1® BDLS is a registered trademark of the American Medical Association® BDLS is a registered trademark of the American Medical AssociationV 2.9 04/07V 2.9 04/07

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““Preparing Our Communities”Preparing Our Communities”

Welcome!Welcome!

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Faculty DisclosureFaculty Disclosure

• For Continuing Medical Education (CME) purposes as required by For Continuing Medical Education (CME) purposes as required by the American Medical Association (AMA) and other continuing the American Medical Association (AMA) and other continuing education credit authorizing organizations:education credit authorizing organizations:– In order to assure the highest quality of CME programming, the AMA In order to assure the highest quality of CME programming, the AMA

requires that faculty disclose any information relating to a conflict of requires that faculty disclose any information relating to a conflict of interest or potential conflict of interest prior to the start of an interest or potential conflict of interest prior to the start of an educational activity. educational activity.

– The teaching faculty for the BDLS course offered today have no The teaching faculty for the BDLS course offered today have no relationships / affiliations relating to a possible conflict of interest to relationships / affiliations relating to a possible conflict of interest to disclose. Nor will there be any discussion of off label usage during disclose. Nor will there be any discussion of off label usage during this course. this course.

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Chemical EventsChemical Events

Chapter 6Chapter 6

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OverviewOverview

• Examples of chemical disasters / terrorismExamples of chemical disasters / terrorism

• Review Classes of Chemical WeaponsReview Classes of Chemical Weapons

• D-I-S-A-S-T-E-RD-I-S-A-S-T-E-R Paradigm for chemicals Paradigm for chemicals

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Industrial AccidentsIndustrial Accidents

• Bophal, Indial 1984Bophal, Indial 1984

• 40 Tons of Methyl 40 Tons of Methyl Isocyanate released Isocyanate released

• Population of 900,000Population of 900,000– 6,000-10,000 immediate 6,000-10,000 immediate

problemsproblems– Up to 400,000 delayed Up to 400,000 delayed

health issueshealth issues

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Transportation EventsTransportation Events

• Releases of Hazardous Material occur Releases of Hazardous Material occur almost daily in the USAalmost daily in the USA

• Events requiring patient decontamination Events requiring patient decontamination are less frequentare less frequent

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Chemicals as WeaponsChemicals as Weapons

First large-scale use in First large-scale use in World War IWorld War I

• Ypres, BelgiumYpres, Belgium– April 1915April 1915– Chlorine, 168 tonsChlorine, 168 tons– 5,000 deaths5,000 deaths– 5 mile front5 mile front

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Chemical Casualties in WWIChemical Casualties in WWI

9,0009,000191,000191,000GermanyGermany

3,0003,00097,00097,000Austria-Austria-HungaryHungary

1,4621,46271,34571,345U.S.U.S.4,6274,62755,37355,373ItalyItaly

56,00056,000419,340419,340RussiaRussia8,0008,000182,000182,000FranceFrance8,1098,109180,597180,597BritainBritain

DeathsDeathsNon-fatalNon-fatalCountryCountry

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Terrorist Use of Chemical WeaponsTerrorist Use of Chemical Weapons

• Tokyo Subway 1995Tokyo Subway 1995

• Sarin Nerve AgentSarin Nerve Agent– 5,500 victims5,500 victims– 11 Dead11 Dead

• 641@ St. Luke’s 641@ St. Luke’s International HospitalInternational Hospital– Poor decontaminationPoor decontamination– Limited EMS Limited EMS

involvementinvolvement

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Agents of OpportunityAgents of Opportunity• Toxic industrial Toxic industrial

chemicalschemicals– AvailableAvailable– Easier to obtain/targetEasier to obtain/target

• Poisoning consumer Poisoning consumer productsproducts

• Examples:Examples:– Chlorine Tank Bombs in Chlorine Tank Bombs in

Iraq Iraq – 1982 Tylenol tampering 1982 Tylenol tampering

incidentincident

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Chemical WeaponsChemical Weapons

BZ, Others?BZ, Others?Incapacitating Incapacitating agentsagents

Mustard, Lewisite, Mustard, Lewisite, Phosgene OximePhosgene Oxime

VessicantsVessicants

Phosgene, chlorine, Phosgene, chlorine, ammonia, pepper sprayammonia, pepper spray

