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Weapons of Mass Weapons of Mass DestructionDestruction
Rosen Chapt 195Rosen Chapt 195
May 17, 2007May 17, 2007
Roy Seitz, M.D.Roy Seitz, M.D.
slides byslides by
Scott Gunderson PGY-3Scott Gunderson PGY-3
Nuclear & Nuclear & Radiological Radiological
EventsEvents
Potential Nuclear/Radiological Potential Nuclear/Radiological Hazards in the U.S.Hazards in the U.S.
Simple Radiological DeviceSimple Radiological Device
““Dirty” Conventional Bomb Dirty” Conventional Bomb
Improvised Nuclear Device (IND)Improvised Nuclear Device (IND)
1kT “Suitcase Nuke”1kT “Suitcase Nuke”
Ballistic Missile AttackBallistic Missile Attack
250 kT Nuclear Weapon – “City Killer”250 kT Nuclear Weapon – “City Killer”
Radiation DispersalRadiation Dispersal
““Dirty bombs”Dirty bombs”Low level Low level contaminationcontaminationAcute radiation Acute radiation casualties are casualties are unlikelyunlikelyDecontamination Decontamination and clean up are and clean up are main issuesmain issues
Texas Motor SpeedwayTexas Motor SpeedwayExercise, November 2004Exercise, November 2004
Three critical gaps identified:Three critical gaps identified: Casualty / Patient TriageCasualty / Patient Triage
Medical Decontamination (Med Decon)Medical Decontamination (Med Decon)
Personal Protective Equipment (PPE)Personal Protective Equipment (PPE)
“We may have lost up to 100 one-kiloton suitcase sized nuclear bombs”
-Alexander Lebed
(Former) Chief, National Security, USSR
Diversion of Nuclear WeaponsDiversion of Nuclear Weapons
Energy PartitionEnergy PartitionEnergy PartitionEnergy Partition
Initial Radiation
5%
Thermal 35%
Blast 50%
Fallout10%
Initial Radiation
5%
Thermal 35%
Blast 50%
Fallout10%
Standard Fission / FusionStandard Fission / FusionStandard Fission / FusionStandard Fission / Fusion
AFRRI, AFRRI, Medical Effects of Nuclear WeaponsMedical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990., “Blast and Thermal Effects” Lecture, 1990.
Scenario: Washington Scenario: Washington MallMall
AFRRI, AFRRI, Medical Effects of Nuclear WeaponsMedical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990., “Blast and Thermal Effects” Lecture, 1990.
Effective Range For Thermal Effective Range For Thermal EnergyEnergy
1 kT Weapon1 kT Weapon
Effective Range For Thermal Effective Range For Thermal EnergyEnergy
1 kT Weapon1 kT Weapon
AFRRI, AFRRI, Medical Effects of Nuclear WeaponsMedical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990., “Blast and Thermal Effects” Lecture, 1990.
AFRRI, AFRRI, Medical Effects of Nuclear WeaponsMedical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990., “Blast and Thermal Effects” Lecture, 1990.
Atlanta SSE Med Wind 250Kton FatalitiesAtlanta SSE Med Wind 250Kton Fatalities
Atlanta 250 kiloton SSE windAtlanta 250 kiloton SSE wind 7mph7mph
Mortality Probability 3.9m Affected
Red 90% Dark Blue 40%
Lt Brown 80% Lt Purple 30%
Yellow 70% Dk Purple 20%
Green 60% Dk Pink 10%
Pale Blue 50% Lt Pink 1%
New York New York City – 250 City – 250 kT Nuclear kT Nuclear DetonationDetonation
What is Fallout?What is Fallout?What is Fallout?What is Fallout?
A complex mixture of over 200 different A complex mixture of over 200 different isotopes of 36 elementsisotopes of 36 elements
2 oz of fission products formed for each kT of 2 oz of fission products formed for each kT of yield.yield.
Size < 1 micron to several mm.Size < 1 micron to several mm.
A complex mixture of over 200 different A complex mixture of over 200 different isotopes of 36 elementsisotopes of 36 elements
2 oz of fission products formed for each kT of 2 oz of fission products formed for each kT of yield.yield.
Size < 1 micron to several mm.Size < 1 micron to several mm.
