1. ® BDLS is a registered trademark of the American Medical Association V 2.9 04/07 ® 1 “Preparing Our Communities” Welcome!

2. V 2.9 04/07 2 Faculty Disclosure For Continuing Medical Education (CME) purposes as required by the American Medical Association (AMA) and other continuing education credit authorizing organizations:For Continuing Medical Education (CME) purposes as required by the American Medical Association (AMA) and other continuing education credit authorizing organizations: –In order to assure the highest quality of CME programming, the AMA requires that faculty disclose any information relating to a conflict of interest or potential conflict of interest prior to the start of an educational activity. –The teaching faculty for the BDLS course offered today have no relationships / affiliations relating to a possible conflict of interest to disclose. Nor will there be any discussion of off label usage during this course.

3. ® BDLS is a registered trademark of the American Medical Association V 2.9 04/07 ® 3 Chemical Events Chapter 6

4. V 2.9 04/07 4Overview Examples of chemical disasters / terrorismExamples of chemical disasters / terrorism Review Classes of Chemical WeaponsReview Classes of Chemical Weapons D-I-S-A-S-T-E-R Paradigm for chemicalsD-I-S-A-S-T-E-R Paradigm for chemicals

5. V 2.9 04/07 5 Industrial Accidents Bophal, Indial 1984Bophal, Indial 1984 40 Tons of Methyl Isocyanate released40 Tons of Methyl Isocyanate released Population of 900,000Population of 900,000 –6,000-10,000 immediate problems –Up to 400,000 delayed health issues

6. V 2.9 04/07 6 Transportation Events Releases of Hazardous Material occur almost daily in the USAReleases of Hazardous Material occur almost daily in the USA Events requiring patient decontamination are less frequentEvents requiring patient decontamination are less frequent

7. V 2.9 04/07 7 Chemicals as Weapons First large-scale use in World War I Ypres, BelgiumYpres, Belgium –April 1915 –Chlorine, 168 tons –5,000 deaths –5 mile front

8. V 2.9 04/07 8 Chemical Casualties in WWI 9,000191,000Germany 3,00097,000 Austria- Hungary 1,46271,345U.S. 4,62755,373Italy 56,000419,340Russia 8,000182,000France 8,109180,597Britain DeathsNon-fatalCountry

9. V 2.9 04/07 9 Terrorist Use of Chemical Weapons Tokyo Subway 1995Tokyo Subway 1995 Sarin Nerve AgentSarin Nerve Agent –5,500 victims –11 Dead 641@ St. Luke’s International Hospital641@ St. Luke’s International Hospital –Poor decontamination –Limited EMS involvement

10. V 2.9 04/07 10 Agents of Opportunity Toxic industrial chemicalsToxic industrial chemicals –Available –Easier to obtain/target Poisoning consumer productsPoisoning consumer products Examples:Examples: –Chlorine Tank Bombs in Iraq –1982 Tylenol tampering incident

11. V 2.9 04/07 11 Chemical Weapons BZ, Others? Incapacitating agents Mustard, Lewisite, Phosgene Oxime Vessicants Phosgene, chlorine, ammonia, pepper spray Irritant Agents Cyanides Blood Agents Tabun, Sarin, Soman, VX Nerve Agents

12. V 2.9 04/07 12 Organophosphate chemicalsOrganophosphate chemicals –Similar to common insecticides –Very high lethality Liquids that are vaporized to disseminateLiquids that are vaporized to disseminate –Rapidly toxic if inhaled –Slower onset with dermal exposure Nerve Agents

13. V 2.9 04/07 13 Nerve Agent Properties SarinSomanTabunVX Household Insecticide Aging 5 hours 5 minutes 14 hours 48 hours 12-24 hours Dermal LD 50 1700 mg 100 mg 1000 mg 10 mg > 35,000 mg Inhaled LCt 50 100 mg/m 3 50 mg/m 3 400 mg/m 3 10 mg/m 3 > 250 mg/m 3 VolatilityHigh LowVery Low PersistenceLow HighIntermediate

