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Home , Binary chemical weapon, Bromoacetone, Bromobenzyl cyanide, Chlorine, Cyanogen bromide, Diphenylcyanoarsine

Medical Aspects of Abbreviations and Acronyms

AbBreviations a n d Acronyms

A CPRP: chemical personnel reliability program CR: dibenz(b,f)(1,4)oxazepine AA: arachidonic CS: o-chlorobenzylidene malononitrile AC: 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: CSMSPD: chemical surety medical support program director AChE: Ct: (C) of agent vapor or 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: 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 autoinjector DA: diphenylchloroarsine ATP: adenosine triphosphate DC: aTSP: active topical 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: DHS: Department of Homeland Security BAL: British anti- (dimercaprol) DM: diphenylaminoarsine BALF: bronchoalveolar lavage fluid 4-DMAP: 4-dimethylaminophenol BAS: battalion aid station DMS: director of medical services BBC: DNA: deoxyribonucleic acid BChE: DoD: Department of Defense BEF: British Expeditionary Forces DOE: Department of Energy BMZ: basement membrane zone DOJ: Department of Justice BTX: batrachotoxin DOT: Department of Transportation BZ: 3-quinuclidinyl benzilate DVA: Department of Veterans Affairs

C E CA: bromobenzyl cyanide ECG: electrocardiogram CaE: carboxylesterase EDTA: ethylenediaminetetraacetate CAI: chemical accident or incident EEG: electroencephalogram CAIRA: chemical accident or incident response and assistance EKG: electrocardiogram cAMP: adenosine 3’,5’-cyclic monophosphate EMEDS: expeditionary medical support CANA: convulsive antidote, nerve agent EMS: emergency medical service CAS: Chemical Abstracts Service EMT: emergency medical technician CB: chemical-biological EOC: emergency operations center CBIRF: Chemical/Biological Incident Response Force EPA: Environmental Protection Agency CBR: chemical, biological, and radiological Eq: equine CBRN: chemical, biological radiological, and nuclear ER: endoplasmic reticulum CBRNE: chemical, biological, radiological, nuclear, explosive Er: YAG: erbium: yttrium--garnet CBRRT: chemical biological rapid response team ESF: emergency support function CDC: Centers for Disease Control and Prevention CEA: cultured epidermal autograft cGMP: current Good Manufacturing Practice F CHASE (Operation): Cut Holes and Sink ‘Em ChE: FBI: Federal Bureau of Investigation CK: FBS: fetal bovine serum CN- : cyanide anion FCC: federal coordinating center CN: chloroacetophenone FDA: Food and Drug Administration CNO- : FEMA: Federal Emergency Management Agency CNS: central nervous system FHP: force health protection COLPRO: collective protection FOC: full operational capability CP EMEDS: collectively protected expeditionary medical support FRC: forward resuscitation care

xxiii Medical Aspects of Chemical Warfare Abbreviations and Acronyms

G L

GA: LCt50: the vapor or aerosol exposure that is lethal to 50% of the GABA(A): gamma-aminobutyric A exposed population GB: LD50: median lethal dose GD: LDPI: laser Doppler perfusion imaging GF: LHON: Leber hereditary optic neuropathy GK-11: LPS: lipopolysaccharide GM1: monosialotetrahexosylganglioside LSD: lysergic acid diethylamide GSA: General Services Administration GSH: M H MAC: multiagency coordination MANAA: medical aerosolized nerve agent antidote H: MCE: maximum credible event H2O2: MDMA: 3, 4-methylene-dioxymethylamphetamine H2S: hydrogen MEDCOM: medical command HAZMAT: hazardous materials MEDEVAC: medical evacuation HAZWOPER: hazardous waste operations and emergency MITS: medical identification and treatment systems response MO: medical officer HC: hexachloroethane MOPP: mission-oriented protective posture HCN: MPE: most probable event HD: mustard (distilled) MRI: magnetic resonance imaging HE: high explosives MRT: mean residence time HHS: Department of Health and Human Services MRT: medical response team HN2: mustard MS C LRIP: milestone C low rate initial production HSS: health service support MT: metric ton Hu PON1: human paraoxonase 1 MTF: medical treatment facility HWA: Heereswaffenamt MULO: multipurpose overboot

I N

ICAM: improved chemical agent monitor N2O: nitrogen ICG: indocyanine green N2O4: nitrogen tetroxide ICS: incident command system NAAG: N-acetyl-aspartyl-glutamate IDLH: immediately dangerous to life or health NaCN: cyanide IgG: immunogammaglobulin NAD+ : nicotinamide adenine dinucleotide IL: interleukin NaNO2: sodium nitrite IM: intramuscular NATO: North Atlantic Treaty Organization IMA: installation medical authority NBC: nuclear, biological, chemical IND: investigational new drug NCO: noncommissioned officer IOC: initial operational capability NCS: National Communications System IOT&E: initial operational test and evaluation NDA: new drug application IP: intraperitoneal injection NDMS: National Disaster Medical System IPE: individual protective ensemble/equipment NF: number facility IV: intravenous NIMS: National Incident Management System NIOSH: National Institute for Occupational Safety and Health NMDA: N-methyl d-aspartate J NO: NO : JFO: joint field office 2 NORTHCOM: Northern Command JPEO: joint program executive office NRP: National Response Plan JPEO-CBD: Joint Program Executive Office for Chemical Biologi- NSAID: nonsteroidal antiinflammatory drug cal Defense NSP: neurotoxic shellfish poisoning JPMO: joint product management office JSGPM: joint service general purpose mask JSLIST: joint service lightweight integrated suit technology O JSMLT: joint service mask leakage tester JSPDS: joint service personnel skin decontamination system OC: capsicum JTF: joint task force OH: hydroxyl OP: organophosphorus OPCW: Organization for the Prohibition of Chemical Weapons K OPIDN: organophosphorus –induced delayed neurotoxicity Ops: operations KCN: cyanide OSHA: Occupational Safety and Health Administration Km: a measure of the strength of binding of a substrate to an

xxiv Medical Aspects of Chemical Warfare Abbreviations and Acronyms

P U PADPRP: poly(adenosine diphosphate-ribose) polymerase UN: United Nations PAF: platelet-aggregating factor USACHPPM: US Army Center for Health Promotion and Preven- 2-PAM Cl: 2- chloride tive Medicine 2-PAM: 2-pralidoxime USAMRICD: US Army Medical Research Institute of Chemical PAPP: p-aminopropiophenone Defense PARP: poly(ADP-ribose) polymerase USAMRIID: US Army Medical Research Institute of Infectious PATS: protection assessment test system Diseases PB: bromide USDA: US Department of Agriculture PBN: -phenyl-N-tert-butylnitrone USJCOM: US Joint Forces Command PBN: N-tert-butyl-alfa-phenylnitrone USMC: US Marine Corps PbTx: brevetoxin PCP: PFIB: perfluoroisobutylene V pHu: plasma-derived human V/Q: ventilation profusion ratio PKC: kinase C VAC: Vacuum-Assisted Closure Therapy PLA : phospholypase A2 2 VR1: vallinoid receptor subtype 1 pMo: plasma-derived mouse 2-PMPA: 2-pentanedioic acid POM: program objective memorandum W PPE: personal protective equipment PR: protective ratio WBGT: wet-bulb globe temperature PS: WMD: weapons of mass destruction PTSD: posttraumatic stress disorder PTX: palytoxin

R RADS: reactive airways dysfunction syndrome RBC-ChE: red blood cell cholinesterase RCA: control agent RD50: dose required to cause a 50% decrease in respiration REM: rapid eye movement RH: relative humidity rHu BChE: recombinant human butyrylcholinesterase RNA: ribonucleic acid RPM: respiratory rate, pulse, and motor function RSDL: Reactive Skin Decontamination Lotion

S SCN- : SE: status epilepticus SERPACWA: skin exposure reduction paste against chemical warfare agents SMART: special medical augmentation response team SNS: strategic national stockpile SRBD: seizure-related brain damage SS: Schutzstaffel START: simple triage and rapid treatment STEL: short-term exposure limit STM: Sacco triage method STX:

T TBSA: total body surface area TEN: toxic epidermal TIC: toxic industrial chemical TIM: toxic industrial material TNF: tumor necrosis factor TRP: transient receptor potential TTX: TWA: time-weighted average

xxv

Medical Aspects of Chemical Warfare Index

Index

A chemical weapons and, 129, 145 compared with Aum Shinrikyo, 129 Aberdeen Biological Chemical Agent Disposal Facility description, 129 mustard agent container drainage, 597 Alexander, Lt. Col. Stewart Abood, Leo disaster and, 105 research, 424 Alkyl methylphosphonic Abramson, Dr. Harold nerve agents and, 694, 695, 696, 698 lysergic acid diethylamide research, 413 Alkyl MPAs. See Alkyl methylphosphonic acids Acetylcholinesterase Alphabet Bomber assays for measuring, 702 chemical attack description, 127 description and mechanism of action, 158, 693 nerve agent effect on, 158, 244, 316, 693–694 incapacitating effects, 420 ACGIH. See American Conference of Governmental Industrial Alternative footwear system Hygienists description, 573 AChE. See Acetylcholinesterase Alzheimer’s disease Acland, K.M. anticholinesterase drug treatment, 158, 704 uses of lasers in dermatological practice, 284 treatment, 228 Acticoat treatment, 704 mustard agent injury dressing, 280 tetrahydroaminacridine treatment, 426 Activated charcoal Ambros, Otto brevetoxin intoxication treatment, 630 sarin research, 47, 156 palytoxin intoxication treatment, 620 views on chemical warfare, 49 saxitoxin treatment, 627 American Academy of Pediatrics tetrodotoxin treatment, 627 forms of terrorism that require immediate attention, 656 Active topical skin protectant resources, 683–684 criteria for, 531–532 American Burn Association development of, 531 criteria for injuries, 278 Acute exposure guidance levels American Conference of Governmental Industrial Hygienists for chemical agents, 143 2-chlorobenzylidene malononitrile exposure guidelines, 447 Acute respiratory distress syndrome American Expeditionary Forces. See also US Army Medical De- dioxide and, 345 partment toxic industrial chemicals and, 354–355 Aisne-Marne Offensive and, 30–31 Adams, Maj. Robert Battle of Belleau and, 28, 29–30 diphenylaminearsine discovery, 464 Battle of Cambrai and, 24–25 AEF. See American Expeditionary Forces Battle of Cantigny and, 27, 29 AEGLs. See Acute exposure guidance levels Battle of Chateau-Thierry and, 28, 29 Afghanistan Battles of Sommervillier and Ansauville and, 25–26 September 11, 2001, terrorist attacks and, 65, 129 Champagne-Marne defensive and, 30 Afghanistan War chemical warfare casualties, 41–42 chemical weapons and, 62 earliest reported description involving chemical warfare on AFS. See Alternative footwear system (exhibit), 22 Age factors first projector attack on (exhibit), 26 butyrylcholinesterase activity, 164 Headquarters, First Army Corps, memorandum on the evacu- erythrocyte cholinesterase, 164 ation of sick and wounded, 1918 (exhibit), 98 Agency for Toxic Substances and Diseases Registry Lys defensive and, 26–27 Hazardous Substance Emergency Events Surveillance System, major defensive campaigns, 1918 (table), 89 540 major offensive campaigns of the AEF, 1918 (table), 101 Meuse-Argonne campaign and, 33, 36 estimation of injuries from, 428 Oise-Aisne offensive and, 32 and, 341 1st Regiment, 22, 37 Aghajanian, George secret field order no. 41, annex no. 7, issued by the Fifth Divi- LSD research, 417 sion, September 9, 1918 (exhibit), 100 Aharoni, A. AEF in offensive and defensive battles involving human paraoxonase 1 research, 251 chemical warfare (table), 23 Airplanes American Heart Association tanks, 120 Pediatric Advanced Life Support Course, 682 used for chemical attacks, 26, 118–119 recommended values for safe cardiovascular function (table), Aisne defensive 542 chemical attacks, 29 Aminophylline Aisne-Marne offensive exposure treatment, 471 chemical attacks, 30–31 inhalation treatment, 354 division field , 95 Amitai, Y. medical personnel as victims, 102 use of atropine in the pediatric population research, 663–664 US participation (figure), 31 AMLs. See Area medical laboratories Al Qaeda

xxvii Medical Aspects of Chemical Warfare Index

clinical presentation, 355–356 Arrhythmias corticosteroid treatment, 353 nerve agent exposure and, 179–180 gaseous ammonia effects at various (table), 355 treatment for, 179, 190 nonmilitary use, 341–342 ventilatory support, 190 signs and symptoms of inhalation, 353 . See Lewisite; AMN. See Atropine methylnitrate Arthur, Vice Admiral Stanley Amyl nitrite chemical warfare comments, 64 cyanide poisoning treatment, 383–384, 394–395, 397, 675–676 AS. See Atropine Anders, M.W. Asahara, Shoko phosgene research, 736 Aum Shinrikyo and, 127 Anesthetics. See also specific agents Ashani, Y. anesthetics, 419–420 plasma-derived human butyrylcholinesterase research, 245 pediatric population and, 665, 667 Ashton, I. Angola dibenz[b,f]-1,4-oxazepine research, 467 use of nerve agents against rebels, 63 “Assay Techniques for Detection of Exposure to Sulfur Mustard, Ansauville, Battle of Cholinesterase Inhibitors, Sarin, Soman, GF, and Cyanide” phosgene and chloropicrin attacks, 25–26 (Technical Bulletin Medical 296), 693 Anthrax Assays of adducts to biomolecules CDC categorization as a category A threat agent, 616 analytical methods, 698–699 Anthrax attacks analytical methods using adducts to biomolecules (table), 700 domestic preparedness and, 761 application to human exposures, 699–701 Strategic National Stockpile and, 765 methods used to confirm human exposures to nerve agent ad- Antibiotics. See also Topical antibiotics ducts to biomolecules (table), 701 exposure treatment, 673 ATCA. See 2-aminothiazoline-4-carboxylic acid mustard agent treatment, 672 Atkisson, Col. E.J. toxic industrial chemical exposure treatment, 363 AEF 1st Gas Regiment leadership, 22 Anticholinergic . See also specific agents Atlanta Olympics bomb scare, 754 ancillary supportive measures for the treatment of ATNAA. See Antidote treatment nerve agent autoinjector (exhibit), 430 AtroPen compound comparisons, 424–425 nerve agent exposure treatment, 182, 663 diagnosis of syndromes caused by, 428 pediatric population and, 663 incapacitating effects, 413, 421, 422–425 Atropine. See also Atropine sulfate; Dry powder inhaler atropine mechanism of action, 422, 425 antidote drug card for pediatric dosing of atropine (figure), safety of, 427 683 summary of BZ and derivatives (exhibit), 429 brevetoxin intoxication treatment, 630 testing on volunteers, 424–425 incapacitating effects, 412, 413, 422, 425, 426 treatment for intoxication, 425–426 pediatric population and, 663–664 Anticonvulsive therapy. See also specific agents saxitoxin treatment, 627 nerve agent exposure and, 189–190 tetrodotoxin treatment, 627 Antidote treatment nerve agent autoinjector Atropine methylnitrate nerve agent exposure treatment, 182–186, 192, 193, 194, 518, soman-induced seizure-related brain damage treatment, 227, 520–521, 651, 663 228 replacement of Mark I kits and, 651, 652 Atropine sulfate adjuncts to, 182 treatment of mustard agent exposure, 282 antidote treatment nerve agent autoinjector, 182–186 Antipsychotic drugs. See also specific agents arrhythmia treatment, 179, 190 incapacitating effects, 420 asymptomatic persons and, 185 side effects, 420 combined with oximes, 183, 188 Anxiety combined with 2-pyridine aldoxime methyl chloride, 183 differential diagnosis of incapacitating agent intoxication, 428 cyclosarin exposure and, 202 Arab-Israeli Six-Day War dosage considerations, 182–186 biological warfare and, 58 eye pain and, 192 nerve agent use, 58 goal of therapy, 184–185 Arab-Israeli Yom Kippur War inhalational exposure to vapor treatment, 185 chemical weapons and, 61 IV delivery of, 180 ARDS. See Acute respiratory distress syndrome Mark I kits, 182–186, 188, 190, 192, 194, 663 Area medical laboratories mechanism of action, 182, 316 domestic preparedness role, 763–764 medical aerosolized nerve agent antidote, 186, 192 endemic diseases section, 764 nerve agent exposure treatment, 175, 182–186, 244, 316 nuclear, biological, and chemical section, 764 organophosphorus compound exposure treatment, 184 occupational and environmental health section, 763–764 pediatric population and, 195 professional officer filler information system, 764 routes of administration, 193–194 structure of, 763 side effects, 182–183 Armed Forces Institute of Pathology topical application of, 190 1-chloroacetophenone research, 463 ventilatory support and, 181, 186, 193 Armed Forces Radiobiology Research Institute aTSP. See Active topical skin protectant CBRNE training program, 768 Atta, Gen. Qassim

xxviii Medical Aspects of Chemical Warfare Index

chlorine gas attack and, 66 Behavioral and psychological changes Aum Shinrikyo categorization of, 176 chemical attacks against judges, 127–128, 695 cyanide poisoning and, 393–394 compared with Al Qaeda, 129 effects of nerve agent exposure, 175–176 sarin attack in the Tokyo subway, 4, 125, 128, 158, 178, 181–182, plasma-derived human butyrylcholinesterase and, 248–249 193, 196–197, 223, 244, 316, 317, 321, 492, 518, 540, 657, Belgian Consensus on SE 695–696, 699, 754 status epilepticus treatment recommendations, 231 Belladonna . See Anticholinergic deliriants introduction, 373 Belleau Wood, Battle of Aviado, D. chemical attacks, 29–30 incapacitating agent research, 442 overview and detailed maps (exhibit), 28 Aviado, D.M. Bellevue Center incapacitating agent research, 442 pediatric nerve agent antidote dosing schedule, 684 Benzodiazepines. See also specific agents B hypothermia and, 548–549 incapacitating effects, 420 Babad, H. LSD intoxication treatment, 417 phosgene research, 345 Berber war Baille, V. description, 42–43 soman-induced brain injury, 224–225 Berthollet, Comte Claude-Louis Baker, Secretary of War Newton D. synthesis of , 116 Chemical Warfare Service and, 43 Beswick, F.W. BAL. See British antilewisite 2-chlorobenzylidene malononitrile research, 450 Balali-Mood, M. Bhopal, India mustard exposure research, 313, 315 accidental release of methyl , 131, 134, 326, 347 BALF. See Bronchoalveolar lavage fluid Biel, John Ballantyne, B. anticholinergic deliriant research, 424 dibenz[b,f]-1,4-oxazepine research, 467, 468 Bigeye bombs hydrogen cyanide research, 354 research on, 123, 125 1-chloroacetophenone research, 460, 461 bin Laden, Osama 2-chlorobenzylidene malononitrile research, 451 formation of Al Qaeda and, 129 Ballough, G.P. September 11, 2001, terrorist attacks and, 65 soman-induced brain injury, 225 Binary chemical weapons . See also specific agents “Bigeye” bomb, 123, 125 description and incapacitating effects of, 418 description, 3, 123 LSD intoxication treatment, 417 development of, 122–124 safety margin, 418 US Congress restrictions on, 124 Barlow, R.J. US Congress review of, 124 uses of lasers in dermatological practice, 284 Bing, Oscar Basic Personal Equipment, 561 LSD research, 417 Baskin, S.I. Bio Shield towelettes cyanide poisoning treatment, 396 incapacitating agents and, 470–471 Bass, Col. Sampson Biobrane Program Manager for Demilitarization of Chemical Materiel mustard agent injury dressing, 280 and, 141 Biological warfare Basson, Dr. Wouter Arab-Israeli Six-Day War and, 58 use of 3-quinuclidinyl benzilate by , 413 “Biotechnology: Impact on Biological Warfare and Biode- Batrachotoxin fense,” 420–421 chemical structure (figure), 632 chemical weapons comparison, 126 laboratory findings, 633 Nixon’s ban on biological warfare agents, 138 lethality of, 633 World War I and, 37 mechanism of action, 632 Biological Weapons Convention monitoring, 633 description, 137–138 physical examination and, 632–633 and, 61–62 blow gun dart use, 632 Bioregulators protection, 633 incapacitating effects, 420–422 sodium channel effects, 617 Bioscavengers sources, 632 advantages of , 245 stability, 633 catalytic type, 250–251 surveillance, 633 categories of, 245 synthesis, 632 free radical scavengers, 232 toxicity, 632 plasma-derived stoichiometric type, 245–249 treatment, 633 Project BioShield, 251 Baud, F.J. recombinant stoichiometric type, 249–250 cyanide poisoning research, 396 “Biotechnology: Impact on Biological Warfare and Biodefense,” Baxter Healthcare Corporation 420–421 plasma-derived human butyrylcholinesterase production, 653 Bis-(2-chloroethyl)sulfide. See Mustard agent BChE. See Butyrylcholinesterase

xxix Medical Aspects of Chemical Warfare Index

Biskup, R.C. use and, 12 dibenz[b,f]-1,4-oxazepine research, 468 Branch Davidian compound, Waco, TX Black, R.M. FBI attack on, 125 blood sample analysis for mustard agent, 723 Brandeis, R. sample analysis for mustard agent, 711, 712, 716, 717 plasma-derived human butyrylcholinesterase research, 249 Black vinyl overboots Brevetoxin description and uses, 573 chemical structure (figure), 629 Blackford, Lt. Col. William W. laboratory findings, 630 chemical weapon use and, 12 mechanism of action, 629 Blair, Prime Minister Tony (Great Britain) monitoring, 630 warning to the UN on Iraq’s weapons of mass destruction physical examination and, 629–630 program, 66 protection, 631 Blister agents. See Vesicants red tide blooms and, 628, 629–630, 631 Blood routes of exposure, 629–630 butyrylcholinesterase, 163–164 signs and symptoms of intoxication, 630 erythrocyte cholinesterase, 164 sodium channel effects, 617 inhibition in, 164–166 stability, 631 nerve agent scavenger activity, 164 surveillance, 631 RBC-ChE monitoring, 161, 163 synthesis, 628–629 relation of cholinesterase activity to vomiting after exposure to toxicity, 629 VX (table), 166 treatment, 630–631 relation of effects of nerve agent exposure to erythrocyte cho- Brisebois, R.J. linesterase activity (table), 166 mustard agent exposure treatment, 279 relation to signs and symptoms of nerve agent exposure, British antilewisite 165–166 lewisite exposure treatment, 291, 293, 523, 667 time course of inhibition, 165 Bronchoalveolar lavage fluid vomiting and, 165–166 inhalational injury from toxic industrial chemicals and, 348 Blood sample analysis Broselow, Dr. James analytical methods, 718–721 Chemical Warfare Involving Kids Response Project and, 681 application to human exposure, 721–726 Broselow-Luten system benefits of, 692 antidote drug card for pediatric dosing of atropine (figure), collection issues, 692 683 cyanide poisoning, 731, 733–734 availability of, 681–682 guidelines for collection, 739 description, 681 lewisite exposure, 728, 731 generic needs of children in a disaster situation and, 681–682 mustard agent exposure and, 718–726 logistical difficulties and, 681–683 published reports (1997-2006) of laboratory analysis of hu- specific needs of children in a chemical disaster and, 682–683 man blood samples following suspected exposure to sulfur steps involved in administering a dose of medication (figure), mustard (table), 727 682 sample considerations, 739 Browder burn severity assessment, 282 sample preparation methods for the gas chromatographic- Brussels Convention mass spectrometric analysis of sulfur mustard adducts to description, 136 blood biomolecules (exhibit), 724–725 BTX. See Batrachotoxin sample preparation procedure for sulfur mustard adducts to BuChE. See Butyrylcholinesterase deoxyribonucleic acid in blood (exhibit), 722 Budesonide Bolimov, Battle of chlorine inhalation treatment, 353 chlorine gas attacks, 17 Bulgaria T-shells used at, 14 accidental release of chloropicrin in Sofia, 443, 455 Bone marrow Bullard, Maj. Gen. Robert mustard agent exposure effects, 288–290, 669, 672 comments on gas attacks, 26 Boomfield, C.A. gas attack order, 22 butyrylcholinesterase research, 245 gas training for troops and, 22 Boots Bullene, Maj. Gen. Egbert alternative footwear system, 573 Korean War comments, 54 black vinyl overboots, 573 Buscher, H. medical problems and, 573 long-term health effects of mustard, 312, 314 risk of falls and, 573 Bush, Pres. George H.W. Borris, D.J. chemical weapons destruction plan, 138 research, 230 Bush, Pres. George W. Botulinum National Incident Management System and, 492 CDC categorization as a category A threat agent, 616 Project BioShield and, 251 Bowers, M.B. US Department of Homeland Security creation and, 755 nerve agent exposure research, 320 warning to the UN on Iraq’s weapons of mass destruction 2-chlorobenzylidene malononitrile research, 452 program, 66 Boyer, A.E. Butyrylcholinesterase. See also Plasma-derived human butyryl- urine sample analysis for mustard agent, 711 cholinesterase Boyton, Capt. E.C. biomolecule assays and, 700–701

