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Home , Arsenical, Chemical terrorism, Hydroxocobalamin, Ricin, Thiosulfate

H5642--Chemical Poster with Bleed_Layout 1 3/8/2012 9:51 AM Page 1

Chemical agents act quickly. Rapid response is essential. Learn to recognize and diagnose the health effects of chemical agents. Chemical agents may contaminate you and your facility. Do not become a casualty! Implement procedures to decontaminate and treat incoming patients.

RECOGnIZInG -RELATED ILLnESSES PERSOnAL PROTECTIVE EQUIPMEnT (PPE) DECOnTAMInATIOn GUIDELInES Adequate planning and regular training are an important aspect to preparedness for terrorism- Exposure can occur from of vapors, dermal contact or eye contact. The following Decontamination is the most important first step in patient care. Confirm or provide patient related events. This wall chart is a quick guide, summary of important information. Healthcare general information can help responders/healthcare providers determine appropriate PPE. decontamination upon arrival. providers should be alert to patterns of illness and reports of chemical exposures that Inhalation Exposure: might signal an act of chemical terrorism event. To decontaminate: Protection from both vapors and particulates may be required when the chemical agent is being L Immediately remove patient clothing, double bag and seal. CDC LRn-C sample collection, packaging, and shipping, SCPaS, see the internet reference at the released. After release, protection from vapors is most important. Half-face and full-face respirators, L Flush patient eyes with plenty of water or normal saline. bottom center of this wall chart. with the appropriate canister, can provide protection from vapors. These operate by negative pres- L Wash patient skin with soap and water, no abrasion and final water rinse. sure and must be fit tested for optimal protection. Powered, air-purifying respirators (PAPR) and L Do not use bleach, concentrated or diluted, on people. Clinical, epidemiological or circumstantial clues that may self-contained breathing apparatus (SCBA) provide even greater protection and operate under posi- suggest a chemical terrorist event: tive pressure so that fit characteristics are less important. Surgical and n-95 masks will not protect L Unusual increase in the number of people seeking care with respiratory, against inhalation of vapors. neurological, dermatological or gastrointestinal symptoms. Dermal Exposure: L Clustering of symptoms or unusual age distribution e.g., chemical exposure in children. Latex examination gloves provide very little protection from most chemical agents and can cause . Gloves made of Viton, nitrile, butyl or neoprene provide better protection and, L Unusual clustering of patients in time or location including those who attended the in some styles, allow adequate dexterity. However, the resistance of these materials to same public or private event. different chemicals varies and it is best to have a variety of gloves available. Double gloving L Location of a chemical release not consistent with expected use. may provide additional protection. Chemical-resistant aprons, suits and boots can also minimize dermal exposure. L Simultaneous impact to human, animal and populations. GB, Tokyo Subway (1995) Cn, Auschwitz, WWII HD, Munition Shell (2010) L Accidental exposure to chemical agent as historical ocean-dumped ordnance, 9-12” military Eye Exposure: ordnance ( Mustard), through commercial or recreational fishing. The chemical-agent Full-face respirators, PAPR and SCBA will provide protection from both splashes and vapors. ordnance may wash ashore with potential exposure to recreational bathers or fishermen. Protective eyewear, such as goggles or a face shield, will not provide protection from chemical vapors. Protective eyewear is necessary during decontamination to prevent splashing L Terrorist use of pure or clandestine-synthesized impure agents. into eyes. For more information, refer to OSHA Best Practices for Hospital-Based First Re- ceivers of Victims fromMass Casualty Incidents Involving the Release of Hazardous Sub- Any unusual symptoms, illnesses or clusters should be stances. Available at: http://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf reported immediately. notify the new Jersey Poison Control Center (1-800-222-1222), and DEP ALERT (1- 877-927-6337). DISCLAIMER: Information provide in wall chart is a quick guide. Emergency staff and hospital clinical DO nOT BECOME A CASUALTy! L, Desert Storm (1991) Cytotoxic GB, GF, Vx, HD staff must confirm treatments with appropriate-current CDC, ATSDR, and medical references. Halabja, Kurdistan (1988)

Table 1. For CHEMICAL TERRORISM, RECOGnIZE, DIAGnOSE, OBTAIn InDICATIVE-TESTS, TREAT, and OBTAIn DEFInITIVE TESTS for the AGEnT, its METABOLITE or BIOMARKER SURROGATE.

