Chemical Weapon Exposures Management in the ED Suj Sivaraman R3 Emergency Medicine McGill University

Chemical Weapon ExposuresChemical Weapon Exposures

Management in the EDManagement in the ED

Suj SivaramanSuj Sivaraman

R3 Emergency MedicineR3 Emergency Medicine

McGill UniversityMcGill University

October 23, 2002

50 Chechen rebels, storm 50 Chechen rebels, storm Moscow’s House of Culture Moscow’s House of Culture Theatre during a performance Theatre during a performance of Nord-Ost, taking 700 of Nord-Ost, taking 700 hostages. The rebels demand hostages. The rebels demand Russian withdrawal from Russian withdrawal from Chechnya, and threaten to kill Chechnya, and threaten to kill the hostages if demands are the hostages if demands are not met. not met.

TV footage from inside the TV footage from inside the shows that the rebels have shows that the rebels have explosives strapped to their explosives strapped to their bodies as well as throughout bodies as well as throughout the theatrethe theatre

October 26, 2002October 26, 2002

After three days of fruitless After three days of fruitless negotiations an unknown negotiations an unknown gas, meant to incapacitate gas, meant to incapacitate the rebels, is released in the rebels, is released in the theatre. Most of the the theatre. Most of the rebels and 116 hostages rebels and 116 hostages die.die.

What kind of gas was released? …What kind of gas was released? …

Chemical WeaponChemical Weapon

““A chemical substance which is A chemical substance which is intended for use in military intended for use in military operations to kill, seriously operations to kill, seriously injure or incapacitate people injure or incapacitate people because of it’s physiologic because of it’s physiologic effects”effects”NATO. Handbook on medical aspects of NBC defensive NATO. Handbook on medical aspects of NBC defensive operations (1996)operations (1996)

OverviewOverview

General Management PrinciplesGeneral Management Principles

Nerve AgentsNerve Agents

Pulmonary AgentsPulmonary Agents

VesicantsVesicants

Incapacitating AgentsIncapacitating Agents

Pre-Hospital CarePre-Hospital Care

Managing Hazardous Material Incidents. Managing Hazardous Material Incidents.

Agency for Toxic Substances and Disease Registry, Center for Agency for Toxic Substances and Disease Registry, Center for Disease Control, 2001Disease Control, 2001

Decontamination ZonesDecontamination Zones

Hot ZoneHot Zone– Respiratory Protection: Respiratory Protection:

Pressure-demand, self-Pressure-demand, self-containedcontained breathing breathing apparatus (SCBA) should apparatus (SCBA) should be used in all responsebe used in all response situations.situations.

– Skin Protection: Skin Protection: Chemical-Chemical-protective clothing should protective clothing should be wornbe worn when local and when local and systemic effects are systemic effects are unknown.unknown.

– Basic ABCsBasic ABCs

HAZMAT Suit Santa Clara Ca, Fire Dept.

Warm Zone Warm Zone (decontamination)(decontamination)– Victims exposed only to Victims exposed only to

gas or vapogas or vapouurs who rs who have no skin or eyehave no skin or eye irritation may be irritation may be transferred immediately transferred immediately to the Support Zone.to the Support Zone.

– All others undergo All others undergo basic decontaminationbasic decontamination

Emergency Response Decon Unit Union County, NJ

DecontaminationDecontamination Patients who are Patients who are

able and able and cooperative may cooperative may assist with theirassist with their own own decontamination. decontamination.

Remove and Remove and double-bag double-bag contaminatedcontaminated clothing and clothing and personal personal belongings.belongings.

Casualty Care research Center, Uniformed Services University, Bethesda, MD

Flush exposed or irritated skin Flush exposed or irritated skin and hair with plain waterand hair with plain water,, mild mild soap, soap, for 3 tofor 3 to 5 minutes.5 minutes.

Flush exposed or irritated eyes Flush exposed or irritated eyes with plain water or saline for atwith plain water or saline for at least 5 minutes. least 5 minutes. – Remove contact lenses if present Remove contact lenses if present

and easilyand easily removable without removable without additional trauma to the eye. additional trauma to the eye.

