Weapons of Mass Destruction
RaPiD-T Manual for
I. RaPiD-T Concept:
RaPiD-T program is designed to increase essential capabilities that
must be possessed by first responders in the event of a Weapon of Mass
Destruction release. Should such an attack occur upon our population,
the calm competent responses on the part of law enforcement, EMS, hospital,
and HAZMAT/Fire professionals will be critical to minimize casualties
and to preserve essential services. The specific components of
this program are R-recognition, P-protection, D-decontamination, and
T-triage/treatment. Recent experiences have indicated that first
responders are particularly susceptible to secondary contamination by
a number of these agents. In addition to the injury and illness
of the target population, it is the precisely the secondary contamination
of first responders that increases the terror potential of these substances.
The ability of these munitions to rapidly produce illness and injury
of large numbers of victims and simultaneously weaken the EMS, hospital,
law enforcement systems will most probably create terror in our society.
Terrorist groups who are willing to use these weapons are currently
attempting to procure these weapons to further their goals. The availability
of required knowledge and raw materials to international and domestic
terrorist groups make it imperative for first responders to increase
their skills in this area.
of Mass Destruction are defined as substances capable of relatively
undetected dissemination and high toxicity such that large numbers of
people may be exposed from a single release. It is important to
recognize that the release of such a weapon does not entail the destruction
of anything but the people exposed. They may then be more aptly
named weapons of mass casualties as there are no large destructive
explosions associated with an attack of this sort. In this way,
weapons of mass destruction are quite stealthy. Substances capable
of such effects may be divided into chemical weapons, biological-toxicological
weapons, and radiological material. Chemical weapons are subdivided
into several categories base upon the effects the agent has upon the
body. Biological-toxicological weapons are naturally-occurring,
disease producing organisms or substances that are purified and prepared
for mass aerosol or food/water distribution. Radioactive isotopes
are used in the construction of nuclear weapons that are quite detectable
at the time of their release. This program is not intended to
prepare the user for management of a nuclear detonation. The scope
of this manual is limited to the effects of radiation exposure from
unshielded sources upon the human body. The inherent difficulty
in the construction of a fission bomb makes the likely-hood of radiation
source exposure much more likely.
Despite the great lethality and limited
detectability of these munitions, the United States has the knowledge
required to manage casualties of this sort. Chemical weapons have
been part of modern warfare since World War I and many substances are
common industrial hazardous materials. Biological weapons are,
after all, really just diseases that are intentionally and efficiently
spread. Radiation sources are also part of our world and have
applications in medicine, and industry. Weapons of mass destruction
are different only in that they are unexpected and are designed for
high lethality. Because recognition of a sudden epidemic
of similar symptoms in the target population is the first and most critical
step in the management, law enforcement and EMS personnel are in a unique
position to view the community at large. The recognition of an
unexpected epidemic in a population who could be exposed in a common
site, combined with awareness of the types of munitions most available
could be the difference between life and death for both the exposed
victims as well as the first responder.
the Persian Gulf War, American soldiers faced the specter of Saddam
Husseins chemical and biological weapons arsenal. We now know
that the Iraqi arsenal included substances such as Botulinum Toxin,
Anthrax spores, Aflatoxin, Sarin/Soman nerve poisons, and Mustard.
These munitions were loaded in delivery vehicles such as SCUD missiles,
gravity bombs, and artillery shells, aimed at American and coalition
soldiers. Potentially, these agents had the capability to deliver
mass casualties to the coalition forces, and significantly alter the
course of the war. For some years now, the medical community of
the United States Military has trained its professionals to recognize
and manage the toxidromes of the likely agents used in just such a conflict.
Because of the extreme toxicitys associated with these munitions, every
soldier in the military is trained and equipped with chemical-biological
countermeasures, and many military vehicles are designed with the threat
in mind. Needless to say, the coalition nations, not to mention
the individual soldier, breathed a heavy sigh of relief when the truce
was called without a deliberate attack utilizing these weapons of mass
destruction. For the most part, the United States watched the
events of the war with curiosity, and patriotism.
1994 and again in 1995, the Aum Shinrikyo cult successfully executed
two terrorist attacks in Japan using chemical weapons. The first
of these attacks occurred in the Tokyo suburb of Matsumoto. A
judge who was trying a cult member was threatened and his residence
subsequently attacked with the use of heated Sarin vapor, delivered
from a vehicle. This attack resulted in 200 casualties and 7 deaths.
Included in the total were a significant number of health care professionals-but
not the judge! Publicity of the Matsumoto incident was initially
suppressed by a concerned Japanese government. Later, in 1995,
the Aum Shinrikyo again struck at the heart of Tokyo in the now infamous
subway attack. In this attack, cult members placed perforated
Sarin containing packets at strategic locations of the Tokyo subway.
Sarin is about four times heavier than air and the vapor was accumulated
in the lower reaches of the subway. Approximately 5,500 casualties,
(1,000 hospitalized) resulted from this incident and again, 132 medical
professionals numbered significantly among the victims in which twelve
deaths occurred. A recent report from Keio University Hospital
cites the time for the majority of the treating physicians in the Emergency
Department to become symptomatic from their contaminated patients as
about 45 minutes. The actions of the Aum Shinrikyo represent the
first time deaths in a civilian population had been caused by the terrorist
use of a chemical weapon. The United States took notice of the
capabilities of these munitions. Chemical and biological weapons
had previously been the domain of the military physician, but times
have changed. The success of the Aum Shinrikyo attack has focused
world attention on the use of war agents against civilian populations.
weapons have been part of the modern battlefield since the first use
of Chlorine gas at Ypres, Belgium in 1915. Dr. Fritz Haber, a
Nobel Prize winning German chemist, was instrumental in the development
of this new type of weapon. The effect of this new munition was
so impressive that a chemical arms race existed during the first World
War with Phosgene, Cyanide, Mustard, and Lewisite being developed by
American, British and German scientists prior to the end of the war.
A new class of chemical weapons, the G-agents, were developed by German
scientists, during the buildup preceding World War II. Although
these weapons were not used on the World War II battlefield, once their
potential was recognized, they quickly became part of the arsenals of
the developed nations. Sarin (GB), the agent used in 1994--95
by the Aum Shinrikyo cult, was first synthesized in 1936 by Dr. Gerhard
Schrader. It is the ability for a private group to manufacture
and deliver a weapon of mass destruction against an unprepared populace
that has caused the recent focus on these agents. Although once
the realm of experimental, and Nobel Prize-winning chemistry, the 60
to 100 year old technology required, and the precursors needed have
become commonplace in the industrial and academic world.
weapons are actually something of a misnomer. Disease has always
been part of any military campaign and, in the pre-antibiotic era, was
typically responsible for a greater share of casualties than the tip
of the spear. Many attempts at contamination of an enemys water
and food date to antiquity. A modern biological weapon is merely
the intentional culture, purification, and weaponization of a known
disease producing organism or toxin. Unit 731 of the Imperial
Japanese army was the first military unit expressly designed for the
purposes of creation of bio-weapons. From 1932-1944, Unit 731
operated near Chang-Teh, Manchuria. American, British, and Australian
prisoners of war, along with an alarming number of Chinese civilians,
were used as subjects in the development of plague, cholera, and botulinum
weapons. Biological weapons were not used on the WWII battlefield,
mainly because of the lack of protective measures and the problem of
containment. The capability of these agents, however, did not
go unnoticed by the victors, as the USSR and Americans took possession
the records, and scientists associated with the Unit 731 program to
start their own programs. Like chemical weapons, the technology
required to create a bio-weapon is now commonplace, and the precursors
naturally occur, or are easily attainable. Perhaps the most ominous
feature of the biological weapons is their stealth. Because all
that is required is contamination of the air, water, or foodstuffs,
there would be no explosion, or discernable cloud, smoke, or odor associated
with the discharge of the weapon. The recognition of a sudden
epidemiological event by the medical community is the first line of
1992 incident in Oregon in which Salmonella was intentionally spread
by followers of the Bhagwan Shree Rajneesh focused attention on the
American medical establishment and the ability to effectively deal with
a biological terrorist incident in America. Because disease-producing
organisms occur naturally, the biological weapons must be differentiated
from naturally occurring outbreaks. Delays in recognition of a
bio-weapon discharge can be expected because many physicians in the
United States are unfamiliar with the etiological agents used in bacterial
warfare. In addition, victims will present in a haphazard manner
to various health care facilities as they become sick. The recognition
of a biological weapon will, therefore, be dependent upon diagnosis
of an unfamiliar epidemic condition by physicians of various specialties,
and facilities. Effective treatment may therefore lag for potentially
treatable victims because of the lack of this focused knowledge.
In addition, biological agents are typically odorless and tasteless
and may be placed in food or water supplies as well as transmitted by
droplet aerosol, further complicating the recognition of the site of
contamination. The cultures of many organisms may also be obtained
from the environment, or low security laboratories, so that prohibition
of the precursors may not be feasible. With commonly available
culture and dispersal equipment, the possibility to infect a very large
number of victims is possible with a minimum of expense and knowledge.
of these successful attacks and a careful assessment of the changing
world climate, former Senator Sam Nunn refers to weapons of mass destruction
as the most significant threat to American society in our lifetimes.