Irritant Irritant AgentsAgents

CyanidesCyanidesBlood AgentsBlood AgentsTabun, Sarin, Soman, VXTabun, Sarin, Soman, VXNerve AgentsNerve Agents

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• Organophosphate chemicalsOrganophosphate chemicals– Similar to common insecticidesSimilar to common insecticides– Very high lethalityVery high lethality

• Liquids that are vaporized to disseminateLiquids that are vaporized to disseminate– Rapidly toxic if inhaledRapidly toxic if inhaled– Slower onset with dermal exposureSlower onset with dermal exposure

Nerve AgentsNerve Agents

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Nerve Agent PropertiesNerve Agent Properties

Sarin Soman Tabun VX HouseholdInsecticide

Aging5

hours5

minutes14

hours48

hours12-24 hours

DermalLD 50

1700mg

100mg

1000mg

10mg

> 35,000 mg

InhaledLCt 50

100 mg/m3

50mg/m3

400mg/m3

10mg/m3 > 250 mg/m3

Volatility High High High Low Very Low

Persistence Low Low Low HighIntermediat

e

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CholinesteraseCholinesterase

AcetylcholineAcetylcholine

Cholinergic Cholinergic ReceptorReceptor

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Acetylcholine MetabolismAcetylcholine Metabolism

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CholinesteraseCholinesterase

AcetylcholineAcetylcholine

OrganophosphateOrganophosphate

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Organophosphate Poisoning Organophosphate Poisoning Signs and Symptoms Signs and Symptoms

DD: defecation: defecation

UU: urination: urination

MM: miosis : miosis

BB: BRONCHORRHEA,: BRONCHORRHEA,

BRONCHOSPASMBRONCHOSPASM

EE: emesis : emesis

LL: lacrimation : lacrimation

SS: secretions/ : secretions/ seizuresseizures

Muscarinic effectsMuscarinic effects

MM: mydriasis : mydriasis

TT: tachycardia: tachycardia

WW: weakness: weakness

ttHH: hypertension: hypertension

FF: fasciculation: fasciculation

SS: seizures: seizures

Nicotinic effectsNicotinic effects

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Acetylcholinesterase InhibitionAcetylcholinesterase Inhibition

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Nerve Agent ExposureNerve Agent Exposure

• Low exposureLow exposure– Miosis, dim vision, eye painMiosis, dim vision, eye pain– RhinorrheaRhinorrhea– DyspneaDyspnea– Localized sweating & fasiciulation (liquids)Localized sweating & fasiciulation (liquids)

• High exposureHigh exposure– Immediate loss of consciousnessImmediate loss of consciousness– SeizuresSeizures– ApneaApnea– Flaccid paralysisFlaccid paralysis

• Vapor – effects occur within secondsVapor – effects occur within seconds• Liquids – onset may be delayedLiquids – onset may be delayed

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Nerve Agents: TreatmentNerve Agents: Treatment

• ABC’s, supportive careABC’s, supportive care

• AntidotesAntidotes–AtropineAtropine

• 2 mg IV, IM or ET2 mg IV, IM or ET

–Pralidoxine (2-PAM)Pralidoxine (2-PAM)• 1 gram slow IV or Autoinjector IM (600 mg)1 gram slow IV or Autoinjector IM (600 mg)

– Benzodiazepines, PRN for seizuresBenzodiazepines, PRN for seizures

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AcetylcholineAcetylcholine

CholinesteraseCholinesterase

OrganophosphateOrganophosphate

AtropineAtropine

2 PAM2 PAM

MuscarinicMuscarinicNicotinicNicotinic

ReceptorsReceptors

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Atropine DosingAtropine Dosing

• Starting dose - 2 mgStarting dose - 2 mg• Maximum cumulative dose - 20 mgMaximum cumulative dose - 20 mg

– Insecticide poisoning may require moreInsecticide poisoning may require more

• Atropine – How much to give?Atropine – How much to give?– Until secretions are drying or dryUntil secretions are drying or dry– Until ventilation is easyUntil ventilation is easy– If conscious or comfortableIf conscious or comfortable– Do not rely on heart rate or pupil sizeDo not rely on heart rate or pupil size

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Irritant GassesIrritant Gasses

• Common industrial chemicalsCommon industrial chemicals– Agent of opportunityAgent of opportunity

• Combine with moisture to Combine with moisture to form acids or basesform acids or bases– Low concentration = Low concentration =

Minor irritationMinor irritation– High concentration or High concentration or

prolonged exposure = prolonged exposure = Chemical burnsChemical burns

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Irritant Gas Site of InjuryIrritant Gas Site of Injury

Highly water soluble

Moderately water soluble

Poorly water soluble

AmmoniaAmmonia

ChlorineChlorine

PhosgenePhosgene

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Irritant Gases: TriageIrritant Gases: Triage

• Majority – Worried well?Majority – Worried well?