xxx Medical Aspects of Chemical Warfare Index

bioscavenger use, 245, 706 saxitoxin effects, 623, 627 description, 158 tetrodotoxin effects, 623, 627 gender differences in activity of, 164 Carfentanil physiological role, 163 description and incapacitating effects, 419 succinylcholine and, 164 Cassava root synthesis of, 163–164 cyanide exposure and, 323, 374, 390, 731 BZ. See 3-quinuclidinyl benzilate Castro, J.A. 1-chloroacetophenone research, 460 C Catalytic bioscavengers chloroperoxidase, 250 CaE. See Carboxylesterase compared with stoichiometric scavengers, 250 CAIs. See Chemical accidents or incidents human paraoxonase 1, 250–251 Calabar bean sources of, 250 use as a nerve agent, 156 CBRNE incidents. See Chemical, biological, radiological, nuclear Calamine lotion or explosive incidents mustard agent exposure treatment, 670 CDC. See Center for Disease Control and Prevention California Center for Disease Control and Prevention. See also National Insti- accidental chloropicrin exposure in Kern, CA, 456, 457 tute for Occupational Safety and Health Calmatives. See Bioregulators classification of bioterrorism agents/diseases (table), 617 Cambrai, Battle of demilitarization of chemical agents and, 142, 143 chemical warfare, 24–25 Enhanced Surveillance Program, 622 trench conditions, 24 Laboratory Response Network and, 765–766 CANA. See Convulsive Antidote, Nerve Agent injector list of toxic chemicals and chemical agents, chemical character- Canada istics, and medical first aid and antidote treatment, 761 Russia’s elimination of chemical weapons and, 145 phosgene inhalation treatment guidelines, 354 Canadian Department of National Defence sample collection, shipping, and storage guidelines, 739–741 Reactive Skin Decontamination Lotion and, 652–653 Strategic National Stockpile and, 765 threat agent categorization, 616–617 description and effects of, 418 Center for Pediatric Emergency Medicine Cantigny, Battle of pediatric nerve agent antidote dosing schedule, 684 chemical attacks, 27, 29 Central Intelligence Agency Capacio, B.R. lysergic acid diethylamide and, 414 blood sample analysis of mustard agent exposure (figure), 725 saxitoxin capsules and, 628 Caplin ammonia inhalation classification, 355 terrorist interest in food and contamination, 672 . See Oleoresin capsicum Central nervous system batrachotoxin effects, 633 characteristics of, 198–199 brain lesions, 178 chemical structure (figure), 198 cyanide poisoning effects, 393–394 compounds included, 158 electroencephalographic effects of nerve agent exposure, mechanism of action, 161, 198 176–177, 321–322 uses of, 158 hypoxia, 178–179, 180, 287 monoxide gas long-term effects of nerve agent exposure, 177–179 Germany’s experimental testing on human subjects in concen- mustard agent effects, 276, 290, 315, 669 tration camps, 105 nerve agent effects, 175–179, 317 Carboxylesterase neuropsychiatric symptoms, 315 bioscavenging use, 246 insecticide effects, 317 Carcinoma palytoxin effects, 621 dibenz[b,f]-1,4-oxazepine exposure and, 468–469 pediatric exposure to toxic agents and, 659 mustard agent exposure and, 312–314, 313–314, 315–316 polyneuropathy, 317 1-chloroacetophenone and, 461 saxitoxin effects, 623, 625–626 palytoxin and, 619 seizures, 178–179 2-chlorobenzylidene malononitrile and, 449 soman effects, 416 Cardiovascular system tetrodotoxin effects, 623, 625–626 American Heart Association recommended values for safe CG. See Phosgene cardiovascular function (table), 542 Chad arrhythmias, 179–180 Libya’s use of chemical weapons against, 63 batrachotoxin effects, 633 Champagne-Marne defensive brevetoxin effects, 630 chemical attacks, 30 change in the electrocardiogram caused by the presence of US participation (figure), 31 cyanide in the tissue (figure), 392 Chapman, A.J. cyanide poisoning effects, 391–393 1-chloroacetophenone research, 462 effects of nerve agent exposure, 179–180 Charles XII, King (Sweden) electrocardiogram from a cyanide-intoxicated individual use of toxic smoke projectiles, 11 (figure), 392 Chateau-Thierry, Battle of heart rate, 180 chemical attacks, 29 incapacitating agent exposure effects, 472 overview and detailed maps (exhibit), 28 palytoxin effects, 619, 620 ChE inhibitors. See Cholinesterase inhibitors paralytic shellfish poisoning effects, 626

xxxi Medical Aspects of Chemical Warfare Index

Chemical, biological, radiological, nuclear or explosive incidents decontamination of, 574 detection and response capabilities of DoD, 761–762 description and composition of, 573 effective information flow and, 754 Chemical Security Analysis Center reach back capabilities of DoD, 763 description and role, 767 training and education issues, 767–770 Chemical Stockpile Emergency Preparedness Program Chemical Accident or Incident Response and Assistance Operations alternative year exercises, 766–767 chemical surety resource, 594 chemical accidents or incidents and, 609 level 1 medical care, 609 chemical depots, 766–767 Medical Management of Chemical and Biological Casualties DoD role, 766 Course, 594–595 federally managed exercises, 766 Toxic Chemical Training Course for Medical Personnel, FEMA role, 766 594–595 Chemical Surety (AR 50-6), 594 Chemical accidents or incidents . See Terrorist attacks Chemical Stockpile Emergency Preparedness Program, 609 “Chemical Warfare in Southeast Asia and Afghanistan” (Haig), 62 coordination required, 607–608 Chemical Warfare Involving Kids Response Project decontamination procedure, 609 description, 681 emergency medical care, 608 “Chemical Warfare Respiratory Protection: Where We Were and information needed, 608–609 Where We Are Going,” 561 levels of medical care, 609 Chemical Warfare Service medical aspects of response to, 607–609 airplane attack testing, 119 medical response teams and, 607 chemical agent and weapon stockpiling, 119 planning , 607 chemical weapon delivery system improvement, 118 Chemical agent detector kits complaints about effectiveness, 83 description and uses, 576–577 creation of, 22, 90, 117, 761 Chemical and biological protected shelters divisions, 22 composition of, 585–586 Gas Service, 22, 89–90 description, 585 Italian-Ethiopian War and, 46 Chemical Biological Medical Systems Joint Project Management low point in funding for, 44 Office monitoring of Japan’s use of chemical weapons in China, 52 responsibilities, 4 name change to , 53 Chemical Corps need for permanent status of, 43–44, 53 air and ground delivery systems for chemical weapons, 120 1920s and, 43–44 research, 418 organophosphorus compound designations, 47 changes of the 1970s, 60–61 plans to use poison gas on Japan, 52–53 Chemical Warfare Service name changed to, 53 staff statistics, 37 incapacitant program, 55–56 standardization of chemical agents, 44 Korean War and, 54 training of troops during World War II, 53 lysergic acid diethylamide testing, 416–417 Chemical weapons. See also Development of chemical weaponry; medical research on human volunteers during the 1950s, 55 specific chemicals; specific conflicts mission, 53–54 agent toxicity determination, 657 1950s changes in, 54–55 capabilities of nations, 131–132 planned changes of the 1970s, 60–61 categories of, 10 sarin production, 55 “chemical threat” definition, 130 3-quinuclidinyl benzilate testing, 414 comparative of chemical warfare agents (table), 135 training and education in CBRNE and, 767 compared with biological weapons, 126 US Army reorganization and, 56–57 delivery systems, 80, 117–118, 119, 120–122, 123, 130, 132–133, Vietnam War and, 57 157 Chemical defense equipment demilitarization of, 609–611 collective protection, 584–587 description, 2, 10 criteria for selection of, 560 desirable outcomes of the use of, 2 decontaminable litters, 588–589 direct injuries from, 10 decontamination equipment, 581–584 effectiveness as weapons, 79 detection and warning systems, 575–579 features of, 133 individual chemical patient resuscitation devices, 587–588 future threats, 4 individual protective equipment, 561–575 general principles of chemical exposure, 657 integrated approach to protection, 560 How to Tell the poem by Maj. Fairfax Downey (exhibit), patient protective wraps, 587 41 principles for optimal outcome, 560 indirect injuries from, 10 , 560 Joint Program Executive Office role, 4 timely detection need, 560 military advantages of, 2 toxic industrial material protection, 580–581 military chemical agents, 133–134 Chemical personnel reliability program modern chemical warfare agents (table), 134 description, 605 nonpersistent agents, 135 medical authority recommendations, 605 persistent agents, 135–136, 244 medical support of, 605, 607 physical properties of chemical agents, 134–136 potentially disqualifying factors, 605 political and legal ramifications of an attack, 692 Chemical protective glove set potential for use in the civilian sector, 692

xxxii Medical Aspects of Chemical Warfare Index

psychological effect of, 2, 19–20 Yemen Civil War and, 57, 58 stockpile management, 3–4 Chloroperoxidase tactical and strategic use of, 132 VX nerve agent and, 250 terrorist threat, 4 Chloropicrin timeline of agents, 2–3 accidental release of, 443, 455 toxin comparison, 616–617 agricultural uses, 443, 455 US stockpile agent destruction (table), 143 characteristics of PS, CN, DM, and CR (table), 458–459 volatility of, 134–135, 168 chemical structure (figure), 456 wind and weather considerations, 80, 117, 131, 135–136 chloropicrin syndrome, 456 Chemical weapons agreements clinical effects, 456–457 Biological Weapons Convention, 137–138 deployment methods, 456 Chemical Weapons Convention, 138–145 development and properties of (exhibit), 20 , 136–137 earliest reported description involving chemical warfare on UN Disarmament Committee, 137 the AEF (exhibit), 22 US-Soviet weapons destruction agreement, 138 introduction of, 20 Chemical Weapons Convention long-term effects, 457 basic tenets, 139 mechanism of action, 455 chemical demilitarization, 141–145, 766 physical characteristics, 456 development of, 138 physiological effects, 456 disarmament provisions, 3 safes and vaults and, 455 fentanyl and, 419 severe medical complications, 457 governmental proliferation threat, 145 synthesis of, 117, 443 implementation issues, 140–141 toxicity of, 443 inspection and verification, 140 US production of, 117 noncompliance issues, 140, 141 World War I use, 25–26, 455 nongovernmental proliferation, 145 Chlorovinylarsonous acid prohibition on the use of in combat, 66, 431, 442 lewisite exposure and, 728 ratification of, 138–139, 157 published analytical approaches for the analysis of CVAA in schedule and category of chemicals and chemical weapons urine (figure), 729 (table), 139 sample preparation methods for gas chromatographic/mass schedule of implementation plan (table), 140 spectrometric analysis of CVAA (exhibit), 730 scheduling issues, 139–140, 157 signing of, 65, 157 LSD intoxication treatment, 417 “toxin” definition, 614 Cholinesterase analysis Chemically protected deployable medical system colorimetric assays in the clinical laboratory, 702, 704 composition of, 584–585 electrometric ChE assay, 704 description, 584 Ellman assay, 702 M28 collective protection equipment, 585 , 704–706 Chen, K.K. laboratory and field assays routinely used by the US Army cyanide poisoning research, 383, 384–385 and their required processing (figure), 703 Children. See Infants and children mass spectrometry, 701–702 China organophosphorus compounds, 701–706 ancient use of toxic smoke, 10, 12, 78 pretreatment therapy for nerve agent poisoning, 704–706 chemical weapon production, 48 Test-Mate kit, 702, 704 incapacitating agent use, 443 Walter Reed Institute of Research Whole Blood Assay, 702, 705 invasion by Japan in 1937, 46 Cholinesterase inhibitors. See also Nerve agents; specific agents Chlorine blood cholinesterases, 161–166 accidental release of, 131, 134 case report: accidental exposure of a man to liquid soman advantages of as a weapon, 126, 342 (exhibit), 162–163, 312 Battle of Loos and, 18–19 cholinesterase in tissue, 158 clinical presentation of exposure to, 672–673 compounds, 158–159 combined with phosgene, 341 development of, 46–47 development of, 14 diagram of neuromuscular conduction (figure), 160 discovery of, 116 mechanism of action, 159–161 general mechanisms of toxic gas exposure (figure), 347 pharmacology of, 158–168 nerve agents compared with, 181 reversible and irreversible types, 156 nonmilitary uses, 342 Cholinesterases pediatric population and, 673 equine serum butyrylcholinesterase, 245 Second Battle of and, 14–18, 21, 80–82 fetal bovine serum AChE, 245 signs and symptoms of exposure, 359 plasma-derived human butyrylcholinesterase, 245–249 treatment for inhalation of, 353, 673 Cholinolytic 3-quinuclidinyl benzilate US production of, 117 perfluoroisobutylene inhalation treatment, 354 “white star” mixture with phosgene, 19–20 Church, Maj. J.R. World War I use, 2, 14–19, 21, 80–82, 83 Chemical Warfare Service leadership, 90 Chloroacetophenone Churchill, Sir Winston nonmilitary uses, 342 plans for gas warfare during World War II, 52 overall effects of, 342 City of New York Bureau of Emergency Medical Services

xxxiii Medical Aspects of Chemical Warfare Index

pediatric nerve agent antidote dosing schedule, 684 incapacitating agent exposure treatment, 471 City of New York Department mustard agent exposure treatment, 282 pediatric nerve agent antidote dosing schedule, 684 phosgene inhalation treatment, 354, 363 Civil War. See US Civil War toxic industrial chemical exposure treatment, 363 CK. See Cyanogen chloride The Covenant, the Sword, and the Arm of the Lord Clark, M.G. chemical attack plan, 127 plasma-derived human butyrylcholinesterase research, 249 CP EMEDS. See Collectively protected expeditionary medical Clean Air Act support destruction of chemical weapons stockpile and, 610 CR. See Dibenz[b,f]-1,4-oxazepine Clermont Creasy, Maj. Gen. William testing, 46, 156 lysergic acid diethylamide research, 414 Clinton, Pres. Bill Crone, H.D. presidential decision directives outlining policy for deterring decontamination research, 529 and responding to terrorism, 754 CS. See O-chlorobenzylidene malononitrile; 2-chlorobenzylidene Clonidine malonitrile incapacitating effects, 421 CSA. See The Covenant, the Sword, and the Arm of the Lord Cluster bombs CSEPP. See Chemical Stockpile Emergency Preparedness Program chemical weapon delivery, 120, 122 Curran, D. CN. See chloroacetophenone; 1-chloroacetophenone anticholinergic deliriant research, 422 EDTA Currie, W.D. cyanide poisoning treatment, 385, 397 phosgene research, 738 Cobalt Cushing, Dr. Harvey cyanide poisoning treatment, 397 account of Royal Army Medical Corps capabilities, Flanders, Cochrane, Capt. Charles Belgium, May 5, 1917 (exhibit), 88 batrachotoxin description, 632–633 chemical attack observations, 101 Cochrane, Rexmond initial impressions of mustard agent, 88–89 Battle of Cantigny and, 27 observations of the , 82 Cohn Fraction IV-4 paste CVAA. See Chlorovinylarsonous acid plasma-derived human butyrylcholinesterase source, 247, 249, CWC. See Chemical Weapons Convention 251 CWS. See Chemical Warfare Service Cole, T.J. Cyanide. See also Cyanogen chloride; Hydrogen cyanide 2-chlorobenzylidene malononitrile research, 450 accidental exposures, 374 Colgrave, H.F. advantages and disadvantages of, 3, 126 dibenz[b,f]-1,4-oxazepine research, 467, 469 analytical methods for determining cyanide in biological Collective protection samples (table), 732–733 categories of, 584 chemical, physical, environmental, and biological properties chemical and biological protected shelters, 585–586 (table), 372 chemically protected deployable medical system, 584–585 conventional wounds contaminated with, 523 collectively protected expeditionary medical support, 585 description, 322, 731 M20 simplified collective protection equipment, 586–587 dietary issues, 323, 372–373, 374, 389 modular general purpose tent system chemical-biological endogenous cyanide concentrations for smokers and non- protective liner system, 587 smokers (table), 381 tactical application, 584 executions and suicides and, 373–374 Collectively protected expeditionary medical support “gas chambers” and, 373–374 description, 585 Germany’s experimental testing on human subjects in concen- Colombian poison dart frogs tration camps, 105 batrachotoxin source, 632 goiter and, 324 COLPRO. See Collective protection historical use, 372–373 ComboPen long-term exposure to, 323–324 2-pyridine aldoxime methyl chloride administration, 187 long-term health effects, 322–324 Cone, D.C. mechanism of action, 343, 397, 731 summary of triage systems, 517 mechanism of toxicity, 673–674, 731 Conner, M.W. military use, 372, 373 hexachloroethane smoke research, 327 and pharmacodynamics, 376 Convulsive Antidote, Nerve Agent injector physiology, 322 diazepam administration, 189–190 quick-kill properties, 373 nerve agent exposure treatment, 651 reference range values, 734 Cooper, G.J. routes of exposure, 322 wound decontamination research, 538–539 sources, 372, 374, 731 Cooper, W.C. terrorist plots using, 4 organophosphate insecticide exposure research, 320 smoke and, 323, 324, 374 Corson, B.B. toxicity, 377 2-chlorobenzylidene malononitrile research, 444 toxicodynamic effects (figure), 384 Corticosteroids. See also specific agents Tylenol poisoned with, 373 ammonia inhalation treatment, 353 uses for, 673 brevetoxin intoxication treatment, 631 volatility of, 373 chlorine exposure treatment, 673 World War I use, 372, 373

xxxiv Medical Aspects of Chemical Warfare Index

Zyklon B development, 15 introduction of, 18 Cyanide poisoning synthesis of, 116 analytical methods, 377, 731–734 US troop training and, 53 analytical methods to identify cyanide and its metabolites in World War I use, 373 biological fluids (table), 378–379 Cyclohexylmethyl phosphonofluoridate. See Cyclosarin antidotal treatment, 383, 518–519, 675–676 Cyclosarin antidotes useful in acute cyanide poisoning (table), 395 aging time, 202 biochemical basis, 374–377 chemical structure (figure), 694 blood sampling issues, 377, 379–381, 382, 387 pathway of sarin, soman, and cyclosarin (figure), cardiac toxicity, 391–393 696 case synopses, 388–389 Iraq’s production of, 202 change in the electrocardiogram caused by the presence of polyneuropathy and, 317 cyanide in the tissue (figure), 392 synthesis of, 157 clinical presentation and management of casualties, 381–386, toxicity and speed of action, 156, 168, 693 518–519, 674, 731 treatment of exposure to, 202 computational models of cardiac tissue, 392–393 volatility of, 168 Cyanokit treatment, 676 decontamination, 386–387 phosgene exposure and, 736 detection of cyanide and cyanide metabolites, 377–381 Cytoxan effect of cyanide on a ventricular cell (figure), 392 similarity of mustard agent to, 313 electrocardiogram from a cyanide-intoxicated individual (figure), 392 D enzyme inhibition, 382–383 DA PAM 40-8. See Occupational Health Guidelines for the Evaluation fire victims and, 390–391, 731 and Control of Occupational Exposure to Nerve Agents GA, GB, GD, fundamentals of cyanide antidote therapy (figure), 385 and VX hemodialysis treatment, 383 DA PAM 40-173. See Occupational Health Guidelines for the Evalu- histopathologic changes in cardiac tissue, 391–392 ation and Control of Occupational Exposure to Mustard Agents H, laboratory findings, 387, 674 HD, and HT lethal dose, 383 DA PAM 50-6. See Chemical Accident or Incident Response and As- long-term effects, 387–389 sistance Operations metabolic routes, 376, 731 DA PAM 385-61. See Toxic Chemical Agent Safety Standards methemoglobin former treatment, 394–396 DAET. See Diisopropyl aminoethanethiol for recognition of cyanide toxicity (exhibit), 675 Dakin solution mortality from, 322, 376, 381, 731 treatment of mustard agent injuries, 280–281, 671 mouth-to-mouth resuscitation and, 675 Dantrolene multistage antidote kit treatment for managing unconscious, combined with diazepam, 228 cyanide-exposed patients (table), 675 dosage considerations, 227 neurological/psychological responses to cyanide and its coun- soman-induced seizure-related brain damage treatment, termeasures, 393–394 227–228 therapy, 385 Dark, Dr. Eric P. patient transport/evacuation, 387 personal account of a chemical attack (exhibit), 102 pediatric considerations, 389–390, 674–676 plot against the US Embassy in Italy, 128 use as an incapacitating agent, 413 polyintoxications, 390–391 Davies, D.R. procedures for collecting and storing blood samples for de- nerve agent research, 317 layed cyanide analysis (exhibit), 382 Davy, Sir Humphry protection of rescuers, 382 synthesis of phosgene, 116 schematic diagram of possible detoxification reaction for cya- Debridement nide in a theoretical cell (figure), 375 enzymes and, 284–285 specific antidotes, 394–397 lasers and, 284 supportive treatment, 323, 383, 674, 675 powered dermabrasion, 284 survivability of, 381–382, 388–389 treatment of mustard agent injuries, 280, 282, 283–285, 290, symptoms of severe ingestions, 323 670–671 therapy principles, 381–386 wound decontamination and, 539 thiocyanate and, 380 Decontaminable litters treatment, 674–676 description and uses, 588–589 triage considerations, 386, 518–519, 521, 522, 523 Decontamination equipment 2-aminothiazoline-4-carboxylic acid and, 376 equipment decontamination, 582–583 US approach to cyanide antidotes (table), 386 joint service personnel skin decontamination system, 582 variation of sodium nitrite and dose with M291 skin decontamination kits, 533, 536, 581 hemoglobin concentration (table), 676 methods in development, 583–584 wound decontamination and, 538 patient thorough decontamination, 543–546 Cyanogen bromide pediatric population and, 661, 678 introduction of, 373 personnel decontamination, 581–582 Cyanogen chloride Decontamination of chemical casualties delayed toxic effect, 373 action of chemical agents on the skin, 529–530 discovery of, 116 air heaters and, 550