In 1996, mass casualty drills conducted both in New York City and Los
Angeles were modeled on the Japanese Sarin tragedy and the results clearly
showed the lack of preparedness of our medical system with respect to
the capabilities of these agents. For medical professionals, basic familiarity
with the various munitions will be increasingly important. The
recognition and management of an attack is incumbent upon the local
pre-hospital and medical professionals. As we will discuss, the
toxicity of the chemical and biological is significant and represents
a major medical threat. Inconsistencies with common epidemiological
or toxicological presentations, and recognition of the signs and symptoms
of chemical weapons casualties are seminal to the discharge of this
responsibility. Referral to the appropriate authorities will be
essential to save lives, and to bring the perpetrator of the attack
to justice. It is the medical professional whose action or inaction
will determine the survival of the victims of such a weapon.
the Aum Shinrikyo experience clearly demonstrates, the transmission
of chemical and biological weapons is important to understand.
Intended victims of an attack are termed the primary casualties, and
are expected to congregate at medical facilities, with or without decontamination.
There is a common misconception that EMS will be able to respond, and
to decontaminate victims of these munitions. Historical data tell
us that around 80% of victims involved in a HAZMAT mass casualty scenario
will seek their own transportation to the perceived site of maximal
care, i.e. the hospital or clinic. Secondary casualties are considered
those individuals whom are exposed by the initial victims, namely the
health care provider. The large numbers of health care professionals
incapacitated by the Aum Shinrikyos attack proved the medical professions
vulnerability to these extremely toxic agents. Although chemical and
biological weapons are targeted at specific segments of the population,
the loss of the healthcare provider will magnify the effect of these
munitions. This subtlety is not lost on the terrorist. To
foment additional terror in the target population, it is becoming more
common to target the healthcare provider with secondary weapons as the
recent experience in Ireland, the Middle East, as well as the Atlanta
abortion clinic bombings demonstrated. Chemical and biological
weapons expose the unprotected and unaware health care professional,
and threaten the viability of our EMS and hospital system. For
these reasons, we in the medical community can no longer afford blissful
ignorance of these issues.
recognition of weapons of mass destruction is based upon some degree
of familiarity with the types of effects the agent has upon the human
body. A great deal of specific knowledge may be required to ultimately
diagnose and treat a specific munition but the recognition of basic
symptom complexes combined with the good judgement already common in
law enforcement, EMS, Fire/HAZMAT, and hospital personnel is all that
is required for the first step.
weapons of mass destruction cause their effects by exposure of the target
population at a common site, a number of normally healthy victims from
such a site is the first warning of a release. In the 1987 salmonella
outbreak in The Dalles Oregon, a religious cult group led by the Bhagwan
Shree Rajneesh intentionally spread the microbe on salad bars throughout
the town as depicted in the photo on the right. Although it would
be possible for a single restaurant to cause such an outbreak, it would
be highly unlikely for a simultaneous outbreak to occur at multiple
sites. Although first responders may not know the initially know
identity of the microbe, or the treatments required, the occurrence
of this unusual event bears investigation. Because individual
doctors at individual hospitals may only see a portion of the community,
it may be difficult for the medical authorities to recognize such an
event. Merely taking the appropriate history along with
awareness of weapons of mass destruction is all that is required to
recognize the event. It is the first responders that possess
the necessary view of the community to best serve as early warning.
addition to a common site of exposure, a common route of exposure is
the next most important concept to understand. Weapons of mass
destruction do not cause death by large explosions or deadly projectiles,
rather, these substances must enter the body and derange the normal
physiology in some way. The best routes to expose a large number
of individuals are to use a respiratory aerosol or to contaminate food
or water supplies. In the salmonella incident cited above, food
supplies were contaminated and gastrointestinal symptoms predominated.
A respiratory aerosol refers to the intentional formation of a cloud
of suspended particles inspired into the lungs and absorbed by the victim.
Also possible is contact absorption of the compound by exposed skin.
A common route of possible exposure is critical to determine by first
responders. Although all three routes of exposure of important
to consider, it is by the respiratory route that biological and chemical
weapons have their greatest potential effect. Unexpected respiratory
symptoms noted in a large number of previously healthy individuals are
therefore clearly cause for concern.
final important concept for recognition is that the victims will develop
severity of symptoms based upon the level of exposure not on their state
of health. We are all aware of natural epidemics of flu and colds that
affect the population. As first responders, we know that the very
old, the very young, and the chronically ill individuals among the population
will be the most affected. A weapon of mass destruction, however,
will have its effect primarily upon those most highly exposed.
Severe symptoms and death in previously young healthy individuals without
corresponding illness in the less healthy individuals of the community
is a significant piece of information. Although the three points
described above do not definitely establish a weapon release, the combination
of these phenomena should trigger an evaluation by higher authorities
of the potential of a terrorist act.
from a weapon of mass destruction is an imperative for first responders
and medical professionals. Although contrary to the natural responses
of most in the first responder community, the most important first action
to take upon recognition of a weapon or mass destruction release is
to protect the first responder. Though it is difficult, one must
focus upon the community under attack rather than the individual.
For the community of victims to survive, medical assets will have to
be brought to bear upon the victims. If the medical assets, namely
the first responders, have contaminated themselves in the rush to help,
they have added themselves as victims rather than preserved their ability
to help. The three women in the photo are rushing to help victims
of the Oklahoma City bombing. Had a chemical, biological or nuclear
device been used in conjunction with this attack, these well meaning
first responders would have been casualties. Instead of constructing
a set of rules to govern every possible situation, it is of probably
greater utility to teach principles and allow the first responder to
choose his or her own path. Toward that end, this manual will
elaborate the elements of cross contamination and the basics of personal
protective equipment (PPE).
All of the chemical and biological agents have different characteristics and affect the victim in different ways but all have in common extreme toxicity. When approaching an unknown situation, one must assume the worst and prepare against the common methodologies of cross-contamination from the victim or the scene. To minimize the possibility of air and water borne contaminates seeping into the staging or treatment area, always locate up hill, up wind, and up stream from any WMD scene. Cross-contamination is the process by which a first responder becomes a victim. The routes of cross-contamination are:
protection is achieved by a variety of mask type appliances that are
applied over the head, and/or nose and mouth. There are three
basic types of respiratory protection. The first type is the use
of an air filtration system like a HEPA (high efficiency particulate
air) filter. This type of filter is common in medical facilities
and is used whenever a contagious patient is treated. The HEPA
filter is very good protection against biological agents and radiological
fallout, but has very little activity against chemical agents. An air-purifying
respirator is the next type of filter and it utilizes a resin made of
typically of charcoal to inactivate chemicals in the air. A typical
configuration is depicted on the right. When combined with a HEPA
type filter, this mask becomes very effective against both chemical
and biological unknowns. The disadvantage of an air-purifying
respirator is that it increases the work of breathing and therefore
limits other work. Charcoal filtration units can also be overcome
by high concentrations of chemicals.
In essence, they can be used up. A hasty source of charcoal filtration
protection is the paint vapor masks sold in most hardware stores.
The best type of respiratory protection is a supplied air respirator
or self-contained breathing apparatus (SCBA). This type of appliance
is either attached to an air source or an air tank (SCBA) from which
clear filtered air is supplied to a regulator type apparatus.
The supplied air respirator ensures the first responders air source
and is considered superior to the filtration type masks. The disadvantage
to a supplied air respirator is that it is dependent upon the air source.
Because air tanks are difficult to carry, and a continuous air source
requires bulky equipment, the supply is limited due to practical considerations.
protection is achieved through disposable barrier clothing. Biological
weapons are easily fended off by the use of standard latex gloves, and
disposable plastic aprons. These items are cheap, plentiful, and
readily available in almost every medical setting. Unfortunately,
latex offers little protection against chemical weapons.
Some chemical weapons require a significantly greater level of protective
gear, made from fabrics not commonly available. The concept of
total encapsulation is used whenever working with the most toxic of
substances. Total encapsulation requires the rescuer to don a
vapor tight bulky suit with a supplied air respirator. The resultant
apparel is cumbersome and retains heat quite efficiently. Thick
butyl rubber gloves, required for protection, limit the fine tactile
skills required to do many common medical tasks. While it is possible
to attain some skills with intensive training, total encapsulation degrades
the ability of the rescuer to below 50% of his or her normal capacity.
The degree of encapsulation is commonly termed Protective Level of
which there are four levels:
Level A: Respiratory: Full face mask SCBA
Contact: Vapor barrier airtight suit enclosing the user and SCBA
Level B: Respiratory: Full face SCBA or supplied air
Contact: Hooded chemical barrier suit with gloves, boots
Level C: Respiratory: Air-purifying respirator
Contact: Hooded chemical barrier suit with gloves, boots
Level D: Respiratory: None
Contact: Standard work uniform
It would be nice to think that
we all had the time to train regularly and be fitted properly for the
highest levels of PPE protection. In reality, only those individuals,
whos job it is to train and prepare for toxic exposures will possess
Level A or B protection. The development of the Metropolitan Medical
Strike Team concept is just this type of unit. The MMST issue
aside, it is the opinion of this program that every rescuer must have
basic familiarity with and access to Level C PPE.
