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101WEAPONS OF MASS DESTRUCTION

Aaron M. Eberhardt, MD, and Peter T. Pons, MD, FACEP

XIX.   EMERGENCY MEDICAL SERVICES SYSTEMS AND  MASS CASUALTY INCIDENTS

1. Whyisitimportantforemergencyphysicianstobefamiliarwithweaponsofmassdestruction(WMD)?Emergency physicians (EPs) play an integral role in the planning, preparation, and response to not only unintentional and natural disasters but also terrorist attacks. Casualities from these types of incidents will largely present to an ED, and EPs are increasingly being looked to to take an authoritative position in the management of a WMD event as well as future policy development.

2. Wehearaboutterrorismallthetime.Aren’twereadytorespond?Although almost 10 years have passed since the attacks of September 11, 2001, and much has been done to address the issue of terrorism prevention, EPs must continue to be guided by the recognition that the threat of terrorism will never be fully eliminated and that the ability to respond to these events must be maintained. Terrorists continue to refine their techniques and become more efficient at their craft. As such, the emergency medical community must maintain a clear understanding of chemical, biologic, radiologic, nuclear, and explosive (CBRNE) weapons and the ability to effectively respond to an event.

3. Don’twehaveHAZMATteamstodealwithnuclear,biologic,andchemical(NBC)attacks?Traditional HAZMAT events usually occur in a relatively well-confined area and usually with a known substance. This allows the HAZMAT team to contain the agent, decontaminate exposed individuals, and control patient flow as needed. NBC attacks will likely occur in population-dense areas to contaminate many people and create significant hysteria. This will make it almost impossible to manage the number of potential patients through a traditional HAZMAT process. A biological weapons attack does not lend itself to a traditional HAZMAT response at all, as a significant amount of time will likely have passed from release of the agent until recognition of the event.

4. Whatelseisuniqueaboutaterroristattack?Any site of a terrorist attack will automatically be a crime scene. The management of such an event will require the coordination of multiple federal, state, and local agencies. The impact of media coverage of a terrorist event will also require a strategic plan. In addition, the impact of a terrorist attack extends far beyond the people directly affected physically by the NBC attack. Terrorists have the objective to not only kill and destroy, but also to create fear.

5. Whatmakesagoodchemicalorbiologicweapon(inaterrorist’smind)?The weapon should create the greatest amount of devastation on its intended target. The goal is to create a weapon that is highly lethal or toxic and easy to disperse over large areas. The chemical or biological agent should be relatively stable in the environment so that it doesn’t break down too fast. All of this needs to be packaged in such a way that the agent can withstand the energy transfer that occurs during delivery. Lastly, an ideal agent and weapon is relatively easy to obtain and inexpensive to manufacture.

6. Whatshouldemergencyphysiciansdotoprepareandprotectthemselves?Emergency physicians must acquire the requisite knowledge about the clinical effects of these various agents, the symptom complex that occurs with each agent to allow for rapid

Chapter 101 WEAPONS OF MASS DESTRUCTION700

recognition, and perhaps, most importantly, the steps to take to protect themselves and ED staff from inadvertent exposure to one of these weapons. The type of personal protective equipment (PPE) needed varies depending upon the type of agent used in the attack.

7. DescribethelevelsofPPE.n Level A: This suit fully encapsulates the body and prevents water and vapor penetration.

Respiratory protection is provided by a self-contained breathing apparatus (SCBA) or supplied air. This level of protection is usually worn for the purpose of rescue, assessing, or mitigating a hazardous material event, often when the specific agent is unknown and may be immediately dangerous to life and health.

n Level B: Less protective than a level A suit. This is a full-body chemical suit with more limited vapor protection. Can be combined with a SCBA or supplied air to increase protection against vapor. This suit is usually worn by responders who have identified the material or agent and are conducting rescue operations or further incident assessment.

n Level C: This is a full-body chemical suit with respiratory protection provided by an ambient air-purifying respirator. Level C protection is appropriate for hospital personnel involved in decontamination.

n Level D: Minimal skin protection and no respiratory protection required.

RADIATION

8. Whatarethebasicphysicsofradiation?Atoms consist of a nucleus of protons and neutrons (except for hydrogen, which has no neutrons) surrounded by electrons. A given element may exist in the form of different isotopes, which have different numbers of neutrons. Some of these isotopes may emit particles or electromagnetic energy and are considered radioisotopes. Protection from these particles or energy is afforded by shielding, distance, and decreased time of exposure.

