MANAGEMENT OF CHEMICAL CASUALTIES

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MANAGEMENT OF CHEMICAL CASUALTIES
csepp multi-hazard medical curriculum
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Objectives

• List three symptoms of a nerve agent exposure
• State three chemical agents that would require
  decontamination to treat the exposure

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Chemical Incidents

• Local Communities must prepare
• Develop regional response plans, protocols and
  resources
• Develop protective systems
• Training is required
• Awareness and operational understanding
• Policies and procedures for assessment and
  treatment

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Chemical Warfare Agents

• Chemical Agents
• Chemicals used in military operations to kill,
  injure or incapacitate
• Local and/or Systemic Effects

IMAGE DOD
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Chemical Agents

• Nerve Agents Tabun, Sarin, Soman, VX
• Cyanide Hydrogen Cyanide,Cyanogen
  Chloride
• Pulmonary Intoxicants Phosgene, Chlorine
• Miscellaneous Ammonia
• Vesicants Mustard, Lewisite
• Riot Control Mace , Pepper Spray,
  Oleoresin Capsicum (OC)

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The Senses - Smell

• Sulfur Mustard
• Garlic
• Horseradish
• Phosgene
• Freshly mown hay
• Cyanide
• Bitter almonds
• Lewisite
• Geraniums

IMAGES CDC, USDA, EPA, USDA
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Nerve Agent History

• Organophosphates (Ops) known in 1800s
• 1936 GA (Tabun)
• 1938 GB (Sarin)
• 1944 GD (Soman)
• Early 1950s VX
• Germany had in munitions in WWII
• Used by Iraq
• In stockpiles
• U.S. has VX, GB, minimal GA

IMAGES CIA
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Chemical Agent Terrorist attacks

• Matsumoto
• Approximately 280 injured
• 7 dead
• Tokyo
• 12 dead
• Approximately 1,000
• hospitalized
• 5,500 sought medical care
• 10 of first responders injured

IMAGES CIA
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Physical Properties

• Clear, colorless liquids (when pure)
• Not nerve gas
• Tasteless, most are odorless
• Freeze/melt lt0ºC
• Boil gt150ºC
• Volatility GBgtGDgtGAgtGFgtVX
• Penetrate skin, clothing

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Toxicity

• LCt50 (mg-min/m3)
  LD50 (mg/70kg)
• GA 400 1,000
• GB 100 1,700
• GD 70 50
• GF 50 30
• VX 10 10

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Examples of AChE Inhibitors

• Carbamates
• Physostigmine (Antilirium)
• Neostigmine (Prostigmine)
• Pyridostigmine (Mestinon)
• Sevin (insecticide)
• Organophosphates
• Malathion
• Diazinon
• Nerve Agents

IMAGE USGS
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Nerve Agent

• A substance that causes biological effects by
  inhibiting acetylcholinesterase (AChE) allowing
  excess acetylcholine (ACh) to accumulate in the
  synaptic junction
• Effects are due to excess acetylcholine

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Normal Nerve Function

IMAGE DOD
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Effects Of Nerve Agents

• Organs with cholinergic receptors
• Muscarinic
• Smooth muscles
• Glands
• Nicotinic
• Skeletal muscles
• Ganglia

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SLUDGE

• S Salivation
• L Lacrimation
• U Urination
• D Defecation
• G Gastrointestinal Distress
• E Emesis

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Signs And Symptoms Muscarinic Sites

• Increased secretions
• Saliva
• Tears
• Runny nose
• Secretions in airways
• Secretions in gastrointestinal tract
• Sweating

IMAGE DOD
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Signs And Symptoms Muscarinic Sites

• Smooth muscle contraction
• Eyes miosis (constriction)
• Airways bronchoconstriction (shortness of
  breath)
• Gastrointestinal hyperactivity (nausea,
  vomiting, and diarrhea)

IMAGE DOD
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Signs and Symptoms Nicotinic Sites

• Skeletal muscles
• Fasciculations
• Twitching
• Weakness
• Flaccid paralysis
• Other (ganglionic)
• Tachycardia
• Hypertension

GB

IMAGE SAIC
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Other Signs And Symptoms

• Cardiovascular
• Tachycardia, bradycardia
• Heart block, ventricular arrhythmias
• Central Nervous System
• Acute
• Loss of consciousness
• Seizures
• Apnea
• Prolonged (4 - 6 weeks)
• Psychological effects

IMAGE USAF
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Signs And Symptoms Vapor Exposure