In cases of ingestion, do not In cases of ingestion, do not induceinduce emesis.emesis.– AdministerAdminister 4 to 84 to 8 ounces of water ounces of water

to dilute stomach contents if the to dilute stomach contents if the patient ispatient is alert. alert. HAZMAT Shower

Emergency Medical Products Inc.

Cold (support) zoneCold (support) zone– Be certain that victims have been Be certain that victims have been

decontaminated properly decontaminated properly – Victims who have undergoneVictims who have undergone

decontamination or who have been decontamination or who have been exposed only to gas orexposed only to gas or vapovapouur and who r and who have no evidence of skin or eye irritationhave no evidence of skin or eye irritation generally pose no serious risks of generally pose no serious risks of secondary contamination. secondary contamination.

– PPersonnel require no specializedersonnel require no specialized protective protective gear.gear.

ED Management PrinciplesED Management Principles

Emergency Room Procedures in Chemical HazardEmergency Room Procedures in Chemical Hazard EmergenciesEmergencies: : CDC National Centre for Environmental Health, November 2002 CDC National Centre for Environmental Health, November 2002

PreparationPreparation 1. Try to determine agent identity. 1. Try to determine agent identity. 2. Break out personal protection equipment, decon 2. Break out personal protection equipment, decon

supplies, antidotes, etc. supplies, antidotes, etc. 3. Don personal protective equipment3. Don personal protective equipment, s, set up hotline. et up hotline. 4. Clear and secure all areas which could become 4. Clear and secure all areas which could become

contaminated.contaminated. 5. Prepare to or secure hospital entrances and 5. Prepare to or secure hospital entrances and

grounds.grounds. 6. Notify local emergency management authorities if 6. Notify local emergency management authorities if

needed.needed. 77. If an organophosphate is involved, notify hospital . If an organophosphate is involved, notify hospital

pharmacy that large amounts of atropine and 2-PAM pharmacy that large amounts of atropine and 2-PAM may be needed.may be needed.

When the victim arrives …When the victim arrives … 88. Does chemical hazard exist? . Does chemical hazard exist?

– Known release/exposure (including late notification) Known release/exposure (including late notification) – Liquid on victim's skin or clothingLiquid on victim's skin or clothing– Symptoms in victim, EMTs, othersSymptoms in victim, EMTs, others– Odour (H, L, phosgene, chlorine) Odour (H, L, phosgene, chlorine)

99. Hold victim outside until preparations are completed. Hold victim outside until preparations are completed

1100. If patient is grossly contaminated OR if there is any suspicion . If patient is grossly contaminated OR if there is any suspicion of contamination, decontaminate patient before entry into buildingof contamination, decontaminate patient before entry into building in isolated decontamination areain isolated decontamination area

General measuresGeneral measures ABCsABCs Skin Exposure Skin Exposure

– If chemical burns are present, treat as thermal burns.If chemical burns are present, treat as thermal burns.

Eye ExposureEye Exposure– Ensure that adequate eye irrigation has been completed. Ensure that adequate eye irrigation has been completed. – TestTest visual acuity. visual acuity. – SSlit lamplit lamp– FFluorescein stain. luorescein stain. – Ophthalmology Ophthalmology for patients who have severe corneal for patients who have severe corneal

injuries.injuries.

Ingestion ExposureIngestion Exposure – Do not induce emesis. If alert administer activated charcoal.Do not induce emesis. If alert administer activated charcoal.– If a corrosive material is suspected, administer 4 to 8 ounces If a corrosive material is suspected, administer 4 to 8 ounces

ofof water do not givewater do not give activated charcoal. Consideractivated charcoal. Consider endoscopy endoscopy – If a large dose has been ingested and the patient’s condition If a large dose has been ingested and the patient’s condition

isis evaluated within 30 minutes after ingestion, consider evaluated within 30 minutes after ingestion, consider gastricgastric lavage.lavage.