Early FalloutEarly FalloutEarly FalloutEarly FalloutReaches the ground during the first 24 hours Reaches the ground during the first 24 hours after detonationafter detonation
Early fallout = 50-70% of total radioactivityEarly fallout = 50-70% of total radioactivity
Highest degree of fallout risk Highest degree of fallout risk
7:10 Rule for estimating exposure7:10 Rule for estimating exposure
HoursHours 11 7 7 49 49
Gy/hr 1 0.1 Gy/hr 1 0.1 0.01 0.01
Reaches the ground during the first 24 hours Reaches the ground during the first 24 hours after detonationafter detonation
Early fallout = 50-70% of total radioactivityEarly fallout = 50-70% of total radioactivity
Highest degree of fallout risk Highest degree of fallout risk
7:10 Rule for estimating exposure7:10 Rule for estimating exposure
HoursHours 11 7 7 49 49
Gy/hr 1 0.1 Gy/hr 1 0.1 0.01 0.01
Delayed FalloutDelayed FalloutDelayed FalloutDelayed Fallout
Arrives after 1Arrives after 1stst day day
Very fine / invisible particles Very fine / invisible particles Settle in very low concentrations over most of the earth’s surfaceSettle in very low concentrations over most of the earth’s surface
40% of total radioactivity40% of total radioactivity
Much lower degree of risk relative to early falloutMuch lower degree of risk relative to early fallout
Arrives after 1Arrives after 1stst day day
Very fine / invisible particles Very fine / invisible particles Settle in very low concentrations over most of the earth’s surfaceSettle in very low concentrations over most of the earth’s surface
40% of total radioactivity40% of total radioactivity
Much lower degree of risk relative to early falloutMuch lower degree of risk relative to early fallout
AlphaAlpha
BetaBeta
GammaGamma
1 m Concrete1 m Concrete
NeutronNeutron
Ionizing RadiationIonizing RadiationAny Radiation Consisting of Directly or Indirectly Ionizing Particles or PhotonsAny Radiation Consisting of Directly or Indirectly Ionizing Particles or Photons
Keys to Limiting ExposureKeys to Limiting ExposureShielding Shielding Dense objects limit the amount of radiation that Dense objects limit the amount of radiation that
can get to youcan get to you
Distance Distance Dose decreases rapidlyDose decreases rapidly as you move awayas you move away from the sourcefrom the source
TimeTime Minimizing time spent in proximity to the source Minimizing time spent in proximity to the source
is importantis important
500 R/hr
125
123Feet
5555
Radiation InjuryRadiation Injury
Chemical Damage
Free Radicals
10-10 Seconds
1. Proteins2. Membrane3. DNA
Cellular Damage
Tissue damage & Loss of organ
function
Hours to years
OrganDamage
Seconds to hours
Distribution of Injuries in aDistribution of Injuries in aNuclear DetonationNuclear Detonation
Distribution of Injuries in aDistribution of Injuries in aNuclear DetonationNuclear Detonation
Burns + Irradiation 40%
Wounds < 5%
Burns + Wounds + Irradiation
20%
Irradiation 15 - 20%
Burns 15 - 20%
Wounds + Irradiation
5%
Wounds + Burns
5%
Burns + Irradiation 40%
Wounds < 5%
Burns + Wounds + Irradiation
20%
Irradiation 15 - 20%
Burns 15 - 20%
Wounds + Irradiation
5%
Wounds + Burns
5%Single Injuries
(30% - 40%)Single Injuries
(30% - 40%)
Combined Injuries(65% - 70%)
Combined Injuries(65% - 70%)
Data from Walker RI, Cerveny TJ Eds., Data from Walker RI, Cerveny TJ Eds., Medical Consequences of Nuclear Warfare,Medical Consequences of Nuclear Warfare, TMM Publications, Falls Church, 1989. p 11. TMM Publications, Falls Church, 1989. p 11.
HemogramHemogram(300 cGy TBI Exposure)(300 cGy TBI Exposure)
HemogramHemogram(300 cGy TBI Exposure)(300 cGy TBI Exposure)
Andrews Lymphocyte NomogramAndrews Lymphocyte NomogramAndrews Lymphocyte NomogramAndrews Lymphocyte Nomogram
Absolute Lymphocyte Absolute Lymphocyte Count over 48 hoursCount over 48 hours
Confirms Significant Confirms Significant Radiation ExposureRadiation Exposure
From From Andrews GA, Auxier JA, Lushbaugh CC: The Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels Management of Persons Exposed to High Levels of Radiation. of Radiation. In In Personal Dosimetry for Radiation Personal Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Accidents. Vienna, International Atomic Energy Agency, 1965, pp 3- 16Agency, 1965, pp 3- 16
From From Andrews GA, Auxier JA, Lushbaugh CC: The Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels Management of Persons Exposed to High Levels of Radiation. of Radiation. In In Personal Dosimetry for Radiation Personal Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Accidents. Vienna, International Atomic Energy Agency, 1965, pp 3- 16Agency, 1965, pp 3- 16
Primary Treatment StrategyPrimary Treatment StrategyTreat life threatening trauma firstTreat life threatening trauma firstRemove clothing / DecontaminateRemove clothing / DecontaminateTreat radiation effectsTreat radiation effects Burn careBurn care Pharmaceutical therapiesPharmaceutical therapies
If surgery is neededIf surgery is needed first 1-2 days first 1-2 days OROR 50 days post-exposure50 days post-exposure
Decontamination Decontamination EquipmentEquipment
Decontamination Decontamination EquipmentEquipment
Hospital Surgical Gown (waterproof)Hospital Surgical Gown (waterproof)
Cap, Face Shield, Booties (waterproof)Cap, Face Shield, Booties (waterproof)
Double Gloves (inner layer taped)Double Gloves (inner layer taped)
DrapesDrapes
Plastic BagsPlastic Bags
Butcher PaperButcher Paper
Large Garbage CansLarge Garbage Cans
Radiation Signs and TapeRadiation Signs and Tape
Hospital Surgical Gown (waterproof)Hospital Surgical Gown (waterproof)
Cap, Face Shield, Booties (waterproof)Cap, Face Shield, Booties (waterproof)
Double Gloves (inner layer taped)Double Gloves (inner layer taped)
DrapesDrapes
Plastic BagsPlastic Bags
Butcher PaperButcher Paper
Large Garbage CansLarge Garbage Cans
Radiation Signs and TapeRadiation Signs and Tape
Decon AgentsDecon AgentsDecon AgentsDecon Agents
Dry RemovalDry Removal Disrobing is 80% effectiveDisrobing is 80% effective
Soap / Shampoo & WaterSoap / Shampoo & Water
Others ??Others ??
