Sign Up
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Bioterrorism and Weapons of Mass Destruction

4 Contact Hours including 4 Advanced Pharmacology Hours
Meets Nevada Requirement
Listen to Audio
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Wednesday, September 17, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


≥92% of participants will be able to recognize an event involving bioterrorism or weapons of mass destruction.


After completing this course, the learner will be able to:

  1. Define acts of terrorism and weapons of mass destruction.
  2. Identify appropriate forms of personal protective equipment and decontamination for dealing with acts of terrorism.
  3. Categorize common symptoms and treatment methods associated with exposure to or injuries caused by chemical, biological, radioactive, and nuclear agents.
  4. Describe syndromic surveillance and reporting procedures for acts of terrorism that involve biological agents.
  5. Summarize access and use of Federal and CDC resources for communities after the Weapon of Mass Destruction attacks.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
  • 0% complete
Hide Outline
Playback Speed

Narrator Preference

(Automatically scroll to related sections.)
Bioterrorism and Weapons of Mass Destruction
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    David Tilton (RN, BSN)

The Nature of the Problem

Fear is the driving force behind weapons that create mass destruction. Possessing weapons of great destruction, death, and grave injury leads to increased safety as enemies hesitate to offend those who might employ them. Employing weapons possessing mass destructive capabilities also benefit aggressors wanting to achieve maximum carnage and confusion to the victims of their violence.

World map

Weapons able to cause horrendous casualties and excessive destruction are not new. Historical accounts convey that during the 6th century BC, the Assyrian army used a chemical agent, rye ergot (a hallucinogen), to poison the drinking wells of enemies, causing terror, and to a lesser extent, death (Pacific Institute, 2019).

The army of the Islamic Tartar nations is recorded as having provoked an outbreak of black plague (a.k.a. bubonic plague) in 1346 during its siege of the merchant city of Kaffa in Crimea. The Islamic army purposely lobbed the diseased and decaying bodies of their own afflicted soldiers over the Kaffa city wall and into the packed civilians sheltering therein. Some historians speculate that the results of this action may have directly propelled the Black Death pandemic into Europe, parts of Asia, and Africa as exposed survivors fleeing the maritime trade city provided a convenient vehicle for the disease spread. Before its end, the Black Death pandemic spread terror and destruction, slaughtering nearly half of Europe’s population (Ishak, 2020).

Title 18 U.S.C. §2332a defines weapons of mass destruction (WMD) as (OLRC, 2021) (FBI, 2021):

  • Any explosive, incendiary, or poison gas, including the following: a bomb, grenade, rocket having an explosive or incendiary charge of more than four ounces, missile having an explosive or incendiary charge of more than one-quarter ounce, mine, or device like any of the previously described devices
  • Any weapons that are designed or intended to cause death or serious bodily injury through the release, dissemination, or impact of toxic or poisonous chemicals, or their precursors
  • Any weapon involving a disease organism
  • Any weapon that is designed to release radiation or radioactivity at a level dangerous to human life

We live in an age of high-tech wonder and terror. There has never been a time in recorded history where the ability to afflict injury and death on large numbers of people has been as readily available to nations and individuals as it is today. In this time of technology, Weapons of Mass Destruction (WMD) are options that driven individuals or groups may use to effect or inflict damage on the rest of us.

Today's instruments of mass destruction can be encompassed by the abbreviation CBRNE, with biologic weapons being the second focus of emphasis.

We will be holding to this structure of presentation in this training.

  • C – Chemical
  • B – Biological
  • R – Radioactive
  • N – Nuclear
  • E – Explosive (high-yield)

As healthcare providers, we should be prepared to recognize and treat those impacted by or exposed to these weapons. Frontline medical staff must learn to identify CBRNE weapons by being aware of abnormal surges in patient presentation patterns.

The recent Covid pandemic has emphasized how recognition of CBRNE weapons holds great importance. Hospitals and medical facilities in our country and industrialized world are designed to handle patients who arrive singularly or in small numbers with intervals between new cases. The Coronavirus phenomenon has shown that an influx or surge of patients in the hundreds, even the thousands over a span ranging from just a few hours to a period of weeks, will strain even the best-designed health system to the point of breakdown.

MCI - Mass Casualty Incident Demands

Mass casualty incident demands on a Health Care System (Hodgson, 2021) (Mills & Helm, 2020):

  • Shortage of bed space, treatment space, particularly critical care beds, ventilators, specialty supplies
  • Medication shortages
  • Need to incorporate or expand into non-traditional or ancillary treatment centers
  • High demand for mortuary holding areas, funeral-related services
  • High demand for counseling and social services
  • Healthcare worker shortages
  • Prolonged drain on medical care resources from weeks to months
  • Loss of essential staff to the casualty event (e.g., medical personnel, police, firefighters, first responders)
  • Elderly and others fearful of leaving their homes for chronic medical care

Chemical Weapon Agents

Chemical Weapons Agents (CWAs) are sometimes referred to as a “poor man’s” bomb due to their relatively low production costs, the physical and mental effects they cause, and their ability to disrupt the infrastructure of population centers targeted.

Chemical weapons are loosely defined as compounds that pose a hazard to living tissues when they come in contact. CWAs may produce incapacitation, serious injury, or death. Substances that may be passed into service as chemical weapon agents are all around us.

Common chemicals that can cause injury are found in virtually every home. The more concentrated compounds used in business, agriculture, and industry magnify the potential end-forms produced. The type of injuries produced from weapon-grade chemicals can originate from various causes. These compounds might occur due to an industrial accident, industrial sabotage, damage to a chemical storage area or stockpile, an act of war, or even a directed terrorist attack.

CWAs are a matter of great concern due to the following characteristics that increase the chances terrorists may use them on civilian populations.

  • The components from which CWAs can be made are widely available
  • Recipes for CWA production are easy to access worldwide on the internet and through a library or educational facilities
  • CWAs are easily transported
  • CWAs may be delivered to victims by a wide variety of means
  • Chemical agents are difficult to protect against
  • CWAs tend to work quickly and incapacitate their targets
  • Very few civilian communities are prepared to deal with a large-scale chemical terrorist attack
  • Area hospitals would be rapidly overwhelmed by the casualty surge

CWAs tend to be placed in broad groupings or categories according to the primary effect they have on living humans or animals.

  • Vesicating or blistering agents - Chemicals that severely irritate or blister the eyes, respiratory tract, and skin on contact
  • Blood agents – Toxins that affect the body by altering blood functions such as the oxygen-carrying capability
  • Caustic agents – Chemicals that corrode or burn the skin, eyes, lining of nose, lungs, throat, or mouth on contact
  • Pulmonary agents - Chemicals that cause severe irritation or swelling of the respiratory tract, such as the lining of the nose, throat, and lungs
  • Incapacitating agents - Toxins that make people unable to think clearly or cause an altered consciousness state. Riot control agents are sometimes placed in this category.
  • Nerve agents - Highly poisonous compounds that work by preventing the nervous system from working properly

“Persistent Agents” is the term used for those chemical warfare substances that remain dangerous for a considerable amount of time. Often a specific action will need to be taken to destroy or neutralize them. These substances usually tend to be liquid or solid at normal room temperatures rather than gaseous.

“Non-persistent agents” are those compounds that typically remain in effective concentrations for only a short time. These chemicals tend to be released as either; 1) airborne particles of a solid (i.e., mace, pepper spray), 2) droplets of a liquid (e.g., the sarin vapor used in the Tokyo subway attacks), or 3) true gases.

Airborne particles are easily affected by prevailing weather conditions and may be quickly dispersed so that the locality in which they have been released soon ceases to be contaminated.

Victims typically are exposed to chemical agents via three main routes:

  1. Skin (by liquid or high vapor concentrations).
  2. Eyes (liquid or vapor).
  3. Respiratory tract (vapor inhalation).

Depending on the agent, the method of delivery, and the amount (concentration) of exposure, chemical warfare agent effects may be seen immediately, or effects may be delayed. Large inhalation exposures to nerve agents or the tissue irritants known as mustards are likely to kill people immediately. Whereas small exposures on the skin to the very same nerve agents and mustards initially only irritate, in the manner of poison ivy or a very annoying insect bite, skin exposure to these chemicals is dangerous. It will progress far beyond the irritation present at first. All individuals exposed to such agents need to be carefully observed for slowly developing or delayed effects.

First responders to an area where a chemical warfare agent has been released are at serious risk from the environment, which may be steeped with invisible concentrations of the chemical contaminant. This area of high concentration danger is known as a Hot Zone. Rescuers can come into skin contact with the particles of chemicals, liquids in fluid or droplet form, or even inhale gaseous vapors. Responders are also at risk if they handle the skin and clothing of victims, especially if a liquid chemical agent was used.

Ideally, emergency personnel will wear personal protective equipment specific to the hazardous material present, decontaminate the victims immediately, provide initial medical support and transport, and have access to specific antidotes to counteract harmful effects.

Fast Fact:

For chemical events, a good safety rule is to move quickly Up, Up, Up!

Uphill, upwind, upstream from the Hot Zone area of danger

Diagnosis of chemical warfare agents has taken a significant upturn in the past few years with the development of test paper strips sensitive to the various agents. Another interesting turn is the blood stick glucometer type system developed by the U.S. Army Medical Research and Development Command's U.S. Army Medical Research Institute of Chemical Defense (USAMRICD). Called the ChemDx test system. With this, point of care diagnostics can be quickly made in the field or care center, revealing just what the crisis client has been exposed to (Kronman, 2021).

Chemical Nerve Agents

Chemical weapons known as nerve agents are highly poisonous manufactured compounds that prevent the nervous system from working properly. Ironically, death is not the purpose of nerve agents, but rather to rapidly incapacitate large numbers of people for extended periods, creating fear, tying up resources, and causing the collapse of support infrastructure. However, many people exposed to nerve agents die depending on the agent used and exposure.

Under the normal room temperature and atmospheric pressure, nerve agents tend to take volatile liquids, which may seem contradictory as they are referred to by the common usage name of “nerve gases.” Their chemical nature can explain this liquid state. Volatile means the liquified gas tends to evaporate quickly. Nerve agent vapors, e.g., nerve gas, are heavier than air and, once airborne, tend to sink into low, sheltered areas such as subways, stairwells, basements, or bomb shelters.

The most volatile nerve agents are sarin, which evaporates at 22 degrees Celsius or 71.6 degrees Fahrenheit. The least volatile agent, VX, has a consistency like that of motor oil and is 100-150 times more toxic than sarin when in contact with skin. Make no mistake; these are dangerous substances, and all chemical warfare nerve agents can rapidly penetrate both skin and clothing due to their high volatility.

Chemical/Nerve Warfare Incidents:
  • 2019, a chemical agent Novichok was used on a Russian presidential candidate either on or shortly before boarding a domestic Russian flight.
  • 2018, Novichok was used on seven people in Salisbury, England, one of whom, a former Russian agent, is presumed to have been the target.
  • In December 2016, the Turkish Islamic military dropped Chlorine and Sarin gases on neighborhoods within Damascus, Hama, Idlib, and Aleppo, Syria, killing at least 64 and afflicting hundreds with symptoms.
  • 2014, ISIS Terrorists massacred thousands of Iraqi and Shi’ite civilians and soldiers, employing Chlorine and Mustard gas bombs.
  • In 2014, the Syrian military bombed Damascus civilians with Choline gas bombs killing 104 and wounding over 200.
  • 2013, the Syrian military released Sarin gas in the suburbs of Damascus, killing 1429 with over 2200 injured.
  • 2013, Afghan Taliban terrorists released industrial pesticides into girls' schools in Takhar and Sar-a-Pul, contaminating air and water, leaving over 1,952 poisoned.
  • 1995, Serbian forces shelled 15,000 Bosnian refugees with BZ. Due to conflicting reports and the simultaneous use of regular explosive and incendiary ordnance on the target, mortality rates are unknown.
  • 1995, Sarin gas attack on the Tokyo subway by the Aum Shinrikyo cult killed 12, blinded 1000, forced a surge of 5,500 to nearby hospitals, forcing several months of shutdowns of vital infrastructure.
  • In the 1980s, Iraq used Tabun, a nerve agent, and other chemical weapons, including Mustard gas, against Iranian civilians and soldiers and Iraqi Kurd civilians in over 350 large-scale chemical attacks. Though casualty numbers are hotly disputed, supposed deaths from chemical weapons were in the hundreds of thousands. Unexploded chemical weapons rounds and buried barrels of toxins are still being uncovered in the contested regions by villagers.
( Editors, 2021) (Warfare History Network, 2019) (Trista, 2019) (Koblentz & Stricker, 2020) (Holstege, 2021)

Around seventy known chemical warfare compounds fall roughly into five types looking at them by effect or three series if chronicling their history. By history, nerve agents are then separated into two main groupings (Sawe, 2020).