Inhalation Exposure Inhalation Exposure – SSupplemental oxygen upplemental oxygen – BBronchodilatorsronchodilators if bronchospastic if bronchospastic

InvestigationsInvestigations CBC, glucose, and electrolyteCBC, glucose, and electrolytes, renal, LFTss, renal, LFTs ECGECG,, cardiac cardiac monitoringmonitoring Chest radiographyChest radiography, , pulse oximetrypulse oximetry, ABG if inhalation , ABG if inhalation

exposureexposure

Nerve Agents

Nerve AgentsNerve Agents Organophosphate compounds discovered in 1936 by Organophosphate compounds discovered in 1936 by

Gerhard Schrader (IG Farben, Germany) while Gerhard Schrader (IG Farben, Germany) while researching organophosphate pesticidesresearching organophosphate pesticides

Never used in WWII, but after the war the Soviets, Never used in WWII, but after the war the Soviets, U.K., and U.S. began pursuing nerve agent researchU.K., and U.S. began pursuing nerve agent research

1980-88: During Iran-Iraq War, Iraq thought to have 1980-88: During Iran-Iraq War, Iraq thought to have used nerve agents against Iran and Iraqi Kurdsused nerve agents against Iran and Iraqi Kurds

March 1995: Japanese Aum Shinrykio cult used March 1995: Japanese Aum Shinrykio cult used Sarin gas in Tokyo underground resulting in 5,500 Sarin gas in Tokyo underground resulting in 5,500 casualties and killing 12casualties and killing 12

Nerve AgentsNerve Agents The G-series:The G-series:

Taban (GA)Taban (GA)

Sarin (GB)Sarin (GB)

Soman (GD)Soman (GD)

The V-series:The V-series:VXVX

At room temp amber to colourless liquid state Weak fruity (G) to fishy (VX) smell G-series more volatile (sarin) than V-series V-series more toxic

Mechanism of actionMechanism of action

Normal Neurotransmission


Nerve agent effects

Signs and SymptomsSigns and Symptoms

AChE inhibitionAChE inhibition

Cholinergic hyperstimulationCholinergic hyperstimulation

Cholinergic toxidromeCholinergic toxidrome


Vapour Exposure

Eyes

Nose

Oral

Airways

Miosis, eye pain, headache,injection, lacrimation

Rhinorrhea

Salivation

Bronchoconstriction, bronchorrhea

Seconds to minutes after exposure


Liquid Exposure

Skin

GI

Localized sweating, fasciculations

Diarrhea, nausea, vomiting

10 minutes to 18 hours after exposure

Cardiac

Brady, heart block


Severe exposureCNS

Resp

GI/GU

LOC, seizures, fasciculations

Weakness, paralysis

Apnea

Bowel/bladder incontinence

Previously described vapour and liquid effects

plus …

Seconds to minutes (vapour)

Minutes to hours (liquid)

ManagementManagement

General managementGeneral management Specific antidotesSpecific antidotes

– AtropineAtropine– Pralidoxime Chloride Pralidoxime Chloride – DiazepamDiazepam– Pre -treatmentPre -treatment

AntidotesAntidotes

Atropine

2 mg IV/IM q5- 15 min to effect

Muscarinic action

-smooth muscle

-glandular epithelium

-cardiac muscle

AntidotesAntidotes

Pralidoxime Chloride

1 g IV over 15-30 min q 1 hr to effect

Nicotinic action

-skeletal muscle

Aging: Irreversible binding of nerve agent to AChE

Soman: 2 minutes

VX: 48 hours

AntidotesAntidotes

Diazepam

Seizure prophylaxis and treatment

10 mg IV at onset of severe symptoms regardless of seizure activity

MARK I kitMARK I kit

Atropine 2 mgAtropine 2 mgPralidoxime Cl 600 mgPralidoxime Cl 600 mg Issued to military personnelIssued to military personnel

Initial dosingInitial dosing Mild Sx (i.e. miosis and mild rhinorrhea)Mild Sx (i.e. miosis and mild rhinorrhea)