14. V 2.9 04/07 14 Cholinesterase Acetylcholine CholinergicReceptor

15. V 2.9 04/07 15 Acetylcholine Metabolism

16. V 2.9 04/07 16 Cholinesterase Acetylcholine Organophosphate

17. V 2.9 04/07 17 Organophosphate Poisoning Signs and Symptoms D: defecation U: urination M: miosis B: BRONCHORRHEA, BRONCHOSPASM BRONCHOSPASM E: emesis L: lacrimation S: secretions/ seizures Muscarinic effects M: mydriasis T: tachycardia W: weakness tH: hypertension F: fasciculation S: seizures Nicotinic effects

18. V 2.9 04/07 18 Acetylcholinesterase Inhibition

19. V 2.9 04/07 19 Nerve Agent Exposure Low exposureLow exposure –Miosis, dim vision, eye pain –Rhinorrhea –Dyspnea –Localized sweating & fasiciulation (liquids) High exposureHigh exposure –Immediate loss of consciousness –Seizures –Apnea –Flaccid paralysis Vapor – effects occur within secondsVapor – effects occur within seconds Liquids – onset may be delayedLiquids – onset may be delayed

20. V 2.9 04/07 20 Nerve Agents: Treatment ABC’s, supportive careABC’s, supportive care AntidotesAntidotes –Atropine 2 mg IV, IM or ET2 mg IV, IM or ET –Pralidoxine (2-PAM) 1 gram slow IV or Autoinjector IM (600 mg)1 gram slow IV or Autoinjector IM (600 mg) –Benzodiazepines, PRN for seizures

21. V 2.9 04/07 21 Acetylcholine Cholinesterase Organophosphate Atropine 2 PAM Muscarinic Nicotinic Receptors

22. V 2.9 04/07 22 Atropine Dosing Starting dose - 2 mgStarting dose - 2 mg Maximum cumulative dose - 20 mgMaximum cumulative dose - 20 mg –Insecticide poisoning may require more Atropine – How much to give?Atropine – How much to give? –Until secretions are drying or dry –Until ventilation is easy –If conscious or comfortable –Do not rely on heart rate or pupil size

23. V 2.9 04/07 23 Irritant Gasses Common industrial chemicalsCommon industrial chemicals –Agent of opportunity Combine with moisture to form acids or basesCombine with moisture to form acids or bases –Low concentration = Minor irritation –High concentration or prolonged exposure = Chemical burns

24. V 2.9 04/07 24 Irritant Gas Site of Injury Highly water soluble Moderately water soluble Poorly water soluble Ammonia Chlorine Phosgene

25. V 2.9 04/07 25 Irritant Gases: Triage Majority – Worried well?Majority – Worried well? Airway compromise – P1, immediateAirway compromise – P1, immediate Severe shortness of breath- P1, immediateSevere shortness of breath- P1, immediate Mild SOB, No airway compromise – P2, delayedMild SOB, No airway compromise – P2, delayed Mild mucous membrane symptoms – P3, minimalMild mucous membrane symptoms – P3, minimal Respiratory arrest – P4, expectantRespiratory arrest – P4, expectant

26. V 2.9 04/07 26 Irritant Gases: Treatment Dry decontamination usually adequateDry decontamination usually adequate Water for mucous membrane irritationWater for mucous membrane irritation ABC’s & Oxygen PRNABC’s & Oxygen PRN Early airway managementEarly airway management –highly and moderately water soluble exposures Inhaled beta agonist PRN wheezingInhaled beta agonist PRN wheezing Observation and supportObservation and support –phosgene 12- 24 hrs?

27. V 2.9 04/07 27 Cyanide Compounds Widely used in IndustryWidely used in Industry Cyanide gas is rapidly lethalCyanide gas is rapidly lethal Oral poisoning is slowerOral poisoning is slower Odor “bitter almonds”? – “musty” smellOdor “bitter almonds”? – “musty” smell –Odor not a reliable indicator

28. V 2.9 04/07 28 Cyanide in Smoke Burning wool, plastic and other materials releases cyanide gasBurning wool, plastic and other materials releases cyanide gas May play a significant role in smoke inhalation and fire-related deathsMay play a significant role in smoke inhalation and fire-related deaths

29. V 2.9 04/07 29 Cyt c Cyt a cyt a3+ Cu ADPATP O 2 + H+ H20H20 O2O2O2O2 O2O2O2O2 O2O2O2O2 O2O2O2O2 Metabolic Acidosis Cyanide Blocks Use of Oxygen