The “G” series, whose first initial connotes the German scientists who researched and developed them, and the “V” series, where the initial represents Venomous, which some authors credit as research branching from crop pesticide studies. All are banned by international law and treaties and are exclusively military weapons. The five most employed nerve agents by name are:

  • Tabun (also referred to by the military designation “GA”)
  • Sarin (GB)
  • Soman (GD)
  • Cyclohexylsarin (GF)
  • VX (along with less common subtypes VE, VG, VM, VR)

The third series of chemical warfare nerve gas agents, called Novichok Nerve Agents, have recently become known. Novichok is the Russian word for “newcomer,” and information regarding these compounds originates from 1992 disclosures to the media by a chemist working in a Russian military chemical complex who voiced concerns that defense conversion money from the west was being used for the development of chemical weapons.

The Novichok series, which is said to be more powerful and deadlier than the previous generations of nerve gases, brings a handling advantage in the form of a binary formula, where it takes two different components to activate, so that they may be handled separately in relative safety, with the deadly nerve agent only appearing when the two parts are mixed, such as during the detonation of an explosive device (Coelho & Foltynova, 2020).

The new edge of safety the Novichok series of nerve agents brings to its handlers, if not to end recipients, has prompted newer spins on older generation chemical warfare compounds. Known binary nerve agents now include:

  • Novichok – particularly Novichok-5, Novichok-7
  • GB binary – sarin, GB2
  • GD binary – soman, GD2
  • VX binary – VX2

The major nerve agents possess chemical structures similar to the common commercial organophosphate pesticide Malathion's active forms. In action, these warfare agents initially stimulate and then paralyze nerve transmissions throughout the body, primarily by inhibiting acetylcholinesterase, a key enzyme in the nervous system. This cholinesterase inhibitor mechanism leads to hyperactivation of cholinergic pathways causing convulsive seizures and respiratory failure.

Terminology Boost:
  • Fasciculations = Small involuntary muscle twitches.
  • Conjunctival injection = Redness in the white sclera of the eye.

Diagnosis of Nerve Agents

Diagnostic testing is unreliable in identifying nerve agents in blood or urine, though test strips and the ChemDx test system are becoming available. Health providers must make their treatment decisions based on the signs and symptoms an afflicted client presents with and information about the type of chemical exposure if known.

Nerve Agent Toxicity :
  • Respiratory – Dyspnea, cough, tachypnea, wheezing, respiratory failure
  • Cardiac – Bradycardia or tachycardia
  • Neurologic – Headache, decreased LOC, weakness, fasciculations, seizures
  • Ophthalmic – Eye pain, miosis, tearing, blurred vision, conjunctival injection
  • ENT – Rhinorrhea
  • Dermal – Sweating
  • Gastric – Nausea, vomiting, diarrhea
  • Urinary – Urinary incontinence
  • Psychological – Agitation, anxiety
(Velez-Daubon, 2021)

Treatment of Nerve Agents

Treatment of victims exposed to chemical warfare nerve agents is like treating those poisoned by organophosphate insecticides, with decontamination and appropriate initial therapy. Serious signs and symptoms of nerve agent toxicity rarely last more than a couple of hours (Velez-Daubon, 2021).

Victims with symptoms require immediate treatment with atropine IV or IM. Atropine aids breathing by drying secretions and opening airways. Atropine also blocks other effects of poisoning, such as nausea, vomiting, abdominal cramping, low heart rate, and sweating. Atropine will not prevent or reverse paralysis. Pralidoxime chloride is a medication with effects like the more readily available atropine and may be given during times of casualty surges should atropine be in short supply.

An emergency nerve agent treatment kit known as the Mark I Kit has been designed for military personnel's self-administration in the field. It consists of two spring-loaded devices for self-injection, one each containing atropine and pralidoxime chloride. The Mark I Kit is not available for civilian use yet can be obtained on a “time of need” basis from Federal Emergency Management Agency (FEMA) controlled regional storage facilities.

The peak toxic effects of nerve agents occur within minutes to hours and go away within 24 hours. People exposed but show no symptoms should be observed for at least 18 hours as some symptoms, including potentially fatal ones, have a gradual onset.

Chemical Blister Agents

Vesicating or Blister Agents are often referred to by the slang term “Mustards.” This agent is not the yellow stuff found on hot dogs at the ballpark. What we are talking about is Nitrogen mustard (HN 1-3), Sulfur mustard (H or HD, also referred to as “mustard gas”), Lewisite (L), and Phosgene oxime (CX).

These compounds cause intense irritation, inflammation, and corrosive burning on contact with living tissue. Mustard agents rapidly penetrate cell walls and generate a highly toxic reaction that disrupts cell function leading to cell death. This chemical reaction is temperature-dependent and is aided by water, which explains why warm, moist tissues like eyes, airways, armpits, or crotches are affected more severely.

Blister agents have the consistency of oily liquids that possess an odor somewhat reminiscent of mustard greens, onion, garlic, or even horseradish. They are highly soluble in oils, fats, and organic solvents. They quickly penetrate the skin and most covering materials or textiles, including rubber.

The nemesis of WWI trench warfare, Sulfur mustard is a persistent agent with low volatility at cool temperatures that quickly becomes a major vapor hazard as temperatures rise. Exposure to mustard vapors, not the more concentrated mustard liquid, is a primary medical concern, as mustard vapor is three times more toxic than a similar concentration of cyanide gas. Skin exposure to as little as one teaspoon of liquid sulfur mustard (seven grams) will be lethal to half of those exposed.

Diagnosis of Blister Agents

Diagnosis of vesicant/ blister agent/ mustard exposure is based on observations of the person’s signs and symptoms and reports from the time of exposure. No standard laboratory tests have proven diagnostic, though if available, the US Army medical research has begun producing both test papers and a glucometer style ChemDx test system that holds promise.

Vesicating agents primarily injure the skin, eyes, respiratory tract, GI tissues, and blood system. Wherever tissue is exposed to the agent, the symptom pattern will reflect corrosive irritation of that area. Skin exposure commonly results in an initial rash followed by blistering, similar to a partial-thickness burn. Vapor exposure primarily damages the upper respiratory tract. Mustards penetrate cell walls in less than 2 minutes, yet serious signs and symptoms may be delayed from 4-6 hours (the range can be from 1-24 hours) (Salameh, 2019).

Treatment of Blister Agents

Decontamination within 2 minutes of exposure is the most critical intervention for skin exposure to any tissue irritant mustards. Any living tissue affected undergoes irreversible cell damage. Decontamination, therefore, remains urgent even if a person shows no obvious signs and symptoms to initial exposure.

Traditionally, Fullers Earth, a type of porous clay, has been the effective primary treatment for tissue exposed to vesicating blister agents. It works by lifting away and absorbing oils and impurities. A new topical product designed to neutralize the toxicity of blister agents and, to an extent, nerve agents were approved for use by the FDA in July of 2003. This product is known by the acronym RSDL, which stands for Reactive Skin Decontamination Lotion, and acts within seconds of being applied to the skin. RSDL is a creamy lotion packaged on a foam applicator in a single-use pouch or tear open single-use towelettes. It is available for use by military and some civilian emergency services. The lotion should be applied within three minutes of skin contamination for the best effect. The residue left by the lotion, which is non-toxic, should be washed away at the earliest convenience (Dachir, Cohen, & Buch, 2021).

Treatment of blister agent exposure following decontamination is symptomatic, with aggressive irrigation taking a primary role. For most blistering agents, there is no agent-specific antidote. The blister agent Lewisite (chlorovinyldichloroarsine) is the only chemical in this grouping with a specific treatment. Lewisite is an arsenical vesicant that is a colorless to brown liquid with a fruity or geranium-like odor. A scavenger molecule, dimercaprol or British anti-Lewisite, works to bind the Lewisite compound, creating an effective antidote when given as early as following possible exposure.

Upper airway obstruction warrants aggressive airway management as tissues permeated by the vesicant agents will continue to worsen. Systematic burn care is essential because skin lesions are slow to heal and prone to infection. Hospitalization time tends to range from two to four months.

Chemical Blood Agents

Blood Agents are chemical warfare agents that affect the victim by being absorbed into the circulating bloodstream. Many poisons contain cyanide ions, which chemically inactivate cytochrome oxidase once in the body and blood, an essential component whose absence prevents cells from utilizing oxygen. This means that although the person’s blood delivers oxygen to their tissues, the cells themselves are poisoned and unable to take the oxygen up. The result is asphyxia with a small degree of cyanosis. Cyanide compounds act rapidly, causing death within the first ten minutes of severe exposure. Fatalities may occur with inhalation or ingestion of the chemical agent.

Cyanide-based compounds are frighteningly easy to obtain. Industrial uses for hydrogen cyanide are numerous. The liquid form of a cyanide agent could be inserted into a water supply or disguised in a strongly flavored food or liquid.

Contrary to popular literature and entertainment media, cyanide compounds in gas make a poor weapon. The gaseous form is volatile, disappearing rapidly into the environment, and poses a grave threat to anyone handling it, especially those releasing it. In addition, the gaseous form either kills or has minimal effect, making it an all-or-nothing agent instead of creating mass casualties leading to an infrastructure collapse, the primary purpose of chemical weapons.

Diagnosis of Blood Agents

Due to the short time interval between exposure and death, diagnosis depends heavily on observation and available facts regarding exposure. A bitter almond odor associated with the patient may suggest cyanide poisoning; however, the lack of odor is not a reliable exposure gauge.

The effects of blood agents include metabolic acidosis, hyperventilation, sudden headache, a venous blood-O2 level above normal, and hypotension. The mucosal membranes and skin of casualties tend to appear an unusual dark red because the tissue cells cannot utilize oxygen. Higher exposure levels provoke coma, convulsions, and cessation of respiration and heartbeat. Laboratory confirmations of cyanide or thiocyanate in blood or urine are useful for later confirmation of the initial diagnosis.

Treatment of Blood Agents

Supplemental oxygen by mask followed by intubation with 100% O2 is the preferred initial treatment. Hydroxocobalamin, sodium nitrite, and sodium thiosulfate are antidotes to cyanide when administered immediately. Nithiodote is a market name for a sodium thiosulfate/sodium nitrate ready mix for rapid intravenous use (NIH Staff, 2021).

The natural form of vitamin B12, hydroxocobalamin, is used intravenously to treat cyanide toxicity, and a rapidly administer pack is marketed under the name Cyanokit. For hydroxocobalamin, a standard dose of 5 gram IV over 15-minutes, with a second dose given in severe toxicity, binds cellular and circulating cyanide molecules, which will then be excreted in the urine. IV sodium thiosulfate reacts with cyanide to form thiocyanate, which is excreted by the kidneys. Amyl nitrite inhalation, one ampoule (0.2 ml) every 5 minutes, might be helpful as it generates methemoglobin that binds molecular cyanide. Full protection from lingering cyanide vapors can be achieved with activated charcoal filters.

