Medical Management of Chemical Casualties Handbook
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US Army Medical Research Institute of Chemical Defense (USAMRICD) MEDICAL MANAGEMENT OF CHEMICAL CASUALTIES HANDBOOK Chemical Casualty Care Division (MCMR-UV-ZM) USAMRICD 3100 Ricketts Point Road Aberdeen Proving Ground, MD 21010-5400 THIRD EDITION July 2000 Disclaimer The purpose of this Handbook is to provide concise supplemental reading material for attendees of the Medical Management of Chemical Casualties Course. Every effort has been made to make the information contained in this Handbook consistent with official policy and doctrine. This Handbook, however, is not an official Department of the Army publication, nor is it official doctrine. It should not be construed as such unless it is supported by other documents. ii Table of Contents Introduction ................................................................................................................... 1 Pulmonary Agents....................................................................................................... 10 Cyanide ........................................................................................................................ 19 Table. Cyanide (AC and AK). Effects From Vapor Exposure ............................. 25 Vesicants ..................................................................................................................... 30 Mustard..................................................................................................................... 31 Table. Effects of Mustard Vapor ..................................................................................... 39 Lewisite .................................................................................................................... 46 Phosgene Oxime...................................................................................................... 52 Nerve Agents ............................................................................................................... 56 Table 1. Vapor Toxicity (mg-min/m3)..................................................................... 60 Table II. LD50 on Skin .............................................................................................. 61 Table III. Nerve Agent Effects. Vapor Exposure.................................................. 69 Table IV. Nerve Agent Effects. Liquid on Skin .................................................... 70 Incapacitating Agents................................................................................................. 75 Riot-Control Agents .................................................................................................... 88 Decontamination ......................................................................................................... 95 Casualty Management in a Contaminated Area...................................................... 105 Chemical Defense Equipment.................................................................................. 112 Appendix A. Patient Decontamination ................................................................... 132 Appendix B. Casualty Receiving Area.................................................................... 145 Appendix C. Personnel Decontamination Station................................................. 146 Appendix D. Toxicity Data ....................................................................................... 148 Appendix E. Physicochemical Data........................................................................ 150 Appendix F. Medical Equipment Set....................................................................... 153 Appendix G. Table of Agents, Effects, First-Aid, Detection, and Skin Decontamination ....................................................................................................... 155 Appendix H. Glossary of Terms.............................................................................. 156 Index...........................................................................................................................158 iii INTRODUCTION PURPOSE Chemical warfare is not a popular topic, and most military health care providers do not willingly become familiar with it. This was painfully obvious during Operation Desert Shield/Desert Storm when it soon became apparent that many health care providers knew little about the effects of chemical agents or the medical defense against them. This ignorance was particularly striking in view of the seven-decade long history of modern chemical warfare and the well-publicized use of mustard and nerve agent during the Iran-Iraq War in the 1980s. The prevailing attitude of military health care providers was that chemical agents would be used only on Hmong, Afghans, Kurds, or similarly unprepared and unprotected groups of people. Further, many health care providers believed if chemical weapons were used the outcome would be disastrous, defense would be impossible, and the casualty rate and loss of life would be high. Through education, however, medical professionals involved in Operation Desert Shield/Desert Storm learned that medical defenses were possible and effective, that chemical casualties could be saved and returned to duty, and that mortality could be minimized. Further, they realized that they might be the targets of chemical agents. More importantly, they rapidly learned that General Pershing's warning (written shortly after World War I) about chemical agents was still true: "...the effect is so deadly to the unprepared that we can never afford to neglect the question." The purpose of this handbook is to provide medical personnel in the field a concise, pocket-sized reference source for the medical management of chemical casualties. It is not intended to be a definitive text on the management of chemical casualties. HISTORY OF CHEMICAL WARFARE AND CURRENT THREAT The use of chemical weapons dates from at least 423 B.C. when allies of Sparta in the Peloponnesian War took an Athenian-held fort by directing smoke from lighted coals, sulfur, and pitch through a hollowed-out beam into the fort. Other conflicts during the succeeding centuries saw the use of smoke and flame, and the Greeks, during the seventh century A.D., invented Greek fire, a combination probably of rosin, sulfur, pitch, naphtha, lime, and saltpeter. This floated on water and was particularly effective in naval operations. During the fifteenth and sixteenth centuries, Venice employed 1 unspecified poisons in hollow explosive mortar shells and sent poison chests to its enemy to poison wells, crops, and animals. The birth of modern inorganic chemistry during the late eighteenth and early nineteenth centuries and the flowering of organic chemistry in Germany during the late nineteenth and early twentieth centuries generated both a renewed interest in chemicals as military weapons and also a spirited debate concerning the ethics of chemical warfare. The British admiralty rejected as, "against the rules of warfare," an 1812 request to use burning, sulfur-laden ships as a prelude to marine landings in France. Forty-two years later, the British War Office similarly condemned Sir Lyon Playfair's proposal to use cyanide-filled shells to break the siege of Sebastopol during the Crimean War, arguing that to use cyanide was "inhumane and as bad as poisoning the enemy's water supply." (Sir Lyon retorted, "There's no sense to this objection. It is considered a legitimate mode of warfare to fill shells with molten metal that scatters upon the enemy and produces the most frightful modes of death. Why a poisonous vapor that would kill men without suffering is to be considered illegitimate is incomprehensible to me. However, no doubt in time chemistry will be used to lessen the sufferings of combatants.") Other nineteenth-century proposals that were never put into practice included the idea of using chlorine-filled shells against the Confederacy during the American Civil War and the suggestion of Napoleon III during the Franco- Prussian War that French bayonets be dipped into cyanide. The Brussels Convention of 1874 attempted to prohibit the use of poisons in war. Delegates to the Hague Conventions in 1899 and 1907 considered the morality of chemical warfare but were unable to draft more than a weak and vaguely worded resolution against the use of chemicals on the battlefield. Against the background of this debate, World War I began. Early in the war, German units used the new, but as yet unreliable invention, the portable flamethrower; and France, where gendarmes had successfully employed riot-control agents for civilian crowd control, used small quantities of these agents in minor skirmishes against the Germans. Riot-control agents, although the first chemicals used on a modern battlefield, proved largely ineffective, and the search for more effective riot-control agents continued throughout the war. It should have been no surprise that the first large-scale use of chemical agents during the war was by heavily industrialized Germany, with its impressive scientific base of theoretical and applied chemistry and its capacity for mass production of chemicals. German units released an estimated 150 tons of chlorine gas from some 6000 cylinders near Ypres, Belgium, during the afternoon of 15 April 1915. Although this attack caused probably no more than 800 deaths, it was psychologically devastating to the 15,000 Allied troops, who promptly retreated. The Germans, however, were unprepared to take advantage of this victory, and chlorine and its