Chemical Agents as Terrorist Weapons

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Chemical Agents as Terrorist Weapons
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Acknowledgements

• South Carolina Area Health Education Consortium
  (AHEC)
• Funded by the Health Resources and Services
  Administration.
• Grant number 1T01HP01418-01-00
• P.I. David Garr, MD, Executive Director AHEC
• BT Project Director Beth Kennedy, Associate
  Program Director AHEC
• Core Team
• BT Co-director Ralph Shealy, MD
• BT Project Manager Deborah Stier Carson, PharmD
• BT CME Director William Simpson, MD
• IT Coordinator Liz Riccardone, MHS
• Web Master Mary Mauldin, PhD
• P.R Coordinator Nicole Brundage, MHA
• Evaluation Specialist Yvonne Michel, PhD
• Financial Director Donald Tyner, MBA

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Acknowledgment

• This material has been prepared for SC AHEC
  Bioterrorism Training Networkby
• Ralph M. Shealy, M.D., FACEPCo-Director of SC
  AHEC Bioterrorism Training Network
• Medical Director for Operations, Charleston
  County EMS
• Medical Director, Charleston County Rescue Squad

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Objectives

• At the conclusion of this presentation, the
  participant will
• Outline the historical frequency with which
  chemical agents have been used.
• Describe common civilian situations in which a
  chemical community health emergency may occur.
• Describe how the physical state of an agents
  influences its effectiveness.
• List the six general classes of chemical agents.
• Describe the signs, symptoms, mechanism of
  action, decontamination procedure, and clinical
  management of each class of chemical agents

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Regarding chemical weapons..
The effect is so deadly to the unprepared that
we can never afford to neglect the
question. General John Pershing Commander
of American Forces in Europe during World War I

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World War I

• 1915 Germans released 150 tons of chlorine gas
  from 600 cylinders in Belgium
• British and French fielded cyanide to a limited
  extent during World War I.
• 1917 Germans deliver artillery shells containing
  sulfur mustard, causing 20,000 casualties.
• Russia suffered 500,000 chemical casualties in
  World War I

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Following World War I

• Britain used chemicals against Russians and
  mustard against the Afghans north of Khyber Pass.
• Spain used mustard shells and bombs against the
  Riff tribes of Morocco.
• Soviet Union used lung irritants against
  tribesmen in Kurdistan
• Italy under Mussolini used mustard against
  Abyssinian tribesmen
• Japan used chemicals against China.

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World War II

• There was limited use of chemical weapons during
  the World War II
• Germany used cyanide in the concentration camps.
• In 1943, Germans bombed an American ship loaded
  with two thousand 100 pound mustard bombs in Bari
  Harbor, Italy, causing 600 military deaths and an
  unknown number of civilian casualties.

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Recent Decades

• Egypt used mustard bombs against North Yemen
  royalists in 1963.
• The United States used defoliants and riot
  control agents in Vietnam and Laos.
• Chemicals were used against Cambodian refugees
  and Hmong tribesmen of Laos in 1970s and 1980s.
• The Soviet Union used chemicals in its war
  against Afghanistan.
• Iraq used mustard and nerve gas against Iran in
  the 1980s.

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Why Tell This Story?

• Chemical weapons have been used frequently in the
  past.
• There is every reason to believe they will be
  used again.
• Chemical weapons give the underdog an advantage.
• The effect is so deadly to the unprepared that
  we can never afford to neglect the question.

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Why would terrorist use chemical agents as
weapons of terrorism?

• Chemical agents are
• Cheap.
• Readily available.
• Do not require technological sophistication.
• Do not require high tech delivery systems.
• Cause fear and panic out of proportion to actual
  physical damage.

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Recent Japanese Experience

• In June 1994, a cult group spread Sarin nerve
  gas in the city of Matsumoto. Seven died and
  fifty-six required hospitalization
• On March 20, 1995, the same group released Sarin
  in the Tokyo subway. Eleven died and 5,500 were
  injured.
• In both incidents, health professionals were
  injured.

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Why not do it the easy way?

• Dangerous chemicals are already available in our
  cities and towns.
• A terrorist need only utilized chemicals that are
  already here.
• Exotic chemical agents used as weapons are not
  necessary.