xxxv Medical Aspects of Chemical Warfare Index

ambient temperature issues, 548–550 ejection, 132 appropriate uses for military decontaminants (table), 535 bulk release, 132 barrier skin creams, 530–532 chemical rockets, 120, 157 casualty decontamination (figure), 502 cluster bombs, 120, 122, 157 chlorine exposure and, 673 drones, 122 civilian workers and, 528–529 explosive release, 132 cold shock and, 548–549 four modes of chemical agent release (figure), 133 cold weather and, 548–550 generator clusters, 122 common problems with potential decontaminants, 533 improvised explosive devices, 130, 145, 580 Contaminated Casualty Decontamination Course, 763 land mines, 120–121, 157 cyanide poisoning and, 386–387, 675 projectors, 26, 118, 119, 123, 157 decontamination methods based on ambient temperature rocket program, 121–122, 157 (table), 550 spray delivery, 132, 157 decontamination shelters, 544–546, 552 spray tanks, 120 description, 528, 551 toxic , 10–11, 134 desirable traits of a skin decontaminant (exhibit), 534 trench mortars, 26, 118, 119 detection devices, 544 typical German chemical cylinder set up and ready for dis- dry decontaminants, 534, 536 charge (figure), 80 equipment for, 543–546, 581–584 vulnerability of battlefield areas, 132 establishing a patient thorough decontamination area, 546–548 Demilitarization of chemical agents field management of chemical casualties and, 497, 498–500, occupational safety issues, 142 501–504, 505, 506 Russian program, 144–145 glove issues, 539 US program, 141–143, 766 hypothermia and, 548–549, 677 Democratic National Convention of 2004 immediate level, 500, 528 CDC Enhanced Surveillance Program data, 622 incapacitating agents and, 469–471, 520 Deoxyribonucleic acid individual protective ensemble and, 528 mustard agent injury and, 264–265, 312, 315–316, 718–721 methods of decontamination, 532–537 sample preparation procedure for sulfur mustard adducts to military and civilian decontamination procedures, 528–529 deoxyribonucleic acid in blood (exhibit), 722 minimal decontamination procedures based on agent charac- DEPMEDS. See Chemically protected deployable medical system teristics (table), 498 Dermatological effects. See Skin effects mustard agent and, 277, 312, 670 Despretz, Cesar-Mansuete nerve agent exposure and, 180–181 synthesis of mustard agent, 116–117, 260 objectives of, 532 Detection and warning systems oxidation, 537 point detectors, 575–577 packaged wet decontaminants, 536–537 standoff detectors, 577–579 palytoxin and, 620, 621 toxic industrial material detection and identification, 580–581 patents covering work on active topical skin protectant at the Development of chemical weaponry US Army Medical Research Institute of Chemical Defense early chemical warfare agents (table), 116 (table), 532 early history, 116–117 patient operational decontamination level, 500, 528, 529 1920s, 118–119 patient thorough decontamination level, 500, 539–548 1930s, 119–120 pediatric population, 670, 676–678 1940s, 120 placement of teams and areas, 514–516, 547 1950s, 120 purposes of, 528 1960s, 120–122 soap and water (hydrolysis), 533–534, 544, 551 1970s, 122–124 special populations and, 550–551 1980s, 124–125 time after exposure and, 528 World War I, 117–118 triage issues, 513–516, 677 World War II, 120 warming tents, 549 waste water disposal, 546–547 mechanism of action, 229–230 water concerns, 546–547 soman-induced seizure-related brain damage treatment, wound decontamination, 538–539 229–230 zones for, 677 DFP. See Diisopropyl fluorophosphate Decontamination shelters DHS. See US Department of Homeland Security fixed facilities and, 545–546 Diagnostics uses of, 544–545 archived human samples from past exposure incidents and, Defense Medical Readiness Training Institute 692–693 CBRNE training program, 768 biomonitoring, 692 Defense Threat Reduction Agency containers for shipping, 740 Defense Nuclear Weapons School, 769 cyanide poisoning, 731–734 medical mission, 4 documentation for containers, 740 responsibilities, 646 far-forward field settings and, 693 Deliriants. See Anticholinergic deliriants labeling specimens, 740 Delivery systems lewisite exposure, 728–731 agent vaporization (figure), 134 method overview, 692–693 airplane smoke tanks, 120 nerve agents, 693–706

xxxvi Medical Aspects of Chemical Warfare Index

packaging specimens, 740 incapacitating effects, 426 phosgene exposure, 734–738 preparing, shipping, and storing specimens, 740–741 soman-induced seizure-related brain damage treatment, sample considerations, 739–741 227–228 sulfur mustard exposure, 706–728 toxic effect of, 228 3-quinuclidinyl benzilate, 738–739 DM. See Diphenylaminearsine Dianisidine chlorosulphonate DNA. See Deoxyribonucleic acid development and use of, 13–14, 79 DoD. See US Department of Defense Diazepam Domankevitz, Y. anticonvulsive therapy, 189–190, 316 mustard agent injury treatment, 285 arrhythmia treatment, 179 Domestic preparedness brevetoxin intoxication treatment, 630 chemical preparedness programs and initiatives, 766–767 Convulsive Antidote, Nerve Agent injector for, 189–190 Chemical Security Analysis Center, 767 incapacitating effects, 420 Chemical Stockpile Emergency Preparedness Program, pediatric population and, 664 766–767 severe nerve agent exposure and, 193, 194, 223, 244, 316, 520 DoD roles, 758–761 soman-induced seizure-related brain damage treatment, DoD support to civil authorities, 761–764 227–228, 230, 231–232 effective information flow and, 754 Dibenz[b,f]-1,4-oxazepine emerging threats, 754 acute effects, 467 exercises, 766–767, 769–770 characteristics of PS, CN, DM, and CR (table), 458–459 federal emergency response plan (figure), 762 chemical structure (figure), 467 “incident command system” and, 754 clinical effects, 467–469 Laboratory Response Network, 765–766 deployment methods, 467 local responses, 754 initial deployment of, 442 military healthcare role, 754, 764 long-term effects, 468–469 National Bio-Defense Analysis and Countermeasure Center, nonmilitary uses, 342 767 physical characteristics, 467 national civilian preparedness, 1990-2001, 754–755 physiological effects, 467 National Disaster Medical System, 765 severe medical complications, 468–469 national preparedness programs and initiatives, 765–766 Dichlorethylsulphide. See Mustard agent “120 Cities Program,” 755 Dicobalt edetate. See Cobalt EDTA organizational outline for incident management command Diglutathionyl dithiocarbonate. See also Glutathione (figure), 757 chemical structure (figure), 735 overview of the initial federal involvement under the Stafford phosgene exposure and, 735–736 Act (figure), 760 Diisopropyl aminoethanethiol post-September 11, 2001, 755–758 VX nerve agent assays and, 695 state and regional authorities and, 754 Diisopropyl fluorophosphate Strategic National Stockpile, 765 bioscavenger use on, 250 training and education, 767–770 British research on, 48 electroencephalographic effects, 321 Alzheimer’s disease treatment, 158 toxicity of, 48 Dorandeu, F. Diisopropyl phosphorofluoridate. See Sarin ketamine research, 230 blood cholinesterase inhibition and, 164–165 Doughty, John electroencephalographic effects, 176–177 chemical warfare proposals, 11–12 insecticide use, 158–159 Downey, Maj. Fairfax Diller, W.F. How to Tell the Gases poem, 41 phosgene research, 735 DPIA. See Dry powder inhaler atropine Dimercaprol. See British antilewisite Drager-Tubes industrial detectors, 580–581 Diphenylaminearsine Drasch, G. acute effects, 465–466 tissue sample analysis of mustard agent exposure, 726 characteristics of PS, CN, DM, and CR (table), 458–459 urine sample analysis for mustard agent exposure, 710, chemical structure (figure), 464 715–716 clinical effects, 465–466 Drones deployment of, 464 nerve agent delivery, 122 development of, 442, 464 Dry decontaminants incapacitating dose, 465 animal studies, 534, 536 incapacitating effects, 416 description, 534 long-term effects, 466 examples of, 536 mortality from, 465 M291 skin decontamination kits, 533, 536, 581 physical characteristics, 464 water issues, 546 physiological effects, 464 Dry powder inhaler atropine severe medical complications, 466 development of, 652 . See Chloropicrin Dugway Proving Ground, UT Dissociative anesthetics. See also specific agents open-air test of lethal chemical agents, 123 description and incapacitating effects, 419–420 sheep-kill incident, 59 Durham, D.

xxxvii Medical Aspects of Chemical Warfare Index

status epilepticus treatment, 231 tear gas Durham, W.F. World War I and, 12–13 organophosphate insecticide exposure research, 319 tear gas Dynport Vaccine Company World War I and, 13 plasma-derived human butyrylcholinesterase production, 653 Ethyl methylphosphonic acid VS nerve agent assays and, 695 E Ethyl-S-diisopropylaminoethyl methylphosphonothiolate. See VX nerve agent Easton, D.F. Explosive release of chemical weapons. See also specific systems, i.e., mustard agent exposure research, 313 Cluster bombs Ecstasy. See 3,4-methylene-dioxymethylamphetamine description, 132 Eddleston, M. droplet release, 132–133 atropine treatment research, 184 vapor release, 132, 134 Edgewood Arsenal, MD Exposure routes of nerve agents. See also specific agents Chemical Warfare Service and, 44, 117 definitions of Ct, LCt , and LD (exhibit), 168 incapacitating agent research, 414, 422–424, 425–426, 463–464, 50 50 dermal exposure to liquid, 169–170, 185–186, 244 466, 467 effects of dermal exposure to liquid nerve agents (table), 169 mustard agent production, 119 effects of exposure to nerve agent vapor (table), 169 phosgene production, 119 inhalational exposure to vapor, 168–169, 185, 244 post-World War I chemical training and research, 103 Eyes -filling plants, 117 atropine treatment and, 191–192 3-quinuclidinyl benzilate research, 422–424 chloropicrin effects, 457 2-chlorobenzylidene malononitrile research, 450 chronic eye disease, 314 EEG effects. See Electroencephalographic effects corneal damage, 274, 314 Egypt dibenz[b,f]-1,4-oxazepine effects, 468 ancient use of toxic smoke, 10 dilute and, 537 Yemen Civil War and, 57–58, 341 dim vision, 171–172 Yom Kippur War and, 61 diphenylaminearsine effects, 466 Eisenhower, Pres. Dwight D. eye pain, 172 incapacitating agent research and, 414 incapacitating agent effects, 442, 471 Eldad, A. irrigation of, 277, 287 mustard agent injury treatment, 284 lewisite exposure effects, 293 Electroencephalographic effects light reduction, 171–172 nerve agent exposure, 176–177, 321–322 mustard agent exposure effects, 274–275, 278, 290, 312, 667, organophosphate insecticide exposure, 321 670, 672 three-stage changes, 177 mustard agent injury treatment, 287, 288 Electrometric ChE assay nerve agent exposure effects, 170–172 description and development of, 704 oleoresin capsicum effects, 455 ELISA. See Enzyme-linked immunosorbent assay 1-chloroacetophenone effects, 461, 463 Ellman assay palytoxin effects, 619, 621 cholinesterase analysis, 702 phosgene oxime exposure effects, 295 Elsayed, N.M. recovery from injury to, 274, 278 mustard agent research, 265 topical antibiotics for, 287, 288 EMPA. See Ethyl methylphosphonic acid transient vision loss, 287 Employment of Chemical Agents, Field Manual 3-10, 136 2-chlorobenzylidene malononitrile effects, 448, 451–452 Enzyme debridement visual acuity, 172 mustard agent injury treatment, 284–285 Enzyme-linked immunosorbent assay F mustard agent exposure, 718, 721, 723 phosgene exposure, 738 Fabrizi, L. Enzymes. See Bioscavengers phosgene research, 737 EPA. See US Environmental Protection Agency FBI. See Federal Bureau of Investigation Eq BChE. See equine serum butyrylcholinesterase FBS AChE. See Fetal bovine serum AChE Equine serum butyrylcholinesterase FDA. See US Food and Drug Administration bioscavenging use, 245, 246 Federal Bureau of Investigation Equipment decontamination counterterrorism plans, 128 M295 equipment decontamination kits, 582 homeland security role, 755 M17 lightweight decontamination system, 583 oleoresin capsicum research, 443 M100 sorbent decontamination system, 582–583 agent use to attack the Branch Davidian com- Erbium:yttrium-aluminum-garnet laser ablation pound in Waco, TX, 125 mustard agent injury treatment, 284 terrorist plot to release chlorine gas at Disneyland and, 657 Er:YAG. See Erbium:yttrium-aluminum-garnet laser ablation Federal Emergency Management Agency Erythrocyte cholinesterase Chemical Stockpile Emergency Preparedness Program role, gender differences in activity of, 164 766–767 physiological role, 164 counterterrorism plans, 128 relation of effects of nerve agent exposure to erythrocyte cho- formation of, 755 linesterase activity (table), 166 state and regional coordination and, 759 . See Italian-Ethiopian War Federal Response Plan xxxviii Medical Aspects of Chemical Warfare Index

assignment of specific emergency support functions, 755 taxonomy of care capabilities (figure), 490 FEMA. See Federal Emergency Management Agency terrorist attack capabilities, 493–494 Fentanyl triage and treatment area (cold zone), 506 description and incapacitating effects, 419 triage area (warm side), 504–505 summary of BZ and fentanyl derivatives (exhibit), 429 vapor control line, 505 use by Russia in the Chechen hostage situation, 3, 65, 107, 413, warm zone, 499–500, 504–505 419 wet-bulb globe temperature and, 495–496 Fetal bovine serum AChE work-rest cycles and water consumption (without protective bioscavenging use, 245, 246 ensemble) (table), 497 Fidder, A. work-rest cycles for workers, 495–496, 542 blood sample analysis for mustard agent (figure), 723 worker fitness level and, 496–497 lewisite exposure research, 728 zones of contamination, 498–500, 543 organophosphorus compound research, 699 Field Management of Chemical Casualties Handbook urine sample analysis for mustard agent, 711, 713 mustard agent treatment, 670 Field management of chemical casualties. See also Treatment of Filbert, M.G. incapacitating agent exposure; Treatment of mustard agent dexanabinol research, 229 exposure; Treatment of nerve agent exposure; Treatment of toxic Fisher, PFC David Allen industrial chemical exposure exposure to mustard agent during the Persian Gulf War attack measures, 494–495 (exhibit), 107 “buddies” and, 486 Fiske, Maj. Norman E. casualty decontamination (figure), 502 Italian-Ethiopian War observation report, 45 casualty number and agent characteristics and, 496 520th Theater Army Medical Laboratory civilian perspective, 492–493 field-forward assays for chemical agent exposure, 693 cold zone, 500, 506 Florida comparison of military battlefield and civilian casualty care paralytic shellfish poisoning and, 624 and decontamination (table), 501 Flumazenil comparison of taxonomy of care capabilities with levels (ech- incapacitating effects, 420 elons) of care particular to chemical casualty management Fluoxetine (table), 488–489 incapacitating effects, 421 core principles, 486 Foch, Marshal Ferdinand decontamination area, 505 Champagne-Marne defensive and, 30 decontamination equipment, 497 Meuse-Argonne campaign and, 33 decontamination levels, 500 Ford, Pres. Gerald detailed example of the layout of a patient decontamination incapacitating agent use and, 443 site (figure), 504 Foroutan, Syed Abbas early control point and arrival area, 503–504 chemical agent exposure in children and, 656 evacuation corridor, 500 nerve agent and mustard agent treatment research, 184, force health protection description, 486 195–196 hazardous materials (HAZMAT) response teams and, 492–493 patient thorough decontamination research, 540, 547 hazardous waste operations and emergency response training Foulkes, Maj. Gen. Charles H. and, 515 effectiveness of gas as a weapon, 79 HAZMAT incident medical treatment site setup (figure), 503 4-dimethylaminophenol health service support description, 486 cyanide poisoning treatment, 395–396 hot line, 505 4-DMAP. See 4-dimethylaminophenol hot zone, 498–499, 501 France. See also specific battles and battle sites integration of military support into civilian homeland re- Berber war, 42–43 sponse, 493–494 chemical warfare use during World War I, 12–21 key objectives, 495 cyanide use during World War I, 373 land-based forces, 487–491 hydroxocobalamin treatment for cyanide poisoning, 396, 676 local responses, 492–493 incapacitating agent use, 443 medical equipment and supplies needed, 497–498 weaponizing of phosgene, 341 medical management process, 494–506 Franco-Prussian War military management concepts in the civilian setting, 500–502 cyanide use, 373 minimal decontamination procedures based on agent charac- Frandsen, A. teristics (table), 498 dantrolene research, 228 National Incident Management System, 492 Franzblau, A. National Response Plan, 492 2-chlorobenzylidene malononitrile research, 452 national site setup and control zones for a hazardous materials Free radical scavengers site (figure), 515 neuroprotectant use, 232 patient processing, 502–506 French, M.C. personnel requirements, 495–497 dibenz[b,f]-1,4-oxazepine research, 467 pillars of force health protection (figure), 487 Fricke, postattack, or recovery, measures, 495 cyanide poisoning treatment, 396 preattack measures, 494 Fries, Maj. Gen. Amos A. rapid and effective response capability, 486 chemical training for soldiers and, 104 sea-based forces, 491–492 Chemical Warfare Service and, 43–44 service-specific operations, 487–492 Gas Service command, 22, 89–90

xxxix Medical Aspects of Chemical Warfare Index

mustard agent and, 20 oleoresin capsicum effects, 455 Fujikawa, D.G. palytoxin effects, 619 ketamine research, 230 2-chlorobenzylidene malononitrile effects, 452 Fuller, Maj. Gen. J.F.C. Gay-Lussac, Joseph Louis Italian-Ethiopian War observation report, 46 cyanide research, 373 GB. See Sarin G GC. See Gas chromatography GD. See Soman G8 Global Partnership against Proliferation of Weapons and Ma- Gender factors terials of Mass Destruction butyrylcholinesterase activity, 164 Russia’s elimination of chemical weapons and, 144 erythrocyte cholinesterase, 164 G-series nerve agents. See also specific agents Geneva Protocol categorization of (exhibit), 47 chemical weapons provisions, 57, 61, 136–137, 341, 413 World War II use of, 3 development of, 136–137 GA. See Tabun United States ratification of, 60, 137 Gacyclidine weakness of, 137 soman-induced seizure-related brain damage treatment, 230 Genovese, R.F. Galanthamine equine serum butyrylcholinesterase research, 249 Alzheimer’s disease treatment, 158 Germany. See also specific battles and battle sites Gangliosides airplane gas attacks during World War I (exhibit), 26 mechanism of action, 227 chemical warfare use during World War I, 12–21, 79–82, 341, soman-induced seizure-related brain damage treatment, 227 413 Gas chromatography chlorine gas attacks, 12, 14–18 blood sample analysis for mustard agent exposure, 721, 723, experimental testing of chemical and biological warfare agents 725, 726 in concentration camps, 105, 157 combined with liquid chromatography for mustard agent as- failure to use chemical weapons in World War II, 48–50, 157, says, 711, 713 262, 413 lewisite exposure, 728 mustard agent attacks, 2–3, 15, 18, 20–21, 25–26, 83, 261–262 nerve agent assays and, 695, 699 nerve agent production, 48, 156 sample preparation methods for the gas chromatographic- nerve agent use in World War II and, 3, 413 mass spectrometric analysis of sulfur mustard adducts to phosgene attacks, 19–20 blood biomolecules (exhibit), 724–725 phosgene oxime production, 294 sample preparation time, 693 Russia’s elimination of chemical weapons and, 145 urine sample analysis for mustard agent, 710, 716–717, 718 secret development of nerve agents, 46 USAMRICD research, 693 trichloromethyl chloroformate attacks, 20 use with MS, 692, 693 use in Nazi concentration camps, 15, 51, 105, 373, “Gas fright” syndrome 397, 656 description, 82 Gershon, S. Gas masks. See also Respirators organophosphate insecticide exposure research, 319, 320 activated charcoal use in, 561 GF. See Cyclosarin butyl rubber and, 562, 563 Giesbrecht, G.G. canisters for, 561 hypothermia research, 548 chemical destruction of the agent and, 561 Gilchrist, Col. Harry L. composition of, 562 chemical training for soldiers and, 103 dead space and, 563 Chemical Warfare Service leadership, 90–91, 97 development of, 18 plan of a division in action for chemical warfare training developmental objectives, 563 purposes (figure), 86 early types, 80 “Symptomology, Pathology and General Treatment of Gas effectiveness against chlorine and phosgene, 19 Cases,” 91 effectiveness against mustard agent, 21 GK-11. See Gacyclidine faceblanks for, 563 Glass, Col. Albert “hypo helmets,” 561 incapacitating agent treatment research, 430 joint service general purpose masks, 563 Glaucoma M17 series, 561 treatment, 158 modern design features, 561–562 Gloves nose cups for, 563 chemical protective glove set, 573–574 original design features, 561 decontamination of chemical casualties and, 539 perfluorocarbon rubber and, 562 joint service lightweight integrated suit technology 2 rubber and, 562, 563 glove upgrade, 574 types of devices (figure), 84 Glutathione. See also Diglutathionyl dithiocarbonate use of for children, 657 description, 735 voicemitters, 562 mechanism of lung injury, 352–353 Gastrointestinal tract mustard agent reactions with, 265, 708, 711, 717–718 brevetoxin effects, 630 phosgene exposure and, 735–736, 738 chloropicrin effects, 457 reaction pathway of glutathione (figure), 712 dibenz[b,f]-1,4-oxazepine effects, 468 Glycolates. See Anticholinergic deliriants diphenylaminearsine effects, 466 GM1 monosialoganglioside mustard agent exposure effects, 275–276, 288, 290, 670, 672 xl Medical Aspects of Chemical Warfare Index

soman-induced seizure-related brain damage treatment, 227 HAPSITE Smart Chemical Identification System Goebbels, Paul Joseph description, 544 views on chemical warfare, 49 Harel, M. Gongwer, L.E. human paraoxonase 1 research, 251 2-chlorobenzylidene malononitrile research, 449 Harrigan, A. Goodman, Ephraim Armed Forces Chemical Journal article, 57 incapacitating agent research, 412–413, 425, 427 Hart, B.H. Liddell Graebe, Carl Italian-Ethiopian War observation, 46 1-chloroacetophenone invention, 442 Hassan, Capt. Kifah Ali Graham, J.S. Iraq’s attacks on the and, 126 mustard agent injury treatment, 284, 285, 671 Hay, Alistair wound debridement of chemical casualties research, 539 Russia’s use of an incapacitating agent against Chechens, 413 Graniteville, South Carolina HC smoke. See Hexachloroethane smoke accidental release of chlorine, 131, 145, 548 HCN. See Hydrogen cyanide Grant, Gen. Ulysses S. HD. See Mustard agent chemical weapon use and, 12 Health Service Support in a Nuclear, Chemical and Biological Environ- Gray, P.J. ment (FM 4-07.7), 609 2-chlorobenzylidene malononitrile research, 451–452 Health Service Support in a Theater of Operations, 512 Great Britain. See also specific battles and battle sites Heart rate chemical warfare use during World War I, 12–21 effects of nerve agent exposure, 180 dibenz[b,f]-1,4-oxazepine use in prisons, 467 Heat injuries excerpt from “Take Me Back to Dear Old Blighty!” (exhibit), 89 acclimatization and, 604 nerve agent research, 48 heat stress physiological monitoring for chemical agent work- plans for gas warfare during World War II, 52 ers, 603–604 Royal Army Medical Corps, 85–89 individual protective ensemble and, 528, 541–543, 569 Russia’s elimination of chemical weapons and, 145 moderating strategies, 603 six chlorine-phosgene cloud attacks: British casualties Decem- training and, 603 ber 1915-August 1916 (table), 83 Heat stroke VX nerve agent synthesis, 157 differential diagnosis of incapacitating agent intoxication, 428 Greece Hebb seizure-related brain damage research, 226 ancient use of incapacitating agents, 412 Hefazi, M. ancient use of toxic smoke, 10, 78, 341 mustard exposure research, 313 cyanide use, 373 Heinrich, U. Greek fire and flaming concoctions, 11, 78, 341 2-chlorobenzylidene malononitrile research, 450 “Green cross.” See Chloropicrin Hellreich, A. Grignard, Francois Auguste Victor 2-chlorobenzylidene malononitrile research, 450 chemical weapons developed by, 15 Hematologic effects Growth factors paralytic shellfish poisoning, 626 mustard agent injury treatment, 285–286 Hemodialysis Gruenthal, M. saxitoxin treatment, 627 dantrolene research, 228 tetrodotoxin treatment, 627 GSCOSG. See Diglutathionyl dithiocarbonate Henderson, Dr. Yandell GSH. See Glutathione toxic gas research, 89 Guide for the Selection of Chemical Agent and Toxic Industrial Material Henderson, NV Detection Equipment for Emergency First Responders, 581 accidental release of chlorine, 131 “Gulf War” syndrome Hesse, isolation of physostigmine, 46, 156 description, 64 Heston, W.E. Gutentag, P.J. mustard exposure research, 313 2-chlorobenzylidene malononitrile research, 449, 450 Hexachloroethane smoke Guthrie sulfur mustard synthesis, 260 composition of, 358 toxic effects of exposure, 324, 327, 358–359 H Higginbottom, R. dibenz[b,f]-1,4-oxazepine research, 467, 468 Haber, Fritz Hill, A.R. comments on the importance of chemical warfare, 41 2-chlorobenzylidene malononitrile research, 452 development of chlorine gas as a weapon, 14, 15, 80 Himsworth, H. Second Battle of Ypres and, 14, 15 2-chlorobenzylidene malononitrile research, 452 Zyklon B development, 15, 51 Historical background The Hague chemical attacks involving children, 656–657 court of arbitration, 136 chemical terrorism, 125–130 Haig, Gen. Douglas chemical warfare capabilities, 130–136 Battle of Loos and, 18 chemical weapons agreements, 136–145 Haig, Secretary of State Alexander M., Jr. cyanide use, 372–373 “Chemical Warfare in Southeast Asia and Afghanistan,” 62 development of chemical weaponry, 116–125 Hair sample analysis early military uses of toxins, 10–11, 78–79 mustard agent, 726 incapacitating agents, 412–414, 443 medical management of chemical casualties, 78–109 pediatric population and, 667