Level C PPE, while insufficient protection for sustained exposure,
would afford the most rescuers, the most adequate protection during
the initial stages of recognition of the WMD event. Level C is
the standard military issue level of PPE to soldiers at risk of exposure
to chemical weapons.
weapons are typically associated with a latent period, or prodrome,
prior to the onset of lethal disease. Biological weapons are odorless,
tasteless and in the prodromal phase are rarely detectable by patient
evaluation. Because of these factors, it is difficult to conceive
of the situation when a first responder could protect him or herself
from the initial dissemination. As in the care of any patient
with a communicable disease, blood and body fluid precautions are the
rule. Because biological weapons are spread as aerosols, a victims
cough containing an aerosol of bacterial or viral droplets can act as
a method of secondary spread. A HEPA filter mask, and latex barriers
are all that is needed to protect oneself from the risks of a biological
is the process by which potential lethal contamination is removed from
the surfaces of a victim in order to allow better medical access and
to protect medical personnel from the dangers of cross contamination.
Never before has cleanliness been so close to godliness. Decontamination
may only be performed by personnel dressed in personal protective equipment
(PPE). Federal standards dictate that Level A as the only acceptable
level of PPE for individuals involved with sustained exposure to potentially
high levels of an unknown chemical. Although this is clearly the
best possible option, it will be little help to those first responders
during the initial stages of a WMD event. Toward that end, several
methods of hasty decontamination will be discussed. Formal training
in decontamination is required to conform to federal standards.
This level of training is best concentrated upon the metropolitan medical
strike team (MMST). It is the opinion of this manual that hasty
decontamination techniques should be taught to every first responder.
recognition and protection phases, the first responders at the scene,
in maximum PPE available, should identify a site for victim collection
and hasty decontamination. The site must be uphill, upstream and
upwind from the WMD event. The site must be divided into a dirty
side termed the hot zone, and a clean side termed the cold zone.
The cold zone must be uphill, upstream, and upwind from the hot zone.
Once established, the victims must be collected in the hot zone.
It is important for the hot zone to be physically marked and the victims
contain themselves in the hot zone. If victims are allowed to
wander about, the clean side of the decontamination area will become
contaminated thereby negating any benefit. The first step of decontamination
contained, the victims should disrobe, and physically remove any observable
contamination from the skin. Clothing must be accumulated deposited
on the downhill, downstream, and downwind portion of the hot zone to
prevent off-gassing. Off-gassing is the continued exposure of
victims from vapors contained upon their clothing. Simply disrobing
victims is 85-90% effective at removing a vapor exposure. Victims
may typically be left in their undergarments. Physical removal
of chemicals from the skin must utilize non-contaminated fabric or paper.
Avoid use of contaminated articles of clothing.
The skin and most importantly the hair must be washed with a decontamination solution or absorbing powder. Decontamination solutions and powders may take several forms. The following list of solutions may be readily available and effective:
Which solution a rescuer should
choose depends upon availability and environmental conditions.
Obviously hosing down half-naked people exposed to winter conditions
may be effective against the contaminate, but potentially lethal to
the victim. Prima non nocere, or first do no harm is a guiding
medical principal since the time of Galen, and it applies to decontamination
methodology. When selecting a decontamination method, remember
that victims continue to absorb the toxic contamination from their skin
as long as the substance remains in contact with the victim. Time
is of the essence. A perfect decontamination solution will do
no good if applied after a lethal contamination has been absorbed.
The guiding principle here is to gain the greatest amount of decontamination
in the shortest amount of time possible.
Probably the best hasty decontamination solution is 0.5% hypochlorite solution. Sodium Hypochlorite is common household bleach. Household bleach is concentrated at 5%, therefore a proper decontamination solution would 10 parts water to one part household bleach. Along with Level C protection, access to bleach and water should be part of every first responders armamentarium. Hypochlorite works equally well for many chemicals and biological weapons. A word of caution, application of hypochlorite solution to a riot control agent exposure will cause the victim to blister. Soap and water is the recommended solution for riot control agents.
VI. Chemical Weapons:
Chemical weapons are compounds that, because of their great toxicity, are considered among the most toxic of poisons. Chemicals may be absorbed through the skin or through the air in aerosols (suspended particles like a mist) or vapors. Chemical weapons are classified by their basic action on man. The basic groups are summarized in the following table:
Cyanide Immediate Minutes-Lethal
Lung Irritant Immediate Hours to symptom onset
Organophosphate Nerve Poisons Immediate 24 hours or more
Blister Delayed Weeks
Riot Control Immediate Short-Non-lethal
of the advent of chemical weapons in World War I and during the buildup
to World War II, the technical knowledge required for the synthesis
of chemical weapons is now commonplace in industry and institutions
of higher learning. Many chemical weapons are no more than useful industrial
compounds. Others require specific synthesis. The organophosphate
nerve poisons are closely related to useful pesticides, and could be
made in the same factories as Malathion, Parathion, or other useful
chemicals. Many nations are known to be engaging in the synthesis
of chemical weapons. Unfortunately, several of these nations are
known to sponsor international terrorist groups. Among these are
Russia, North Korea, Iran, Iraq, China, and the Sudan. Well-organized
and well-funded terrorist groups are equally capable of synthesizing,
and using chemical weapons in quite sophisticated ways. Previously
considered inhuman, and indecent, the use of these weapons has been
justified by national or religious ideology. Terrorism from within
our borders is also a risk. The Atlanta, and Birmingham abortion
clinic bombings, along with the Oklahoma City tragedy demonstrate the
ease Americans will kill Americans to foment their ideology. Racial,
religious, political, and anti-Federal ideologies have been used as
justification for spilled American blood.
Recognition: Non-specific agitation/obtundation, or collapse. Bitter almond odor.
Protection: Respiratory protection; SCBA or Charcoal filtration
Decontamination: Remove from source, soap and water wash
Triage: Delayed: ambulatory, Immediate: collapsed
kit for Immediate category only
is a common industrial chemical and is used in industries such as printing,
electroplating, photography, and agricultural chemicals. In the
United States, annual production of cyanide (for peaceful purposes)
exceeds 300,000 tons. Cyanide is shipped around the country in
33,000-gallon rail cars that largely go unguarded. For these reasons,
it is not difficult to obtain cyanide for clandestine purposes.
A white separatist group, The Covenant, managed to obtain a 33 gallons
of cyanide of the mid-1980s, for what purpose, we do not know.
The Tylenol poisonings of the same time period are a testament to the
ease of acquisition and use of cyanide as a weapon of terror.
The most recent event involving cyanide was the alleged use of cyanide
in the 1993 World Trade Center bombing. Hydrogen cyanide, (the
active ingredient in gas chamber executions) was alleged to have been
produced in an attempt to contaminate the routes of egress from the
building. Because of the volatility (lighter than air) of hydrogen
cyanide, the attack of a structure combining an explosion and cyanide
contamination of the routes of escape demonstrates a significant degree
of sophistication on the part of the terrorist.
mechanism of cyanide is that it binds to ferric (Fe+++) iron.
Iron is used to carry the oxygen used in energy production on the molecular
level. Examples of iron containing molecules include hemoglobin,
myoglobin, and cytochrome oxidase. Iron itself exists in two basic
forms called valance states. Understanding valance states is
admittedly a bit tedious but, the valance state of iron will become
important in understanding the treatment for cyanide. Ferric Iron
(Fe+++) is found on cytochrome oxidase. Cytochrome oxidase is
part of the metabolic engine of each cell and is vital to the production
of energy. Ferrous iron (Fe++) is the form used in hemoglobin
and myoglobin to transiently store oxygen. The basic mechanism of toxicity
is for the Cyanide molecule to bind to the ferric iron (Fe+++) present
in the cytochrome oxidase enzyme, rendering the enzyme useless in the
production of energy. If a lethal dose of cyanide is given, the
sudden loss of energy causes immediate cessation of cardiovascular and
central nervous system function. Death can occur in minutes.
poisoning is difficult to detect because, in sub-lethal doses, it produces
non-specific symptoms. Because of the interference with oxygen
metabolism, these symptoms would include non-specific agitation or obtundation.
These findings are indicative of the brain losing energy, and are similar
to a patient with low oxygen level. Please note; the oxygen level
will be normal! Because the cytochrome oxidase enzyme has been
poisoned, it is the cell that cannot use the oxygen present in the blood
and suffocates in the midst of plenty. Because little oxygen
will be extracted in higher doses of cyanide exposure, a cherry red
color to the body has been described. This is due to the oxyhemoglobin
(red blood) present in the veins and capillaries. Unfortunately,
cherry red coloration is an inconsistent finding, and not clinically
useful. The most reliable assessment is the presence of unexplained
metabolic acidosis in a number of patients, some of whom may have collapsed,
from the same site of exposure. Carbon Monoxide would also present
in a similar manner but would be detectable by co-oximetry available
in most hospitals, and suspected by the setting in which the exposure
occurred. A bitter almond odor is associated with hydrogen cyanide
gas, but up to 40% of the population cannot detect this odor.
Cyanide levels are not readily available in most hospital laboratories.