9. Whataretheunitsofradiation?See Table 101-1.

Radiation Absorbed Dose (Rad)Gray(Gy)

Measure of the energy deposited into matter (the body) by ionizing radiationBeing replaced by the International System unit the Gray (Gy)1 Gy 5 100 rads1 Gy 5 1 Joule/KgThe Gy dose is the total amount of energy absorbed per gram of tissue

Sievert (Sv)Radiation Equivalent, man (Rem)

The international unit for radiation equivalencyDifferent types of radiation have different effects on the body.These differences are adjusted by multiplying by a Quality Factor (QF)By definition, Gamma radiation has a QF of 1.1 Gy of pure gamma radiation 5 1 Sv1 Sv 5 100 Rem

TABLE 101–1. UNITS OF RADIATION

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10. Describethedifferenttypesofradiationandtheirshieldingrequirements.See Table 101-2.

11. Whatarethetypesofradiationinjury?n External irradiation—when all or a portion of the body is exposed to penetrating gamma

radiation from an external source. Significant cellular damage can occur. Following exposure, the patient is not radioactive and can be managed like any other patient with no threat to staff, such as a patient undergoing radiation therapy.

n Contamination—Radioactive particulate matter is released into the environment and contaminates the person externally, internally (swallowed or inhaled), or both. PPE should be worn when treating or decontaminating these patients.

Radiation Description Shielding

a-particles Consist of two neutrons and two protons that have been ejected from the nucleus of a radioactive atom

A doubly charged particle that loses its energy quickly in matter

Generally only dangerous if inhaled or swallowed

Stopped by paper

b-particles High-energy electrons that are emitted from a nucleus along with an antineutrino

Much smaller than a-particles and have only one charge

Like a-particles, they can cause damage if swallowed or inhaled.

May also cause cellular damage to unprotected skinLargely found in fallout radiation

Interact less with target material

Require plastic, glass, or thin metal

Some levels of PPE

g Not particles but rather uncharged pulses of very high-energy electromagnetic radiation

No mass or charge and only lose its energy when they collide with the electron shell of target atoms

Easily pass through the human bodyPotential to cause significant cellular damage

Concrete, earth, or dense metal such as lead

Neutrons Uncharged particles emitted during nuclear detonation; not a fallout hazard

About the same mass as a proton but no chargeBecause of this lack of charge, they interact directly

with the nucleus of target atom instead of its electrons.

Do not react well with material so they can travel large distances

Can cause previously stable atoms to become radioactive

Thick concrete or significant amount of earth

PPE, personal protective equipment.

TABLE 101–2. DIFFERENT TYPES OF RADIATION AND SHIELDING REQUIREMENTS

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n Incorporation—Refers to the uptake of radioactive material in cells, tissues, or organs. Contamination must occur for incorporation to occur. Incorporation allows for continued internal exposure and long-term injury and illness.

12. Whatarethedifferenttypesofattacks?n Environmental exposure (also known as simple radiologic device)—Placement of a

radioactive source in a public location or within the food or water supply. Although many people would be exposed with this method, very few would likely be significantly contaminated. This type of attack, however, would generate a significant amount of fear and panic.

n Radiological Dispersal Device (RDD)—a device designed to spread radioactive material for the purpose of terrorism by using conventional explosives to disperse the radioactive material; this is referred to as a dirty bomb. Most of the damage caused by this sort of weapon would be created primarily by the explosion, as the dissemination of radioactive material would be limited in effect. Exposed or contaminated individuals would be those in close proximity to the blast area.

n Attack/Sabotage of a nuclear reactor—could lead to significant release of radioactive material into environment.

n Nuclear bomb—Obviously the most potentially devastating attack. The least likely method of attack due to strict security measures of existing stockpiles and the money and technology needed to manufacture a new weapon.

13. Describethethreeacuteradiationsyndromes(ARS).n Bone marrow (hematopoietic syndrome)—This syndrome is caused by damage to stem

cells in the bone marrow resulting in a reduction in cell lines. Symptoms include bleeding and infection (low platelets and leukocytes). Usually occurs after exposure to between 0.7 and 10 Gy (70– 1,000 rads).

n Gastrointestinal (GI) syndrome—Irreversible destruction of the GI lining causing nausea, vomiting, and diarrhea. Survival is extremely unlikely as death is caused by overwhelming sepsis and electrolyte disturbances. Usually occurs after exposure to between 6 and 10 Gy (600–1,000 rads).

n Central nervous/cardiovascular syndrome—Symptoms include confusion, seizures, and coma. Death usually occurs within 3 days as a result of circulatory collapse and increased intracranial pressure caused by edema, vasculitis, and meningitis. The full syndrome will usually occur with a dose greater than approximately 50 Gy (5,000 rads) but can occur at lower levels. This is uniformly fatal and, in a mass casualty situation, such patients should be triaged to the expectant category.

14. DescribethefourstagesofARS.n Prodromal (Initial) stage: Symptoms include loss of appetite, nausea, vomiting, and diarrhea.