– 1 MARK I kit or equivalent1 MARK I kit or equivalent

OROR– No Rx and observe for 1 hr if vapour exposure No Rx and observe for 1 hr if vapour exposure

and mild symptoms and mild symptoms

Moderate SxModerate Sx– 1-2 MARK I kits or equivalent1-2 MARK I kits or equivalent

Severe SxSevere Sx– 3 MARK I kits or equivalent3 MARK I kits or equivalent– Diazepam auto-injector or equivalentDiazepam auto-injector or equivalent

Pre-TreatmentPre-TreatmentPyridostigmine

In animal studies shown to be effective, particularly against rapidly aging nerve agents (e.g. Soman)

No human evidence

FDA waiver for use by military during Gulf War but not currently approved for civilian use in Canada or U.S.

30 mg po q8h

? association with Gulf War Syndrome


Additional testsAdditional tests

RBC–AChERBC–AChE– Decreased in nerve agent poisonings Decreased in nerve agent poisonings

(cholinesterase inhibition)(cholinesterase inhibition)– Systemic effects correlate with decrease of Systemic effects correlate with decrease of

20-25% in levels20-25% in levels– Significant variability so treat the patient Significant variability so treat the patient

not the valuenot the value– Useful for documenting exposure and Useful for documenting exposure and

monitoring recoverymonitoring recovery

DispositionDisposition Patients exposed to nerve agent vapour who Patients exposed to nerve agent vapour who

have only miosishave only miosis and/or mild rhinorrhea when and/or mild rhinorrhea when they reach the medical facility dothey reach the medical facility do not need to not need to be admitted. be admitted.

All other patients who have hadAll other patients who have had exposure to exposure to nerve agent should be hospitalized nerve agent should be hospitalized for for observation.observation.

Pulmonary Agents

ChlorineChlorine First used as a First used as a

chemical weapon in chemical weapon in 1915 by Germany at 1915 by Germany at Ypres, BelgiumYpres, Belgium– Released 160 tons of ClReleased 160 tons of Cl22

when wind was when wind was favourable, resulting in favourable, resulting in 5,000 dead and 10,000 5,000 dead and 10,000 woundedwounded

Bruce Bairnsfather (1888-1959)

ChlorineChlorine Largest cause of major toxic release incidents Largest cause of major toxic release incidents

worldwideworldwide Between 1988-1992, 27,788 exposures to Between 1988-1992, 27,788 exposures to

chlorine in US chlorine in US Attractive as chemical weapon because of Attractive as chemical weapon because of

ease of availabilityease of availability

Chlorine Chlorine DescriptionDescription

– At room temperature, yellow-green gas with aAt room temperature, yellow-green gas with a pungent irritating odopungent irritating odouur. r.

– OOnly slightly soluble in water, but on contact withnly slightly soluble in water, but on contact with moisture it forms moisture it forms hypochlorous acidhypochlorous acid (HClO) and (HClO) and hydrochlorichydrochloric acid acid (HCl)(HCl).. HClO readily HClO readily decomposes, formingdecomposes, forming oxygen free radicals.oxygen free radicals.

– Not explosive but reacts or forms explosive Not explosive but reacts or forms explosive compounds with other substances (e.g. NHcompounds with other substances (e.g. NH33, , acetylene)acetylene)

Routes of exposureRoutes of exposure– InhalationInhalation– Skin/Eye contactSkin/Eye contact

PathophysiologyPathophysiology

Cl2 + H2O

2 HCl (hydrochoric acid)+

[O-]

HCl+

HOCl (hypochlorous acid)

Cellular injury via oxidation of

functional groups in cell components

HCl + [O-]

Clinical effectsClinical effects

Chlorine

Eyes

Upper airway

- Irritation, ocular burns

- Nasal,pharynx, tracheal inflammation

- Laryngospasm

May occur minutes to 24 hours after

exposure

Lower airway - Inflammation and loss of pulmonary capillary integrity

Pulmonary edema, hypoxia

Skin- Irritation, frostbite

Pre-hospital managementPre-hospital management General measuresGeneral measures Low risk of secondary contamination from Low risk of secondary contamination from

victims who have been exposed to gas, victims who have been exposed to gas, however liquid soaked skin or clothing may however liquid soaked skin or clothing may cause off-gassingcause off-gassing