xli Medical Aspects of Chemical Warfare Index

nerve agent use, 156–158 properties of, 343–344 1920s, 42–45 Hydrolysis compound assays 1930s, 45–47 analytical methods, 695 1950s, 54–56 analytical methods for assay of nerve agent hydrolysis prod- 1960s, 56–60 ucts (table), 697 1970s, 60–62 application to human exposure, 695–698 1980s, 62–63 hydrolysis pathway of sarin, soman, and cyclosarin (figure), 1990s, 63–65 696 21st century, 65–66 methods used to confirm human exposures to nerve agents via US Civil War, 11–12 assay of hydrolysis products (table), 698 World War I, 12–42 Hydroxocobalamin World War II, 48–54 cyanide poisoning treatment, 385, 390, 393, 396–397, 651, 676 History of the Peloponnesian War (Thucydides), 10, 78 properties, 396–397 Hitler, Adolf side effects, 396 chlorine gas attack and, 17, 49, 157 Hypochlorite Germany’s failure to use chemical weapons in World War II decontamination of chemical casualties and, 537 and, 49, 157, 413 pediatric casualties and, 677 HN-1. See Hypothermia Hoch, Dr. Paul decontamination issues, 548–549, 677 lysergic acid diethylamide research, 413 pediatric population and, 661 Hoffmann, Albert stages and symptoms of (table), 548 lysergic acid diethylamide research, 413 Holland, P. I 1-chloroacetophenone research, 463 Ibuprofen Holmes, J.H. phosgene inhalation treatment, 354 organophosphate insecticide exposure research, 319, 320 ICAMs. See Improved chemical agent monitors ICG. See Indocyanine green fluorescence imaging eye pain and, 192 IEDs. See Improvised explosive devices topical application of, 190 Improved chemical agent detectors “Honest John” rockets false readings and, 576 nerve agent delivery, 122 simplicity of operation, 576 Hospitals Improved chemical agent monitors decontamination shelters, 545–546 cold weather operation of, 550 Hospital Management of CBRNE Incidents Course, 769 description, 544, 576 M22 automatic chemical agent detector and alarm and, 577 effects on decontamination, 531 patient thorough decontamination areas, 529 Improvised explosive devices How to Tell the Gases (Downey), 41 development and use of, 130, 145 HS. See Mustard agent toxic industrial material used in, 580 H S. See 2 Incapacitating agents. See also specific agents Hu, H. anticholinergic deliriants, 422–425 2-chlorobenzylidene malononitrile research, 452 antipsychotic drugs, 420 HU-211. See Dexanabinol armed robots and, 415 Hu PON1. See Human paraoxonase 1 auditory method of incapacitation, 414 Human paraoxonase 1 cannabinoids, 418 mutation designs, 250–251 characteristics of PS, CN, DM, and CR (table), 458–459 Hun stoffe. See Mustard agent chemical methods of incapacitation, 415–425 Hup A. See Huperzine A chloropicrin, 443, 455–457 Huperzine A common features, 442 compared with physostigmine, 704 controversy over using, 431–432 mechanism of action, 705–706 conventional wounds contaminated with, 523 pretreatment with, 704–706 decontamination, 469–471 red blood cell and acetylcholinesterase protection studies us- delivery systems, 122 ing pyridostigmine bromide and huperzine A after ex-vivo diagnosis of syndromes caused by, 428–430 exposure to soman (table), 705 dibenz[b,f]-1,4-oxazepine, 442, 467–469 Hurricane Katrina differential diagnosis for (table), 429 National Response Plan and, 492 diphenylaminearsine, 443, 464–466 Huxley, Aldous dissociative anesthetics, 419–420 “psychedelic” definition and, 416 factors in decisions to employ, 412, 415 Hydrocyanic acid FBI’s use to attack the Branch Davidian compound in Waco, US troop training and, 53 TX, 125 Hydrogen cyanide. See also Cyanide poisoning features of, 133–134 discovery of the properties and composition of, 116 goal of, 412 introduction of, 18 higher integrative or cognitive functions and, 415 nonmilitary uses, 342–343 history and modern development of, 412–414, 443 treatment for inhalation of, 353–354 indole-based psychedelics, 416–418 volatility of, 134, 136 irritants, nausea-producing agents, and toxins, 416 Hydrogen sulfide Kratschmer reflex and, 442 xlii Medical Aspects of Chemical Warfare Index

legal barriers to acceptance as weapons, 431 chemicals; Toxic industrial chemicals; Toxic industrial materials; lethality of, 415 specific chemicals medical care issues, 469–472 Infants and children. See also Medical management of chemical medical management, 430 toxicity in pediatrics methods of incapacitation, 414–425 accidental exposures to mustard agent, 263 microwave effects, 414 cyanide poisoning and, 389–390, 394 mortality from, 442 decontamination issues, 550–551 nerve agents, 416 treatment of nerve agent exposure, 195 neuropeptides and neuromodulators, 420–422 2-chlorobenzylidene malononitrile ingestion and, 452 new developments and future use, 472 Inhalational exposure to nerve agent vapor. See also Pulmonary nonchemical methods of incapacitation, 414–415 system nonlethal land mines, 415 atropine treatment, 185 nonmilitary uses, 342 compared with dermal exposure, 169–170 oleoresin capsicum, 443, 452–455 effects of, 168–169 olfactory devices, 414–415 long-term health effects, 324–327 1-chloroacetophenone, 443, 460–464 severe exposures, 168–169 , 418–419 Inhalational injury from toxic industrial chemicals personal protection, 469 airway compartments (figure), 355 -based psychedelics, 418 arterial blood gases and, 360 physiological responses to, 348, 472–473 biochemical responses, 351–353 department use, 443 bronchoalveolar lavage and, 361 policy perspective on, 431–432, 443 levels and, 361 production of, 59 cell membrane destruction, 350 psychoactivity manifestations, 415 centrally acting agents, 355–356, 359 purpose of, 442, 472 chemicals that act on both the central and peripheral airways, research on, 55–56 359 safety margin variations, 415 chest radiographs and, 360 safety of, 442 clinical presentation and diagnosis, 355–361 safety of glycolates, 427 decreased body weight and, 348 sedative hypnotics, 418 determination of the damaged compartment, 340 , 418 diagnostic tests, 360–361 summary of BZ and fentanyl derivatives (table), 429 “dry land drowning,” 357 tranquilizers, 420 gaseous ammonia effects at various concentrations (table), 355 treatment, 425–426, 471–472 general mechanisms of toxic gas exposure (figure), 347 triage considerations, 520, 521, 522, 523 general schema for the study of acute and chronic lung injury 2-chlorobenzylidene malononitrile, 416, 443, 444–452 (figure), 352 use of light, 414 glutathione and, 352–353 vesicants, 416 inflammatory pathways, 350–351 India long-term health effects, 354–355, 365 accidental release of in Bhopal, 131, 134, main inflammatory agents involved in acute lung injury, their 326, 347 source and action (table), 351 Individual chemical patient resuscitation devices mechanism of injury, 340, 355, 356–357 composition and uses of, 587–588 mechanism of lung injury and repair (figure), 349 description, 587 mechanisms of lung injury of gaseous respiratory irritants Individual protective ensemble (table), 346 barrier creams and, 531 mechanistic effects, 346–353 cold weather and, 549 medical management, 361–365 heat injuries and, 528, 541–543 pathophysiological effects, 348–350 M20 simplified collective protection equipment and, 586 patient transport and, 365 name and job markings for, 547 peripherally acting agents, 356–360 removal of, 547 physiological responses, 347–348 Individual protective equipment pulmonary capillary wedge pressure and, 361 decontamination personnel requirements, 543–544 pulmonary function tests and, 360–361 protective clothing, 569–574 specific inhaled toxic-gas-induced effects and their treatments, psychological factors in the use of, 575 353–355 respiratory protection, 561–569 ventilation/perfusion scans and, 361 toxic industrial material and, 580 Insecticides. See also Organophosphate insecticides training in the use of, 575 organophosphorus compounds used as, 158–159, 316 vapor penetration of, 543–544 Institute of Medicine Individuals with physical or mental disabilities study on the effects of mustard agent and lewisite exposure, decontamination issues, 551 312–313, 314, 315, 316 Indocyanine green fluorescence imaging Interagency for Research on mustard agent injury assessment, 283 classification of mustard as a human , 315–316 Indole-based psychedelics. See also specific agents Intermediate syndrome experiments using, 3, 56 nerve agents and, 318–319 “psychedelic” definition, 416 organophosphate insecticides and, 318–319 Industrial chemicals. See Inhalational injury from toxic industrial International Classification of Epileptic Seizures

xliii Medical Aspects of Chemical Warfare Index

status epilepticus definition, 223 incapacitating agent use, 443 International Red Cross invasion of China in 1937, 46, 262 Yemen Civil War and, 58 paralytic shellfish poisoning and, 624 IPE. See Individual protective ensemble Japanese puffer fish. See Tetrodotoxin Ipratropium Jobst brevetoxin intoxication treatment, 631 isolation of physostigmine, 46, 156 Iran Johnston Island case history: nerve agent exposure in Nazhmar, Iran (exhibit), demilitarization of chemical agents, 142, 157 662 Joint Combat Developer Iran- role in chemical weapon management, 4 assay techniques for mustard exposure, 692–693, 713, 715, 716, Joint Commission on Accreditation of Healthcare Organizations 721 disaster and medical response to mass casualty events, 492, chemical weapons use, 3, 62–63, 106, 157–158, 195–196, 260, 493–494 312, 314, 373, 656 training and education for domestic preparedness and, 767 mustard agent and, 262–263, 279, 288, 314, 315, 656, 667 Joint Program Executive Office Iraq. See also Iran-Iraq War; Persian Gulf War role in chemical weapon management, 4 accidental exposure of two US soldiers to sarin in Baghdad, Joint Program Executive Office for Chemical Biological Defense 157–158, 168, 195, 197 medical identification and treatment systems joint product case history: exposure in 14 children and teenag- management office, 647–650 ers from , Iraq (exhibit), 667 medical program management, 647 chemical weapon stockpiles, 157, 312 responsibilities, 646–647 clinical cases of mustard exposure from Mofid Medical Center Joint Project Management Office for Decontamination following the Halabja, Iraq, attack on March 17, 1988 (ex- Reactive Skin Decontamination Lotion and, 652–653 hibit), 668–669 Joint Requirements Office for Chemical, Biological, Radiological, clyclosarin synthesis, 157 and Nuclear Defense cyclosarin production, 202 responsibilities, 646, 650 Operation Iraqi Freedom and, 65–66, 130 role in chemical weapon management, 4 stocks of sarin and VX, 202 Joint Science and Technology Office use of chemical weapons against the Kurds, 63, 65, 106, 126 responsibilities, 650 use of 3-quinuclidinyl benzilate during the Persian Gulf War, role in chemical weapon management, 4 413 Joint service general purpose masks Irving, Capt. T.C. composition, 567 report on field sanitation, 84–85 description, 563 Isoproterenol M50 and M51 models, 567–568 phosgene inhalation treatment, 354 sizes, 568 Isosorbide dinitrate TIC filters, 568 palytoxin intoxication treatment, 622 Joint service lightweight integrated suit technology Israel block 2 glove upgrade, 574 Arab-Israeli Six-Day War, 58 description and composition of, 572 deaths from improper use of gas masks, 657 design of, 572–573 midazolam use for status epilepticus and, 664 two versions of, 573 possible use of DM against Palestine, 443 Joint service mask leakage tester Yom Kippur War, 61 description, 564 Italian-Ethiopian War fit and, 563, 564 chemical weapons role, 45–46, 137, 262 key features, 565 Italy Joint service personnel skin decontamination system Centro Chemico Militaire, 43 description and uses, 582, 652 cyanide plot against the US Embassy, 128 Joint services lightweight standoff chemical agent detectors early use of poison projectiles, 11 description and uses, 579 Italian-Ethiopian War, 45–46 Joint Test and Evaluation Executive office mustard agent disaster at Bari, 21, 53, 105, 262 role in chemical weapon management, 4 Russia’s elimination of chemical weapons and, 145 Joint Vaccine Acquisition Program description, 4 J responsibilities, 647 Jones, Jim Jaeger, Private August mass suicide of followers using cyanide, 374 warning of a German gas attack, 80 Josse, D. Jakubowski, E.M. human paraoxonase 1 research, 251 nerve agent research, 699 JPEO. See Joint Program Executive Office skin sample analysis for mustard agent exposure, 726 JPEO-CBD. See Joint Program Executive Office for Chemical urine sample analysis for mustard agent exposure, 716 Biological Defense Jane’s NBC Protection Equipment, 561 JSGPMs. See Joint service general purpose masks Japan JSLIST. See Joint service lightweight integrated suit technology accidental palytoxin poisoning, 620 JSLSCADs. See Joint services lightweight standoff chemical agent Aum Shinrikyo sarin attacks, 4, 125, 127–128, 158, 178, detectors 181–182, 193, 196–197, 223, 244, 316, 317, 321, 492, 518, 540, JSMLT. See Joint service mask leakage tester 657, 695–696, 699, 754 chemical weapon production, 48 xliv Medical Aspects of Chemical Warfare Index

K Kuschner, W.G. hexachloroethane smoke research, 327 Kargin, Col. V.A. Kuwait capture of soman research documents, 51 Iraq’s invasion of, 63–64 Keeler, J.R. interaction of pyridostigmine bromide with other commonly L used battlefield medications, 201–202 Kemp, K.H. Laboratory Response Network 2-chlorobenzylidene malononitrile research, 452 description and role, 765–766 Kennedy, Pres. John F. reference laboratories, 766 incapacitating agent research and, 414 sentinel laboratories, 766 Ketamine Lacrimators. See Incapacitating agents adverse effects, 231 Lam, D.G. combined with diazepam, 230–231, 232 mustard agent injury treatment, 285 description and incapacitating effects, 419–420 Land mines dosage considerations, 230, 231–232 nonlethal types, 415 mechanism of action, 230 used in conjunction with military barrier systems, 135 off-label use as a neuroprotectant, 231 VX nerve agent delivery, 120–121, 157 soman-induced seizure-related brain damage treatment, Lange, Willy 230–232 organophosphorus compound research, 47, 156 Kibler, A.L. Larimer, E. 1-chloroacetophenone research, 462–463 cold-weather protection of decontamination personnel, 549 Kiese, M. Laser Doppler perfusion imaging cyanide poisoning research, 394, 395–396 mustard agent injury assessment, 283 “King of the war gases.” See Mustard agent Lashley Kirwin, W.E. seizure-related brain damage research, 226 1-chloroacetophenone research, 462 LC. See Liquid chromatography Kishi, Y. LDPI. See Laser Doppler perfusion imaging tetrodotoxin synthesis, 623 Kjellstrom, B.T. Conference for the Supervision of the International Trade in mustard agent injury treatment, 284 Arms and Ammunition, 136–137 Klasen, H.J. Leber hereditary optic neuropathy enzyme debridement of mustard agent injuries, 284 cyanide exposure and, 323–324 Kling, A. LeGrand, Walter phosgene research, 736 gas chamber execution, 374 Kluchinsky, T.A., Jr. Lemercier, G. 2-chlorobenzylidene malononitrile research, 447 nerve-agent-induced brain damage research, 223 Koenig, K.L. Leven summary of triage systems, 517 physostigmine isolation, 46 Kolokol-1. See Fentanyl Levin, H.S. Kondritzer, Albert organophosphate insecticide exposure research, 320 3-quinuclidinyl benzilate research, 423 Levine, R.A. Konzo 1-chloroacetophenone research, 463 cyanide exposure and, 323 Lewis, Capt. W. Lee Koplovitz, I. lewisite named for, 117, 292 memantine research, 228 Lewisite Korean War additives for, 135 chemical weapons and, 54, 105 analysis of urine and blood samples, 728 Korte, W.D. antidote for, 291 skin sample analysis for mustard agent, 726 application to human exposure, 728–731 Krar, William biochemical mechanisms of injury, 292, 667 terrorist attack plan, 128–129 biomarkers for, 728 Krueger, clinical effects, 292, 667 organophosphorus compound research, 156 cold weather and, 548 Krutzsch, Walter compared with mustard agent, 261, 291 criticism of the Chemical Weapons Convention, 140–141 description, 728 Kubic, V.L. diagnosis, 293 phosgene research, 736 early production of, 3 Kuhn, Richard Germany’s experimental testing on human subjects in concen- soman discovery and synthesis, 48, 51, 157 tration camps, 105 Kukenthal, Hans Institute of Medicine study on the effects of mustard agent tabun research, 47 and lewisite exposure, 312–313, 314 Kumar, P. Japan’s use of against China, 46 1-chloroacetophenone research, 460–461 laboratory tests, 293 Kurbegovic, Muharem. See Alphabet Bomber “lewisite shock,” 293 Kurds long-term effects, 294 Iraqi use of chemical weapons against, 63, 65, 106, 126, 373, mechanism of action, 136, 728 656–657 military use, 292

xlv Medical Aspects of Chemical Warfare Index

properties of, 292 mustard agent exposure and, 313–314 published analytical approaches for the analysis of CVAA in Lungs. See Pulmonary system urine (figure), 729 Luten, Dr. Robert putative mechanism by which lewisite causes tissue damage Broselow-Luten system and, 681–683 (figure), 292 Chemical Warfare Involving Kids Response Project and, 681 sample preparation methods for gas chromatographic/mass Lys defensive spectrometric analysis of CVAA (exhibit), 730 chemical attacks, 26–27 toxicity, 292 Lysergic acid diethylamide treatment, 293, 667 blood level assays, 417 US production of, 117 Chemical Corps testing of, 416–417 Veterans Administration study on the effects of mustard agent historical background of research on, 413–414 and lewisite exposure, 312–313 mode of action, 417 Ley, Robert physiological effects, 417, 428 views on chemical warfare, 49 research on effects of, 56 LHON. See Leber hereditary optic neuropathy toxicity of, 417 Libya treatment for intoxication by, 417 increase in chemical weapon development, 65 unique features of, 416 use of chemical weapons against Chad, 63 unpredictability of effects, 417–418 Lidocaine saxitoxin treatment, 627 M tetrodotoxin treatment, 627 M22 automatic chemical agent detector and alarm Limitation of Arms Conference description, 544 stockpiling of chemical weapons and, 44 description and uses, 577 Lindsay, C.D. M272 chemical agent water testing kits mustard agent injury treatment, 285 description and detection limits, 577 Liquid chromatography M45 chemical-biological masks blood sample analysis for mustard agent, 723, 725, 726 description, 566 combined with gas chromatography for mustard agent assays, Land Warrior program and, 567 711, 713 voicemitters, 566–567 combined with mass spectrometry for mustard agent assays, M53 chemical-biological protective masks 692, 713, 720–721, 723 audio frequency modifiers, 569 nerve agent assays and, 695 protective hoods, 568–569 phosgene, 737 sizes, 568 urine sample analysis for mustard agent, 716–717, 718, 720–721 US Special Operations Command requirements, 568 “Little John” rockets M8 chemical detector paper nerve agent delivery, 122 description and uses, 544, 575 Livens projectors M9 chemical detector paper description, 118, 119 description and uses, 544, 575–576 Long-term health effects M28 collective protection equipment chloropicrin exposure, 457 description and uses, 585 cyanide poisoning, 387–389 M295 equipment decontamination kits dibenz[b,f]-1,4-oxazepine exposure, 468–469 description and uses, 582 lewisite exposure, 294 M17 lightweight decontamination system mustard agent exposure, 291, 312–316 description and uses, 583 nerve agent exposure, 177–179 M41 protection assessment test system oleoresin capsicum exposure, 455 description, 564 1-chloroacetophenone exposure, 463–464 fit and, 563 retrospective studies and, 313 M21 remote sensing chemical agent alarms toxic industrial chemical exposure, 354–355, 365 description, 578 2-chlorobenzylidene malononitrile exposure, 452 placement of, 579 Loos, Battle of uses of, 579 chlorine gas attacks, 18–19 M20 simplified collective protection equipment Lorazepam description, 586 brevetoxin intoxication treatment, 630 IPE and, 586 LSD intoxication treatment, 417 M291 skin decontamination kits nerve agent exposure treatment, 190, 223 Ambergard resin and, 652–653 Lott, Joseph components, 536, 581 chemical warfare proposal, 12 description, 533, 581 LRN. See Laboratory Response Network introduction of, 536 LSD. See Lysergic acid diethylamide Reactive Skin Decontamination Lotion and, 536, 653 Ludendorff, Gen. Erich SERPACWA and, 652 Lys Defensive and, 26 M100 sorbent decontamination system Lund, description and uses, 582–583 burn severity assessment, 282 M256A1 chemical agent detector kits Lundy, P.M. description and uses, 576–577 VX nerve agent research, 529 detection limits, 577 M42A2 chemical-biological combat vehicle masks xlvi Medical Aspects of Chemical Warfare Index

description and uses, 566 MCU-2/P chemical-biological masks M40A1 chemical-biological field masks description and uses, 566 components, 565–566 MDMA. See 3,4-methylene-dioxymethylamphetamine composition of, 565 Meade, Capt. John sizes, 565–566 Italian-Ethiopian War observation report, 45–46 voicemitters, 565 MEDCOM. See US Army Medical Command MacArthur, Gen. Douglas Medical aerosolized nerve agent antidote comments on US chemical warfare policy, 44–45 description, 651 Madden, J.F. nerve agent exposure treatment, 186, 192, 651–652 1-chloroacetophenone research, 463 purpose of, 651–652 Maddern shelf life issues, 652 cyanide research, 373 Medical chemical defense acquisition programs Mafenide acetate acquisition manufacturing strategy, 649 pediatric population and, 672 acquisition process, 646 treatment of mustard agent injuries, 280, 281, 671–672 business and contracting strategy, 650 challenges, 650–651 blood cholinesterase inhibition and, 165 compound purity and, 651 insecticide use, 158 concept development (pre-milestone A activities), 647–648 MANAA. See Medical aerosolized nerve agent antidote current good manufacturing processes and, 649 Manning, K.P. intellectual property rights and, 649 mustard agent exposure research, 313 joint vaccine acquisition program, 647 March, Chief of Staff Gen. Peyton C. lifecycle management products, 651–652 Chemical Warfare Service and, 43 manufacturing challenges, 651 Mark I kits medical chemical acquisition organizations, 646–647 buddy administration of, 190 medical chemical acquisition processes and concerns, 647–651 components, 651 model for integrating pharmaceutical development, FDA FDA approval for, 651 regulatory, and the Department of Defense acquisition pro- nerve agent exposure treatment, 182–186, 188, 190, 192, 194, cesses (figure), 648 518, 520–521, 523, 651–652 operations and support phase, 649 pediatric population and, 663, 683 production and deployment, 649 treatment of children and, 195 products in advanced development, 652–654 Marrs, T.C. specific concerns, 650–651 dibenz[b,f]-1,4-oxazepine research, 468 status of, 651–654 hexachloroethane smoke research, 327 sustainment programs, 652 2-chlorobenzylidene malononitrile research, 449 system development and demonstration, 649 Martin, L.J. technology development and, 648–649 “-necrosis continuum,” 224 test and evaluation strategy, 649–650 Mass spectrometry transformational medical technologies initiative, 647 basis for, 692 US Food and Drug Administration and, 646, 647, 648–653 blood sample analysis for mustard agent exposure, 721, 725, Medical Defense Against Mustard Gas: Toxic Mechanisms and Pharma- 726 cological Implications, 265 cholinesterase analysis, 701–702 Medical Identification and Treatment Systems combined with liquid chromatography for mustard agent as- description, 4 says, 713, 720–721 Medical identification and treatment systems joint product man- lewisite exposure, 728 agement office mustard agent assays, 708, 716–717, 718, 720–721 acquisition business and contracting strategy and, 650 nerve agent assays and, 695, 699 advanced development of drugs and, 650 phosgene, 737 “animal rule” for drug product approval and, 647, 651 sample preparation methods for the gas chromatographic- coordination with the technology base, 648 mass spectrometric analysis of sulfur mustard adducts to lifecycle management, 649 blood biomolecules (exhibit), 724–725 mission of, 647 sample preparation time, 693 production and deployment plans and, 649 Maxwell, D.M. responsibilities, 647 fetal bovine serum AChE research, 245 streamlining of acquisition, 650 McBride, Capt. Lewis M. technology development and, 648–649 rifling of the Stokes barrel, 118 Medical Management of Chemical Agent Casualties Handbook, 184 McCombie, Hamilton Medical management of chemical casualties. See also Medical diisopropyl fluorophosphate research, 48 management of chemical toxicity in pediatrics McLean, M.J. Medical Management of Chemical and Biological Casualties memantine research, 228 Course, 763, 768 McLeod, C.G., Jr. post-World War I, 103–107 nerve-agent-induced brain damage research, 223 pre-World War I, 78–79 McNamara, B.P. projections for the future, 108 1-chloroacetophenone research, 460 World War I, 79–102 2-chlorobenzylidene malononitrile research, 446–447, 449, 450 Medical management of chemical toxicity in pediatrics McNamara, Secretary of Defense Robert S. Broselow-Luten system: a systematic approach with color and Project 80 and, 56 coding, 681–683

