Targets of OpportunitySteven M MarcusMedical Director

NJ Poison Information & Education SystemNew Jersey Medical School

Chemical Agents used during WWI include: chlorine, phosgene, and nitrogen mustard gases. These chemical lead to 100,000 deaths and 1.2 million casualties.

Nazis killed millions of civilians with Zyklon B gas (HCN) in WWII.

Agent Orange (a dioxin and defoliant) was used in the Vietnam War, which may have lead

to skin cancer in our veterans.

Chemical Terrorist Events

• 1985 - Covenant Group found to 1985 - Covenant Group found to possess 33 gallons of cyanidepossess 33 gallons of cyanide

• 1992 - Police prevent Neo-Nazis from 1992 - Police prevent Neo-Nazis from using cyanide in synagogueusing cyanide in synagogue

• 1994 - Aum Shinrikyo uses sarin in 1994 - Aum Shinrikyo uses sarin in Matsumoto – 7 dead, 280 injuredMatsumoto – 7 dead, 280 injured

In 1995 in Tokyo, Sarin (very potent organophosphate nerve gas) caused 12 deaths and 5,500 injuries.

More Chemical Terrorism

• Copycat attacks in Japan using Copycat attacks in Japan using cyanide, phosgene, and pepper spraycyanide, phosgene, and pepper spray

• FBI thwarts possible sarin attack in FBI thwarts possible sarin attack in DisneylandDisneyland

• 1997 - Sydney, Australia – chlorine 1997 - Sydney, Australia – chlorine bombs in shopping centers injure 14 - bombs in shopping centers injure 14 - 500 evacuated500 evacuated

Types - Chemical Agents

• Nerve AgentsNerve Agents Tabun, Sarin, Tabun, Sarin, Soman, VXSoman, VX

• Blood agentsBlood agents Hydrogen Hydrogen Cyanide,Cyanide,

Cyanogen Cyanogen ChlorideChloride

• Pulmonary IntoxicantsPulmonary Intoxicants Phosgene, Phosgene, ChlorineChlorine

• MiscellaneousMiscellaneous AmmoniaAmmonia• VesicantsVesicants Mustard, LewisiteMustard, Lewisite• Riot ControlRiot Control MaceMace ® ®, Pepper Spray, Pepper Spray• Incapacitating AgentsIncapacitating Agents BZBZ

The Bhopal Disaster:

Twenty years ago an explosion at a chemical factory sent 27 tons of poisonous methyl isocyanate wafting over the slumbering residents of Bhopal, India. The aftermath was apocalyptic. Between 7,000 and 10,000 people died in the three days after the explosion and 15,000 more have died since. 

There is virtually no location in the There is virtually no location in the state of NJ beyond the range of state of NJ beyond the range of toxicity from an explosion in a toxicity from an explosion in a chemical storage or production chemical storage or production plant!plant!

Top Ten Most Prevalent Hazardous Chemicals in NJ

Ammonia Hydrogen sulfide

Chlorine Ozone

Difluoroethane Pentane

Hydrogen chloride Toluene diisocyanate

Hydrogen fluoride Vinyl acetate

Chlorine

• Used in swimming Used in swimming pools and pools and laboratorieslaboratories

• Industrial exposures Industrial exposures may produce large may produce large numbers of numbers of casualtiescasualties

Chlorine - Civilian Uses

• Chlorinated lime (bleaching powder)Chlorinated lime (bleaching powder)• Water purificationWater purification• DisinfectionDisinfection• Synthesis of other compoundsSynthesis of other compounds

– synthetic rubbersynthetic rubber– plasticsplastics– chlorinated hydrocarbonschlorinated hydrocarbons

• Don’t try this at home! (bleach + acid)Don’t try this at home! (bleach + acid)

Historical Exposures

• 1996 Bethlehem, Pa 13 pool victims

• 1998 Rome, Italy 282 pool victims

• Diyarbakir, Turkey 2000 106 victims leaking tanker car

Chlorine - Characteristics

• PropertiesProperties– Greenish-yellow gas, pungent odorGreenish-yellow gas, pungent odor

– Chlorine + water = HCl + Free OChlorine + water = HCl + Free O22 30x 30x more irritating to lungs than HClmore irritating to lungs than HCl

• EffectsEffects– Eye irritation, cough, SOB, and wheezingEye irritation, cough, SOB, and wheezing– delayed ARDSdelayed ARDS

Chlorine - Tissue Effects

• Topical rather than systemicTopical rather than systemic

• In central airways - from HClIn central airways - from HCl– necrosis, sloughingnecrosis, sloughing

• In peripheral airwaysIn peripheral airways– oxygen free radicalsoxygen free radicals

– react with sulfhydryl groups, disulfide bondsreact with sulfhydryl groups, disulfide bonds

– damage to alveolar-capillary membranedamage to alveolar-capillary membrane

Chlorine - Clinical Effects

• Mild ExposureMild Exposure– suffocation, choking sensationsuffocation, choking sensation– ocular, nasal irritationocular, nasal irritation– chest tightness, cough chest tightness, cough – exertional dyspneaexertional dyspnea

• Moderate ExposureModerate Exposure– above sx + hoarseness, stridorabove sx + hoarseness, stridor– pulmonary edema within 2-4 hourspulmonary edema within 2-4 hours