No need for decontamination if no skin or eye No need for decontamination if no skin or eye irritationirritation

ED ManagementED Management Decontamination if not done previouslyDecontamination if not done previously Resp:Resp:

– Fluid restriction in patients with Fluid restriction in patients with pulmonary edema/ pulmonary edema/ ARDSARDS

– Beta agonists Beta agonists – If intubation needed perform under direct If intubation needed perform under direct

visualization (avoid blind techniques)visualization (avoid blind techniques)

Burns:Burns:– Treat as thermalTreat as thermal

DispositionDisposition 6 to 24 hours observation6 to 24 hours observation Asymptomatic patients or minor Sx (eyes, Asymptomatic patients or minor Sx (eyes,

cough) may be released with close follow-up cough) may be released with close follow-up and advice to return if respiratory symptoms and advice to return if respiratory symptoms recur recur

Hospitalization if:Hospitalization if:– Symptoms persist after 6 hours.Symptoms persist after 6 hours.– Patient was severely exposed.Patient was severely exposed.– Child was exposed.Child was exposed.– Patient has a history of underlying respiratory or Patient has a history of underlying respiratory or

cardiovascular disease.cardiovascular disease.

PhosgenePhosgene First synthesized in First synthesized in

1812 1812 First used in 1915 by First used in 1915 by

Germany at Ypres, Germany at Ypres, BelgiumBelgium

Attractive as chemical Attractive as chemical weapon because of weapon because of ease of availabilityease of availability

British soldiers at Somme, 1915

PhosgenePhosgeneDescriptionDescription

– At room temperature, colourless, nonflammable At room temperature, colourless, nonflammable gas with a suffocating odour like new mown hay.gas with a suffocating odour like new mown hay.

– Odour threshold is five times Odour threshold is five times higher higher thanthan permissible exposure levelpermissible exposure level

•i.e. Odour provides insufficient warning of toxic levels•Prolonged severe exposure more likely than with Cl2

–At < 8 degrees C, colorless fuming liquidAt < 8 degrees C, colorless fuming liquid–CCombustion product of manyombustion product of many household products household products that contain volatile organochlorinethat contain volatile organochlorine c compounds. ompounds. ((household solvents, paint removershousehold solvents, paint removers))

Routes of exposureRoutes of exposure–InhalationInhalation–Skin/Eye contactSkin/Eye contact


Phosgene

Directly reacts with amine, sulfhydryl, and alcohol groups in

cells

Hydrolyzes to HCL

Stimulates LT synthesis

Combines with and depletesglutathione stores


Phosgene

Eyes

Upper airway

- Irritation, ocular burns

- Nasal,pharynx, tracheal inflammation

- LaryngospasmMay occur minutes to

72 hours after exposure

Lower airway - Inflammation and loss of pulmonary capillary integrity


Precipitated by exertion

Skin- Irritation, frostbite



No need for decontamination if no skin or eye No need for decontamination if no skin or eye irritationirritation

Keep warm and quietKeep warm and quiet; any activity ; any activity subsequent to exposure may increase subsequent to exposure may increase likelihood of deathlikelihood of death

ED ManagementED Management Decontamination if not done previouslyDecontamination if not done previously RespResp::

– Fluid restriction in patients with Fluid restriction in patients with pulmonary edema/ pulmonary edema/ ARDSARDS

– Beta agonists Beta agonists – High dose inhaled/IV steroids for severe High dose inhaled/IV steroids for severe

inflammation or known severe exposureinflammation or known severe exposure– PEEPPEEP– If intubation needed perform under direct If intubation needed perform under direct

visualization (avoid blind techniques)visualization (avoid blind techniques) Burns:Burns:

– Treat as thermalTreat as thermal

Animal studies have shown some benefit withAnimal studies have shown some benefit with – NN-Acetylcystine-Acetylcystine– LT antagonists (monteleukast, zafirleukast)LT antagonists (monteleukast, zafirleukast)– NSAIDsNSAIDs– AminophyllineAminophylline