Suspected victims of a cyanide exposure are triaged into two categories. Immediate casualties are those individuals who have collapsed. Delayed casualties are those who are still ambulatory. The main treatment of cyanide exposure is removal from the source. For the severely exposed victims, the medical treatment of cyanide involves manipulation of the elemental iron present in the hemoglobin molecule through the use of a cyanide kit. The first step in the use of the cyanide kit is to create methemoglobin which converts ferric iron (Fe+++) to ferrous iron (Fe++). Inhaled amyl nitrite and intravenous sodium nitrite are capable of rapid methemoglobin formation. It is important to understand that methemoglobin does not carry oxygen and is potentially lethal, particularly if an adult dose is given to a child. As dangerous as methemoglobin may be, a collapsed patient will succumb to cyanide poisoning unless intervention occurs. It is the ferrous iron (Fe++) of methemoglobin that will bind the cyanide molecule from the cytochrome oxidase enzyme and create cyanomethemoglobin. Once cyanide has been removed from the cytochrome enzyme, the second agent, sodium thiosulfate is administered. The sodium thiosulfate will provide additional sulfur to the aid in the detoxification of this cyanomethemoglobin by the liver enzyme rhodanese. A cyanide treatment kit contains instructions and includes the following ingredients:
Amyl Nitrite Pearls -aromatic methemoglobin former
Sodium Nitrite (100 mg adult dose) -intravenous methemoglobin former
Sodium Thiosulfate -sulfur doner to
help detoxification, given IV
Phosgene: Newly mown hay, non-irritating
Chlorine: Swimming pool water, highly irritating
Anhydrous Ammonia: Acrid, highly irritating
Protection: Level C minimum
Decontamination: Disrobe, soap and water wash
Triage: Immediate: Dyspnea within 6 hours, Delayed: No respiratory distress
Supportive oxygen and ventilation therapy. Enforced rest.
irritants or pulmonary edema formers are a group of common industrial
compounds that are known to produce significant lung injury. The
compounds included in this class of weapon include Chlorine gas, Phosgene
gas, and Anhydrous Ammonia. All the chemicals in this class are
detectable by odor and therefore avoidable unless released in very large
amounts. Unfortunately, these chemicals are manufactured in vast
amounts and shipped, unguarded, across country in trucks and by rail.
Clearly, their ready availability represents a significant threat to
the populace. For example, the 1984 Bhopal India disaster involved
the reaction between isocyanate and phosgene to create methy-isocyanate.
In the Bhopal tragedy, 50,000 pounds of reagent was accidentally allowed
to escape from a reaction chamber and 150,000 casualties were produced
downhill from the Union Carbide facility. By intentionally damaging
a chemical plant, a population center may be threatened through industrial
sabotage of its resident industry. All three compounds are amenable
to this type of action. Indeed, every community in America with
a water treatment plant has a large tank of chlorine within easy access
of a determined saboteur. Chlorine and Phosgene were significant
chemical agents in World War I. Both are heavier than air and
collect in the trenches causing the unfortunate soldier to choose between
death by suffocation or death by gunfire. Neither prospect being
of particular appeal, the threat of the use of this weapon terrorized
the troops of both sides and energized the development of the defensive
masks and suits we use today.
inhaled by the victim, these compounds set about a chain of physiologic
events that result in the accumulation of excess lung water. Because
it is the least irritating agent, phosgene is thought to have the greatest
lethality and will be discussed in detail. Upon contact with mucous
membranes, phosgene reacts with water to form hydrochloric acid.
This acid exposure causes the initial symptoms of cough and pharyngeal
irritation. Phosgene is about 4 times heavier than air and is
widely used in chemical synthesis because of its ability to donate single
carbon groups. It is this donation of carbonyl groups that causes
the true toxicity of the compound. When absorbed into the lower
respiratory tract, phosgene goes to work adding carbon groups onto the
working cell constituents. The ultimate death of the cell, the
liberation of mediators of inflammation, and the formation of resultant
non-cardiogenic pulmonary edema is the pathophysiology of concern.
The formation of non-cardiogenic pulmonary edema therefore lags behind
the time of exposure. Do not be fooled by the resolution of initial
respiratory symptoms. A phosgene exposure must be observed for
24 hours. Onset of pulmonary edema within 6 hours of exposure
is a poor prognostic sign and indicative of a lethal exposure.
a phosgene casualty should be removed from the source, disrobed, and
washed with soap and water to prevent continued exposure of the patient
and the health care workers. Treatment of a phosgene casualty
includes supplemental oxygen and assisted ventilation. A peculiarity
of phosgene is that exercise will increase the rate of pulmonary edema
formation. For these reasons, the victim must be encouraged to
remain restive. It is important to realize that, because pulmonary
edema fluid will be taken from the rest of the body fluid, the phosgene
casualty will likely be volume depleted despite the formation of pulmonary
edema. For these reasons, resist the temptation to treat lung
edema with a diuretic. An asymptomatic but definitely exposed
patient should be triaged as Delayed. Victims with signs and symptoms
of pulmonary edema and those with associated health risks should be
triaged as Immediate.
ammonia exposure causes immediate symptoms in the victim because of
the very alkaline pH and the caustic nature of the compound. Mucous
membrane irritation is severe with only a minimal exposure. Prolonged
exposure to anhydrous ammonia is lethal. The mechanism by which
death occurs is a direct result of the highly alkaline nature of anhydrous
ammonia. Cells and biological compounds, when exposed to highly
alkaline substances undergo liquifaction necrosis. Liquifaction
necrosis involves the reduction of complex molecules and cellular structures
into their respective monomers. In essence, the cell is turned
into sauce. Tissue destruction and the resultant pulmonary edema
formation are the common causes of death. Rescuers should be wary
of the contact risk involved with caring for these victims. Treatment
of the victim begins with removal from the source, disrobing, and washing.
Prolonged irrigation is required for complete decontamination.
A pH test paper (nitrazine paper) can be used to verify continued areas
contamination. Immediate casualties are those with respiratory
symptoms. Minimal casualties are those without respiratory involvement.
exposure also causes immediate symptoms as hydrochloric acid is rapidly
produced when the chlorine gas contacts water in the nasal passages.
Formation of hydrochloric acid in the lower respiratory tract quickly
causes lung damage due to coagulation necrosis. Coagulation necrosis
refers to the process of welding cells and biological compounds together
into a single mass. The frying of an egg is an example of thermal
coagulation. The sudden loss of respiratory surface area along
with the resultant tissue injury quickly produces death in significant
exposures. Treatment of the victim begins with the removal from
the source, disrobing, and washing of the patient. Again, pH paper
(nitrazine paper) is of significant utility in the detection of contaminated
surface areas. Immediate casualties are those with respiratory
involvement. Delayed casualties are those individuals without
Recognition: Vapor Liquid
Miosis Fasciculations, sweating
Protecton: Level C minimum
Decontamination: 0.5% hypochlorite
Based upon symptom complex as depicted below
Vapor-onset in 1-2 minutes
Liquid-onset in several minutes
Miosis, Rhinorrhea, Dim Vision,
Local fasciculations, Local sweating
All above with Nausea, Vomiting
All above with Nausea, Vomiting
Convulsions, Apnea, Death
Convulsions, Apnea, Death
Treatment: Based upon triage
category as depicted below
2mg atropine, 600mg 2-PAM, Observation
2 mg atropine, 600 mg 2-PAM, Observation
2-4 mg atropine,600-1200 mg 20PAM Observation
6 mg atropine, 1800 mg 2-PAM, 10 mg Diazepam
6 mg atropine, 1800 mg 2-PAM, 10 mg, Diazepam
now infamous Sarin gas belongs to group of super toxic organophosphate
compounds, termed nerve agents. Included in this group are the
following compounds: Tabun (designated GA), Sarin (designated GB), Soman
(designated GD), and VX. The nerve agent compounds are odorless and
tasteless, and are readily absorbed through the skin, or by inhalation.
They are highly toxic by either route. When inhaled, toxicity
is determined by a concentration time product in which the milligram
concentration per cubic meter is multiplied by the time of contact.
Sarin, for example, has a LCt50 of 100 mg-min/m3. This means that
50% mortality is achieved when adult subjects are exposed to 100 mg
total exposure. It is important to recognize that the cumulative
dose may be achieved by inspiring a low concentration for a longer period
of time. It is this feature of nerve agent toxicity that mandates
decontamination. In the Tokyo example, a significant number of
health personnel were overcome by breathing the vapor contained on victims
clothing. Simply disrobing the patients, and setting up a triage
post in open air would have alleviated a number of casualties.
Nerve agents are liquids at room temperature and have relatively low vapor pressures. Sarin (GB) is the most volatile at 2 mm. Hg, which is similar to waters vapor pressure. The photo to the left demonstrates the physical appearance of common chemical weapons. Note that the compound is an oily brownish liquid. When heated, as in the Matsumoto incident, Sarin will come out of solution at a faster rate and produce a highly toxic concentration of agent. The nerve agents are also about 4 times heavier than air so they collect in low-lying areas. The Tokyo subway attack utilized this property by allowing the unheated vapor to accumulate in the lower reaches of the subway with obvious lethal consequences. The other G nerve agents are less volatile than Sarin and the agent VX is only considered a contact risk. It is important to note that some of the victims of the Subway attack include individuals who attempted to pick up the packets of agent and sustained a subsequent liquid exposure. Liquid exposure presents its own problems in management as the agent VX could be laid down at a location prior to occupation by the intended victims. An understanding of the effect route of exposure has on the presentation of the clinical toxidrome is critical to the management of the victim.