Chlorine - Clinical Effects

• Severe ExposureSevere Exposure– severe dyspnea at restsevere dyspnea at rest– may cause pulmonary edema within 30-60 may cause pulmonary edema within 30-60

minmin– copious upper airway secretionscopious upper airway secretions– sudden death may occur from sudden death may occur from

laryngospasmlaryngospasm

Clinical Considerations

• These agents cause pulmonary edemaThese agents cause pulmonary edema– damage alveolar-capillary membranedamage alveolar-capillary membrane

• Latent PeriodLatent Period– symptom onset may be delayed hours to dayssymptom onset may be delayed hours to days– objective signs appear later than symptomsobjective signs appear later than symptoms

• Sudden Death may occur Sudden Death may occur – laryngeal obstruction (edema/spasm)laryngeal obstruction (edema/spasm)– bronchospasmbronchospasm

Clinical Considerations

• Infectious Bronchitis / Pneumonitis commonInfectious Bronchitis / Pneumonitis common– usually occurs usually occurs 3-53-5 days post-exposure days post-exposure

– fever, elevated WBC, infiltrates NOT always infectionfever, elevated WBC, infiltrates NOT always infection

– prophylactic antibiotics NOT indicatedprophylactic antibiotics NOT indicated

• Effects exacerbated by exertionEffects exacerbated by exertion– compensatory mechanisms overwhelmedcompensatory mechanisms overwhelmed

– strict rest, even if asymptomaticstrict rest, even if asymptomatic

• No specific therapy existsNo specific therapy exists

Ammonia

• Colorless, water-Colorless, water-soluble, alkaline gassoluble, alkaline gas

• Pungent odorPungent odor

• Wide industrial useWide industrial use

• Used to make Used to make fertilizer, explosives, fertilizer, explosives, dyes, and plasticsdyes, and plastics

Ammonia - Characteristics

• Household ammonia pH < Household ammonia pH < 12 - limited damage12 - limited damage

• Anhydrous ammonia pH > Anhydrous ammonia pH > 12 - severe damage12 - severe damage

• Rapidly absorbed by Rapidly absorbed by mucosal surfaces (eyes, mucosal surfaces (eyes, throat, and lungs) throat, and lungs)

• Corrosive produced when Corrosive produced when combined with water - combined with water - Liquefaction necrosisLiquefaction necrosis

Ammonia - Clinical Signs/Symptoms

• EyesEyes– Burning, tearing, Burning, tearing,

severe pain -> injury of severe pain -> injury of the cornea and lensthe cornea and lens

• LungsLungs– Cough, SOB, chest Cough, SOB, chest

pain, wheezing and pain, wheezing and laryngitis with mild laryngitis with mild exposureexposure

– Hypoxia, chemical Hypoxia, chemical pneumonia, pneumonia, hemorrhage with hemorrhage with moderate - severe moderate - severe exposuresexposures

Ammonia - Clinical Signs/Symptoms

• SkinSkin– Pain, blister formation, deep burnsPain, blister formation, deep burns

• Gastrointestinal (ingestion)Gastrointestinal (ingestion)– Severe mouth pain, cough, and abdominal Severe mouth pain, cough, and abdominal

painpain– Nausea and vomitingNausea and vomiting– Edema to lips and mouth (leading to airway Edema to lips and mouth (leading to airway

obstruction)obstruction)– Esophageal strictures and perforationEsophageal strictures and perforation

Hydrogen flouride

• Production of electronic circuits

• Etching: glass, metal, stone and porcelain

• Cleaning products: wheel and chrome cleaners

• Rust removers

Hydrogen fluoride

• Dissolved in water as hydrofluoric acid

• Weak acid

• Volatizes easily

• Local and systemic effects

• Delayed symptoms

HF-clinical effects

• Local: pain out of proportion to apparent injury

• Systemic: hypocalcemia, hypomagnesemia and hyperkalemia

HF-therapy

• Decontamination

• Calcium compresses

• Nebulized calcium?

• Eye wash

Fluoride Release Leads to Evacuation of Texas Neighborhood

 International Fluoride Information Network July 10, 2003

Yesterday, July 9, an explosion occurred at a Texas oil refinery which resulted in the release of an unspecified, but potentially large amount of hydrogen fluoride. According to the article which appeared in today's Corpus Christi Caller Times, a seven block area adjacent to the plant was soon evacuated after winds blew the HF gas in its direction. "The unpublicized usage of deadly hydrofluoric acid at half of all refineries is endangering refinery communities...The environmental hazards of HF as used at refineries have to do with the high volumes utilized, the potential for high temperatures and pressures to be involved in a release, and the tendency of HF, once released to the environment, to form deadly gas clouds that do not easily diminish...This makes it an extremely dangerous material to be utilized at refineries in highly populated areas. The danger posed is thought by many experts to be as severe as the accident in Bhopal, India in which thousands were killed at a Union Carbide  chemical plant in 1984."

14 feared killed in refinery blast Rescuers search for survivors at oil plant in Texas

Thursday, March 24, 2005 BY PAM EASTON Associated Press

TEXAS CITY, Texas -- A thunderous explosion tore through a BP oil refinery yesterday, shooting flames and billowing smoke into the sky and showering the area with ash and chunks of charred metal. At least 14 were believed

dead and more than 100 were injured.