xlvii Medical Aspects of Chemical Warfare Index

case history: mustard gas exposure in 14 children and teenag- pharmacokinetics of, 228 ers from Halabja, Iraq (exhibit), 667 soman-induced seizure-related brain damage treatment, case history: nerve agent exposure in Nazhmar, Iran (exhibit), 228–229 662 Memorandum on Gas Poisoning in Warfare with Notes on its Pathology challenges to, 657–661 and Treatment, 90 Chemical Warfare Involving Kids Response Project, 681 Mendelson, J.A. clinical cases of mustard exposure from Mofid Medical Center treatment of mustard agent injuries, 281 following the Halabja, Iraq, attack on March 17, 1988 (ex- hibit), 668–669 clinical effect research, 56 color coding system, 681–683 Metabolic system decontamination equipment and treatment supplies, 661 cyanide poisoning and, 376 dermatologic vulnerability, 659 pediatric vulnerability to toxic agents and, 660 developing a family emergency plan (exhibit), 680 fume fever effects of specific agents, 661–676 hexachloroethane smoke and, 327, 358 example of a pediatric-specific hospital emergency drug cache Metcalf, D.R. (table), 679 organophosphate insecticide exposure research, 319, 320 family emergency plan, 678, 680 Methemoglobin formers. See also specific agents general principles of chemical exposure, 657 cyanide poisoning treatment, 383–384, 386, 390, 394–396 history of chemical attacks involving children, 656–657 Methotrexate logistical time increase, 681–682 similarity of mustard agent to, 313 management of mild to moderate nerve agent exposures Methyl isocyanate (table), 665 accidental release of in Bhopal, India, 131, 134, 326, 347 management of severe nerve agent exposure (table), 667 Methylprednisolone management of vesicant exposures (table), 671 toxic industrial chemical exposure treatment, 363 managing exposures (table), 674 Meuse-Argonne offensive metabolic vulnerability, 660 army-level gas hospitals, 97 National Center for Disaster Preparedness, 683 chemical attacks, 33, 36 neurobehavioral vulnerability, 660 overview of (figure), 35 neurological vulnerability, 659 Spanish influenza and, 101 organ maturity and, 660 Meyer, Victor pediatric signs of mustard exposure (table), 670 mustard agent research, 117, 260 pediatric vulnerabilities and implications for clinical manage- Michel, H.O. ment (table), 658 electrometric ChE assay research, 704 plasma protein binding and, 659 Midazolam preoperative care of children with nerve agent intoxication, brevetoxin intoxication treatment, 630 665, 667 developmental concerns, 653 preparing for a chemical event, 678–680 FDA approval issues, 653 psychological impact, 678, 680 nerve agent exposure treatment, 190, 223, 664 psychological vulnerability, 660 Military medicine. See also Medical management of chemical resources, 681–684 casualties respiratory vulnerability, 659 chemical accident and incident preparedness, 142–143 steps involved in administering a dose of medication (figure), chemical weapon implications, 145–146 682 preparation for chemical attacks, 132 strategies to help children cope with terrorist events (exhibit), Minami, M. 680 sarin research, 695, 696 traumatic injury vulnerability, 660 Mion, G. uncooperative or nonverbal children, 678 ketamine research, 230 unique vulnerabilities, 656 Mirzayanov, Vladimir volume of distribution and, 659–660 nerve agent development by Russia and, 3 volume status and, 659 Mission-oriented protective posture Medical surveillance for chemical agent workers barrier creams and, 531 diagram (figure), 598 gear for levels 1-4 (figure), 570 factors determining the type and frequency of surveillance, levels of (exhibit), 570–571 599 levels of protection, 569 heat stress physiologic monitoring, 603–604 patient thorough decontamination and, 543 medical surveillance compared with personnel reliability, 599 soap and water decontamination and, 534 periodic medical examinations, 600–601 triage of chemical casualties and, 513, 514 potential exposure evaluations, 602 water issues, 546 preplacement examinations, 599–600, 603–604 Mitochondrial permeability transition inhibitors clearances, 602 neuroprotectant use, 232 screening, 599 MITS JPMO. See Medical identification and treatment systems substance abuse and dependency screening, 602–603 joint product management office termination examinations, 601–602 MK-801. See Dizocilpine Meier, H.L. MMB4 dimethanesulfonate PARP inhibitor treatment, 227 development of, 653 Memantine stability concerns, 653 Alzheimer’s disease treatment, 228 Modular general purpose tent system chemical-biological protec-

xlviii Medical Aspects of Chemical Warfare Index

tive liner system medical management, 83, 135 description and uses, 587 , 265 military use, 262–263 medical aerosolized nerve agent antidote and, 652 mortality rates, 266, 276, 277, 278 MOPP. See Mission-oriented protective posture , 315–316 Morgenstern, P. name derivation, 261–262 long-term health effects of mustard, 312, 314 nerve agents compared with, 181 neuropsychiatric symptoms and, 315 description and incapacitating effects, 418 neutralization of, 533 MS. See Mass spectrometry partial-thickness injury treatment, 283 MSMTESE. See 1-methylsulfinyl-2-[2-(methylthio)ethylsulfonyl] pattern of injury, 3 pediatric population and, 669–670 Multiservice Tactics, and Procedures for NBC Protection (Field pediatric signs of mustard exposure (table), 670 Manual 3-11.4), 569 PFC David Allen Fisher’s exposure to mustard agent during Murray, V. the Persian Gulf War, 106–107 2-chlorobenzylidene malononitrile research, 451–452 properties, 263 Mustard agent. See also Nitrogen mustard published reports (1997-2006) of laboratory analysis of hu- accidental exposures, 263, 717–718, 723, 725 man blood samples following suspected exposure to sulfur additives for, 135 mustard (table), 727 of deoxyribonucleic acid and, 264–265, 312, 718 published reports (1995-2006) of laboratory analysis of human analysis of specimens, 706–708 urine samples for glutathione reaction products following a analytical methods used to verify exposure to sulfur mustard suspected exposure to sulfur mustard (table), 720 in biomedical samples (table), 714–715 published reports (1995-2006) of laboratory analysis of hu- barrier skin creams for, 530, 531 man urine samples for hydrolysis metabolites following biochemical mechanisms of injury, 263–265, 708 suspected exposure to sulfur mustard (table), 719 blister fluid analysis, 726 putative mechanisms by which sulfur mustard causes tissue blood sample analysis, 718–726 damage (figure), 264 carcinogenesis, 290, 312–314, 315–316 rapidity of reaction to, 265, 514, 656 case history: mustard gas exposure in 14 children and teenag- reaction pathway of glutathione (figure), 712 ers from Halabja, Iraq (exhibit), 667 reactions with glutathione, 265 casualties caused by, 20, 261, 262–263, 266, 667 recovery time after exposure to, 262, 278, 519 central nervous system effects, 276, 290, 315 reports published prior to 1995 showing laboratory analysis of chronic eye disease and, 314 human biomedical samples following suspected exposure to chronic pulmonary disease and, 314 sulfur mustard (table), 709 clinical cases of mustard exposure from Mofid Medical Center reproductive toxicity, 315–316 following the Halabja, Iraq, attack on March 17, 1988 (ex- respirator effectiveness, 25–26, 83 hibit), 668–669 sample preparation methods for the gas chromatographic- clinical effects, 266–276, 312, 356, 519, 656, 667, 669 mass spectrometric analysis of sulfur mustard adducts to compared with phosgene oxime and lewisite, 261, 291 blood biomolecules (exhibit), 724–725 Cushing’s impressions, 88–89 sample preparation methods for the gas chromatographic/ day of death after exposure in World War I fatal mustard mass spectrometric/mass spectrometric analysis of the sul- casualties (table), 266 fur mustard urinary β-lyase metabolites (exhibit), 713 decontamination issues, 277, 312 sample preparation procedure for sulfur mustard adducts to description (exhibit), 21 deoxyribonucleic acid in blood (exhibit), 722 development and properties of, 15, 20, 83 scarring of epithelial surfaces and, 315 diagnosis, 276–277, 692–693 skin effects, 267–274 disaster at Bari, 21, 53, 105, 262 skin sample analysis, 726 Edgewood Arsenal, MD, production, 119 soap and water decontamination, 533, 534 gas mask effectiveness and, 21 synthesis of, 116–117, 312 German production statistics, 48 teratogenesis, 315–316 Germany’s experimental testing on human subjects in concen- tissue sample analysis, 726 tration camps, 105 toxicity, 667 hair sample analysis, 726 treatment of exposure to, 277–291, 670–672 hospitalization and, 262, 277, 281, 670 triage issues, 519 hydrolysis of sulfur mustard to produce , followed urine sample analysis, 708–718 by oxidation reactions (figure), 708 US production of, 117 initial clinical effects from mustard exposure (table), 266 US troop training and, 53 Institute of Medicine study on the effects of mustard agent Veterans Administration study on the effects of mustard agent and lewisite exposure, 312–313, 314 and lewisite exposure, 312–313 introduction of, 18, 261 Vietnam War and, 57 Italian-Ethiopian War use, 45–46 volatility of, 135 Japan’s use of against China, 46 weather considerations, 135–136, 263, 266 laboratory findings, 669 World War I use, 2–3, 15, 18, 20–21, 25–26, 27, 260, 261 laboratory tests for, 277 wound decontamination and, 538 long-term health effects, 291, 312–316 Yemen Civil War and, 57, 58 mechanism of action, 136, 312, 656 Mutagenic effects median lethal dose, 519 2-chlorobenzylidene malononitrile, 448

xlix Medical Aspects of Chemical Warfare Index

Myasthenia gravis Project BioShield and, 251 treatment of, 156, 198 National Medical Chemical and Biological Advisory Team description and role, 764 N National Research Council acute exposure guidance levels for chemical agents, 143 N- dibenz[b,f]-1,4-oxazepine and, 467 phosgene inhalation treatment, 354 1-chloroacetophenone and, 463 N-methyl-d-aspartate receptor antagonists 2-chlorobenzylidene malononitrile gene mutation and, 448 dexanabinol, 229–230 National Response Framework dizocilpine, 228 coordination guidelines for DHHS, 761 gacyclidine, 230 description and role, 758 ketamine, 230–232 National Response Plan memantine, 228–229 description, 492, 755–756 Nagao, M. federal department or agency support to state and local gov- sarin research, 699 ernments, 758–759 Nakajima, T. integration of the federal government’s domestic prevention, sarin research, 695, 696 preparedness, response, and recovery plans, 756 Naloxone National Security Strategy of the United States of America, 758 overdose treatment, 418 National Strategy for Homeland Security, 755, 758 Namba, T. National Toxicology Program organophosphate insecticide exposure research, 320 2-chlorobenzylidene malononitrile carcinogenicity and, 449 NAPP. See Nerve agent pyridostigmine pretreatment NATO Handbook on the Medical Aspects of NBC Defensive Operations Nasal effects mustard agent treatment, 670 nerve agent exposure, 172–173 NDMS. See National Disaster Medical System Nasser, Pres. Gamal Abdul (Egypt) Yemen Civil War and, 57–58 description, 158 National Academy of Sciences tetrodotoxin treatment, 628 anticholinergic deliriant research and, 424 Nernst, Walther Hermann causal relationship between lewisite exposure and chronic accomplishments, 15 respiratory disease, 294 dianisidine chlorosulphonate development, 13–14, 15, 79, 80 National Bio-Defense Analysis and Countermeasure Center Nernst Ni-Shrapnel. See Dianisidine chlorosulphonate description and role, 767 Nerve agent pyridostigmine pretreatment National Center for Disaster Preparedness description, 158 Mark I kit recommendations, 663 dosage considerations, 202 Program for Pediatric Preparedness, 683 Nerve agents. See also Incapacitating agents; Neuroprotection National Defence Research Institute of Sweden as a treatment for nerve agent survivors; Organophosphorus hair specimen analysis for mustard agent, 726 compounds; Pyridostigmine bromide; Treatment of nerve agent National Defense Authorization Act exposure; specific agents and types of agents “Defense against Weapons of Mass Destruction,” 128, 754 accessibility of and ease of manufacturing, 244, 251 National Defense Strategy of the United States of America, 758 adducts to biomolecules, 698–701 National Disaster Medical System advantages of as a weapon, 126 description, 765 agents included, 661 National Fire Protection Agency aging half-time of nerve agents (table), 198 levels of protection, 580 analytical methods for assay of nerve agent hydrolysis prod- National Guard ucts (table), 697 domestic preparedness role, 763 Arab-Israeli Six-Day War and, 58 National Incident Management System behavioral effects, 175–179 command and management component, 756 bioscavengers, 232, 244–253 description, 492, 755–756 cardiovascular system effects, 179–180 incident-specific resources, 756 case history: nerve agent exposure in Nazhmar, Iran (exhibit), organizational outline for incident management command 662 and coordinating centers (figure), 759 case report: accidental exposure of a man to liquid soman National Institute for Occupational Safety and Health (exhibit), 162–163 levels of protection, 580 central nervous system effects, 175–179 permissible chlorine exposure level, 359 chemical, physical, and environmental properties (table), 167 phosgene limits, 734 chemical structure (figure), 694 powered-air purifying respirators and, 544 cholinesterase analysis, 701–706 2-chlorobenzylidene malononitrile exposure guidelines, 447, clinical presentation, 662 450 compared with chlorine, phosgene, and mustard agent, 181 Working in Hot Environments, 541 compared with commonly used ChE inhibitors, 166–168 National Institute of Justice compared with insecticides, 316–317 Guide for the Selection of Chemical Agent and Toxic Industrial Ma- conventional wounds contaminated with, 522–523 terial Detection Equipment for Emergency First Responders, 581 definitions of Ct, LCt , and LD (exhibit), 168 National Institute of Standards and Technology 50 50 dermal exposure to liquid, 169–170, 185–186, 244 3-quinuclidinyl benzilate monitoring, 739 description, 204, 316 National Institutes of Health diagnostics, 693–706 carcinogen bioassays on chemical agents, 134 effects of dermal exposure to liquid nerve agents (table), 169 1-chloroacetophenone research, 461 l Medical Aspects of Chemical Warfare Index

effects of exposure to nerve agent vapor (table), 169 ryanodine receptor antagonists, 227–228 effects of nerve agents in humans (table), 170 Neuroprotection as a treatment for nerve agent survivors effects on organs and organ systems, 170–180 free radical scavengers, 232 exposure routes, 168–170 mitochondrial permeability transition inhibitors, 232 eye effects, 170–172 neuropathology and the mechanism of nerve-agent-induced fluoride regeneration and, 699 damage, 223–225 general clinical tests, 694 neuroprotectants, 226–232 general treatment principles, 180–190, 205, 316 “neuroprotection” definitions, 225–226 German production of, 48 neuroprotective hypothermia, 232 Germany’s development of, 46–47 relevance of neuroprotection to nerve agent survivors, 225–226 Germany’s experimental testing on human subjects in concen- Neuroprotective hypothermia tration camps, 105 nerve agent exposure treatment, 232 historical background of the use of, 156–158 Neuropsychiatric symptoms hydrolysis compound assay, 695–698 mustard agent exposure and, 315 inhalational exposure to vapor, 168–169, 185, 244 nerve agent exposure and, 320–321 intermediate syndrome and, 318–319 organophosphate insecticide exposure and, 319–320 laboratory findings, 662 Neurotoxic shellfish poisoning lessons learned from Iran, Japan, and Iraq, 195–197, 223 brevetoxin and, 631 lethality of, 244, 661 treatment, 631 long-term health effects, 316–322 Neuve-Chapelle, Battle of mechanism of action, 156, 159, 204–205, 662 dianisidine chlorosulphonate use, 14 median lethal dose, 244 Newmark, J. methods used to confirm human exposures to nerve agent ad- treatment guidelines for children, 195 ducts to biomolecules (table), 701 Ni-shells. See Dianisidine chlorosulphonate methods used to confirm human exposures to nerve agents via Nicoloau, K. assay of hydrolysis products (table), 698 brevetoxin research, 628 mnemonic for crisis (exhibit), 662 Nicotera, P. molecular models (figure), 166 mustard agent research, 265 muscle necrosis and, 318 Niebauer, M. nasal effects, 172–173 dantrolene research, 228 nerve agent antidote kits and pretreatments, 64 Niemann, neuropsychiatric symptoms and, 320–321 sulfur mustard synthesis, 260 parent compound assay, 694–695 NIMS. See National Incident Management System pediatric population effects, 661–667 1920s pediatric treatment, 195 airplane use for chemical attacks, 26, 118–119 persistent nature of, 244 Berber war with France and Spain, 42–43 pharmacology of, 166–168 Chemical Warfare Service and, 43–44 physical properties, 167–168 improvements in chemical weapon delivery systems, 118 polyneuropathy, 317 new US policy on chemical warfare, 44–45 production during the 1950s, 55 1930s pulmonary system effects, 173–174 Italian-Ethiopian War, 45–46 return to duty considerations, 194–195 Japanese invasion of China, 46 rocket program, 121–122 new chemical agent development, 119 secondary contact and, 244 new chemical weapon development, 119–120 signs and symptoms of mild to severe exposure, 191–194 organophosphorus compound development, 46–47 skeletal muscle effects, 174–175, 188 1940s skin effects, 169–170, 185–186, 244, 529, 661 chemical weapon delivery system improvements, 120 specific treatment by exposure category, 190–194 1950s toxicity of, 661 Chemical Corps changes, 54–55 toxicological studies, 322 chemical weapon delivery system improvements, 120 triage considerations, 518, 520–521, 522–523 incapacitant program, 55–56 use in combination with other weapons, 244 Korean War, 54 volatility of, 134–135, 168 medical research on human volunteers, 55 World War II use, 3, 48 nerve agent production and development, 55 wound decontamination and, 538 Soviet threat, 56 Yemen Civil War and, 57 1960s Neuroleptics. See Antipsychotic drugs Arab-Israeli Six-Day War, 58 Neuropathology of nerve-agent-induced brain damage Army reorganization, 56–57 seizure-related brain damage, 224–225 chemical warfare program changes, 59–60 seizures and status epilepticus, 223–224, 664 chemical weapon delivery system improvements, 120–122 Neuropeptides and neuromodulators. See also specific agents Dugway Proving Ground incident, 59 incapacitating effects, 420–422 incapacitating chemical agent development, 59 Neuroprotectants Operation CHASE, 59, 60 classes of drugs, 226–227 psychedelic agent experiments, 3 gangliosides, 227 public hostility toward chemical weapons, 59 N-methyl-d-aspartate receptor antagonists, 228–232 sarin accident in Okinawa, 59 poly(ADP-ribose) polymerase inhibitors, 227 Vietnam War, 57

li Medical Aspects of Chemical Warfare Index

Yemen Civil War, 57–58 characteristics of (table), 445 1970s chemical structure (figure), 446 binary weapon development, 122–124 chronic toxicology, 449 plans to abolish the Chemical Corps, 60–61 clinical effects, 447–452 restoring the Chemical Corps, 61 deployment of, 444 restrictions on sea dumping of chemical weapons, 60 exposure guidelines, 447 Soviet Union’s use of chemical warfare agents, 61–62 human studies, 449–452 Yom Kippur War, 61 incapacitating effects, 416, 444 1980s inhalation toxicology studies, 448 Afghanistan War, 62 introduction of, 342, 443 chemical training, 63 long-term effects, 452 Haig Report, 62 personal defense spray use, 443 Iran-Iraq War, 62–63 physical characteristics, 444 Soviet-US Memorandum of Understanding, 63 repeat exposures, 448–449 1990s safety of, 472 chemical attacks, 125 severe medical complications, 452 chemical weapon development in Libya, 65 subclinical toxicology studies, 449 Persian Gulf War, 63–65 symptoms of exposure to, 444 Nishioka, N.S. thermal degradation products, 444, 446–447 mustard agent injury treatment, 285 Vietnam War use, 444 Nitrites O-ethyl N,N-dimethyl phosphoramidocyanidate. See Tabun cyanide poisoning treatment, 383–384, 386, 390, 394–395, 397 O-ethyl-S-[2(diisopropylamino)ethyl]. See VX nerve agent Nitrogen OC. See Oleoresin capsicum toxic effects of exposure, 326–327 Occupational health and the chemical surety mission Nitrogen dioxide administrative documentation to support a chemical surety pathophysiological effects, 350 inspection (exhibit), 606–607 Nitrogen mustard. See also Mustard agent advising agencies for the treatment of chemical agent injury biochemical mechanisms of injury, 263–265 (exhibit), 595 description, 119 categorization of workers based on their likelihood of expo- gastrointestinal tract effects, 276 sure to chemical agents (exhibit), 601 potential terrorist use and, 667 chemical agent definition, 594 synthesis of, 260 chemical agent workplace, 596–597 three forms of, 262 Chemical Surety (AR 50-6), 594 use of in , 260–261 chemical surety definition, 594 Nixon, Pres. Richard M. demilitarization of chemical warfare agents, 609–611 ban on biological warfare agents, 138 information sources for chemical surety, 594 destruction of chemical weapons and, 61, 122 inspection of chemical storage containers, 596 United States ratification of the Geneva Protocol and, 60, 137 installation medical authority responsibilities, 594, 599–604, . See Pelargonyl vanillylamide 608 Nonlethal weapons. See Incapacitating agents medical aspects of a chemical accident or incident response Nonsteroidal antiinflammatory drugs and assistance, 607–609 treatment of mustard agent exposure, 282 Medical Management of Chemical and Biological Casualties Noort, D. Course, 594–595, 608 phosgene research, 737 medical response team and, 607–609 sarin research, 696 medical support of the chemical personnel reliability program, North Korea 599, 605–607 chemical weapons capability, 145 medical surveillance for chemical agent workers, 597–604 Notes on Gas as a Weapon in Modern War, 90 personal protective equipment needs, 596–597, 599 Nozaki, H. refresher training programs, 605 patient thorough decontamination research, 540 safe treatment and disposal of chemical agents and weapons, NRF. See National Response Framework 596–597 NRP. See National Response Plan Toxic Chemical Training Course for Medical Personnel, NSAIDs. See Nonsteroidal antiinflammatory drugs 594–595, 608 NSP. See Neurotoxic shellfish poisoning training and education for chemical agent workers, 604–605 Nunn, Sen. Sam understanding patients’ occupational healthcare needs and, chemical warfare comments, 125 595 Nunn-Lugar Cooperative Threat Reduction Program Occupational Health Guidelines for the Evaluation and Control of Oc- Russia’s elimination of chemical weapons and, 144 cupational Exposure to Mustard Agents H, HD, and HT Nunn-Lugar-Domenici Act chemical surety resource, 594 domestic preparedness program provision, 128, 754–755 potential exposure evaluations, 602 RBC-ChE monitoring, 601 O Occupational Health Guidelines for the Evaluation and Control of Oc- cupational Exposure to Nerve Agents GA, GB, GD, and VX O-chlorobenzylidene malononitrile categories of personnel required to have RBC-ChE measured, acute effects, 447–448 601 acute inhalation toxicity of CS in animals (table), 448 chemical surety resource, 594 animal studies of effects, 448–449 potential exposure evaluations, 602 carcinogenicity studies, 449 lii Medical Aspects of Chemical Warfare Index

