DOCSLIB.ORG

Toxidrome Recognition in Chemical- Weapons Attacks

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Toxidrome Recognition in Chemical- Weapons Attacks The new england journal of medicine Review Article Dan L. Longo, M.D., Editor Toxidrome Recognition in Chemical- Weapons Attacks Gregory R. Ciottone, M.D.​​ errorist attacks are increasing in both frequency and com- From Beth Israel Deaconess Medical plexity around the world. In 2016 alone, there were more than 13,400 ter- Center, Harvard Medical School, Boston. 1 Address reprint requests to Dr. Ciottone rorist attacks globally, killing more than 34,000 people. Of equal concern, at Beth Israel Deaconess Medical Center, T Dept. of Emergency Medicine, Rosenberg chemical-warfare agents that were developed for the battlefield are being used on civilians in major cities and conflict zones. The recent sarin attacks in Syria,2,3 the Building, 1 Deaconess Rd., Boston, MA 02215, or at gciotton@ bidmc . harvard . edu. latest in a series of chemical attacks in that region,3,4 along with the use of the nerve agent VX in the assassination of Kim Jong-nam in Malaysia and the Soviet- N Engl J Med 2018;378:1611-20. 5 DOI: 10.1056/NEJMra1705224 era agent Novichok in the poisoning of Sergei Skripal in the United Kingdom, all Copyright © 2018 Massachusetts Medical Society. represent a worrisome trend in the use of deadly chemical agents by various rogue groups in civilian settings. In light of the rise in coordinated, multimodal terrorist attacks in Western urban centers,6,7 concern has been expressed about an increase in the use of chemical agents by terrorists on civilian targets around the world. Such attacks entail unique issues in on-the-scene safety8,9 and also require a rapid medical response.10 As health care providers, we must be proactive in how we prepare for and respond to this new threat. This article reviews the toxidromes (constellations of signs and symptoms that are characteristic of a given class of agents) for known and suspected chemical- warfare agents that have properties that are well suited for terrorist attacks — namely, high volatility and rapid onset of incapacitating or lethal effects.11 Poison- control procedures currently use toxidromes to identify specific classes of agents. Although symptoms such as eye irritation and coughing are common to a number of classes, specific clinical findings, including fasciculations, hypersecretions, early seizure, and miosis or mydriasis, can be rapidly identified as part of an acute- phase triage system and used to differentiate among classes of agents. This should lead to reduced morbidity and mortality while also decreasing the risk to respond- ing health care workers.12 The combined group of chemical-warfare agents exam- ined here includes nerve agents, asphyxiants (blood agents), opioid agents, anes- thetic agents, anticholinergic (antimuscarinic) agents, botulinum toxin, pulmonary agents, caustic agents (acids), riot-control agents, T-2 toxin, and vesicants (Table 1). History Chemical warfare is not new. As early as 10,000 B.C., rival tribes used various poi- sons derived from plants and animals to coat their spear tips before battle.13 The modern world witnessed the first large-scale use of chemical weapons on the battlefields of World War I, where chlorine,14 phosgene,15,16 and sulfur mustard17,18 were deployed, with devastating effects.19 During World War II, the Nazi regime developed new and much more lethal nerve agents, such as sarin,20 tabun,21 and soman,22 though they were never deployed on the battlefield against the Allied n engl j med 378;17 nejm.org April 26, 2018 1611 The New England Journal of Medicine Downloaded from nejm.org by RICHARD PEARSON on June 11, 2018. For personal use only. No other uses without permission. Copyright © 2018 Massachusetts Medical Society. All rights reserved. The new england journal of medicine Table 1. Classes of Chemical-Warfare Agents (CWAs) Likely to Be Used in a Civilian