Targets of Opportunity Steven M Marcus Medical Director NJ Poison Information & Education System New Jersey Medical School

Chemical Agents used during WWI include: chlorine, phosgene, and nitrogen mustard gases. These chemical lead to 100,000 deaths and 1.2 million casualties. Nazis killed millions of civilians with Zyklon B gas (HCN) in WWII. Agent Orange (a dioxin and defoliant) was used in the Vietnam War, which may have lead to skin cancer in our veterans.

Chemical Terrorist Events Covenant Group found to possess 33 gallons of cyanide Covenant Group found to possess 33 gallons of cyanide Police prevent Neo-Nazis from using cyanide in synagogue Police prevent Neo-Nazis from using cyanide in synagogue Aum Shinrikyo uses sarin in Matsumoto – 7 dead, 280 injured Aum Shinrikyo uses sarin in Matsumoto – 7 dead, 280 injured

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

More Chemical Terrorism Copycat attacks in Japan using cyanide, phosgene, and pepper sprayCopycat attacks in Japan using cyanide, phosgene, and pepper spray FBI thwarts possible sarin attack in DisneylandFBI thwarts possible sarin attack in Disneyland Sydney, Australia – chlorine bombs in shopping centers injure evacuated Sydney, Australia – chlorine bombs in shopping centers injure evacuated

Types - Chemical Agents Nerve AgentsTabun, Sarin, Soman, VXNerve AgentsTabun, Sarin, Soman, VX Blood agentsHydrogen Cyanide, Cyanogen ChlorideBlood agentsHydrogen Cyanide, Cyanogen Chloride Pulmonary IntoxicantsPhosgene, ChlorinePulmonary IntoxicantsPhosgene, Chlorine MiscellaneousAmmoniaMiscellaneousAmmonia VesicantsMustard, LewisiteVesicantsMustard, Lewisite Riot ControlMace ®, Pepper SprayRiot ControlMace ®, Pepper Spray Incapacitating AgentsBZIncapacitating AgentsBZ

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

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

Top Ten Most Prevalent Hazardous Chemicals in NJ AmmoniaHydrogen sulfide ChlorineOzone DifluoroethanePentane Hydrogen chlorideToluene diisocyanate Hydrogen fluorideVinyl acetate

Chlorine Used in swimming pools and laboratoriesUsed in swimming pools and laboratories Industrial exposures may produce large numbers of casualtiesIndustrial exposures may produce large numbers of casualties

Chlorine - Civilian Uses Chlorinated lime (bleaching powder)Chlorinated lime (bleaching powder) Water purificationWater purification DisinfectionDisinfection Synthesis of other compoundsSynthesis of other compounds –synthetic rubber –plastics –chlorinated hydrocarbons Don’t try this at home! (bleach + acid)Don’t try this at home! (bleach + acid)

Historical Exposures 1996 Bethlehem, Pa 13 pool victims 1998 Rome, Italy 282 pool victims Diyarbakir, Turkey victims leaking tanker car

Chlorine - Characteristics PropertiesProperties –Greenish-yellow gas, pungent odor –Chlorine + water = HCl + Free O 2 30x more irritating to lungs than HCl EffectsEffects –Eye irritation, cough, SOB, and wheezing –delayed ARDS

Chlorine - Tissue Effects Topical rather than systemicTopical rather than systemic In central airways - from HClIn central airways - from HCl –necrosis, sloughing In peripheral airwaysIn peripheral airways –oxygen free radicals –react with sulfhydryl groups, disulfide bonds –damage to alveolar-capillary membrane

Chlorine - Clinical Effects Mild ExposureMild Exposure –suffocation, choking sensation –ocular, nasal irritation –chest tightness, cough –exertional dyspnea Moderate ExposureModerate Exposure –above sx + hoarseness, stridor –pulmonary edema within 2-4 hours

Chlorine - Clinical Effects Severe ExposureSevere Exposure –severe dyspnea at rest –may cause pulmonary edema within min –copious upper airway secretions –sudden death may occur from laryngospasm