DispositionDisposition

All patients should be hospitalized for All patients should be hospitalized for 48 hours for observation48 hours for observation– Respiratory symptoms warrant ICU admissionRespiratory symptoms warrant ICU admission

Survival to 48 hours predicts likely Survival to 48 hours predicts likely recoveryrecovery

Vesicants

IntroductionIntroduction A group of chemical agents that burn and A group of chemical agents that burn and

blister tissue with which they come into blister tissue with which they come into contactcontact

Mustard gases Lewisite

Halogenated oximesSulfur mustard

Phosgene Oxime

Mustard gasesMustard gases A group of A group of sulphur-, sulphur-,

nitrogen-, and nitrogen-, and oxygen-based oxygen-based vesicant vesicant compounds compounds with similar chemical with similar chemical and biological and biological effects effects

First used by First used by Germany at Ypres, Germany at Ypres, Belgium in 1917Belgium in 1917

“Gassed” John Singer Sargent, 1918

Since then has been used extensively in Since then has been used extensively in numerous conflicts, including by Iraq in the numerous conflicts, including by Iraq in the 1980s1980s

Stored at 7 sites in the U.S.Stored at 7 sites in the U.S.

Sulfur MustardSulfur Mustard DescriptionDescription

– Typically a yellow to Typically a yellow to brown oily substance brown oily substance with a slight garlic or with a slight garlic or mustard odor.mustard odor.

– Individual odor threshold Individual odor threshold variabilityvariability

– Because of stable liquid Because of stable liquid form can be used coat form can be used coat (slime) surfaces (slime) surfaces

Routes of exposureRoutes of exposure– InhalationInhalation– Skin/Eye contactSkin/Eye contact– IngestionIngestion


Mustard

Alkylating effect leads to cross-linking and degradation of DNA,

protein, other molecules

Thus high turnover celllines most affected

Cholinergic stimulation

Clinical effectsClinical effects Distinguished by relative lack of symptoms Distinguished by relative lack of symptoms

immediately after exposureimmediately after exposure

Variable latent period depending upon Variable latent period depending upon severity, route of exposureseverity, route of exposure

Clinical effectsClinical effectsTissue Severity Clinical Effects Time

Eyes Mild Tearing, itching, burning 4 –12 h

Mod Erythema, lid edema, pain 3 – 6 h

Severe Corneal damage 1 – 2 h

Airways Mild Rhinorrhea, epistaxis hoarseness,cough

6 – 24 h

Severe SOB, productive cough 2 – 6 h

Skin Mild Erythema 2 – 24 h

Severe Vesication 2 – 24 h

Delayed clinical effectsDelayed clinical effects Leukopenia +/- pancytopenia can occur 3-5 Leukopenia +/- pancytopenia can occur 3-5

days post-exposuredays post-exposure



Decontaminate all casualties!Decontaminate all casualties!

Decontamination within 1 to 2 minutes is the only way to prevent tissue damage

ED ManagementED Management Decontamination if not done previouslyDecontamination if not done previously

– Shower, mild soap, Na hypochlorite solutionShower, mild soap, Na hypochlorite solution

RespResp::– Beta agonists prn Beta agonists prn – If intubation needed perform under direct If intubation needed perform under direct

visualization (avoid blind techniques)visualization (avoid blind techniques) Skin:Skin:

– BlistersBlisters• Drain large, tense blistersDrain large, tense blisters• Blister fluid is not vesicantBlister fluid is not vesicant

– EythemaEythema• Topical analgesiaTopical analgesia

Additional testsAdditional tests UUrine thiodiglycolrine thiodiglycol

DispositionDisposition Observation for 12 hoursObservation for 12 hours If asymptomatic or mild Sx can discharge with If asymptomatic or mild Sx can discharge with

close follow-upclose follow-up

LewisiteLewisite An arsenical vesicant, first synthesized in An arsenical vesicant, first synthesized in

19181918 No confirmed use in warfare, although No confirmed use in warfare, although

stockpiled by several nations stockpiled by several nations

LewisiteLewisite DescriptionDescription

– Pure Lewisite is an Pure Lewisite is an oily, colourless liquid, oily, colourless liquid, while impure while impure Lewisite is amber to Lewisite is amber to black with odour of black with odour of geraniums. geraniums.