Attack. Last Known Use or Attempted Use Class Representative Agents as a CWA* Nerve agents (cholinesterase G-series (sarin, soman, cyclosarin, tabun), Syria, 2017: sarin; Malaysia, 2017: VX inhibitors) V-series (VE, VG, VM, VX), organo- phosphates Asphyxiants (blood agents) Hydrogen cyanide, cyanogen chloride New York City subway, 2003: cyanide Opioid agents Fentanyl, carfentanil, remifentanil Moscow theater, 2002: fentanyl or carfentanil (used to subdue terrorists) Anesthetic agents Chloroform, halothane, nitrous oxide No known use as CWA Anticholinergic 3-Quinuclidinyl benzilate (BZ), Agent 15 (chemi- Syria, 2012: Agent 15 (antimuscarinic) agents cally the same as or related to BZ), atropine Vesicant agents Mustards (nitrogen and sulfur), lewisite, Syria and Iraq, 2016: mustard gas phosgene oxime Caustic agents (acids) Hydrochloric acid, hydrofluoric acid, sulfuric acid London, 2017: sulfuric acid Riot-control agents Chloroacetophenone (CN), chlorobenzy- Falkland Islands, 1982: “tear gas” lidenemalononitrile (CS), bromobenzyl- used on British troops cyanide (CA) Trichothecene mycotoxins T-2 toxin Possible use in Vietnam War, 1970: T-2 Pulmonary agents Chlorine, phosgene, diphosgene Syria, 2017: chlorine Botulinum toxin Botulinum toxin Tokyo, 1995: botulinum toxin used by Aum Shinrikyo * Information on previous use of CWAs is from the Global Terrorism Database, University of Maryland,1 and other sources.3,9,10 troops.23,24 The Nazis did, however, combine hy- rately; however, when combined, they become a drogen cyanide with an absorbent to form Zyk- lethal chemical agent. VX is an example of a lon B, which was then used to kill millions of chemical-warfare agent that has two nontoxic people in gas chambers.25 Chemical weapons binary precursors, and there has been some have also been used in the Iran–Iraq war and speculation that the assassination of Kim Jong- present-day Syria.26-28 As a response to the devel- nam may have involved the application of two opment and use of such agents, the Chemical such binary agents.5 Nontraditional agents such Weapons Convention, essentially an arms-con- as Novichok are next-generation chemical com- trol agreement put into effect on April 29, 1997, pounds with varying effects, levels of detection, prohibits the development, stockpiling, transfer, and mechanisms of action. These newly devel- and use of chemical weapons by state entities.29 oped chemicals are considered classified by the Late in the 20th century, terrorist groups be- United States, so little is known about them gan to obtain chemical-warfare agents and use outside of the government. them on civilian targets. The most extensively documented case was the use of sarin in the Agents of Concern subways of Tokyo by the Aum Shinrikyo group in 1995.30,31 During the same period, a number Chemical weapons vary in their onset of action, of countries clandestinely developed more ad- toxicity, and symptomatology.34-36 The character- vanced and more lethal chemical weapons that istics most suitable for use in a terrorist attack were safer to handle and transport yet harder to include high volatility, fast and effective absorp- detect.32,33 Such agents include binary agents and tion through the respiratory tract or skin, and lesser known, nontraditional agents. Binary for- rapid onset of lethal or incapacitating effects.37 mulations are two chemically stable and non- Some toxins (i.e., poisons produced by living lethal precursors that are safe to carry sepa- organisms) can behave like chemical weapons. 