Clinical Considerations These agents cause pulmonary edemaThese agents cause pulmonary edema –damage alveolar-capillary membrane Latent PeriodLatent Period –symptom onset may be delayed hours to days –objective signs appear later than symptoms Sudden Death may occurSudden Death may occur –laryngeal obstruction (edema/spasm) –bronchospasm

Clinical Considerations Infectious Bronchitis / Pneumonitis commonInfectious Bronchitis / Pneumonitis common –usually occurs 3-5 days post-exposure –fever, elevated WBC, infiltrates NOT always infection –prophylactic antibiotics NOT indicated Effects exacerbated by exertionEffects exacerbated by exertion –compensatory mechanisms overwhelmed –strict rest, even if asymptomatic No specific therapy existsNo specific therapy exists

Ammonia Colorless, water- soluble, alkaline gasColorless, water- soluble, alkaline gas Pungent odorPungent odor Wide industrial useWide industrial use Used to make fertilizer, explosives, dyes, and plasticsUsed to make fertilizer, explosives, dyes, and plastics

Ammonia - Characteristics Household ammonia pH < 12 - limited damageHousehold ammonia pH < 12 - limited damage Anhydrous ammonia pH > 12 - severe damageAnhydrous ammonia pH > 12 - severe damage Rapidly absorbed by mucosal surfaces (eyes, throat, and lungs)Rapidly absorbed by mucosal surfaces (eyes, throat, and lungs) Corrosive produced when combined with water - Liquefaction necrosisCorrosive produced when combined with water - Liquefaction necrosis

Ammonia - Clinical Signs/Symptoms EyesEyes –Burning, tearing, severe pain -> injury of the cornea and lens LungsLungs –Cough, SOB, chest pain, wheezing and laryngitis with mild exposure –Hypoxia, chemical pneumonia, hemorrhage with moderate - severe exposures

Ammonia - Clinical Signs/Symptoms SkinSkin –Pain, blister formation, deep burns Gastrointestinal (ingestion)Gastrointestinal (ingestion) –Severe mouth pain, cough, and abdominal pain –Nausea and vomiting –Edema to lips and mouth (leading to airway obstruction) –Esophageal strictures and perforation

Hydrogen flouride Production of electronic circuits Etching: glass, metal, stone and porcelain Cleaning products: wheel and chrome cleaners Rust removers

Hydrogen fluoride Dissolved in water as hydrofluoric acid Weak acid Volatizes easily Local and systemic effects Delayed symptoms

HF-clinical effects Local: pain out of proportion to apparent injury Systemic: hypocalcemia, hypomagnesemia and hyperkalemia

HF-therapy Decontamination Calcium compresses Nebulized calcium? Eye wash

Fluoride Release Leads to Evacuation of Texas Neighborhood International Fluoride Information Network July 10, 2003 Yesterday, July 9, an explosion occurred at a Texas oil refinery which resulted in the release of an unspecified, but potentially large amount of hydrogen fluoride. According to the article which appeared in today's Corpus Christi Caller Times, a seven block area adjacent to the plant was soon evacuated after winds blew the HF gas in its direction. "The unpublicized usage of deadly hydrofluoric acid at half of all refineries is endangering refinery communities...The environmental hazards of HF as used at refineries have to do with the high volumes utilized, the potential for high temperatures and pressures to be involved in a release, and the tendency of HF, once released to the environment, to form deadly gas clouds that do not easily diminish...This makes it an extremely dangerous material to be utilized at refineries in highly populated areas. The danger posed is thought by many experts to be as severe as the accident in Bhopal, India in which thousands were killed at a Union Carbide chemical plant in 1984."

14 feared killed in refinery blast Rescuers search for survivors at oil plant in Texas Thursday, March 24, 2005 BY PAM EASTON Associated Press TEXAS CITY, Texas -- A thunderous explosion tore through a BP oil refinery yesterday, shooting flames and billowing smoke into the sky and showering the area with ash and chunks of charred metal. At least 14 were believed dead and more than 100 were injured.