CHEMICAL AND RADIOLOGICAL AGENTS

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CHEMICAL AND RADIOLOGICAL AGENTS

• California Preparedness Education Network
• A Program of the California Area Health Education
  Centers
• Presented by
• Funded by HRSA Grant T01HP01405

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Chemical and Radiological Agents
Outline

• Present threat of chemical terrorism (CT)
• History of chemical warfare, terrorist attacks
• Chemical agents of concern
• Nerve agents Sarin
• Cyanides Hydrogen cyanide
• Blistering agents Mustard
• Pulmonary agents Phosgene
• Radiological agents
• Disaster preparedness

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What do You Need to Know?

• Understand the risk for chemical terrorist or
  hazardous materials (HAZMAT) events
• Recognize a potential chemical terrorist or
  HAZMAT event
• Meet immediate care needs of patients
• Notify appropriate authorities
• Participate in coordinated emergency response

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RISK!!
LOW
HIGH
TECHNICAL COMPLEXITY
LOW
HIGH
Chemical low complexity, high probability
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Chem/Rad vs. Biological Weapons
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Chemical agent Overview
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Classes of Chemical Agents
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Chemical Warfare HistoryWWI

• WWI Large-scale use of CW
• 1915 Germans deployed
• 150 tons chlorine gas
• 15,000 wounded
• 1,000 deaths
• Psychologically devastating
• High volatility limited usefulness

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Chemical Warfare WWI

• 1917 Germans used
• Sulfur mustard
• Artillery shells
• Many casualties
• Overwhelmed system
• lt5 died
• High persistence
• Contaminated large areas

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Chemical Warfare WWII

• 1940 Germans synthesized
• Nerve agent Sarin
• Weaponized thousands of tons
• Never used
• Hitler mustard casualty, WWI
• Allies threatened retaliation
• Nazi concentration camps
• Cyanide used in gas chambers

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Chemical Warfare Postwar Period

• US 1945-1970
• Large stockpiles of chemical weapons
• Massive arsenal nerve agents, sulfur mustard
• Defensive systems developed
• Gas masks, PPE, decontamination
• Atropine antidote for nerve agent toxicity
• US 1980-2002
• Destruction of chemical weapons stockpiles

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Chemical Warfare Iran-Iraq War

• Iran-Iraq War 1980-88
• Iraq Chemical weapons
• Widespread use
• Blistering agent Lewisite
• Nerve agent Tabun
• Heavy Iranian casualties, deaths

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Chemical Terrorism Iraqi Kurds
- 1988 Iraq bombed their Kurds with mustard,
nerve and cyanide gas
- Over 5,000 died 75 women and
children
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Chemical Terrorism Japan

• Aum Shinrikyo
• 1994, 1995
• Sarin gas in Japan
• Matsumoto, Tokyo
• 20 killed
• gt5,000 injured
• Leader Asahara
• Sentenced to hang

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Present Chemical Terrorist Threats

• Al Qaida threat
• Documents found
• Chemical agents
• Bombs
• Reported attempt
• Jordan, 2004
• US Embassy
• Suicide missions
• Easier success

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Chemical Agents Physical Properties

• Exists as liquid, solid, vapor
• Depends upon agent, temperature and pressure
• Stored as liquid
• Dispersed as liquid, gas or aerosol
• Aerosol particles suspended in gas
• Persistence tendency to remain for long time
• Volatility tendency to evaporate
• Smell fruity, almonds, mustard, or no smell

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Chemical Agent 1 Simulation
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Cyanide Overview

• Cyanide
• High volatility
• Needs high concentrations, closed space
• Smell bitter almonds (60 can smell)
• Sudden loss of consciousness, seizures, death
• Used in Nazi concentration camps
• Ubiquitous in all living things
• Pits of peaches, almonds ingestion has caused
  death
• Industrial US uses gt 300,000 tons/year
• Electroplating, dyeing, printing, photography

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Cyanide Toxicity

• Cyanide gas inhalation
• Rapidly distributed to all organs, tissues
• Reacts with metals in body iron
• Reaction reversible
• Prevents intracellular O2 utilization in
  mitochondria
• Anaerobic metabolism results in lactic acidosis
• Reacts with sulfur-contained compounds
• Reaction irreversible
• Sodium thiosulfate
• Product less toxic, excreted in urine

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Cyanide Signs and Symptoms

• Signs and symptoms
• Central nervous system
• Dizziness, headache, nausea, vomiting, seizures
• Respiratory shortness of breath, chest tightness
• Skin and eyes Cherry red venous blood
• Cyanosis occurs only after cardiovascular
  collapse
• Laboratory
• Lactic acidosis
• Arterial oxygen normal, venous oxygen high

