since vapors and gases can penetrate the openings in garments

South Carolina Area Health Education Consortium

Chemical Agents as Chemical Agents as Terrorist WeaponsTerrorist Weapons


AcknowledgementsAcknowledgements• South Carolina Area Health Education

Consortium (AHEC)– Funded by the Health Resources and Services

Administration. • Grant number: 1T01HP01418-01-00

– P.I. : David Garr, MD, Executive Director AHEC– BT Project Director: Beth Kennedy, Associate

Program Director AHEC– Core Team:

• BT Co-director: Ralph Shealy, MD• BT Project Manager: Deborah Stier Carson, PharmD• BT CME Director: William Simpson, MD• IT Coordinator: Liz Riccardone, MHS• Web Master: Mary Mauldin, PhD• P.R Coordinator: Nicole Brundage, MHA• Evaluation Specialist: Yvonne Michel, PhD• Financial Director: Donald Tyner, MBA


AcknowledgmentAcknowledgment

This material has been prepared for SC AHEC Bioterrorism Training Network

by Ralph M. Shealy, M.D., FACEP

Co-Director of SC AHEC Bioterrorism Training Network

Medical Director for Operations, Charleston County EMS

Medical Director, Charleston County Rescue Squad


ObjectivesObjectives

• At the conclusion of this presentation, the participant will:– Outline the historical frequency with which chemical

agents have been used.– Describe common civilian situations in which a

chemical community health emergency may occur.– Describe how the physical state of an agents influences

its effectiveness.– List the six general classes of chemical agents.– Describe the signs, symptoms, mechanism of action,

decontamination procedure, and clinical management of each class of chemical agents


Regarding chemical Regarding chemical weapons..weapons..

“The effect is so deadly to the unprepared that we can never afford to neglect the question.”

General John PershingCommander of American Forces in Europe during World War I


World War IWorld War I

• 1915: Germans released 150 tons of chlorine gas from 600 cylinders in Belgium

• British and French fielded cyanide to a limited extent during World War I.

• 1917: Germans deliver artillery shells containing sulfur mustard, causing 20,000 casualties.

• Russia suffered 500,000 chemical casualties in World War I


Following World War IFollowing World War I

• Britain used chemicals against Russians and mustard against the Afghans north of Khyber Pass.

• Spain used mustard shells and bombs against the Riff tribes of Morocco.

• Soviet Union used lung irritants against tribesmen in Kurdistan

• Italy under Mussolini used mustard against Abyssinian tribesmen

• Japan used chemicals against China.


World War IIWorld War II

• There was limited use of chemical weapons during the World War II

• Germany used cyanide in the concentration camps.

• In 1943, Germans bombed an American ship loaded with two thousand 100 pound mustard bombs in Bari Harbor, Italy, causing 600 military deaths and an unknown number of civilian casualties.


Recent DecadesRecent Decades

• Egypt used mustard bombs against North Yemen royalists in 1963.

• The United States used defoliants and riot control agents in Vietnam and Laos.

• Chemicals were used against Cambodian refugees and Hmong tribesmen of Laos in 1970s and 1980s.

• The Soviet Union used chemicals in its war against Afghanistan.

• Iraq used mustard and nerve gas against Iran in the 1980s.


Why Tell This Story?Why Tell This Story?

• Chemical weapons have been used frequently in the past.

• There is every reason to believe they will be used again.

• Chemical weapons give the underdog an advantage.

• “The effect is so deadly to the unprepared that we can never afford to neglect the question.”


Why would terrorist use Why would terrorist use chemical agents as chemical agents as

weapons of terrorism?weapons of terrorism?• Chemical agents are:

– Cheap.– Readily available.– Do not require technological

sophistication.– Do not require high tech delivery

systems.– Cause fear and panic out of proportion

to actual physical damage.


Recent Japanese Recent Japanese ExperienceExperience

• In June 1994, a cult group spread Sarin nerve gas in the city of Matsumoto. Seven died and fifty-six required hospitalization

• On March 20, 1995, the same group released Sarin in the Tokyo subway. Eleven died and 5,500 were injured.

• In both incidents, health professionals were injured.


Why not do it the easy Why not do it the easy way?way?

• Dangerous chemicals are already available in our cities and towns.