• Airway compromise – P1, immediateAirway compromise – P1, immediate• Severe shortness of breath- P1, immediateSevere shortness of breath- P1, immediate• Mild SOB, No airway compromise – P2, delayedMild SOB, No airway compromise – P2, delayed• Mild mucous membrane symptoms – P3, minimalMild mucous membrane symptoms – P3, minimal• Respiratory arrest – P4, expectantRespiratory arrest – P4, expectant

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Irritant Gases: TreatmentIrritant Gases: Treatment

• Dry decontamination usually adequateDry decontamination usually adequate• Water for mucous membrane irritationWater for mucous membrane irritation• ABC’s & Oxygen PRNABC’s & Oxygen PRN• Early airway management Early airway management

– highly and moderately water soluble exposureshighly and moderately water soluble exposures

• Inhaled beta agonist PRN wheezingInhaled beta agonist PRN wheezing• Observation and support Observation and support

– phosgene 12- 24 hrs?phosgene 12- 24 hrs?

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Cyanide CompoundsCyanide Compounds

• Widely used in IndustryWidely used in Industry

• Cyanide gas is rapidly lethalCyanide gas is rapidly lethal• Oral poisoning is slowerOral poisoning is slower

• Odor “bitter almonds”? – “musty” smellOdor “bitter almonds”? – “musty” smell– Odor not a reliable indicatorOdor not a reliable indicator

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Cyanide in SmokeCyanide in Smoke

• Burning wool, plastic and Burning wool, plastic and other materials releases other materials releases cyanide gascyanide gas

• May play a significant May play a significant role in smoke inhalation role in smoke inhalation and fire-related deathsand fire-related deaths

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Cyt c Cyt a cyt a3+ Cu

ADP ATP

O2 + H+

H20

OO22

OO22 OO22

OO22

Metabolic AcidosisMetabolic Acidosis

Cyanide Blocks Use of OxygenCyanide Blocks Use of Oxygen

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Cyanide - SourcesCyanide - Sources

• Pits of many plantsPits of many plants– Cherries, peaches, almonds, lima beansCherries, peaches, almonds, lima beans– Cassava plant rootCassava plant root

• Combustion of carbon -> cyanideCombustion of carbon -> cyanide– Plastics- acrylonitrilesPlastics- acrylonitriles

• U.S. sources manufacture 300,000 tons of hydrogen U.S. sources manufacture 300,000 tons of hydrogen cyanide annuallycyanide annually

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Cyanide TriageCyanide Triage

• M-A-S-S TriageM-A-S-S Triage

• Likely few critical victimsLikely few critical victims– Most either deadMost either dead

– Others with minor exposureOthers with minor exposure

• Good supportive care may save Good supportive care may save many in absence of antidotemany in absence of antidote

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Cyanide TreatmentCyanide Treatment• Remove to Fresh AirRemove to Fresh Air• Oxygen, supportive careOxygen, supportive care

• Antidotes ?Antidotes ?–3 Drug Antidote Kit3 Drug Antidote Kit–HydroxocobalaminHydroxocobalamin

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Fe2+Hb

Fe3+MetHb

Amyl NitriteInhale for 30 sec

Sodium Nitrite300mg IV

Fe3+

Sodium Thiosulfate12.5g IV

ThiocyanateExcreted in urine

Fe3+ Cyt a3

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HydroxocobalaminHydroxocobalamin

• Hydroxocobalamin – 5 g IVHydroxocobalamin – 5 g IV– Vit. B12aVit. B12a

• Chelates CyanideChelates Cyanide– Need 50:1 ratioNeed 50:1 ratio

• CyanocobalaminCyanocobalamin– Vit. B12 – nontoxic!Vit. B12 – nontoxic!