• Mild exposure
• Miosis with dim vision eye pain, rhinorrhea,
  dyspnea
• Moderate exposure
• Pronounced dyspnea, nausea, vomiting, diarrhea,
  weakness
• Severe exposure
• Immediate loss of consciousness, seizures, apnea,
  and flaccid paralysis
• Effects occur within seconds, peak within
  minutes no delayed onset

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Signs And Symptoms Liquid Exposure

• Mild exposure (onset of symptoms up to 18 hrs)
• Localized sweating
• Fasciculations
• No miosis
• Moderate exposure (ltLD50) (onset of symptoms up
  to 18 hours)
• Gastrointestinal effects
• Miosis uncommon

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Signs And Symptoms Liquid Exposure

• Severe exposure (LD50) (onset of symptoms lt30
  minutes)
• Sudden loss of consciousness
• Seizures
• Apnea
• Flaccid paralysis
• Death

IMAGE SAIC
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Diagnosis Of Nerve Agent Exposure

• Symptomatic
• May be systemic or organ-specific
• Combination of symptoms is more definitive
• Situational
• Multiple casualties with similar symptoms
• Time or location factors in common

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Nerve Agent Treatment

• Airway/ventilation
• High resistance
• Antidotes
• Atropine
• 2-PAM Cl
• Benzodiazepine
• Valium
• Versed

IMAGE USMC
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Nerve Agent Treatment

• Atropine
• Antagonizes muscarinic effects
• Dries secretions relaxes smooth muscles
• Given IV, IM, ET
• No effect on pupils
• No effect on skeletal muscles
• Given IV in hypoxic patient may cause ventricular
  fibrillation

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Nerve Agent Treatment

• Starting dose - 2 mg atropine
• Enough must be administered to abate respiratory
  distress if casualty is to survive
• Insecticide poisoning requires more atropine than
  chemical warfare agents per equivalent amount
• Side effects in non-contaminated or non-exposed
  people
• Mydriasis
• Blurred vision
• Tachycardia
• Decreased secretions and sweating

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Nerve Agent Treatment

• Atropine - How much to give?
• Until secretions are drying or dry
• Until ventilation is easy
• If conscious or casualty is comfortable
• Do not rely on heart rate/pupil size

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Nerve Agent Treatment

• Pralidoxime Chloride (2-PAM Cl)
• Removes nerve agent from AChE in absence of aging
• 1 gram slowly (20-30 minutes) in IV infusion
• Hypertension with rapid infusion
• For IM use, up to 1.8 grams
• No effects at muscarinic sites
• Helps at nicotinic sites

IMAGE SAIC
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Treatment - Autoinjectors
600 mg pralidoxime chloride (IM) in injector 2 2
mg atropine (IM) in injector 1

IMAGE SAIC
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Autoinjection vs. IM Or IV
Source Unknown

IMAGE DOD
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Mark I Autoinjector - Dispersal

IMAGE DOD
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Nerve Agent Treatment

• A benzodiazepine
• Decreases seizure activity
• Reduces seizure-induced brain injury
• Given to casualties with severe symptoms whether
  convulsing or not
• 10 mg increments, titrate to effect

IMAGE DOD
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Nerve Agent Treatment

• Treatment regimen
• No signs/symptoms or miosis only
• Reassure
• Observe
• Vapor 1 hour
• Liquid Up to 18 hours

IMAGE EPA
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Nerve Agent Treatment

• Mild vapor exposure
• Miosis, rhinorrhea - observation only
• Increasing SOB - treat
• Mild liquid exposure
• Localized fasciculations sweating - treat

• One Mark I Antidote Kit (2 mg atropine/ 600 mg 2
  PAM Cl) IM
• OR
• 1 gram 2-PAM Cl IV
• 2 mg atropine, IM or IV
• Parenteral atropine will not reverse miosis

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Nerve Agent Treatment

• Moderate vapor or liquid exposure
• One or two Mark I Antidote Kits
• Or give IV
• 2 to 4 mg atropine initial dose
• 1gm 2-PAM Cl (infusion)
• Titrate to effect

IMAGE USAF
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Nerve Agent Treatment

• Severe - vapor or liquid
• Give 3 Mark I Antidotes Kits or 6 mg atropine and
  1 gram of 2-PAM Cl as soon as possible
• Airway
• Ventilation/Oxygen
• Diazepam 10 mg (2 to 5 mg increments, IV or IM)
• Repeat atropine every 5 to10 minutes as needed
• Repeat 2-PAM Cl in one hour

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Nerve Agent Age-related Treatment

• Atropine - Initial treatment
• Infants children (IV/IO/IM) 0.02 mg/kg
• IM
• Infant (0 to 2) 0.5 mg
• Child (2 to 10) 1.0 mg
• Elderly 1.0 mg