The toxic effects of nerve agent compounds are achieved through the
inhibition of acetylcholinesterase, and the subsequent over-stimulation
of the acetylcholine receptor. Muscarinic, Nicotinic, and CNS
subtypes of receptors are affected. Muscarinic receptors, when
stimulated, increase the activity of salivary glands, lacrimal glands,
smooth muscle, and pupillary constriction (miosis). The muscarinic
syndrome is best remembered by the SLUDGE acronym; S (salivation), L
(lacrimation), U (urination), D (diarrhea/diaphoresis), G (general weakness),
E (emesis). Of specific concern for medical personnel is the effect
upon bronchial smooth muscle and bronchial mucous glands. Nicotinic
receptors are found primarily on skeletal muscle as well as certain
ganglia, most significantly, the adrenal medulla. Stimulation
of nicotinic receptors results in fasciculation and ultimate paralysis
of the affected skeletal muscle. The CNS effects of these compounds
are sedation, seizure, apnea, and ultimate death.
agent toxidromes are described on the basis of both route and amount
of exposure. The following table depicts toxidromes of vapor and
Vapor-onset in 1-2 minutes
Liquid-onset in several minutes
Miosis, Rhinorrhea, Dim Vision,
Local fasciculations, Local sweating
All above with Nausea, Vomiting
All above with Nausea, Vomiting
Convulsions, Apnea, Death
Convulsions, Apnea, Death
Please note that the symptoms
produced by the same agent will vary with portal of entry. In
both Aum Shinrikyo attacks, almost all the exposures, both primary and
secondary, were by vapor. Because the nerve agents are not particularly
volatile, a large number of people were affected with a relatively low
concentration. The most severely injured victims had the longest
times of exposure or were closest to the munition. One should
not make that same assumption in a liquid or aerosol exposure.
Because of slower rates of percutaneous absorption, the need for surface
decontamination, and the persistence of agents on clothing, the risk
of delayed symptoms and progression to lethal dose exposures is greater
with liquid exposures. Aerosol exposures have components of both
vapor and liquid because an aerosol is composed of small droplets of
liquid agent, which may be inhaled, or may settle on the skin or other
objects. An aerosol is easily created by common industrial or
agricultural spraying devices.
of nerve agent victims consists of the opposition of the cholinergic
crisis with several medications. Atropine directly opposes the
binding of acetylcholine at muscarinic receptors and will serve to relieve
bronchospasm, and decrease secretions. Atropine does not have
activity at nicotinic sites, does not cross the blood brain barrier,
and therefore will not relieve paralysis or convulsions. Oximes
are a class of compounds that bind with organophosphates preferentially
to many other compounds including the acetylcholinesterase enzyme.
It is this preferential binding that will remove the offending agent
from the acetylcholinesterase enzyme. Pralidoxime chloride (2-PAM)
is the most commonly used oxime for this purpose. Although organophosphate
binding to acetylcholinesterase is considered irreversible, permanent
inactivation of the enzyme is by the transfer of the phosphate moiety.
This process is agent and time dependent and is referred to as aging.
Pralidoxime does not work once this process has occurred. In addition,
oximes do not cross the blood brain barrier, and will not decrease convulsions.
Diazepam has proven to be effective in animal studies to both reduce
mortality and improve morphological brain lesions, and is currently
recommended for severe exposures.
and pralidoxime are contained in autoinjectors commonly known in the
military as a Mark I kit. The Mark I kit is simple to use and
contains 2 mg. of atropine in one autoinjector and 600 mg. pralidoxime
in a second autoinjector, paired in a safety base. These dosages
are considered initial treatment doses and are given in multiple doses
based upon therapeutic response. The medications may be given IV with
the following considerations. Intravenous atropine will induce
Torsade de Pointes (intractable V-fib) when given to hypoxic patients
so the IM route is suggested. Pralidoxime will induce significant
hypertension if given IV push, therefore an infusion of one gram over
30-60 minutes is the current recommendation. Nerve agent therapy
differs from other organophosphate therapy in that the maximum dosages
required for treatment are less. The maximum dosage needed to
resuscitate a single Tokyo subway casualty was 20 mg. This may
favorably compare to reports of 1-2 grams of atropine required for a
more common organophosphate intoxication. The following table
contains current treatment recommendations, based upon presentation:
In judging therapeutic response
of atropine, the endpoint is the easing of bronchospasm and a drying
of secretions. Atropine will oppose the action of nerve agents
only at the muscarinic sites. The use of miosis, or heart rate
is not useful. Observation is a key component of the treatment
algorithm. Because liquid agents will provide a slower but greater
total absorption of agent, further treatment may be needed, despite
a good initial response.
of the nerve agent casualty depends on the type of exposure. Similar
to cigarette smoke, nerve agent vapor clings to clothing. Disrobing
the vapor casualty is estimated to provide 80-90% effective decontamination
with exposed skin and hair cleansing responsible for the remainder.
Off-vapors from clothing were the primary cause of secondary injury
to health care workers. In the Tokyo experience, 13 of 15 treating
physicians at Keio University Hospital were overcome within 40 minutes
by off-vapors. Simply disrobing the patients outside would have
saved health professionals from exposure. As noted in the photo
to the right, little effort was taken in Tokyo to prevent this exposure
risk. Liquid contamination remains persistent on surfaces including
patients and fomites, and therefore, becomes a risk for treating professionals.
Liquid agent exposure requires physical removal or washing. Nerve
agents are deactivated by hydrolysis which may be facilitated by the
addition of 0.5% hypochlorite. A 0.5% hypochlorite solution is
a 10:1 dilution of household bleach. Because of the extreme toxicity
of these agents, health care professionals are at significant risk for
secondary contamination. Every hospital likely to receive patients
of this sort must have the capability to decontaminate patients.
Triage of organophosphate nerve agent casulties relates to their triage category and response to therapy. Because of the rapid onset of symptoms, field treatment is mandated for these casualties. Immediate category casualties are those with severe exposures, followed by moderate exposures. Following successful field treatment, a casualty may be down-graded to Delayed and monitored for recurrence of symptoms. Minimal category casualties may decontaminated and observed in the field. Expectant category casualties would include those severely exposed casualties for whom field treatment is unavailable.
Recognition: Delayed onset of blister formation in contact areas
Protection: Level C minimum, contact protection for casualty care
Decontamination: 0.5% hypochlorite
Triage: Airway compromise must be treated. LD50 for man is 20% body surface area.
Survivors reported up to 90% body surface area
Treatment: Airway protection.
prototype blister agent is Mustard Gas. Mustard is actually
not related to table mustard, nor is it typically a gas. Mustard
is a thick oily liquid that freezes at 57 degrees F. The odor
of the substance is that of horseradish, onions, garlic or mustard,
hence its moniker. Mustard is the chemical weapon most frequently
used in warfare since its synthesis in 1917, and proved the most effective
chemical weapon in WWI. In addition, mustard is probably the weapon
most easily synthesized by terrorists. Mustard was recently used
by Iraq in the Iran-Iraq war. Interestingly, mustard is not highly
lethal but an incapacitating agent. In the military setting, an
incapacitating agent is often more useful than a rapidly lethal agent
because of the resources required to care for casualties individuals
and the distracting concern of fellow soldiers for their buddies.
For the terrorist, the main advantage of mustard is its persistence.
There are structures in France that still contain detectable mustard
absorbed in the wood and other building material. Persistence
allows the terrorist to lay down the vesicant agent prior to the occupation
of the space by the intended victim. Mustard is painless when
absorbed but exerts its action within 1-2 minutes. Unfortunately,
the identifiable effects develop in 4-24 hours.
is a DNA alkylation agent, which is its primary mode of action.
DNA alkylation refers to the action of mustard to stop DNA synthesis
and therefore kill growing cells. For this reason, the less toxid
nitrogen mustard is actually one of the first chemotherapeutic agents,
and it is still in use today. Sulfur or distilled mustards are
considered the likely weaponized form of the compound. The initial
signs of mustard exposure are erythema and the formation of vesicles
that occurs within the first 8 hours. These effects form at the
site of exposure, so if heated mustard vapor or a mustard aerosol is
used, the eyes, nose and airway will be most effected. This was
the primary mode of exposure for the majority of WWI casualties.
Airway management, therefore, is the critical issue for airborne mustard
exposures. After the airway risks, the ultimate cause of death
from mustard exposure is the DNA akylation of rapidly dividing cells
in the immune system. Similar to radiation, death from this process
takes some time. Because mustard is absorbed from the skin, the
LD50 for mustard is related to the body surface area involved.
The LD50 for mustard is 20% BSA (about 7.5 grams). It is important
to understand that mustard burns do not require the same fluid volumes
that are associated with thermal burns. Additionally, there are
reports of survivors from mustard up to 90% BSA, however, for triage
purposes, a 50% BSA burn is considered expectant.
vesicants include Lewisite, various industrial corrosives, and electromagnetic
radiation. Mustard may be suspected by odor, delayed presentation,
and confirmed by various testing devices. Lewisite has the odor
of geraniums, and is immediately active upon application to the skin.
