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Chemical Agents

Chemical Agents. Chapter 6. Overview. History of chemical disasters / terrorism D-I-S-A-S-T-E-R Paradigm for chemical agents Specific Agents Nerve agents Choking / Irritant Gases Cyanide Blister / Vesicants Agents Incapacitating agents. Potential Chemical Agents. History: World War I.

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Chemical Agents

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  1. Chemical Agents Chapter 6

  2. Overview • History of chemical disasters / terrorism • D-I-S-A-S-T-E-R Paradigm for chemical agents • Specific Agents • Nerve agents • Choking / Irritant Gases • Cyanide • Blister / Vesicants Agents • Incapacitating agents

  3. Potential Chemical Agents

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

  5. Chemical Casualties in WWI

  6. Terrorist Attacks Matsumoto, June 1994 • 280 injured • 7 dead • Tokyo, March 1995

  7. Tokyo: Hospital Response • 5,500 victims • 11 Dead • 641- St. Luke’s International Hospital • No decon • No EMS involvement for most

  8. Tokyo, Japan 1995

  9. Bhopal India 1984 • 40 Tons of Methyl Isocyanate • Population of 900,000 • Estimates of affected • 6,000-10,000 • ? Affected ~ 400,000 • Lack of safety devices • Manuals in English • “Mini-Bhopals in US?”

  10. D:Detection I: Incident Command S: Safety & Security A: Assess Hazards S: Support T: Triage & Treatment E: Evacuation R: Recovery

  11. D: Detection I: Incident Command S: Safety & Security A: Assess Hazards S: Support T: Triage & Treatment E: Evacuation R: Recovery

  12. Rapid onset little or no warning Common symptoms Low lying clouds or vapors Dying animals or insects Unexplained odors Concentrations of Dead, dying, or sick people at the scene Detection

  13. Detection • Likely based on symptoms • DUMBELS – Nerve Agent • Respiratory symptoms – irritant gases • Skin symptoms – vesicants • Altered mental status and anti-cholinergic syndrome – BZ

  14. D: Detection I:Incident Command S: Safety & Security A: Assess Hazards S: Support T: Triage & Treatment E: Evacuation R: Recovery

  15. Incident Command • Must supply the following information: • number and type of casualties • substances involved • estimated time of arrival to hospital • time of the incident and incident site • method of contamination (vapor or liquid) • necessary decontamination • hazards to health care providers • role of the health care facility in the incident • updated information

  16. D: Detection I:Incident Command S:Safety & Security A: Assess Hazards S: Support T: Triage & Treatment E: Evacuation R: Recovery

  17. Scene Security

  18. Scene 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 decontamination must wear PPE

  19. Scene Security Minimum Site BoundariesOpen Area Chemical Release COLD ZONE CCP Uphill if agent heavier than air, downhill or level iflighter than air WARM ZONE 300 ft WIND DIRECTION HOT ZONE 60 ft WARM ZONE RS COLD ZONE Casualty Collection Point 6,000 ft RS= Release Site Adapted from Illinois Emergency Management Agency Chem-Bio Handbook. April 2000 HOT ZONE 6,000 ft Figure 5

  20. D: Detection I:Incident Command S: Safety & Security A:Assess Hazards S: Support T: Triage & Treatment E: Evacuation R: Recovery

  21. Assess Hazards • Ongoing threat of contamination to other individuals • contamination control must be continually assessed and enforced by safety officer • badges must be given to hospital personnel • guards must wear PPE at ingress points • law enforcement assist with crowds, traffic, and casualty flow • Secondary devices?

  22. D: Detection I:Incident Command S: Safety & Security A: Assess Hazards S:Support T: Triage & Treatment E: Evacuation R: Recovery

  23. Public health organizations Poison control centers Health care providers Medical research centers Medical examiners Emergency response units and first responder organizations DMAT’s State Disaster Teams Safety and medical equipment manufacturers Federal agencies FBI Hazardous Materials Response Unit Local law enforcement Support

  24. Use primary care clinics and urgent care centers Volunteers All individuals should be oriented to the disaster plan Support:Health care providers

  25. Support:Supplies / Pharmaceuticals • Vendor Agreements • ventilators • other equipment • Essential pharmaceuticals • Atropine can be stockpiled • powder form

  26. D: Detection I:Incident Command S: Safety & Security A: Assess Hazards S: Support T:Triage &Treatment E: Evacuation R: Recovery

