RECOGNIZING CHEMICAL TERRORISM-RELATED ILLNESSES Adequate planning and regular training are the key to preparedness for terrorism- , related events. Healthcare providers should be alert to illness patterns and reports of rogram, chemical exposure that might signal an act of terrorism. The following clinical, epidemi- ological and circumstantial clues may suggest a possible chemical terrorist event: , diarrhea raining P • An unusual increase in the number of people seeking care, especially with respiratory, neurological or gastrointestinal symptoms . • Any clustering of symptoms or unusual age distribution . atient Considerations , conjunctivitis, corneal damage reparedness T atients may gasp for air Copious secretions/sweating Seizures Confusion Seizures prior to death (e.g., chemical exposure in children) Sore throat Chest tightness P similar to asphyxiation but more abrupt onset ed airway damage -Miosis (pinpoint pupils) -Blurred/dim vision -Headache -Nausea, - -Muscle twitching/fasciculations -Breathing difficulty - - -Nausea - - -Eye and skin irritation -Airway irritation -Dyspnea, cough - - Initial Effects ol. I, II, III. edness and blisters of the skin

• Location of release not consistent with a chemical’s use epeated antidote administration may earing . Severe irritation Mild respiratory distress to mark Altered consciousness, delusions, denial of illness, belligerence T Onset of symptoms from dermal May cause delayed pulmonary edema, even following a symptom-free period that varies in duration with the amount inhaled contact with liquid forms may be delayed R be necessary and chloride may cause delayed pulmonary edema - -R - - -May cause death -Dry mouth and skin -Initial tachycardia - -Hyperthermia -Ataxia (lack of coordination) -Hallucinations -Mydriasis (dilated pupils) atient Considerations Initial Effects - - - - • Simultaneous impact to human, animal and plant populations Other P • Any unusual clustering of patients in time or location ossible pulmonary edema ossible serious arrhythmias Specific antidote British Anti- (BAL) may decrease systemic effects of Lewisite oxime causes immediate pain Lewisite has immediate burning pain, blisters later Mustard has an asymptomatic latent period Specific antidote (physostigmine) may be available Hyperthermia and self-injury are largest risks Hard to detect because it is an odorless and non-irritating substance There is no antidote or treatment for mustard Other P - -P - - - - (e.g., persons who attended the same public event) - - -P - e e Any unusual symptoms, illnesses or clusters of these should be reported e immediately. EMS personnel should call their medical control facility and , as needed dispatching agency. The county health department and local Poison Control roving Ground: Aberdeen, MD therapy age.htm AM) chloride Center should also be notified. , echnician EMS Course. Domestic P PHONE NUMBERS itleP . ublic Health Service: Atlanta, GA , forced rest ossible cherry red skin ossible cyanosis ossible frostbite* New York State Department of Health (NYSDOH) ossible frostbite* Copious secretions is a greenish-yellow gas with pungent odor Phosgene gas smells lik newly-mown hay or grass Muscle twitching/fasciculations . 1999. T Any Unique Characteristics -Miosis (pinpoint pupils) - - -P -P -P - -P Bureau of Toxic Substance Assessment 518-402-7800 - apid treatment with oxygen ralidoxime (2-P resh air Semi-upright position Other supportive If signs of respiratory distress are present, oxygen with or without positive airway pressure may be needed For , use antidotes (sodium nitrite and then sodium thiosulfate) May appear as mass drug intoxication with erratic Mustard (HD) has an odor lik burning garlic or horseradish Lewisite (L) has an odor lik penetrating geranium (CX) has a pepperish or pungent odor behaviors, shared realistic and distinct hallucinations, disrobing and confusion First Aid Assess ABCs -Atropine before other measures -P Any Unique Characteristics -R - -F - - - - -Hyperthermia -Mydriasis (dilated pupils) Wadsworth Center Laboratories 518-474-7161 - - - emove heavy clothing ash area with plenty of warm water to release clothing Supportive care Supportive care give oxygen If breathing difficulty Monitor core temperature carefully After hours: NYSDOH Duty Officer 1-866-881-2809 normal saline for 10-15 minutes - -Immediately decontaminate skin -Flush eyes with water or - -R -Evaluate mental status -Use restraints as needed - - First Aid Assess ABCs TH EFFECTS OF CHEMICAL TERRORISM TH EFFECTS OF CHEMICAL TERRORISM edHandbook/001T After hours: SEMO State Warning Point 518-457-2200 . W TSDR). 2001. Managing Hazardous Materials Incidents V