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Cyanide Treatment

• Cyanide antidote kit
• Nitrites
• Reaction couples with cyanide less toxic
• Amyl nitrite perle in mask while preparing sodium
  nitrite
• Sodium nitrite 3 10mL over gt 5 minutes
  (hypotension)
• Thiosulfate
• Sulfur donor excreted in urine
• Sodium thiosulfate 25 50 mL over 10-20 minutes
• Supportive care
• Intubation, 100 oxygen

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Chemical Agent 2 Simulation
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Nerve Agents Overview

• Nerve agents Sarin, soman, tabun, VX
• Inhibit acetylcholinesterase
• Similar to organophosphate pesticides
• Pupil constriction, secretions, convulsions,
  death
• Liquid and vapor hazard
• Most toxic chemical agent
• Most successful terrorist event
• No industrial sources
• Smell fruity or none

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NEURON
Acetylcholine (Ach)
Ach
Cholinesterase
Acetic acid Choline
Ach
MUSCLE
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Nerve Agents Toxicity

• Nerve agents
• Absorbed through eyes, skin, respiratory tract
• Mechanism of action
• Bind and inhibit acetylcholinesterase
• If nerve agent remains attached, aging occurs
  (irreversible)
• Cholinergic overactivity
• Nicotinic sweating, fasciculations, paralysis
• Muscarinic pupil constriction, secretions,
  vomiting, diarrhea
• Central confusion, convulsions, respiratory
  depression

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Nerve Agents Treatment

• Atropine
• Blocks muscarinic receptors
• Dries secretions, relaxes smooth muscle
• No effect on nicotinic receptors
• Twitching, paralysis
• Pralidoxime
• Removes agent from esterase
• Only affects nicotinic system
• Should be given before aging occurs

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Nerve Agents Treatment

• Nerve agent antidote kit
• Atropine, titrate until secretions dried
• 2 mg IV/IM every 3-5 minutes
• Pralidoxime chloride (2-PAM)
• 1-2 gm IV/IM, repeat every hour as needed
• Diazepam for seizures
• 5-10 mg IV every 5-10 minutes
• Supportive care
• Decontamination, if liquid exposure expected
• Tropicamide eye drops for eye pain, constriction

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Chemical Agent 3 Simulation
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Pulmonary Agents Overview

• Pulmonary agents organohalides
• Phosgene, chlorine, ammonia
• Liquid to gas vapor hazard
• Eye irritation, shortness of breath
• Delayed pulmonary edema
• Bhopal, India, 1984 Phosgene and methylamine
• 3,000 deaths
• US produces gt 1 billion tons/year
• Phosgene smells of newly mown hay
• By-product of chlorinated compounds, household
  solvents

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Pulmonary Agents Toxicity

• Pulmonary agents
• Absorbed by inhalation
• Readily penetrates respiratory system
• Mucous membrane irritation
• Immediate eye, nose, airway irritation
• Direct alveolar toxicity
• Capillary permeability, leukotriene synthesis
• Pulmonary edema after latent period 12-48 hours
• Reaction increased with physical activity,
  exertion

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Pulmonary Agents Toxicity
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Pulmonary Agents
Signs and Symptoms

• Signs and symptoms
• Respiratory dyspnea, cough
• Gradually progressive over hours
• Lung exam coarse crackles in all lung fields
• Eye mucous membrane irritation
• Laboratory
• ABG decreased arterial oxygen and CO2
• Can be warning of increased interstitial fluid

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Pulmonary Agents CXR Findings

• CXR
• Normal for several hours
• Early changes by 8 hours
• Late
• Hyperinflation
• Pulmonary edema
• No cardiomegaly
• No vascular redistribution

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Pulmonary Agents Treatment

• Treatment is supportive
• Remove patient to fresh air
• Decontaminate if any liquid exposure
• Enforced rest
• Activity increases capillary reaction
• Monitor for 12-48 hours
• Intubation, oxygen
• IV fluids for hypotension
• IV steroids for bronchospasm

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Chemical Agent 4 Simulation
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Blistering Agents Overview

• Blistering agents
• Sulfur mustard, phosgene oxime, lewisite
• Nitrogen mustard
• Past used for chemotherapy (high toxicity)
• Smell mustard, garlic, geraniums
• Oily liquid, evaporates slowly
• Persistence hazard
• Vapor hazard increases with heat
• Erythema, blisters, bone marrow suppression
• Injury similar to radiation
• WWI, Iran-Iraq war

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Blistering Agents Toxicity

• Local damage
• Easily enters skin, eyes, respiratory tract
• Enhanced moisture, heat, thin skin
• 50 burns in scrotum, axilla
• Protease digestion in skin
• Erythema, vesicles, bullae
• Dermal-epidermal junction
• May be delayed 1-2 days
• Fluid does not contain vesicant

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Sulfur Mustard Skin Toxicity
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Sulfur Mustard Eye Signs

• Eyes most sensitive organ
• Symptoms soon after exposure
• Conjunctivitis, photophobia
• Corneal epithelium
• Swelling and scarring
• Resolves over weeks
• Permanent corneal damage lt1
• Scarring increases risk glaucoma

