Chemical / Radiological Principles CHEMICAL TERRORISM

Chemical / Radiological Principles

CHEMICAL TERRORISM

Chemical / Radiological Principles

OBJECTIVES• Learn how to perform a rapid assessment

of a nerve agent terrorism situation.

• Recognize characteristic signs and symptoms of nerve agent poisoning.

Chemical / Radiological Principles

OBJECTIVES

• Understand proper decontamination for nerve agent poisoning.

• Learn medical management of nerve agent exposed victims.

• Learn specific antidotes for nerve agent poisoning victims.

Chemical / Radiological Principles

• An unknown gas is released in the downtown rapid transit station. It is described as a thick mist, and was found in 5 separate stops. Thousands of commuters rapidly fled the stations to the streets. EMS transport is overwhelmed, and several local ED’s are unable to absorb the patients presenting by ambulance, car, taxi, and on foot.

• Many patients present to offices and local health departments.

ScenarioFriday, January 31 – 8:47 AM (Rush Hour)

Chemical / Radiological Principles

• One patient that presents to a local health clinic complains of tearing and runny nose. He also has mild shortness of breath. Mild wheeze is noted on exam.

• Ten other patients at the clinicare asymptomatic, but are very worried.

ScenarioFriday, January 31 – 10:02 AM

Chemical / Radiological Principles

• Public health officials confirm that the gas was Sarin, similar to the toxin used in the subway of Tokyo.

ScenarioFriday, January 31 – 10:27 AM

Chemical / Radiological Principles

• Has your staff been adequately trained about chemical weapons?

• Does your staff understand basic principles of decontamination?

• Who should your staff alert?

• Who will alert your staff in the event of a chemical terrorism event?

Things to Consider

Chemical / Radiological Principles

Nerve Agents

Chemical / Radiological Principles

• Liquids that disseminate in the vapor/aerosolized form

• Onset is abrupt (seconds to hours)• Designed to irritate, incapacitate, injure

or kill• Predominantly inhalational and dermal

threats• If death occurs, usually respiratory cause

Characteristics of Nerve Agents

Chemical / Radiological Principles

• Chemical incidents are obvious shortly after exposure.

• Biological agents will take days to cause symptoms.

• ONE patient can contaminate your facility

• First responders/health care providers are in the line of fire

Characteristics of Nerve Agents

Chemical / Radiological Principles

• First used as a weapon during WWI

• Most recent event - Japanese subway incident in 1995– Aum Shinrikyo cult released Sarin into 5

subway cars in downtown Tokyo– 12 deaths, hundreds injured, 5500 sought

care – 4,600 self-referred– 135 first responders were injured

History of Nerve Agent Weapons Use

Chemical / Radiological Principles

Shoko Asahara

Chemical / Radiological Principles

NERVE AGENTS

Chemical / Radiological Principles

• Military– Tabun (GA), Sarin (GB), Soman (GD), VX

• Commercial– Parathion, Sevin

• Therapeutic Drugs– Antilirium®– Prostigmine ®– Mestinon ®

General Characteristics

Chemical / Radiological Principles

• Effects of vapor - immediate

• Wide range of symptoms- Affects sensitive organs of the face

and respiratory system

- Over-stimulation of the central nervous system

General Characteristics

Chemical / Radiological Principles

AChACh

Normal Nerve Function

Chemical / Radiological Principles

AChACh

AChEAChE

Normal Nerve Function

Chemical / Radiological Principles

AChEAChE

AChACh GBGB

Nerve Agent Action

Chemical / Radiological Principles

SLUGBAM:• Salivation• Lacrimation• Urination• GI distress (Nausea, Vomiting, Diarrhea)• Bronchorrhea (Bradycardia, Bronchospasm)• Abdominal cramps• Miosis

Signs and SymptomsMuscarinic Effects

Chemical / Radiological Principles

How Bad Is This Stuff?

VX – LD50

Chemical / Radiological Principles

System Effect

Skeletal muscles TwitchingWeaknessFlaccidity

Cardiovascular HRBlood Pressure

CNS LOC, Seizures

Signs and Symptoms

Nicotinic Effects

Chemical / Radiological Principles

Exposure Symptom

Very small drop SweatingLocal twitch

Small drop NauseaVomitingDiarrhea

Drop LOCConvulsionsApneaFlaccid paralysis

Signs and Symptoms

Dermal Exposure Effects

Chemical / Radiological Principles

Exposure Symptom

Small amount MiosisSLUGBAMSOBChest tightness

Large amount LOCConvulsionsParalysisDeath

Signs and Symptoms

Vapor Exposure Effects

3

6

13

20

41

62

Signs and SymptomsEffect on pupil at x number of days

Chemical / Radiological Principles

• Clinical picture is key• Erythrocyte acetylcholinesterase activity level

- Amount of inhibition does not correlate with symptoms

• Various electronic and “paper” detectors are available - for HAZMAT use

Diagnosis

Chemical / Radiological Principles

GENERAL PATIENT MANAGEMENT

Chemical / Radiological Principles

Chemical / Radiological Principles

• PPE (mask, gloves and protective suit)

• Decontamination– Don’t let your setting become contaminated

• ABC’s • Communicate with public health officials • Poison Control Center (800 222-1222)• Antidotes where appropriate

General Management

Chemical / Radiological Principles

• Soap and Water

• Hypochlorite Solution– 0.5% for skin

• 6 oz calcium hypochlorite in 5 gallons water

– 5.0% for equipment• 48 oz calcium hypochlorite in 5 gallons water

Prehospital Management

Chemical / Radiological Principles

• Adult atropine dose: “enough”• Give atropine regardless of heart rate• Pediatric Considerations

– 0.01mg/kg

• Atropine used until endpoint achieved (resolution of secretions)

Treatment

Chemical / Radiological Principles

• Atropine - Blocks the effects of neurotransmitter

• 2-PAMCl (Pralidoxime)

- Removes nerve agent from the enzyme

• Military Autoinjector– MARK I

Antidote

AChEAChE 2-PAMCl

Nerve AgentNerve Agent

Chemical / Radiological Principles

Name Synonym Aging T1/2

Sarin GB ~5 hours

Soman GD ~2 min

Tabun GA >40 hours

VX None >40 hours

“Aging”

Chemical / Radiological Principles

Nerve Agent Questions

Chemical / Radiological Principles

What was the public health lesson learned from the 1995 Sarin terrorists attack in the subway system of Tokyo, Japan?

a. This bioterrorist attack could only occur in a large city with an enclosed underground subway system.

b. The walking wounded and hysterical patients often overload the medical system

c. Religious cults should be placed under strict federal surveillance

d. Ample supplies of the antidotes are readily available

Question #1

Chemical / Radiological Principles

In the acute phase of poisoning, one of the consistent findings that differentiates Sarin poisoning from hysteria is:

a. Cholinesterase enzyme blood levels b. Garlic smell on victims c. Pinpoint pupils d. Tachycardia

Question #2

Chemical / Radiological Principles

Based on past experience, which of the hospital supplies/equipment below is most likely to run out after a mass casualty exposure to Sarin gas?

a. Ventilatorsb. Personal Protective Equipment c. Hemodialysis machinesd. Atropine

Question #3

Chemical / Radiological Principles

This completes the current presentation.