ences 249 (2006) 50–54www.elsevier.com/locate/jns

Journal of the Neurological Sci

Weapons of mass destruction: Overview of the CBRNEs(Chemical, Biological, Radiological, Nuclear, and Explosives)

Leon D. Prockop ⁎

Department of Neurology, University of South Florida College of Medicine, Tampa, Florida, USA

Available online 21 August 2006

Abstract

The events of September 11, 2001, made citizens of the world acutely aware of disasters consequent to present-day terrorism. This is awar being waged for reasons obscure to many of its potential victims. The term “NBCs” was coined in reference to terrorist weapons of massdestruction, i.e., nuclear, biological and chemical. The currently accepted acronym is “CBRNE” which includes Chemical, Biological,Radiological, Nuclear, and Explosive weapons. Non-nuclear explosives are the most common terrorist weapon now in use. Nuclear andradiological weapons are beyond the scope of this publication, which focuses on the “CBEs”, i.e. chemical, biological and explosiveweapons.

Although neurologists will not be the first responders to CBEs, they must know about the neurological effects in order to providediagnosis and treatment to survivors. Neurological complications of chemical, biological and explosive weapons which have or may be usedby terrorists are reviewed by international experts in this publication. Management and treatment profiles are outlined.© 2006 Published by Elsevier B.V.

Keywords: Terrorism; Weapons of mass destruction; Nervous system damage; Nerve agents; Brain trauma; Bioterrorism

1. Introduction

Even though attempts to create terror among combatantsand civilians during times of war have been a part of humanbehavior since the beginning of recorded history, terrorism hasperhaps reached new heights in the past decade. The events ofSeptember 11, 2001, in NewYork City andWashington, D.C.,USA, forced citizensworldwide to focus on awar beingwagedin an unconventional manner. Rather than being a war foughtprimarily for territorial gain, as common in most previouswars, those events sought to attempt to promote the dominanceof concepts and beliefs, doing so in part by creating fear inindividuals and instability in societies.

The weapons of mass destruction (WMD) which terroristsmight use are nuclear, chemical, and biological, the so-calledNBCs. Non-nuclear explosives are now the most popularterrorist weapons, often in the context of suicide bombers.The acronym currently accepted is “CBRNE” referring toChemical, Biological, Radiological, Nuclear and Explosive

⁎ Tel.: +1 813 974 9915; fax: +1 813 974 7473.E-mail address: lprockop@hsc.usf.edu.

0022-510X/$ - see front matter © 2006 Published by Elsevier B.V.doi:10.1016/j.jns.2006.06.017

weapons. Nuclear and radiological weapons are not subjectsof this publication. Chemical, biological and non-nuclearexplosives can cause extensive nervous system damage and/or neurobehavioral effects upon survivors of an attack.

When such an attack occurs, neurologists will be calledupon to provide diagnosis and management of such damageand effects. Neurologists will not only be called upon to treatthose with specific nervous system diseases, e.g. epilepsyafter head injury caused by explosives, but also will be calledupon to evaluate and manage those who have not sufferedphysical or biochemical nervous system damage but whobelieve they have suffered such. The premise of thispublication is that worldwide neurologists who have littleor no experience with such nervous system damage andneurobehavioral effects should be educated. Therefore, thispublication reviews such damages and effects, sometimesproviding management and treatment information.

2. Discussion

Bloodletting was a well-accepted and the “prevailingpractice” of medical therapy for centuries, not ending until

Fig. 1. Cutaneous smallpox seen as a propensity to develop associatedencephalitis and/or a post encephalitic encephalitis.

51L.D. Prockop / Journal of the Neurological Sciences 249 (2006) 50–54

the early part of the nineteenth (19th) century [1]. Elaboratetheories were constructed to support its proposed efficacies.For example, the death of George Washington, who was thefirst President of the United States, was either hastened orcaused by bloodletting [2]. Present-day medical therapies aremainly humane and increasingly evidence-based. Medicalbloodletting is now rarely appropriate. Violent bloodlettingwas always and continues to be a common practice in otherareas of human activity, i.e. politics, fanatic religiosity,personal and national self-aggrandizement. Such violentbloodletting often occurs in the form of wars. Elaboratetheories are constructed to justify its use. Combatants oftensuffer death; however, non-combatants often lose their life'sblood. In survivors, extensive bodily trauma occurs, e.g. lostlimbs. Survivors often suffer psychological trauma as well,e.g. the so-called “post traumatic stress disorder (PTSD)”[3].Likewise, nervous system complications in the survivors ofwarfare are common including port-traumatic encephalo-pathy with associated dementia, seizures and behavioralchanges; cerebellar dysfunction; spinal cord injury; radicu-lopathies, peripheral neuropathies; and myelopathies [4–6].