Dry RemovalDry Removal Disrobing is 80% effectiveDisrobing is 80% effective
Soap / Shampoo & WaterSoap / Shampoo & Water
Others ??Others ??
Nuclear SummaryNuclear SummaryNuclear & Radiological Devices Nuclear & Radiological Devices Lots of trauma and burn injuriesLots of trauma and burn injuries ARS and cancersARS and cancers
Care Issues Care Issues Bed Capacity / AvailabilityBed Capacity / Availability Burn & Trauma careBurn & Trauma care Decontamination Decontamination AntidotesAntidotes
Need for extensive planningNeed for extensive planning
Biological Biological WeaponsWeapons
Definition of BioterrorismDefinition of Bioterrorism
Cause harm to humansCause harm to humans
Influence government conductInfluence government conduct
Intimidate or coerce a civilian populationIntimidate or coerce a civilian population
Intentional use of pathogen or bacterial product Intentional use of pathogen or bacterial product to:to:
Bioterrorism Release TypesBioterrorism Release Types
Overt ReleaseOvert Release Notice of release providedNotice of release provided May contain a threatMay contain a threat Designed to create panic or fearDesigned to create panic or fear White powder hoaxesWhite powder hoaxes May be hoax or credible threatMay be hoax or credible threat
Covert ReleaseCovert Release No notice or threatNo notice or threat Difficult to detectDifficult to detect
Biological Biological Agent OverviewAgent Overview
AnthraxAnthrax
Bacillus anthracisBacillus anthracis
Anthrax- GeneralAnthrax- GeneralEndemic in animals worldwide with Endemic in animals worldwide with occasional human cases (usually occasional human cases (usually cutaneous)cutaneous)
Spores used for bioattackSpores used for bioattack Aerosolized directly or sent in Aerosolized directly or sent in
mail/packagesmail/packages
Three formsThree forms Cutaneous, Inhalation, GICutaneous, Inhalation, GI
Anthrax – Clinical FeaturesAnthrax – Clinical Features
InhalationInhalation Incubation: 2-43 days (may be longer)Incubation: 2-43 days (may be longer) Prodrome Prodrome
fevers, malaise, dry cough, chest pain, fevers, malaise, dry cough, chest pain, dyspnea, myalgiadyspnea, myalgia
Abrupt onset of fulminant illnessAbrupt onset of fulminant illness Widened mediastinum, pleural effusions; Widened mediastinum, pleural effusions;
meningitis in ~50%meningitis in ~50% Actual pneumonia uncommonActual pneumonia uncommon
Inhalational anthrax—US index case
Anthrax – Clinical FeaturesAnthrax – Clinical Features
CutaneousCutaneous Incubation: 1 to 7days (may be up to 12 days)Incubation: 1 to 7days (may be up to 12 days) Erythematous papule Erythematous papule ulcer ulcer characteristic characteristic
black eschar with surrounding erythema and black eschar with surrounding erythema and edemaedema
Regional adenopathy and systemic symptoms Regional adenopathy and systemic symptoms (e.g., fever, malaise) may develop(e.g., fever, malaise) may develop
Cutaneous AnthraxCutaneous Anthrax
Anthrax – Clinical FeaturesAnthrax – Clinical Features
GastrointestinalGastrointestinal Incubation period 1-7 daysIncubation period 1-7 days Not likely after a bioattackNot likely after a bioattack Presents as febrile illness with bloody diarrheaPresents as febrile illness with bloody diarrhea
Anthrax DiagnosisAnthrax DiagnosisBlood cultures Blood cultures usually positive in <24husually positive in <24h
Gram stain/Dx of pleural fluid or CSFGram stain/Dx of pleural fluid or CSF
Sputum is usually NOT positive by stain/cultureSputum is usually NOT positive by stain/culture
Fever and widened mediastinum on CXR/CT very Fever and widened mediastinum on CXR/CT very suggestivesuggestive
Cutaneous diseaseCutaneous disease culture fluid from under escharculture fluid from under eschar
Nasal swabs are a poor testNasal swabs are a poor test
Anthrax in CSF—US index case
Anthrax - TreatmentAnthrax - Treatment
Ciprofloxacin 400 mg IV q12hCiprofloxacin 400 mg IV q12h 10-15 mg/kg for children 10-15 mg/kg for children other fluoroquinolones probably also effectiveother fluoroquinolones probably also effective
OROR
Doxycycline 100 mg IV q12hDoxycycline 100 mg IV q12h 2.2 mg/kg for children2.2 mg/kg for children
PLUSPLUS
1 or 2 additional antibiotics1 or 2 additional antibiotics (clindamycin, rifampin, vancomycin, penicillin, (clindamycin, rifampin, vancomycin, penicillin,
chloramphenicol, imipenem, clarithromycin)chloramphenicol, imipenem, clarithromycin)
Switch to oral therapy when clinically Switch to oral therapy when clinically appropriateappropriate 60 days therapy (or until third dose vaccine)60 days therapy (or until third dose vaccine) ciprofloxacin 500 mg PO BID orciprofloxacin 500 mg PO BID or doxycycline 100 mg PO BIDdoxycycline 100 mg PO BID
Anthrax - TreatmentAnthrax - Treatment
Prophylaxis and Infection Prophylaxis and Infection ControlControl
ProphylaxisProphylaxis Ciprofloxacin 500 mg PO BID (10-15 mg/kg for Ciprofloxacin 500 mg PO BID (10-15 mg/kg for
children )children )
oror Doxycycline 100 mg PO BID (2.2 mg/kg for children)Doxycycline 100 mg PO BID (2.2 mg/kg for children) Continue for 60 days (? 100 days)Continue for 60 days (? 100 days) Vaccine available for DOD forcesVaccine available for DOD forces
Infection ControlInfection Control Standard barrier precautions are neededStandard barrier precautions are needed
17
VaccineVaccine
PlaguePlague
Yersinia pestisYersinia pestis
Yersinia pestis Yersinia pestis Source: www.cdc.govSource: www.cdc.gov