Occupational Safety and Health Administration volunteer acute exposure studies, 461 disaster and medical response to mass casualty events, 492 “120 Cities Program” fixed decontamination shelter recommendations, 545–546 description and focus of, 755 hazardous waste operations and emergency response training, 1-methylsulfinyl-2-[2-(methylthio)ethylsulfonyl]ethane 515 urine sample analysis for mustard agent and, 711, 716–717 levels of personal protective equipment (exhibit), 542, 580 1,1’-sulfonylbis[2-(methylsulfinyl)ethane] monitoring of decontamination personnel guidelines, 542 urine sample analysis for mustard agent and, 711, 717, 718 OSHA Best Practices for Hospital-Based First Receivers of Victims OPCW. See Organization for the Prohibition of Chemical Weapons from Mass Casualty Incidents Involving the Release of Hazardous Operation CHASE Substances, 493 chemical weapon dumping and, 59, 60 permissible chlorine exposure level, 359 Operation Desert Shield, 64 personal protective equipment guidelines, 515 Operation Desert Storm. See also Persian Gulf War powered-air purifying respirators and, 544 accidental battlefield exposure to chemical agents, 129–130 work-rest cycle recommendations, 495–496 description, 64–65 Ochsner, Gen. Hermann pyridostigmine bromide therapy and, 202–204 nonlethal gas attacks on Soviet troops, 52 Operation Enduring Freedom views on chemical warfare, 49 September 11, 2001, attacks and, 65 Office of the Surgeon General Operation Iraqi Freedom CBRNE programs and, 768 improvised explosive devices and, 130 Oise-Aisne offensive Iraq’s failure to report its chemical warfare research and weap- chemical attacks, 32 ons production and, 65–66 US participation (figure), 33 Operation Shield, 87 Okinawa field training for chemical attacks, 106 accidental release of sarin, 59, 60 OPIDN. See Organophosphorus ester-induced delayed neurotox- Oklahoma City icity bombing of the Murrah Federal Building, 754 Opioids. See also specific agents Okumura, T. cyanide poisoning treatment, 523 Aum Shinrikyo sarin attack on the Tokyo subway, 493 description and incapacitating effects of, 418–419, 421 patient thorough decontamination research, 540 nerve agent exposure treatment, 523 Olajos, E.J. overdose treatment, 418 oleoresin capsicum research, 455 pediatric population and, 667 tear gas research, 342 popularity as illicit drugs, 419 Oleoresin capsicum side effects, 667 acute effects, 454 OPs. See Organophosphorus compounds characteristics of (table), 445 Oral effects chemical structure (figure), 453 2-chlorobenzylidene malononitrile, 448 clinical effects, 454–455 Organization for the Prohibition of Chemical Weapons deployment methods, 453 Chemical Weapons Convention and, 138, 140–141 description, 452–453 Organophosphate insecticides. See also specific agents FBI research on, 443 compared with nerve agents, 316–317 historic use of, 453 electroencephalographic effects, 321 long-term effects, 455 intermediate syndrome and, 318 medical complications, 455 muscle necrosis and, 317–318 medicinal use of, 453 neuropsychiatric symptoms and, 319–320 personal protection use, 443 polyneuropathy, 317 physical characteristics, 453 Organophosphorus compounds. See also Insecticides; Nerve physiological effects, 453, 454 agents; specific agents safety of, 472 anticholinesterase use, 251–252 US Postal Service use, 442 atropine treatment, 184 1-chloroacetophenone brain injury and, 223 animal studies, 460–461 cardiac arrhythmias and, 190 carcinogenicity, 461 categorization of (exhibit), 47 characteristics of PS, CN, DM, and CR (table), 458–459 compounds included, 158 chemical structure (figure), 460 earliest reported incident of toxicity from, 47 deployment methods, 460 German development of, 46–47 description, 457 incapacitating effects, 416 harrassing dose, 461 mechanism of action, 161, 244, 701 human studies, 461–464 original use for, 244 incapacitating effects, 416 pediatric effects, 658, 661 invention of, 442 physostigmine development, 46 long-term effects, 463–464 Test-Mate OP Kit field-forward assay, 693 personal defense spray use, 443 tetraethyl pyrophosphate development, 46–47 physical characteristics, 457, 460 toxicity of, 661–662, 701 physiological effects, 460 Organophosphorus ester-induced delayed neurotoxicity severe medical complications, 464 description, 317 sublethal effects, 461 Orrenius, S. toxicology, 460–461 mustard agent research, 265

liii Medical Aspects of Chemical Warfare Index

OSHA Best Practices for Hospital-Based First Receivers of Victims blood cholinesterase inhibition and, 165 from Mass Casualty Incidents Involving the Release of Hazardous eye effects of exposure to, 170 Substances, 493 insecticide use, 158 Osmond, Humphry muscle necrosis and, 318 “psychedelic” definition and, 416 Convention. See Chemical Weapons Convention OTZ. See 2-oxothiazolidine-4-carboxylic acid PARP inhibitors. See Poly(ADP-ribose) polymerase inhibitors Owens, E.J. Patel, Marilyn Hall dibenz[b,f]-1,4-oxazepine research, 468 gas chamber executions with cyanide and, 374 of nitrogen Patient protective wraps air and, 344–345 description and uses, 587 diagnosis of exposure to, 358 Patient thorough decontamination forms of, 344 benefits of, 540 sources of, 358 civilian sector and, 540–541 toxic effects of, 326–327, 358 decontamination shelters, 544–546, 552 Oximes. See also Mark I kits; specific agents decontamination worker protection, 541–543 administration considerations, 188–189, 702 description, 500, 528 antidote treatment nerve agent autoinjector and, 188, 189 detection devices, 544 combined with atropine, 183, 188, 223 handling patients, 547 cyclosarin exposure and, 202 hospital areas for, 529 description, 186 individual protective equipment, 543–544 differences among agents, 187 medical monitoring, 541 dosage considerations, 187–188 musculoskeletal injury to decontamination workers, 541 mechanism of action, 186–187 need for, 539–540 nerve agent exposure treatment, 186–189, 197–198, 663, 702 night operations and, 547–548 pediatric population and, 663 personnel needs, 540–541 transport equipment, 544 P water concerns, 546–547 work-rest cycles for workers, 542, 543 P-aminopropiophenone worker safety and, 541–543 cyanide poisoning treatment, 394, 396 wound contamination and, 538 Palestine PATS. See M41 protection assessment test system Israel’s possible use of DM against, 443 Pattle, R.E. Palmer, Col. John M. dibenz[b,f]-1,4-oxazepine research, 467 military training program comments, 56 Paulet, G. Palytoxin cyanide poisoning research, 394, 396 accidental exposure, 620 PAVA. See Pelargonyl vanillylamide adverse effects of human palytoxin intoxication (exhibit), 621 PB. See Pyridostigmine bromide bioterrorism threat from, 622 PbTx. See Brevetoxin chemical structure (figure), 618 PCP clinical signs and symptoms of intoxication, 619 description and incapacitating effects, 419 health effects, 619 treatment for intoxication by, 420 laboratory findings, 619–620 Pediatrics. See Infants and children; Medical management of lethality of, 622 chemical toxicity in pediatrics mechanism of action, 617–618 Pelargonyl vanillylamide median lethal dose, 618–619 chemical structure (figure), 453 physical examination results, 619 police department use, 443 primary source, 617 synthesis of, 453 protection against, 622 public health surveillance programs, 622 description and incapacitating effects, 418–419 routes of exposure, 619, 620, 622 Pereira, M.A. sodium channel effects, 617–618 phosgene research, 737 stability of, 622 Perfluoroisobutylene synthesis, 617 nonmilitary uses, 357 toxicity, 618–619, 620 physiological effects, 354 treatment, 620–622 supportive care for exposure to, 358 Papaverine toxic effects of, 324, 326, 345 palytoxin intoxication treatment, 622 toxic fumes from, 357–358 Papirmeister, B. treatment for inhalation of, 354 mustard agent research, 278 Periodic medical examinations for chemical workers PAPP. See P-aminopropiophenone comparing data from preplacement examinations, 600 Paralytic shellfish poisoning frequency and extent of, 600–601 clinical signs and symptoms, 625–626 interval medical history and physical, 601 food sources, 624–625 Pershing, Gen. John J. physical examination and, 626 AEF leadership, 22, 24, 25, 27, 33, 36, 89 red tide blooms and, 622 comments on the importance of chemical warfare, 41 saxitoxin and, 622, 624–625, 625–626 Pershing missiles tetrodotoxin and, 624–625 nerve agent delivery, 122 liv Medical Aspects of Chemical Warfare Index

Persian Gulf War. See also Operation Desert Storm World War I use, 2, 19–20, 25–26, 83, 341 chemical weapons and, 63–65, 106–107 Yemen Civil War and, 57 “Gulf War” syndrome, 64 Phosgene oxime nerve agent antidote kits and pretreatments, 64, 704 biochemical mechanisms of injury, 294 PFC David Allen Fisher’s exposure to mustard agent, 106–107 clinical effects, 295 pyridostigmine bromide therapy and, 202–204 compared with mustard agent and lewisite, 261 use of 3-quinuclidinyl benzilate by Iraq, 413 compared with phosgene, 294 Pert, Candace eye effects of exposure, 295 morphine research, 418 military use, 294 Pesticides. See Organophosphate insecticides patient management, 295 Petras, J.M. properties, 294 nerve-agent-induced brain damage research, 223 pulmonary effects of exposure, 295 PFIB. See Perfluoroisobutylene putative mechanisms by which phosgene oxime causes tissue Pharmacology of cholinesterase inhibitors damage (figure), 294 blood cholinesterases, 161–166 skin effects of exposure, 295 cholinesterase in tissue, 158 pHuBChE. See Plasma-derived human butyrylcholinesterase cholinesterase-inhibiting compounds, 158–159 Physostigmine inhibition of blood cholinesterases, 164–166 adverse effects, 426, 704 mechanism of action, 159–161 chemical structure (figure), 198 nerve agents, 166–168 compared with huperzine A, 704 Phenethylamine-based psychedelics deliriant intoxication treatment, 425–426, 523 description and effects of, 418 description, 158 development and isolation of, 46 LSD intoxication treatment, 417 mechanism of action, 425, 426 Philippe, Henri PCP intoxication treatment, 420 Champagne-Marne Defensive and, 30 3-quinuclidinyl benzilate intoxication treatment, 426 Phosgene Pinacoloxymethyl-fluorophosphonate. See Soman accidental release of, 134 Plasma-derived human butyrylcholinesterase animal studies, 735 administration of, 247 chemical reactivity, 354 advantages for human use, 246–247, 252, 253 combined with chlorine or diphosgene, 341 availability of, 249, 653 compared with phosgene oxime, 294 behavioral safety of, 248–249 cysteine adducts, 736 Cohn Fraction IV-4 paste source, 247, 249, 251 development of, 15, 734 compared with fetal bovine serum AChE, 245 earliest reported description involving chemical warfare on efficacy of, 247–248, 252 the AEF (exhibit), 22 immunological safety of, 248, 252 Edgewood Arsenal, MD, production, 119 pharmacokinetics, 247, 252–253, 702 France’s weaponizing of, 341 prophylactic dose, 247 Germany’s experimental testing on human subjects in concen- protection by human butyrylcholinesterase against nerve tration camps, 105 agent poisoning (table), 252 glutathione and glutathione adducts and, 735–736 purification from human plasma, 247 inflammatory pathways, 350–351 pyridostigmine bromide and, 251 inhalation of, 734–735 recombinant type, 249–250 interleukin-6 levels and, 737–738 safety of, 247, 252–253 latent for symptoms, 324–325 sarin and, 698–699 lethal dose, 735 stability of, 247, 252 long-term health effects of exposure, 324–326, 354 Plasma-derived stoichiometric bioscavengers macromolecule adducts, 737 cholinesterases, 245–247 mechanism of action, 136, 734 compared with catalytic bioscavengers, 250 metabolism and markers for exposure, 735–737 plasma-derived human butyrylcholinesterase, 245–247 nerve agents compared with, 181 Playfair, Lyon nonmilitary uses, 345 cacodyl cyanide shell proposal, 11 odor of, 734, 735 Point detectors pathophysiological effects, 348, 349, 734 chemical agent detector kits, 576–577 pediatric effects of exposure to, 673 improved chemical agent detectors, 576 physiological responses, 348, 354, 734 M22 automatic chemical agent detector and alarm, 577 properties and attributes of (exhibit), 19 M8 chemical agent detection paper, 575 regulatory threshold limit value, 734 M9 chemical agent detection paper, 575–576 replacement of chlorine with, 18 M272 chemical agent water testing kits, 577 small molecule adducts, 736–737 Polhuijs, M. synthesis of, 116 sarin research, 696, 698–699 toxicity of, 734 Poly(ADP-ribose) polymerase inhibitors treatment for inhalation of, 354–355, 363 soman-induced seizure-related brain damage treatment, 227 triage issues, 521, 522 fume fever US production of, 117 perfluoroisobutylene and, 358 , 734 polytetrafluoroethylene and, 345 “white star” mixture with chlorine, 19–20 Polyneuropathy

lv Medical Aspects of Chemical Warfare Index

nerve agents and, 317 PSP. See Paralytic shellfish poisoning organophosphate insecticides and, 317 Psychedelic agents. See Indole-based psychedelics Polytetrafluoroethylene Psychochemicals. See Incapacitating agents formation of toxic gases, 345 Psychological effects pathophysiological effects, 349–350 chemical weapons, 2, 19–20 polymer fume fever and, 345 cyanide poisoning, 393–394 Porcine heterograft pediatric population and, 660 mustard agent injury dressing, 280 PTSD. See Posttraumatic stress disorder Porter, E. PTX. See Palytoxin 2-chlorobenzylidene malononitrile research, 446 Pulmonary system. See also Inhalational exposure to nerve agent Porter, Maj. Gen. William N. vapor; Inhalational injury from toxic industrial chemicals; spe- chemical weapon warnings, 48 cific agents and disorders Posttraumatic stress disorder batrachotoxin effects, 633 comorbidity with other mental illness, 321 brevetoxin effects, 630 nerve agent exposure and, 175, 319, 321 chlorine effects, 673 pediatric population and, 660, 680 chloropicrin effects, 456–457 Powered dermabrasion chronic pulmonary disease, 314 mustard agent injuries and, 284 dibenz[b,f]-1,4-oxazepine effects, 467–468 Powers, Francis Gary diphenylaminearsine effects, 466 saxitoxin capsules and, 628 incapacitating agent effects, 442, 471–472 Pregnant women intubation, 288 cyanide poisoning treatment, 385 lewisite exposure effects, 293, 294 pyridostigmine bromide pretreatment safety, 201 mustard agent exposure and, 275, 287, 288–290, 290–291, 312, sarin exposure and treatment, 196 313–314, 670, 672 Preplacement examinations for chemical workers nerve agent exposure effects, 173–174 baseline data, 600 oleoresin capsicum effects, 454 factors restricting the wearing of protective clothing and, 600 1-chloroacetophenone effects, 461–462 functions of, 600 onset of symptoms, 275 heat stress monitoring and, 603–604 paralytic shellfish poisoning effects, 626 job description and, 599 pediatric exposure to toxic agents and, 659 medical history questionnaire, 600 phosgene exposure effects, 295, 325–326 Pretreatment therapy for nerve agent poisoning pulmonary cancer relationship to mustard agent exposure, huperzine A, 704–706 313–314 pyridostigmine bromide, 158, 197–204, 244, 252, 651, 704 respiratory failure, 174 Professional officer filler information system 2-chlorobenzylidene malononitrile effects, 447–449, 449–450 area medical laboratories’ endemic diseases section and, 764 ventilation considerations, 173 MEDCOM personnel and, 764 Pulsed CO2 laser ablation PROFIS. See Professional officer filler information system mustard agent injury treatment, 284 Program for Pediatric Preparedness Pumiliotoxin goals of, 683 sodium channel effects, 617 Web site, 683 Punte, C.L. Project 80 1-chloroacetophenone research, 461 description, 56 2-chlorobenzylidene malononitrile research, 449, 450, 451 Project 112 Pyridostigmine description, 56 chemical structure (figure), 198 Project BioShield myasthenia gravis treatment, 156, 198 interagency partnership on, 251 nerve agent exposure treatment, 174, 244 Projectors soman exposure and, 179 attacks on the AEF (exhibit), 26 Pyridostigmine bromide binary weapons and, 123 adverse effects, 201, 202–203 CWS standardization of, 120, 121–122 compared with atropine and oxime therapy, 199–200 description, 26 dosage considerations, 202, 704 Livens projectors, 118, 119 effect of therapy on median lethal dose in monkeys exposed to rockets, 120, 121–122 soman (table), 199 VX nerve agent delivery, 121–122 effect of therapy with and without pyridostigmine pretreat- Protective clothing ment on protective ratios in animals exposed to nerve agents boots, 573 (table), 200 fabrics for, 569 effects of pyridostigmine pretreatment on US soldiers in the factors in the decision to wear, 569 Persian Gulf War (table), 203 gloves, 573–574 efficacy of for pretreatment, 158, 199–201, 202, 704 heat and, 569 FDA post-marketing studies, 652 joint service lightweight integrated suit technology, 572–573 informed consent issues, 204, 650–651 MOPP levels and, 569 interaction with other commonly used battlefield medications, protective ensembles, 572–573 201–202 Protective equipment. See Gas masks; Respirators; Individual myasthenia gravis treatment, 158 protective equipment “off-label” use of, 650 PS. See Chloropicrin pretreatment for nerve agent poisoning, 197–204, 244, 252, 651,

lvi Medical Aspects of Chemical Warfare Index

704 fit issues, 560, 563 red blood cell and acetylcholinesterase protection studies us- powered-air purifying type, 544 ing pyridostigmine bromide and huperzine A after ex-vivo training in use of, 560 exposure to soman (table), 705 use of for children, 657 regulatory status, 204 Respiratory protection safety of administration, 201–202 general principles, 561 surgery and, 204 joint service general purpose masks, 567–568 unexplained medical symptoms and, 203–204 joint service mask leakage tester, 563, 564–565 wartime use, 202–204 M45 chemical-biological masks, 566–567 M53 chemical-biological protective masks, 568–569 Q M41 protection assessment test system, 563, 564 M42A2 chemical-biological combat vehicle masks, 566 Quayle, Vice Pres. Dan M40A1 chemical-biological field masks, 565–566 chemical weapon comments, 64 masks, 561–569 Queen, F.B. MCU-2/P chemical-biological masks, 566 1-chloroacetophenone research, 463 small box respirators, 561 R Return to duty mustard agent exposure and, 290–291 RADS. See Reactive airways dysfunction nerve agent exposure and, 194–195 Rapsahl, Julius Rhoads, Dr. Cornelius P. warning of a German gas attack, 80 Bari disaster and, 105 Raveh, L. Rhodanese fetal bovine serum AChE research, 245 hydrogen cyanide inhalation treatment, 353–354 plasma-derived human butyrylcholinesterase research, rHu BChE. See Recombinant human butyrylcholinesterase 245–246, 249 Rice, P. RBC-ChE. See Red blood cell cholinesterase mustard agent injury treatment, 285 Reactive airways disease syndrome Riche, Alfred 2-chlorobenzylidene malononitrile exposure and, 452 synthesis of mustard agent, 117, 260 Reactive airways dysfunction and, 345 CDC categorization as a category B threat agent, 616 2-chlorobenzylidene malononitrile and, 342 Rinkel, Max Reactive Skin Decontamination Lotion lysergic acid diethylamide research, 413 description, 533, 536–537, 652–653, 653 Riot control agents. See Incapacitating agents development of, 652–653 Ritter, Franz M291 SDK and, 536, 653 sarin research, 47 safety of, 653 Rivastigmine Read, R.W. Alzheimer’s disease treatment, 158 urine sample analysis for mustard agent, 711, 716, 717 Rockets Reagan, Pres. Ronald “Honest John” rocket, 122 binary chemical weapons and, 3, 124–125 “Little John” rocket, 122 Recombinant human butyrylcholinesterase nerve agent delivery, 120, 121–122, 157 clinical trials, 653–654 Roman empire sources of, 249–250 ancient use of toxic smoke, 10–11, 78 Recombinant stoichiometric bioscavengers cyanide use, 372–373 recombinant human butyrylcholinesterase, 249–250 incapacitating agent use, 443 Red blood cell cholinesterase Roosevelt, Pres. Franklin D. description, 158 no-first-use policy for chemical weapons, 52, 137 monitoring, 161, 163 Rosenstock, L. periodic medical examinations for chemical workers and, 600 organophosphate insecticide exposure research, 320 preplacement examinations for chemical workers and, 600 Rotenberg, J.S. temperature effect on inhibition, 165 cyanide poisoning research, 674 Regional Emergency Medical Advisory Committee of New York treatment guidelines for children, 195 City Roth, V.S. pediatric nerve agent antidote dosing schedule, 684 2-chlorobenzylidene malononitrile research, 452 Remifentanyl Rowntree, D.W. description and use of, 667 organophosphate insecticide exposure research, 320 Rengstorff, R.H. Royal Army Medical Corps dibenz[b,f]-1,4-oxazepine research, 468 advanced dressing stations, 87 1-chloroacetophenone research, 463 base hospitals, 87 2-chlorobenzylidene malononitrile research, 450–451 casualty clearing stations, 87 Renshaw, B. collecting, evacuating, and distribution zones, 85 long-term health effects of mustard agent, 315 Dr. Harvey Cushing’s account of Royal Army Medical Corps Republican National Convention of 2004 capabilities, Flanders, Belgium, May 5, 1917 (exhibit), 88 CDC Enhanced Surveillance Program data, 622 evacuation modes, 87 Respirators. See also Gas masks main dressing stations, 87 clearances for chemical workers, 602 regimental aid posts, 86–87 effectiveness against mustard agent, 25–26, 83 responsibilities, 85

lvii Medical Aspects of Chemical Warfare Index

Royall, Under Secretary of War Kenneth C. signs and symptoms reported by Tokyo hospital workers chemical warfare comments, 53 treating victims of sarin subway attacks (table), 541 RSDL. See Reactive Skin Decontamination Lotion Soviet Union production of, 156 Rüdiger, Col., synthesis of, 693 sarin research, 47, 156 toxicity and lethality of, 47, 693 Russia toxicological studies, 322 Chemical Weapons Convention and, 3, 65, 157 2-pyridine aldoxime methyl chloride treatment, 187 demilitarization of chemical agents and, 144–145 US production of, 120 stockpile destruction (table), 144 volatility of, 134, 168 use of fentanyl in the Chechen hostage situation, 3, 65, 107, Saudi Arabia. See Arab-Israeli Six-Day War 413, 419 Saunders, Bernard Charles Russian VX. See also VX nerve agent diisopropyl fluorophosphate research, 48 chemical structure (figure), 694 Saxitoxin Ryanodine receptor antagonists chemical structure (figure), 623 soman-induced seizure-related brain damage treatment, clinical signs and symptoms of poisoning, 624–626 227–228 laboratory findings, 626–627 lethal dose, 623–624 S mechanism of action, 623 monitoring, 627 Sacco triage method protection issues, 628 description, 517 sodium channel effects, 617, 623 sources of, 622 bombing of Sardasht using mustard agent, 656 stability, 627, 628 Iraq’s chemical weapon capabilities and, 64 synthesis, 622–623 Iraq’s invasion of Kuwait and, 63–64 toxicity, 623–624 Saint Mihiel offensive treatment, 627, 628 chemical attacks, 32–33 SBME. See 1,1’-sulfonylbis[2-(methylsulfinyl)ethane] division field hospitals, 95–96 Scheele, Carl Wilhelm medical support for the treatment of chemical casualties, 99 cyanide research, 116, 373 overview and detailed map of US participation (figure), 34 discovery of chlorine, 116 Salem, H. Schouosboe, A. hydrogen cyanide research, 354 dantrolene research, 228 incapacitating agent research, 442 Schrader, Gerhard oleoresin capsicum research, 455 organophosphorus compound research, 47 tear gas research, 342 sarin research, 156 Lake City, UT tabun research, 47, 156, 693 accidental release of ammonia, 145 Schwarzkopf, Gen. H. Norman Sandberg, C.G. chemical warfare comments, 64 cyanide poisoning research, 393 Sciuto, A.M. Sarin phosgene research, 348, 736, 737–738 accidental exposure of two US soldiers to in Baghdad, 157–158, 168, 195, 197 description and incapacitating effects, 421, 422 advantages of as a weapon, 126 SE. See Status epilepticus animal testing of, 47 Seizure-related brain damage atropine treatment, 179 description, 223 Aum Shinrikyo cult attack with sarin in the Tokyo subway, 4, mechanisms contributing to nerve-agent-induced SRBD 125, 127–128, 158, 178, 181–182, 193, 196–197, 223, 244, 316, (figure), 225 317, 321, 492, 518, 540, 657, 695–696, 699, 754 neuropathology of, 224–225 behavioral effects of exposure, 175, 176 secondary stroke injury and, 226 carboxylesterase and, 246 Seizures case report: exposure of three men to sarin (exhibit), 172 brain damage cause, 223 chemical structure (figure), 694 central nervous system effect of nerve agent exposure, clinical effects, 316 178–179, 244 codenames for, 47 neuropathology of, 223–224 electroencephalographic effects of exposure, 177, 321–322 seizure-related brain damage, 223 German production of, 48, 119, 156 status epilepticus and, 223 hydrolysis pathway of sarin, soman, and cyclosarin (figure), therapeutic window, 223 696 September 11, 2001, terrorist attacks intermediate syndrome and, 318–319 domestic preparedness issues, 755–758, 765, 767–768, 769 Iran-Iraq War and, 157, 195–196 Operation Enduring Freedom and, 65 (figure), 166 Strategic National Stockpile and, 765 muscle necrosis and, 318 Serotonin 5-HT plasma-derived human butyrylcholinesterase and, 245 incapacitating effects, 421 polyneuropathy and, 317 SERPACWA. See Skin exposure reduction paste against chemical production during the 1950s, 55 warfare agents projectile delivery, 121–122 Settle, J.A.D. properties of, 3 mustard agent exposure treatment, 279 pulmonary system effects, 173–174 lviii Medical Aspects of Chemical Warfare Index