Lewisite contains arsenic, but is somewhat less toxic than mustard.
The heavy metal chealator BAL (British Anti-Lewisite) may be used for
absorbed arsenic. Because of the immediate onset of symptoms,
cross-contamination is more avoidable than in mustard casualties.
The decontamination for either type of vesicant is the physcial removal
of the compound from body surfaces. It should be noted that the
decontamination run-off will contain active compound therefore, it should
be closely contained. Again 0.5% hypochlorite is the solution
of choice to aid in hydrolysis. In the Iran-Iraq war, Iranian
mustard casualties were sent to European hospitals and contaminated
several health care workers and facilities. This highlights the
persistence threat from mustard. Although mustard may be transferred
by fomites, the blister fluid from the casualty contains no active compound.
Triage of mustard casualties is somewhat problematic because of the delay of symptom onset. Immediate category casualties would include all those with airway compromise. Delayed category casualties would include all other exposures. Because casualties have survived with upwards of 90% body surface area contamination, no casualty should be classed as Expectant, although in cases of finite resources, one should bear in mind the LD50 for body surface area exposure is 20%.
Recognition: Sudden onset of mucosal, conjuctival irritation
Protection: Charcoal filtration mask, not dermally active
Decontamination: Soap and water, NO HYPOCHLORITE
Triage: Based upon exacerbation of pre-existent disease
Treatment: Based upon pre-existent
control agents consist of a group of compounds known for their intense
mucosal irritant properties. Commonly sold as personal protective
devices, these agents are familiar and available anyone. Although
considered non-lethal, if present in very high concentrations and in
enclosed spaces, deaths have been reported. The most probable
use of these compounds is as a hoax agent. Significant panic
in the lay public could be induced by the application of these agents
under the threat of a more lethal agent. Bear in mind that, while
Cyanide, Organophosphate Nerve agents are rapidly acting, they are typically
non-irritating. In addition, organophosphate nerve agents will
produce characteristic symptoms of miosis, sweating and fasciculation.
Mustard may produce intense blistering of the exposed skin surface while
riot control agents only work upon mucosa. Lung irritants may
be most easily confused with riot control agents but their characteristic
odors will aid in their discrimination. Treatment of a riot control
casualty is largely supportive with removal from the source and disrobing
typically all that is necessary. Although not dermally active,
it is important to note that the application of hypochlorite with riot
control agents will produce intense skin irritation and blister formation.
For this reason, soap and water only is used as a decontamination solution.
Individuals with pulmonary diseases or cardiovascular risks may develop
exacerbations of their disease states in response to these agents.
Triage all individuals with mucosal symptoms only as Minimal.
Individuals with secondary exacerbations of pre-existent disease should
be triaged according to their disease and acuity.
the domain of the military physician, the intentional spread of infectious
disease with the use of modern technology affords the terrorist with
a cheap, stealthy, and highly lethal modality to foment their organizational
ideology. Biological weapons, because they naturally occur, are
available to anyone with knowledge and a small amount of equipment,
as demonstrated by Larry Wayne Harriss ability to obtain both plague
and anthrax. A home-brewers kit is a fermentation vehicle built
for yeast culture. Very little modification is needed to make
a bacterial fermenter. Viral agents may be cultured in a fertilized
egg under the proper conditions. There are over 400 potential
or actualized etiological agents amenable for biological weapons construction.
Progress in the area of gene splicing and molecular biology makes it
possible to custom design a variety of pathological characteristics
as well as antibiotic resistance capabilities into a chosen pathogen.
For this reason it is less important understand each disease process.
One should direct ones energies to the recognition of an atypical epidemic
in a potential target population. The commonality of symptoms
and site of exposure are the keys to detection of a bio-weapon.
It should be noted, a devastating crop disease may ultimately produce
more harm to the nation than the loss of a population segment
infect a large section of the population, the distribution of a biological
weapon would be by aerosol, that is, the suspension of infective particles
in air. A biological aerosol is odorless, tasteless, and invisible.
The particle size for optimum pulmonary transmission is 1-5 microns.
The technology used to create this particle size us non-proprietary,
and in common use. As scene in the figure to the left, a hand-held
military aerosol generator is in use. In addition, many bacilli
are 1-5 microns in their natural state. A large number of organisms
can easily be produced by the geometric propagation of biological progeny.
With the use of an airplane equipped with a crop-dusting aerosol generator,
an entire city may be exposed. It is estimated that 50 kg of anthrax
spores, aerosolized in the proper conditions over a city of 500,000,
would produce a lethal form of pneumonia in 24,000 people. It
is this capability that earns the biological weapons reputation as
a weapon of mass destruction.
The stealth quality of the biological weapon comes from the incubation period for disease presentation. Once exposed to the pathogen, the development of disease may take 2-14 days, allowing the assailant to escape prior to the recognition of the bio-weapon. Individuals exposed will also develop their symptoms at different times and present to various health care facilities. This will further complicate the recognition of the intentional epidemic. Many of the agents are treatable, but only if recognized early. The EMS and public health system are the best early warning systems currently available. Naturally occuring epidemics are part of the medical experience. Differentiation of a naturally occuring epidemic from a biological weapon is therefore the critical feature of management. The key to the recognition of a biological weapon is:
Victims of a suspected
biological should all be triaged as Delayed, unless the victim is in
shock. If shock or respiratory failure is present, the victim
should be triaged as Immediate. Because of the lag time between
exposure and symptom presentation, biological weapons victims may not
seek immediate care from EMS. Victims are expected to auto-triage
to the health facility of choice, at the time of their choosing.
The individuals with the best view of the community as a whole are the
most likely to recognize the epidemic first. EMS and hospital
workers are in the best position for early recognition.
A. Bacterial Weapons
prototype bacterial agent is anthrax. Bacillus Anthracis causes
a fatal disease in herbivores, and is responsible for Woolsorters
Disease in man. Anthrax is a common soil bacteria, and typically
enters the skin through a cut or scratch. In the US, 5-10 cases
per year of cutaneous anthrax occur in individuals who come in contact
with slaughtered animals. In the Middle East, 100-300,000 cases
occur each year, and in 95-99% of cases the form of the disease is cutaneous.
The bacterium causes an abscess in a local lymph node with a typical
blackened eschar as noted int the picture to the right. The disease
progresses to fatal septicemia in about 20% of cases without treatment.
With treatment the mortality is essentially 0. This hardy bacterium
is capable of forming a spore that can remain viable without nutrients
for up to 40 years. It is this ability to sporulate that gives
anthrax its reputation as a formidable biological weapon. Because
the organism, once weaponized, requires no ongoing care, considerably
less care must be taken to ensure a viable and infective organism.
Anthrax is a found in Michigan soil.
weaponized form of anthrax is an aerosol of bacterial spores.
Because of the aerosol distribution, an unusual respiratory form of
the disease will occur. The anthrax bacteria enter through the
respiratory tract and no visable eschar is formed, rather a chest cold
like syndrome is produced. Although respiratory symptoms occur,
chest X-ray findings are non-specific. Initially, the flu-like
syndrome will show improvement in 2-6 days. However, in the 4-6
day period, the terminal septic phase develops and maximal antibiotic
treatment will not prevent death. There are rapid ELISA tests
for anthrax antigens but these are not commonly available. An
occasional finding in the septic phase is the fulminate overgrowth of
bacteria visible on gram stain of the blood. Should the septic
phase develop, death typically occurs within 24 hours. Antibiotic
treatment, initiated prior to the onset of the terminal septic phase,
can be life-saving for those exposed to anthrax. For this reason,
it is critical to recognize this disease and treat the community at
the earliest moment.
400 mg IV q 8-12
500mg po BID for 4 weeks
100 mg IV q 12
100 mg po BID for 4 weeks
There is an approved vaccine
for this agent available from the Michigan Department of Public Health.
Although little known in the United States, we are currently experiencing the worlds 4th modern pandemic of plague. The epicenter of this outbreak is China and India. Approximately 3,000 new cases of plague are diagnosed worldwide with 8-10 cases occurring in the US. The plague is responsible for the Black Death epidemic in which 25 million people were killed during the Middle Ages. The terror potential of spreading the Black Death is not to be underestimated. Because of the inexperience of American health professionals with this agent, a significant delay in initial diagnosis and treatment can be expected
is a disease of rodents, historically the rat, and is caused by the
organism Yersinia Pestis. In the US, ground squirrels and prairie dogs
provide the reservoir. It is not the rodent, however, that spreads
the disease, it is the flea, as seen on the right. In its naturally
occuring state, the plague has two forms, bubonic and pneumonic.
Bubonic plague is the most common form of the disease and typically
precedes the pneumonic form. The disease is transmitted to the
flea feeding upon an infected rodent. The Yersinia Pestis
bacteria then reproduce within the flea and eventually obstruct the
foregut of the flea. The starving, plague laden fleas, in a frantic
effort to survive, abandon the rodent and bite the human victim.
The flea bite introduces the bacteria into the lymphatic system.
In the lymph node, an abscess with a blackened eschar is termed a Bubo.
