1. Toxins of Terrorism and Mass Aggression Rama B. Rao, MD NYUMC/Bellevue Hospital Center

2. Non-Traditional Weapons 5th Century B.C. use of pitch and sulfur in wars between Athens and Sparta

3. 19th Century Hong Kong 1857 Arsenic laced bread sold to British patrons to induce terror at the E Sing Bakery

5. Toxin Classes Chemical Warfare Biologicals Nuclear Agent Others

6. Classification of Chemical Agents Blistering agents or vesicants Pulmonary or choking agents Cellular asphyxiants or blood agents Nerve Agents Incapacitants

7. Blistering Agents/ Vesicants Lewisite Phosgene oxime Mustards of –Sulfur –Nitrogen

8. Blistering Agents Irritation to: –Mucus Membranes –Skin –Occasionally deeper tissues Onset minutes to hours Care supportive Decontamination BAL?

14. Pulmonary/ Choking Agents Phosgene Chlorine Oxides of Nitrogen Impaired gas exchange

15. Pulmonary/Choking Agents Onset can be delayed Pulmonary edema Treatment supportive Role of LT antagonists for phosgene uncertain

16. Blood Agents: Arsine (AsH 3 ) Fishy/garlic odor Onset 2-24 hours Oxidant stressor Topical: frostbite Intravascular hemolysis and its complications Limited decontamination Treatment Supportive

17. Cellular Asphyxiants Cyanide Cyanogen chloride Mitochondrial toxins Rapidly fatal Antidote kit Zyklon B, WWII Auschwitz

18. Cyanide Antidote Kit Cyanide Methemoglobin Cyanomethemoglobin Sodium Thiosulfate Cyt a-a 3 Mitochondria Sodium Thiocyanate Hemoglobin Nitrites Rhodanese

19. Nerve Agents Sarin Cyclohexy Sarin Soman Tabun VX Organophosphate insecticides

20. Normal Cholinergic Function Target Organ Neuron ++++++++++ ------------------ +++++++ Target Event ACh

21. Cholinesterase Function _ N-CH 2 -CH 2 -O-C-CH 3 H3CH3C H3CH3C O-O- + H3CH3C N + -HO H 3 C-N-CH 2 -CH 2 -OH H3CH3C H3CH3C Choline + Cholinesterase HO-C-CH 3 O Acetic Acid ACh

22. Normal Cholinesterase Function Target Organ Neuron ACh Termination of Event ++++++++++ ------------------ ----- Choline Acetic acid

23. Cholinesterase Poisoning _ RO-P=OR’ O-O- N + -HO Poisoned Cholinesterase O N-CH 2 -CH 2 -O-C-CH 3 H3CH3C H3CH3C O-O- + H3CH3C ACh

24. Cholinesterase Poisoning Target Organ Neuron ACh Repeated Stimulation ----+++------------- +++--------+++

25. Cholinergic Agents: Muscarinic Effects Salivation Small Pupils Lacrimation Urination Defacation GI Emesis Bradycardia Bronchorrhea Bronchospasm

26. Atropine:Muscarinic Blocker ACh M Target Organ Neuron ACh ----+++-------------------------+++ Atropine

27. CNS ParasympatheticGangliaSympathetic Excess ACh M Excess ACh N Catecholamines Bradycardia Bronchospasm Bronchorrhea Tachycardia HTN Mydriasis Hypoxia AUTONOMIC NERVOUS SYSTEM

28. CNS ParasympatheticGangliaSympathetic ACh M ACh N Catecholamines Bradycardia Bronchospasm Bronchorrhea Tachycardia HTN Neuromuscular Junction SOMATIC NERVOUS SYSTEM ACh N NERVOUS SYSTEM

29. Excess Acetylcholine: NMJ: Nicotinic Skeletal Muscle:ACh N Neuron ACh Contraction ----+++------------- +++--------+++ Contraction FASCICULATIONS

30. Excess Acetylcholine: NMJ: Nicotinic Skeletal Muscle:ACh N Neuron ACh ----+++++++++++++++++++++++ FLACCID PARALYSIS

31. _ RO-P=OR’ O-O- Pralidoxime binds cholinesterase O 2-PAM _ RO-P=OR’ O-O- O 2-PAM Reactivates cholinesterase Pralidoxime, 2-PAM

32. Nerve Agents Atropine for muscarinic toxicity Oximes for nicotinic toxicity –Pralidoxime –Obidoxime Aggressive decontamination

33. Protective Equipment Decontamination –Shower –Bed Fluid collection Gown Mask –Full face –PAPR –SCBA GLOVES –Rubber –Nitrile rubber –Neoprene rubber –Butyl rubber –Vitron

34. Crowd Control Agents Lacrimators Superfentanyl

35. Toxins of Mass Aggression Identify agent or classify clinical effects Decontamination Live saving maneuvers Be prepared for the undiagnosed exposure Personal protection Handling secondary fears

36. Resources www.bt.cdc.gov/AgentlistChem.asp chemdef.apgea.army.mil/textbook/contents. asp www- cgsc.army.mil/carl/resources/csi/Heller/HE LLER.asp