Symptoms occur minutes to days after the exposure. In general, the more rapid the onset of symptoms, the greater the radiation dose received by the victim and the poorer the outcome.

n Latent period: Resolution of symptoms experienced in the initial stage with the patient appearing relatively well. Can last hours to approximately 2 weeks.

n Manifest illness stage: Symptoms will vary depending on radiation dose. For doses ranging from 1 to 8 Gy (100 to 800 rad), symptoms are the result of suppression of the hematopoietic system (decreased leukocytes and platelets) and include infection and bleeding. For doses over 8 Gy (800 rads), the primary effects are on the lining of the intestines leading to diarrhea, fever, sepsis, and electrolyte disturbance.

n Recovery or death: Survival is highly unlikely with doses exceeding 10 Gy (1,000 rad).

15. Allthesenumbersaregreat,butwhatisthebottomline?n Exposure to 1 Gy is the threshold for nausea and vomiting, but no deaths from acute

radiation should occur at this level.n Exposure to 3.5 Gy will be 50% lethal at 60 days if untreated.n Exposure to 6.0 Gy is 100% lethal if untreated at 60 days.

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16. HowistheabsolutelymphocytecounthelpfulinevaluatingARS?See Table 101-3.

17. Whattreatmentoptionsareavailableforradiationexposure?A complete primary and secondary survey must be done to ensure that no other, acutely life-threatening injuries exist. After appropriate triage and decontamination, supportive care becomes the foundation of treatment. Local radiation injury should be treated in the same manner as burns with 18% of total body surface area being considered a major burn. Treatment of whole body irradiation becomes more complicated with numerous adjunctive medications that may be useful, including KI, diethylenetriaminepentaacetate (DTPA), Prussian blue, and Neupogen. Such patients should be considered to be immunocompromised and treated as such. There is an excellent overview of weapons of mass destruction in general and these treatments in particular on the Centers for Disease Control and Prevention (CDC) website.

18. What’sthedealwithpotassiumiodine(KI)tablets?Following a radiological or nuclear event, it is possible that radioactive iodine may be released. This radioactive iodine can lead to internal contamination through inhalation or ingestion. The thyroid gland will then absorb this radioactive iodine, which can lead to irreversible destruction of the gland. KI tablets contain stable (non-radioactive) iodine and, if given before exposure to radioactive iodine, can saturate the thyroid gland. This effectively blocks the thyroid from absorbing the radioactive iodine. The CDC website has an informational sheet about KI tablets including indications and appropriate dosing. This information can be found at: http://www.bt.cdc.gov/radiation/ki.asp

CHEMICAL WEAPONS

19. Listthecharacteristicsofchemicalweapons.n Volatility describes the tendency of a liquid to evaporate into a gas. Most chemical weapons

are liquids at normal atmospheric pressures and temperatures and are dispersed as fine liquid droplets after detonation. The more volatile a chemical is, the more quickly it will evaporate (e.g., phosgene and cyanide). Less volatile agents will remain liquids (e.g., VX and sulfur mustard). Also, all agents except hydrogen cyanide are heavier than air and will concentrate in low-lying places.

n Persistence is inversely related to volatility. Agents are categorized as non-persistent or persistent based on their ability to vaporize in less than or greater than 24 hours respectively. Persistent chemicals will remain on objects and patients longer, creating the potential for ongoing exposure and contamination.

From Koenig KL, Goans RE, Hatchett RJ, et al: Medical treatment of radiological casualties: current concepts. Ann Emerg Med 45:643–652, 2005.

Minimal Lymphocyte Count within 48 Hours of Exposure

Estimated Absorbed Dose (Gy) Prognosis

1,000–3,000 0–0.5 Likely no injury

1,000–1,500 1–2 Significant but good prognosis

500–1,000 2–4 Severe, may survive

100–500 4–8 Very severe, likely die

,100 .8 Will likely die

TABLE 101–3. ROLE OF THE ABSOLUTE LYMPHOCYTE COUNT

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n Toxicity is the ability of an agent to cause harm to a person. The usual measurement is the concentration-time product (Ct). This is the product of the concentration in the air times the amount of time a patient is exposed. One can go further and look at the LCt50, which is the Ct of a vapor or aerosol that will kill 50% of those exposed to the agent.

n Latency describes the time delay between when a patient is exposed to an agent and the clinical manifestation of signs and symptoms. Health care providers must be aware of this principle because victims who do not show any clinical signs or symptoms may still be exposed and need to be decontaminated and treated.

20. Whatarethedifferentclassesofchemicalweapons?See Table 101-4.

21. Describethepathophysiologyandclinicalsymptomscausedbynerveagents.Nerve agents are chemicals whose effects are similar to the organophosphate insecticides.