30. V 2.9 04/07 30 Cyanide - Sources Pits of many plantsPits of many plants –Cherries, peaches, almonds, lima beans –Cassava plant root Combustion of carbon -> cyanideCombustion of carbon -> cyanide –Plastics- acrylonitriles U.S. sources manufacture 300,000 tons of hydrogen cyanide annuallyU.S. sources manufacture 300,000 tons of hydrogen cyanide annually

31. V 2.9 04/07 31 Cyanide Triage M-A-S-S TriageM-A-S-S Triage Likely few critical victimsLikely few critical victims –Most either dead –Others with minor exposure Good supportive care may save many in absence of antidoteGood supportive care may save many in absence of antidote

32. V 2.9 04/07 32 Cyanide Treatment Remove to Fresh AirRemove to Fresh Air Oxygen, supportive careOxygen, supportive care Antidotes ?Antidotes ? –3 Drug Antidote Kit –Hydroxocobalamin

33. V 2.9 04/07 33 Fe2+ Hb Fe3+ MetHb Amyl Nitrite Inhale for 30 sec Sodium Nitrite 300mg IV Fe3+ Sodium Thiosulfate 12.5g IV Thiocyanate Excreted in urine Fe3+ Cyt a3

34. V 2.9 04/07 34Hydroxocobalamin Hydroxocobalamin – 5 g IVHydroxocobalamin – 5 g IV –Vit. B12a Chelates CyanideChelates Cyanide –Need 50:1 ratio CyanocobalaminCyanocobalamin –Vit. B12 – nontoxic! CN

35. V 2.9 04/07 35 Blister Agents/Vesicants  Sulfur Mustard  Also - Lewisite, Phosgene oxime

36. V 2.9 04/07 36Mustard Most widely used chemical weaponMost widely used chemical weapon Morbidity is higher than mortalityMorbidity is higher than mortality Garlic odorGarlic odor Freezes at 57 FFreezes at 57 F Penetrates rubber glovesPenetrates rubber gloves

37. V 2.9 04/07 37 Mustard Mechanism Penetrates cells and generates toxic intermediatePenetrates cells and generates toxic intermediate AlkylatesAlkylates –DNA/RNA, Proteins Rapidly dividing cells most susceptibleRapidly dividing cells most susceptible

38. V 2.9 04/07 38 Vesicant Symptoms Onset of symptoms ?Onset of symptoms ? –High vs low dose Topical – Eyes, Airway, SkinTopical – Eyes, Airway, Skin Binds Irreversibly within minutes “Fixing”Binds Irreversibly within minutes “Fixing” Systemic effects ?Systemic effects ?

39. V 2.9 04/07 39 Mustard - Skin Erythema 2-24 hoursErythema 2-24 hours Small vesicles may coalesce to form bullaeSmall vesicles may coalesce to form bullae High dose exposure – central zone of coagulation necrosisHigh dose exposure – central zone of coagulation necrosis

40. V 2.9 04/07 40 Vesicant Treatment Immediate decontamination (~2 minutes)Immediate decontamination (~2 minutes) –Victim may not undergo decontamination since symptoms delayed –Remove clothes and wash skin with soap and water Avoid overhydration; fluid losses less than with thermal burnsAvoid overhydration; fluid losses less than with thermal burns Possible antidotesPossible antidotes –N-acetylcystiene (NAC) for Mustard –Dimercaperol (BAL) for Lewisite

41. V 2.9 04/07 41 Incapacitating Agents Not meant to be lethalNot meant to be lethal –“Inability to perform one’s mission” BZ (quinuclidinyl benzilate)BZ (quinuclidinyl benzilate) –Aerosolized Anticholinergic –25x more potent than atropine Others possibleOthers possible –Benzodiazepines –Opiate derivatives –Psychedelics

42. V 2.9 04/07 42 BZ: Treatment Control patientControl patient Consider benzodiazepinesConsider benzodiazepines KEEP VICTIM COOLKEEP VICTIM COOL PhysostigminePhysostigmine –1-2 mg IV –atropine at bedside –seizures and cardiac arrhythmias rare

43. V 2.9 04/07 43 D: Detection I: Incident Command I: Incident Command S: Safety & Security A: Assess Hazards S: Support T: Triage & Treatment E: Evacuation R: Recovery

44. V 2.9 04/07 44 D: Detection Clinical presentationClinical presentation Detection devicesDetection devices Information sourcesInformation sources

