Preparing for the unthinkable
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Preparing for the Unthinkable. Respiratory Care and Gas Warfare Terrorism Scope of the threat and possible responses. N – B – C is not TV. Nuclear Biological (BW) Chemical (CW) B-N-I-C-E: biological, nuclear, incendiary, chemical, explosive. Introduction. History of the use of toxic gases

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Preparing for the unthinkable

Preparing for the Unthinkable

Respiratory Care and Gas Warfare Terrorism

Scope of the threat and possible responses

Prof. T. Johnson

N b c is not tv
N – B – C is not TV

  • Nuclear

  • Biological (BW)

  • Chemical (CW)

  • B-N-I-C-E: biological, nuclear, incendiary, chemical, explosive

Prof. T. Johnson


  • History of the use of toxic gases

  • The agents may be employed by terrorists

  • Pre-hospital response /Hospital response-Lessons Learned from Tokyo and the WTC Attack

  • 10 Conclusions

Prof. T. Johnson

The chemical weapons
The Chemical Weapons

  • What are the chemical agents?

  • How are they dispensed?

  • What are the characteristic of chemical warfare agents?

  • What symptomology do they present?

  • What immediate care must be rendered?

  • How does one protect the medical personnel?

Prof. T. Johnson

The tokyo attack timeline
The Tokyo Attack Timeline

  • March 20, 1995

Prof. T. Johnson

Topic one chemical agents
Topic One: Chemical Agents

  • Pulmonary agents: chlorine, phosgene, cyanide

  • Blister agents: Lewisite and the nitrogen mustard agents

  • Nerve Agents: Tabun, sarin and VX

  • Lachrymators: CN (Mace), CS

  • Insecticides: Malathion, parathion and sevin

Prof. T. Johnson

Topic two characteristics
Topic Two: Characteristics

  • Pulmonary Agents: asphyxia, mucosal edema and bronchorhea.

  • Blister Agents: Burn-like phenomenon affecting eyes, bronchi and skin

  • Nerve agents: nausea, fasiculations, rhinorrhea, bronchorrhea, sweating, drooling, diarrhea, loss of consciousness, flaccid paralysis, apnea

Prof. T. Johnson

Characteristic symptomology nerve gas
Characteristic Symptomology: Nerve Gas

  • Eyes: Miosis, tearing, conjunctival injection (pain, dim vision, blurred vision)

  • Nose: Rhinorrhea

  • Airway: Bronchoconstriction, bronchorrhea, dyspnea, cough

  • GI: Hypermotility, nausea, vomiting, diarrhea, cramps

  • Skeletal muscles: Fasciculations, twitching, paralysis, muscle weakness

  • CNS: High dose Loss of Consciousness, seizures, apnea; Low dose cognitive difficulties

  • Other: Salivation and diaphoresis

Prof. T. Johnson

Inhaled nerve gas vapor
Inhaled Nerve Gas Vapor

  • Mild: Miosis, rhinorrhea, dyspnea, weakness, blurred vision

  • Severe: as above with – Loss of consciousness, seizures and apnea – death

  • Onset: Within seconds to minutes of exposure

  • Treatment: Atropine and pralidoxime auto-injectable.

Prof. T. Johnson

Dermal conjunctival liquid exposure to nerve agents
Dermal/conjunctival/liquid Exposure to Nerve Agents

  • Mild: Local sweating and fasciculations

  • Moderate: Nausea, vomiting, diarrhea, weakness

  • Severe (as above plus): Loss of consciousness, seizures, apnea – death

  • Onset: 5 min to 18 hrs

  • Treatment: Atropine, diazepam and 2-PAM (2 pyridine-aldoxime-methiodide), ventilatory and cardiovascular support.

Prof. T. Johnson

Vesicants or blister agents
Vesicants or Blister Agents

  • Mustard gas vapor causes no pain on contact.

  • Onset: 4 to 8 hrs (range 2 to 24 hrs)

  • Initial/Mild: Erythema, periorbital edema, blurring, oro-nasal edema, hoarseness, non-productive cough

  • Late/Severe: Corneal damage, leukocytopenia, decreased RBC & platelets, sepsis, airway obstruction, atelectasis, sepsis, DIC, death

  • TX: Early skin decontamination, anti-lewisite, support care similar to burn management.

Prof. T. Johnson

Inhaled cyanide
Inhaled Cyanide

  • Severe: Brief period of hyperpnea, seizures, decreased breathing rate, arrhythmias, apnea – death

  • Mild: Nausea, vertigo, weakness, shortness of breath.

  • TX: Amyl nitrite by inhalation; sodium nitrite and sodium thiosulfate IV; assisted ventilation and oxygen

Prof. T. Johnson

Topic three care
Topic Three: Care

  • Early andGENTLE Skin decontamination

  • Pulmonary Agents: OXYGEN, amyl nitrate inhalation, IV sodium nitrate or sodium thiosulfate

  • Blister agents: Early and Gentle skin surface decontamination to include the eyes, anti-Lewsite for internal injury, & burn wound care

  • Nerve agents: Atropine sulfate, 2-Pam (2 pyridine-aldoxime-methiodide) and Valium (diazepam)

Prof. T. Johnson

Real life protect the care givers
Real Life – Protect the Care Givers

  • Military hospitals treating Iranian casualties of the Iran-Iraq War had casualties in hospital personnel

  • The Tokyo Experience: 10% of EMT, firefighters and police became casualties – none seriously; 110 hospital staff became casualties, 1 nurse required hospitalization.

Prof. T. Johnson

Lessons learned from tokyo
Lessons Learned from Tokyo

  • Decontamination of victims not accomplished.

  • Charting became improvised.

  • Communications became impossible by phone or page. (The WTC attack overloaded phones too.)

  • Misleading Initial Data: gas explosion, tear gas, etc. (Expect secondary casualties.)

  • Inadequate Pharmacological support in volume.

  • No transfer plan and failure of police to clear traffic.

Prof. T. Johnson

What worked
What Worked?

  • In-house hospital databases.

Prof. T. Johnson


New age of terrorism: individuals & cults

CW & BW are within the grasp of terrorists

CW & BW attacks overwhelm the healthcare system

Psychogenic casualties persist beyond the initial incident, even PTS in care givers.

“Hero Effect” results in casualties.

6. Medical staff is unfamiliar with these injuries.

7. HVAC and C level protection for staff.

8. Insufficient drug stocks.

9. Decontamination areas inadequacy.

10. Communication system will be overloaded.


Prof. T. Johnson

Lessons learned from the wtc

Each hospital worked with only its own staff.

NYC was divided into security zones.

Communications/Legal/Risk Management issues limited use of clinical volunteers.

Lessons Learned From the WTC

Prof. T. Johnson

What this means to you
What This Means to You

  • Respiratory Therapists are vital to the care of these victims and must don PPE early.

  • Respiratory Care is unprepared, under-educated and insufficiently cross-trained

  • Respiratory Therapists have a responsibility to know how to treat these victims.

  • Preparation, Anticipation, Recognition, Action-Plan Training Issues Must be addressed.

Prof. T. Johnson

Take home message
Take Home Message

  • Educate your people!

  • Contact your local office of Emergency Preparedness

  • Work with your Emergency Medical and Nursing staff to develop an action-plan.

  • Conduct disaster drills on all shifts.

  • Managers must be prepared with manpower, supplies and staff readiness education.

Prof. T. Johnson