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Sulfur Mustard Pulmonary Toxicity

• Pulmonary damage
• Necrosis and destruction of lung mucosa
• Pseudomembrane formation
• Upper and lower airways
• Pulmonary edema can occur
• Only when damage severe
• Respiratory failure
• Most common cause death with sulfur mustard
• Although death is very rare

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Sulfur Mustard Systemic Toxicity

• Systemic absorption
• Occurs frequently
• Organ damage only at high concentration
• DNA alkylation
• Cell death, inflammation
• Bone marrow suppression
• Rare cause of death
• May contribute to pneumonia, sepsis

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Sulfur Mustard Treatment

• Supportive
• Aggressive decontamination essential
• Soap and water
• Household bleach to clean surfaces
• Avoid bleach on skin
• Burn creams to skin
• Unroof large blisters with normal skin underneath
• Healing may take months
• Ophthalmic ointments to eyes
• Homatropine to reduce scarring

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Chemical Agents Summary
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NUCLEAR / RADIOLOGICAL
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Nuclear Bomb

• Creates large amounts of energy from fission
  fusion of atomic nuclei

• Large numbers of casualties
• Blast thermal injuries
• Nuclear energy released gamma rays
• Fallout particulate radiation
• Technologically complex

UNLIKELY TO SEE THIS TYPE OF BOMB
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Ionizing Radiation

• Any radiation with sufficient energy to disrupt
  an atom or molecule with which it impacts
• Types of radiation exposure
• Wave Gamma, x-rays
• Penetrating energy
• Particle Alpha, beta emitters
• Must be inhaled, instilled, or injected to cause
  harm

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Radiation Effects

• Acute Radiation Sickness
• Early effect after high radiation doses
• Dose-dependent, predictable
• Death due to multi-organ failure and infection
• Long-Term Effects
• Impossible to predict at time of exposure
• Cancer risk, fertility, birth defects

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Dirty Bombs

• Radiation Dispersal Device
• Conventional explosive radioactive material
• Injuries due to blast burns
• Little risk of acute radiation injury
• Panic, fear, environmental contamination

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Decontamination/Treatment
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Chemical Agents Decontamination

• Decontamination
• Wash with large amount water and soap
• Especially important for liquid hazards
• Household bleach use to clean solid surfaces
• Diluted in water (110)
• Avoid in human decontamination (toxic)
• First responders
• May need to use personal protective equipment
• Remove patient to fresh air, remove clothing

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Chemical Agents Personal
Protective Equipment

• Personal Protective Equipment
• Full face piece
• Breathing apparatus
• Gloves, boots
• Butyl rubber
• PPE suit

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Radiological Threat Personal Protective
Equipment

• Risk to medical staff from radioactive
  particulate matter is very low
• Biggest risk is related to incorporation
• (put directly into the body)
• Use Level D protection
• Gloves (latex OK for radiation event)
• Gown
• Mask
• Face shield

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Radiological Threat Decontamination

• Goal decrease dose, incorporation, spread
• Removal of clothing
• Will decontaminate 80-90
• Wash with soap water
• All wounds are contaminated irrigate

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Radiological Threat Combination Injury

• Patients present with blast/burn injury
• As well as radioactive contamination
• Use Personal Protective Equipment
• Care for life-threat burn/blast injuries first
• Decontaminate after initial injuries addressed

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Radiological Threat Iodine Treatment

• Nuclear reactors contain large amounts of
  radioactive iodine
• Potassium iodineblocking agent
• Prevents incorporation of radioactive iodine into
  thyroid
• May be distributed if there is a reactor release

Diablo Canyon nuclear plant one of the two
active nuclear plants in CA
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Chemical and Radiological Agents Summary

• Effects from chemical agents occur rapidly
• Early decontamination is important
• Clothing removal is 80-90 of decon
• May be all that is needed in a gas/vapor event
• Appropriate use of PPE
• Important for chemicals, especially liquids
• Antidotes are available for some agents
• Give early to be effective

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Chemical and Radiological Agents Summary

• Dirty bomb more likely than nuclear blast
• Unlikely to cause much radiation
• Risk mostly fear and panic
• With standard precautions
• Risk from radiation-contaminated patients to
  healthcare workers is minimal
• Care of burn/blast injuries
• Takes precedent over radiation decon

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Chemical and Radiological Agents Disaster Plan

• Need to have an all hazards approach
• Know how to activate plan
• Know who activates plan
• Procedures specific to potential threats
• Chemical, Biological, Radiological, Nuclear,
  Explosive
• Decontamination
• Secondary contamination
• Personal Protective Equipment
• Management

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QUESTIONS?

• Please remember to complete
• Personal data sheet
• Evaluation
• Sign-in sheet (include your degree or job
  function AND your license number if applicable to
  receive CEUs)

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