CN

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Blister Agents/VesicantsBlister Agents/Vesicants

Sulfur MustardSulfur Mustard Also - Lewisite, Phosgene oximeAlso - Lewisite, Phosgene oxime

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MustardMustard

• Most widely used chemical weaponMost widely used chemical weapon

• Morbidity is higher than mortalityMorbidity is higher than mortality

• Garlic odorGarlic odor

• Freezes at 57 FFreezes at 57 F

• Penetrates Penetrates rubber rubber glovesgloves

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Mustard MechanismMustard Mechanism

• Penetrates cells and generates toxic Penetrates cells and generates toxic intermediateintermediate

• Alkylates Alkylates – DNA/RNA, ProteinsDNA/RNA, Proteins

• Rapidly dividing cells most Rapidly dividing cells most susceptiblesusceptible

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Vesicant SymptomsVesicant Symptoms

• Onset of symptoms ?Onset of symptoms ?–High vs low doseHigh vs low dose

• Topical – Eyes, Airway, SkinTopical – Eyes, Airway, Skin• Binds Irreversibly within Binds Irreversibly within

minutes “Fixing”minutes “Fixing”• Systemic effects ?Systemic effects ?

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Mustard - SkinMustard - Skin

• Erythema 2-24 hoursErythema 2-24 hours

• Small vesicles may Small vesicles may coalesce to form coalesce to form bullaebullae

• High dose exposure – High dose exposure – central zone of central zone of coagulationcoagulation necrosisnecrosis

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Vesicant TreatmentVesicant Treatment

• Immediate decontamination (~2 minutes)Immediate decontamination (~2 minutes)– Victim may not undergo decontamination since Victim may not undergo decontamination since

symptoms delayedsymptoms delayed– Remove clothes and wash skin with soap and waterRemove clothes and wash skin with soap and water

• Avoid overhydration; fluid losses less than with Avoid overhydration; fluid losses less than with thermal burnsthermal burns

• Possible antidotesPossible antidotes– N-acetylcystiene (NAC) for MustardN-acetylcystiene (NAC) for Mustard– Dimercaperol (BAL) for LewisiteDimercaperol (BAL) for Lewisite

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Incapacitating AgentsIncapacitating Agents

• Not meant to be lethalNot meant to be lethal– ““Inability to perform one’s Inability to perform one’s

mission”mission”

• BZ (quinuclidinyl benzilate)BZ (quinuclidinyl benzilate)– Aerosolized Anticholinergic Aerosolized Anticholinergic – 25x more potent than atropine25x more potent than atropine

• Others possibleOthers possible– BenzodiazepinesBenzodiazepines– Opiate derivativesOpiate derivatives– PsychedelicsPsychedelics

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BZ: TreatmentBZ: Treatment

• Control patientControl patient

• Consider benzodiazepinesConsider benzodiazepines

• KEEP VICTIM COOLKEEP VICTIM COOL

• PhysostigminePhysostigmine– 1-2 mg IV1-2 mg IV– atropine at bedsideatropine at bedside– seizures and cardiac arrhythmias rareseizures and cardiac arrhythmias rare

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D: D: DetectionDetection I:I: Incident CommandIncident CommandS:S: Safety & Security Safety & SecurityA:A: Assess Hazards Assess HazardsS:S: Support SupportT:T: Triage & Treatment Triage & TreatmentE:E: Evacuation EvacuationR:R: Recovery Recovery

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D:D: DetectionDetection

• Clinical presentationClinical presentation

• Detection devices Detection devices

• Information sourcesInformation sources

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Clinical DetectionClinical Detection

• Rapid symptom onsetRapid symptom onset• Multiple victims and civilian panicMultiple victims and civilian panic

– Similar signs and symptomsSimilar signs and symptoms– Present at same timePresent at same time– History of similar site exposureHistory of similar site exposure– Absence of traumatic injuriesAbsence of traumatic injuries

• Toxidromes Toxidromes – will guide treatment at hospital will guide treatment at hospital

• Unusual or irritating odorsUnusual or irritating odors•

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Chemical Detection ToolsChemical Detection Tools

All have limited ranges of substancesAll have limited ranges of substances

• Chemical Detection PapersChemical Detection Papers– Concentrated vapors or liquidsConcentrated vapors or liquids