Lewisite

Exact mechanism of cell damage not known. Inhibits enzymes with

thiol groups (e.g. alcohol dehydrogenase)

Clinical effectsClinical effects Absorbed 10 times faster than mustardsAbsorbed 10 times faster than mustards Immediate clinical effectsImmediate clinical effects More toxic than mustardMore toxic than mustard

– 14 ug of Lewisite can cause vesication14 ug of Lewisite can cause vesication


LewisiteEyes

- Irritation, severe ocular burns

Skin

-Immediate pain

-Erythema within 30 min

-Vesication within a few hours

GI

-Severe abdo pain, n, hematochezia if ingested

- Hepatic necrosis


Lewisite

Cardiovascular

Upper airway

- Nasal,pharyngeal, tracheal inflammation

- Laryngospasm

Lower airway

- Inflammation and loss of pulmonary capillary integrity


- Lewisite shock



Decontaminate all casualtiesDecontaminate all casualties

ED ManagementED Management Decontamination if not done previouslyDecontamination if not done previously

– Shower, mild soap, Na hypochlorite solutionShower, mild soap, Na hypochlorite solution

RespResp::– Beta agonists prn Beta agonists prn – If intubation needed perform under direct If intubation needed perform under direct

visualization (avoid blind techniques)visualization (avoid blind techniques) Skin:Skin:

– BlistersBlisters• Drain large, tense blistersDrain large, tense blisters• Blister fluid is not vesicantBlister fluid is not vesicant

– EythemaEythema• Topical analgesiaTopical analgesia

AntidotesAntidotes

British Anti-Lewisite (BAL)

3-5 mg/kg IM q4h x 4 doses

If severe exposure additional doses 2 mg/kg qd x 3-4 d

No effect on the local lesions of the skin, eyes

Binds to arsenic moiety of L and prevents/reverses binding to enzymes

Severe toxicity thus use only if shock or severe pulmonary injury

Alkalization of the urine stabilizes the Alkalization of the urine stabilizes the Dimercaprol-metalDimercaprol-metal complex and has been complex and has been proposed to protect the kidneys duringproposed to protect the kidneys during chelation therapy. chelation therapy.

If acute renal insufficiency develops,If acute renal insufficiency develops, hemodialysis should be considered to remove hemodialysis should be considered to remove the Dimercaprol-arsenicthe Dimercaprol-arsenic complex.complex.

Additional testsAdditional tests Urinary arsenic excretionUrinary arsenic excretion

DispositionDisposition Observation for 18-24 hoursObservation for 18-24 hours If asymptomatic or mild Sx can discharge with If asymptomatic or mild Sx can discharge with

close follow-upclose follow-up

Riot control agents

Riot control agentsRiot control agents IrritantsIrritants Hallucinogens (e.g. BZ)Hallucinogens (e.g. BZ) Vomiting agents (e.g. Adamsite)Vomiting agents (e.g. Adamsite)

IrritantsIrritants CNCN (Chloroacetophenone,Mace)(Chloroacetophenone,Mace)

– First RCAFirst RCA

CSCS (orthochlorobenzalomalonitrile) (orthochlorobenzalomalonitrile)

– More effective and less toxic than More effective and less toxic than CNCN

OCOC (oloresin capiscum, pepper spray) (oloresin capiscum, pepper spray)

– Currently used by most law Currently used by most law enforcement agenciesenforcement agencies

DescriptionDescription– All are solids and All are solids and

require dispersion require dispersion device to aerosolize device to aerosolize particles particles