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Nerve Agent Age-related Treatment

• 2-PAM Cl
• lt 20 kg 15 mg/kg IV
• Elderly 1/2 adult dose (7.5 mg/kg IV)
• gt 20 kg 600-mg IM autoinjector
• 2 PAM Cl-induced hypertension
• Phentolamine Adult 5 mg IV
• (regitine) Child 1 mg IV

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Nerve Agent Age-related Treatment

• Diazepam
• Children gt 30 days old to 5 years
• 0.2 - 0.5 mg/kg IV q 2 to 5 min (max 5 mg)
• Children gt 5 years
• 1 mg IV q 2 to 5 min (max 10 mg)

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Nerve Agent Summary

• Vapor exposure
• Symptoms develop suddenly
• Most ambulatory victims require minimal
  intervention
• Risk of secondary contamination, which is
  minimized by removing the victims clothing
• Requires immediate access to antidotes

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Nerve Agent Summary

• Liquid exposure
• Symptoms delayed minutes to hours
• Greater need for decontamination
• High risk of secondary contamination victims
  require decontamination
• Requires immediate access to antidotes

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Blister Agents Or Vesicants

• Definition
• Military vesicants
• Sulfur mustard
• Lewisite
• Other vesicants
• Riot control agents
• Poison ivy, poison oak sumac
• Industrial chemicals
• Sunlight
• Cancer chemotherapeutics

IMAGES DOD, NIBB/USGS, CDC, DOD
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Mustard

• Vapor and liquid threat
• Latent period between exposure and effects
• Topical eye, skin, and airway damage
• Treatment is symptomatic
• Systemically toxic damages bone marrow

IMAGE DOD
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Mustard - Onset

• Chemical cell damage 1 to 2 minutes
• Clinical effects 2 to 48 hours usually 4 to 8
  hours
• Initial responders will not see these casualties
  at the scene, but may be called upon to transport
  them hours later when they manifest symptoms

IMAGE DOD
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How Mustard Works

• Quickly cyclizes in tissue
• Alkylates cell components, such as DNA
• DNA damage, cell death
• May affect eyes, skin, and respiratory tract
• Vesicle fluid does not contain agent

IMAGE SAIC
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Mustard Eye Effects

• Mild conjunctivitis
• Moderate/severe conjunctivitis, lid inflammation
  and edema, blepharospasm, corneal roughening
• Corneal opacification, ulceration, and/or
  perforation
• 85 of the mustard casualties had mild to
  moderate conjunctivitis (WWI)
• Under 1 had permanent damage to cornea by liquid

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Mustard Skin Effects

• Erythema
• Small vesicles later coalesce
• Blisters/bulla
• Possible coagulation necrosis with liquid agent
  exposure

IMAGES SAIC
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Mustard Airway Effects

• Upper
• Nose bleeding
• Sore throat
• Hacking cough
• Mid Larynx (hoarseness)
• Lower Bronchioles (dyspnea, productive cough)
• Pulmonary edema rare

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Mustard Airway Effects

• Cross-section of airway bronchiole with necrosis
  and sloughing of tissue occluding the lumen

IMAGE DOD
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Mustard Bone Marrow Effects

• Damages stem cells
• Decreased WBC, RBC, platelets
• Survival rare if WBC lt 200 (normal 3,000 to
  10,000)

IMAGE NASA
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Mustard Gastrointestinal Effects

• Within 24 hours
• Nausea, vomiting, diarrhea
• After 3 to 5 days
• May have tissue destruction

IMAGES SAIC, USN / CDC
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Mustard Skin Decontamination

• Part of supportive treatment
• Physical removal of agent
• Remove clothing
• Flush skin with soap and water
• Flush eyes with sterile saline or sterile water
• Must be done within 2 minutes to prevent damage
• Delays in decontamination will not prevent
  illness, but will prevent
  cross-contamination

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Mustard Treatment

• Administer oxygen/intubate if indicated
• Administer bronchodilators if indicated
• Cover/shield eyes (no pressure) after flushing if
  pain associated with light
• Reassure patient

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Lewisite

• Vesicant effects similar to sulfur mustard
• Causes severe irritation immediately upon
  exposure to eyes, skin and airways
• Produces skin blisters, eye and lung injury, and
  pain
• No bone marrow effects

IMAGES USN / CDC-NIOSH
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Lewisite Treatment

• Self protection
• Immediate decontamination
• British anti-lewisite (BAL)
• For systemic effects
• 2-5 mg/kg IV