Chemical Agent Agent names Mode of Action and Symptoms Indicative Tests Treatment Definitive Tests: Clinical Samples Classification (See Tables 2-6) sent to nJPHEAL or CDC LRn-C

nerve Agents Cyclohexylsarin, GF; Inhibits acetyl Miosis (pinpoint pupils). Depression of both erythrocyte (red . Metabolites in Urine are , GB Sarin, GB; , . Rhinorrhea; bronchorrhea; obstructed blood cells) and plasma (anticholinergic); GF-acid, GB-acid, GD; Russian (Soviet) Inhalation: Sarin (GB): breathing; unconsciousness; cholinesterase within several hours chloride (2- GD-acid, rVx-acid and 3 rVx; and Vx LCt50 = 100 mg.min/m ; flaccid paralysis, apnea. of exposure. PAMCl); (prolonged Vx-acid 3 Vx: LCt50 = 10 mg.min/m . seizures). Reportable Range: 1 - 200 ppb.

Asphyxiants Salt Cyanide binds iron in Cyanosis is a late-finding. Lactic acidosis (Cn interferes Mechanical ventilation. Cyanide in Whole Blood Cyanide, Cn Gas cytochrome a3 reduces intra- Reduced reflexes at 1000 – <2500 with lactate oxidation by liver); Antidote: Sodium or Cyanide, Cn Hydrogen Cyanide, HCn cellular utilization. ppb; coma/ death 2500 – >3000 arterial oxygen is normal but , and then sodium Reportable Range: 25 - 2500 ppb. Inhalation: LCt50 = 2500 – ppb Cn in blood. venous oxygen is high. . Alternative anti- 5000 mg.min/m3. dote: B12a, hydroxocabalamin.

Blistering Vesicant I Sulfur Mustard (HD) Lipid soluble, irreversibly Latency period is hours to days. none, obtain definitive test for Skin blisters: < 2 cm apply Metabolite in Urine SBMTE or Sulfur Mustard, HD; persistent oily binds to skin. Incapacitating eye, skin injuries, SBMTE, the HD metabolite in urine antibiotics and cover; when 1,1'-sulfonylbis [2(methylthio)ethane] distilled Sulfur Mus- liquid that slowly LD50 = 0.7 mg/kg oral. and respiratory disease. for confirmation of exposure. > 2 cm debride and irrigate. Reportable Range: 0.1 – 3100 ppb tard, >96% purity evaporates. Inhalation: LCt50 = 1500 mg.min/m3.

Blistering Vesicant II (L) Skin: systemic poison. Immediate. none, obtain definitive test for Skin blister < 2 cm apply Metabolite in Urine, Lewisite, L () persistent oily Inhalation: pulmonary Dermal: burns, erythema, blisters. CVAA, the metabolite in urine, for antibiotics, and cover; when CVAA (2-chlorovinylarsonous acid)

Agentsliquid that Awareness slowly ; . Eyes: incapacitating burns and confirmation of Lewisite, L, > 2 cm debride and irrigate. Reportable Range: 11 – 3850 ppb evaporates. Toxicity: blisters > 14 ug; inflammation of cornea. exposure. BAL (British Anti-Lewisite), LDLo = 37.6 mg/ kg; and Inhalation: respiratory tract mucosa , 4-5 mg/kg IM; LD50 = 2.8 gm (skin). and may cause death. severe: additional 2 mg/kg 3 LCt50 = 20 mg.min/m . q.d. (once per day) for 3-4 d. Cytotoxic ( com- Injection and Inhalation: , , seizures, and none; obtain definitive tests for Mechanical ventilation. Surrogate Biomarkers Ricin, munis, Castor Bean) militarized powder. blood-in-urine. Ricinine and Abrine biomarkers in Supportive care: respiration (naturally occurring with each Cytotoxin as powder or solution. Ricin: LD50 22 ug/kg; Multi-organ failure; urine as confirmation of exposure therapy, fluids, medication for protein) in Urine: Abrin (Abrus precato- Abrin: LD50 0.7 ug/kg. death is possible in 3 - 5 days. to Ricin/Abrin cytotoxic proteins. , and low-BP. Ingestion Ricinine Reportable Range: 0.3 – 300 ppb; rius, Rosary Pea) as Ingestion: Lethal dose < 1 hour: flushing stomach Abrine Reportable Range: 3.5 – 3500 ppb powder or solution. 20-30 mg/ kg. with charcoal slurry.