1612 n engl j med 378;17 nejm.org April 26, 2018 The New England Journal of Medicine Downloaded from nejm.org by RICHARD PEARSON on June 11, 2018. For personal use only. No other uses without permission. Copyright © 2018 Massachusetts Medical Society. All rights reserved. Toxidrome Recognition in Chemical-Weapons Attacks In World War II, botulinum toxin was produced nation is a medical countermeasure that miti- and used by the Japanese; after the war, it was gates the conversion of an external dose to an produced by some other countries, which main- internal dose. tained large stockpiles.38 The two lethal toxins included in this review, botulinum toxin and T-2 The Problem toxin (a trichothecene mycotoxin), can be ab- sorbed through the respiratory system or skin Chemical-weapons attacks occur without warn- and are relatively fast-acting.38,39 ing and create chaotic scenes, resulting in con- The effects of nerve agents such as sarin and fusion on the part of emergency medical re- VX, asphyxiants such as cyanide, and opioids sponders and hospital-based personnel, most of such as fentanyl and carfentanil, can be coun- whom are unprepared40,41 and have very little tered by the emergency administration of spe- training in the recognition of a chemical attack42 cific antidotes. Nerve agents inhibit cholines- or in the donning and doffing of personal pro- terase at the synapse, leading to a build-up of tective equipment.43,44 In addition, the initial acetylcholine and requiring atropine and prali- scene of a chemical attack may look very similar doxime as antidotes. Asphyxiants block cellular to other incidents involving mass casualties, respiration, requiring urgent administration of particularly if release of the agent is combined hydroxocobalamin or sodium thiosulfate and with use of conventional weapons as part of a sodium nitrite as antidotes, and opioids cause multimodal attack. The chaos of the early phase respiratory depression, requiring rapid adminis- of such an event may lead to further delay in tration of naloxone. All other agents are inca- identifying the chemical agent, placing respond- pacitating and potentially lethal but have no ers at risk while also delaying potentially life- specific lifesaving antidote, therefore requiring saving treatment for the victims. An understand- urgent decontamination and supportive care ing of the patterns of signs and symptoms initially. Anesthetic agents may cause sedation (toxidromes) that characterize the classes of and bradypnea, whereas pulmonary agents cause known agents, as well as familiarity with the pat- eye and throat irritation, coughing, chest pain, terns of injuries caused by conventional weapons, and shortness of breath.
Load more

Recommended publications
  • Critical Care Management of Chemical Exposures 4 the Patients Were Decontaminated Prior to Arriving at the Hospital
    Chapter 4: CRITI C AL CARE MANAGE M ENT OF CHE M I C AL EXPOSURES James Geiling, MD, FCCM Vincent M. Nicolais, MD, FCCM Gregory M. Susla, PharmD, FCCM The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Objectives ■ Review measures of preparedness and planning. ■ Describe the purpose of decontamination. ■ Discuss how to evaluate whether a patient has been adequately decontaminated to enter the emergency department (ED), hospital, or intensive care unit (ICU). ■ Summarize the steps necessary to protect hospital staff: decontamination, personal protective equipment (PPE). ■ Review specific agents: diagnosis, identification, and management. If supposedly civilized nations confined their warfare to attacks on the enemy’s troops, the matter of defense against warfare chemicals would be purely a military problem, and therefore beyond the scope of this study. But such is far from the case. In these days of total warfare, the civilians, including women and children, are subject to attack at all times. Colonel Edgar Erskine Hume, Victories of Army Medicine, 1943 Fundamental Disaster Management Case Study A young couple was transported to your hospital’s ED from a local cinema. You have been told there are many others who are being cared for by the emergency medical services and are en route. The 18-year-old male and 17-year-old female were admitted to your ICU after intubation and placement on mechanical ventilation. They are unresponsive and diaphoretic, and they have constricted pupils with excessive lacrimation, vomiting, diarrhea, and restlessness.