Shaw, F.H. onset of symptoms, 267, 312 organophosphate insecticide exposure research, 319, 320 penetration of the skin, 529 Shellfish poisoning. See Brevetoxin; Saxitoxin; Tetrodotoxin return to duty considerations, 291 Shih, T.M. scarring of epithelial surfaces, 315 dizocilpine research, 228 skin cancer, 313, 315 memantine research, 228 skin and immunohistopathology, 272–274 Shryock, Richard thermal burns compared with, 278–279, 290 Vedder’s comments on, 108 threshold amount needed to produce skin lesions, 267, 312 Sibert, Maj. Gen. William L. treatments, 278–287, 290 Chemical Warfare Service leadership, 22, 90 ultrastructural pathology, 271–272 nitrate solution vesication, 267, 270–274, 279–281 treatment of mustard agent injuries, 280 Skin effects of toxin intoxication Silver sulfadiazine cream brevetoxin, 630 treatment of mustard agent injuries, 281, 670, 671 palytoxin, 620, 621 Silverlon tetrodotoxin, 627 mustard agent injury dressing, 280 Skin exposure reduction paste against chemical warfare agents Simple triage and rapid treatment system application of, 531 description, 517 barrier properties, 530–531 Six-Day War. See Arab-Israeli Six-Day War components, 530, 532 Skeletal muscle system development of, 530 brevetoxin effects, 630 effectiveness, 531 effects of nerve agent exposure, 174–175, 188, 318 effects on decontamination, 531 effects of organophosphate insecticide exposure, 317–318 function, 531 muscle necrosis and, 317–318 M291 skin decontamination kits and, 652 paralytic shellfish poisoning effects, 626 Skin exposure to liquid nerve agents saxitoxin effects, 627 atropine treatment, 185–186 tetrodotoxin effects, 627 compared with inhalational exposure, 169–170 Skin cancer effects of dermal exposure to liquid nerve agents (table), 169 mustard exposure and, 313 factors in effects of, 169 Skin effects of chemical agents. See also specific agents Skin substitutes active barrier creams, 531–532 advantages of, 286 active topical skin protectant and, 531–532 mustard agent injury treatment, 286–287 barrier skin creams and, 530–532 selection of, 286 classes of barrier creams, 531 Sleep-Eze factors affecting the absorption of agent, 529–530 description and uses, 421 patents covering work on active topical skin protectant at the Small Business Innovative Research Program US Army Medical Research Institute of Chemical Defense funding for seizure detectors, 223 (table), 532 Smoking pediatric population and, 659 cyanide levels and, 323, 324, 374, 731 skin “compartments,” 529 endogenous cyanide concentrations for smokers and non- skin exposure reduction paste against chemical warfare smokers (table), 381 agents, 530–531 SNS. See Strategic National Stockpile Skin effects of incapacitating agents Snyder, Solomon chloropicrin, 457 morphine research, 418 dibenz[b,f]-1,4-oxazepine, 468 Soap and water (hydrolysis) diphenylaminearsine, 466 infants and children and, 551, 677 oleoresin capsicum, 454–455 mechanism of action, 533–534 1-chloroacetophenone, 461, 462–463 patient thorough decontamination and, 534, 544 treatment, 471 skin decontamination method, 533–534 2-chlorobenzylidene malononitrile, 448, 450–451 water concerns, 546 Skin effects of lewisite exposure Sodium channel toxins. See also Batrachotoxin; Brevetoxin; Pumil- blistering, 292–293 iotoxin; Saxitoxin; Tetrodotoxin erythema, 292 three-dimensional representation of a voltage-gated sodium Skin effects of mustard agent exposure channel sitting in a phospholipid bilayer membrane (figure), bulla description, 267, 671 624 compared with toxic epidermal necrosis, 278, 279 Sodium nitrite cosmetic and/or functional deficits, 278 cyanide poisoning treatment, 383–384, 394–395, 675–676 current treatments, 278–281 hydrogen cyanide inhalation treatment, 353 cutaneous sensitivity, 315 limitations of, 396 cytopathology, 269–270 side effects, 394 erythema, 267, 268, 279, 667 use in children, 390 healing time for skin lesions, 268, 270, 278 Sodium thiosulfate hyperpigmentation, 268–269, 315, 672 combined with hydroxocobalamin, 396, 676 immediate treatment improvements, 281–282 cyanide poisoning treatment, 383, 386, 390, 391, 396, 397, improved therapies, 281–287 675–676 injury assessment, 282–283 dosage considerations, 396 models and histopathology, 270–271 hydrogen cyanide inhalation treatment, 353

lix Medical Aspects of Chemical Warfare Index

Solomon, I. Spanish influenza 2-chlorobenzylidene malononitrile research, 452 effects of, 101 Soman Speer, Albert additives for, 135 views on chemical warfare, 49–50 aging half-time, 316 Spray delivery assays for, 699 description, 132 atropine treatment, 179 nerve agents, 120, 157 barrier creams and, 531 SRBD. See Seizure-related brain damage behavioral effects of exposure, 176 SS John Harvey capture of research documents, 51 mustard agent disaster at Bari, Italy and, 21, 53, 262 carboxylesterase and, 246 Stafford Act case report: accidental exposure of a man to liquid soman federal department or agency support to state and local gov- (exhibit), 162–163, 312 ernments and, 758–759 central nervous system effects, 416 overview of the initial federal involvement under the Stafford chemical structure (figure), 694 Act (figure), 760 diazepam treatment, 179 Stahl, C.J. effect of therapy on median lethal dose in monkeys exposed to 1-chloroacetophenone research, 463 soman (table), 199 Stalin, Josef effects of soman on acetylcholinesterase activity in whole no-first-use policy on chemical weapons during World War II, blood from human volunteers who had taken pyridostig- 51–52 mine bromide (figure), 706 Stander, T. effects of soman on acetylcholinesterase activity in whole 1-chloroacetophenone research, 463 blood from human volunteers who were given an increasing Standoff detectors dose of huperzine A (figure), 707 early warning for line-of-sight distances, 577 fetal bovine serum AChE and, 245 joint services lightweight standoff chemical agent detectors, hydrolysis pathway of sarin, soman, and cyclosarin (figure), 579 696 M21 remote sensing chemical agent alarms, 578–579 incapacitating effects, 416 Stanton, Secretary of War Edwin M. median lethal dose, 694–695 Doughty’s chemical warfare proposal and, 12 molecular model (figure), 166 Staphylococcal enterotoxin B muscle necrosis and, 318 CDC categorization as a category B threat agent, 616 neuropsychiatric effects, 320 Stark, Col. A.N. oxime treatment and, 189 emergency gas teams and, 97 plasma-derived human butyrylcholinesterase and, 245–249 START triage system pulmonary system effects, 174 description, 517 pyridostigmine bromide pretreatment, 179, 199, 201, 704 Status epilepticus red blood cell and acetylcholinesterase protection studies us- brain damage cause, 223 ing pyridostigmine bromide and huperzine A after ex-vivo definition of, 223 exposure to soman (table), 705 nonconvulsive type, 223 seizure-related brain damage, 224–225, 226–232, 244 pediatric population and, 664 severe exposure to, 161 therapeutic window, 223 synthesis of, 48, 157, 693 Steenland, K. toxicity and lethality of, 47, 693 organophosphate insecticide exposure research, 319 toxicological studies, 322 Stein, A.A. volatility of, 168 1-chloroacetophenone research, 462 Somme, Battle of the Stenhouse, John “white star” mixture of phosgene and chlorine and, 19 synthesis of chloropicrin, 117 Sommervell, Maj. William V. . See also Corticosteroids symptomology of gas poisoning, 91 palytoxin intoxication treatment, 621 Sommervillier, Battle of Stimson, Secretary of State Henry L. phosgene and chloropicrin attacks, 25–26 letter from Gen. MacArthur, 44–45 Soviet Union. See also Russia Stimulants Afghanistan War and, 62 description and effects of, 418 Biological Weapons Convention and, 61–62 STM. See Sacco triage method capture of soman research documents, 51 Stokes mortars chemical weapons threat, 56 description, 118, 119 “Foliant” chemical agent program, 3 Stoughton, R.W. Memorandum of Understanding with the United States on 2-chlorobenzylidene malononitrile research, 444 prohibiting chemical weapons, 63 Strasbourg Agreement of 1675 nerve agent weaponization, 3 description, 136 no-first-use policy on chemical weapons during World War II, Strategic National Stockpile 51–52 description and role, 765 sarin and tabun production, 156 pediatric-ready medications and, 678 US-Soviet weapons destruction agreement, 138 “push packages” of pharmaceutical and supplies, 765 use of chemical warfare agents in the 1970s, 61–62 Strategy for Homeland Defense and Civil Support Spain objectives, 758 Berber war, 42–43 Stroke

lx Medical Aspects of Chemical Warfare Index

seizure-related brain damage and, 226 changes in duties and, 601–602 Stubbs, Maj. Gen. Marshall timing of, 601 Soviet chemical weapons threat comments, 56 Terrorist attacks STX. See Saxitoxin advantages of chemical agents for, 126–127 Substance abuse and dependency Al Qaeda, 129 screening of chemical agent workers, 602–603 “Alphabet Bomber,” 127 US Army policies, 602–603 Aum Shinrikyo, 4, 125, 127–128, 129, 158, 178, 181–182, 193, Succinylcholine 196–197, 223, 244, 316, 317, 321, 492, 518, 540, 657, 695–696, butyrylcholinesterase and, 164 699, 754 pediatric population and, 666 chemical terrorism incidents, 126–129 Sudecon Decontamination Wipes The Covenant, the Sword, and the Arm of the Lord, 127 incapacitating agents and, 470 cyanide plot against the US Embassy, Italy, 128 Sulfur dioxide “domestic terrorism” definition, 126 common sources of, 345 fear of future chemical attacks, 560 Sulfur mustard. See Mustard agent military installation protection, 126 Super Bowl of 2001 September 11, 2001, attacks, 65, 560 CDC Enhanced Surveillance Program data, 622 “terrorism” definitions, 125–126 Suschitzkey, H. “terrorist” definition, 125 dibenz[b,f]-1,4-oxazepine research, 467, 468 William Krar, 128–129 Swanston, D.W. Test-Mate kit dibenz[b,f]-1,4-oxazepine research, 468 field-forward assay for organophosphorus exposure, 693, 702, 1-chloroacetophenone research, 460 704 Switzerland Tetraethyl pyrophosphate Russia’s elimination of chemical weapons and, 145 development of, 46–47 “Symptomology, Pathology and General Treatment of Gas Cases” synthesis of, 46, 156 (Gilchrist), 91 Tetrahydroaminacridine Syria Alzheimer’s disease treatment, 426 Yom Kippur War and, 61 3-quinuclidinyl benzilate intoxication treatment, 426 Systox Tetrodotoxin blood cholinesterase inhibition and, 165 chemical structure (figure), 623 clinical signs and symptoms of poisoning, 624–626 T laboratory findings, 626–627 lethal dose, 623–624 T-2 mycotoxin mechanism of action, 623 CDC categorization as a category B threat agent, 616 monitoring, 627 T-shells. See physical examination and, 626 Tabershaw, I.R. protection issues, 628 organophosphate insecticide exposure research, 320 signs and symptoms of intoxication, 628 Tabun sodium channel effects, 617, 623 advantages of as a chemical weapon, 47 sources of, 622 assays for, 699 stability, 627, 628 behavioral effects of exposure, 175 surveillance, 628 capture of German facility for manufacturing, 50–51, 157 synthesis, 622–623 chemical structure (figure), 694 toxicity, 623–624 development of, 693 treatment, 627, 628 German production of, 48, 119, 156, 693 Thiodiglycol Iran-Iraq War and, 157, 195–196 analysis methods for urine samples to measure thiodiglycol or molecular model (figure), 166 thiodiglycol and thiodiglycol-sulfide (table), 710 muscle necrosis and, 318 mustard agent exposure and, 707, 708–711, 713–718 properties of, 3 target analytes for analysis methods outlined in Table 22-7 pulmonary system effects, 174 (table), 711 pyridostigmine bromide pretreatment, 199, 201 Thiodiglycol sulfide Soviet Union production of, 156 analysis methods for urine samples to measure thiodiglycol or synthesis of, 156 thiodiglycol and thiodiglycol-sulfide (table), 710 testing of, 47 target analytes for analysis methods outlined in Table 22-7 toxicity and lethality of, 47, 693 (table), 711 toxicological studies, 322 Thiodiglycol sulfoxide volatility of, 168 mustard agent exposure and, 708, 710–711, 716–718 Taniyama, S. Thiosulfate. See Sodium thiosulfate palytoxin research, 620 Thirty Years War TDG. See Thiodiglycol use of toxic smoke projectiles, 11 TDG-sulfoxide. See Thiodiglycol sulfoxide Thomas, S.J. Tear gas. See Incapacitating agents mustard agent exposure treatment, 279 Teflon. See Polytetrafluoroethylene 3,4-methylene-dioxymethylamphetamine TEN. See Toxic epidermal necrosis description and effects of, 418 Terbutaline 3-quinuclidinyl benzilate chlorine inhalation treatment, 353 analytical methods for exposure to, 739 Termination examinations for chemical workers

lxi Medical Aspects of Chemical Warfare Index

Chemical Corps research, 414, 422–424 Toxic smokes chemical structure (figure), 739 common sources, 345 clinical pharmacology, 422–423 early military use, 10–11, 78, 341 delirium features, 423–424 pathophysiological effects, 350 description and incapacitating effects, 422, 427, 738 uses for, 134 development of, 3, 59 Toxicological studies duration of action, 738 nerve agents, 322 inhalation studies, 422–423, 427 Toxins. See also specific agents lethal dose, 738 accidental exposure, 616 mechanism of action, 738–739 biotoxin threat, 616 molecular weight, 738 categories of, 614 parameter definitions, 423 chemical warfare agent comparison, 616–617 physostigmine treatment for intoxication by, 426, 523 Chemical Weapons Convention definition, 614 placidity and, 425 delivery methods and use of, 614, 616 routes of administration, 422 emergent threats, 617 safety of, 427 established threats, 616–617 stockpiles of, 739 food and water supplies and, 616 summary of BZ and fentanyl derivatives (table), 429 list of known toxins and their sources (table), 615–616 tetrahydroaminacridine treatment for intoxication by, 426 nature of the threat from, 614 therapeutic ratio, 427 storage capability and use of, 614 use of by Iraq during the Persian Gulf War, 413 terrorism and use of, 614, 633 weaponization of, 738 Transformational medical technologies initiative Thucydides description, 647 History of the Peloponnesian War, 10, 78 Treatment of Chemical Agent Casualties, 184 TICs. See Toxic industrial chemicals Treatment of incapacitating agent exposure. See also Field manage- TIM. See Toxic industrial material ment of chemical casualties; specific agents and drugs Tissue sample analysis cardiovascular system, 472 mustard agent, 726 eyes, 471 Tobacco use. See Smoking laboratory findings, 472 Tobramycin respiratory tract, 471–472 mustard agent treatment, 672 skin, 471 Tooele Army Depot, UT Treatment of mustard agent exposure. See also Field management demilitarization of chemical agents, 141–142, 143, 157 of chemical casualties; specific agents and drugs Topical antibiotics. See also Antibiotics airway injuries, 287–290 treatment of mustard agent exposure, 280, 672 antimicrobials, 280–281 Torngren, S. antioxidants, 282 individual protective equipment research, 543–544 biologic dressings, 280 Torsade de pointes bone marrow issues, 288–290, 672 nerve agent exposure and, 179 burn centers and, 278 Total-body cooling categories of casualties, 277 neuroprotectant use, 232 changing of dressings, 280 Toxic Chemical Agent Safety Standards debridement, 280, 282, 283–285, 290, 670 protection levels for workers, 596 decontamination, 277, 312, 670 Toxic epidermal necrosis deep injury treatment, 281, 283 compared with skin injuries from mustard agent, 278, 279 depth of injury assessment, 282–283 Toxic industrial chemicals. See also Toxic industrial material; dressings, 280, 282, 285 specific agents eye injuries, 287 common sources, 340 fluid and monitoring, 278, 279 definitions of airborne toxic material (table), 340 gastrointestinal tract issues, 288, 290 description, 340 goal of blister management, 670 forms of, 340 growth factors, 285–286 history and use, 341–345 hospitalization issues, 262, 277, 281 inhalational injury from, 340–365 indocyanine green fluorescence imaging, 283 mechanism of injury, 340, 355, 356–357 Laser Doppler perfusion imaging, 283 mechanisms of toxicity, 345–353 long-term effects, 291 military uses, 341 nonsteroidal antiinflammatory drugs, 282 nonmilitary uses, 341–345 off-gassing and, 282, 671 potential for accidental or deliberate exposure, 341 pain control, 278, 279 respiratory protection equipment, 563 pediatric population and, 670–672 triage considerations, 519–520, 522, 523 return to duty guidelines, 290–291 US Army Center for Health Promotion and Prevention Medi- secondary infection risk, 281, 288–289 cine toxic industrial chemicals (table), 343–344 skin injuries, 278–287, 670–672 Toxic industrial material. See also Toxic industrial chemicals skin substitutes, 286–287 detection and identification, 580–581 supportive care, 278 individual protection, 580 topical antibiotics, 280 respiratory protection equipment, 563 unroofing and cleansing of blisters, 279–280 use in improvised explosive devices, 580 vacuum-assisted closure therapy, 287

lxii Medical Aspects of Chemical Warfare Index

Treatment of nerve agent exposure. See also Field management of 522–523 chemical casualties; Neuroprotection as a treatment for nerve cyanide and, 518–519, 521, 522, 523 agent survivors; specific nerve agents and drugs cyanide poisoning, 386 anticonvulsive therapy, 189–190 decontamination, 513–514 antidote treatment nerve agent autoinjector, 182–186, 192, 193, delayed treatment category, 516, 521, 577 194 development of a pharmaceutical cache of medications, 678 atropine therapy, 182–186, 244 division triage stations, 94 cardiac arrhythmia treatment, 190 dynamic nature of, 513, 524 challenges of administration, 244, 253 emergent category, 516 decontamination of the patient, 180–181 essential information for, 512 effect of therapy on median lethal dose in monkeys exposed to evacuation issues, 516–517 soman (table), 199 expectant treatment category, 516, 522, 577 general principles, 180–190, 244, 316 immediate treatment category, 516, 520–521, 577 mild exposure, 192 incapacitating agents and, 520, 521, 522, 523 minimal exposure, 191–192 levels of care, 513 moderate exposure, 192 lung-damaging agents and, 519–520, 522, 523 moderately severe exposure, 192–193 medical management issues, 517–520 oxime therapy, 186–189, 197–198 minimal treatment category, 516, 521–522, 577 pediatric population and, 663–665 national site setup and control zones for a hazardous materials pretreatment considerations, 197–204, 244 site (figure), 515 protection of the rescuer, 180, 193 natural course of disease and, 512–513 psychogenic casualties and, 196 nerve agents and, 518, 520–521, 522–523 recommended therapy for casualties of nerve agents (table), nonemergent category, 516 191 pediatric population and, 677 regimen of antidotal therapy, 223, 244 placement of teams, 514–516, 547 severe exposure, 193–194 principles and processes, 512–516, 524 suspected exposure, 191 Sacco triage method, 517 terminating the exposure, 180–181 START system, 517 timing of administration, 244, 252 treatment, decontamination, and transport linkage, 514–516 treatment by exposure category, 190–194 triage and treatment area (cold zone), 506 value of aggressive treatment, 197 triage area (warm side), 504–505 ventilatory support, 181–182, 186 triage by category and agent, 520–522 “Treatment of Status Epilepticus in Adults: Columbia University “triage” definition, 512 Protocol,” 231 triage for casualties of lung-damaging toxic industrial chemi- Treatment of toxic industrial chemical exposure. See also Field cals (exhibit), 364 management of chemical casualties; specific agents and drugs US military triage categories, 516–517 acute medical management, 362–365 vesicants and, 519, 521–522, 523 airway secretion management, 363–364 Triazolam clinical care, 365 incapacitating effects, 420 establishing an airway, 362–363 Trichloromethyl chloroformate. See Chloropicrin history assessment for casualties exposed to lung-damaging Trilon of nerve agents. See Sarin; Soman; Tabun agents (exhibit), 362 Tropical ataxic neuropathy hypotension treatment and prevention, 364–365 cyanide exposure and, 323 hypoxia prevention and treatment, 364 Truman, Pres. Harry S patient history, 361 United States ratification of the Geneva Protocol and, 60, 137 patient transport, 365 Tsuchihashi, H. physical assessment for casualties of lung-damaging chemical VX nerve agent research, 695 agents (exhibit), 363 TTX. See Tetrodotoxin physical examination, 361–362 Turpin, Eugene pulmonary edema treatment, 364 secret weapon developed by, 80 rest from physical exertion, 363 22nd Chemical Battalion termination of exposure, 362 mission of, 597 triage for casualties of lung-damaging toxic industrial chemi- 21st century cals (exhibit), 364 Operation Enduring Freedom, 65 Treaty of Versailles Operation Iraqi Freedom, 65–66 description, 136 Russia’s use of fentanyl in the Chechen hostage situation, 3, Trench mortars 65, 413 attacks on the AEF (exhibit), 26 20th Support Command CWS standardization of, 119–120 domestic preparedness role, 763 description, 26 2-aminothiazoline-4-carboxylic acid Stokes mortars, 118, 119 cyanide poisoning and, 376 Triage of chemical casualties 2-chlorobenzylidene malonitrile alternative areas for, 678 nonmilitary uses, 342 benefit of assistance issues, 512–513 overall effects of, 342 challenges unique to, 516 Yemen Civil War and, 341 combined injuries and, 522–523 2-oxothiazolidine-4-carboxylic acid conventional wounds contaminated with chemical agents, chemical structure (figure), 736