Clinical effectsClinical effects Prolonged conjunctivitis, corneal opacities Prolonged conjunctivitis, corneal opacities

and iritis associated with CNand iritis associated with CN CS exposure under high humidity and CS exposure under high humidity and

temperature can lead to skin vesicationtemperature can lead to skin vesication Reports of permanent eye damage due to Reports of permanent eye damage due to

blast force from dispenserblast force from dispenser

Reports of death in literatureReports of death in literature– Associated with CNAssociated with CN

• Agent used in excess, and exposed refused to exit Agent used in excess, and exposed refused to exit confined spaceconfined space

– 1977 case report of 11 year old boy, 1977 case report of 11 year old boy, • Exposed to OC, initially asymptomatic for four hours, Exposed to OC, initially asymptomatic for four hours,

then upper airway obstruction and respiratory arrestthen upper airway obstruction and respiratory arrest• 1994 review by International Association of Police Chiefs 1994 review by International Association of Police Chiefs

concluded that OC was not a factor in any reviewed concluded that OC was not a factor in any reviewed deathsdeaths

– 18 of 22 associated with positional asphyxia exacerbated 18 of 22 associated with positional asphyxia exacerbated by drugs or underlying diseaseby drugs or underlying disease


Irritants

Eyes-Lacrimation, blepharospasm, injection

Skin

-Pain, burning, erythema

ENT

-Sneezing, salivation

Resp

-Cough, broncorrhea, subjective sensation of breathing difficulty

ManagementManagement DecontaminationDecontamination

– Wash exposed skin with mild soap, water +/- 6% Wash exposed skin with mild soap, water +/- 6% Na bicarbonate solutionNa bicarbonate solution

– Na hypochlorite solution can exacerbate skin Na hypochlorite solution can exacerbate skin lesionslesions

– Saline irrigation of exposed eyesSaline irrigation of exposed eyes Supportive managementSupportive management

– Effects generally self-limitingEffects generally self-limiting Most patients can be discharged, further Most patients can be discharged, further

inpatient monitoring and care if respiratory or inpatient monitoring and care if respiratory or severe symptomssevere symptoms

For the prize …For the prize …

“For a charm of powerful trouble,For a charm of powerful trouble,

Like a hellLike a hell broth boil and bubblebroth boil and bubble… …

Double, double, toil and trouble;Double, double, toil and trouble;

Fire burn and cauldron bubbleFire burn and cauldron bubble””

Macbeth, Act IV, Scene IMacbeth, Act IV, Scene I

William Shakespeare, 1623William Shakespeare, 1623

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Decisions in Emergency Medicine. 1999 Aug. 13 (12): 1-7. Janowsky DS. Central anticholinergics to treat nerve agent poisoning. Lancet. 2002 Jan 19; 359

(9302): 256-6. Karalliedde L, Gauci CA, Carter M. Chemical waepons. BMJ. 1991 Feb 23; 302 (6774): 474. Lockwood AH. Chemical and biological weapons. JAMA. 1991 Aug 7; 266 (5): 652 Murray VS, Volans GN. Management of injuries due to chemical weapons. BMJ. 1991 Jan 19;

302 (6769): 129-30 Sidell FR, Borak J. Chemical warfare agents: II. Nerve agents. Ann emerg Med. 1992 Jul;21

(7):865-71. Stone A. Chemical weapons. U.S. research on sedatives in combat sets off alarms. Science.

2002 Aug 2; 297 (5582): 764 Waeckerle JF. Domestic preparedness for events involving weapons of mass destruction.

JAMA. 2000 Jan 12; 283 (2): 252-4 Wright P. Injuries due to chemical weapons. BMJ. 1991 Jan 26; 302 (6770): 239

Online ResourcesOnline Resources Agency for Toxic Substances and Disease Registry (ATSDR) Managing

Hazardous Materials Series http://www.atsdr.cdc.gov A Review of the Scientific Literature as it Pertains to Gulf War Illnesses --

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American Academy of Clinical Toxicology http://www.clintox.org/ CDC National Center for Environmental Health http://www.cdc.gov/nceh/ The Chemical Weapons Convention (1997) & Organisation for the Prohibition of

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Documents

Chemical Weapon Exposures Management in the ED Suj Sivaraman R3 Emergency Medicine McGill University