    [Show full text]
  • View Document
    Terrorism WHAT CLINICIANS and NEED TO Disaster KNOW Sarin Sponsored for CME Credit by Rush University Medical Center Release Date: April 1, 2005 Expiration Date: March 31, 2007 errorism WHAT T CLINICIANS and NEED TO Disaster KNOW SERIES Uniformed Services University Guest Faculty EDITORS Health Sciences Ronald E. Goans, PhD, MD, MPH* Bethesda, Maryland Clinical Associate Professor Rush University Tulane University School of Public Health & David M. Benedek, MD, LTC, MC, USA Medical Center Tropical Medicine Associate Professor of Psychiatry Chicago, Illinois New Orleans, LA Stephanie R. Black, MD* Steven J. Durning, MD, Maj, USAF, MC* Sunita Hanjura, MD* Assistant Professor of Medicine Associate Professor of Medicine Rockville Internal Medicine Group Section of Infectious Diseases Rockville, MD Department of Internal Medicine Thomas A. Grieger, MD, CAPT, MC, USN* Associate Professor of Psychiatry Niranjan Kanesa-Thasan, MD, MTMH* Daniel Levin, MD* Associate Professor of Military & Director, Medical Affairs & Pharmacovigilance Assistant Professor Emergency Medicine Acambis General Psychiatry Residency Director Assistant Chair of Psychiatry for Graduate Cambridge, MA Department of Psychiatry & Continuing Education Jennifer C. Thompson, MD, MPH, FACP* Gillian S. Gibbs, MPH* Molly J. Hall, MD, Col, USAF, MC, FS* Chief, Department of Clinical Investigation Project Coordinator Assistant Chair & Associate Professor William Beaumont Army Medical Center Center of Excellence for Bioterrorism Department of Psychiatry El Paso, TX Preparedness Derrick Hamaoka, MD, Capt, USAF, MC, FS* Faculty Disclosure Policy Linnea S. Hauge, PhD* Director, Third Year Clerkship It is the policy of the Rush University Medical Educational Specialist Instructor of Psychiatry Department of General Surgery Center Office of Continuing Medical Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC* Education to ensure that its CME activities Associate Professor of Medicine are independent, free of commercial bias AUTHORS and beyond the control of persons or organi- Rush University Benjamin W.
    [Show full text]
  • Toxicological Profile for Acetone Draft for Public Comment
    ACETONE 1 Toxicological Profile for Acetone Draft for Public Comment July 2021 ***DRAFT FOR PUBLIC COMMENT*** ACETONE ii DISCLAIMER Use of trade names is for identification only and does not imply endorsement by the Agency for Toxic Substances and Disease Registry, the Public Health Service, or the U.S. Department of Health and Human Services. This information is distributed solely for the purpose of pre dissemination public comment under applicable information quality guidelines. It has not been formally disseminated by the Agency for Toxic Substances and Disease Registry. It does not represent and should not be construed to represent any agency determination or policy. ***DRAFT FOR PUBLIC COMMENT*** ACETONE iii FOREWORD This toxicological profile is prepared in accordance with guidelines developed by the Agency for Toxic Substances and Disease Registry (ATSDR) and the Environmental Protection Agency (EPA). The original guidelines were published in the Federal Register on April 17, 1987. Each profile will be revised and republished as necessary. The ATSDR toxicological profile succinctly characterizes the toxicologic and adverse health effects information for these toxic substances described therein. Each peer-reviewed profile identifies and reviews the key literature that describes a substance's toxicologic properties. Other pertinent literature is also presented, but is described in less detail than the key studies. The profile is not intended to be an exhaustive document; however, more comprehensive sources of specialty information are referenced. The focus of the profiles is on health and toxicologic information; therefore, each toxicological profile begins with a relevance to public health discussion which would allow a public health professional to make a real-time determination of whether the presence of a particular substance in the environment poses a potential threat to human health.