Plague - GeneralPlague - GeneralEndemic in animals many parts of the worldEndemic in animals many parts of the world Including prairie dogs in the southwestern usIncluding prairie dogs in the southwestern us
High potential as a BT agent High potential as a BT agent
Endemic form Endemic form Spread to humans via a flea vector Spread to humans via a flea vector Bubonic form of the diseaseBubonic form of the disease
BioattackBioattack Most likely aerosolizedMost likely aerosolized Pneumonic plaguePneumonic plague
Plague – Clinical FeaturesPlague – Clinical Features
Following BioattackFollowing Bioattack 1-6 day incubation1-6 day incubation Abrupt onset Abrupt onset
High feverHigh fever
Chills, malaiseChills, malaise
Cough with bloody sputumCough with bloody sputum
SepsisSepsis Severe rapidly progressive pneumoniaSevere rapidly progressive pneumonia
BuboesBuboes
Bubonic PlagueBubonic Plague
Source: www.cdc.govSource: www.cdc.gov
Plague - DiagnosisPlague - DiagnosisCXR with patchy infiltratesCXR with patchy infiltrates
Culture of blood and sputumCulture of blood and sputum Need to inform the laboratory if you Need to inform the laboratory if you
suspect plaguesuspect plague
Gram stain may show characteristic “safety-Gram stain may show characteristic “safety-pin” bipolar stainingpin” bipolar staining
Yersinia pestis in blood
Source: www.cdc.govSource: www.cdc.gov
PlaguePlague
Plague pneumonia
Plague - TreatmentPlague - TreatmentPreferredPreferred
StreptomycinStreptomycin 1 g IM q12h 1 g IM q12h 15 mg/kg/dose for children15 mg/kg/dose for children Avoid in pregnant womenAvoid in pregnant women
GentamicinGentamicin 5 mg /kg IM or IV qd 5 mg /kg IM or IV qd or 2 mg/kg load the 1.7 mg/kg q8hor 2 mg/kg load the 1.7 mg/kg q8h for children use 2.5 mg/kg q8hfor children use 2.5 mg/kg q8h
AlternativeAlternativeDoxycycline Doxycycline 100 mg IV q12h100 mg IV q12h
2.2 mg/kg/dose q12h for children2.2 mg/kg/dose q12h for children
Ciprofloxacin Ciprofloxacin 400 mg IV q12h 400 mg IV q12h other fluoroquinolones probably effectiveother fluoroquinolones probably effective for children 15 mg/kg/dose q12hfor children 15 mg/kg/dose q12h
Plague - Infection ControlPlague - Infection Control
ProphylaxisProphylaxisDoxycycline 100 mg PO bidDoxycycline 100 mg PO bid 2.2 mg/kg for children2.2 mg/kg for children
Ciprofloxacin 500 mg PO bidCiprofloxacin 500 mg PO bid 20 mg/kg for children20 mg/kg for children other fluoroquinolones probably effectiveother fluoroquinolones probably effective
Treat for 7 daysTreat for 7 days
IsolationIsolationDroplet precautionsDroplet precautions
SmallpoxSmallpox
Source: www.cdc.govSource: www.cdc.gov
Smallpox - GeneralSmallpox - GeneralOne of the deadliest disease knownOne of the deadliest disease known Mortality rate of 30%Mortality rate of 30%
US stopped vaccinating in 1972US stopped vaccinating in 1972
Declared eradicated by WHODeclared eradicated by WHO 19801980
Bioattack Bioattack aerosolized virus or by exposure to purposefully aerosolized virus or by exposure to purposefully
infected terroristsinfected terrorists
Smallpox - Clinical FeaturesSmallpox - Clinical FeaturesIncubation periodIncubation period 7-17 day (average 12d)7-17 day (average 12d)
Severe prodromeSevere prodrome 2-3 day of fever, severe myalgias, prostration, occ. n/v, 2-3 day of fever, severe myalgias, prostration, occ. n/v,
deleriumdelerium 10% with light facial erythematous rash10% with light facial erythematous rash
Distinctive rash Distinctive rash initially on face and extremities initially on face and extremities including palms and solesincluding palms and soles spreads to trunk spreads to trunk
Small Pox - Clinical FeaturesSmall Pox - Clinical Features
Rash Rash macules macules papules papules vesicles vesicles pustules pustules unlike chicken pox, lesions don’t appear in “crops”unlike chicken pox, lesions don’t appear in “crops”
All lesions in area same stage of developmentAll lesions in area same stage of development
Lesions are firm, deep, frequently umbilicatedLesions are firm, deep, frequently umbilicated
Rash scabs over in 1-2 weeksRash scabs over in 1-2 weeks scars after scabs separatescars after scabs separate
SmallpoxSmallpoxSource: www.cdc.govSource: www.cdc.gov
Smallpox vs. ChickenpoxSmallpox vs. Chickenpox
ChickenpoxChickenpox
SmallpoxSmallpoxSource: www.cdc.govSource: www.cdc.gov
Smallpox DiagnosisSmallpox Diagnosis
Clinical recognition essentialClinical recognition essential
All patients with disseminated vesicular/pustular rash All patients with disseminated vesicular/pustular rash should be screenedshould be screened
Notify public health authorities on clinical Notify public health authorities on clinical suspicion alone, suspicion alone, beforebefore diagnosis is confirmed diagnosis is confirmed
Confirmatory tests available at CDCConfirmatory tests available at CDC
SmallpoxSmallpox
Source: www.cdc.govSource: www.cdc.gov
SmallpoxSmallpoxThe main diagnostic tool for smallpoxThe main diagnostic tool for smallpox
Source: www.cdc.govSource: www.cdc.gov
is the history and physical!is the history and physical!
Smallpox - TreatmentSmallpox - TreatmentVaccinationVaccination in the early stages of diseasein the early stages of disease
Supportive careSupportive care Penicillinase-resistant antibiotics (for secondary Penicillinase-resistant antibiotics (for secondary
infection)infection) Daily eye rinsing Daily eye rinsing Adequate hydration and nutritionAdequate hydration and nutrition
No specific therapy has been FDA approved.No specific therapy has been FDA approved. Topical idoxuridine for corneal lesions Topical idoxuridine for corneal lesions Cidofovir?Cidofovir?