Chemical Incapacitating Agents

Incapacitating agents include a wide range of chemicals whose actions produce physiologic or mental inability to function. In military terms, these agents are referred to as Harassing Weapons. Their purpose is to confuse, disorient, frighten, and render individuals incapable of performing any semblance of normal activities.

Incapacitating Agents in Action:
  • 2021 March – Tear gas used at Montreal anti-lockdown protest
  • 2020 July – Tear gas used on Portland protestors
  • 2002 October - Aerosolized fentanyl derivative used by the Russian military to incapacitate terrorists holding hostages at the Moscow Dubrovka Theater. 127 of the 800 hostages perished; the rest were treated for degrees of respiratory effects
(Oakes, 2021) (Theen, 2020) (McCranor et al., 2020)

An incapacitating agent known as 3-quinuclidinyl benzilate (QNB or BZ) may be the most used compound of this nature currently in use. QNB has played a role in military and civil unrest actions in several countries such as Mozambique and Bosnia. There are no credible reports of its use by law enforcement in the United States, although ample time and funding have been channeled into the Department of Defense Joint Non-Lethal Weapons Program. QNB can cause intense visual and aural hallucinations in those exposed to it, producing an overwhelming loss of reality. It is pharmacologically related to commonly used anticholinergic drugs, and these chemical traces are present in some over-the-counter sleeping medications.

Lacrimation Agents (tear gas) are incapacitating agents used by police and military in the United States and other countries, primarily for riot control. The mode of action of these agents is an intense immobilizing irritation to the eyes, respiratory tract, and skin. Weapon-grade versions of these agents can provoke fatal inflammatory reactions in vulnerable populations, particularly the young and old.

Table 1: Incapacitants
  • BZ – Central nervous system effects
  • 3-Quinuclidinyl benzilate (QNB)
Lacrimation Agents (Tear Gases):
  • OC – Pepper Sprays
  • CN – Effects on the senses, aka Mace
  • CS – Effects on the senses
  • PS – A fumigant
  • Oleoresin Capsicum
  • 2-Chloro-1-phenylethanone
  • 2-Chlorobenzalmalononitrile
  • Chloropicrin
Vomiting Agents:
  • DA – Tissue irritation, nausea
  • DC – Tissue irritation, nausea
  • DM (Adamsite) – Tissue irritation, nausea
  • Diphenylchlorarsine
  • Diphenylcyanoarsine
  • 10-Chloro-5,10-dihydrophenarsazine

New incapacitating agents are cropping up all the time. In October 2002, Soviet security officials flooded a crowded Moscow theater with an aerosolized form of the common post-surgical pain medication fentanyl. This medication resulted in most of the 800 hostages held by terrorists being rescued. Unfortunately, it also meant that 127 people perished, with no accurate account of how many deaths were directly due to the incapacitating agent used (McCranor et al., 2020).

Diagnosis of Incapacitation Agents

Awareness of emergent events in the region is a great help when dealing with early arriving walk-in or staged triage clients secondary to incapacitation agents. With a sense of irony, be aware that most exposure to incapacitation, aka “riot” agents, will be due to civil authorities using them on their civilians. It is against the world Chemical Weapons Convention to utilize an incapacitation chemical weapon against an enemy combatant. Yet, through the same accord, governments may feel free to use any of the “less lethal” chemical weapons on their citizenry (Zanders, 2020).

Look for incapacitating effects. Clients are unable to function adequately, with difficulty seeing, walking, and concentrating. If available, a Rapid Toxic Screen may reveal the offending agent. If not available, the Centers for Disease Control (CDC) maintains a 24-hour laboratory response system, sometimes referred to as the CDC Chemical Emergency Response Team, which can assist with diagnosis and treatment decisions (CDC ERB, 2019).

BZ - 3-Quinuclidinyl benzilate, also referred to as QNB, should never cross the threshold of your facility. It is a hallucinogenic anticholinergic delirium compound banned worldwide by the Organization for the Prohibition of Chemical Weapons (OPCW). In the US, national stockpiles have been officially destroyed. Think of it as LSD that floats as an aerosol through the air, being inhaled and sticking to clothing and objects where it can be picked up and absorbed through the skin of secondary targets. Be alert for the “4B” classic toxic anticholinergic syndrome: “dry as a Bone, red as a Beet, hot enough to Boil, and blind as a Bat.” Also, confusion, hallucinations, sinus tachycardia, mydriasis (pupil dilatation), flushed, dry, warm skin, diminished bowel sounds, hyperthermia, and urinary retention may be present. Seizures may occur in severe poisoning. It is important to note that pupillary dilatation may be mild or even absent at doses capable of causing delirium. As a side note, many of those affected by BZ will tend to hyperactivity and disrobing. The desire to be naked is not sexual. No, I am unaware of any studies on this aspect, merely anecdotal reports of sufficient frequency worth considering and getting naked, most likely due to hyperthermia and a “bugs crawling” feeling from nervous stimulation (Holstege, 2021).

OC – Pepper Sprays
In its various forms, Pepper spray is employed frequently in legal and civil actions. These are OC – oleoresin capsicum in various forms and formulas. OC sprays do not have a great potential for lethality; however, they make the banned weapons of warfare list from OPCW.
Illegal to use against enemy combatants, yet the first line in use protecting against personal assailants, subduing civilians or dispersing protests.
When it encounters a person's eyes, OC causes burning, pain, and tears, with a cough or shortness of breath when inhaled.
Treatment consists of moving to fresh air, flushing the eyes and skin with water (without soap!), blinking the eyes rapidly to help flush out the oil-based chemical, and carefully removing contaminated clothing.
OC exposures usually resolve in 10-30 minutes and rarely require medical care.
(Smith, A., 2020)

Lacrimation agents, aka tear gas, are the most used of the incapacitating chemical weapons. CS, the most frequently used after OC (pepper sprays), is the “big brother” of CN, aka Mace, a sensory irritant causing tearing, coughing, and disorientation used heavily in Vietnam and Korean conflicts before being phased out by the more tear-producing CS formula. CN has the most propensity for tissue damage in high doses, causing corneal epithelial damage. CS has a higher sensation of the eye and tissue burning, though less lasting tissue damage. The pepper sprays are the most difficult to get off the skin and out of the eyes enough to function. The diagnosis comes down to observation. Look for tissue irritation, inflammation, tearing, redness of eyes, and chest tightness if inhaled, and yes, it is difficult not to inhale a riot gas sprayed onto you! (Tompkins, 2020).

The vomiting agents DA and DM (Adamsite) are aerosols primarily absorbed through the respiratory system, though skin absorption may occur. No point of care (POC) or rapid tests are available to diagnose vomiting agents. Clinicians should base the diagnosis on their observations suspecting exposure in clients presenting with eye irritation who progress to nausea, vomiting, abdominal cramping, and eventually diarrhea. Again, keeping an ear to the pavement for any reports of civil disturbances or mass casualty events can indicate which direction a diagnosis should swing (Holstege, CBRNE - Vomiting Agents - Dm, Da, Dc Workup, 2020).

Treatment of Incapacitation Agents

Treatment of incapacitating agents is symptomatic, with irrigation of the eyes and supplemental oxygen being the most common initial treatment. Careful handling of both persons and clothing and protective coverings for health workers is essential across the board. Those exposed require monitoring for individual effects specific to the chemical agent used.

BZ treatment may be deceptive, so let us get the knee-jerk intervention off the table right away. Peripherally acting anticholinesterase medications which do not cross the blood-brain barrier (e.g., pyridostigmine, neostigmine, pilocarpine) will be ineffective against the central nervous effects of this agent. No specific antidote for BZ/QNB exists. However, diazepam and some of the other physostigmine effects may be helpful. Supportive care will be the focus treatment allowing the agent to wear off and be excreted. The focus is skin decontamination, oxygenation, early and aggressive cooling measures to thwart any hyperthermia symptoms, hydration, and preventing self-harm due to delusional thinking (Holstege, 2021).

Lacrimation agent treatment is clear cut. Get it off! Get contaminated clothing off, get the residue off of skin and eyes by water irrigation, and get your contacts out. Let us say a little more about eye contact. CS gas is a finely ground powder cast into the air by grenade force or compressed air. CS adheres to the surface of the contact lens. Get them out as quickly as possible! If your client uses a rescue inhaler for asthma or other conditions, help them use it. As mentioned earlier, riot agents will be inhaled. Sometimes just a trace, other times much more. The irritation of mucosal and lung tissues can exacerbate existing conditions (Smith J., 2020).

Treatment for repetitive emesis is handled with IV fluids and antiemetics. No single antiemetic has proven superior when treating chemical vomiting agent effects, so go with personal experience and preference. Vomiting inducing weapons also affect other tissues such as eyes, skin, and lungs. Flush eyes profusely if redness is present. Watch for skin redness and the formation of vesicles/ blisters—gentle skin irrigation followed by applying soothing compounds such as calamine or camphor. Be sure to leave small vesicles intact. However, large ones that are likely to break should be drained with follow-up irrigation several times a day and topical antibiotics. Wheezing respirations warrant nebulized albuterol and close watch, though intubation is rarely needed following vomiting agent exposure (Holstege, CBRNE - Vomiting Agents - Dm, Da, Dc Workup, 2020).

Differential Diagnosis of Inhaled Agents
  • Phosgene is distinguished by its mowed grass smell in high concentrations and the delayed onset of pulmonary edema.
  • Chlorine has a characteristic odor even in low concentrations, immediate onset of respiratory distress, bronchospasm, eye, skin, and upper airway irritation.
  • Riot agents cause an acute onset of burning sensation in the eyes and upper airway without progression of symptoms with ongoing exposures.
  • Nerve agents induce watery secretions and respiratory distress but have a host of other symptoms, such as miosis, seizures, and rapidity of onset, that distinguish them from pulmonary agents.
  • The respiratory toxicity of vesicants (i.e., Blister Agents, Mustard Gas) is usually delayed and affects the central rather than the peripheral airway. Vesicant toxicity severe enough to cause dyspnea typically causes airway necrosis, often with upper airway obstruction.
(NIH, 2021)

Chemical Pulmonary Agents

Pulmonary or Choking Agents are chemicals that act directly on the lungs and respiratory system tissues. Many of these chemicals are commonly used in agriculture and industry and are readily accessible to individuals willing to break the law. They include phosgene, chlorine, diphosgene, chloropicrin, oxides of nitrogen, and sulfur dioxide.

Pulmonary agents are chiefly gaseous compounds or aerosolized liquids. The effects are often immediate yet may be delayed up to 24 hours, rarely up to 72 hours. Individuals may be asymptomatic following initial low exposure. Lack of symptoms does not make them clear, as tissue irritation and swelling can begin hours after exposure to the agent.

Phosgene (CG) is a good example of a pulmonary agent chemical weapon due to the intriguing dichotomy of its legitimate use in numerous industries and past use as a terror weapon by both warring nations and extremist groups. In industry, phosgene is a valuable reagent that smells of freshly cut grass or slightly moldy hay and synthesizes pharmaceuticals and other organic compounds. As a chemical warfare weapon, phosgene is a pulmonary toxicant. Exposure to it leads quickly to injury of the respiratory tract and suffocation. Phosgene has an insidious side, with inhalation initially having an irritant effect like tear gas and a somewhat delayed, extremely serious onset of pulmonary edema developing around 4 hours after exposure (GUWS, 2020).

Diagnosis of Pulmonary Agents

No specific tests are readily available, though a good history will help identify source and exposure characteristics. Chest x-rays may help confirm the presence of pulmonary infiltrates. Initial signs of respiratory tract irritation such as coughing, runny nose, or wheezing may be followed by the development of a pulmonary infiltrate and shortness of breath. Chest tightness often progresses to laryngeal spasms. Acute Respiratory Distress Syndrome (ARDS) is common, leading to non-cardiogenic pulmonary edema.