Class DescriptionSigns and  Symptoms

Examples and  Designation

Blister agents/vesicants

Damage cellular components and create blisters on dermal and mucosal surfaces minutes to hours later

Dyspnea, dermal irritation and pain, vesicles, conjunctivitis, possibly severe respiratory compromise

Lewisite (L) Nitrogen mustardPhosgene oximeSulfur mustard

Blood agents Absorbed into the bloodstream and interfere with aerobic metabolism

Dyspnea, chest pain, anxiety, flushed skin

Arsine (SA) Carbon monoxideCyanogen chloride (CK)Hydrogen cyanidePotassium cyanide (KCN)Sodium cyanide (NaCN) Sodium monofluoroacetate (compound 1080)

Caustics Directly burn and irritate mucous membranes, skin, and eyes

Burning and severe irritation, pulmonary irritation if inhaled

Hydrofluoric acid

Choking/ pulmonary agents

Irritate the lining of the lungs and throat, causing edema of the mucous membranes

Coughing, dyspnea, dysphagia, chest pain, eye irritation, burning sensation in throat

Ammonia Bromine (Br) Chlorine (Cl) Hydrogen chloride Phosgene (CG) Sulfuryl fluoride

Incapacitating agents

Cause altered mental status and affect victim’s ability to think clearly

Altered mental status, anticholinergic syndrome (BZ), opioid toxidrome

3-quinuclidinyl benzilate (BZ)Fentanyl (aerosolized)

TABLE 101–4. CLASSES OF CHEMICAL WEAPONS

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The nerve agents inhibit acetylcholinesterase at the postsynaptic nerve receptors. This leads to excessive acetylcholine accumulation and causes overstimulation of muscarinic and nicotinic receptors in the parasympathetic nervous system (PNS) and central nervous system (CNS), resulting in a clinical cholinergic toxidrome. Stimulation of muscarinic receptors causes activity of exocrine glands (e.g., salivation, bronchorrhea). Stimulation of the nicotinic receptors is responsible for muscle fasciculations, flaccid paralysis, hypertension, and tachycardia.

The clinical toxidrome is complex, involving many different organ systems. One of the best ways to remember the toxidrome is by the SLUDGE mnemonic which stands for: Salivation, Lacrimation, Urination, Defecation, GI symptoms, and Emesis. The patient can have life-threatening bronchorrhea and bronchospasm. The CNS symptoms can include seizure, coma, or apnea.

22. Howdeadlyarenerveagents?The dose of VX, which will kill half of exposed victims (LD50), is 10 mg (skin exposure) on a 70-kg man. To give you a frame of reference, this means that a drop of VX that is large enough to cover two columns of the Lincoln Memorial on the back of a U.S. penny is enough to kill half of exposed victims who have this amount placed on exposed skin.

23. Whatisthetreatmentfornerveagenttoxicity?Treatment is based on a three-pronged approach. Atropine is given to counteract the muscarinic effects, thereby drying up secretions and improving ventilation. Pralidoxime chloride (2-PAM) reverses the nicotinic effects of nerve agents, thereby reversing paralysis. When nerve agents combine with ACHE, a process called “aging” takes place during which a permanent covalent bond is formed and the enzyme is permanently deactivated. To be effective, 2-PAM must be

Class DescriptionSigns and  Symptoms

Examples and  Designation

Nerve agents Inhibit acetylcholinester-ase, thereby interfering with nerve transmission

Cholinergic toxidrome,salivation, lacrimation, paralysis

Sarin (GB)Soman (GD)Tabun (GA)VX

Riot control/tear gas

Very irritating but nonlethal agents used for crowd control and riot suppression

Mucous membrane irritation.Lacrimation, rhinorrhea, coughing, sneezing

Bromobenzylcyanide (CA)Chloroacetophenone (CN) Chlorobenzylidenemalone nitrile (CS)Chloropicrin (PS)Dibenzoxazepine (CR)

Vomiting agents

Ocular, nasal, and respiratory tract irritation; GI upset and vomiting

Vomiting starting minutes to hours after exposure

Adamsite (DM)

GI, gastrointestinal.

TABLE 101–4. CLASSES OF CHEMICAL WEAPONS—cont’d

From Emergency preparedness and response: chemical emergencies, Centers for Disease Control: www.bt.cdc.gov/chemical

Chapter 101 WEAPONS OF MASS DESTRUCTION706

administered before this happens. This time ranges from 2 minutes for Soman (GD) to 48 hours for VX. Finally, seizures are treated with diazepam. SeeTable 101-5 for specific dosages.