45. V 2.9 04/07 45 Clinical Detection Rapid symptom onsetRapid symptom onset Multiple victims and civilian panicMultiple victims and civilian panic –Similar signs and symptoms –Present at same time –History of similar site exposure –Absence of traumatic injuries ToxidromesToxidromes –will guide treatment at hospital Unusual or irritating odorsUnusual or irritating odors

46. V 2.9 04/07 46 Chemical Detection Tools All have limited ranges of substances Chemical Detection PapersChemical Detection Papers –Concentrated vapors or liquids Air Sampling DevicesAir Sampling Devices –Vapors or gasses in low concentration

47. V 2.9 04/07 47 Shipping Papers & Placarding ANY hazardous material being transported must have documents identifying the HazMatANY hazardous material being transported must have documents identifying the HazMat Large shipments are placardedLarge shipments are placarded Placard identifies the type of chemicalPlacard identifies the type of chemical Emergency Response GuidebookEmergency Response Guidebook Decodes ID# and provides informationDecodes ID# and provides information –Health and fire hazards –Protective Equipment needed –Containment & Evacuation –First aid & Emergency response

48. V 2.9 04/07 48 Red color & pictogram = Flammable #3 = Flammable liquid UNID # = isopropyl alcohol

49. V 2.9 04/07 49 Material Safety Data Sheet Required for chemical used in a workplaceRequired for chemical used in a workplace Chemical NameChemical Name Hazard IdentificationHazard Identification Physical & Chemical PropertiesPhysical & Chemical Properties

50. V 2.9 04/07 50 NFPA Labels FlammabilityFlammability Health HazardHealth Hazard InstabilityInstability –0 = Good –4 = Very Bad Special HazardsSpecial Hazards –Oxidizer –Water Reactive –Radiation

51. V 2.9 04/07 51 NIOSH Guide Chemical Name, synonymsChemical Name, synonyms Chemical and physical propertiesChemical and physical properties Toxic concentrations in airToxic concentrations in air PPE RecommendationPPE Recommendation Information on Health HazardsInformation on Health Hazards

52. V 2.9 04/07 52 Poison Control Centers In depth information about health effectsIn depth information about health effects In depth treatment informationIn depth treatment information Antidote availabilityAntidote availability Toxicologist ConsultationToxicologist Consultation

53. V 2.9 04/07 53 I: Incident Management Critical information:Critical information: –Time of the incident and incident site –Substances involved –Method of contamination (vapor or liquid) –Hazards to health care providers –Need for PPE & decontamination

54. V 2.9 04/07 54 S: Security Scene must be secured to prevent more casualtiesScene must be secured to prevent more casualties Most (4/5) victims will go to the hospital by private/ public transportation vehicle!!!Most (4/5) victims will go to the hospital by private/ public transportation vehicle!!! PREVENT THE HOSPITAL FROM BECOMING CONTAMINATEDPREVENT THE HOSPITAL FROM BECOMING CONTAMINATED –all personnel involved in triage & decontamination must wear PPE

55. V 2.9 04/07 55 A: Assess Hazards Ongoing threat of contamination to other individualsOngoing threat of contamination to other individuals Secondary devices?Secondary devices? –Several cyanide gas bombs found in subway restrooms after sarin attack

56. V 2.9 04/07 56 S: Support Know your capabilities/limitationsKnow your capabilities/limitations Take protective measuresTake protective measures – –Isolate – –Evacuate – –Perimeter/site control Call in other resources as needed.Call in other resources as needed.

57. V 2.9 04/07 57 T: Treatment DecontaminationDecontamination A B C’sA B C’s Symptom driven supportive care and antidote selectionSymptom driven supportive care and antidote selection

58. V 2.9 04/07 58 E: Evacuation Most victims will self transportMost victims will self transport Consider school buses for minimal ptsConsider school buses for minimal pts CautionCaution –Contaminated pts –Off-gassing –Open windows –Use vents

59. V 2.9 04/07 59 R: Recovery Most difficult aspect of a chemical eventMost difficult aspect of a chemical event All potentially contaminated areas must be checked for persistence of chemicalsAll potentially contaminated areas must be checked for persistence of chemicals Psychological sequelaePsychological sequelae

60. V 2.9 04/07 60 Questions?