Treatment of Pulmonary Agents

No specific antidotes are available for pulmonary or choking agents. Aggressive pulmonary lavage is not effective at this time. Treatment must center on enforced rest while aggressively maintaining the airway along with management of the secretions. The emphasis on rest cannot be overstated. Increasing pulmonary pressures due to building inflammation and edema can readily lead to cardiac collapse. High-dose steroids may be employed to prevent pulmonary edema. Treatment of pulmonary edema centers on the use of mechanical ventilation with positive end exhalation pressure (PEEP) to maintain a PO2 above 60 mm Hg (NIH, 2021).

Case Study:
The Urgent Care Clinic next to City Center, where Wallace works, has been frantically busy. Rush hour adults from the nearby mass transit station recently began to pour in, eyes streaming, coughing hoarsely. Several reported toy drones trailing a white, gray cloud circling over transit center crowds.
Amongst the noisy, crowded chaos, Wallace smells the heavy, cloying odor of molding hay or newly cut grass.
One call to EMS activates the city’s emergency management plan. Following the plan, an urgent care staff member leads ambulatory clients away from the city center to an open area uphill and upwind from the mass transit station. EMS moves quickly to set up triage and decontamination units outside the transit center, the suspected hot zone. Workers arrive to evacuate the more severely affected from the Urgent Care.
Wallace’s call was one of several received almost simultaneously from several key spots around the transit station. Police and aid units were immediately dispatched, setting up blockades to keep civilians safely away from the area and establishing triage areas. EMS is notifying hospitals and care centers in an expanding zone to activate their emergency plans and prepare for incoming updates as more information is gathered.
Simultaneously, the city emergency center is activated to coordinate efforts and direct assistance into the needed area while bringing the injured out. Less severe cases are being moved to more distant hospitals, keeping severe injuries available close to the scene.
After Action Notes:
  • Emergency management in a potential WMD event is not about rushing people through; it centers on a smooth, swift flow toward the next station in the links of an extended chain of care.
  • All health agencies and establishments must have written plans for dealing with emergencies. Please, know your plan. Know where the plan is. Know the first steps toward safety.
  • Always move toward the next stage of care. However, if unsure what the next step is, locate a place of safety, let authorities know where you are and await direction. It is more important to wait for a little and then find the correct next step, rather than rushing blindly in an unsafe direction.

Chemical Caustic Agents

Chemicals that corrode or burn the eyes, skin, or mucous membranes immediately on contact due to being too strong an acid or base are called caustic chemical agents. Contrary to popular thought, acids, for example, do not actually “eat” substances they encounter. Instead, acids cause rapid oxidation. Binding with the contact surface to form new, foreign molecules was once clothing, metal, or tissue.

Phosphoric acid, sulfuric acid, or the most weaponized caustic, hydrofluoric acid, is unhappily easy to obtain due to common use in industry. Hydrofluoric acid, or hydrogen fluoride, is often a favorite due to a secondary effect wherein the acid molecules corrode and combine with other materials, highly flammable hydrogen gas is released, setting the stage for a secondary fire or explosion. Caustics may be tricky to handle due to their tendency to corrode or make unusable containers or delivery devices. However, their effect when dispersed can be significant.

Yes, there is a difference between exposure to an alkaline or “base” chemical agent and an acid. Strong alkaline chemicals liquefy the tissues they encounter, while strong acids cause coagulation necrosis of the tissue. Alkaline burns may hurt less, giving a false sense of damage as alkali materials block nervous conduction. Both are extremely destructive, and until it is known what caustic chemical type has been encountered, irrigate generously with a neutral substance, water! (Rice & Orgill, 2021).

Delivery/dissemination of caustics:
  • Air – Hydrogen fluoride (hydrofluoric acid) can be released into the air as an aerosolized spray or as a gas.
  • Water – Hydrogen fluoride can readily contaminate a water source.
  • Food – Aerosolized hydrogen fluoride can be absorbed into food before consumption.
  • Caustics exposure can be by skin contact, ingestion, or inhalation.

Diagnosis of Caustic Chemical Agents

Due to the rapid exposure to effect, diagnosis is by observation and any available knowledge of events leading up to exposure.

Table 2: Caustic Chemical Exposure:
Skin Contact:
  • Pain and tissue destruction occurs immediately following exposure to a concentrated caustic
  • Redness and pain can occur up to 24 hours from contact with a dilute caustic
  • Immediate irritation and swelling of tissues may occur or be delayed up to 36 hours with less concentrated exposure
  • Cough, shortness of breath, and possibly pulmonary edema
  • Corrosiveness to tissues increases with both the amount and concentration of the agent. Be alert for severe bloody emesis, abdominal pain, chemical burns to the mouth and esophagus, hypotension, and severe metabolic pH swings.
  • Lowering of blood calcium and magnesium levels
  • Climbing potassium levels
  • Cardiac dysrhythmias
  • Seizures
  • Lesser exposures may lead to hemorrhagic gastritis and pancreatitis.
(Edet, 2019) (Burns, 2021)

Treatment of Caustic Chemical Agents

Immediate decontamination is a must. If a dry powder is present, brush it off quickly yet not with your exposed hand! Keep fluids or powders off your unprotected skin. Cut off contaminated clothing, being aware that clothing may stick to a caustic burn. Cut around trouble spots, then quickly come back to them with a combination of irrigation and gentle pulling.

Watch the eyes! The ocular surface is extremely sensitive to caustics, and some emergency specialists feel that starting with the eyes and working down may achieve the best results. Irrigate eyes even if there are contacts in place. Once supplies are present, pause and quickly remove contacts, then resume irrigation. Tetracaine ophthalmic drops are considered safe during caustic treatment and should be used at the earliest you can utilize their numbing effect. If you lack the Morgan lens's standard eye irrigation piece, try hooking fluid up to a nasal cannula and positioning it to drip steadily into the client’s eye for irrigation (Olson, 2020).

Use available personal protective equipment (PPE) strategically until the appropriate PPE for the substance and situation is available. Flush the affected areas with large amounts of room temperature water to dilute and carry as much of the caustic agent as possible. Closely monitor and correct blood electrolytes and ph levels as well as airway management.

Biological Warfare Agents

Disease as a means of terror and widespread destruction has been used since before written history. In modern times, isolating or modifying a particular organism and replicating it in a controlled environment has encouraged illness as living weapons. The threat of biological agents used as weapons is now higher than at any time in recorded history.

Most biological weapon agents are bacteria and viruses and the toxins they produce. However, any living organism that can cause illness or death in humans or domestic animals can conceivably be a biological weapon. The advantages of biological agents include:

  • Death or incapacitation of the target population
  • The ability of certain biological agents to continue increasing in affected individuals and, potentially, in the local population and surrounding areas
  • The relatively low cost of producing various biological weapons
  • Insidious symptoms that can mimic endemic diseases
  • The difficulty of immediately detecting the use of a biological agent due to the incubation period preceding the onset of illness (or the slow onset of symptoms)
  • High incidence of panic or terror associated with biological weapon use
  • Preservation of property and physical surroundings (compared with conventional or nuclear weapons)
Recent Notes on Biological Warfare Agents:
  • 2019 – Current. Worldwide ???
  • 2014 – Atlanta USA, CDC exposes at least 62 employees to Anthrax
  • 2014 - University of Wisconsin-Madison USA, scientists recreate an airborne version of the extremely deadly 1918 Spanish flu
  • 2004 – In the USA, three U.S. Senate office buildings were closed after the toxin ricin was found in a mailroom
  • 2001 - USA media and government offices received Anthrax in the mail. There were five deaths as a result
  • 1994 - Japanese sect Aum Shinrikyo sprayed into the air Anthrax from the tops of buildings in Tokyo
  • 1986 – Iraq disclosed vast reserves of ready bombs, missiles, artillery shells, and sprayer-equipped aircraft fitted with botulinum toxin, anthrax, and aflatoxin
  • 1984 – Oregon USA, followers of the Bhagwan Shree Rajneesh, infected 751 people with Salmonella by purposely contaminating restaurant salad bars
  • 1979 – Sverdlovsk USSR, at least 66 were killed following a release of weaponized Anthrax from a weapons facility
(Hooker, 2020) (Floridatimesdaily, 2021)

The National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) categorizes agents of biologic warfare into three categories - A, B, and C - based on their likelihood of use, how easily they can be dispersed into a target population, as well as the severity of illness or death that they might be expected to produce (Jabbour, Parker, Hutter, & Weckhuysen, 2021).

The Centers for Disease Control (CDC) identifies more than 65 potential bioterrorism agents, so we will only be looking at a few (Moore, 2021)

Category “A” Bio-agents are bacteria, viruses, or biological products that pose a high level of risk to the public due to the following characteristics they share:

  • It can be easily disseminated or transmitted from person to person.
  • Result in high mortality rates.
  • Have the potential for major public health impact.
  • It might cause public panic and social disruption.
  • Mandate special action in the way of public health preparedness.

Category “A” Bio-agents include:

  • Anthrax (Bacillus anthracis)
  • Botulism (Clostridium botulinum toxin)
  • Plague (Yersinia pestis)
  • Smallpox (Variola major)
  • Tularemia (Francisella tularensis)
  • Viral hemorrhagic fevers (members of the filovirus and arenavirus families)
  • Filoviruses - Ebola, Marburg
  • Flaviviruses – Dengue
  • Arenaviruses - Lassa, Machupo, Chapare, Junin, etc.
  • Bunyaviruses – Hanta pulmonary syndrome viruses, Rift Valley Fever, Crimean Congo Hemorrhagic Fever

Category “B” Bio-agents are the second-highest level of concern. These organisms pose a risk because they:

  • Tend to be moderately easy to disseminate.
  • May result in moderate morbidity rates and lower mortality rates than the category “A” bio-agents.
  • Require CDC diagnostic and enhanced disease surveillance abilities to detect or track.

Category B Bio-agents include:

  • Brucellosis (Brucella species)
  • Epsilon toxin (from Clostridium perfringens)
  • Food Safety Threats (e.g., select strains of Salmonella, E. coli, Shigella, Listeria, Campylobacter, Yersinia)
  • Glanders (Burkholderia mallei)
  • Melioidosis (Burkholderia pseudomallei)
  • Psittacosis (Chlamydia psittaci)
  • Q fever (Coxiella burnetii)
  • Ricin toxin (extract from castor beans)
  • Epsilon toxin (Clostridium perfringens)
  • Staphylococcal enterotoxin B
  • Typhus fever (Rickettsia prowazekii)
  • Caliciviruses
  • Hepatitis A
  • Viral encephalitis (especially alphaviruses such as Venezuelan, equine encephalitis, western equine encephalitis, eastern equine encephalitis)
  • Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum, Giardia, Entamoeba, Toxoplasma)
  • Microsporidia fungi

Category “C” Bio-agents are pathogens that have the potential to be engineered for mass dissemination. These organisms pose a risk because of:

  • Availability
  • Ease of production or dissemination
  • Potential for major health impact on populations

Category “C” Bio-agents include:

  • Nipah virus
  • Hantaviruses
  • Tick-borne hemorrhagic fevers
  • Tick-borne encephalitis
  • Yellow Fever
  • Multidrug-resistant tuberculosis
  • Tuberculosis
  • Influenza
  • Rabies virus
  • Prions
  • Chikungunya virus
  • Coccidioides species
  • Respiratory syndrome coronaviruses

Weapons of mass destruction in biological warfare focus on the deliberate spread of disease-causing organisms or organic toxins among humans, essential stock animals, or crop plants. Disease results when these new pathologies enter the target population and multiply, usually after an incubation period. During this incubation period, and even afterward, when active symptoms are displayed, WMD disease organisms may have the ability to self-spread into other available hosts or areas, beginning the process anew. This self-dissemination process can be a slow increase or enlarge blindingly fast. With many biological warfare agents, as the initial symptoms of the quick-spreading disease become apparent, those affected become incapacitated, creating a societal drain of resources and rapid loss of the very personnel able to contain the outbreak or those needed to give care to the affected. Incapacitation continues until those infected begin to recover, become stabilized in their infirmity, or die.

