H5642--Chemical Terrorism 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 CHEMICAL TERRORISM-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 inhalation 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 allergies. 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 plant 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 (Sulfur 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 chemical warfare 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 Protein 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 Toxicity (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 Mechanical ventilation. Metabolites in Urine are Sarin, GB Sarin, GB; Soman, cholinesterase. Rhinorrhea; bronchorrhea; obstructed blood cells) and plasma Atropine (anticholinergic); GF-acid, GB-acid, GD; Russian (Soviet) Inhalation: Sarin (GB): breathing; unconsciousness; cholinesterase within several hours Pralidoxime chloride (2- GD-acid, rVx-acid and 3 rVx; and Vx LCt50 = 100 mg.min/m seizures; flaccid paralysis, apnea. of exposure. PAMCl); Diazepam (prolonged Vx-acid 3 Vx: LCt50 = 10 mg.min/m . seizures). Reportable Range: 1 - 200 ppb. Asphyxiants Cyanide Salt Cyanide binds iron in Cyanosis is a late-finding. Lactic acidosis (Cn interferes Mechanical ventilation. Cyanide in Whole Blood Cyanide, Cn Hydrogen Cyanide Gas cytochrome a3 reduces intra- Reduced reflexes at 1000 – <2500 with lactate oxidation by liver); Antidote: Sodium nitrite or Cyanide, Cn Hydrogen Cyanide, HCn cellular oxygen utilization. ppb; coma/ death 2500 – >3000 arterial oxygen is normal but amyl nitrite, and then sodium Reportable Range: 25 - 2500 ppb. Inhalation: LCt50 = 2500 – ppb Cn in blood. venous oxygen is high. thiosulfate. 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 Lewisite (L) Skin: systemic poison. Immediate. none, obtain definitive test for Skin blister < 2 cm apply Metabolite in Urine, Lewisite, L (Arsenical) 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 edema; hypotension. 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 dimercaprol, 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 Proteins Ricin (Ricinus com- Injection and Inhalation: Vomiting, diarrhea, seizures, and none; obtain definitive tests for Mechanical ventilation. Surrogate Biomarkers Ricin, Abrin 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. seizure, 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. nERVE AGEnT AnTIDOTE RECOMMEnDATIOnS Table 3. CyAnIDE AnTIDOTE RECOMMEnDATIOnS Table 4. SULFUR MUSTARD TREATMEnT OPTIOnS nerve agent antidotes 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