Smallpox - Infection ControlSmallpox - Infection Control
ProphylaxisProphylaxis Vaccine is effective if given within 3 days of Vaccine is effective if given within 3 days of
exposureexposureIsolationIsolation
Airborne and contact precautionsAirborne and contact precautionsFebrile illness after potential exposure should prompt Febrile illness after potential exposure should prompt isolation isolation beforebefore rash starts rash starts
Immediate contact your hospital Immediate contact your hospital epidemiologist and the public health epidemiologist and the public health authoritiesauthorities
Viral Hemorrhagic FeversViral Hemorrhagic Fevers
Ebola virusEbola virusSource: www.cdc.govSource: www.cdc.gov
VHF - GeneralVHF - GeneralNaturally occurring disease Naturally occurring disease Transmitted to humans by contact with infected animals or Transmitted to humans by contact with infected animals or
arthropod vectors.arthropod vectors. Sporadic outbreaks in Africa,parts of Asia and EuropeSporadic outbreaks in Africa,parts of Asia and Europe
VHF viruses as bioterrorism agentsVHF viruses as bioterrorism agents Weaponized by several counties Weaponized by several counties AerosolizationAerosolization
Case fatality ratesCase fatality rates Omsk hemorrhagic feverOmsk hemorrhagic fever 0.5%0.5% EbolaEbola 90%90%
VHF - Clinical FeaturesVHF - Clinical FeaturesIncubation 2 - 21days Incubation 2 - 21days Depends on virusDepends on virus
Initial presentationInitial presentation Nonspecific prodrome (fever, myalgias, headache, Nonspecific prodrome (fever, myalgias, headache,
abdominal pain, prostration)abdominal pain, prostration) Exam may show only flushing of face and chest, Exam may show only flushing of face and chest,
conjunctival injection, and petechiaeconjunctival injection, and petechiae
Disease progresses to shock and generalized Disease progresses to shock and generalized mucous membrane hemorrhagemucous membrane hemorrhage
VHF - DiagnosisVHF - DiagnosisClinical presentationClinical presentation thrombocytopenia, leukopenia, AST elevation thrombocytopenia, leukopenia, AST elevation
commoncommon
Definitive diagnosis requires detection of Definitive diagnosis requires detection of antigens or antibodiesantigens or antibodies testing done at CDCtesting done at CDC
Do Do notnot wait to confirm the diagnosis before wait to confirm the diagnosis before notifying the local public health authoritiesnotifying the local public health authorities
VHF - TreatmentVHF - Treatment
Supportive careSupportive care
Ribavirin may be usefulRibavirin may be useful adults and children: 30 mg/kg IV load (max 2 adults and children: 30 mg/kg IV load (max 2
g) g) then 16 mg/kg (max 1g) q6h x 4 daysthen 16 mg/kg (max 1g) q6h x 4 days
then 8 mg/kg (max 500 mg) IV q8h for 6 daysthen 8 mg/kg (max 500 mg) IV q8h for 6 days an oral dosing regimen is also availablean oral dosing regimen is also available
VHF - Infection ControlVHF - Infection ControlProphylaxisProphylaxis: None at this time: None at this time
IsolationIsolation Blood and bodily fluids Blood and bodily fluids extremelyextremely infectious infectious Liquid-impervious protective coverings, including leg Liquid-impervious protective coverings, including leg