IMAGES SAIC
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Cyanide

• Widely used throughout the U.S.
• Printing
• Agriculture
• Photography
• Manufacturing of paper and plastics
• Over 300,000 tons produced annually
• Combustion byproduct of burning synthetic
  materials

IMAGES USCG, USN
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Cyanide Characteristics

• Cyanide
• Salts (solids)
• Sodium, potassium, calcium
• Liquids
• Hydrocyanic acid, cyanogen chloride
• Bitter almond odor - unreliable since undetected
  by 40 of the population
• Must be delivered in large quantities (bombs and
  shells) to produce death

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Types Of Cyanide

• Hydrocyanic Cyanogen
• Acid (AC) Chloride
  (CK)
• Vapor Lighter than air Heavier than air
• Density
• Odor Bitter Almonds Pungent
• Irritation None Eyes,
  nose, throat

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How Cyanide Works

• Small amounts
• Metabolized and excreted
• Minimal toxicity
• Large amounts
• Binds to iron in mitochondria preventing cells
  from using oxygen
• Without oxygen, cells die - heart and brain
  affected initially

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Acute Inhalational Cyanide Poisoning

• Low concentrations (non-lethal)
• Victims become anxious
• Hyperventilate
• Develop headache, dizziness, and vomiting
• Symptoms improve when victim is removed from the
  source

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Acute Inhalational Cyanide Poisoning

• High concentrations (inhalation)
• 0 to 15 seconds - anxious and hyperventilate
• 0 to 30 seconds - seizures
• 3 to 5 minutes - breathing ceases
• 6 to 10 minutes - asystole -gt death
• Normal or dilated pupils
• Initial absence of cyanosis
• Skin may be flushed or cherry red color
  (terminal finding)

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Cyanide Inhalational Treatment Regimen

• Remove from area take off clothing
• If conscious and breathing - administer oxygen
  and observe no antidotes
• If unconscious - administer oxygen, provide
  airway management, ventilate with bag-valve mask,
  administer cyanide antidote kit
• Mechanical resuscitation is required - no
  mouth-to-mouth

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Cyanide - Severe Inhalation
or Symptomatic Ingestion

• Remove cyanide from the cell
• Cyanide likes to bind to iron (Fe)
• Convert hemoglobin (Fe) ? methemoglobin (Fe)
  using amyl nitrite/sodium nitrite
• Add sodium thiosulfate to complete detoxification
• Oxygen, hyperventilate, bicarbonate, IV fluids

IMAGE DOD
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Cyanide - Severe Inhalationor Symptomatic
Ingestion (contd)

• Amyl Nitrite Perles
• Break gauze, 30 seconds rx
• Methemoglobin
• Sodium Nitrite
• 300 mg (10 cc amp) over 5 min, hypotension
• Sodium Thiosulfate
• 12.5 gm (50 cc amp) IV over 5 min
• Thiocyanate in urine

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Cyanide - Severe Inhalationor Symptomatic
Ingestion (contd)

• If cyanide antidotes available
• Amyl nitrite - give until IV started
• Sodium nitrite IV
• Sodium thiosulfate IV
• If cyanide antidotes not available
• Intubate/hyperventilate
• Administer oxygen
• Administer IV fluids/sodium
  bicarbonate

IMAGE SAIC
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Chemical Weapons Differential Diagnosis

• Cyanide
• Pupils normal
• Few secretions noted
• No twitching
• Convulsions
• Nausea only

• Nerve Agents
• Miosis
• Copious secretions
• Muscle twitching
• Convulsions
• GI effects (nausea, vomiting, diarrhea)

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Pulmonary Intoxicants(Phosgene, Chlorine,
Ammonia)

• Cause severe life-threatening injury after
  inhalation
• Adverse effects often delayed
• Treatment is supportive

IMAGE DOD
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Phosgene

• Manufacturing of dies, coal tar, pesticides,
  pharmaceuticals
• Used in WWI

IMAGE National Archives
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Phosgene (contd)

• 1984 Bhopal tragedy
• 50,000 lbs. methylisocyanate released
• 150,000 affected
• 10,000 severely injured
• 3,300 killed
• Phosgene and isocyanate injuries

IMAGES CIA
70
Phosgene - Characteristics

• Colorless gas (white appearance may be due to
  water vapor)
• Smells like freshly mown hay
• Four times heavier than air
• Converts to a gaseous state above 47F

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Phosgene - Toxicity

• Inhalation hazard
• Phosgene Water Carbon dioxide Hydrochloric
  Acid
• When phosgene comes in contact with mucous
  membranes, it will produce irritation to eyes,
  nose, throat, and airways with delayed injury
• Mild cough, transient

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Phosgene - Toxicity (contd)