BIOLOGICAL AGENTS

24. Whatisbioterrorism?Bioterrorism is an attack in which there is the deliberate release of viruses, bacteria, or biologic toxins used to cause illness or death in people, animals, or plants.

25. Haveterroristsreallyusedbiologicalagents?Biological weapons have been used in warfare since antiquity. In the 14th and 15th centuries, warring armies would hurl plague-infected corpses over the walls of cities they were attempting to conquer. Accounts exist of biological weapons being used in both World War I and World War II. Many terrorist groups have used biological weapons as well. In 1984, 750 people in Oregon became sick after eating at salad bars in four different restaurants that had been intentionally laced with Salmonella by the Bagwan Sri Rajneesh sect. Beginning September 18, 2001, anthrax spores were sent via the U.S. mail system. This attack led to 22 cases of inhalational and cutaneous anthrax, including five fatalities.

26. Doesn’tthemanufacturingofbiologicalagentsrequirealotofmoneyandsophisticatedequipment?The manufacture and dispersal of a biological agent is significantly easier to accomplish than a nuclear attack. The previously mentioned incidents with Salmonella and anthrax demonstrate how easily this can happen.

Patient Age Mild to Moderate Symptoms Severe Symptoms

Infant (0–2) Atropine: 0.05 mg/kg IM or 0.02 mg/kg IV2 PAM: 15 mg/kg IV slowly

Atropine: 0.1 mg/kg IM or 0.02 mg/kg IV2 PAM: 15 mg/kg IV slowly

Child (2–10) Atropine: 1 mg/kg IM2 PAM: 15 mg/kg IV slowly

Atropine: 2 mg/kg IM2 PAM: 15 mg/kg IV slowly

Adolescent (10–18) Atropine: 2 mg IM2 PAM: 15 mg/kg IV slowly

Atropine: 4 mg IM2 PAM: 15 mg/kg IV slowly

Adult Atropine: 2–4 mg IM2 PAM: 15 mg/kg (1.0 gram) IV slowly

Atropine: 6 mg IM2 PAM: 15 mg/kg (1.0 gram) IV slowly

Notes:

1. May repeat atropine (2 mg IM or 1 mg IM for infants) every 5–10 minutes until secretions dry and breathing become more comfortable.

2. Phentolamine can be used for 2PAM-induced hypertension (5 mg IV for adults and 1 mg IV for children)

3. Diazepam can be used for seizures.

IM, intramuscularly; IV, intravenously.

TABLE 101–5. TREATMENT FOR NERVE AGENT TOXICITY

From Department of Health and Human Services. Agency for Toxic Substances and Disease Registry. Medical Management Guidelines for Nerve Agents: Tabun (GA); Sarin (GB); Soman (GD); GF; and VX. http://www.atsdr.cdc.gov/MHMI/mmg166.html

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27. Howarebiologicalattacksdifferentfromexposuretoradiationorchemicalagents?A biological attack creates two significant challenges not present with a radioactive exposure or chemical attack. First, the development of symptoms can be delayed. Second, symptoms may initially be very non-specific and initially be attributed to a less serious cause. These factors will likely lead to a significant delay in recognition and therefore the ability to appropriately respond to a biological attack. If the agent used is highly communicable, an epidemic could develop very quickly.

28. HowdoestheCDCcategorizebiologicalagents?The CDC prioritizes biological agents into three categories (A, B, and C), based on the characteristics of the agents, including ease of dissemination and transmission and ability to create a significant negative impact on public health infrastructure. The U.S. Public Health System and primary health care providers, including emergency physicians, must be prepared to address various biologic agents, including pathogens that are rarely seen in the United States.n Category A:

Definition: High-priority agents include organisms that pose a risk to national security because they can be easily disseminated or transmitted from person to person, result in high mortality rates and have the potential for major public health impact, might cause public panic and social disruption, and require special action for public health preparedness.

Examples: Anthrax (Bacillus anthracis), botulism (Clostridium botulinum toxin), Plague (Yersinia pestis), smallpox (Variola major), tularemia (Francisella tularensis), viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])

n Category B: Definition: Second highest priority agents include those that are moderately easy to

disseminate, generally result in moderate morbidity rates and low mortality rates, and require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance.