Table 2. RECOMMEnDATIOnS Table 3. CyAnIDE AnTIDOTE RECOMMEnDATIOnS Table 4. SULFUR MUSTARD TREATMEnT OPTIOnS nerve agent may be obtained as auto-injector syringes. These devices rapidly deliver anti- Victims whose clothing or skin are contaminated with hydrogen cyanide liquid or solution can Sulfur mustard patient may be asymptomatic for 2 - 24 hours. Sulfur mustard is more dense than air; dotes intramuscularly, typically to the thigh or buttocks. Atropine, in auto-injector form, is available secondarily contaminate response personnel by direct contact or through off-gassing vapors. stable – persistent, mutagenic and carcinogenic chemical. Target organs: skin, eyes and lungs. as the AutoPen in amounts of 0.5, 1, or 2 mg. 2-PAM chloride, in auto-injector form, is available as the Avoid dermal contact with cyanide-contaminated victims or with gastric contents of victims who 600 mg ComboPen. A Mark I kit contains two auto-injector syringes; the smaller one with 2 mg at- may have ingested cyanide-containing materials. Victims exposed only to hydrogen cyanide gas Patient Mild Severe Other ropine and the larger one with 600 mg 2-PAM chloride. do not pose contamination risks to rescuers. If the patient is a victim of recent smoke inhalation (Blisters < 2% (Vesicles > 2-5% body surface, Treatment (may have high carboxyhemoglobin levels), administer only . body surface) penetrates clothing) The spring-loaded design of the auto-injectors provides a forceful delivery that may cause tissue damage, especially to children and smaller patients. Children weighing less than 15 lb (about 7 kg), Child Blisters: < 2 cm Confirm decontamination. Dyspneic: Vesicles > 2 cm generally those younger than 6 months old, should not ordinarily be treated with the nerve agent Patient Mild Severe Other cover with topical provide oxygen. debride; irrigate with antidote auto-injectors. In this age group, atropine should be individualized at doses of 0.05 mg/kg. antibiotics. may occur. Treat burns: first/second sterile saline (aq); (conscious) (unconscious) Treatment degree with convalescence. topical antibiotics: sulfadiazine. Child If patient is : 0.12 - 0.33 For sodium nitrite- Adult Blisters: < 2 cm Confirm decontamination. Dyspneic: Eyes: irrigate; apply conscious and has mL/kg, not to exceed 10 mL of induced orthostatic cover with topical provide oxygen. Pulmonary edema topical antibiotics; Patient Mild/Moderate Severe Other antibiotics. may occur. Patient may need petroleum jelly may 1 2 no other signs or 3% solution (300 mg) slow IV hypotension, normal Effects Effects Treatment symptoms, over absolutely no less than saline infusion and continuing care for burns. be applied to eyelids. antidotes may 5 minutes, or slower if supine position are not be necessary. hypotension develops, and recommended. Child Atropine: Atropine: Assisted ventilation after anti- 0.05 mg/kg IM or 0.1 mg/kg IM or IV dotes for severe exposure. Sodium thiosulfate: 1.65 If still apneic after Table 5. LEWISITE (L) AnTIDOTE RECOMMEnDATIOnS IV (minimum 0.1 mg, mL/kg of 25% solution IV over antidote administra- British Anti-Lewisite (BAL, dimercaprol) was developed as an antidote for Lewisite and is used Repeat atropine at 2-5 minute in- 10 - 20 minutes. tion, consider sodium (minimum 0.1 mg, maximum 5 mg); tervals until secretions have medicinally as a chelating agent for heavy metals. BAL can be toxic. maximum 5 mg); and bicarbonate for diminished and breathing is com- severe acidosis. and 2-PAM chloride: fortable or airway resistance has Adult If patient is Sodium nitrite: 10 - 20 mL 2-PAM chloride: 50 mg/kg IM or IV returned to near normal. conscious and of 3% solution slow IV Oxygen Therapy: Patient Mild Severe Other 25 mg/kg IM or IV (maximum 2 g IM the human will (Blisters < 2 cm) (Vesicles > 2 cm) Repeat 2-PAM chloride once at has no other signs over absolutely no less than Treatment (maximum 2 g IM or 1 g IV) or symptoms, 5 minutes, or slower if metabolize cyanide or 1 g IV) 30-60 minutes, then at one-hour quickly in low doses. intervals for 1-2 doses, as antidotes may hypotension develops, and Blisters: < 2 cm Administer as in adults using Vesicles > 2 cm not be necessary. Child necessary. Sodium thiosulfate: 50 mL of cover with topical weight-based dosing. 