and shoe coveringsand shoe coverings Double glovesDouble gloves N-95 or better respiratorsN-95 or better respirators Face shields or gogglesFace shields or goggles Negative pressure roomNegative pressure room
Chemical Chemical AgentsAgents
History: World War IHistory: World War IFirst large-scale useFirst large-scale use
Ypres, BelgiumYpres, Belgium April 1915April 1915 Chlorine, 168 tonsChlorine, 168 tons 5,000 deaths5,000 deaths 5 mile front5 mile front
Chemical Casualties in WWIChemical Casualties in WWI
9,0009,000191,000191,000GermanyGermany
3,0003,00097,00097,000Austria-Austria-HungaryHungary
1,4621,46271,34571,345U.S.U.S.4,6274,62755,37355,373ItalyItaly
56,00056,000419,340419,340RussiaRussia8,0008,000182,000182,000FranceFrance8,1098,109180,597180,597BritainBritain
DeathsDeathsNon-fatalNon-fatalCountryCountry
Potential Potential Chemical AgentsChemical Agents
Mustards, LewisiteMustards, LewisiteVessicantsVessicants
BZ, Others?BZ, Others?Incapacitating Incapacitating agentsagents
Phosgene, chlorine, Phosgene, chlorine, ammonia, pepper sprayammonia, pepper spray
Irritant Irritant AgentsAgents
CyanidesCyanidesBlood AgentsBlood AgentsTabun, Sarin, Soman, VXTabun, Sarin, Soman, VXNerve AgentsNerve Agents
Nerve AgentsNerve Agents
Nerve AgentsNerve Agents• OrganophosphatesOrganophosphates
• Are similar to Are similar to insecticides:insecticides:– MalathionMalathion– DiazinonDiazinon– Chlorpyrifos Chlorpyrifos
SarinSarin
SomanSomanTabunTabun
VXVX
Nerve Agent PathophysiologyNerve Agent Pathophysiology
AcetylcholineAcetylcholine Neurotransmitter Neurotransmitter
parasympathetic parasympathetic nervous systemnervous system
Neuromuscular endplateNeuromuscular endplate GangliaGanglia
SympatheticSympatheticparasympatheticparasympathetic
AChEAChE
AChACh
Ach Ach ReceptorReceptor
AChEAChE
AChACh
Nerve Nerve AgentAgent
Nerve Agents Nerve Agents Signs and Symptoms Signs and Symptoms
DD - defecation- defecation
U – urinationU – urination
M – miosis (pinpoint pupils)M – miosis (pinpoint pupils)
B – BRONCHORRHEA, BRONCHOSPASMB – BRONCHORRHEA, BRONCHOSPASM
E – emesis (vomiting)E – emesis (vomiting)
L – lacrimation (watery eyes)L – lacrimation (watery eyes)
S – secretionsS – secretions
Muscarinic toxidromeMuscarinic toxidrome
Nerve Agent Nerve Agent Signs & SymptomsSigns & Symptoms
Days of the weekDays of the week M: mydriasis (pupil dilation)M: mydriasis (pupil dilation) T: tachycardiaT: tachycardia W: weaknessW: weakness tH: hypertensiontH: hypertension F: fasciculationsF: fasciculations
Nicotinic toxidromeNicotinic toxidrome
Nerve agent exposureNerve agent exposure
Low exposureLow exposure Miosis, dim vision, eye painMiosis, dim vision, eye pain RhinorrheaRhinorrhea DyspneaDyspnea Localized sweating & fasiciulation (liquids)Localized sweating & fasiciulation (liquids)
High exposureHigh exposure Immediate loss of consciousnessImmediate loss of consciousness SeizuresSeizures ApneaApnea Flaccid paralysisFlaccid paralysis
Vapor – effects occur within secondsVapor – effects occur within secondsLiquids – onset may be delayedLiquids – onset may be delayed
Nerve Agent-TriageNerve Agent-Triage
Tokyo SarinTokyo Sarin 3/6 victims in cardiac arrest resuscitated3/6 victims in cardiac arrest resuscitated Majority were worried wellMajority were worried well
Consider Consider cardiaccardiacarrest as arrest as immediate?immediate?