• A terrorist need only utilized chemicals that are already here.

• Exotic chemical agents used as weapons are not necessary.


More Probable EventsMore Probable Events

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


The Bottom LineThe Bottom Line

• THIS REALLY CAN HAPPEN TO YOU!


Physical States of Physical States of Chemical AgentsChemical Agents

• Chemical agents in weapons are usually liquids.

• Aerosols are very small particles of a solid or tiny droplets of a liquid suspended in the air.

• Liquid agents evaporate to form a vapor.• Solids and liquids tend to be persistent,

while vapors and aerosols are non-persistent.


Vapors and GasesVapors and Gases

• Vapors and gases attack:– the lungs – the tracheobronchial tree– mucous membranes, including the eyes

• Vapors and gases require special personal protective equipment.


Six Types of Chemical Six Types of Chemical AgentsAgents

• Lung damaging agents

• Cyanide (also called blood agents)

• Vesicants (also called blister agents)

• Nerve agents

• Incapacitating agents

• Riot-control agents


Toxidrome (Toxic Toxidrome (Toxic Syndrome)Syndrome)

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


Pulmonary AgentsPulmonary Agents

• Phosgene and chlorine.

• Attack mucous membranes and respiratory system.

• Odor of new mown hay.

• Decontaminate with fresh air and copious water irrigation.

• Supportive care.


CyanideCyanide• Hyperpnea with flushed skin.• Seizures.• Respiratory and cardiac arrest.• Odor of almonds.• Causes cellular asphyxia and profound

metabolic acidosis.• Decontaminate with fresh air and copious

water irrigation.• Use nitrates to liberate cyanide from

hemoglobin and thiosulfate to facilitate excretion.


VesicantsVesicants

• Sodium mustard is the prototype blistering agents

• Delayed onset of symptoms• Attacks skin, eyes, airway, lungs, GI tract,

and bone marrow• Odor of onion, garlic, or mustard.• Immediately decontaminate with

hypochlorite to prevent damage.• No specific therapy.


VesicantsVesicants

• Lewisite causes immediate pain on contact, which encourages immediate escape from exposure and decontamination.

• Lewisite produce skin, eye, and respirator damage similar to mustard.

• Lewisite causes systemic toxicity• BAL is the antidote


Nerve AgentsNerve Agents

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

fluid irrigation.• Atropine and pralidoxime are antidotes.


Incapacitating AgentsIncapacitating Agents

• Impair performance by CNS effects.

• Anticholinergic agents that have opposite effects of nerve agents.

• Cause decreased concentration, impaired memory, loss of judgment, and distortion of perceptions.

• Physostigmine is a specific antidote.


Riot Control AgentsRiot Control Agents

• Known as “tear gas”, “Mace”, and “pepper spray”.

• Burning and pain on exposed mucous membranes and skin, eye pain and tearing, burning nostrils, and respiratory discomfort

• Occasional deaths with prolonged exposure to high concentrations in a confined space.

• Effects typically brief and self limiting.


DecontaminationDecontamination

• The reduction or removal of a chemical agent. • Achieved by physical means, such as washing, or

by chemical neutralization or detoxification• The single most effective decontamination

procedure is the removal of contaminated garments.

• The most important and most effective decontamination is done within the first minute or two after exposure.

• Effective early decontamination can mean the difference between survival and death.


SummarySummary

• Chemical agents have frequently been used in warfare by many nations.

• There are many civilian situations that may result in a chemical community health emergency.

• There are six general classes of chemical agents, each with its own toxidrome, decontamination procedure, and clinical management.

• Preparation is the best defense against a terrorist attack with chemical agents.


AcknowledgementsAcknowledgements

• This presentations borrows heavily from – “The Medical Management of Chemical

Casualties Handbook,” Third Edition, produced by the U.S. Army Medical Research Institute of Chemical Defense.

– Emergency Medicine, Fourth Edition, produced by the American College of Emergency Physicians and edited by Judith Tintinalli, M.D.


Questions?

since vapors and gases can penetrate the openings in garments

Business

class of chemical agents

exotic chemical agents

blister agents nerve

agents riotcontrol agents

liquid agents

types of chemical agents

chemical casualties

riot control agents