lxiii Medical Aspects of Chemical Warfare Index

phosgene and, 736 published reports (1995-2006) of laboratory analysis of human 2-PAM Cl. See 2-pyridine aldoxime methyl chloride urine samples for glutathione reaction products following a 2-pralidoxime chloride. See 2-pyridine aldoxime methyl chloride suspected exposure to sulfur mustard (table), 720 2-pyridine aldoxime methyl chloride published reports (1995-2006) of laboratory analysis of hu- administration considerations, 187, 188–189, 652, 682–683 man urine samples for hydrolysis metabolites following combined with atropine, 183, 223, 651 suspected exposure to sulfur mustard (table), 719 dosage considerations, 187, 189, 194 sample considerations, 739 intermediate syndrome treatment, 318 sample preparation methods for the gas chromatographic/ limitations of, 653 mass spectrometric/mass spectrometric analysis of the sul- nerve agent exposure treatment, 174, 183, 197–198, 244, 316, fur mustard urinary β-lyase metabolites (exhibit), 713 651 US Air Force pediatric population and, 663, 664, 682–683 collectively protected expeditionary medical support and, 585 side effects, 187, 188 field management of chemical casualties, 490–491 soman-induced seizure-related brain damage treatment, 227 US Army. See also Chemical Corps; Chemical Warfare Service; US treatment of children and, 195 Department of Defense; specific divisions and installations area medical laboratories, 763–764 U binary weapon research, 122–123 Chemical Materials Agency, 142, 143 Uniformed Services University of the Health Sciences Chemical Stockpile Emergency Preparedness Program, CBRNE training programs, 768 142–143 United Kingdom. See Great Britain chemical training improvements during the 1980s, 63 United Nations Defense Medical Readiness Training Institute, 768 Bush’s and Blair’s warning on Iraq’s weapons of mass destruc- demilitarization of chemical agents, 141–143 tion program, 66 destruction of chemical weapons stockpile and, 610–611 Disarmament Committee, 137 Employment of Chemical Agents, 136 Iran-Iraq War and, 63 field management of chemical casualties, 481, 487, 489 report condemning the production and stockpiling of chemical 520th Theater Army Medical Laboratory, 693 weapons, 60 M20 simplified collective protection equipment and, 587 Yemen Civil War and, 58 Medical Department, 79 United States. See also specific conflicts, leaders, cities, states, military Medical Management of Chemical Agent Casualties Handbook, 184 installations, agencies, and departments reorganization of, 56–57 chemical demilitarization program, 141–143, 609–611, 766 substance abuse and dependency policies, 602–603 Chemical Weapons Convention and, 65, 157 Toxic and Hazardous Materials Agency, 141 , 672 Treatment of Chemical Agent Casualties, 184 chloropicrin production, 455 20th Support Command, 763 diphenylaminearsine production, 464 US Army Center for Environmental Health Research gas chamber executions with cyanide, 374 biomonitoring device, 631 Geneva Protocol ratification, 60, 137, 443 US Army Center for Health Promotion and Prevention Medicine Memorandum of Understanding with the Soviet Union on domestic preparedness role, 763, 764 prohibiting chemical weapons, 63 US Army Chemical Corps. See Chemical Corps nerve agent weaponization, 3 US Army Chemical Materials Agency phosgene production, 345, 672 chemical accidents or incidents and, 607 plans for gas warfare during World War II, 52–53 missions of, 596–597 post-World War I chemical warfare policy, 44–45 US Army Chemical School Russia’s elimination of chemical weapons and, 144 CBRNE courses, 769 sarin production, 157 US Army Materiel Command stockpile agent destruction (table), 143 chemical accidents or incidents and, 607 US-Soviet weapons destruction agreement, 138 US Army Medical Command VX nerve agent development and production, 157 domestic preparedness role, 761, 763, 764 World War I experience of chemical warfare, 21–42, 117 resources of, 764 University of Medical Center US Army Medical Department coordination with local resources, 678 ambulance company dressing stations, 93–94 triage for chemical agent casualties, 677 army-level gas hospitals, 97 University of Pennsylvania base and gas hospitals, 95 neuropeptide research, 420 bathing of chemical casualties, 92, 93, 95 Upshall, D.G. battalion aid stations, 92–93 dibenz[b,f]-1,4-oxazepine research, 467, 469 bulletins aimed at keeping personnel current on chemical Urine sample analysis warfare developments, 91 analysis methods for urine samples to measure thiodiglycol or casualty cards, 97 thiodiglycol and thiodiglycol-sulfide (table), 710 classification of chemical casualties, 94–95 analytical methods, 708–713 classification of wounded soldiers, 97 application to human exposure, 713, 715–718 company aid posts, 92 collection issues, 692 defensive gas training, 89 cyanide poisoning, 734 difficulty of carrying “anti-gas” medical equipment, 96 guidelines for collection, 739 division field hospitals, 95–96 lewisite exposure, 728, 729 division gas medical officers, 92 mustard agent exposure, 708–718 division triage stations, 94 noninvasive, 692 lxiv Medical Aspects of Chemical Warfare Index

evacuation hospitals, 94–95 demilitarization of chemical agents and, 142 evacuation in trench versus open warfare, 99–101 law controlling storage, testing, and disposal of agents outside evacuation methods, 97–99 the United States, 60 gas-proofing of dugouts, 93 review of binary weapons, 124–125 Headquarters, First Army Corps, memorandum on the evacu- subcommittee on noxious gases, 21–22 ation of sick and wounded, 1918 (exhibit), 98 US Defense Intelligence Agency increase in the number of gas casualties and, 91 “Biotechnology: Impact on Biological Warfare and Biode- organization of, 89–101 fense,” 420–421 origination of, 89 US Department of Agriculture Royal Army Medical Corps as basis for, 89 domestic preparedness role, 761 Sanitary Corps staffing, 90 Laboratory Response Network and, 765–766 secret field order no. 41, annex no. 7, issued by the Fifth Divi- US Department of Defense. See also US War Department sion, September 9, 1918 (exhibit), 100 analysis of possible accidental battlefield exposure to chemical separation of chemical casualties from other wounded sol- agents during Operation Desert Storm, 129–130 diers, 97 Army reorganization, 56–57 special wards for chemical casualties, 94 Assembled Chemical Weapons Alternatives Program, 142 specialized hospital gas teams, 92 chemical agent medical countermeasure requirements, 646 techniques to detect malingerers, 92 Chemical Stockpile Emergency Preparedness Program role, training and education in CBRNE and, 767, 768 766–767 uniform procedure for handling chemical casualties, 91 defense acquisition executive responsibilities, 646 US Army Medical Institute of Infectious Disease domestic preparedness roles, 755, 758–764, 767–770 CBRNE training program, 768 5000 series documents, 647–648 Contaminated Casualty Decontamination Course, 763 incapacitating agents characteristics, 412 Hospital Management of CBRNE Incidents Course, 769 investigational new drugs and, 650 Medical Management of Chemical and Biological Casualties military installation protection from terrorist attacks, 126 Course, 763, 768 National Medical Chemical and Biological Advisory Team, 764 US Army Medical Research and Materiel Command Project BioShield and, 251 drug acquisition responsibilities, 650 pyridostigmine bromide informed consent issues, 204, 650–651 US Army Medical Research Institute of Chemical Defense Quadrennial Defense Review Report of 2006, 758, 770 “Assay Techniques for Detection of Exposure to Sulfur requests for assistance in chemical casualty management, 494 Mustard, Cholinesterase Inhibitors, Sarin, Soman, GF, and support for civilian chemical casualty management, 493 Cyanide,” 693 support to civil authorities, 761–764 barrier skin creams, 530–532 “terrorism” definition, 125 CBRNE training, 768 22nd Chemical Battalion support operations, 597 chemical casualty site teams, 607 2-chlorobenzylidene malononitrile variation creation, 444 chemical warfare exposure assay development, 693 US Department of Energy Contaminated Casualty Decontamination Course, 763 domestic preparedness role, 755 Field Management of Chemical and Biological Casualties US Department of Health and Human Services Course, 768–769 Chemical Stockpile Emergency Preparedness Program role, glove issues in decontamination, 539 766 Hospital Management of CBRNE Incidents Course, 769 disaster and medical response to mass casualty events, 492 Medical Management of Chemical and Biological Casualties drug acquisition responsibilities, 650 Course, 594–595, 608, 763, 768 first responder policy recommendations, 493 role and responsibilities, 5 homeland security role, 755 sample collection, shipping, and storage guidelines, 739–741 Laboratory Response Network and, 765–766 Toxic Chemical Training Course for Medical Personnel, National Response Framework coordination guidelines for, 594–595, 608 761 working conditions, 597 Project BioShield and, 251 US Army Northern Command Strategic National Stockpile and, 765 domestic preparedness role, 761, 763, 764 US Department of Homeland Security US Army Ordinance Corps color-coded threat condition chart, 755 training and education in CBRNE and, 767 creation of, 755 US Army Research and Development laboratory homeland security councils and, 755 3-quinuclidinyl benzilate monitoring, 739 Laboratory Response Network and, 765–766 US Army Soldier and Biological Chemical Command federal agency for domestic incident management, 755 glove issues in decontamination, 539 National Incident Management System, 492, 755–756 US Bureau of Mines National Response Framework, 758 toxic gas research, 89 National Response Plan, 755–756 US Civil War Office for Domestic Preparedness, 770 chemical warfare proposals, 11–12 organizational outline for incident management command US Coast Guard (figure), 757 field management of chemical casualties, 491, 492 Project BioShield and, 251 US Code state and regional coordination and, 759 “terrorism” definition, 126 Strategic National Stockpile and, 765 US Congress. See also specific legislation US Department of State antiterrorism training bill, 125 “terrorism” definition, 125 binary chemical weapon development restrictions, 124 US Environmental Protection Agency

lxv Medical Aspects of Chemical Warfare Index

Chemical Stockpile Emergency Preparedness Program role, Van Hooidonk, C. 766 decontamination research, 534, 536 demilitarization of chemical agents and, 142, 143 Vanderbelt, J.M. levels of protection, 580 cyanide poisoning research, 396 waste water disposal issues, 546 Vedder, Lt. Col. Edward US Food and Drug Administration career of (exhibit), 103 “animal rule” for drug product approval, 647, 651 chemical training for soldiers and, 103 anticholinesterase treatment for Alzheimer’s disease, 158 comments on Shryock, 108 clinical trial phases, 647 Medical Aspects of Chemical Warfare, 104 investigational new drug submissions, 649, 650 1-chloroacetophenone research, 462 Laboratory Response Network and, 765–766 Vee medical chemical defense acquisition programs and, 646, 647, physostigmine isolation, 46 648–653 Ventilatory support “off-label” uses for drugs, 650 arrhythmias and, 190 phosgene inhalation treatment guidelines, 354 atropine and, 181, 186, 193 Project BioShield and, 251 hydrogen cyanide inhalation, 354 pyridostigmine bromide approval, 204 incapacitating agent exposure and, 471–472 Reactive Skin Decontamination Lotion approval, 536 intermediate syndrome, 318 US General Accounting Office mass casualty incidents, 181, 519–520 CBRNE training programs and, 768 mechanical devices for, 181 US Joint Forces Command mouth-to-mouth ventilation, 181, 675 domestic preparedness role, 764 mustard agent injuries, 288–289, 672 US Marine Corps nerve agent exposure treatment, 181–182, 520 chemical/biological incident response force, 762–763 triage issues, 519–520 field management of chemical casualties, 489–490 Vesicants. See also Incapacitating agents; Lewisite; Mustard agent; Joint Non-lethal Weapons Directorate, 431 Phosgene oxime M20 simplified collective protection equipment and, 587 chemical, physical, environmental, and biological properties of US Navy vesicating agents (table), 260–261 binary weapon research, 123 conventional wounds contaminated with, 523 field management of chemical casualties, 489, 491–492 description, 260, 667 hospital ships, 491–492 management of vesicant exposures (table), 671 US Office of Management and Budget pediatric population and, 667–673 Project BioShield funding, 251 prolonged morbidity from, 667 US Postal Service triage considerations, 519, 521–522, 523 oleoresin capsicum use, 443 types of, 260–261 US War Department. See also US Department of Defense Veterans Administration chemical warfare plan, 22 phosgene exposure research, 325–326 chemical weapon stockpiles and, 44 study on the effects of mustard agent and lewisite exposure, gas warfare function centralization, 22 312–313 Memorandum on Gas Poisoning in Warfare with Notes on its Viala, B. Pathology and Treatment, 90 2-chlorobenzylidene malononitrile research, 471 Notes on Gas as a Weapon in Modern War, 90 Vietnam War USACHPPM. See US Army Center for Health Promotion and Agent Orange use, 341 Prevention Medicine defoliant use, 105 USAMRICD. See US Army Medical Research Institute of Chemical mustard agent use, 57 Defense tear gas use for clearing tunnels, 105 USAMRIID. See US Army Medical Institute of Infectious Disease 2-chlorobenzylidene malononitrile use, 444 USNS Comfort Vinci, Leonardo da hospital ship capability, 491 poison projectile proposal, 11 USNS Mercy Vision. See Eyes hospital ship capability, 491 Volunteers USS Bon Homme Richard anticholinergic deliriant testing on, 424–425 hospital ship capability, 491 effects of soman on acetylcholinesterase activity in whole USS Kearsage blood from human volunteers who had taken pyridostig- hospital ship capability, 491 mine bromide (figure), 706 effects of soman on acetylcholinesterase activity in whole V blood from human volunteers who were given an increasing dose of huperzine A (figure), 707 V-series nerve agents. See also specific agents medical research on human volunteers during the 1950s, 55 categorization of (exhibit), 47 1-chloroacetophenone testing on, 461 production during the 1950s, 55 von Deimling, Gen. weaponization of, 3 chemical warfare comments, 15–16 VAC. See Vacuum-assisted closure therapy von der Linde, Hans-Jürgen Vacuum-assisted closure therapy sarin research, 47, 156 contraindications to, 287 von Krueger, Gerde mustard agent injuries, 287 organophosphorus compound research, 47 van Galen, Christoph Bernhard von Tappen, Hans use of toxic smoke projectiles, 11 lxvi Medical Aspects of Chemical Warfare Index

T-shell development, 14 cyanide poisoning description, 373 VR nerve agent Wet decontaminants description, 156 Reactive Skin Decontamination Lotion, 533, 536–537 toxicity of, 168 water issues, 546 vapor hazard, 168 White, C. volatility of, 168 1-chloroacetophenone research, 462 VS nerve agent White, R.G. weather conditions and, 135 1-chloroacetophenone research, 463 VX nerve agent White House Office of Homeland Security additives for, 135 creation of, 755 assays for, 699 National Strategy for Homeland Security, 755 barrier creams and, 531 WILD20 behavioral effects of exposure, 175–176 soman-induced seizure-related brain damage treatment, 227 carboxylesterase and, 246 Willder, W.B. chemical structure (figure), 694 2-chlorobenzylidene malononitrile research, 452 chloroperoxidase and, 250 Willems, Jan L. clinical effects, 316 Iranian mustard casualties, 263, 266, 268, 715 eye effects of exposure to, 170 Wils, E.R.J. incapacitating effects, 416 skin sample analysis for mustard agent, 726 inhibition of blood ChE activity, 165 urine sample analysis for mustard agent, 708–709, 716 delivery, 120–121 Wilson, I.B. molecular model (figure), 166 oxime research, 186–187 mortality from, 316 Wilson, President Woodrow neuropsychiatric effects, 320 World War I and, 12, 21 plasma-derived human butyrylcholinesterase and, 245–246, Wind and weather considerations 247, 249 chemical attacks, 80, 117, 121, 135–136 projectile delivery, 121 cold shock, 548–549 pulmonary system effects, 174 decontamination in cold weather, 548–550 RBC-ChE inhibition, 165 hypothermia, 548–549 relation of cholinesterase activity to vomiting after exposure to stages and symptoms of hypothermia (table), 548 (table), 166 Winternitz, M.C. routes of exposure, 695 phosgene exposure research, 325 skin effects, 529 Wolfe, A.D. soap and water decontamination, 533, 534 fetal bovine serum AChE research, 245, 246 synthesis and production of, 157 Wolff, H.C. toxicity of, 693, 695 anticholinergic deliriant research, 422 vapor hazard, 168 Wooten, J.V. volatility of, 135, 168, 316 lewisite exposure research, 728 Vycudilik, W. World Health Organization urine sample analysis for mustard agent, 708, 713 diphenylaminearsine exposure research, 466 World Trade Center W bombing in 1993, 754 World Trade Organization Wada, S. CDC Enhanced Surveillance Program data, 622 mustard agent exposure research, 314 World War I. See also American Expeditionary Forces; specific Waitt, Maj. Gen. Alden H. battles, battle sites, and countries assessment of the future of chemical warfare in 1946, 54 aftermath, 36–37, 41 chemical training for soldiers and, 103–104 Allied retaliation against chemical warfare, 18 post-World War II discovery of German gas reserves, 104–105 an attack on a platoon of the 28th Division (exhibit), 27 summary of CWS’s planning for the next war, 119 armistice ending, 36 Walker, M.C. casualties attributed to gas, 36–37, 41–42, 82, 83, 341 ketamine research, 231 chemical agent production, 117 Wallace rule of nines, 282 chemical agents used (in chronological order) (table), 342 Walter Reed Institute of Research Whole Blood Assay chemical attacks involving children and civilians, 656 cholinesterase analysis, 702, 705–706 chemical casualties (table), 79 Ward, Kyle, Jr. chemical warfare use by France, Great Britain, and Germany, description of nitrogen mustard, 119 12–21, 79–82, 312, 341, 373, 397 Water testing kits. See M272 chemical agent water testing kits chemical weapons, 117–118 Watson, Maj. Gen. Gerald G. chlorine gas use, 2 chemical training and, 63 detailed map of Ypres (figure), 17 Weather. See Wind and weather considerations Dr. Harvey Cushing’s account of Royal Army Medical Corps Weger, N. capabilities, Flanders, Belgium, May 5, 1917 (exhibit), 88 cyanide poisoning research, 394, 395–396 earliest reported description involving chemical warfare on Weigand, D.A. the AEF (exhibit), 22 2-chlorobenzylidene malononitrile research, 451 early Allied chemical warfare plans, 12–13 Weimar, J.T. evacuation in trench versus open warfare, 99–101 2-chlorobenzylidene malononitrile research, 451 excerpt from “Take Me Back to Dear Old Blighty!” (exhibit), 89 Wepfer

lxvii Medical Aspects of Chemical Warfare Index

field sanitation and, 83–85 2-chlorobenzylidene malononitrile research, 451–452, 471 first airplane gas attacks on American forces (exhibit), 26 Yom Kippur War. See Arab-Israeli Yom Kippur War first projector attack on the AEF (exhibit), 26 Yperite. See Mustard agent “gas fright” syndrome, 82 Ypres, First Battle of gas mask development, 18, 19, 80, 561–562 stalemate result of, 14 historical summary of chemical warfare agents used in (table), Ypres, Second Battle of 38–41 casualties, 82 hospitalized casualties, in percentages by causative weapon chlorine gas attacks, 14–18, 21, 79–82 (figure), 85 detailed map of Ypres (figure), 17 incapacitating agent use, 443, 455 prewar intelligence and, 79–82 initial responses to gas attacks, 82–85 map of Belgian-French border (figure), 16 Z map of western Europe (figure), 13 Zante, R. medical personnel as victims, 101–102 phosgene research, 735 mustard agent use, 2–3, 15, 18, 20–21, 25–26, 27, 260, 261–262, Zeiler, A.G. 530 phosgene research, 345 phosgene use, 2, 734 Zhukov, Soviet Defense Minister prewar intelligence and the Second Battle of Ypres, 79–82 chemical weapons threat, 56 profiles of chemists (exhibit), 15 oxide Royal Army Medical Corps role, 85–89 physiological effects, 358–359 six chlorine-phosgene cloud attacks: British casualties Decem- toxic effects of exposure, 327 ber 1915-August 1916 (table), 83 Zyklon B Spanish influenza and, 101 development of, 15 trichloromethyl chloroformate use, 20 use in Nazi concentration camps, 15, 51, 373, 397, 656 US experience with chemical warfare, 21–42 World War II capture and detainment of German military scientists in Op- eration Dustbin, 51 capture of soman research documents, 51 chemical weapon delivery system improvements, 120 demilitarization of captured weapons, 54 German gas reserves, 104–105 Germany’s experimental testing of chemical and biological warfare agents in concentration camps, 105, 157 nerve agents and, 3, 48 no-first-use policy on chemical weapons, 51–52 sea dumping of captured chemical weapons, 54 smoke and flames agents and, 104 Zyklon B use in Nazi concentration camps, 15, 51, 105, 373, 397, 656 Worldwide NBC Mask Handbook, 561 Wound decontamination general considerations, 538 initial decontamination, 538 off-gassing and, 282, 538–539 thickened agents and, 538 wound exploration and debridement, 539 Wurtz, Charles A. discovery of cyanogen chloride, 116 synthesis of tetraethyl pyrophosphate, 156 tetraethyl pyrophosphate synthesis, 46 X Xylyl bromide development and use of, 14, 17, 79 Y “ cross.” See Mustard agent Yemen Civil War chemical weapons use, 57–58, 262, 341 Compromise of 1970, 58 Yen, D. cyanide poisoning research, 385 Yeung, D.T. human paraoxonase 1 research, 251 Yih, J.P.

lxviii Medical Aspects of Chemical Warfare

Dedicated to the Memory of Brennie E. Hackley, Jr, and Frederick R. Sidell

uted to the elucidation of mechanisms of reactions of with organophosphorus compounds and synthesized a number of oximes, for which he held 18 patents. One oxime synthesized by Dr Hackley, tox- ogonin, was adopted as an antidote against chemical nerve agents by the US Air Force. In 1984 Dr Hackley was designated Chief Scientist and Scientific Advisor to the Commander of the US Army Medical Research Institute of Chemical Defense (USAMRICD). During Operation Desert Storm, Dr Hackley responded to emergency calls by combat divisions for predeployment briefings on medical management of chemical casualties, initiating a traveling training program that prepared deploying medical personnel to treat soldiers on the battlefield if chemical weapons were employed. As an instruc- tor and course director for USAMRICD’s Medical Management of Chemical and Biological Casualties course, Dr Hackley delivered lectures in Saudi Ara- bia; Johnston Island, ; Okinawa, Japan; and Germany on pulmonary agents, cyanide, vesicants, and nerve agent threats. DR BRENNIE E. HACKLEY, JR While serving as chairman of the Scientific Steering Chemist, Teacher, Scientific Advisor Committee on Nerve Agent Antidotes, he advised the Command that one of the precursors for the then cur- July 29, 1924 – November 5, 2006 rent synthesis of the oxime HI-6, under consideration Dr Hackley received a BS in chemistry from Wil- as a replacement for the fielded 2-PAM chloride, was berforce University in 1946. Following graduation, he carcinogenic and would not pass scrutiny by the Food enlisted in the US Army and was later commissioned as and Drug Administration. Additionally, Dr Hackley an officer. After more than 30 years’ service, he retired convinced the Command that HI-6 wasn’t cost effec- from the US Army Reserve Corps in 1981 at the rank of tive, and that its effectiveness compared to 2-PAM chlo- colonel. Dr Hackley began his civilian career in 1952 as ride was not great enough to justify its replacement. an organic research chemist in the Medicinal Chemistry Dr Hackley represented the US Army Medical re- Branch of the Army Chemical Center and went on to search program competently and effectively for almost earn advanced degrees in chemistry from the Univer- 6 decades. His efforts significantly improved commu- sity of Delaware, including a PhD in 1957. During his nication and relationships between the Chemical and career, Dr Hackley studied the relationship between Medical Corps and strengthened USAMRICD’s image chemical structures and chemotherapeutic activity in as the lead laboratory for the development of medical reference to efficacy against toxic agents. He contrib- countermeasures for chemical threat agents.

lxix Medical Aspects of Chemical Warfare

program and served as the course director for many years. Eventually, such training was expanded to ad- ditional courses for nonmedical personnel and military leaders. Dr Sidell also prepared and updated detailed educational materials addressing nerve agents, vesi- cants, cyanide, and pulmonary agents, and provided education and training for the Chemical Stockpile Emergency Preparedness Program and the Domestic Preparedness Program. Dr Sidell’s expertise was nationally and interna- tionally recognized, and he was often called upon for highly sensitive assignments that required technical expertise. These included a trip to southeast Asia in 1979 to investigate the alleged use of “” against the Hmong in Laos. In 1988, he examined Kurdish civilian casualties who were victims of chemi- cal warfare in their homeland. He traveled to Japan in 1995 to assist and advise Japanese physicians on the care of causalities from a terrorist-led sarin nerve agent incident in the Tokyo subway system. Dr Sidell was the lead editor of the first edition of DR FREDERICK R. SIDELL Medical Aspects of Chemical and Biological Warfare, pub- lished in 1997, contributing to many of the chapters Physician, Teacher, Scientist on chemical warfare agents. His research and studies July 27, 1934 – February 14, 2006 have been published in over 100 reports and articles, and he also wrote several handbooks on the treatment No physician has contributed more to the US Army of chemical casualties. Following his official retirement, Medical Department’s chemical defense training and Dr Sidell continued providing education and training education programs than Dr Frederick Sidell. Dr Sidell in the management of chemical agents and casualty graduated from Marietta College in Marietta, Ohio, treatment to civilian first responders, including many in 1956, and also later from the New York University emergency medical treatment units throughout the School of Medicine. He completed his internship and United States. residency in internal medicine at Cleveland Metropoli- In addition to the many achievement awards and tan General Hospital. Dr Sidell initially served 2 years commander’s medals received by Dr Sidell, a new on active duty with the Army Medical Corps in the building at the Edgewood area of the Aberdeen rank of captain. He was stationed at Edgewood Arsenal Proving Ground was named the Sidell Learning in Maryland, an assignment that would determine his Center in 2002 in recognition of his great contribu- future in medicine and lead to his subsequent employ- tion to medical education and training. In 2003 Dr ment with the Department of Defense. While with the Sidell was inducted into the Marietta College Hall Department of Defense Dr Sidell became one of the of Honor, becoming one of only 24 people to be so world’s leading experts and educators in the field of recognized at that time. Dr Sidell’s knowledge, ex- medical effects of chemical warfare agents. He retired perience, and dedication contributed greatly to the in 1995 after 30 years in government service. development of the outstanding medical training In the late 1960s, when training in medical chemical programs throughout the Department of Defense defense was very limited, Dr Sidell and some of his col- today. His insight and pragmatic views have guided leagues recognized the need for specialty training and the development of medical policy against weapons developed a course for military medical personnel on of mass destruction and medical research on safe the medical management of chemical agent casualties. and effective medical countermeasures against cur- Dr Sidell guided the development of this new training rent and future chemical threats facing the military.

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