Until recently, a term, the “NBCs”, was used to designateweapons of mass destruction (WMD) potentially available toterrorists [7]. The currently accepted acronym “CBRNE”;which includes Chemical, Biological, Radiological, Nuclearand Explosive weapons, acknowledges that the use ofdynamite and other non-nuclear explosives is the prevailingpractice of terrorist.

Although, the authors of this publication acknowledgethat nuclear and radiological events may occur, such eventsare beyond the publication's scope. The explosion of full-scale hydrogen bombs would cause immediate catastrophicloss of human life and destruction of physical structures aswell as widespread long-term illness, e.g. development ofcancer in survivors living at a distance from the explosioncenter. Those who do not die immediately but who sufferneurological effects because of high radiation exposure, e.g.400–500 rads, will die within hours or days of the event.

The effects of a so-called “dirty bomb” would have lessdramatic immediate loss of life and property. A “dirty bomb”or a Radiological Dispensed Device (RDD) is not the sameas an atomic bomb, which involves the splitting of atoms anda huge release of energy that produces the atomic mushroomcloud [8]. Instead, a dirty bomb is a mixture of explosiveswith radioactive powder or pellets. Radioactive materials arewidely used in hospitals, research facilities, industrialfacilities and construction sites. These radioactive materialsare used in diagnosis and treatment of diseases, sterilizingequipment, and inspecting welding seams. In the USA, over21,000 organizations are licensed to use such materials. Thevast majority of these sources are not useful for constructingan RDD. Furthermore, the extent of availability of suchmaterials to potential terrorists is not well-known. A dirtybomb cannot create an atomic blast. However, it usesdynamite or other explosives to scatter radioactive dust,smoke of other materials in order to cause radioactive

contamination. Such materials would probably not createenough radiation exposure to cause immediate severe illness,except to those very close to the blast site. The radioactivedust and smoke spread far away from the explosion site andcan be dangerous to physical health while creating wide-spread terror. The main immediate danger is from theexplosion, of which details are provided by Dr. MichaelFinkel in another section of the publication.

Dr. Michael Donaghy has expertly reviewed biologicalterrorism in this publication. Neurologists are most likelyto become involved in diagnosis and treatment ofbioterrorist's attacks utilizing: botulitum toxin with itscharacteristic descending paralysis, anthrax with its poten-tial for hemorrhagic meningitis, and Venezuelan equineencephalitis (Fig. 1).

Even though the terroristic use of mycotoxins has notbeen discussed in the lay media, e.g. the press and television,their potential use in low-level exposure with subsequentdevelopment of Parkinsonism is of special interest toneurologists. Juan Sanchez-Ramos, M.D., PhD. providesinsights into this prospect.

Neurological consequences of explosives are legion andinclude penetration injuries, “primary blast” injuries to thebrain and spinal cord, neurapraxis to receptor organs of theear; cerebral evisceration; contusions and concussions ofnervous tissue; peripheral nerve injury; and hypoxicencephalopathy secondary to primary injury to the chestwall and the heart. A cerebral and spinal column computedtomography (CT) analysis of injuries inflicted by missilesand explosives in 53 people during the war in the Republic ofCroatia from June through December 1992 has been reported[9] (Fig. 2). Multiple injuries complicate recovery because ofconcurrent problems with cognition affect, attention, mem-ory, and special sensory deficits. Chronic pain, dementia, andepilepsy will require neurologists to participate in manage-ment and treatment. Michael Finkel, M.D. provides expertinsight on these issues. The use of explosives evidenced ahighly dramatic and lethal effect in the World Trade events in

Fig. 2. Interhemispherical and hemispherical subdural hematoma andcerebral edema after a penetration head wound. Cerebral tissue waseviscerated through the large skull defect (exit wound).