Because fleas most commonly bite the lower extremities, the most common
site for buboe formation is the inguinal lymph nodes as noted in the
picture above. Bubonic plague takes its name from this finding.
The death rate from bubonic plague is about 50% without treatment, and
falls to 5% with proper antibiotics. In those fatal cases, the
disease progresses to the septicemic form in which the lungs are involved.
the lungs are infected, respiratory droplets containing the
Yersinia Pestis bacteria are spread by coughing. Pneumonic plague
occurs when these droplets are inspired and a plague-pneumonia is formed.
A useful diagnostic tip is that pneumonic plague will present with bloody
sputum in a large number of people. Typically, a lymph node aspirate
is used for gram stain and culture, but sputum, and/or blood must be
used for pneumonic plague diagnosis. When visualized on gram stain,
the bacterium exhibits a characteristic Safety Pin gram negative pattern
as shown in the figure to the right. Pneumonic plague is 100%
fatal without treatment but, like anthrax, mortality from pneumonic
plague can be reduced to 8-10% with early antibiotic therapy. For this
reason, it is critical to recognize this disease and treat the community
at the earliest moment. The characteristics of a biological attack
would include, pneumonic plague with no bubonic form will occur and
the disease will not be found in the rodent population. Treatment is
summarized in the following table.
400 IV q12 x10 days
500mg po BID x10 days
100mg q12 x 10 days
100 mg po BID x 10 days
30mg/kg/day divided q12 x10 days IM
There is an approved vaccine
for against Yertsinia Pestis that has proven efficacy against the bubonic
is normally a disease of rabbits, transmitted by biting insects to man.
The normal form of the disease is termed ulceroglandular fever, commonly
known as rabbit fever. The organism propagates in a lymph node
and there it forms an abscess with a small ulceration. The lesion
can be easily confused with a spider envenomation. The disease
in uncomfortable, but not serious. Like anthrax and plague, the
weaponized, the form of disease is pneumonia because of the respiratory
mode of transmission. Tularemia pneumonia is typically not fatal
with or without antibiotics but the organism is difficult to grow on
standard culture media. Because tularemia does not normally cause
pneumonia, and is difficult to detect, a significant delay in diagnosis
can be expected. The characteristic that makes tularemia an effective
biological weapon is its extreme infectivity. As few as 10 organisms
are required to be effective. Although a mortality rate of only
4% has been reported, if a large number of victims are infected, the
end result would be a significant number of casualties. High rates
of infectivity and difficulty in detection make tularemia an effective
terror weapon. An investigational vaccine is currently being evaluated.
is a form of bacterial enteritis common in many parts of the world,
and is caused by the organism Vibrio Cholerae. It is not commonly seen
in the United States because of our water and sewage treatment.
The disease is characterized by profuse rice water diarrhea up to
15 liters per day. Typically, the victim is incapacitated by this
amount of diarrhea. The weaponized form of the disease is primarily
a water or food-borne risk. Cholera causes a secretory diarrhea.
Secretory diarrhea induces the loss of electrolytes and fluids.
The disease is only lethal in those unable to rehydrate by oral means
in areas without IV therapy. Most cholera patients are treated
with oral rehydration as the degree of nausea is insignificant.
The World Health Organization oral rehydration formula is 20 grams glucose,
3.5 grams NaCl, and 2.5 grams NaHCO3, and 1.5 grams KCl per liter of
fluid. There exists no vaccine. Antibiotic therapy may shorten
the disease marginally.
hemorrhagic fevers are endemic in discreet locations. These diseases
have very specific hosts and the disease is limited by the range of
the animal or insect hosts. Because of the limited and remote
range of the host, this group of diseases is ever increasing in number
as they are discovered. Common characteristics of viral hemorrhagic
fevers are abnormal bleeding and fever. Although common in many
parts of the world, viral hemorrhagic fevers are uncommon in the United
States. The hantavirus (see picture on right) outbreak in the
four-corners region of the desert southwest in May of 1993 is an example
of this disease type, and the difficulty in management. The host
for hantavirus is various species of mouse found in the southwest.
The method of transmission is through aerosolizaton of mouse feces.
The disease causes the onset of non-cardiogenic pulmonary edema and
has a high mortality. Significant delays in recognition of the
viral etiology as well as effective methods of treatment caused serious
concern on the part of the medical community. Hantavirus
positive patients have been demonstrated throughout the United States
prior to the outbreak in the southwest indicating that this disease
has been present for some time prior to its recognition. Diseases
of this type are termed emerging and if intentionally spread, would
cause significant confusion in the medical system.
is the most lethal viral hemorrhagic disease yet discovered. Initially,
the disease was reported in Zaire, but the most current outbreak is
in Gabon. The characteristics include abnormal bleeding, purpura,
petichia, renal failure, obtundation, and death. The mortality
rate is around 88% for the Zairian strain and around 53% for the Gabon.
The host is considered to be primates, and the mode of dissemination
is thought to be aerosol. In addition to the African experience,
an outbreak of a viral hemorrhagic fever occurred in Marburg Germany
in the late 1980s. The outbreak was limited to animal care workers
with contact to a shipment of African Green monkeys. The mortality
of the Marburg strain was 26%. The virus was again detected in
1989 in Reston, VA, and 1990 in Alice TX. The hosts were from
Philippine macaques, and although the disease was fatal in the primate,
the virus did not cause fulminate disease in humans. In all cases,
the virus appears as the shepherds crook, as depicted above, and
is morphologically identical. DNA sequencing reveals minor mutation
between all the strains. No reservoir has been found for Ebola
Gabon or Zaire, but it is suspected to be another primate. There
is no treatment or vaccine.
caused by the Variola virus, is a cutaneous disease related to chicken-pox.
The presentation of the disease is a vescular eruption most heavily
on the face. Due to the diligent work of health care workers,
and active vaccination programs, smallpox was declared eradicated in
1980, and the US stopped vaccination in 1981. Small reserves remain
however, at the CDC in the US and at Vektor in present day Russia. It
is suspected that knowledge and perhaps the agent itself was distributed
within the old USSR and is now in the possession of terrorist sponsoring
nations. Because of the 1981 cessation of the vaccination
program in the US, we are a population at risk. Transmission is typically
by contact with infected individuals. No data exists on respiratory
transmission. The rash may be discriminated from chicken pox by
the heavy crop of vesicles on the face, and the lack of vesicles in
various states of healing. Thirty percent of exposed victims will
develop the disease, and thirty percent of those with the disease will
die. There is no treatment, but a vaccine exists.
Equine Encephalitis is caused by an arbovirus (see micrograph on right)
common to horses and responsible for large outbreaks in South America.
It is spread to humans by a biting insect and has a high rate of infectivity.
The disease produced manifests with fever, prostration and viral meningitis.
A very high rate of infectivity is noted, in fact, only ten organisms
are needed to create the disease. Although not highly lethal,
morbidity is widely experienced, and this disease only retrospectively
diagnosed by serologic testing. There is some controversy over
the effects of an aerosolized agent. Some argue that, because
of the proximity of the olfactory bulb, the respiratory route would
induce an higher rate of meningitis and therefore a higher mortality
rate. There remains no published data on the subject. The
characteristics of a biological attack would the potential high rate
of viral meningitis and the absence of pre-existent disease in the equine
population. There is no specific treatment but an investigational
vaccine does exist.
weapons are substances derived from living organisms and therefore represent
a hybrid between chemical and biological weapons. Toxin as a group
are much more toxic milligram per milligram than are chemical weapons.
Unlike biological weapons, they require no growth media and are typically
stable for storage. Toxins are typically odorless and tasteless
and produce no symptoms upon exposure. The recognition of a toxidrome,
or group of symptoms, is seminal to the detection of the attack.
toxin is produced by the bacterium Clostridium Botulinum and has the
distinction of being the most toxic substance known to man. The
lethal dose in man for botulinum toxin is 0.001 ug/kg or 1 nanogram
per kilogram of body weight. This toxicity is 15,000 times more
lethal than VX, the most lethal of the chemical agents. A single
milligram of pure toxin contains 200 lethal doses for the average size
man. Clostridium Botulinum is found in the soil and the toxin
is active in an impure state. In a naturally occurring outbreak,
a contaminated foodstuff is the source of the agent. The typical
scenario is improperly canned food or perhaps food that is left in a
warmed exposed condition for significant amounts of time. A natural
outbreak will be traceable to a common food source consumed within the
past 24-36 hours. In a biological terrorist attack, the agent
may be aerosolized and inhaled, or spread upon a food source.
Whether inhaled or consumed, the toxin will exert the same effect.
onset of symptoms occurs within 24-36 hours and typically presents with
ptosis or droopy eye lids. The paralysis proceeds from the head
downward over the body, ultimately causing a cessation of respiration.
Botulinum toxin exerts its effect by binding with the motor end-plate,
that is where the nerve plugs into the muscle. A destruction of
this end-plate structure occurs and the muscle is unable to take voluntary
commands. Once destroyed, 6-8 weeks are required to reconstruct
the end-plate. Should ventilatory failure occur, the victim would
remain dependent on the ventilator for 1-2 months.
an exposure to botulinum toxic is suspected, one may treat the patient
with an antitoxin. The antitoxin consists of equine derived Fab
(antibodies) antitoxin fragments that work well for unbound, toxin in
the circulation. Once the toxin has bound to the end-plate, the
antitoxin is of little use, therefore, one would give the antitoxin
on the basis of exposure, rather than the onset of symptoms. A
vaccine is investigational and not commonly available.