1 mL/ debride; irrigate with antibiotics. 50 lbs patient weight. sterile saline (aq); Diazepam for seizures: 25% solution (12.5 g) IV over Atropine: Atropine: . topical antibiotics: Child - 0.05 to 0.3 mg/kg IV 10 - 20 minutes Adult 2 to 4 mg IM or 6 mg IM; Blisters: < 2 cm IM: 4-5 mg/ kg or 1 mL/ 50 lbs silver sulfadiazine. IV; and (maximum 10 mg); Adult cover with topical Adult - 5 mg IV patient weight; repeat 4 hours Eyes: irrigate; apply and 2-PAM chloride3: antibiotics. for four (4) doses. topical antibiotics; 2-PAM chloride3: 1,800 mg IM, or Other benzodiazepines (e.g. Alternative Cyanide Antidote IV: never administer BAL in oil. petroleum jelly may be 600 mg IM, or 50 mg/kg IV lorazepam, midazolam) may applied to eyelids. 25 mg/kg IV slowly provide relief. slowly Phentolamine for 2-PAM Patient Mild Severe Other chloride induced : (conscious) (unconscious) Treatment Table 6. CyTOTOxIC PROTEIn TREATMEnT OPTIOnS 1 mg IV for children; 5 mg IV for Ricin protein, Ricinus communis, Castor Bean; Abrin protein, , Rosary Pea, from adults. Child If patient is Cyanokit ® (hydroxo- Second dose may weaponized powder or IV aqueous solution. Inhalation and skin exposure are most toxic; Antidotes conscious and no cobalamin for injection) be used (patient oral exposure is less toxic. Multiple-organ damage is likely in survivors. Ricin/Abrin may cause death. other symptoms, 70 mg/kg IV infusion over in extremis) over 1. Mild/Moderate effects of nerve agents include localized sweating, muscle fasciculations, , vomiting, weakness, dyspnea. antidote may not 15 minutes. a 15 min to 2 hour 2. Severe effects of nerve agents include unconsciousness, seizures, apnea, flaccid paralysis. be necessary. period. Patient Mild Severe Other 3. Dose selection of 2-PAM chloride for elderly patients should be cautious (usually starting at 600 mg IM, Treatment or 25 mg/kg IV slowly) to account for the generally decreased organ functions in this population, Adult If patient is Cyanokit ® (hydroxo- Second dose may nOTE: 2-PAM chloride is pralidoxime chloride or Protopam Chloride. conscious and no cobalamin for injection) be used (patient Child Supportive care Confirm patient decontamination. Antidotes for other symptoms, 5 g IV over 15 min; in extremis) over and treatment. Supportive care: respiration therapy, Ricin are in CHEMPACK: human clinical CHEMPACK is a federal program to provide nerve agent antidotes (Atropine, 2-PAM, Diazepam) to medical personnel during an antidote may not the diluent is 0.9% naCl. a 15 min to 2 hour fluids, treat for seizure/ low-blood emergency. Contact your county EMS coordinator, health department or emergency management office for more information. be necessary. period. pressure. Recent Ingestion: flush trials. Ricin stomach with charcoal slurry. vaccination trials for US may not be readily available at Sentinel or ER hospitals military Adult Supportive care Confirm patient decontamination. personnel are Centers for Disease Control and Prevention, Shipping Instructions for Specimens Collected and treatment. Supportive care: respiration therapy, being studied. fluids, treat for seizure/ low-blood from People Who May Have Been Exposed to Chemical-Terrorism Agents: pressure. Recent Ingestion: flush Chris Christie, Governor Mary E. O’Dowd, MPH, Commissioner new Jersey Poison Control http://emergency.cdc.gov/labissues/pdf/shipping-samples.pdf, accessed 11/23/11. stomach with charcoal slurry. Kim Guadagno, Lt. Governor Christina Tan, MD, State Epidemiologist new Jersey Poison Information, Education System (nJPIES) December 2011 H5642