• Air Sampling DevicesAir Sampling Devices– Vapors or gasses in low concentrationVapors or gasses in low concentration

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Shipping Papers & PlacardingShipping Papers & Placarding

• ANYANY hazardous material being transported hazardous material being transported must have documents identifying the HazMatmust have documents identifying the HazMat

• Large shipments are placardedLarge shipments are placarded• Placard identifies the type of chemical Placard identifies the type of chemical • Emergency Response GuidebookEmergency Response Guidebook• Decodes ID# and provides informationDecodes ID# and provides information

– Health and fire hazardsHealth and fire hazards– Protective Equipment neededProtective Equipment needed– Containment & EvacuationContainment & Evacuation– First aid & Emergency responseFirst aid & Emergency response

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Red color & pictogram = Flammable

#3 = Flammable liquid

UNID # = isopropyl alcohol

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Material Safety Data SheetMaterial Safety Data Sheet

• Required for chemical Required for chemical used in a workplaceused in a workplace

• Chemical NameChemical Name• Hazard IdentificationHazard Identification• Physical & Chemical Physical & Chemical

PropertiesProperties

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NFPA LabelsNFPA Labels

• FlammabilityFlammability

• Health HazardHealth Hazard

• InstabilityInstability– 0 = Good0 = Good– 4 = Very Bad4 = Very Bad

• Special HazardsSpecial Hazards– OxidizerOxidizer– Water ReactiveWater Reactive– RadiationRadiation

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NIOSH GuideNIOSH Guide

• Chemical Name, synonymsChemical Name, synonyms

• Chemical and physical Chemical and physical propertiesproperties

• Toxic concentrations in airToxic concentrations in air

• PPE RecommendationPPE Recommendation

• Information on Health HazardsInformation on Health Hazards

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Poison Control CentersPoison Control Centers

• In depth In depth information about information about health effectshealth effects

• In depth treatment In depth treatment informationinformation

• Antidote Antidote availabilityavailability

• Toxicologist Toxicologist ConsultationConsultation

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I:I: Incident Management Incident Management

• Critical information:Critical information:– Time of the incident and incident siteTime of the incident and incident site– Substances involvedSubstances involved– Method of contamination (vapor or liquid)Method of contamination (vapor or liquid)– Hazards to health care providersHazards to health care providers– Need for PPE & decontaminationNeed for PPE & decontamination

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S:S: Security Security

• Scene must be secured to prevent more Scene must be secured to prevent more casualtiescasualties

• Most (4/5) victims will go to the hospital by Most (4/5) victims will go to the hospital by private/ public transportation vehicle!!!private/ public transportation vehicle!!!

• PREVENT THE HOSPITAL FROM BECOMING PREVENT THE HOSPITAL FROM BECOMING CONTAMINATEDCONTAMINATED– all personnel involved in triage & all personnel involved in triage &

decontamination must wear PPEdecontamination must wear PPE

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A:A: Assess Hazards Assess Hazards

• OngoingOngoing threat of contamination to threat of contamination to other individualsother individuals

• Secondary devices?Secondary devices?– Several cyanide gas bombs found in subway Several cyanide gas bombs found in subway

restrooms after sarin attackrestrooms after sarin attack

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S:S: Support Support

• Know your capabilities/limitationsKnow your capabilities/limitations

• Take protective measures Take protective measures

– Isolate

– Evacuate

– Perimeter/site control• Call in other resources as needed.Call in other resources as needed.

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T:T: Treatment Treatment

• DecontaminationDecontamination

• A B C’sA B C’s

• Symptom driven supportive Symptom driven supportive care and antidote selectioncare and antidote selection

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E:E: Evacuation Evacuation

• Most victims will self transportMost victims will self transport• Consider school buses for minimal ptsConsider school buses for minimal pts• CautionCaution

– Contaminated ptsContaminated pts– Off-gassingOff-gassing– Open windowsOpen windows– Use ventsUse vents

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R:R: Recovery Recovery• Most difficult aspect of a chemical event Most difficult aspect of a chemical event

• All potentially contaminated areas must be All potentially contaminated areas must be checked for persistence of chemicalschecked for persistence of chemicals

• Psychological sequelaePsychological sequelae

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Questions?Questions?