• Penetrates slowly down airways
• Symptom-free period (2 to 24 hours)
• Carbonyl group attacks alveolar capillary
  membrane leakage of fluid into air cells
• Up to 1 liter per hour
• Patients become severely short of breath
  (non-cardiogenic pulmonary edema) and hypotensive
• NO DIURETICS

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Phosgene - Treatment

• At the scene
• ABCs
• Remove from source of exposure
• Keep victims quiet, do not allow them to ambulate
• Transport by stretcher
• Decontaminate by removal of clothing prior to
  transport
• NO EXERTION

IMAGE DOD
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Phosgene - Treatment (contd)

• During transport
• ABCs
• SpO2 monitoring
• NO EXERTION
• For Advanced Providers
• IV Fluids
• Bronchodilators
• Need for positive pressure ventilation may
  necessitate early intubation
• NO DIURETICS

IMAGE DOD
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Ammonia

• Colorless, water-soluble, alkaline gas
• Pungent odor
• Wide industrial use
• Used to make fertilizer, explosives, dyes, and
  plastics

IMAGE OSHA
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Ammonia - Characteristics

• Rapidly absorbed by mucosal surfaces (eyes,
  throat, and lungs)
• Corrosive produced when combined with water
• Liquefaction necrosis
• Household ammonia pH lt 12
• Limited damage
• Anhydrous ammonia pH gt 12
• Extensive damage

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Ammonia - Clinical Signs

• Eyes
• Burning, tearing, severe pain -gt injury to the
  cornea and lens
• Lungs
• Cough, SOB, chest pain, wheezing and laryngitis
  with mild exposure
• Hypoxia, chemical pneumonia, hemorrhage with
  moderate to severe exposures

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Ammonia - Clinical Signs (contd)

• Skin
• Pain, blister formation, deep burns
• Gastrointestinal (ingestion)
• Severe mouth pain, cough, abdominal pain
• Nausea and vomiting
• Edema to lips and mouth (leading to airway
  obstruction)
• Esophageal strictures and perforation

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Ammonia - Treatment

• Remove from the exposure
• Decontaminate in field prior to transport
• Irrigate eyes (Morgan lens)
• Early intubation (if inhaled)

IMAGE DOE
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Chlorine

• Significant irritant to the eyes and respiratory
  tract
• Characteristic pungent odor
• Used in swimming pools and laboratories
• Industrial exposures produce large number of
  casualties

IMAGE EPA
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Chlorine - Characteristics

• Properties
• Greenish-yellow gas
• Less alkaline than ammonia
• Chlorine water Hydrochloric acid Free
  oxygen radicals
• 30x more irritating to lungs than hydrochloric
  acid
• Effects
• Eye irritation, cough, SOB, wheezing
• 12 to 24 hours, non-cardiogenic pulmonary edema
• Sudden death due to hypoxia

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Chlorine - Treatment

• Remove from source of exposure
• ABCs
• Flush skin eyes with water
• Administer oxygen, cool mist, bronchodilators
• Airway management (intubation, Positive End
  Expiratory Pressure PEEP management)
• Hydration

IMAGE SAIC
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Riot Control Agents

• Irritating agents, lacrimators, or tear gas
• Eye, nose, mouth, lung irritation
• Widely used as self-protection
• Effects last about 30 minutes

IMAGE USCG
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Riot Control Agents

• CN (Mace?)
• CS (tear gas)
• OC (oleoresin capsicum, capsaicin, pepper spray)
• DM (adamsite)

IMAGE SAIC
85
Riot Control Agents

• Medical management
• Most victims will not seek medical care
• Most effects over in 30 minutes
• lt 1 will need care of physician
• Patients seeking care MUST be decontaminated -
  high potential of cross-contamination
• Skin soap and cool water
• Eye irrigation
• Lungs bronchodilators, oxygen

IMAGE SAIC
86
Chemical Weapons Key Points

• Agent Effects Onset
• Nerve Vapor miosis, Seconds rhinorrhea,
  dyspnea
• Liquid SLUDGE Minutes Both seizures, apnea
  to hours
• Pulmonary Dyspnea, coughing Hours

87
Chemical Weapons Key Points

• Agent Effects Onset
• Vesicants Erythema, blisters, Hours eye
  irritation, cough, dyspnea
• (immediately after Lewisite)
• Cyanide Loss of consciousness, Seconds
  convulsions, apnea

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Summary

• Safe medical response to any hazardous materials
  incident
• Development and implementation of
• Local resources, protocols, policies
• ABCs, antidotes, decontamination
• Exercises, equipment
• Integration of multi-agency planning and training

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Questions
?