Weapons of Mass Destruction

1. Weapons of Mass Destruction Rosen Chapt 195 May 17, 2007 Roy Seitz, M.D. slides by Scott Gunderson PGY-3

2. Nuclear & Radiological Events

3. Potential Nuclear/Radiological Hazards in the U.S. • Simple Radiological Device • “Dirty” Conventional Bomb • Improvised Nuclear Device (IND) • 1kT “Suitcase Nuke” • Ballistic Missile Attack • 250 kT Nuclear Weapon – “City Killer”

4. Radiation Dispersal “Dirty bombs” • Low level contamination • Acute radiation casualties are unlikely • Decontamination and clean up are main issues

5. Texas Motor SpeedwayExercise, November 2004 Three critical gaps identified: • Casualty / Patient Triage • Medical Decontamination (Med Decon) • Personal Protective Equipment (PPE)

6. Diversion of Nuclear Weapons • “We may have lost up to 100 one-kiloton suitcase sized nuclear bombs” • Alexander Lebed (Former) Chief, National Security, USSR

7. Energy Partition Standard Fission / Fusion AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

11. Scenario: Washington Mall

12. AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

13. Effective Range For Thermal Energy1 kT Weapon AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

14. AFRRI, Medical Effects of Nuclear Weapons, “Blast and Thermal Effects” Lecture, 1990.

15. Atlanta SSE Med Wind 250Kton Fatalities

16. Atlanta 250 kiloton SSE wind7mph

17. New York City – 250 kT Nuclear Detonation 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%

18. What is Fallout? • A complex mixture of over 200 different isotopes of 36 elements • 2 oz of fission products formed for each kT of yield. • Size < 1 micron to several mm.

19. Early Fallout • Reaches the ground during the first 24 hours after detonation • Early fallout = 50-70% of total radioactivity • Highest degree of fallout risk • 7:10 Rule for estimating exposure Hours 1 7 49 Gy/hr 1 0.1 0.01

20. Delayed Fallout • Arrives after 1st day • Very fine / invisible particles • Settle in very low concentrations over most of the earth’s surface • 40% of total radioactivity • Much lower degree of risk relative to early fallout

21. Alpha Beta Gamma Neutron 1 m Concrete Ionizing Radiation Any Radiation Consisting of Directly or Indirectly Ionizing Particles or Photons

22. 3 2 1 Feet Keys to Limiting Exposure • Shielding • Dense objects limit the amount of radiation that can get to you • Distance • Dose decreases rapidly as you move away from the source • Time • Minimizing time spent in proximity to the source is important 500 R/hr 125 55

23. Radiation Injury Organ Damage Cellular Damage Chemical Damage Free Radicals 10-10 Seconds 1. Proteins 2. Membrane 3. DNA Tissue damage & Loss of organ function Hours to years Seconds to hours

25. Distribution of Injuries in aNuclear Detonation Single Injuries (30% - 40%) Combined Injuries (65% - 70%) Data from Walker RI, Cerveny TJ Eds., Medical Consequences of Nuclear Warfare, TMM Publications, Falls Church, 1989. p 11.

26. Hemogram(300 cGy TBI Exposure)

27. Absolute Lymphocyte Count over 48 hours Confirms Significant Radiation Exposure Andrews Lymphocyte Nomogram From Andrews GA, Auxier JA, Lushbaugh CC: The Importance of Dosimetry to the Medical Management of Persons Exposed to High Levels of Radiation. In Personal Dosimetry for Radiation Accidents. Vienna, International Atomic Energy Agency, 1965, pp 3- 16

28. Primary Treatment Strategy • Treat life threatening trauma first • Remove clothing / Decontaminate • Treat radiation effects • Burn care • Pharmaceutical therapies • If surgery is needed • first 1-2 days OR • 50 days post-exposure

29. Decontamination Equipment • Hospital Surgical Gown (waterproof) • Cap, Face Shield, Booties (waterproof) • Double Gloves (inner layer taped) • Drapes • Plastic Bags • Butcher Paper • Large Garbage Cans • Radiation Signs and Tape

30. Decon Agents • Dry Removal • Disrobing is 80% effective • Soap / Shampoo & Water • Others ??

31. Nuclear Summary • Nuclear & Radiological Devices • Lots of trauma and burn injuries • ARS and cancers • Care Issues • Bed Capacity / Availability • Burn & Trauma care • Decontamination • Antidotes • Need for extensive planning

32. Biological Weapons

33. Definition of Bioterrorism Intentional use of pathogen or bacterial product to: • Cause harm to humans • Influence government conduct • Intimidate or coerce a civilian population

34. Bioterrorism Release Types • Overt Release • Notice of release provided • May contain a threat • Designed to create panic or fear • White powder hoaxes • May be hoax or credible threat • Covert Release • No notice or threat • Difficult to detect

35. Biological Agent Overview

36. Bacillus anthracis Anthrax

37. Anthrax- General • Endemic in animals worldwide with occasional human cases (usually cutaneous) • Spores used for bioattack • Aerosolized directly or sent in mail/packages • Three forms • Cutaneous, Inhalation, GI

38. Anthrax – Clinical Features • Inhalation • Incubation: 2-43 days (may be longer) • Prodrome • fevers, malaise, dry cough, chest pain, dyspnea, myalgia • Abrupt onset of fulminant illness • Widened mediastinum, pleural effusions; meningitis in ~50% • Actual pneumonia uncommon

39. Inhalational anthrax—US index case

40. Anthrax – Clinical Features • Cutaneous • Incubation: 1 to 7days (may be up to 12 days) • Erythematous papule  ulcer  characteristic black eschar with surrounding erythema and edema • Regional adenopathy and systemic symptoms (e.g., fever, malaise) may develop

41. Cutaneous Anthrax

42. Anthrax – Clinical Features • Gastrointestinal • Incubation period 1-7 days • Not likely after a bioattack • Presents as febrile illness with bloody diarrhea

43. Anthrax Diagnosis • Blood cultures • usually positive in <24h • Gram stain/Dx of pleural fluid or CSF • Sputum is usually NOT positive by stain/culture • Fever and widened mediastinum on CXR/CT very suggestive • Cutaneous disease • culture fluid from under eschar • Nasal swabs are a poor test

44. Anthrax in CSF—US index case

45. Anthrax - Treatment • Ciprofloxacin 400 mg IV q12h • 10-15 mg/kg for children • other fluoroquinolones probably also effective OR • Doxycycline 100 mg IV q12h • 2.2 mg/kg for children PLUS • 1 or 2 additional antibiotics • (clindamycin, rifampin, vancomycin, penicillin, chloramphenicol, imipenem, clarithromycin)

46. Anthrax - Treatment • Switch to oral therapy when clinically appropriate • 60 days therapy (or until third dose vaccine) • ciprofloxacin 500 mg PO BID or • doxycycline 100 mg PO BID

47. Prophylaxis and Infection Control • Prophylaxis • Ciprofloxacin 500 mg PO BID (10-15 mg/kg for children ) or • Doxycycline 100 mg PO BID (2.2 mg/kg for children) • Continue for 60 days (? 100 days) • Vaccine available for DOD forces • Infection Control • Standard barrier precautions are needed

48. Vaccine 17

49. Yersinia pestis Plague Source: www.cdc.gov Yersinia pestis

50. Plague - General • Endemic in animals many parts of the world • Including prairie dogs in the southwestern us • High potential as a BT agent • Endemic form • Spread to humans via a flea vector • Bubonic form of the disease • Bioattack • Most likely aerosolized • Pneumonic plague