Biological weapons are living organisms or products that tend to have the ability to adapt to new environments as well as resist treatments that used to work. Biological agent exposure routes are:

  • Inhalation into the lungs as an aerosol (Lungs)
  • Oral ingestion into the digestive tract in food or water (Digestive)
  • Dermal absorption through the skin or placed on the skin to cause damage to the integument (Skin)
  • Percutaneous penetration by being injected or somehow forced into bodily tissue (Tissue)

Organic toxins may also form the basis for biological weapons of mass destruction. These toxins themselves are non-living products of plants or microorganisms and can be collected and “harvested,” even stored in advance for use as a weapon later. Toxins from microbes such as botulinum toxin or enterotoxin B find themselves alongside plants such as ricin from castor beans and even shellfish products, like saxitoxin. Like the synthetic agents of chemical warfare, Toxins can only affect those exposed to them and cannot reproduce or produce any form of transmissible disease.

Diagnosis of Biological Weapons Agents

Symptomatic treatment is not enough when dealing with biological warfare agents. An exact disease diagnosis is essential and has consequences beyond its normal importance in treating any individual patient. The origin of the disease outbreak must be identified quickly to predict the further spread of the organism, estimate control requirements, and contain the disease source. For these reasons, and for the ability to provide your patients with the best possible individualized care, early notification of public health officials and epidemiological specialists is vital.

Fast Fact:
  • Isolation is the restriction of an infected person.
  • Quarantine is the restriction of an exposed person.
Question for Consideration:
With coronavirus travel restrictions, banned international travel, intermittent facilities for specified travelers, mandatory social distancing, mandated mask wear, civil/ financial/ criminal penalties for non-compliance with “recommendations.” Have you been?
  • A) In isolation
  • B) In quarantine
  • C) In a situation beyond public health accepted definition

Even when everything runs smoothly, gathering the necessary information and diagnostic testing requires time. The more sophisticated the test, the more time results tend to take. If a biological warfare agent is released, delays in instituting system-level responses while waiting on “a definitive diagnosis” vastly increase the size and degree of the problem. It may be necessary to begin initial treatment in response to symptom type, patterns of location, and exposure of involved individuals before a specific causative organism is determined. This method of early mass response goes against hard-learned habits for many practitioners. However, by involving local emergency response authorities and public health officials, determining whether aggressive treatment of large populations is needed can be made as early as possible.

Interestingly, we may not always have to play the diagnostic waiting game. The Federal Emergency Management Agency (FEMA) and other agencies promote the development of electrochemical biosensors for deployment at sensitive public sites, e.g., airports, transit centers, etc. While early versions have reportedly been deployed, work on more sensitive, greater specificity detectors continue (O'Brein, Varty, & Ignaszak, 2021).

Indications of Possible Biologic Weapons Event:
  • Abnormally high numbers of patients with similar symptoms
  • Unusually large numbers of unexplained symptoms, diseases, or deaths
  • Presence of a disease (or strain) not locally endemic
  • Greater than anticipated morbidity and mortality in known disease
  • New resistance with known diseases to traditional treatment
  • Atypical patient distribution
  • Atypical disease presentation
  • Presence of pathogen characteristics/genetics from distinctly different sources
  • Pathogen strains that are unusual, atypical, genetically altered, or of an antiquated strain
  • Induced transmission of toxins or organisms (i.e., by aerosol, in food, in water)
  • Abnormal animal death or illness congruent to death or illness in humans


Bacillus anthracis or anthrax is a zootrophic (e.g., from animals) large, non-motile, gram-positive, spore-forming, aerobic bacillus that can be found worldwide in domestic and wild animals. In humans, apart from its appearance as a biological warfare agent, the occurrence of anthrax is exceedingly rare. In the United States, an average of one naturally occurring case per year has been reported during the last twenty years (Cennimo, 2021).

In 2021 Anthrax was chosen as number ten of the ten deadliest biological weapons known or admitted to by humankind. Lest you think that overstatement, anthrax, now worldwide, is thought by researchers to have originated in Egypt and has been associated with the biblical fifth plague of Egypt. Too esoteric for you? Then remember 1932 when Japanese aircraft rained down mists of weaponized anthrax on eleven Chinese cities, delivering incapacitating plague into the very homes of their enemies (Malikyte, 2021).

Table 3: Anthrax
Bio-agent: AnthraxSigns and SymptomsHandling
  • Cutaneous Anthrax
  • Incubaiton1-2 days
  • Intense itching followed by painless papular lesions
  • Lesions progress into dark vesicular lesions, then eschar surrounded by edema
  • Contact precautions
  • Post-exposure prophylaxis
  • Inhalation Anthrax (Woolsorter’s Disease)
  • Incubation is latent for up to 60 days
  • Flu-like symptoms for 1-2 days followed by slight improvement proceeding to sudden respiratory failure
  • Standard precautions
  • Post-exposure prophylaxis
  • Gastrointestinal Anthrax
  • Incubation 1-7 days
  • Abdominal pain, nausea, diarrhea, GI bleed, and fever
  • Standard precautions
  • Post-exposure prophylaxis
(NCEZID, 2020)

In Greek, anthrakis, the root of anthrax, means “black.” After caring for a client with a distinctive necrotic skin lesion, it all clicks together.

Image 2: Cutaneous Anthrax

Cutaneous Anthrax

Licensed from Shutterstock

Anthrax infection may be determined by symptom presentation as well as:

  • Blood or Sputum Culture
  • ELISA (Enzyme-Linked Immunoassay)
  • PCR (Polymerase Chain Reaction)
  • DFA (Direct Fluorescent Antibody) testing

Treatment of anthrax centers on antibiotic choice. Ciprofloxacin (Cipro), doxycycline (Vibramycin), and penicillin are FDA-approved antibiotics for the treatment of anthrax (Hooker, 2020).

Botulism Toxin

Somewhat a surprise, I feel, the biological weapon chosen as the 2021 ninth most deadly bio-warfare substance is botulism. Or, more specifically, the toxin of botulism (Malikyte, 2021).

Clostridium botulinum is an anaerobic spore-forming, gram-positive bacillus. The seven subtypes of botulinum toxin are the number-one, most deadly series of toxins that we know. Botulinum toxin is so incredibly lethal and easy to manufacture and weaponize that it is considered one of the most likely to-be-seen biological warfare agents for the foreseeable future. Exposure is likely to occur as a weapon following inhalation of aerosolized toxin or ingestion of toxin-contaminated food. During the follow-ups on the Gulf Wars, Iraqi officials admitted to a robust weaponization of botulism, with its deployment more than 100 times in and around 1995 (Hooker, 2020).

Image 3


All seven subtypes of botulinum toxin act by similar mechanisms, whether ingested or inhaled. The toxin binds with presynaptic nerve terminals at cholinergic autonomic sites and neuromuscular junctions to inflict muscular weakness and paralysis.

Table 4: Botulism Toxin
Bio-AgentSigns and SymptomsHandling
  • Botulism (7 subtypes)
  • Incubation for refined toxin
  • none, for spores 12-72 hours
  • Standard precautions
  • No post-exposure prophylaxis is available
(Hooker, 2020)

Diagnosis of botulism toxin exposure relies heavily on clinical examination skills. Some initial signs include blurred vision, speech difficulty, dysphagia, dizziness, difficulty moving eyes, and nystagmus. An unsteady gait with symmetric descending muscular weakness strongly indicates exposure; this generally proceeds into flaccid paralysis and respiratory failure. Nasal swabs can be obtained along with serum toxin assays.

Respiratory failure secondary to paralysis is considered the most serious complication of exposure. Mechanical ventilation should be available, and the CDC possesses an antitoxin (Hooker, 2020).


The virus Variola, aka smallpox, was declared “extinct in the wild” in a 1980 declaration issued by the World Health Organization. As a bioweapon in waiting, it gets top marks and the distinction of 2021’s eighth most deadly biological weapon of mass destruction (Malikyte, 2021).

Image 4: Smallpox


Variola is highly infectious when spread in an aerosolized form and is associated with a high death rate and good secondary spread. In 2003 the United States began vaccinating military personnel; however, much of the American population has no immunity, and the vaccine is in short supply. However, a new 2021, FDA-approved treatment for smallpox, Tembexa (brincidofovir), whose testing was on viruses closely related to variola smallpox (FDA, 2021).

Table 5: Smallpox

Bio-AgentSigns and SymptomsHandling
  • Smallpox
  • Incubation 7-17 days
  • Malaise, fever, vomiting, headache, backache
  • Skin lesions (pox) form after the second day of symptoms and progress from macules to papules to vesicles and pustules
  • PPE and N95 mask
  • Early post-exposure vaccinations
(Davis, 2021)

Diagnosis of smallpox falls largely on the alertness of medical personnel to the differences in smallpox lesion development from their more benign counterparts found in chickenpox or allergic contact dermatitis. As we currently have a “never seen it” younger generation of clinicians, the CDC has developed an online recognition tool for assessing the smallpox rash here (Davis, 2021).

In smallpox, the rash from which pustules arise has a centrifugal distribution (greatest concentration of lesions on the face and distal extremities) with the presence of raised lesions in the same stage of development occurring on any one part of the body (e.g., on the leg, face, arm the lesions will be in the same development stage). Swab cultures may be taken off formed lesions to confirm the diagnosis, and observation of the characteristic viral particles with electron microscopy is definitive. A Gispen modified silver stain is available for more rapid testing yet is non-sensitive. A gel diffusion test may be used in which vesicular fluid antigen from one of the pustule lesions incubated with vaccine hyperimmune serum.

Q Fever

The bacteria Coxiella burnetii, aka Q Fever, is a worldwide zoonotic (animal-borne) disease designated as a potential bioweapon of concern. It falls under category B from the CDC and NCEZID yet stars as 2021’s seventh most deadly biological weapon. Coxiella, at a glance, does not seem much of a threat. It is present globally, mildly infecting mostly sheep and goats and a few hundred people who demonstrate flu-like symptoms (Malikyte, 2021).

A spore-like form of Coxiella has been cultivated by arms production in several countries. This form is long-lived in the environment, heat, pressure waterproof, and resistant to many cleaning solutions. Airborne distribution is a worrying scenario as those exposed may carry the organism in a further spread during the 10-14 days it takes for the first mild yet increasing symptoms to appear.

Table 6: Q Fever
Bio-AgentSigns and SymptomsHandling
  • Coxiella Burnetii
  • Fever up to 13 days, chills, headache, sweating, aches, fatigue, loss of appetite
  • Cough occurs late in the illness
  • Chest pain, rash, facial pain, and hallucinations in some case
  • N95 mask and PPE while in spore drop hot zone
  • Standard precautions out of the hot zone
  • Postexposure prophylaxis with oral doxycycline
  • Treat with doxycycline and rotate antibiotics
  • Q-Vax is licensed in Australia
(Hooker, 2020)

No typical pattern of symptoms occurs, nor do any distinctive patterns such as rashes or blisters appear. A serologic blood test is available; however, you need to suspect the presence of Q fever. Typical symptoms include chills, headache, sweating, aches, fatigue, and loss of appetite. In later stages, coughing often develops, leading to pneumonia or endocarditis. Doxycycline is the initial medication of choice, though if Q fever slips into its more deadly chronic phase, combination antibiotics for around eighteen months of treatment are generally required (Mayo Staff, 2020).


Tularemia is usually thought of as a disease of animals, thus the common names of “deer tick fever” or “rabbit fever.” It makes the A list of biological weapons for two very excellent reasons. It is very incapacitating and extremely easy to contract when in a weaponized form. It is considered, by those who have a hopefully rare focus on the dark places in this world, to be the most dangerous bacteria ever discovered. Thus, it is no surprise to find it at number six in the ten deadliest bioweapons of 2021 (Malikyte, 2021).