52 L.D. Prockop / Journal of the Neurological Sciences 249 (2006) 50–54

New York City, USA, on 9/11/2001. (Fig. 3) However,terroristic explosive events have continued to occur in manycities worldwide, e.g. Istanbul, Madrid, and London tomention a few (Fig. 4).

Fig. 3. The explosive events of 9

The use of explosives has been the preferred terroristtechnique in recent years, often complicated by suicidebombings. Even though the toll of death and injury causedby terrorist's suicide bombings in the last several years isprobably unprecedented in history, suicide bombingsoccurred in World War II, e.g., during the Battle of Okinawain 1945 [10].

The use of chemical agents or toxic poisons, especiallynerve agents, is of special interest to neurologist because ofthe direct effects on the nervous system. Chemical agentswere used in World War I and were subsequently banned foruse in warfare. (Fig. 5). Whether that ban will be honored bypresent-day terrorists is not known. However, the regime ofSadam Hussein, former leader of Iraq, apparently used nerveagents while quelling political discontent among citizens ofIraq; thereby, causing significant mortality and morbidity. Itshould be remembered historically poisoning has been a wellfavored method in attempts to achieve political ends by theelimination of an individual seeking or already holding theposition of power sought by the perpetrator of the poisoning.As recently as 2004, Viktor Yuchenko was poisoned withDioxin, presumably in an attempt to inflict such terror in himthat he would withdraw as a candidate of the Presidency ofUkraine. He did not and is now President [11]. (Fig. 6) In this

/11/2001, New York, USA.

Fig. 4. The explosive event of 11/20/2003 in Istanbul, Turkey.

53L.D. Prockop / Journal of the Neurological Sciences 249 (2006) 50–54

publication, Nobuo Yanagisawa, M.D., PhD. Reminds usabout the Sarin experience in Japan in 1994. A terroristattack in Matsumoto left 7 dead and 260 injured. Ninemonths later, a second Sarin attack in a Tokyo subway left 11dead. However, some 5560 victims came to medicalattention concerned about injury much of which wasneuropsychiatric in nature. Dr. Yanagisawa and his collea-gues, H. Morita and T. Nakajimo provide us information

Fig. 5. Chemical events in World

about the acute toxicity and long term neurobehavioraleffects of these terroristic attacks.

Col. Kevin Cannard, M.D. of the Walter Reed ArmyMedical Center accurately describes the symptoms and signsof the nerve agents which may be used in chemical terrorism.These symptoms and signs are caused by their effect uponthe nervous system. Col. Cannard also provides protocols fordecontamination and treatment of victims of such exposures.

War I, Europe, 1914–1918.

Fig. 6. Viktor Yuchenko, President of Ukraine, before and after poisoning bythe use of Dioxin with its resultant choracne.

54 L.D. Prockop / Journal of the Neurological Sciences 249 (2006) 50–54

Even though neurologists will probably not be justresponders to such potential chemical events, they will becalled upon to provide diagnosis and treatment of survivors.Often, the clinical acumen of neurologists will be required toseparate those victims with neurological damage from thosewith predominantly neurobehavioral syndromes.

3. Conclusion

The NBCEs of terrorism may well occur in the future withresultant havoc upon civilian populations would-wide. Whatwill be the role of neurologists? The erudite statements madeby Dr. Michael Donaghy concerning biological weaponsalso apply with varying degree to chemical and explosiveweapons. At times these weapons will be deliveredsporadically or randomly into civilian populations withoutthe intention of causing somewhat limited medical/neurolo-gical disease, e.g. injury and death to scores of people in asubway explosion. However, the weapons will be used withits intention of paralyzing a society by creating widespreadterror amongst civilians. In this setting, physicians will have

complex demands to diagnose and treat disease not withintheir prior experience. They will be required to managephysical disease and dysfunction in a manner in whichprovides reassurance to those with psychological symptomscaused by the fear of exposure and disease. For neurologistsworld-wide, it will be taxing to separate those individualswith neurological sequelae of the CBEs from those with orwithout such sequelae but whose lives have been altered bythe terror intended by those terrorists. Neurologists, alongwith other health care professionals will treat those withneurological disease and those with neurobehavioral pro-blems. Therefore, neurologists should know the issuesinvolved, i.e. “Terrorism for the Neurologist.”

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