    [Show full text]
  • Introduction to Emergency Management Second Edition
    Introduction to Emergency Management Second Edition Introduction to Emergency Management Second Edition George D. Haddow Jane A. Bullock With Contributions by Damon P. Coppola Amsterdam • Boston • Heidelberg • London • New York • Oxford • Paris San Diego • San Francisco • Singapore • Sydney • Tokyo Elsevier Butterworth–Heinemann 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA Linacre House, Jordan Hill, Oxford OX2 8DP, UK Copyright © 2006, Elsevier Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Permissions may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone: (+44) 1865 843830, fax: (+44) 1865 853333, e-mail: permissions@elsevier. co.uk. You may also complete your request on-line via the Elsevier homepage (http://elsevier.com), by selecting “Customer Support” and then “Obtaining Permissions.” Recognizing the importance of preserving what has been written, Elsevier prints its books on acid-free paper whenever possible. Library of Congress Cataloging-in-Publication Data Haddow, George D. Introduction to emergency management / George D. Haddow, Jane A. Bullock. — 2nd ed. p. cm. Includes bibliographical references and index. ISBN 0-7506-7961-1 (hardcover : alk. paper) 1. Emergency management. 2. Emergency management—United States. I. Bullock, Jane A. II. Title. HV551.2.H3
    [Show full text]
  • What Clinicians Need to Know
    Terrorism WHAT CLINICIANS and NEED TO Disaster KNOW Sarin errorism WHAT T CLINICIANS and NEED TO Disaster KNOW SERIES Uniformed Services University Guest Faculty EDITORS Health Sciences Ronald E. Goans, PhD, MD, MPH* Bethesda, Maryland Clinical Associate Professor Rush University Tulane University School of Public Health & David M. Benedek, MD, LTC, MC, USA Medical Center Tropical Medicine Associate Professor of Psychiatry Chicago, Illinois New Orleans, LA Stephanie R. Black, MD* Steven J. Durning, MD, Maj, USAF, MC* Sunita Hanjura, MD* Assistant Professor of Medicine Associate Professor of Medicine Rockville Internal Medicine Group Section of Infectious Diseases Rockville, MD Department of Internal Medicine Thomas A. Grieger, MD, CAPT, MC, USN* Associate Professor of Psychiatry Niranjan Kanesa-Thasan, MD, MTMH* Daniel Levin, MD* Associate Professor of Military & Director, Medical Affairs & Pharmacovigilance Assistant Professor Emergency Medicine Acambis General Psychiatry Residency Director Assistant Chair of Psychiatry for Graduate Cambridge, MA Department of Psychiatry & Continuing Education Jennifer C. Thompson, MD, MPH, FACP* Gillian S. Gibbs, MPH* Molly J. Hall, MD, Col, USAF, MC, FS* Chief, Department of Clinical Investigation Project Coordinator Assistant Chair & Associate Professor William Beaumont Army Medical Center Center of Excellence for Bioterrorism Department of Psychiatry El Paso, TX Preparedness Derrick Hamaoka, MD, Capt, USAF, MC, FS* Faculty Disclosure Policy Linnea S. Hauge, PhD* Director, Third Year Clerkship It is the policy of the Rush University Medical Educational Specialist Instructor of Psychiatry Department of General Surgery Center Office of Continuing Medical Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC* Education to ensure that its CME activities Associate Professor of Medicine are independent, free of commercial bias AUTHORS and beyond the control of persons or organi- Rush University Benjamin W.
    [Show full text]
  • Chemical Weapon Threats—Are You Prepared
    Chemical Terror Threats—Are You Prepared? NYSNA Continuing Education The New York State Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This course has been awarded 3.6 contact hours. All ANCC accredited organizations' contact hours are recognized by all other ANCC accredited organizations. Most states with mandatory continuing education requirements recognize the ANCC accreditation/approval system. Questions about the acceptance of ANCC contact hours to meet mandatory regulations should be directed to the professional licensing board within that state. NYSNA has been granted provider status by the Florida State Board of Nursing as a provider of continuing education in nursing (Provider number 50-1437). How to Take This Course Please take a look at the steps below; these will help you to progress through the course material, complete the course examination and receive your certificate of completion. 1. REVIEW THE OBJECTIVES The objectives provide an overview of the entire course and identify what information will be focused on. Objectives are stated in terms of what you, the learner, will know or be able to do upon successful completion of the course. They let you know what you should expect to learn by taking a particular course and can help focus your study. 2. STUDY EACH SECTION IN ORDER Keep your learning "programmed" by reviewing the materials in order. This will help you understand the sections that follow. 3. COMPLETE THE COURSE EXAM After studying the course, click on the "Course Exam" option located on the course navigation toolbar.