Francisella tularensis is a non-spore-forming gram-negative coccobacillus available worldwide. It can be distributed by aerosol or touch as few as ten bacteria can pass it from person to person by open wound contact. Even insects that bite an infected animal or person can spread tularemia. Just as in both anthrax and plague, several forms of tularemia are possible and may involve the skin, lymph nodes, lungs, or other organs. Additionally, those recovering from tularemia’s effects can anticipate a protracted recovery, creating a drain on available health resources.

Table 7: Tularemia
Bio-AgentSigns and SymptomsHandling
  • Tularemia
  • Incubation 3-6 days
  • Enlarged lymph noted, fever, headache, cough, muscle aches
  • In the skin form, at least one large chancre-like ulceration is common
  • In the respiratory form, pneumonia, vomiting, joint pain, sore throat, abdominal pain, diarrhea
  • Standard precautions
  • Droplet precautions for pulmonary presentations and lab workers
  • Post-exposure prophylaxis
(CDC, 2021b)

In the absence of a known outbreak, diagnosis of tularemia often depends upon laboratory findings as the physical symptoms can be wide-ranging, though generally debilitating. Both serologic bacterial agglutination and ELISA testing are effective, and culture of Francisella tularensis can be obtained from specimens of blood, sputum, lesion, or a wide variety of exudates.

All the various forms of tularemia should be sensitive to streptomycin or gentamicin. In mass casualty situations, doxycycline or ciprofloxacin may be considered. Currently, no vaccine is available (CDC, 2021b).

Image 5: Tularemia Lesion


In yet to be diagnosed cases, an experienced practitioner may have a high level of suspicion on observing the presence of a single somewhat characteristic “heaped” ulceration of a cutaneous tularemia infection, which will often be found on an extremity. While these chancre-like ulcerations are the most observed sign of tularemia, they will be absent in clients whose infection does not involve the skin.


Bunyavirus, Bunyaviridae, is a family term for 300-some enveloped single-strand RNA viruses commonly referred to as viral hemorrhagic fevers (VHFs). Three branches of the bunyavirus family have the dubious distinction of being known killers. Nairovirus, Phlebovirus, and Hantavirus. Hantavirus, as an example, raised its head during the Korean war under the name of Korean hemorrhagic fever, where over 3000 soldiers of both America and Korea became infected. However, both sides denied using Hantavirus as a bioweapon during the conflict (Army Technology, 2020).

The common name is due to this group generating related illnesses characterized by hemorrhage and fever. We have our Soviet neighbors and their experimentation into weapons of global death to thank for this, the fifth most deadly bioweapon group of 2021 (Malikyte, 2021).

Bunyavirus is carried by arthropods (mosquitos, ticks, fleas, etc.) and rodents in their natural habitat. When humans catch Bunyavirus, it tends to cause relatively mild illness, at least in those humans acclimated to their ecosystem. At times, an outbreak is severe and life-threatening, involving multiple organ system damages. Bunyavirus diseases include Hanta Pulmonary Syndrome (HPS), Rift Valley fever, and Crimean-Congo hemorrhagic fever. A biological attack outside of its home ecosystem is estimated to be devastating to people and susceptible livestock, involving fever, rash, and systemic bleeding (Army Technology, 2020).

All the Bunyaviruses can potentially be transmitted via airborne aerosol. Combined with the virus's ability to cause serious illness, this capability has resulted in their consideration as biological weapons.

Table 8: Bunyavirus
Bio-AgentSigns and SymptomsHandling
  • Bunyavirus
  • Bunyaviridae
  • Fatigue, fever, muscle aches, headache, dizziness, chills, nausea, vomiting, diarrhea, abdominal pain
  • Cough, shortness of breath, pulmonary edema
  • Clotting problems
  • N95 mask, PPE, meticulous handwashing
  • Supportive care, fluid and electrolyte replacement
(Army Technology, 2020)

Diagnosis of any viral hemorrhagic fevers relies primarily on initial provider awareness of observable symptoms and available history that the patient or family can provide. While laboratory testing may be helpful to spot leukopenia and thrombocytopenia, along with protein and blood in the urine, a definitive laboratory diagnosis requires specific virologic testing, which is generally available only through the CDC or the US Army Medical Research Institute of Infectious Diseases located in Frederick, Maryland. Even ELISA testing is of limited aid as, while detection can be made of early immunoglobulin antibody response during the acute phase, test results tend to take from 3 to 10 days. Treatment is supportive.


A historic visitor in times of floods and famine, Vibrio cholerae is an acute bacterial diarrheal disease that infects 1 to 3 million every year and can kill within hours if untreated. By 2021 it is considered the fourth most deadly bioweapon (Malikyte, 2021) (WHO, 2021).

Cholera had been investigated in the past as a potential biological weapon and passed by as too cumbersome. Not easy to spread human to human, cholera traditionally infects food and water contaminated by human waste and is only troublesome when consumed. Yet wait, this is the age of genetic manipulation and cellular enhancement. It is bringing new life and purpose that can weaponize biological pretenders. New strains less dependent on feces-saturated groundwater seem to be now available, making the contamination of drinking water reservoirs and post-water treatment conduits a tempting target for terrorists or other pocket dictators the world over.

Table 9: Cholera
Bio-AgentSigns and SymptomsHandling
  • Vibrio cholerae
  • Sudden intestinal cramps beginning 12-72 hours after consumption
  • Watery diarrhea, vomiting, malaise, headache
  • Fever is uncommon
  • Generally, it lasts 1-7 days
  • Electrolyte disturbances and dehydration may be fatal
  • Standard precaution
  • Fluid and electrolyte replacement
  • Tetracycline or doxycycline shortens the duration of diarrhea
  • Ciprofloxacin or erythromycin may be used for a few days
(WHO, 2020)

Diagnosis should be suspected when several clients present with abdominal cramps, excessive watery diarrhea, headache, and vomiting. A definitive diagnosis can be made with stool cultures on a thiosulfate citrate bile sucrose (TCBS) agar or taurocholate tellurite gelatin agar (TTGA). There are rapid cholera tests. However, they lack specificity and cannot be recommended at this time (Hooker, 2020).

Marburg Virus

Coming in at number three of the ten most deadly biological weapons in 2021 is a zootrophic virus ranked as the world's number one most deadly viruses the World Health Organization, Marburg Virus (aka, MARV) (Slawson, 2021).

The CDC agrees with WHO and lists Marburg as a category A bioterrorism agent, awarding it a Risk Group 4 Pathogen rating.

Fast Fact: Biological Risk Group Designations

For those of us who do not live in a world of atmosphere-contained full-body rubberized suits designed to thwart the tiniest nanoparticle, Risk Group 4 means rigorously maintained airtight workspaces, pressure regulated, with multiple layers of containment to look at a sealed vial of the specimen.

Or, as WHO puts it.

Biological Risk Group 4: Poses a high individual and community risk. It causes life-threatening animal or human diseases and presents a serious hazard to laboratory workers. Highly transmissible from one individual to another. Effective preventive measures (for the organism) and treatment (of the disease) are not usually present.
Biological Risk Group 4 is the level of the Wuhan China bioweapons laboratory.
(Sapkota, 2020) (Durden, 2021)

Almost simultaneous outbreaks in 1967 of an unknown hemorrhagic fever in the German cities of Marburg, Frankfurt, as well as Belgrade, the capital of Yugoslavia, announced the arrival of a new, previously unknown viral pathogen, which gained the name of Marburg, one of the first places to isolate and describe it. This virus was traced to a shipment of green monkeys (aka, Grivet monkeys) originating from the West Congo region of Africa (Malikyte, 2021).

Marburgvirus, of the viral family Filoviridae, proceeded smoothly, and aerosolized release of the new bioweapon achieved around an 88% mortality rate in trials.

Marburg virus spreads easily by aerosolized mist from planes, missiles, or drones, and once infected, humans continue to spread it readily to each other by touching a contaminated surface or infected person. Direct contact with broken skin, bodily fluids, or contaminated surfaces successfully spreads the virus. Even contact with a contaminated dead body often transmits the disease.

Incubation periods until sickness vary from two days to twenty-one. The first symptoms grow rapidly to high fever, headache, fatigue, severe diarrhea, abdominal pain with cramping, generalized muscle pain, and frequent nausea and vomiting. Of diagnostic significance is a hollow, sunken face beginning around day three, featuring an expressionless face, sunken eyes, and severe non-itchy rashes. By day five to seven, severe bleeding begins both internally and externally. They are generally starting around the gums, nose, and genitals. The inability of the body to form blood clots promotes bruising and bleeding from the slightest of touches. Death generally occurs around day nine, with the precursor of central nervous system (CNS) impairment. This CNS collapse brings about confusion, irritability, and often, aggression. Generalized organ failure and circulatory collapse quickly follow (Slawson, 2021).

Table 10: Marburg Virus
Bio-AgentSigns and SymptomsHandling
  • Marburg Marburgvirus
  • Marburgvirus filoviridae
  • Fever, headache, fatigue, aches, diarrhea, abdominal pain and cramps, nausea, vomiting
  • Sunken eyes, expressionless face, a severe rash that does not itch
  • Severe bleeding and inability to clot
  • CNS impairment, confusion, irritability, aggression
  • Organ failure, cardiac collapse, death
  • PPE and N95 mask
  • Hazmat disposal of any non-autoclavable clients’ possessions
  • Fluid and electrolyte replacement
(WHO, 2020)

Treatment is supportive as there is no known antidote, vaccine, or drug treatment to halt the progress of this disease. There are a few experimental treatments. However, no human trial opportunities are available, which, I tend to think, is a good thing (Zayed, 2020).


Oh, come on, weaponized toxic mold? Well, yes. The mycotoxins produced in deadly molds are easy to gather, convert to powder, and distribute in an aerosolized spray or dropped as powder. An added benefit if you are a lazy terrorist or just a very nasty person, and hey, if you are cultivating bioweapons to use on civilian targets, you get an automatic entry into the nasty person membership, is that mold spores are easy to include in your weapon of mass destruction. That means the parent of the toxins will multiply where sprayed and continue to excrete poison for generations to come.

We are talking about a deadly toxin produced by certain molds and fungi found worldwide and third in our top ten deadly 2021 bioweapons. In their normal place in nature's ecosystem, aflatoxins degrade and destroy up to a quarter of the world’s crops every year. The source is stale grain, damp animal feed, humid drywall panels, basically anywhere and on anything warm, damp, organic, and undisturbed. When purposely deployed, these toxins can readily destroy a nation's ability to feed itself and produce long-term effects on both animals and humans, such as liver and organ failure and multisystem cancers (Hamdani, 2021).

Aflatoxins have been cultivated for and probably deployed in the war. The United Nations Special Commission (UNSCOM) acknowledged in 1995 when it chastised Iraq for producing toxic molds and aflatoxins for use against its Kurdish peoples and its Iranian neighbors. At the same time, the United Nations supervised the destruction of multiple aflatoxins producing facilities in the aftermath of the gulf wars. No real efforts were made to clear up the lingering effects where these long-lasting agents were likely deployed (Army Technology, 2020) (Hooker, 2020).

Table 11: Aflatoxins
Bio-AgentSigns and SymptomsHandling
  • Mycotoxins from aspergillus flavus and other toxic molds
  • Acute exposure: fatigue, nausea, vomiting, abdominal pain, yellowing of the skin, seizures, coma, death in about 25%, especially children
  • Chronic exposure: liver failure, immunotoxicity, and congenital disabilities
  • One of the major causes of liver cancer in developing countries
  • PPE, N95 masks
  • Disposal of clothing thought to have bioweapon powder on them
  • Supportive care
  • Fluid and electrolyte replacement
  • Vitamins B and K, high protein, moderate carbohydrate diet
(Dhakal, 2021)

Aflatoxins are generally consumed in food or water, though breathing in the mycotoxin and mold spores is a close second.

