Preparing for the Unthinkable

1. Preparing for the Unthinkable Respiratory Care and Gas Warfare Terrorism Scope of the threat and possible responses Prof. T. Johnson

2. N – B – C is not TV • Nuclear • Biological (BW) • Chemical (CW) • B-N-I-C-E: biological, nuclear, incendiary, chemical, explosive Prof. T. Johnson

3. Introduction • History of the use of toxic gases • The agents may be employed by terrorists • Pre-hospital response /Hospital response-Lessons Learned from Tokyo and the WTC Attack • 10 Conclusions Prof. T. Johnson

4. The Chemical Weapons • What are the chemical agents? • How are they dispensed? • What are the characteristic of chemical warfare agents? • What symptomology do they present? • What immediate care must be rendered? • How does one protect the medical personnel? Prof. T. Johnson

5. The Tokyo Attack Timeline • March 20, 1995 Prof. T. Johnson

6. Tokyo Terrorist’s Gas Victims Prof. T. Johnson

7. Topic One: Chemical Agents • Pulmonary agents: chlorine, phosgene, cyanide • Blister agents: Lewisite and the nitrogen mustard agents • Nerve Agents: Tabun, sarin and VX • Lachrymators: CN (Mace), CS • Insecticides: Malathion, parathion and sevin Prof. T. Johnson

8. Topic Two: Characteristics • Pulmonary Agents: asphyxia, mucosal edema and bronchorhea. • Blister Agents: Burn-like phenomenon affecting eyes, bronchi and skin • Nerve agents: nausea, fasiculations, rhinorrhea, bronchorrhea, sweating, drooling, diarrhea, loss of consciousness, flaccid paralysis, apnea Prof. T. Johnson

9. Characteristic Symptomology: Nerve Gas • Eyes: Miosis, tearing, conjunctival injection (pain, dim vision, blurred vision) • Nose: Rhinorrhea • Airway: Bronchoconstriction, bronchorrhea, dyspnea, cough • GI: Hypermotility, nausea, vomiting, diarrhea, cramps • Skeletal muscles: Fasciculations, twitching, paralysis, muscle weakness • CNS: High dose Loss of Consciousness, seizures, apnea; Low dose cognitive difficulties • Other: Salivation and diaphoresis Prof. T. Johnson

10. Inhaled Nerve Gas Vapor • Mild: Miosis, rhinorrhea, dyspnea, weakness, blurred vision • Severe: as above with – Loss of consciousness, seizures and apnea – death • Onset: Within seconds to minutes of exposure • Treatment: Atropine and pralidoxime auto-injectable. Prof. T. Johnson

11. Dermal/conjunctival/liquid Exposure to Nerve Agents • Mild: Local sweating and fasciculations • Moderate: Nausea, vomiting, diarrhea, weakness • Severe (as above plus): Loss of consciousness, seizures, apnea – death • Onset: 5 min to 18 hrs • Treatment: Atropine, diazepam and 2-PAM (2 pyridine-aldoxime-methiodide), ventilatory and cardiovascular support. Prof. T. Johnson

12. Vesicants or Blister Agents • Mustard gas vapor causes no pain on contact. • Onset: 4 to 8 hrs (range 2 to 24 hrs) • Initial/Mild: Erythema, periorbital edema, blurring, oro-nasal edema, hoarseness, non-productive cough • Late/Severe: Corneal damage, leukocytopenia, decreased RBC & platelets, sepsis, airway obstruction, atelectasis, sepsis, DIC, death • TX: Early skin decontamination, anti-lewisite, support care similar to burn management. Prof. T. Johnson

13. Inhaled Cyanide • Severe: Brief period of hyperpnea, seizures, decreased breathing rate, arrhythmias, apnea – death • Mild: Nausea, vertigo, weakness, shortness of breath. • TX: Amyl nitrite by inhalation; sodium nitrite and sodium thiosulfate IV; assisted ventilation and oxygen Prof. T. Johnson

14. Topic Three: Care • Early andGENTLE Skin decontamination • Pulmonary Agents: OXYGEN, amyl nitrate inhalation, IV sodium nitrate or sodium thiosulfate • Blister agents: Early and Gentle skin surface decontamination to include the eyes, anti-Lewsite for internal injury, & burn wound care • Nerve agents: Atropine sulfate, 2-Pam (2 pyridine-aldoxime-methiodide) and Valium (diazepam) Prof. T. Johnson

15. Real Life – Protect the Care Givers • Military hospitals treating Iranian casualties of the Iran-Iraq War had casualties in hospital personnel • The Tokyo Experience: 10% of EMT, firefighters and police became casualties – none seriously; 110 hospital staff became casualties, 1 nurse required hospitalization. Prof. T. Johnson

16. Lessons Learned from Tokyo • Decontamination of victims not accomplished. • Charting became improvised. • Communications became impossible by phone or page. (The WTC attack overloaded phones too.) • Misleading Initial Data: gas explosion, tear gas, etc. (Expect secondary casualties.) • Inadequate Pharmacological support in volume. • No transfer plan and failure of police to clear traffic. Prof. T. Johnson

17. What Worked? • In-house hospital databases. Prof. T. Johnson

18. New age of terrorism: individuals & cults CW & BW are within the grasp of terrorists CW & BW attacks overwhelm the healthcare system Psychogenic casualties persist beyond the initial incident, even PTS in care givers. “Hero Effect” results in casualties. 6. Medical staff is unfamiliar with these injuries. 7. HVAC and C level protection for staff. 8. Insufficient drug stocks. 9. Decontamination areas inadequacy. 10. Communication system will be overloaded. Conclusions Prof. T. Johnson

19. Each hospital worked with only its own staff. NYC was divided into security zones. Communications/Legal/Risk Management issues limited use of clinical volunteers. Lessons Learned From the WTC Prof. T. Johnson

20. What This Means to You • Respiratory Therapists are vital to the care of these victims and must don PPE early. • Respiratory Care is unprepared, under-educated and insufficiently cross-trained • Respiratory Therapists have a responsibility to know how to treat these victims. • Preparation, Anticipation, Recognition, Action-Plan Training Issues Must be addressed. Prof. T. Johnson

21. Take Home Message • Educate your people! • Contact your local office of Emergency Preparedness • Work with your Emergency Medical and Nursing staff to develop an action-plan. • Conduct disaster drills on all shifts. • Managers must be prepared with manpower, supplies and staff readiness education. Prof. T. Johnson