    [Show full text]
  • (12) United States Patent (10) Patent No.: US 8,318,728 B2 Chong (45) Date of Patent: Nov
    US008318728B2 (12) United States Patent (10) Patent No.: US 8,318,728 B2 Chong (45) Date of Patent: Nov. 27, 2012 (54) COMPOUNDS AND COMPOSITIONS FOR (56) References Cited TREATING CHEMICAL WARFARE AGENT INDUCED INURES U.S. PATENT DOCUMENTS 4,297,494 A 10/1981 Groman et al. (75) Inventor: Jayhong A. Chong, Brookline, MA (US) 4,871,742 A 10, 1989 Bonne et al. 4,960,773. A 10, 1990 KorbonitSet al. 5,068,236 A 11/1991 Suzuki et al. (73) Assignee: Hydra Biosciences, Inc., Cambridge, 6,545,002 B1 4/2003 Linden et al. MA (US) 6,608,069 B1 8/2003 Daluge et al. 7,135,475 B2 11/2006 Dunten et al. (*) Notice: Subject to any disclaimer, the term of this 2004.0053973 A1 3/2004 Ohkawa et al. 2006, O247226 A1 11/2006 Himmelsbach et al. patent is extended or adjusted under 35 2007/OO72851 A1 3/2007 Buchanan et al. U.S.C. 154(b) by 371 days. 2007/0219.222 A1 9, 2007 Moran et al. (21) Appl. No.: 12/466,187 FOREIGN PATENT DOCUMENTS WO 2007073505 A2 6, 2007 (22) Filed: May 14, 2009 OTHER PUBLICATIONS (65) Prior Publication Data Cassillas et al., J. Appl. Toxicol. 20, S145-S151 (2000).* US 2012/O108613 A1 May 3, 2012 International Search Report dated Jun. 14, 2010 for related applica tion PCT/US 10/35005. European Agency for the Evaluation of Medicinal Products. EMEA Related U.S. Application Data CPMP Guidance Document on the Use of Medicinal Products for the (60) Provisional application No.
    [Show full text]
  • FM 4-02.285. Multiservice Tactics, Techniques, and Procedures For
    ARMY, MARINE CORPS, NAVY, AIR FORCE MULTISERVICE TACTICS, TECHNIQUES, AND PROCEDURES FOR TREATMENT OF CHEMICAL AGENT CASUALTIES AND CONVENTIONAL MILITARY CHEMICAL INJURIES FM 4-02.285 (FM 8-285) MCRP 4-11.1A NTRP 4-02.22 AFTTP (I) 3-2.69 SEPTEMBER 2007 DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited. MULTISERVICE TACTICS, TECHNIQUES, AND PROCEDURES FOREWORD This publication has been prepared under our direction for use by our respective commands and other commands as appropriate. RUSSELL J. CZERW JAMES F. AMOS Major General, DC Lieutenant General, US Marine Corps Commander, US Army Medical Deputy Commandant for Combat Department Center and School Development and Integration T. L. DAVISON THOMAS J. LOFTUS Captain, US Navy Major General, USAF, MC, CFS Acting Assistant Surgeon General Navy Warfare Development Command Health Care Operations Office of the Surgeon General This publication is available through the US Army at Army Knowledge Online (AKO) (www.us.army.mil) and at the General Dennis J. Reimer Training and Doctrine Digital Library (www.train.army.mil) websites; through the US Marine Corps website (https://www.doctrine.usmc.mil); through the US Navy at Navy Knowledge Online (https://www.nko.navy.mil) accessed via the Navy Warfare Library (located on the Reference Page) and the Navy Warfare Development Command SIPRNET Doctrine Discussion Group (DDG) (www.nwdc.navy.smil.mil); and through the US Air Force at the Air Force Publishing website (www.e-publishing.af.mil). PREFACE 1. Purpose This publication provides multiservice tactics, techniques, and procedures (MTTP) and is designed for use as a reference for trained members of the Armed Forces Medical Services and other medically qualified personnel on the recognition and treatment of chemical agent casualties and conventional military chemical injuries.