Severe or acute aflatoxin poisoning, referred to as aflatoxicosis, is associated with acute liver failure, rhabdomyolysis, and painful death of around 25% of those exposed. Children are especially vulnerable. Due to variations of acute symptoms, diagnosis of acute poisoning is frequently missed, increasing the death toll by allowing liver and other organ system failures before an accurate diagnosis can be made (Dhakal, 2021).

ELISA testing of client blood can be diagnostic and AFB-guanine detection in urine. AFB-albumin adduct levels in the blood serum tend to be a more reliable assay than urine testing.

Be aware that even an extremely low level of aflatoxin exposure occurring over a period can damage a population and a region for years or decades to come. Watch for dramatic spikes in the region’s liver failure and cancer case numbers. Congenital disabilities and stunted growth in humans and animals are epidemiologically significant for aflatoxins in the area.


The number one of the most dangerous and deadly biological weapons for 2021 is the hemorrhagic fever Ebola. Although it has only been recognized since 1976, when Ebola disease outbreaks struck simultaneously in the Republic of Sudan and the Democratic Republic of Congo, this monkey-borne illness has many characteristics that weapons makers seek (Harding & Lanese, 2020).

Spread in the wild is through direct contact with an infected monkey or human of any bodily fluid (blood, sweat, urine, feces, vomit, mucus, milk, or tears). Even touching the body of a person who died of Ebola can transmit the disease and say no to the African delicacy known as “bushmeat.” This delicacy contains the raw meat, blood, and bodily fluids of animals. A sort of “catch of the day” African take on the sushi craze (CDC, 2021a).

An aerosolized mist that is breathed in or brought to the mouth or open wound seems to suffice in a weaponized form. Four major strains of Ebola are known, with the highest mortality rates found in natural outbreaks coming in at about 90% mortality.

The 1976 Ebola outbreak in Zaire, West Africa, had an 80-90% mortality rate. At the same time, during the 2014 Ebola outbreak in Sierra Leone's mortality came in at 50%. The June 2016 Sierra Leone Ebola outbreak, after the World Health Organization (WHO) declared the area Ebola-free in 2015, brought 11,000 deaths and a 40% mortality rate (Hooker, 2020).

Table 12: Ebola
Bio-AgentSigns and SymptomsHandling
  • Ebola
  • Genus: Ebolavirus
  • Family: Filoviridae
  • Fatigue, high fever, muscle pain, weakness, sore throat, decreased appetite
  • Nausea, vomiting, abdominal pain, cramps, diarrhea
  • Rash, chest pain, breathing problems, dehydration
  • Coughing up blood, bloody stools, vomiting blood
  • Coma, death
  • PPE, N95 mask
  • Disposal of clothing thought to have been exposed
  • Supportive care
  • Fluid and electrolyte replacement
(CDC, 2021a)

The exposure to this virus is followed by incubation from two to twenty-one days, depending on the strain of Ebola, natural resistance that the infected possess, comorbidities influencing the immune system, and such. Initial symptoms are sudden influenza: extreme fatigue, high fever, muscle pain and weakness, sore throat, and decreased appetite. Abdominal pain, nausea, vomiting, cramping, and diarrhea are common during the viral spread, leading to dehydration and electrolyte imbalances. Around five to seven days from the first symptoms, respiratory problems begin, chest pain and severe rashes develop, followed quickly by internal and external bleeding. Coughing up blood, bloody vomit, and stools all stem from the viral attack on the body's clotting mechanism. When severe, the infected often enter a coma followed by circulatory collapse and death (Slawson, 2021).

Treatment is supportive. Among Ebola survivors’ lifelong medical complications are common. Such things as liver inflammation, chronic fatigue, deafness, impaired vision, and appetite complications.

The U.S. Food and Drug Administration (FDA) approved an Ebola vaccine rVSV-ZEBOV (called Ervebo®) in 2019. Ervebo, though in short supply, is reasonably effective against one of the major Ebola strains, Zaire ebolavirus. Only Level 4 Biosafety Facilities can work with Ebola, and all personnel potentially exposed to this virus are vaccinated (CDC, 2021a).

Bioweapon Features

Weapons of mass destruction of biological origin possess a uniquely mobile feature (human carriers) that circumvents logical prediction and response methods. People do not stay put, especially when they are fearful. As most biological weapons have incubation periods, those initially exposed may travel far from the initial point of contact before becoming aware there is a problem. Longer incubation periods result in the secondary spread of the warfare agent from the movement of those initially exposed.

Identification of the spreading disease is of utmost importance since the transmissibility of infection must be known to plan appropriate containment for the spread of the disease. Diseases that are transmissible through casual contact, by nonhuman vectors, or by respiratory droplets carry high rates of secondary infections. In contrast, other diseases pose little risk to those not initially infected.

Fast Fact:
HIPAA Privacy Rules expressly PERMIT personal health information (PHI) sharing for public health purposes without authorization.


Let us put our deductive reasoning to work. At the time of this article, there are no conclusions whether Covid-19 started as a biological weapon of mass destruction, nor can it be concluded it was not developed for that purpose. True, many experts have opinions. However, we have insufficient proof either way.

To alleviate tension, let me say that the viral group Coronaviruses, and specifically severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the parent virus of the 2019 novel coronavirus (2019-nCoV), also called human coronavirus 2019 (HCoV-19) or the illness COVID-19 (coronavirus disease 2019), the respiratory sickness responsible for the global COVID-19 pandemic, is now classified as a potential biological weapon and being looked at by many countries and terror minded groups.

As forward-looking analysts emphasize, the origin of the covid pandemic is important, yet great damage has already been done in biological weapon use. Nations and terror groups can now study a worldwide mass casualty event and analyze weaknesses in response and benefits that can readily be exploited (Means, 2020).

Established documentation is available that level 4 biological laboratories in China and elsewhere have examined the SARS-CoV-1 virus since its 2003 introductory pandemic originating in China and spreading to a dozen countries. A second severe coronavirus appeared in 2012 in Saudi Arabia and was named the Middle East respiratory syndrome coronavirus, MERS-CoV. A key feature shared by SARS-CoV-1 and MERS-CoV is that an animal vector needs to be present before the virus can infect humans. Civet cats for SARS-1 and camels for MERS (John Hopkins, 2020).

Let us look at SARS-CoV-2, the parent coronavirus from which the Covid-19 variant was either genetically adapted or spontaneously sprang. According to experts, SARS-CoV-2 does not exist in nature, either in animals or humans, before the Covid-19 pandemic. Careful study of CoV-type viral strains, especially those from bats and pangolins, show a close-yet-no genetic sequencing, notably of the bat virus coronavirus RaTG13 that Chinese officials claim is responsible for human-to-human transmission. CoV-RaTG13 laboratory-created variants (aka chimera) have recently been revealed to have been an amazing example of gene-spliced creation by Dr. Zhengli Shi, who had submitted her brilliant laboratory grown chimera work to the scientific journal Nature well before the Covid pandemic (Yan, Shu, Guan, & Hu, 2020).

SARS-CoV-2 Characteristics – It Makes a Good Bioweapon:
  • Ease of Access: SARS-CoV-2 is currently readily available across the world.
  • Ease of Manufacture: Viruses like SARS-CoV-2 can be grown with readily available equipment.
  • Presence Causes Panic: SARS-CoV-2 as a bioweapon scores big points here. Across the world, economies face collapse, and the media has terrorized citizens into quivering jellies.
  • Disrupts Infrastructure: SARS-CoV-2 scores a big win here. Half of all small business has shut down in the last eighteen months.
  • Overwhelms Health Resources: SARS-CoV-2 has forced a triage mentality onto health care globally. Human and material resources are exhausted and, in places, near collapse. As a biological weapon, SARS-CoV-2 scores big here.
SARS-CoV-2 Characteristics – It Makes a Poor Bioweapon:
  • Stability in the Atmosphere: SARS-CoV-2 fails here, as while it is relatively stable indoors, it dries quickly outside, in seconds, especially in sunlight.
  • High Number of Infected Become Ill: This is a bioweapon failure. Most infected only have a sniffle, with serious illness focused mainly on the already sick or elderly.
  • Users of the SARS-CoV-2 Bioweapon are Protected from the weapon: Again, a failure. Those deploying the weaponized agent share the same risks as everyone else.
SARS-CoV-2 Characteristics – The Unknowns:
  • Contagious: SARS-CoV-2 is only moderately contagious. Much like any influenza or cold virus.
  • Small Amounts Must Spread Widely: We still do not know. It can spread globally yet has difficulty crossing the street or a park to infect those nearby.
  • Incapacitates Troops: SARS-CoV-2 has little effect on young, healthy people, such as those serving in the military. It seems to target the older or infirm by preference. Some say it targets those a militaristic culture might consider a societal burden.
(Kortepeter, 2020) (Shi, 2021) (Buckley, 2020) (John Hopkins, 2020)

In 2015 a Chinese research document was published titled 'The Unnatural Origin of SARS and New Species of Man-Made Viruses as Genetic Bioweapons.' This document details Chinese scientists discussing the process of weaponizing coronaviruses a full four years before the COVID-19 pandemic struck the world. While Chinese authorities do not deny the research paper or its contents, they emphasize that it was speculative (The Weekend Australian, 2021).

Eminent Chinese virologist and whistleblower, currently a refugee from government persecution, Dr. Li-Meng Yan, is insistent that the Chinese Communist Party (CCP) has been working for years developing coronaviruses as “non-traditional” “global” bioweapons. Dr. Yan anonymously released information in 2018, and again in the months ahead of the first reported pandemic case, describing the Chinese virus and how the CCP desired the virus to damage world society and economies. She explained that low mortality rates were an acceptable trade for a pathogen that would frequently mutate and remain in circulation, destabilizing civilization for decades. Dr. Yan further reflects on the ruling philosophy of the CCP, which, according to her, does not care if the people it governs become ill and is willing to accept and cover up much greater human loss than it reports to the West (Vachhatani, 2021).

Now it is your turn. Considering what you know, with the knowledge that you are an independent thinker and can possess your own opinions, could Covid-19 have been meant as a pandemic bioweapon?

Radioactive and Nuclear Agents

The threat of radioactive and nuclear weaponry is just as real today as during the cold war when “fallout drills” blared throughout elementary schools across the nation. Some terrorism experts believe the risk for radiological weapons of mass destruction is higher now than it has ever been before! The genuine possibility of such an event within the United States makes it vital that healthcare staff looks for radioactive contamination signs and symptoms.

Radioactive and Nuclear agents are categorized separately. Nevertheless, they are closely related. Nuclear weapons are instruments of mass destruction that have a primary focus related on explosive impact and physical damage. Radioactive dispersion weapons differ in that they are all about radiation fallout. With radioactive weapons, the primary focus is to frighten and sicken people while making buildings or land unusable for extended periods. Due to their overlap, we will look at both in this section, then deal with concussive events in the explosives section.

A nuclear explosion creates destruction and demolition using a huge concussion wave created by the explosion. Secondary effects are the firestorm of heat and the debris spray of radioactive particles (fallout) associated with a nuclear explosion. Survivors of a nuclear explosion should be triaged and cared for like the survivors of any large-scale explosive disaster. Radiation-specific care should be added when and if it is needed.

Image 6: Nuclear Explosion


Licensed from Shutterstock

Radiological dispersion devices (RDDs) are used specifically to spread radiation-emitting material over a wide area. An RDD may not directly kill many people, yet the degree of terror and societal disruption caused by its use would be almost indescribable. An RDD is often referred to as a "dirty bomb" and consists of conventional (e.g., non-nuclear) explosives wrapped in some container containing low-grade fissionable material or radioactive waste. An RDD is simple to produce as a weapon and does not require extensive technology to arm and deploy. The effect of exploding this type of device would be to spread radioactive debris over a wide area, creating an area of lingering illness and suffering far beyond the impact of conventional explosives.

