The Terrible Toxins: Chemical Terrorism

1. The Terrible Toxins: Chemical Terrorism Cynthia Aaron MD FACMT FACEP Medical Director, Michigan Regional Poison Control Center

2. 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

3. 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

4. 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

5. Toxic Terrorism • 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

6. 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

7. 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

8. 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

9. 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

10. Chemicals used by terrorists • Corrosives-alkali/acids • Metals (arsenic, mercury, thallium) • Cyanide • Rodenticides • Pesticides • “Poison gas” Montery Institute database 2002

11. 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

12. 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

13. 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

14. Dissemination

15. 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

16. 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

17. 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

18. Miosis 99% 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

19. 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

20. 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”

21. 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% HA 11% Throat pain 8% Dypsnea 5% Nausea 3% Dizziness 2.5% Nose pain 2%

22. 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

23. Sulfur mustard • Transparent yellow liquid • Impurities give it odor • Volatile • Persistent (days/weeks) • Lipophilic • Alkylating agent

24. Sulfur mustard • Local tissue damaging effects • Mucous membranes, lungs, eyes, skin • Systemic distribution • Systemic effects • Liver, kidneys, intestines, brain, hematopoietic

25. 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

26. Sulfur mustard • Decontaminate early-patient • Copious amounts water • Water soluble-can spread • Dry agents • Decontaminate late-caretakers

27. Toxic Terrors • Identification • Simultaneous large amount of people at one site • EASY • Delayed onset • HARD • Syndromic surveillance

28. 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

29. 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

30. 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

31. Poison Center • 1-800-222-1222 • Physician available 24/7 • Multiple resources • AHLS training • Education