    [Show full text]
  • The Human and Environmental Effects of CBRN Weapons
    Fordham University Masthead Logo DigitalResearch@Fordham Student Theses 2015-Present Environmental Studies May 2015 The umH an and Environmental Effects of CBRN Weapons Brendan M. Doran Fordham University, [email protected] Follow this and additional works at: https://fordham.bepress.com/environ_2015 Part of the Environmental Health and Protection Commons, Environmental Monitoring Commons, and the Natural Resources Management and Policy Commons Recommended Citation Doran, Brendan M., "The umH an and Environmental Effects of CBRN Weapons" (2015). Student Theses 2015-Present. 10. https://fordham.bepress.com/environ_2015/10 This is brought to you for free and open access by the Environmental Studies at DigitalResearch@Fordham. It has been accepted for inclusion in Student Theses 2015-Present by an authorized administrator of DigitalResearch@Fordham. For more information, please contact [email protected]. Doran 1 The Human and Environmental Effects of CBRN Weapons Brendan Doran Senior Thesis Environmental Policy May 2015 “For the Angel of Death spread his wings on the blast, And breathed in the face of the foe as he passed; And the eyes of the sleepers waxed deadly and chill, And their hearts but once heaved, and forever grew still!” - Lord Byron, “The Destruction of Sennacherib” Doran 2 Abstract Since the first use of modern weapons of mass destruction during the First World War, the World has lived in fear of these horrifying instruments of death. Gripped by this fear, countries around the world have continued to research, develop, and test these weapons in the spirit of mutually assured destruction. Over the years, science and warfare have continually refined their methods of human extermination, bringing forth some of the most terrifyingly effective weapon systems ever devised.
    [Show full text]
  • ATP 4-02.85. Multi-Service Tactics
    *ATP 4-02.85 MCRP 3-40A.1 *NTRP 4-02.22 *AFTTP(I) 3-2.69 MULTI-SERVICE TACTICS, TECHNIQUES, AND PROCEDURES FOR TREATMENT OF CHEMICAL WARFARE AGENT CASUALTIES AND CONVENTIONAL MILITARY CHEMICAL INJURIES AUGUST 2016 DISTRIBUTION RESTRICTION: Approved for public release; distribution is unlimited. *This publication supersedes ATP 4-02.85/NTRP 4-02.22/AFTTP(I) 3-2.69, dated 19 August 2015. FOREWORD This publication has been prepared under our direction for use by our respective commands and other commands as appropriate. This publication is available at the Army Publishing Directorate site at https://armypubs.army.mil/ and at the Central Army Registry site at https://atiam.train.army.mil/catalog/dashboard. Also available through the United States Marine Corps Doctrine site at https://www.doctrine.usmc.mil/, United States Navy site at https://ndls.nwdc.navy.mil/, and through the United States Air Force Doctrine site at https://doctrine.af.mil/. ATP 4-02.85, C1 MCRP 4-11.1A NTRP 4-02.22 AFTTP(I) 3-2.69 Change 1 Army Techniques Publication No. 4-02.85 Headquarters Marine Corps Reference Publication 4-11.1A Department of the Army Navy Technical Reference Publication 4-02.22 Washington, DC, 16 April 2019 Air Force Tactics, Techniques, and Procedures (Instruction) 3-2.69 Multi-Service Tactics, Techniques, and Procedures for Treatment of Chemical Warfare Agent Casualties and Conventional Military Chemical Injuries 1. This change updates pyridostigmine bromide (PB) use in accordance with Food and Drug Administration (FDA)-approved labeling and updates the Marine Corps number to ATP 4-02.85/MCRP 3-40A.1/NTRP 4-02.22/AFTTP(I) 3-2.69, Multi-Service Tactics, Techniques, and Procedures for Treatment of Chemical Warfare Agent Casualties and Conventional Military Chemical Injuries.