Examples: Brucellosis (Brucella species), epsilon toxin of Clostridium perfringens, food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella), Glanders (Burkholderia mallei), melioidosis (Burkholderia pseudomallei), psittacosis (Chlamydia psittaci), Q fever (Coxiella burnetii), ricin toxin from Ricinus communis (castor beans), staphylococcal enterotoxin B, typhus fever (Rickettsia prowazeki), viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]), water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

n Category C: Definition: Third highest priority agents include emerging pathogens that could be

engineered for mass dissemination in the future because of availability, ease of production and dissemination, and potential for high morbidity and mortality rates and major health impact

Examples: Emerging infectious diseases such as Nipah virus and hantavirus

29. Whatarethegeneraldescriptivecharacteristicsofbiologicalagents?See Table 101-6.

30. Givemethebasicsaboutanthrax.Bacillus anthracis is an encapsulated, Gram positive, spore-forming bacterium. The spores are highly resistant to environmental factors, allowing them to survive for decades. Anthrax can manifest in three forms: inhalational, GI, and cutaneous. After a biological attack, the aerosolized anthrax spores are inhaled, taken up by macrophages in the lung, and transported

Chapter 101 WEAPONS OF MASS DESTRUCTION708

to mediastinal lymph nodes where they transform into a vegetative state. Once the bacteria start replicating, they produce toxins that cause edema (edema factor) and hemorrhage and necrosis (lethal factor).

31. Whatarethesignsandsymptomsofanthrax?Cutaneous anthrax begins with an area of localized redness and swelling and progresses to a painless, necrotic black lesion or ulcer. GI anthrax presents with stomach pain, fever, diarrhea, and loss of appetite. Inhalational anthrax initially is a very nonspecific, flu-like syndrome with fever, nausea, vomiting, muscle aches, and fatigue. This can quickly progress to difficulty breathing, respiratory failure, shock, and death. Of 10 patients presenting with inhalational anthrax in the 2001 attacks, all had fever, chills, malaise, and fatigue. Most of the patients developed cough, chest discomfort, and dyspnea. Chest radiograph abnormalities were universal and included widened mediastinum, pleural effusions, air bronchograms, necrotizing pneumonic lesions, or consolidations.

32. HowshouldItreatanthrax?Current CDC recommendations for inhalational anthrax include ciprofloxacin and doxycycline, plus one or two additional antibiotics. For cutaneous anthrax, ciprofloxacin and doxycycline also are first-line therapy. A potential for reactivation of latent infection may exist. Therefore, persons with cutaneous anthrax associated with this attack should be treated for 60 days. A recent addition to the Strategic National Stockpile is raxibacumab (ABthraxtm), which is a monoclonal antibody active against the factor produced by anthrax that allows edema factor and lethal factor to enter a cell. Animal studies have shown great promise for benefit of this new medication.

From Public health response to biological and chemical weapons: WHO guidance (2004). www.who.int/csr/delibepidemics/biochemguide/en/

Infectivity The ability of an agent to enter, multiply, and survive in a host

ID50 is the dose that would infect 50% of an exposed population

Virulence The relative severity of the disease

Different strains of the same agent can cause varying severities of disease

Incubation period Time between exposure and onset of symptoms

Lethality The ability of an agent to cause death

Contagiousness Measured by the number of secondary cases occurring after exposure to the primary case

Mechanisms of transmission Manner by which the disease is transmitted (i.e., respiratory, blood borne, vector borne, food contamination)

TABLE 101–6. GENERAL CHARACTERISTICS OF BIOLOGIC AGENTS

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33. Whatothersourcesareavailabletolearnmoreaboutbiologicalweapons?The Journal of the American Medical Association (JAMA) has a series of articles titled: Medical and Public Health Management Following the Use of a Biological Weapon: Consensus Statements of the Working Group on Civilian Biodefense. They are available through the JAMA website:n Anthrax: jama.ama-assn.org/cgi/reprint/287/17/2236.pdfn Botulism: jama.ama-assn.org/cgi/reprint/285/8/1059.pdfn Hemorrhagic fevers: jama.ama-assn.org/cgi/reprint/287/18/2391.pdfn Plague: jama.ama-assn.org/cgi/reprint/283/17/2281.pdfn Smallpox: jama.ama-assn.org/cgi/reprint/281/22/2127.pdfn Tularemia: jama.ama-assn.org/cgi/reprint/285/21/2763.pdfThe CDC also maintains extensive information on biological weapons including case definitions. You can access this information by going to: http://emergency.cdc.gov/bioterrorism/

34. HowshouldIprotectmyselfwhenIamcaringforpatientsexposedtobiologicalweapons?Universal precautions should be observed at all times when dealing with a biological event. The following table lists person-to-person transmissibility and isolation requirements by biological agent, when known. If the agent causing the patient’s symptoms is unknown, as it likely will be on initial presentation to the ED, strict isolation precautions should be utilized. See Table 101-7.

