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Preparing Our Communities

• Welcome!

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Faculty Disclosure

• For Continuing Medical Education (CME) purposes
  as required by the American Medical Association
  (AMA) and other continuing education credit
  authorizing organizations
• In order to assure the highest quality of CME
  programming, the AMA requires that faculty
  disclose any information relating to a conflict
  of interest or potential conflict of interest
  prior to the start of an educational activity.
• The teaching faculty for the BDLS course offered
  today have no relationships / affiliations
  relating to a possible conflict of interest to
  disclose. Nor will there be any discussion of
  off label usage during this course.

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Chemical Events

• Chapter 6

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Overview

• Examples of chemical disasters / terrorism
• Review Classes of Chemical Weapons
• D-I-S-A-S-T-E-R Paradigm for chemicals

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Industrial Accidents

• Bophal, Indial 1984
• 40 Tons of Methyl Isocyanate released
• Population of 900,000
• 6,000-10,000 immediate problems
• Up to 400,000 delayed health issues

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Transportation Events

• Releases of Hazardous Material occur almost daily
  in the USA
• Events requiring patient decontamination are less
  frequent

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Chemicals as Weapons

• First large-scale use in World War I
• Ypres, Belgium
• April 1915
• Chlorine, 168 tons
• 5,000 deaths
• 5 mile front

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Chemical Casualties in WWI
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Terrorist Use of Chemical Weapons

• Tokyo Subway 1995
• Sarin Nerve Agent
• 5,500 victims
• 11 Dead
• 641_at_ St. Lukes International Hospital
• Poor decontamination
• Limited EMS involvement

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Agents of Opportunity

• Toxic industrial chemicals
• Available
• Easier to obtain/target
• Poisoning consumer products
• Examples
• Chlorine Tank Bombs in Iraq
• 1982 Tylenol tampering incident

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Chemical Weapons
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Nerve Agents

• Organophosphate chemicals
• Similar to common insecticides
• Very high lethality
• Liquids that are vaporized to disseminate
• Rapidly toxic if inhaled
• Slower onset with dermal exposure

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Nerve Agent Properties
Sarin Soman Tabun VX Household Insecticide
Aging 5 hours 5 minutes 14 hours 48 hours 12-24 hours
Dermal LD 50 1700 mg 100 mg 1000 mg 10 mg gt 35,000 mg
Inhaled LCt 50 100 mg/m3 50 mg/m3 400 mg/m3 10 mg/m3 gt 250 mg/m3
Volatility High High High Low Very Low
Persistence Low Low Low High Intermediate
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Acetylcholine Metabolism
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Acetylcholine
Cholinesterase
Organophosphate
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Organophosphate Poisoning Signs and Symptoms
Muscarinic effects

• D defecation
• U urination
• M miosis
• B BRONCHORRHEA,
• BRONCHOSPASM
• E emesis
• L lacrimation
• S secretions/ seizures

Nicotinic effects
M mydriasis T tachycardia W weakness tH
hypertension F fasciculation S seizures
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Acetylcholinesterase Inhibition
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Nerve Agent Exposure

• Low exposure
• Miosis, dim vision, eye pain
• Rhinorrhea
• Dyspnea
• Localized sweating fasiciulation (liquids)
• High exposure
• Immediate loss of consciousness
• Seizures
• Apnea
• Flaccid paralysis
• Vapor effects occur within seconds
• Liquids onset may be delayed

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Nerve Agents Treatment

• ABCs, supportive care
• Antidotes
• Atropine
• 2 mg IV, IM or ET
• Pralidoxine (2-PAM)
• 1 gram slow IV or Autoinjector IM (600 mg)
• Benzodiazepines, PRN for seizures

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Acetylcholine
Cholinesterase
Organophosphate
Atropine
2 PAM
Receptors
Muscarinic
Nicotinic
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Atropine Dosing

• Starting dose - 2 mg
• Maximum cumulative dose - 20 mg
• Insecticide poisoning may require more
• Atropine How much to give?
• Until secretions are drying or dry
• Until ventilation is easy
• If conscious or comfortable
• Do not rely on heart rate or pupil size

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Irritant Gasses

• Common industrial chemicals
• Agent of opportunity
• Combine with moisture to form acids or bases
• Low concentration Minor irritation
• High concentration or prolonged exposure
  Chemical burns

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Irritant Gas Site of Injury
Highly water soluble
Ammonia
Moderately water soluble
Chlorine
Poorly water soluble
Phosgene
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Irritant Gases Triage

• Majority Worried well?
• Airway compromise P1, immediate
• Severe shortness of breath- P1, immediate
• Mild SOB, No airway compromise P2, delayed
• Mild mucous membrane symptoms P3, minimal
• Respiratory arrest P4, expectant

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Irritant Gases Treatment

• Dry decontamination usually adequate
• Water for mucous membrane irritation
• ABCs Oxygen PRN
• Early airway management
• highly and moderately water soluble exposures
• Inhaled beta agonist PRN wheezing
• Observation and support
• phosgene 12- 24 hrs?