    [Show full text]
  • Composites Based on Conductive Polymer with Carbon Nanotubes in DMMP Gas Sensors – an Overview
    Nr 2 (83–154) LUTY 2021 Tom LXVI POLIMERY Composites based on conductive polymer with carbon nanotubes in DMMP gas sensors – an overview N.M. Nurazzi1) (ORCID ID: 0000-0001-7697-0511), M.M. Harussani1), N.D. Siti Zulaikha1) (0000-0001-6706-7216), A.H. Norhana1) (0000-0001-8077-824X), M. Imran Syakir2) (0000-0002-3805-9919), A. Norli1), *) (0000-0002-8519-3379) DOI: dx.doi.org/10.14314/polimery.2021.2.1 Abstract: A number of recent terrorist attacks make it clear that rapid response, high sensitivity and sta- bility are essential in the development of chemical sensors for the detection of chemical warfare agents. Nerve agent sarin [2-(fluoro-methyl-phosphoryl) oxypropane] is an organophosphate (OP) compound that is recognized as one of the most toxic chemical warfare agents. Considering sarin’s high toxicity, being odorless and colorless, dimethyl methylphosphonate (DMMP) is widely used as its simulant in the laboratory because of its similar chemical structure and much lower toxicity. Thus, this review serves to introduce the development of a variety of fabricated chemical sensors as potential sensing materials for the detection of DMMP in recent years. Furthermore, the research and application of carbon nanotubes in DMMP polymer sensors, their sensitivity and limitation are highlighted. For sorption-based sensors, active materials play crucial roles in improving the integral performances of sensors. The novel active materials providing hydrogen-bonds between the polymers and carbon nanotubes are the main focus in this review. Keywords: carbon nanotubes, DMMP, chemical sensor, conductive polymer. Kompozyty na osnowie polimeru przewodzącego z udziałem nanorurek węglowych w czujnikach gazu DMMP – przegląd literatury Streszczenie: Przeprowadzone w ostatnich latach liczne ataki terrorystyczne jasno wskazują, że w wy- padku czujników do wykrywania chemicznych środków bojowych są niezbędne: ich wysoka czułość, szybka reakcja i stabilność.
    [Show full text]
  • Medical Aspects of Chemical Warfare Abbreviations and Acronyms
    Medical Aspects of Chemical Warfare Abbreviations and Acronyms ABBREVIATIONS AND ACRONYMS A CPRP: chemical personnel reliability program CR: dibenz(b,f)(1,4)oxazepine AA: arachidonic acid CS: o-chlorobenzylidene malononitrile AC: hydrogen cyanide CSA: The Covenant, the Sword, and the Arm of the Lord ACGIH: American Conference of Governmental Industrial Hy- CSEPP: Chemical Stockpile Emergency Preparedness Program gienists CSF: colony-stimulating factor Ach: acetylcholine CSMSPD: chemical surety medical support program director AChE: acetylcholinesterase Ct: concentration (C) of agent vapor or aerosol in air multiplied ADMS: assistant director of medical services by time (t) of exposure AEF: American Expeditionary Forces CWA: chemical warfare agent AEGL: acute exposure guidance level CWC: Chemical Weapons Convention (1993) AML: area medical laboratory CWS: US Army Chemical Warfare Service AMN: atropine methylnitrate AR: Army Regulation ARC: American Red Cross D ARDS: acute respiratory distress syndrome ATCA: 2-aminothiazoline-4-carboxylic acid DA PAM: Department of the Army pamphlet ATNAA: antidote treatment nerve agent autoinjector DA: diphenylchloroarsine ATP: adenosine triphosphate DC: diphenylcyanoarsine aTSP: active topical skin protectant DCE: defense coordinating element A-V: atrial-ventricular DEET: N,N-diethyl-meta-toluamide DEPMEDS: deployable medical system DFP: diisopropyl phosphorofluoridate B DHHS: Department of Health and Human Services DHP: diisopropylfluorophosphate BA: bromoacetone DHS: Department of Homeland Security BAL:
    [Show full text]