Nerve Agents: TreatmentNerve Agents: Treatment
• ABC’s, supportive careABC’s, supportive care
• AntidotesAntidotes–Atropine Atropine
• 2 mg IV, IM or ET2 mg IV, IM or ET
–Pralidoxine (2-PAM)Pralidoxine (2-PAM)• 1 gram slow IV or Mark I kit IM (600 mg)1 gram slow IV or Mark I kit IM (600 mg)
– Benzodiazepines, PRN for seizuresBenzodiazepines, PRN for seizures
AChEAChEAChACh
Nerve Nerve AgentAgent
AtropineAtropine
2 PAM2 PAM
MuscarinicMuscarinicNicotinicNicotinic
ReceptorsReceptors
Nerve Agent TreatmentNerve Agent TreatmentAtropine Starting dose - 2 mgAtropine Starting dose - 2 mg
Maximum cumulative dose - 20 mgMaximum cumulative dose - 20 mg Insecticide poisoning requires moreInsecticide poisoning requires more
Atropine – How much to give?Atropine – How much to give? Until secretions are drying or dryUntil secretions are drying or dry Until ventilation is easyUntil ventilation is easy If conscious or comfortableIf conscious or comfortable Do not rely on heart rate or pupil sizeDo not rely on heart rate or pupil size
Irritant GassesIrritant GassesCombine with moisture to Combine with moisture to form acids or basesform acids or bases
Low concentrationLow concentration Minor irritationMinor irritation
High concentrationHigh concentration Chemical burnsChemical burns
Irritant Gas - SymptomsIrritant Gas - SymptomsExcess mucous Excess mucous productionproductionConjunctivitisConjunctivitisCoughing & DysphoniaCoughing & DysphoniaStridor and aphoniaStridor and aphoniaBronchospasm Bronchospasm Shortness of breathShortness of breathNon- cardiogenic Non- cardiogenic pulmonary edemapulmonary edema
LowerLower
ConcentrationConcentration
Higher ConcentrationHigher Concentration
Or Prolonged ExposureOr Prolonged Exposure
Highly Water Soluble Highly Water Soluble Irritant GasesIrritant Gases
AmmoniaAmmonia
FormaldehydeFormaldehyde
Hydrogen Chloride Hydrogen Chloride
Sulfur DioxideSulfur Dioxide
Mostly upper airway to vocal cordsMostly upper airway to vocal cords laryngospasmlaryngospasm
Moderately Water Soluble Moderately Water Soluble Irritant GasesIrritant Gases
ChlorineChlorine Hydrochloric acid Hydrochloric acid Hypochlorus acidHypochlorus acid Greenish-yellow gasGreenish-yellow gas
Slightly slower to combine with waterSlightly slower to combine with water
Affects upper & lower airwaysAffects upper & lower airways
Poorly Water Soluble Poorly Water Soluble Irritant GasesIrritant Gases
Phosgene (COClPhosgene (COCl22)) Forms hydrochloric acidForms hydrochloric acid
Nitrogen dioxide (NONitrogen dioxide (NO22)) Forms nitric acidForms nitric acid
Inhaled into alveoli before combining with Inhaled into alveoli before combining with waterwater
Results in pulmonary edema Results in pulmonary edema Onset often delayed (20 min to 24 hrs)Onset often delayed (20 min to 24 hrs)
Phosgene (CG)Phosgene (CG)Most dangerous of pulmonary agentsMost dangerous of pulmonary agents Developed as warfare agent, first use 1917Developed as warfare agent, first use 1917 > 1 billion pounds/yr for industrial uses> 1 billion pounds/yr for industrial uses
Poor Warning PropertiesPoor Warning Properties Odor of New Mown HayOdor of New Mown Hay
Accumulates in low areas (trenches)Accumulates in low areas (trenches)Initial presence/absence of symptoms do Initial presence/absence of symptoms do not predict severity of exposurenot predict severity of exposure
Irritant Gases: TreatmentIrritant Gases: Treatment
Dry decontamination usually adequateDry decontamination usually adequate
Water for mucous membrane irritationWater for mucous membrane irritation
ABC’s & Oxygen PRNABC’s & Oxygen PRN
Early airway management Early airway management highly and moderately water soluble exposureshighly and moderately water soluble exposures
Inhaled beta agonist PRN wheezingInhaled beta agonist PRN wheezing
Observation and support Observation and support phosgene 12- 24 hrs?phosgene 12- 24 hrs?