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Cyanide Compounds

• Widely used in Industry
• Cyanide gas is rapidly lethal
• Oral poisoning is slower
• Odor bitter almonds? musty smell
• Odor not a reliable indicator

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Cyanide in Smoke

• Burning wool, plastic and other materials
  releases cyanide gas
• May play a significant role in smoke inhalation
  and fire-related deaths

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Cyanide Blocks Use of Oxygen
Cyt a cyt a3 Cu
Cyt c
Metabolic Acidosis
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Cyanide - Sources

• Pits of many plants
• Cherries, peaches, almonds, lima beans
• Cassava plant root
• Combustion of carbon -gt cyanide
• Plastics- acrylonitriles
• U.S. sources manufacture 300,000 tons of hydrogen
  cyanide annually

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Cyanide Triage

• M-A-S-S Triage
• Likely few critical victims
• Most either dead
• Others with minor exposure
• Good supportive care may save many in absence of
  antidote

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Cyanide Treatment

• Remove to Fresh Air
• Oxygen, supportive care
• Antidotes ?
• 3 Drug Antidote Kit
• Hydroxocobalamin

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Fe3 Cyt a3
Amyl Nitrite Inhale for 30 sec
Sodium Nitrite 300mg IV
Sodium Thiosulfate 12.5g IV
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Hydroxocobalamin

• Hydroxocobalamin 5 g IV
• Vit. B12a
• Chelates Cyanide
• Need 501 ratio
• Cyanocobalamin
• Vit. B12 nontoxic!

CN
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Blister Agents/Vesicants

• Sulfur Mustard
• Also - Lewisite, Phosgene oxime

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Mustard

• Most widely used chemical weapon
• Morbidity is higher than mortality
• Garlic odor
• Freezes at 57 F
• Penetrates rubber gloves

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Mustard Mechanism

• Penetrates cells and generates toxic intermediate
• Alkylates
• DNA/RNA, Proteins
• Rapidly dividing cells most susceptible

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Vesicant Symptoms

• Onset of symptoms ?
• High vs low dose
• Topical Eyes, Airway, Skin
• Binds Irreversibly within minutes Fixing
• Systemic effects ?

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Mustard - Skin

• Erythema 2-24 hours
• Small vesicles may coalesce to form bullae
• High dose exposure central zone of coagulation
  necrosis

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Vesicant Treatment

• Immediate decontamination (2 minutes)
• Victim may not undergo decontamination since
  symptoms delayed
• Remove clothes and wash skin with soap and water
• Avoid overhydration fluid losses less than with
  thermal burns
• Possible antidotes
• N-acetylcystiene (NAC) for Mustard
• Dimercaperol (BAL) for Lewisite

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Incapacitating Agents

• Not meant to be lethal
• Inability to perform ones mission
• BZ (quinuclidinyl benzilate)
• Aerosolized Anticholinergic
• 25x more potent than atropine
• Others possible
• Benzodiazepines
• Opiate derivatives
• Psychedelics

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BZ Treatment

• Control patient
• Consider benzodiazepines
• KEEP VICTIM COOL
• Physostigmine
• 1-2 mg IV
• atropine at bedside
• seizures and cardiac arrhythmias rare

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• D Detection
• I Incident Command
• S Safety Security
• A Assess Hazards
• S Support
• T Triage Treatment
• E Evacuation
• R Recovery

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D Detection

• Clinical presentation
• Detection devices
• Information sources

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Clinical Detection

• Rapid symptom onset
• Multiple victims and civilian panic
• Similar signs and symptoms
• Present at same time
• History of similar site exposure
• Absence of traumatic injuries
• Toxidromes
• will guide treatment at hospital
• Unusual or irritating odors

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Chemical Detection Tools

• All have limited ranges of substances
• Chemical Detection Papers
• Concentrated vapors or liquids
• Air Sampling Devices
• Vapors or gasses in low concentration

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Shipping Papers Placarding

• ANY hazardous material being transported must
  have documents identifying the HazMat
• Large shipments are placarded
• Placard identifies the type of chemical
• Emergency Response Guidebook
• Decodes ID and provides information
• Health and fire hazards
• Protective Equipment needed
• Containment Evacuation
• First aid Emergency response

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Material Safety Data Sheet

• Required for chemical used in a workplace
• Chemical Name
• Hazard Identification
• Physical Chemical Properties

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NFPA Labels

• Flammability
• Health Hazard
• Instability
• 0 Good
• 4 Very Bad
• Special Hazards
• Oxidizer
• Water Reactive
• Radiation

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NIOSH Guide

• Chemical Name, synonyms
• Chemical and physical properties
• Toxic concentrations in air
• PPE Recommendation
• Information on Health Hazards

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Poison Control Centers

• In depth information about health effects
• In depth treatment information
• Antidote availability
• Toxicologist Consultation

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I Incident Management

• Critical information
• Time of the incident and incident site
• Substances involved
• Method of contamination (vapor or liquid)
• Hazards to health care providers
• Need for PPE decontamination

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S Security

• Scene must be secured to prevent more casualties
• Most (4/5) victims will go to the hospital by
  private/ public transportation vehicle!!!
• PREVENT THE HOSPITAL FROM BECOMING CONTAMINATED
• all personnel involved in triage
  decontamination must wear PPE

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A Assess Hazards

• Ongoing threat of contamination to other
  individuals
• Secondary devices?
• Several cyanide gas bombs found in subway
  restrooms after sarin attack

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S Support

• Know your capabilities/limitations
• Take protective measures
• Isolate
• Evacuate
• Perimeter/site control
• Call in other resources as needed.

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T Treatment

• Decontamination
• A B Cs
• Symptom driven supportive care and antidote
  selection

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E Evacuation

• Most victims will self transport
• Consider school buses for minimal pts
• Caution
• Contaminated pts
• Off-gassing
• Open windows
• Use vents

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R Recovery

• Most difficult aspect of a chemical event
• All potentially contaminated areas must be
  checked for persistence of chemicals
• Psychological sequelae

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Questions?