(SEMO - State Emergency Management Office) , H) New York City Department of Health TMENT TMENT roving Ground: Aberdeen, MD

Poison Control Center 212-764-7667 . 2000. Medical Management of Chemical Casualties Handbook, Third edition. egistry (A Your County Health Department Consult phone book blue pages under “County Offices” esponse Card: Poison Control Centers 1-800-222-1222 .mil/products/handbooks/R

MEDICAL PREPAREDNESS REFERENCES AND RESOURCES . Department of Health and Human Services. P T remove any adhering clothing . S emove clothing immediately if no emove clothing immediately if emove clothing immediately .cdc.gov/mhmi.html TION AND TREA esearch, Development and Engineering Center This response card is only a summary of important information. For more detail for (HN-1, HN-2, HN-3) Agent Names -Agent 15/BZ Gently wash skin with soap and water R frostbite* For eyes, flush with plenty of water or normal saline -Mustard/Sulfur mustard (HD - (H) - -Lewisite (L) -Phosgene oxime (CX) Gently wash skin with soap and water Gently wash skin with soap and water R no frostbite* For eyes, flush with plenty of water or normal saline For eyes, flush with plenty of water or normal saline emove clothing immediately emove clothing immediately TION AND TREA , U - - -Do not abrade skin - - - -Do not abrade skin - -R - -Do not abrade skin - esearch Institute of Chemical Defense (USAMRICD). Aberdeen P Decontamination abun (GA) Gently wash skin with water or Gently wash skin with soap and water soap and water Immediate decontamination is essential to minimize damage For eyes, flush with plenty of water or normal saline Cyclohexyl (GF) Sarin (GB) (GD) Cyanogen chloride Chlorine VX T -R - -Do not abrade skin - -R - -Do not abrade skin - preparedness planning, review the following resources and those at the end of Table 2: Decontamination Agent Names ------Arsine - - - -Hydrogen chloride -Nitrogen oxides -Phosgene .atsdr . Army SBCCOM. Aberdeen P

*Textbook of Military Medicine – Medical Aspects of Chemical and Biological Warfare. reparedness and R (continued) .S AMINA oxicology oxic Substances and Disease R 2. http://ccc.apgea.army.mil/products/textbook/HTML_Restricted/index.htm AMINA ype - 2. (continued) - ype ype http://chemdef.apgea.army.mil/textbook/contents.asp ype http://www http://ccc.apgea.army . Army Medical R *Centers for Disease Control and Prevention Public Health Emergency . Army Edgewood R ulmonary- ABLE .S .S ersion 8.0. U ABLE 1. ABLE 1. ulmonary- Agent T Asphyxiant/ Blood esicant Choking/ P damaging T ABLE Nerve DECONT V Division of T U Agency for T Chemical Casualty Care Division USAMRICD U rostbite may occur from skin contact with liquid arsine, cyanogen chloride or phosgene. esicant T

Preparedness and Response Agent T T Agent T RECOGNIZING AND DIAGNOSING HEAL RECOGNIZING AND DIAGNOSING HEAL Asphyxiant/ Blood Blistering/ V Nerve Choking/ P damaging eferences for P T Agent T altering Incapacitating/ Behavior Blistering/ V DECONT Incapacitating/ Behavior altering R 1. 2. 3. *F http://www.bt.cdc.gov/Agent/AgentlistChem.asp *For frostbite areas, do NO