Cyanide (AC, CK)Cyanide (AC, CK)Formerly referred to as “blood agents”Formerly referred to as “blood agents”
Odor “bitter almonds”? – “musty” smellOdor “bitter almonds”? – “musty” smell
Odor not a reliable indicator (genetic)Odor not a reliable indicator (genetic)
Inhibits Oxygen Utilization (bright red Inhibits Oxygen Utilization (bright red venous blood)venous blood)
Cyt c Cyt a cyt a3+ Cu
ADP ATP
O2 + H+
H20
OO22
OO22 OO22
OO22
Cyanide - SourcesCyanide - Sources
Pits of many plantsPits of many plants Cherries, peaches, almonds, lima beansCherries, peaches, almonds, lima beans Cassava plant rootCassava plant root
Combustion of carbon -> cyanideCombustion of carbon -> cyanide Plastics- acrylonitrilesPlastics- acrylonitriles
U.S. sources manufacture 300,000 tons of U.S. sources manufacture 300,000 tons of hydrogen cyanide annuallyhydrogen cyanide annually
Cyanide TreatmentCyanide Treatment
Remove to Fresh AirRemove to Fresh AirOxygen, supportive careOxygen, supportive careAntidotesAntidotes
Cyanide AntidotesCyanide AntidotesStep 1Step 1 Amyl nitrite Amyl nitrite
inhale 30 sec/min until IV)inhale 30 sec/min until IV)
Step 2Step 2 Sodium nitriteSodium nitrite
10 ml of 3% IV over 5-10 minutes10 ml of 3% IV over 5-10 minutes
Step 3Step 3 Sodium thiosulfateSodium thiosulfate
50ml of 25% IV over 20 minutes50ml of 25% IV over 20 minutes
Fe2+Hb
Fe3+MetHb
Amyl Nitrite
Sodium Nitrite
Fe3+
Sodium Thiosulfate
ThiocyanateExcreted in urine
Fe3+ Cyt a3
Blister Agents/VesicantsBlister Agents/Vesicants
Sulfur & Nitrogen mustardSulfur & Nitrogen mustard LewisiteLewisite
Vesicant SymptomsVesicant Symptoms
Onset of symptoms ?Onset of symptoms ?
Topical – Eyes, Airway, SkinTopical – Eyes, Airway, Skin
Binds Irreversibly within minutes Binds Irreversibly within minutes “Fixing”“Fixing”
Systemic effects ?Systemic effects ?
Vesicant MechanismsVesicant MechanismsMustardsMustards
Penetrates cells and Penetrates cells and generates toxic generates toxic intermediateintermediate
Alkylates Alkylates DNA/RNA, ProteinsDNA/RNA, Proteins
Rapidly dividing cells Rapidly dividing cells most susceptiblemost susceptible
LewisiteLewisite
Immediate irritant/caustic Immediate irritant/caustic effecteffect
As uncouples oxidative As uncouples oxidative phosphorylationphosphorylation Impairs energy productionImpairs energy production
Vesicant TreatmentVesicant Treatment
Immediate decontamination (2 minutes)Immediate decontamination (2 minutes)
Victim may not undergo decontamination Victim may not undergo decontamination since symptoms delayedsince symptoms delayed
Remove clothes and wash skin with soap and Remove clothes and wash skin with soap and waterwater
Avoid overhydration; fluid losses less than Avoid overhydration; fluid losses less than with thermal burnswith thermal burns
Lewisite TreatmentLewisite TreatmentBritish Anti-Lewisite (BAL)British Anti-Lewisite (BAL) Chelating agentChelating agent Topical application for decontaminationTopical application for decontamination Administer IM to victims with shock or severe Administer IM to victims with shock or severe
pulmonary injury in consultation with the pulmonary injury in consultation with the poison centerpoison center
Side effects: nausea/vomiting, headache, Side effects: nausea/vomiting, headache, burning sensation of lips, chest pain, anxietyburning sensation of lips, chest pain, anxiety
SummarySummary
Triage, decontamination, and isolation Triage, decontamination, and isolation preparredness are keypreparredness are key
Nuclear events present with blast and burn Nuclear events present with blast and burn injuries acutelyinjuries acutely
Aerosol dispersal is most likely for Aerosol dispersal is most likely for chemical and biological agents and will chemical and biological agents and will present with respiratory complaints present with respiratory complaints