  27. D: Detection I:Incident Command S: Safety & Security A: Assess Hazards S: Support T: Triage &Treatment E:Evacuation R: Recovery

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

  29. D: Detection I:Incident Command S: Safety & Security A: Assess Hazards S: Support T: Triage & Treatment E: Evacuation R:Recovery

  30. Recovery • Most difficult aspect of a chemical event • All areas of the hospital, buses, ambulances, equipment checked for persistence of chemicals • Law enforcement investigate human remains for evidence • Psychological sequelae

  31. Nerve Agents

  32. Nerve Agents • Organophosphates • Are similar to insecticides: • Malathion • Diazinon • Chlorpyrifos Sarin VX Soman Tabun

  33. Nerve Agents G-agents Volatile Nonpersistent vapor and liquid threat • Nerve agents • liquids ambient temperatures • Vapor heavier than air • VX • Nonvolatile • Persistent • liquid threat

  34. Agent Tabun (GA) Sarin (GB) Soman (GD) VX LCt50 Mg(min)/m3 400 100 50 10 Vapor Density (air = 1) 5.63 4.86 6.33 9.20 Topical LD50 mg 1000 1700 100 10 Aging half-life 14 hours 5 hours 2-6 minutes 48 hours Nerve Agent Properties

  35. Nerve Agent Pathophysiology • Acetylcholine • Neurotransmitter parasympathetic nervous system • neuromuscular endplate • Ganglia • Sympathetic • parasympathetic

  36. Cholinergic Nerve Function AChE ACh

  37. Cholinergic Nerve Function AChE GB ACh

  38. Acetycholine Metabolism

  39. Acetylcholinesterase Inhibition

  40. Nerve Agent Symptoms • Diarrhea • Urination • Miosis • Bradycardia, Bronchoconstriction, Bronchorrhea • Emesis • Lacrimation • Salivations, Secretions,Sweating (dumbells)

  41. Nerve Agent Symptoms: Nicotinic • Mnemonic for the days of the week • M: mydriasis (pupil dilation) • T: tachycardia • W: weakness • tH: hypertension • F: fasciculations

  42. Nerve agent exposure - Vapor • Low exposure • Meiosis (dim vision, eye pain) • Rhinorrhea • Dyspnea • High exposure • Immediate loss of consciousness • Seizures • Apnea • Flaccid paralysis • Vapor effects occur within second, peak within minutes: no late onset

  43. Small amount (up to 18 hrs) Localized sweating Fasiculations No miosis Moderate amount (<LD50) (18 hrs) GI effects Miosis uncommon Large amount (LD50) (<30 minutes) Sudden loss of consciousness Seizures Apnea Flaccid paralysis Death Nerve Agents: Liquid

  44. Nerve Agent-Triage • Tokyo Sarin • 3/6 victims in cardiac arrest resuscitated • Majority were worried well • Consider cardiac arrest as immediate?

  45. Nerve Agents: Treatment • ABC’s, supportive care • Antidotes • Atropine 2 mg IV/IM/ET • Repeat doses as necessary • End point is dry secretions, easier ventilation • 2-PAMCl • 1 gram slow IV or Mark I kit IM (600 mg) • Benzodiazepines, PRN for seizures

  46. Nerve agent: Treatment • Atropine Starting dose - 2 mg • Maximum cumulative dose - 20 mg • Insecticide poisoning requires much more • Side effects in normal people • Mydriasis • Blurred vision • Tachycardia • Decreased secretions and sweating

  47. Nerve Agent Treatment • Atropine – How much to give? • Until secretions are drying or dry • Until ventilation is easy • If conscious or the patient is comfortable • Do not rely on heart rate or pupil size

  48. Nerve Agents:Treatment summary • Vapor exposure • Symptoms develop suddenly • Most ambulatory victims require minimal intervention • Risk of secondary contamination, which is minimized by removing the victim’s clothing • Requires immediate access to antidotes • Liquid exposure • Symptoms delayed minutes to hours • Greater need for decontamination • High risk of secondary contamination; victims require decontamination (clothing removal & washdown) • Requires immediate access to antidotes

  49. Irritant Gases (Choking Agents)

  50. Irritant Agents • Irritate respiratory tract or damage lung tissue • Combine with moisture to form acids or bases • Three groups based on water solubility • Highly water soluble • Moderately water soluble • Low water solubility • Examples: • Ammonia, chlorine, phosgene

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