35. HowwillIrecognizeifabiologicalattackhasoccurred?Recognizing a biological attack can be very difficult for the reasons that have already been stated. In general, disease pattern recognition will be vital to the early identification of a biologic event. In 2000, Dr. Paul Rega published a list of covert assault clues that can aid clinicians in this process. These covert assault clues are as follows:n Severe manifestations of disease in previously healthy peoplen Greater than normal numbers of patients with fever, respiratory, or GI complaintsn Multiple patients with similar complaints from a common locationn An endemic disease that occurs during an unusual time of yearn An unusual number of rapidly fatal casesn A greater number of sick or dead animalsn Rapidly rising and falling epidemic curven Larger number of patients with severe pneumonia, sepsis, sepsis with coagulopathy, fever

with rash, or diplopia with progressive weakness

Illness Person to Person? Isolation Required?

Anthrax No No

Botulism No No

Hemorrhagic fevers Yes Yes

Plague Yes (pneumonic form) Yes

Smallpox Yes Yes

Tularemia Likely not No

TABLE 101–7. TRANSMISSIBILITY AND ISOLATION REQUIREMENTS FOR BIOLOGICAL WEAPONS

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36. WhatshouldIdoifIsuspectanattackhasoccurred?Every emergency provider should familiarize themselves with their hospital’s internal disaster plan and reporting process. Early involvement of local and state public health is important for both diagnostic and epidemiologic followup. The CDC provides a mechanism to report an incident as well as helpful phone numbers that may be needed during the management of an incident. This information can be accessed at the CDC’s Emergency Preparedness and Response website located at: http://emergency.cdc.gov/

EXPLOSIVES

37. Withalltheseotherhighlyeffectiveandlethalterroristweapons,aretheyreallystillusingexplosives?Absolutely. The widespread use of NBC weapons is significantly limited as they are expensive to acquire and difficult to manufacture in an effective dispersal mechanism. Explosive devices are much easier to acquire and are increasingly being improvised to create maximal body counts. In the year 2008, worldwide, over 8,000 people were killed in terrorist attacks by bombing or combined bombing/arson. There has also been a significant increase in “high-fatality attacks” (those killing more than 10 people), many of which are carried out using explosive devices. From 2004 to 2006, approximately 205 people were injured or killed in the United States as a result of criminal bombing incidents.

38. Describethefiveblastinjurycategoriesafterexplosions.n Primary: The direct effect produced by contact from the blast shockwave with the body.

This creates shear and stress forces on tissues. Typical injuries include tympanic membrane (TM) rupture, blast lung, ocular injuries, and concussions.

n Secondary: Injury produced by impact of primary fragments (pieces of the exploding device) or secondary fragments (fragments from the surrounding environment). Typical injuries include penetrating trauma, amputations, or lacerations.

n Tertiary: Injuries created when the blast wave propels victims’ bodies into objects or large objects strike the body. Typical injuries include crush injuries and blunt trauma.

n Quaternary: Effects include burns, inhalational injury, exposure to toxic substances, and injury from environmental contamination that was created as the result of the explosive device.

n Quinary: Injuries resulting from additives such as bacteria or radiation (dirty bombs).

39. Isthereaquickscreeningmethodtotriagevictimsofblastinjuries?Otoscopic examination of the TM is a quick (but not foolproof) way to assess the severity of blast injury. The TM can be ruptured by an increase in atmospheric pressure as low as 5 psi above normal. If there is no TM rupture, then the chance of hollow organ injury is significantly lower. It is not zero, however. It was found that in 17 critically injured patients after the Madrid train bombing in 2004, 13 had ruptured TMs, but 4 did not. Obviously, if other symptoms such as shortness of breath are present, one must suspect other injuries.

40. Whatisblast lung?Blast lung is the term used to describe the significant pulmonary barotrauma after a high-order explosive detonation. The blast wave’s impact with the lung causes tearing, hemorrhage, contusion, and edema with resultant ventilation-perfusion mismatch. Blast lung is a clinical diagnosis characterized by respiratory difficulty and hypoxia.

In general, blast lung is treated similarly to any other pulmonary contusion. Patients exposed to a significant explosion who have normal chest radiographs, normal arterial blood gases, and no complaints that would suggest blast lung injury can be considered for discharge after 4 to 6 hours of observation.

Chapter 101 WEAPONS OF MASS DESTRUCTION 711

DECONTAMINATION

41. WhatshouldIknowaboutdecontamination?Decontamination is a critical aspect of the medical management of NBC attacks. The benefits of decontamination are threefold. It protects the patient from continued injury due to residual agent on the patient’s clothes or skin, the health care providers from exposure and injury, and the health care facility itself, allowing it to remain open and to care for more patients.

