Targets of Opportunity

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Targets of Opportunity

• Steven M Marcus
• Medical Director
• NJ Poison Information Education System
• New Jersey Medical School

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(No Transcript)
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Chemical Agents used during WWI include
chlorine, phosgene, and nitrogen mustard gases.
These chemical lead to 100,000 deaths and 1.2
million casualties. Nazis killed millions of
civilians with Zyklon B gas (HCN) in WWII. Agent
Orange (a dioxin and defoliant) was used in the
Vietnam War, which may have lead to skin cancer
in our veterans.
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Chemical Terrorist Events

• 1985 - Covenant Group found to possess 33 gallons
  of cyanide
• 1992 - Police prevent Neo-Nazis from using
  cyanide in synagogue
• 1994 - Aum Shinrikyo uses sarin in Matsumoto 7
  dead, 280 injured

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In 1995 in Tokyo, Sarin (very potent
organophosphate nerve gas) caused 12 deaths and
5,500 injuries.
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More Chemical Terrorism

• Copycat attacks in Japan using cyanide, phosgene,
  and pepper spray
• FBI thwarts possible sarin attack in Disneyland
• 1997 - Sydney, Australia chlorine bombs in
  shopping centers injure 14 - 500 evacuated

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Types - Chemical Agents

• Nerve Agents Tabun, Sarin, Soman, VX
• Blood agents Hydrogen Cyanide, Cyanogen
  Chloride
• Pulmonary Intoxicants Phosgene, Chlorine
• Miscellaneous Ammonia
• Vesicants Mustard, Lewisite
• Riot Control Mace , Pepper Spray
• Incapacitating Agents BZ

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The Bhopal Disaster Twenty years ago an
explosion at a chemical factory sent 27 tons of
poisonous methyl isocyanate wafting over the
slumbering residents of Bhopal, India. The
aftermath was apocalyptic. Between 7,000 and
10,000 people died in the three days after the
explosion and 15,000 more have died since. 
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There is virtually no location in the state of NJ
beyond the range of toxicity from an explosion in
a chemical storage or production plant!
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Top Ten Most Prevalent Hazardous Chemicals in NJ
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Chlorine

• Used in swimming pools and laboratories
• Industrial exposures may produce large numbers of
  casualties

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Chlorine - Civilian Uses

• Chlorinated lime (bleaching powder)
• Water purification
• Disinfection
• Synthesis of other compounds
• synthetic rubber
• plastics
• chlorinated hydrocarbons
• Dont try this at home! (bleach acid)

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Historical Exposures

• 1996 Bethlehem, Pa 13 pool victims
• 1998 Rome, Italy 282 pool victims
• Diyarbakir, Turkey 2000 106 victims leaking
  tanker car

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Chlorine - Characteristics

• Properties
• Greenish-yellow gas, pungent odor
• Chlorine water HCl Free O2 30x more
  irritating to lungs than HCl
• Effects
• Eye irritation, cough, SOB, and wheezing
• delayed ARDS

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Chlorine - Tissue Effects

• Topical rather than systemic
• In central airways - from HCl
• necrosis, sloughing
• In peripheral airways
• oxygen free radicals
• react with sulfhydryl groups, disulfide bonds
• damage to alveolar-capillary membrane

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Chlorine - Clinical Effects

• Mild Exposure
• suffocation, choking sensation
• ocular, nasal irritation
• chest tightness, cough
• exertional dyspnea
• Moderate Exposure
• above sx hoarseness, stridor
• pulmonary edema within 2-4 hours

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Chlorine - Clinical Effects

• Severe Exposure
• severe dyspnea at rest
• may cause pulmonary edema within 30-60 min
• copious upper airway secretions
• sudden death may occur from laryngospasm

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Clinical Considerations

• These agents cause pulmonary edema
• damage alveolar-capillary membrane
• Latent Period
• symptom onset may be delayed hours to days
• objective signs appear later than symptoms
• Sudden Death may occur
• laryngeal obstruction (edema/spasm)
• bronchospasm

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Clinical Considerations

• Infectious Bronchitis / Pneumonitis common
• usually occurs 3-5 days post-exposure
• fever, elevated WBC, infiltrates NOT always
  infection
• prophylactic antibiotics NOT indicated
• Effects exacerbated by exertion
• compensatory mechanisms overwhelmed
• strict rest, even if asymptomatic
• No specific therapy exists

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Ammonia

• Colorless, water-soluble, alkaline gas
• Pungent odor
• Wide industrial use
• Used to make fertilizer, explosives, dyes, and
  plastics

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Ammonia - Characteristics

• Household ammonia pH lt 12 - limited damage
• Anhydrous ammonia pH gt 12 - severe damage
• Rapidly absorbed by mucosal surfaces (eyes,
  throat, and lungs)
• Corrosive produced when combined with water -
  Liquefaction necrosis

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Ammonia - Clinical Signs/Symptoms

• Eyes
• Burning, tearing, severe pain -gt injury of the
  cornea and lens
• Lungs
• Cough, SOB, chest pain, wheezing and laryngitis
  with mild exposure
• Hypoxia, chemical pneumonia, hemorrhage with
  moderate - severe exposures

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Ammonia - Clinical Signs/Symptoms

• Skin
• Pain, blister formation, deep burns
• Gastrointestinal (ingestion)
• Severe mouth pain, cough, and abdominal pain
• Nausea and vomiting
• Edema to lips and mouth (leading to airway
  obstruction)
• Esophageal strictures and perforation

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Hydrogen flouride

• Production of electronic circuits
• Etching glass, metal, stone and porcelain
• Cleaning products wheel and chrome cleaners
• Rust removers

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Hydrogen fluoride

• Dissolved in water as hydrofluoric acid
• Weak acid
• Volatizes easily
• Local and systemic effects
• Delayed symptoms

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HF-clinical effects

• Local pain out of proportion to apparent injury
• Systemic hypocalcemia, hypomagnesemia and
  hyperkalemia

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HF-therapy

• Decontamination
• Calcium compresses
• Nebulized calcium?
• Eye wash

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"The unpublicized usage of deadly hydrofluoric
acid at half of all refineries is endangering
refinery communities...The environmental hazards
of HF as used at refineries have to do with the
high volumes utilized, the potential for high
temperatures and pressures to be involved in a
release, and the tendency of HF, once released to
the environment, to form deadly gas clouds that
do not easily diminish...This makes it an
extremely dangerous material to be utilized at
refineries in highly populated areas. The danger
posed is thought by many experts to be as severe
as the accident in Bhopal, India in which
thousands were killed at a Union Carbide 
chemical plant in 1984."
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14 feared killed in refinery blast Rescuers
search for survivors at oil plant in Texas
Thursday, March 24, 2005 BY PAM EASTON
Associated Press TEXAS CITY, Texas -- A
thunderous explosion tore through a BP oil
refinery yesterday, shooting flames and billowing
smoke into the sky and showering the area with
ash and chunks of charred metal. At least 14 were
believed dead and more than 100 were injured.