TABLE 3. ANTIDOTE RECOMMENDATIONS FOLLOWING TABLE 4. ANTIDOTE RECOMMENDATIONS FOLLOWING PERSONAL PROTECTIVE EQUIPMENT (PPE) DECONTAMINATION GUIDELINES EXPOSURE TO CYANIDE EXPOSURE TO NERVE AGENTS DO NOT BECOME A CASUALTY! Proper decontamination is often the most important first step in treating a Note – Victims whose clothing or skin is contaminated with hydrogen cyanide patient exposed to chemical agents. Immediate removal of patient clothing can Antidotes First responders face the greatest exposure potential, often to unidentified agents. liquid or solution can secondarily contaminate response personnel by direct Patient Mild/Moderate Severe Other remove up to 90 percent of the contaminant. Removed clothing should be contact or through off-gassing vapors. Avoid dermal contact with cyanide- To protect yourself: Age Effects1 Effects2 Treatment bagged, sealed and retained as possible evidence. contaminated victims or with gastric contents of victims who may have ingested • Be alert cyanide-containing materials. Victims exposed only to hydrogen cyanide gas do Infants Atropine: Atropine: Assisted ventilation After the clothing is removed, the patient’s skin and eyes may need to be • Keep an appropriate distance decontaminated. In most cases, decontamination of skin can be accomplished not pose contamination risks to rescuers. If the patient is a victim of recent (0-2 yrs) 0.05 mg/kg IM, or 0.1 mg/kg IM, or after antidotes for smoke inhalation (may have high carboxyhemoglobin levels), administer 0.02 mg/kg IV; 0.02 mg/kg IV; severe exposure. • Stay upwind by gentle and thorough washing with soap and water followed by a thorough only sodium thiosulfate. and and water rinse. For eyes, flush with plenty of water. Decontamination water may 2-PAM Chloride: 2-PAM Chloride: Repeat atropine • Wait for assessment by a HAZMAT team before entering need to be contained. 15 mg/kg IM or 25 mg/kg IM, or (2 mg IM, or 1 mg Patient Mild Severe Other IV slowly 15 mg/kg IV slowly Ideally, responders in an unknown situation should wear Level A PPE. Bleach solutions, concentrated or dilute, should not be used on people. Diluted IM for infants) Exposure can occur from inhalation of vapors, dermal contact or eye contact. (conscious) (unconscious) Treatment Child Atropine: Atropine: at 5 - 10 minute bleach (1 part household bleach to 9 parts water) can be used on equipment 1 mg IM, or 2 mg IM, or The following is a general discussion to help responders/healthcare providers and other hard surfaces. Because bleach solutions irritate the eyes, skin 1 (2-10 yrs) intervals until Child If patient is Sodium nitrite : For sodium nitrite- 0.02 mg/kg IV; 0.02 mg/kg IV; secretions have determine appropriate PPE. and respiratory tract, they must be handled with caution and used with Preparedness conscious and has 0.12 - 0.33 ml/kg, induced orthostatic and and 2-PAM Chloride3: 2-PAM Chloride3: diminished and PPE to Prevent Inhalation Exposure: adequate ventilation. no other signs not to exceed 10 ml hypotension, normal breathing is and or symptoms, of 3% solution2 slow saline infusion and 15 mg/kg IM or 25 mg/kg IM, or Protection from both vapors and particulates may be required when the It is important not to abrade the skin during washing or rinsing. This is IV slowly 15 mg/kg IV slowly comfortable or chemical agent is being released. After release, protection from vapors is most especially true after exposure to blistering/vesicant agents which bind to skin. antidotes may not IV over no less than 5 supine position are airway resistance Adolescent Atropine: Atropine: important. Surgical and N-95 masks will not protect against inhalation of These agents may leave the skin compromised and susceptible to further Response Card be necessary. minutes, or slower if recommended. has returned to hypotension develops (>10 yrs) 2 