Enterotoxin B is another food borne toxin that commonly causes outbreaks
of food poisoning. It is derived from the bacterium Staphylococcu
Aureous. Staphylococcus Aureous is a common skin organism.
A natural outbreak would include the onset of nausea, vomiting, fever,
prostration, and diarrhea within 6-12 hours of the consumption of the
contaminated foodstuff. The most common type of foodstuff is mayonnaise
or creamy salads. All victims can be traced back to the common
source, and the symptoms subside with the expulsion of the toxin from
the gastrointestinal tract.
toxin may be weaponized as an aerosol and, in this form, the symptoms
include fever, prostration, and cough without the same degree of gastrointestinal
symptoms. Although benign and self-limiting, the toxidrome is
indistinguishable from more virulent forms of biological weapons, hence
its use as a terror weapon. As a military weapon, it is used to
temporarily render an opponents forces incapable of action, or used
in conjunction with a more lethal agent. For the terrorist, non-lethal
retribution against a target population is considered a likely scenario.
Since all that is needed to form staphylococcal enterotoxin B is potato
salad and a warm day, this toxin is highly accessible to amateurs and
is a plant toxin derived from castor beans. Ricin is active by
ingestion or inhalation, and is a potent inhibitor of protein synthesis.
If ingested, ricin causes gastrointestinal hemorrhage, and the necrosis
of the liver, spleen and kidney. If inhaled, ricin causes necrotizing
pulmonary lesions, pulmonary edema, and respiratory failure. In
either case, death occurs by day 3. An interesting use of ricin
involved the 1978 assassination of Bulgarian KGB defector Georgi Markov.
It happened that a KGB loyalist used a spring-loaded umbrella to fire
a small hollow pellet containing ricin into Mr. Markovs calf while
he waited at a bus stop. Mr. Markov shortly became quite ill with
a mysterious illness. Not until the small pellet was recovered
from the leg of Mr. Markov was his illness confirmed as a toxicological
assassination. Mr. Markov ultimately succumbed to the effects
of the toxin.
beans are processed into castor oil in many parts of the world for manufacture
of products such as hydraulic and brake fluids. Ricin is contained
in the waste mash or water soluable component of processing.
The worlds annual production of waste mash is around 1 million tons.
This waste mash is 5-10% ricin. The separation process is simple
and compound is stable. Diagnosis of ricin exposure is difficult
to detect initially, as it requires recovery of the toxin and chemical
analysis. There are no available treatments, and no vaccine.
are derived from the Fusaria species of grain mold. There are
about 6 species of Fusaria capable of making a heterogenous group of
40 compounds we know as mycotoxins. During periods of deprivation,
the disease toxic alimentary aleukia occurs when fusaria are ingested
in significant amounts. Mycotoxins are potent inhibitors
of both protein and DNA synthesis. In addition, mycotoxins are
the only known biological agent toxic by contact route. When ingested,
inhaled, or absorbed, the syndrome includes emesis, hemorrhage, and
immune compromise. Lethal amounts are known to cause death within
24 hours. Diagnosis of mycotoxin exposure requires recovery of
the toxin and chemical analysis. There is no known method of treatment,
civil defense owes much to the threat of nuclear exchange with the former
Soviet Union. There is a great deal of awareness of nuclear weapons
and a great deal of appropriate fear of their discharge. The de-novo
construction and successful detonation of a nuclear device is, however,
a difficult task. To create such a weapon, significant amounts
of high grade fissionable material must be stolen or manufactured, ultra-precise
bomb mechanics must be machined and tested, high grade containment facilities
must be used to avoid detection during manufacture of the weapon, and
a necessary understanding of nuclear physics at the highest level must
supervise design and construction. Although fissionable material
is available on the black market, these significant resources are
typically only possessed by nations. It is this level of resource
expenditure that makes the terrorist detonation of a nuclear device
an actual nuclear device may be difficult to achieve, possession of
radioactive material is not. Radioactive sources are in use in
many industries as well as available for purchase from unscrupulous
vendors. The combination of a radioactive source with a conventional
explosive device presents a particular problem for first responders.
Therefore, an understanding of radiation effects on the human body and
safe levels of radiation exposure is necessary for the safe management
of this contingency. To aid in our discussion, radiation devices
are divided into the following categories:
a. Non-explosive radioactive source placed in proximity to the victims.
a. Conventional explosive device laced with radioactive material
the device, it is important to understand the difference between irradiation,
and contamination. Irradiation of a victim refers to the exposure
of that victim to an amount of ionizing radiation such as X or gamma
rays. We are exposed to small amounts of electromagnetic irradiation
from the sun, hospital X-ray machines, and microwave ovens on a continuous
basis. Unless the victim is exposed to large doses of high-energy
gamma rays, the irradiated victim is not radioactive and no protective
equipment is required to care for the victim. A simple radiological
device will produce such victims. Like the X-ray machine at the
hospital, the simple radiological device delivers a fairly constant
amount of radiation per unit of time. This amount of radiation
is measurable by radiation dosimeters, and just like the X-ray machine,
safe amounts of exposure are well known. Safety at the scene and
the ultimate survival of the victims will be based upon the level of
irradiation present, and the time of exposure.
with radiological material is more important to consider. Contamination
refers to radioactive fallout or radioactive dust that can be inspired,
ingested or retained on the skin. Both Radiological Dispersal
Devices and Improvised Nuclear Devices create fallout contamination
in addition to the risk of irradiation. With advance knowledge,
the first responder can easily protect him or herself from fallout contamination
with appropriate disposable clothing, and HEPA filter respiratory protection.
As mentioned in the preceding paragraph, safe working times in a given
level of exposure are well established. Without knowledge of potential
radiological contamination, the first responder is likely to unknowingly
contaminate him or herself
recognition of a radiological event is clearly evident in the case of
an Improvised Nuclear Device. Federal level assets will be brought
to bear on the crisis and what remains of the local authorities will
be incorporated into the ongoing management efforts. In the case
of a Radiation Dispersion Device, potential contamination must be suspected
by the managing authority. Confirmation of a radioactive component
to the explosion must be confirmed by a radiation-measuring device such
as a dose rate meter or Geiger-Mueller Counter. The use of a Simple
Nuclear Device or radiation source may be suspected on
radiation sickness encountered in workers or inhabitants of a given
locale. Radiation sickness is a constellation of symptoms that
will be described in a later paragraph. Confirmation of a radioactive
source is again dependent on the use of radiation measuring device.
Radiation measuring devices must be available to all first responders
at the scene of a potential terrorist event.
Protection of first responders in a radiological event is composed of two distinct goals:
As mentioned, irradiation may
be measured in a given area and safe times of exposure may then be calculated.
The safe level of radiation for man varies with a persons age and reproductive
status, but 40-50,000 milli-REM (40-50 REM) is considered safe for a
single exposure in a year. This is the same amount of radiation
exposure given to a patient during a cardiac catheterization.
Therefore, if the level of irradiation in a given area is100 milli-REM
per minute, it would take 400 minutes or about 6.5 hours to achieve
the maximum level. A time-dosage calculation must be done for
every first responder involved. Because of the risk of fallout
contamination, skin and respiratory protection must be given to each
one moves away from the radiological source, the level of irradiation
falls. Specifically, the level of radiation will decrease by a
factor of 4 (the square root) if the distance is doubled. Distance
is therefore the best and most readily attainable method of reducing
exposure to victims and first responders. It should be noted that
in the case of a Simple Radiological Device, the level of irradiation
obeys the inverse square rule. That is, the level of irradiation
will increase by a factor of four, each time the distance to the source
is halved. For this reason, never directly contact a radiological
is composed of either particles or electromagnetic radiation.
Particulate radiation may take the form of alpha, beta, or neutron particles.
Each type of particle possesses different characteristics of tissue
penetrance and ionization. Several types of radioactive particles
are shielded by personal protective equipment. Alpha and Beta
particles for example require only ordinary work clothing for shielding.
Neutrons however penetrate more effectively and more effective shielding
is required. Electromagnetic radiation exists in waves of energy,
similar to radio or microwaves. The difference is in the level
of energy, and therefore the degree of penetrance. The higher
the frequency of the wave, the higher the energy the wave will possess.
High-level gamma radiation, for example, requires many inches of lead
for protection and therefore, shielding becomes somewhat impractical.
Standard, disposable level C suits, in combination with time-dosage
calculations, and respect for the effects of distance from the source
are adequate protection for first responders.
Radiation effects on man are related to DNA damage caused by ionization. Because rapidly dividing cells are most susceptable to DNA damage, the gastrointestinal and hematopoetic cells are typically the first, and most severly effected. Data from past nuclear experience indicates the lethal dose of irradiation in man to be about 350-450,000 milli-REM. It is important to note that while 50% of those victims exposed to this level of radiation will die, it may take up to 60 days. Radiation sickness will progress according to the following stages: