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Copyright © 2003 Robert C. Jones, M.D. GAS GAS GAS! Introduction to Weapons of Mass Destruction for Anesthesia Providers Robert C. Jones, M.D. LtCol, USAF,

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1 Copyright © 2003 Robert C. Jones, M.D. GAS GAS GAS! Introduction to Weapons of Mass Destruction for Anesthesia Providers Robert C. Jones, M.D. LtCol, USAF, MC Staff Anesthesiologist 89 th Medical Wing Andrews AFB, MD Version 1.0

2 Copyright © 2003 Robert C. Jones, M.D. Alexander Pope ( ) on Education via Powerpoint ® Slides: "A little learning is a dangerous thing; / Drink deep, or taste not the Pierian spring; / There shallow draughts intoxicate the brain, / And drinking largely sobers us again." This presentation should be considered only a brief introduction to the complex topic of WMD/NBC warfare Many U.S. and allied military personnel have spent their entire careers researching and teaching this material...the author was given far less time than that… The reference pages include hyperlinks to exhaustive and authoritative sources for further study…please use them. Your future patients will thank you. The CD also includes many helpful resources in Adobe Acrobat ® format; you can get the free Acrobat ® reader here: If you cant get the hyperlinks to work, see this workaround from Microsoft:

3 Copyright © 2003 Robert C. Jones, M.D. Disclaimer: Fair Use of Online Resouces In order to educate military health care providers, this presentation contains graphics and information obtained on the internet which may be copyrighted According to Sections 107 and 504c of United States Code title 17, this material is considered to be fair use of copyrighted intellectual property; it is to be used for non-commercial purposes only Fair Use is the use of a copyrighted work for purposes such as criticism, comment, news reporting, teaching (including multiple copies for classroom use), scholarship, or research. –In determining whether the use made of a work in any particular case is a fair use, the factors to be considered shall include: The purpose and character of the use, including whether such use is of a commercial nature or is for nonprofit educational purposes; The nature of the copyrighted work; The amount and substantiality of the portion used in relation to the copyrighted work as a whole; and The effect of the use upon the potential market for or value of the copyrighted work. The purpose and character of this presentation is for nonprofit educational purposes in support of human health and welfare and the mission of the United States Air Force; the nature of the copyrighted work is individual graphics and quotes; the amount and substantiality of the portion used is minimal; and the effect on the potential market for or value of the copyrighted use is negligible. In fact, the hyperlink references crediting the original sources should increase the market value of said copyrighted works by increasing traffic to the websites presenting this material. This presentation was produced in the United States Air Force medical environment in the interest of academic freedom and the advancement of national defense-related concepts. The views expressed in this presentation and linked-to material are those of the author(s) of said material and do not reflect the official policy or position of the U.S. Air Force, Department of Defense, or the United States government. Nor do educational links to internet websites or reference sources constitute any kind or degree of verification or validation of information presented therein. Point of Contact for questions regarding copyright infringement shall be the current U.S. Department of Defense designated agent to receive notification of claimed DMCA copyright infringement (courtesy of Department of Redundancy Department [DoRD]) FAIR USE NOTICE: This contains copyrighted material, which is reproduced under the Fair Use Provision of Title 17, U.S.C. Section 107, and is posted for purposes such as criticism, comment, news reporting, teaching, scholarship, or research. This material is posted without profit for the benefit of those who, by accessing this material, are expressing a prior interest in this information for research and educational purposes.

4 Copyright © 2003 Robert C. Jones, M.D. Part 1: Chemical Warfare Historical Perspective Classes of Chemical Warfare Agents Clinical Details of Chemical Agents Specific Anesthesia-related Issues References

5 Copyright © 2003 Robert C. Jones, M.D. Part 2: Biological Warfare Historical Perspective Classes of Biological Warfare Agents Specific Anesthesia-related Issues References

6 Copyright © 2003 Robert C. Jones, M.D. Part 3: Nuclear/Radiological Warfare Historical Perspective Types of Radiological Warfare Agents Specific Anesthesia-related Issues Future Issues: The Final Frontier? References

7 Copyright © 2003 Robert C. Jones, M.D.

8 Part 1: Chemical Warfare Historical Perspective Classes of Chemical Warfare Agents Clinical Details of Chemical Agents Specific Anesthesia-related Issues References

9 Copyright © 2003 Robert C. Jones, M.D. Part 1: Chemical Warfare 1000 BCE: Chinese used arsenical smoke as weapon 600 BCE: Solon placed hellebore in water of Kirrha 500 BCE: Sun Tzu writes of military uses of fire 300 BCE: Indian Text Arthashastra, Chapter XIV, describes recipes for chemical/biological warfare 678 CE: Byzantines use Greek Fire to destroy fleet References: Historical Perspective

10 Copyright © 2003 Robert C. Jones, M.D. First Modern Use: WWI: Ypres, France, 22 April cylinders of chlorine gas released by Germans Phosgene, Mustard gas soon followed Reference: Historical Perspective (cont'd)

11 Copyright © 2003 Robert C. Jones, M.D. Historical Perspective (contd) Nerve Agents first developed by German Chemist Gerhard Schrader prior to WWII: –Tabun (GA) [1936], Sarin (GB) [1938], Soman (GD) [1944] (Note: G stands for German) U.K. Developed VX in 1952– given to U.S. Iraq known to possess Cyclosarin (GF), Dusty VX References:

12 Copyright © 2003 Robert C. Jones, M.D. Historical Perspective (contd) Defoliants, incapacitant BZ used by U.S. in Vietnam Iraq and Iran used chemical weapons extensively during Iran-Iraq war (mustard, tabun, mycotoxins, etc.) Sarin deployed by Aum Shinri Kyo, Tokyo, 1995 References: From

13 Copyright © 2003 Robert C. Jones, M.D. Classes of CW Agents (with examples) Blister (mustard, Lewisite, phosgene oxime) Blood (HCN, cyanogen chloride, arsine) Choking (Chlorine, Phosgene) Nerve (tabun, soman, sarin, VX) Incapacitating (BZ, LSD, Agent 15) Vomiting (DA, DC, DM) Irritants (CS, CN, CR) Used mainly for law enforcement/crowd control; not covered in this lecture

14 Copyright © 2003 Robert C. Jones, M.D. Modified from: U.S. Military Chemical Warfare Agent Classification CategoryUS CodeCommon Name Blister AgentsHDDistilled Mustard LLewisite CXPhosgene oxime Blood AgentsACHydrogen cyanide CKCyanogen chloride Choking AgentsCGPhosgene CLChlorine Nerve AgentsGATabun GBSarin GDSoman VX Incapacitation AgentsBZ, QNBQuinuclidinyl benzilate

15 Copyright © 2003 Robert C. Jones, M.D. Blister (Vesicant) Agents Mustard/Nitrogen Mustard: Attack DNA via alkylation; hydrolysis releases HCl (moist parts of body especially vulnerable– groin, axilla, eyes…) Phosgene oxime: not true vesicant; unbearable pain; penetrates chem gear and rubber easily Mustard heavier than air; persistent in cold temps < 5% fatality rate for mustard-- morbidity overwhelms care facilities, degrades readiness; psychological effect Mustard Gas: Sources:

16 Copyright © 2003 Robert C. Jones, M.D. Blister (Vesicant) Agents (Cont'd) Sources: ; WW I British Soldiers blinded by Mustard (note bandages: not good idea…keeps agent in contact with cornea longer)

17 Copyright © 2003 Robert C. Jones, M.D. Blood Agents "Blood Agent" antiquated term: actual site of toxicity inside cells (not bloodstream) Cyanide moiety binds to cytochrome a3 halts oxidative phosphorylation CNCl one of many cyanide-producing substances (including many seeds, cassava root, etc.) Scent of "bitter almonds" genetically determined– 40-50% of population can't detect odor Hydrogen Cyanide: Sources: ;

18 Copyright © 2003 Robert C. Jones, M.D. Blood Agents From: CN - Blocks electron transfer from cyt-a3 to oxygen

19 Copyright © 2003 Robert C. Jones, M.D. Blood Agents Deadly via ingestion or inhalation, cyanide forces cells to resort to anaerobic metabolism death by cellular anoxia in minutes Jonestown massacre, 1978: ingested in fruit drink Gaseous HCN used during WWII at Nazi "Extermination Camps"

20 Copyright © 2003 Robert C. Jones, M.D. Blood Agent Treatment 100% oxygen– intubate as needed Cyanide Antidote Kit (often stocked in hospitals): Amyl nitrite via inhalation– 1 amp (0.2 cc) q 5 mins PRN Sodium nitrite: 300 mg iv over 5-10 mins Sodium thiosulfate: 12.5 grams iv Blood agents kill so quickly, many patients will die before treatment Patients who are awake/alert >5 mins after exposure often need no significant treatment

21 Copyright © 2003 Robert C. Jones, M.D. Choking Agents John Doughty, a New York City schoolteacher, first suggested use of chlorine gas as a CW agent during the American Civil War (not used) Chlorine: Reacts with water in lungs to form HCl, hypochlorous acid, free radicals Phosgene: HCl released in lungs; scent:new-mown hay Heavier than air: collected in WWI trenches Common pathophysiology: fulminant pulmonary edema/ARDS; little long-term damage if survived Phosgene: Chlorine release on battlefield, WWI ARDS/SIRS caused by phosgene Sources:

22 Copyright © 2003 Robert C. Jones, M.D. Nerve Agents VX nerve agent: Control Room! he gasped then, and every speaker throughout the great cruiser of the void blared out the warning as he forced his already evacuated lungs to absolute emptiness. Vee-Two Gas! Get tight! --First Officer Conway Costigan, Triplanetary, E.E. Doc Smith, © 1948 Nerve Agents are among the most feared of all weapons of war Insidious, odorloss, colorless, extremely lethal All are anticholinesterases; antidotes/treatment available Macromedia Shockwave graphic of neuronal transmission:

23 Copyright © 2003 Robert C. Jones, M.D. Pathophysiology of Nerve Agents Nerve agents interfere with acetylcholinesterase; excessive ACh leads to depolarizing neuromuscular blockade downregulation of ACh receptors nondepolarizing blockade long-term effects

24 Copyright © 2003 Robert C. Jones, M.D. Nerve Agent Symptoms: Salivation Lacrimation Urination Defecation Gastrointestinal pain/gas Emesis Early symptoms due to muscarinic effects (mnemonic: SLUDGE): Note: also Early Signs: bronchospasm, bradycardia, miosis from cholinergic effects

25 Copyright © 2003 Robert C. Jones, M.D. Nerve Agent Symptoms (contd): Nicotinic Effects: –Impaired motor ability –Tachycardia (adrenal stimulation/hypercarbia) –Weakness –Flaccid paralysis –Apnea death GABA Antagonism: – tremors seizures/convulsions death Late signs/symptoms due to nicotinic effecs and GABA antagonism:

26 Copyright © 2003 Robert C. Jones, M.D. Types of Nerve Agents Tabun (GA)– first developed Sarin (GB)– used by Aum Shinri Kyo Soman (GD)– receptor aging a factor Cyclohexyl Sarin (GF)– sarin derivative VX– persistent agent; 100X more deadly than Sarin via skin, 2 X deadlier via inhalation Dusty VX– VX + carrier (talc, diatomaceous earth): penetrates standard chem gear easily See: for details of individual agents/treatment guidelines; see for chemical structures of agents; see for dusty agent infohttp://www.bt.cdc.gov/agent/agentlistchem-category.asp#nervehttp://www.verifin.helsinki.fi/cwc/cwa.asp

27 Copyright © 2003 Robert C. Jones, M.D. Nerve Agent Antidotes Unlike many chem/bio weapons, specific antidotes available for nerve agents Excellent discussion of nerve agent treatment: Atropine: anticholinergic; 2 mg q 2-5 mins titrated to antimuscarinic effect (reversal of bronchospasm, diminished airway secretions, improvement of bradycardia); NO effect on nicotinic sxs (weakness/paralysis); Mark 1 autoinjector: 2 mg IM dose Oximes (Pralidoxime [2-PAM Chloride, protopam], others): disrupts covalent bond between nerve agent and ACh; prevents aging of receptors if given fast enough (2 minutes for soman); 1-2 grams IV/IM; Mark 1 autoinjector: 600 mg IM dose Benzodiazepines (midazolam, diazepam): for seizures; barbiturates CONTRAINDICATED (effects increased by anticholinesterases) Mydriatic cycloplegics (Tropicamide [Mydriacyl ®, others]): for eye pain, miosis Experimental/Future Antidotes: H-series oximes, exogenous anticholinesterase, monoclonal antibodies against nerve agents

28 Copyright © 2003 Robert C. Jones, M.D. Pyridostigmine, Soman, and Aging Soman causes rapid permanent inactivation of ACh receptors (minutes), vs. hours for other nerve agents Pyridostigmine bromide (PB) protects subset of ACh receptors during soman exposure– improves outcome with immediate atropine/oxime treatment only PB has side-effects (controversial topic) See references below for more info Brief review: Extensive review:

29 Copyright © 2003 Robert C. Jones, M.D. Persistence and Dissemination Environmental stability of chemical agents varies greatly HCN gas dissipates rapidly (minutes) in sunlight; mustard, VX persist for weeks/months in cold environment Expect waves of casualties based on secondary contamination Primary threat of chemical weapons is aerosol; contact threat from mustard/VX See for detailed description of persistence/dissemination info on chem/bio agentshttp://hld.sbccom.army.mil/ip/bca_qr_text_only.htm

30 Copyright © 2003 Robert C. Jones, M.D. General Principles of Treatment for Chemical Casualties Force Protection: Dont become a casualty yourself Terminate Exposure: Remove from attack site Triage: Immediate/Delayed/Minimal/Expectant Decontaminate: full exposure/wash/rinse/repeat Antidotes: based on clinical suspicion; wont know agent early on Atropine is your friend: may need mg for severe cases; dose to effect (tachycardia is not endpoint) Benzos for seizures: midazolam, diazepam Intubation: consider non-depolarizing agent Children/Elderly most susceptible to chemical agents Modified from:

31 Copyright © 2003 Robert C. Jones, M.D. Decontamination of Chemical Warfare Casualties Rule #1: Dont become a casualty yourself! Many physicians/healthcare providers became nerve gas casualties after Tokyo sarin attack…standard universal precautions USELESS Expect at least a 5:1 ratio of unaffected to affected casualties Decontaminate victims as soon as possible Disrobing is decontamination; head to toe, more removal is better Water flushing generally is the best mass decontamination method After a known exposure to liquid chemical agent, emergency responders should be decontaminated as soon as possible to avoid serious effects. From SBCCOM Online Homeland Defense site: also see

32 Copyright © 2003 Robert C. Jones, M.D. Decontamination of Chemical Warfare Casualties (contd) Rule #2: Refer to Rule #1! Decontamination before Operation! See and for Decon Station setup/management; pictures from and First responders should assess ABCs/start Triage All care providers in MOPP 4 or civilian equivalent protective gear Ambulatory victims directed to marked safe area for decon All clothing/jewelry removed; clothing/belongings bagged/tagged Flush with water 2-5 mins (flush eyes 15 mins if exposed) Never transport patients to hospital before full decon Hospital should guard against contaminated walk-ins

33 Copyright © 2003 Robert C. Jones, M.D. Anesthesia Care for Chemical Warfare Casualties Airway Management –Assume full stomach/associated injuries/hypovolemia –Bronchospasm common effect of chlorine, phosgene, riot- control agents (CS, CN), nerve agents treat with inhaled beta-agonists –Secretions markedly increased treat with atropine for nerve agents (central effects) or glycopyrrolate for others (peripheral effects) –Intubation facilitated with ketamine– safest induction agent –Patients intubatable without drugs due to coma/flaccid paralysis: consider triage to expectant if limited resources

34 Copyright © 2003 Robert C. Jones, M.D. Anesthesia Care for Chemical Warfare Casualties (contd) Breathing –Oxygen therapy titrated to effect –Assume massive requirement for nebulized bronchodilators; consider combined albuterol + ipratropium bromide treatment (DuoNeb®) for increased anticholinergic effect (nerve agents) – Consider ventilator status: may need to draft hospital personnel to bag patients while awaiting transport to other facilities –Pulmonary toilet key: frequent endotracheal suctioning may be required, especially with phosgene/chlorine (fulminant toxic [non-cardiac] pulmonary edema)

35 Copyright © 2003 Robert C. Jones, M.D.

36 Anesthesia Care for Chemical Warfare Casualties (contd) Circulation: –Remember associated injuries from blast/trauma –Assume hypovolemia –Blister agent victims do not require massive resuscitation of thermal injury patients –Tachycardia from antidote treatment (correctly or incorrectly administered) may take away monitor for hypovolemia– watch urine output; may need invasive monitoring in severe cases –Warm fluids– patients may be hypothermic from decontamination and environmental exposure

37 Copyright © 2003 Robert C. Jones, M.D. Anesthesia Care for Chemical Warfare Casualties (contd) Disability: –Treat seizures with benzos –Anticipate lots of unexposed anxious patients– may see hyperventilation mimic toxic exposure –Central Anticholinergic Syndrome (CAS): from excess atropine effect; Mnemonic: Hot as a hare (Hyperthermia from impaired sweating) Dry as a bone (Dry mouth from antisialogogue effect) Red as a beet (Flushed skin) Blind as bat (Mydriasis) Mad as a hatter (Delirium from central anti-ACh effect of atropine) –treat CAS with pysostigmine 1-2 mg iv gingerly; patient may need protection from self-injury (restraints) See

38 Copyright © 2003 Robert C. Jones, M.D. Anesthesia Care for Chemical Warfare Casualties (contd) Exposure: –Patient should have been stripped/decontaminated before presenting to anesthesia (if not, refer to Rule #1: Dont become a casualty yourself) –At the first sign of toxicity in yourself, seek treatment for exposure: you are no good to your patients dead –Treat hypothermia with forced air warming blankets, warmed fluids, increased ambient temperature See

39 Copyright © 2003 Robert C. Jones, M.D. Anesthesia Care for Chemical Warfare Casualties (contd) Other: –Pyridostigmine pretreatment and anesthesia: See the article by Keeler on CD: sidell_keeler_1990.pdfsidell_keeler_1990.pdf –Basic issues are resistance to succinylcholine and sensitivity to non-depolarizers; risk of phase II block with succinylcholine drip; use nerve stimulator to assess status of NMJ to prevent prolonged blockade –Atropine resistance due to AChE effects of PYR –Use nerve stimulator (DoRD guideline) See

40 Copyright © 2003 Robert C. Jones, M.D. References: Chemical Warfare (USAMRIID instructional materials)http://www.usamriid.army.mil/education/instruct.html (CDC bioterrorism site)http://www.bt.cdc.gov/ 9/3toc.htm (NATO handbook on NBC Defense)http://www.fas.org/nuke/guide/usa/doctrine/dod/fm8- 9/3toc.htm ICAL_BIOLOGICAL_RADIOLOGICAL_NUCLEAR_ AND_EXPLOSIVES.htm (excellent site; CME available)http://www.emedicine.com/emerg/WARFARE__CHEM ICAL_BIOLOGICAL_RADIOLOGICAL_NUCLEAR_ AND_EXPLOSIVES.htm (SBCCOM Homeland Defense site)http://hld.sbccom.army.mil/ (amazing Virtual Naval Hospital site; See NBC links about half way down page; Go Navy!)http://www.vnh.org/Providers.html

41 Copyright © 2003 Robert C. Jones, M.D.

42 Part 2: Biological Warfare Historical Perspective Classes of Biological Warfare Agents Specific Anesthesia-related Issues References

43 Copyright © 2003 Robert C. Jones, M.D. Biowar: Historical Perspective Ancient use of cadavers to poison wells Neolithic use of frog poisons (curare) in South America 1347, Kaffa, Crimea: Tatar leader Kipchak khan Janibeg (supported by Venetians) catapulted bodies of bubonic plague victims into Genoese city 1763: British forces gave smallpox-infected blankets to immunolically-naïve Native Americans Christopher, GW, et al, Biological warfare: a historical perspective, JAMA. 1997;278: ;

44 Copyright © 2003 Robert C. Jones, M.D. Biowar: Historical Perspective WWI: Burkholderia (Pseudomonas) mallei and Bacillus anthracis used by German agents to infect horses with glanders and anthrax WWII: Japanese biowarfare Unit 731 and others conducted experiments on prisoners; Chinese cities attacked with B anthracis, V cholerae, Shigella spp, Salmonella spp, and Y pestis. Vietnam: pungi sticks smeared with excrement 1984: Salad bars in Oregon contaminated with Salmonella Typhimurium to influence local election Christopher, GW, et al, Biological warfare: a historical perspective, JAMA. 1997;278:

45 Copyright © 2003 Robert C. Jones, M.D. Definition of Biowarfare Agent The NATO definition of a biological agent is: a microorganism (or a toxin derived from it) which causes disease in man, plants or animals or which causes the deterioration of material Toxin. A poisonous substance produced or derived from living plants, animals, or microorganisms… toxins have a relatively simple biochemical composition and are not able to reproduce themselves. In many aspects, they are comparable to chemical agents Source: FM 8-9: NATO Handbook on the Medical Aspects of NBC Defensive Operations AMedP-6(B): Part II - Biological;

46 Copyright © 2003 Robert C. Jones, M.D. Classes of Biowarfare Agents Bacteria (self-replicate; many communicable) Viruses (replicate via host; communicable) Toxins (most lethal substances; non-communicable) Future: Genetically Modified Organisms Future: Nanotech mechanical viruses

47 Copyright © 2003 Robert C. Jones, M.D. Bacillus Anthracis

48 Copyright © 2003 Robert C. Jones, M.D. Bacteria likely to be used in Biowarfare Bacillus anthracis (anthrax) : deadly attacks on Washington D.C., Florida, October 2001 Francisella tularensis ( tularemia) Yersinia pestis (plague) Coxiella burnetii (Q-Fever) Pseudomonas pseudomallei (Melioidosis) Vibrio cholerae (cholera)-- toxin Clostridium botulinum (botulism)-- toxin

49 Copyright © 2003 Robert C. Jones, M.D. Ebola Virus

50 Copyright © 2003 Robert C. Jones, M.D. Viruses likely to be used in Biowarfare Venezuelan Equine Encephalitis (VEE) Viral hemorrhagic fever agents (Marburg, Ebola, Congo-Crimean Hemorrhagic Fever, Rift Valley Fever, etc.) Variola (smallpox) Genetically-engineered superviruses

51 Copyright © 2003 Robert C. Jones, M.D. Ricin (from ricinus communis)

52 Copyright © 2003 Robert C. Jones, M.D. Toxins likely to be used in Biowarfare Saxitoxin-- neurotoxin from marine dinoflagellates Botulinum-- C. botulinum Ricin-- castor bean seeds Staphylococcal Enterotoxin B (SEB) Alpha toxin-- C. perfringens Tetrodotoxin-- from blowfish Tricothecene mycotoxins (>40)-- Yellow Rain; significant as only dermally-active toxin

53 Copyright © 2003 Robert C. Jones, M.D. Toxin Case Study: Georgi Markov Bulgarian émigré writer and journalist Critical of communist regime Assassinated in London: microball laced with ricin injected via modified umbrella weapon 7 Sep 1978 Died 4 days later-- No antidote

54 Copyright © 2003 Robert C. Jones, M.D. Picture: Polio virus "To construct the virus, the researchers say they followed a recipe they downloaded from the internet and used gene sequences from a mail-order supplier"

55 Copyright © 2003 Robert C. Jones, M.D. GMO Agents: Brave New World? 2002: Cello, et al.: Synthetic polio virus created from scratch Genetically Modified Organisms (GMO) increasingly common in food supply-- soon among biowarfare agents? Possible to create resistance to known treatments, increased virulence, altered disease pattern to disguise source, etc. Cello J, Paul AV, Wimmer E, Chemical synthesis of poliovirus cDNA: Generation of infectious virus in the absence of natural template. Science 2002 July 11.

56 Copyright © 2003 Robert C. Jones, M.D. Nanobot injecting red cells

57 Copyright © 2003 Robert C. Jones, M.D. Nanotech Agents: Mors ex machina Nanotechnology: "Research and technology development at the atomic, molecular or macromolecular levels, in the length scale of approximately nanometer range" Disruptive Technology-- could render current offensive/defensive/sensor systems obsolete U.S. Government National Nanotechnology Initiative site: area of intense research Micromechanical Doomsday Plague? (Crichton, M., Prey: A Novel, Harper-Collins, 2002)

58 Copyright © 2003 Robert C. Jones, M.D. Warning Signs of Biowar Attack

59 Copyright © 2003 Robert C. Jones, M.D. Anesthesia Care for Victims of Biowarfare Attack Refer to Rule #1 for Chemical Agents: Dont become a casualty yourself Dont assume that vaccination is 100% protective Patients should be decontaminated before being brought to hospital Hospital should guard against contaminated walk-ins– potential to shut down facility Specific treatment based on agent– seek advice from Infectious Disease consultants/CDC/internet resources

60 Copyright © 2003 Robert C. Jones, M.D. References: Biowar (Medical Management of Biological Casualties Handbook)http://www.usamriid.army.mil/education/bluebook.html (Defense against Toxin Weapons)http://www.vnh.org/DATW/toc.html (NATO Handbook on NBC Defense: Biological)http://www.vnh.org/MedAspNBCDef/2toc.htm (includes CDC categories A, B, C with definitions) (CDC Anthrax home)http://www.bt.cdc.gov/agent/anthrax/index.asp (Smallpox slideset)http://www.who.int/emc/diseases/smallpox/slideset/

61 Copyright © 2003 Robert C. Jones, M.D.

62 Part 3: Nuclear/Radiological Warfare Historical Perspective Types of Radiological Warfare Agents Specific Anesthesia-related Issues Future Issues: The Final Frontier? References

63 Copyright © 2003 Robert C. Jones, M.D. Nuclear Warfare: Historical Perspective Ancient Atomic Warfare?: 5,000 year old Indian texts describe the military use and aftereffects of nuclear weapons Some geological formations (Saharan green glass, Scottish vitrified forts) have been interpreted as evidence of ancient atomic explosions Ancient flying machines (vimanas) are well-described in Indian literature used to deliver nuclear weapons?

64 Copyright © 2003 Robert C. Jones, M.D. Now I am become Death, the Destroyer of Worlds – The Bhagavad Gita Dr. Robert Oppenheimer, Father of the A-Bomb When asked in an interview at Rochester University seven years after the Alamogordo nuclear test whether that was the first atomic bomb ever to be detonated, (Oppenheimers) reply was: Well, yes, in modern history, of course.

65 Copyright © 2003 Robert C. Jones, M.D. Nuclear Warfare: Historical Perspective (Modern) Hiroshima, 6 August 1945: U-235; 13 kiloton yield; 75,000 + immediate fatalities; many more causalties Nagasaki, 9 August 1945: U-239; 20 kilton yield; 40,000 + immediate fatalities; many more casualties Hiroshima, ;http://www.wikipedia.org/wiki/Fat_Manhttp://www.wikipedia.org/wiki/Fat_Man

66 Copyright © 2003 Robert C. Jones, M.D. Nuclear Warfare: Historical Perspective (Modern) Seattle, WA, Feb 29, picture from:http://news.bbc.co.uk/1/hi/health/ stm scenario fictitious ; 5 KT dirty bomb laced with U-238 exploded atop Space Needle 207 initial deaths from blast; 2,109 radiation victims; entire city disrupted for 5 days following attack; fear >>> destruction

67 Copyright © 2003 Robert C. Jones, M.D. Types of Nuclear Weapons Fission: splitting of uranium isotope atoms; easier technically; less destructive than fusion Fusion: combination of hydrogen atoms helium; requires fission trigger; more complex Dirty Bomb: conventional bomb laced with radioactive material; far less destructive than nuclear explosion; nuclear disruption of populace vs. destruction

68 Copyright © 2003 Robert C. Jones, M.D. Medical Effects of Nuclear Blast Immediate Ionizing Radiation Infrared radiation (heat); Indirect effect (fires) Electromagnetic Pulse (EMP) Blast (overpressure) Fallout (delayed radiation) Psychological effects (panic)

69 Copyright © 2003 Robert C. Jones, M.D. Effects of 1 Megaton Blast Table 3 - Blast Effects of a 1-Mt Explosion 8,000 ft Above the Earth's Surface Distance from ground zero Peak overpr essure Peak wind velocity (mph) Typical blast effects (stat. Miles) (Kilome ters) psi470Reinforced concrete structures levelled psi290Most factories and commercial buildings are collapsed. Small wood-frame and brick residences destroyed and distributed as debris psi160Lightly constructed commercial buildings and typical residences are destroyed. Heavier construction is severely damaged psi95Walls of typical steel-frame buildings are blown away; severe damage to residences. Winds sufficient to kill people in the open psi35Damage to structures, people endangered by flying glass and debris.

70 Copyright © 2003 Robert C. Jones, M.D. Radiation Units Roentgen: amount of x-ray or gamma ray radiation (electromagnetic radiation) that produces 1/3 x 10-9 coulomb of electric charge in one cubic centimeter of dry air at standard conditions. RAD: The rad is a unit used to measure a quantity called absorbed dose. This relates to the amount of energy actually absorbed in some material, and is used for any type of radiation and any material. One rad is defined as the absorption of 100 ergs per gram of material. The unit rad can be used for any type of radiation, but it does not describe the biological effects of the different radiations. REM: The rem is a unit used to derive a quantity called equivalent dose. This relates the absorbed dose in human tissue to the effective biological damage of the radiation. Not all radiation has the same biological effect, even for the same amount of absorbed dose. Equivalent dose is often expressed in terms of thousandths of a rem, or mrem. To determine equivalent dose (rem), you multiply absorbed dose (rad) by a quality factor (Q) that is unique to the type of incident radiation. Gray: The gray is a unit used to measure a quantity called absorbed dose. The unit gray can be used for any type of radiation, but it does not describe the biological effects of the different radiations. Absorbed dose is often expressed in terms of hundredths of a gray, or centi-grays. One gray is equivalent to 100 rads. Sievert: The sievert is a unit used to derive a quantity called equivalent dose. This relates the absorbed dose in human tissue to the effective biological damage of the radiation. Not all radiation has the same biological effect, even for the same amount of absorbed dose. Equivalent dose is often expressed in terms of millionths of a sievert, or micro-sievert. To determine equivalent dose (Sv), you multiply absorbed dose (Gy) by a quality factor (Q) that is unique to the type of incident radiation. One sievert is equivalent to 100 rem. (boring stuff you thought youd never have to see again after USU)

71 Copyright © 2003 Robert C. Jones, M.D. Radiological Weapons (Dirty Bombs) Non-nuclear spread of radioactive materials via conventional explosion Most likely isotope: Cesium-137 (gamma ray hazard; 30 year half-life; very common [byproduct of nuclear reactors; used in radiation therapy]) Increased risk of cancer long-term (but not severe)

72 Copyright © 2003 Robert C. Jones, M.D. Medical Effects of Dirty Bomb Blast (1000s of times less than nuclear) Radiation (1000s of times less than nuclear) Psychological Effect (panic, possibly severe) Terror, not absolute destruction, goal of dirty bomb So clothes off, wash up, use an N-95 mask. -- Elizabeth Cohen, CNN News, minimizing radiological effects

73 Copyright © 2003 Robert C. Jones, M.D. Anesthesia Implications of Nuclear/Radiological Weapons Duck and Cover

74 Copyright © 2003 Robert C. Jones, M.D. 10 Basics of Response to Nuclear/Radiological Attack 1. Assure medical staff that when an incident combines radiation exposure with physical injury, initial actions must focus on treating the injuries and stabilizing the patient. 2. You or your hospital must be prepared to manage large numbers of frightened, concerned people who may overwhelm your treatment facility. 3. You or your hospital must have a plan for distinguishing between patients needing hospital care and those who can go to an off-site facility. 4. You or your hospital must know how to set up an area for treating radiation incident victims in an emergency room. 5. You or your hospital should be aware that a good way to approach decontaminating a radioactively contaminated individual is to act as if he or she had been contaminated with raw sewage. 6. You or your hospital must know how to avoid spreading radioactive contamination by using a double sheet and stretcher method for transporting contaminated patients from the ambulance to the emergency treatment area. 7. You must know how to recognize and treat a patient who has been exposed to significant levels of radiation. 8. You should recognize the radiological findings of illness/injury caused by biological or chemical terrorist agents. 9. You should know what agencies or organizations to contact in the event of a radiation emergency and how to reach them. 10. You or your hospital must have a plan to evaluate and counsel noninjured patients exposed to radiation at a location outside of the hospital.

75 Copyright © 2003 Robert C. Jones, M.D. Triage of Radiation Casualties From:

76 Copyright © 2003 Robert C. Jones, M.D. Anesthesia Implications Rule #1: Dont become a casualty yourself! Ensure appropriate patient decon before admission to hospital Hospital should have system to guard against contaminated walk-ins; Geiger counters at entrances Primary surgical issues will be conventional traumatic injuries (possible pneumothorax/barotrauma from overpressure; most injuries caused by flying debris); initial ATLS approach appropriate after decon Supportive care; careful attention to sterile technique in patients with crashing immune systems/incipient neutropenia Brain irradiation may cause unpredictable CNS dysfunction Radiation victims far less threat to health care providers than chem-bio warfare victims (radiation decreases as square of distance from source); most damaging radiation to tissues (alpha) also short-range (millimeters)

77 Copyright © 2003 Robert C. Jones, M.D. Future Issues

78 Copyright © 2003 Robert C. Jones, M.D. Future Issues: Directed Energy Weapons Frying Purple People Heater: U.S. military has deployed directed V-MADS directed energy weapon crowd control purposes; uses 95 GHz millimeter waves to heat skin; range 700 meters U.S. Army Field Manual 71-2, Appendix D: The battlefield of the next war will include directed-energy weapons (DEWs). Several threat weapons have already been tested in combat; improved versions of these weapons may be fielded soon. For the task force commander, the DEW battlefield is here now. Potential terrorist weapon: Insidious, painful, difficult to counteract Vehicle-Mounted Active Denial System (V-MADS)

79 Copyright © 2003 Robert C. Jones, M.D. Future Issues: The Final Frontier? From Lord Sri Krsna drove the chariot between the two armies on the Battlefield of Kuruksetra, and while there He shortened the life spans of the opposite party by His merciful glance. Revolutions in military affairs: Saltatory evolution (stone stick sword bow and arrow gun directed energy ? psychic weapons ) Air University Study Air Force 2025 explicitly mentions psychotronic weapons as a wild card of future warfare that may vitiate U.S. conventional military advantage (along with nanotechnology, genetic engineering…) U.S. Army Command and General Staff Colleges Military Review, December 1980, The New Mental Battlefield: Beam Me Up, Spock: Psychotronics, mind control, and remote viewing as elements of 21 st century warfare rod.env?CQ_SESSION_KEY=HIJULEYVRIOP&CQ_QH=124183&CQDC=12&CQ_PDF_HIGHLIGHT= rod.env?CQ_SESSION_KEY=HIJULEYVRIOP&CQ_QH=124183&CQDC=12&CQ_PDF_HIGHLIGHT= YES&CQ_CUR_DOCUMENT=1;

80 Copyright © 2003 Robert C. Jones, M.D. References: Treating Radiation Casualties 10A.pdfhttp://www.vnh.org/BUMEDINST A/ A.pdf about,text:/departments/educ/disaster_prep/dp_primer.htmlhttp://www.acr.org/cgi-bin/fr?mast:masthead- about,text:/departments/educ/disaster_prep/dp_primer.html getop (Health Consequences of Nuclear War)http://books.nap.edu/books/ /html/205.html#pa getop (Nuclear War Resources)http://nuketesting.enviroweb.org/hew/ 9/1toc.htm (NATO Handbook on Medical Aspects of Nuclear Warfare)http://www.fas.org/nuke/guide/usa/doctrine/dod/fm8- 9/1toc.htm

81 Copyright © 2003 Robert C. Jones, M.D. Questions? This is my PowerPoint. There are many like it but mine is My PowerPoint is my best friend. It is my life. I must master it as I master my life. My PowerPoint without me is useless. Without my PowerPoint, I am useless. I must format my slides true. I must brief them better than the other staff sections who are trying to out brief me. I must brief the impact on the CINC before he asks me. I will. My PowerPoint and myself know that what counts in this war is not the information. We know that it is the number of slides, the colors of the highlights, and the format of the bullets that counts. My PowerPoint is human, even as I, because it is my life. Thus I will learn it as a brother. I will learn its weaknesses, its strengths, its fonts, its accessories, its formats, and its colors. I will keep my PowerPoint slides current and ready to brief. We will become part of each other. We will… Before The Goddess I swear this creed. My PowerPoint and myself are defenders of my country. We are the masters of our subject. We are the saviors of my career. So be it, until victory is America's and there is no enemy, but peace (and the next exercise)! --The Powerpoint Rangers Creed


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