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More Probable Events

• South Carolina health professionals are more
  likely to be confronted by
• Industrial releases
• Transportation accidents with leakage
• Agricultural exposures

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The Bottom Line

• THIS REALLY CAN HAPPEN TO YOU!

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Physical States of Chemical Agents

• Chemical agents in weapons are usually liquids.
• Aerosols are very small particles of a solid or
  tiny droplets of a liquid suspended in the air.
• Liquid agents evaporate to form a vapor.
• Solids and liquids tend to be persistent, while
  vapors and aerosols are non-persistent.

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Vapors and Gases

• Vapors and gases attack
• the lungs
• the tracheobronchial tree
• mucous membranes, including the eyes
• Vapors and gases require special personal
  protective equipment.

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Six Types of Chemical Agents

• Lung damaging agents
• Cyanide (also called blood agents)
• Vesicants (also called blister agents)
• Nerve agents
• Incapacitating agents
• Riot-control agents

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Toxidrome (Toxic Syndrome)

• A toxidrome is a set of clinical signs and
  symptoms by which a class of toxic agents can be
  recognized. Recognition of a toxidrome by
  clinicians can often lead to the identification
  of a causative agent faster and more effectively
  than can the analytical laboratory.

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Pulmonary Agents

• Phosgene and chlorine.
• Attack mucous membranes and respiratory system.
• Odor of new mown hay.
• Decontaminate with fresh air and copious water
  irrigation.
• Supportive care.

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Cyanide

• Hyperpnea with flushed skin.
• Seizures.
• Respiratory and cardiac arrest.
• Odor of almonds.
• Causes cellular asphyxia and profound metabolic
  acidosis.
• Decontaminate with fresh air and copious water
  irrigation.
• Use nitrates to liberate cyanide from hemoglobin
  and thiosulfate to facilitate excretion.

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Vesicants

• Sodium mustard is the prototype blistering agents
• Delayed onset of symptoms
• Attacks skin, eyes, airway, lungs, GI tract, and
  bone marrow
• Odor of onion, garlic, or mustard.
• Immediately decontaminate with hypochlorite to
  prevent damage.
• No specific therapy.

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Vesicants

• Lewisite causes immediate pain on contact, which
  encourages immediate escape from exposure and
  decontamination.
• Lewisite produce skin, eye, and respirator damage
  similar to mustard.
• Lewisite causes systemic toxicity
• BAL is the antidote

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Nerve Agents

• May cause death within minutes.
• Inhibit serum acetylcholinesterase.
• Smooth muscles become hyperactive.
• Striated muscle becomes flaccid.
• Secretory glands become hyperactive.
• Decontamination is with hypochlorite and fluid
  irrigation.
• Atropine and pralidoxime are antidotes.

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Incapacitating Agents

• Impair performance by CNS effects.
• Anticholinergic agents that have opposite effects
  of nerve agents.
• Cause decreased concentration, impaired memory,
  loss of judgment, and distortion of perceptions.
• Physostigmine is a specific antidote.

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Riot Control Agents

• Known as tear gas, Mace, and pepper spray.
• Burning and pain on exposed mucous membranes and
  skin, eye pain and tearing, burning nostrils, and
  respiratory discomfort
• Occasional deaths with prolonged exposure to high
  concentrations in a confined space.
• Effects typically brief and self limiting.

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Decontamination

• The reduction or removal of a chemical agent.
• Achieved by physical means, such as washing, or
  by chemical neutralization or detoxification
• The single most effective decontamination
  procedure is the removal of contaminated
  garments.
• The most important and most effective
  decontamination is done within the first minute
  or two after exposure.
• Effective early decontamination can mean the
  difference between survival and death.

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Summary

• Chemical agents have frequently been used in
  warfare by many nations.
• There are many civilian situations that may
  result in a chemical community health emergency.
• There are six general classes of chemical agents,
  each with its own toxidrome, decontamination
  procedure, and clinical management.
• Preparation is the best defense against a
  terrorist attack with chemical agents.

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Acknowledgements

• This presentations borrows heavily from
• The Medical Management of Chemical Casualties
  Handbook, Third Edition, produced by the U.S.
  Army Medical Research Institute of Chemical
  Defense.
• Emergency Medicine, Fourth Edition, produced by
  the American College of Emergency Physicians and
  edited by Judith Tintinalli, M.D.

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• Questions?

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