fatigue 37%

Cough 34%

Agitation 33%

Fasciculations 23%

Convulsions 2.7%

Tokyo


Points of comparison

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

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

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

  • 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%

HA 11%

Throat pain 8%

Dypsnea 5%

Nausea 3%

Dizziness 2.5%

Nose pain 2%


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

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

  • Transparent yellow liquid

    • Impurities give it odor

    • Volatile

    • Persistent (days/weeks)

    • Lipophilic

    • Alkylating agent


Sulfur mustard1
Sulfur mustardhttp://www.frontmed.co.nz/products/product-details/_cat2_/120/Military-Tactical/Emergency--Medical-Training/_prod_/Mass-Destruction-Casualty-Simulation-Kit?productlistPCMID=226

  • Local tissue damaging effects

    • Mucous membranes, lungs, eyes, skin

  • Systemic distribution

    • Systemic effects

      • Liver, kidneys, intestines, brain, hematopoietic


Sulfur mustard2
Sulfur mustardhttp://www.frontmed.co.nz/products/product-details/_cat2_/120/Military-Tactical/Emergency--Medical-Training/_prod_/Mass-Destruction-Casualty-Simulation-Kit?productlistPCMID=226

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

  • Decontaminate early-patient

    • Copious amounts water

      • Water soluble-can spread

    • Dry agents

  • Decontaminate late-caretakers


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

  • Identification

    • Simultaneous large amount of people at one site

      • EASY

    • Delayed onset

      • HARD

  • Syndromic surveillance


What to do

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

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

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

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

  • 1-800-222-1222

  • Physician available 24/7

  • Multiple resources

  • AHLS training

  • Education


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