mg IM, or 4 mg IM, or vapors. Half-face and full-face respirators, with the appropriate canister, will damage. For choking/pulmonary-damaging agents or incapacitating/behavior- 0.02 mg/kg IV; 0.02 mg/kg IV; near normal. provide good protection from vapors. These operate by negative pressure and and If still apneic and and altering agents, a rinse in water alone may be adequate. Sodium thiosulfate: after antidote 2-PAM Chloride3: 2-PAM Chloride3: Phentolamine must be fit tested for optimal protection. Powered, air-purifying respirators 1.65 ml/kg of administration, 15 mg/kg IM or 25 mg/kg IM, or for 2-PAM-induced (PAPR) and self-contained breathing apparatus (SCBA) provide even greater ODORS 25% solution IV consider sodium IV slowly 15 mg/kg IV slowly hypertension: protection and operate under positive pressure so that fit characteristics are Some chemical agents are accompanied by a characteristic odor that may over 10 - 20 minutes bicarbonate for Adult Atropine: Atropine: (5 mg IV for adults; less important. 1 mg IV for children). provide a warning. However, after a while, people may become used to the 1 severe acidosis. 2 to 4 mg IM or IV; 6 mg IM; Adult If patient is Sodium nitrite : and and PPE to Prevent Dermal Exposure: chemical and no longer detect the smell. The chemical may still be present conscious and has 10 - 20 ml of 3% 2-PAM Chloride: 2-PAM Chloride: Diazepam for Latex examination gloves provide very little protection from most chemical even if there is no detectable odor. no other signs solution2 slow IV 600 mg IM, or 1,800 mg IM, or convulsions: agents and can cause allergies. Gloves made of Viton, nitrile, butyl or neoprene or symptoms, over no less than 5 15 mg/kg IV slowly 15 mg/kg IV slowly (0.2 to 0.5 mg IV provide more protection and, in some styles, allow adequate dexterity. for infants less DISCLAIMER antidotes may not minutes, or slower Elderly, Atropine: Atropine: However, the resistance of these materials to different chemicals varies and be necessary. if hypotension 1 mg IM; 2 to 4 mg IM; than 5 years; The information on this card is meant to be a quick guide and is not intended frail and 1 mg IV for children it is best to have a variety of gloves available. Double gloving may provide to be comprehensive. This information or the web sites and references develops and additional protection. Chemical-resistant aprons or suits can also prevent and 2-PAM Chloride: 2-PAM Chloride: 5 years and older; listed in this card are not a substitute for professional medical advice, 10 mg/kg IM, or 25 mg/kg IM, or dermal exposure. Sodium thiosulfate: 5 to 10 mg/kg IV 5 mg IV for adults). diagnosis, or treatment of the individual. Please consult other references, 50 ml of 25% slowly 5 to 10 mg/kg IV slowly PPE to Prevent Eye Exposure: Poison Control Center, and check antidote dosages, particularly for children solution IV over 1. Mild/Moderate effects include localized sweating, muscle fasciculations, nausea, Full-face respirators, PAPR and SCBA will provide protection from both and pregnant women. 10 - 20 minutes vomiting, weakness, dyspnea. splashes and vapors. Protective eyewear, such as goggles or a face shield, State of New York • George E. Pataki, Governor 2. Severe effects include unconsciousness, convulsions, apnea, flaccid paralysis. will not provide protection from chemical vapors. Protective eyewear is required Department of Health • Antonia C. Novello, M.D., M.P.H., Dr. P.H., Commissioner 1. If sodium nitrite is unavailable, administer amyl nitrite by inhalation from crushable ampules. 3. If calculated dose exceeds the adult IM dose, adjust accordingly. 2. Available in Pasadena Cyanide Antidote Kit, formerly Lilly Cyanide Kit. NOTE: 2-PAM Chloride is Pralidoxime Chloride or Protopam Chloride. during decontamination to prevent splashing into eyes. 7002 08/02