42. HowdoIdecontaminatevictimsofchemicalexposure?Decontamination of patients exposed to chemical agents should ideally be performed in the prehospital setting. However, hospitals should be prepared to provide decontamination outside of the ED for the patients that will inevitably self-present for evaluation and care. Hospital staff members involved in the decontamination process should utilize Level C protection. Wet decontamination is the method of choice for liquid chemical exposure. Patients should first have their clothes removed, maintaining as much modesty as possibly. Soap and copious amounts of water should then be applied and are considered adequate for decontamination. While a variety of neutralizing solutions, such as dilute bleach solution, have been suggested as decontamination solutions, most are not used in the hospital setting as they require prolonged contact time (15-20 minutes) and have the potential for causing additional skin injury.

43. HowdoIdecontaminateapatientthathasbeenexposedtoradioactivematerial?Once the patient is removed from the radiological hazardous environment, standard PPE is adequate for decontamination personnel (scrubs, masks, gloves, eye protection, and shoe coverings). Decontamination personnel should be equipped with dosimeters to monitor radiation exposure. Decontamination can then be broken down into two components:n Gross Decontamination: This involves removing all of the patient’s clothes and bagging the

clothes appropriately. The patient should then be washed with copious amounts of soap and water or the commercially available 0.5% hypochlorite solution. Care must be taken to avoid washing contaminated water towards mucous membranes. Care must also be taken to not abrade the skin as radionuclides can be absorbed through skin abrasions. This process will successfully remove approximately 95% of the contamination.

n Secondary Decontamination: This is a meticulous process to ensure the patient is fully decontaminated. Eyes, ears, mucous membranes, and wounds should be swabbed, and the swabs should be analyzed for radioactivity. Additionally, these same areas should be copiously irrigated. The patient’s eyes should be anesthetized and copiously irrigated. The ears should be checked for perforated TMs and irrigated copiously if intact. Dentures should be removed and the mouth rinsed copiously without swallowing the rinse water. Wounds should also be irrigated and covered with waterproof dressings to avoid run-off contamination from irrigating other areas. The hospital’s radiation safety officer should be involved with this process.

44. Howarevictimsofbiologicagentexposuredecontaminated?In most cases, victims of a biologic attack will present when they become clinically ill. This finding indicates that the exposure occurred days earlier, in which case decontamination is not necessary. Only in those instances of recognized powder exposure is decontamination required. As with chemical exposure, decontamination personnel must use appropriate PPE during the decontamination process. Clothing should be removed and then showering with soap and water accomplished.

Chapter 101 WEAPONS OF MASS DESTRUCTION712

1. The ideal terrorist weapon is cheap, easy to manufacture, easy to disseminate, and will produce large numbers of casualties.

2. The most likely WMD to be used by a terrorist is a conventional explosive.

3. A chemical agent attack will generally be recognized by having a large number of casualties present with similar symptoms over a short period of time in a relatively small geographic area.

4. In the event of a biological agent attack, all patients should be considered to be infectious until a definitive diagnosis of a nontransmissible agent is confirmed.

5. The most likely radiologic incident will be a dirty bomb, i.e., radiologic dispersal device that involves using a conventional explosive to disperse some radioactive material.

KEY POINTS: WMD

WEBSITES

Anthrax: http://www3.niaid.nih.gov/topics/anthrax/overview.htm

Biological weapons: http://emergency.cdc.gov/bioterrorism/

Bioterrorism agents: http://emergency.cdc.gov/agent/agentlist-category.asp#catdef

CDC’s Emergency Preparedness and Response website located at: http://emergency.cdc.gov/

Journal of the American Medical Association: http://jama.ama-assn.org

KI tablets: http://www.bt.cdc.gov/radiation/ki.asp

U.S. Department of Health & Human Services: http://www.hhs.gov/disasters/emergency/manmadedisasters/bioterorism/index.html

BIBLIOGRAPHY

1. Bushberg JT, Kroger LA, Hartman MB, et al: Nuclear/radiological terrorism: emergency department management of radiation casualties. J Emerg Med 32(1);71–85, 2007.

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3. CDC, Emergency preparedness and response: chemical emergencies, Centers for Disease Control: www.bt.cdc.gov/chemical

4. CDC, Emergency preparedness and response: radiation emergencies. Centers for Disease Control: www.bt.cdc.gov/radiation

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12. Karwa M, Currie B, Kvetan V: Bioterrorism: preparing for the impossible or the improbable. Crit Care Med 33:1, 2005.

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16. Medical management of radiologic casualties handbook, ed 2, Bethesda, MD, 2003, Military Medical Operations, Armed Forces Radiobiology Research Institute,www.afrri.usuhs.mil/outreach/pdf/2edmmrchandbook.pdf.

17. Mettler FA, Voelz GL: Major radiation exposure-What to expect and how to respond. N Engl J Med 346:1554–1561, 2002.

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20. Public health response to biological and chemical weapons: WHO guidance. 2004: http://www.who.int/csr/delibepidemics/biochemguide/en/

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