Fast Fact:
Material that emits radiation is used daily in medical centers, laboratories, food irradiation plants, and many industrial uses. Many of these materials, or their waste products, could be used in radiological dispersal devices and RDDs, if stolen or otherwise acquired.

Some experts believe that the concern over being ‘contaminated’ by a radiation-producing substance is one of those things that would spark fear far beyond the actual potential for injury. A radiologic incident would lead to a “rush” on local hospitals and health facilities, as well-intentioned yet fearful people seek reassurance and assistance. This rush of fearful individuals would keep the staff from those who genuinely need their services.

Explosions are not necessary for radioactive weapons of mass destruction. Radiation-emitting material can be distributed using a passive dispersion device. These devices can be as simple as hand sowed radioactive powders or waste products used to contaminate a neighborhood or product, such as a playground or a batch of cosmetics. Radiation-emitting compounds could slowly accumulate in an individual’s body without any easily recognizable warning signs. Paradigms need to be changed, segregating the horror of a nuclear explosion from the insidious poisoning that might be caused using radiological weaponry. Healthcare professionals need to be aware of signs of radioactive weapons.

Diagnosis of Radioactive Injury

Medical effects from radiation fall into two general categories, acute and chronic. Outcomes depend on the dose, duration of exposure, means of exposure, and the type of radiation.

High yield energy exposure to radiation can occur during the detonation of a nuclear weapon or by being in the presence of a nuclear reaction without an explosion. For example, when high-grade nuclear material is allowed to reach a critical mass releasing large amounts of gamma and neutron radiation. These high-energy events often result in immediate mortality from burns and tissue destruction. Advanced medical treatments and supportive care can be lifesaving for those who survive the initial radiation release.

Should radiation exposure occur over a prolonged period, at lower levels, or without a single catastrophic event to mark the presence of radiation, it may well be difficult to identify. Seeing large numbers of people with vague, nonspecific symptoms, skin rashes, burns, or tender areas with abnormal redness may indicate the use of a radiological weapon. Involved tissues begin to display disruption in mitosis, motility, cell growth, and permeability. Actively dividing cells are the most affected. The systems most vulnerable include gastrointestinal mucosal cells and hematopoietic tissues (especially lymphocytes and primitive stem cells). Spermatogenesis and the granulosa cells of the ovary are also extremely sensitive. The result of radiation exposure in the long term is often manifested by sterility and general syndromes related to the physiological response to radiation exposure (Mayo Clinic Staff, 2020).

Acute Radiation Syndrome

Acute Radiation Syndrome (ARS) is also referred to as radiation toxicity or radiation sickness. Cellular sensitivity is a key component in acute symptoms of radiation exposure, with the most rapidly dividing cells demonstrating a heightened effect of radiation. ARS is an acute illness caused by irradiation of a large portion of the body by a high dose of penetrating radiation in a truly short time, usually exposure for a mere matter of minutes. One of the lead factors in this syndrome is the depletion of immature parenchymal stem cells in tissues.

Stages of Acute Radiation Syndrome (Stoppler, 2021)

  • Prodromal stage: Classic symptoms are nausea, vomiting, anorexia, and possibly diarrhea. Symptoms occur from minutes to days after exposure. The symptoms may be episodic. Hair loss often occurs.
  • Latent stage: The patient looks and generally feels healthy for a few hours or even up to a few weeks.
  • Manifest illness stage: Symptoms depend on the specific syndrome and last from hours up to several months, with intense immunosuppression being common.
  • Recovery or death: Most patients who do not recover will die within months of exposure. The recovery process lasts from several weeks up to two years, with life-long follow-up required due to chronic effects of radiation exposure.

Neurovascular Radiation Syndrome

Sometimes called cerebrovascular syndrome or CNS (Central Nervous System) syndrome, it results from the damage caused by ionizing radiation to cells in the central nervous system. Within minutes, fever, hypotension, cognitive impairment, and severe prodromal symptoms suggest a super lethal dose of radiation. Lesser but still fatal exposures to the CNS will present with persistent nausea, vomiting, headache, neurological deficits, and cognitive impairment. Physical exam may show papilledema, ataxia, reduced or absent deep tendon, and corneal reflexes. A latent period of a few hours of improvement is common, but severe symptoms start within five to six hours. The final stage may mimic sepsis with hypotension, cerebral edema, increased intracranial pressure, and cerebral anoxia. Death usually occurs within two days (Dey,2020).

Gastrointestinal Radiation Syndrome

GI radiation syndrome results from the ionizing effect of radiation damaging rapidly dividing cells composing the intestinal lining. Typically, it is associated with a single exposure to a radiation source. The onset of symptoms is generally two to ten days post-exposure. Often there is an abrupt onset of diarrhea when the symptoms occur, with associated severe fluid loss, frequently with hemorrhage. Treatment focuses on massive fluid and electrolyte replacement and aggressive control of opportunistic intestinal bacterial infections. Those suffering from gastrointestinal syndrome will also face hematopoietic syndrome in most cases. When gastrointestinal symptoms are mild, generally limited to one or two episodes of diarrhea with associated abdominal pain, the prognosis for an eventual recovery is very encouraging.

Hematopoietic Radiation Syndrome

Sometimes, Bone Marrow syndrome results from induced apoptosis (metabolic cell death) of delicate cells such as stem cells in the bone marrow and lymphatic organs. Symptoms include bleeding, infection, and anemia. Significant drops in blood cell counts may be seen anywhere from an hour to two days post-exposure. The reduction in cell counts may last from weeks to months. Supportive care allows the diminished stem cells to be replaced, and even in those who suffer from complete stem cell die-off, bone marrow and stem cell transplants can aid the slow recovery process.

Recent Notes on Radioactive and Nuclear Warfare Agents:
  • 2021 – Nagpada, India. An anti-terrorism task force arrested smugglers attempting to sell seven kilograms and 100 grams of highly radioactive uranium.
  • 2019 – USA. The International Atomic Energy Agency (IAEA) reported 189 nuclear and radiologic material theft cases for trafficking and malicious use occurred in 36 American states.
  • 2019-1993 – USA. 3,686 radiologic accidents or cases of misuse/theft of radiological or nuclear materials occurred in the United States during these sixteen years.
  • 2019 – Severodvinsk, Russia. Massive radiation spike following the explosion of a global range nuclear-powered cruise missile test launch. Two were killed and an undeclared number removed in radiation contamination containment.
  • 2013 – India. Communist guerrillas in northeast India illegally collected uranium ore from a government-run milling facility and locked it into high explosives to make a dirty bomb before the police arrest.
  • 2011 - New York, USA. Radioactive induced cancers diagnosed in 911 rescuers and survivors suggests radioactive powder or other radiation released at the crime scene.
  • 2009 – India. A nuclear reactor employee in southwest India purposefully killed hundreds of his coworkers with a radioactive isotope.
  • 2006 – London, UK. Alexander Litvinenko was poisoned by polonium.
  • 1999 – Tokyo, Japan. Tokaimura incident in the non-nuclear portion of a nuclear power plant was recorded as the fourth most serious civilian release of radiation in history. Three dead, 119 contaminated, and more than 300,000 evacuated.
(Mulhern, 2021) (Planas, 2021) (Stieb, 2019) (Winter, 2020) (Mukhtar & Aziz, 2021)

Cutaneous Radiation Syndrome

Cutaneous radiation syndrome focuses on the complex pathological processes resulting from radiation exposure to the skin. Epidermal basal cells exposed to radiation reflect the presence of damage with inflammation, erythema, and desquamation of either the dry or moist type. Epilation, or sudden hair loss, occurs when hair follicles are damaged. Erythema with itching can occur soon after radiation exposure, typically within hours, followed by a latent phase lasting a few days or weeks. After the latency period, intense reddening, blistering, and ulceration commonly occur. Cutaneous exposure healing occurs eventually, though lasting effects are common, such as permanent hair loss, dermal fibrosis, damage to sweat and sebaceous glands, change in skin pigmentation, and ulceration or necrosis of exposed tissues.

Treatment of Radioactive Injury

Early management at the incident scene or in an emergency department should follow basic triage criteria. It is important to assume that all victims are contaminated, whether by physical radioactive material on the skin or absorbed contaminants by ingestion or inhalation. Preliminary decontamination, such as removing clothing and washing skin, should decrease 90 to 95 percent external contamination. Persons at the scene of a radiologic incident that show no or minor injuries should be relocated to a staging area upwind of the site (but not at a hospital to decrease congestion of emergency facilities). Evaluation and decontamination can then proceed at a more controlled pace.

Signs and symptoms of radiation exposure can be initially quite vague. Special attention should be placed on history taking, emphasizing the location of the person related to the incident, duration of possible exposure, and the exact time that the exposure occurred. Careful observation for nausea, gastric symptoms (e.g., cramping, diarrhea), fatigue, fever, or mental changes should be made with exact times of occurrence and duration of episodes noted. These details will play an important role in estimating the degree of radiation exposure, around which care planning will revolve.

Laboratory testing should be as thorough and wide-ranging as permitted, as comparisons of initial results with those obtained over the following days, weeks, and months have an important role in care. A careful collection of bodily excretions can be helpful. For example, the collection of bilateral nasal swabs within the first hour post-incident can measure how amounts of radioactive particles inhaled can be estimated. Blood tests such as a CBC with white blood cell differential and platelet count are important, as are routine chemistry profiles. Please note the time of collection carefully because of time-sensitive changes in the lymphocyte count.

When internal contamination is suspected, action can be taken to minimize damage by reducing the absorption of radioactive material and promoting rapid excretion from the body using binding agents and cathartics. Strategies to consider include (Acosta, 2021):

  • Blocking organ uptake by using oral potassium iodide (KI) if radioiodine is suspected as a potential contaminant.
  • Gastric washing to remove radioactive material tends to be most effective within 1–2 hours of ingesting contaminated material.
  • Antacids may be indicated to reduce gastrointestinal absorption. Aluminum hydroxide is especially effective if strontium has been ingested. Magnesium sulfate will bind radium
  • Cathartics like phospho-soda or bisacodyl will rapidly increase intestinal transit time and may be taken orally or as an enema.
  • Pharmacologic doses of sodium bicarbonate, orally or intravenously, are useful and safe countermeasures for uranium exposure, though uranium is not a likely component of an RDD.
  • Tritium is susceptible to induced diuresis by forcing fluids and barium sulfate or aluminum phosphate orally and will reduce the effects of ingested strontium.
  • Studies for the oral use of Prussian blue for cesium and thallium contamination by ingestion have led to its approval for that use by the FDA.

Suppose exposure levels hint that a hematopoietic event is likely. In that case, any open wound repairs, severe burn debridement, or any other anticipated surgical procedure must be done on an emergency basis and sutured completely closed within forty-eight hours after radiation exposure. This urgency is due to the anticipated blood cell count changes that will drastically affect granulation and healing once they set in.

Explosive Agents

Explosives, at times, fail to be listed among Weapons of Mass Destruction simply because we are used to them. Concussive explosive devices are readily available worldwide, and hardly a day goes by without a major media story, either in the news or entertainment media, talking about them. Explosives are easy to transport and operate without special training. They tend to be cheap, effective, and efficient. They can also be produced in large quantities using readily available components, as portrayed by the Oklahoma City Bombing that left 168 people dead and many more injured. The fact that they are readily available worldwide brings a sort of casual regard to weapons possessing the potential to create multiple casualties at the flick of a switch.

Remembering Explosive Weapons Attacks
  • 2021, July – Mogadishu, Somalia. A vehicle loaded with explosives as a suicide bomber targeting a senior police official killed nine people in the second terrorist attack by Al-Shabaab militants this month.
  • 2017 – New York, US. New York subway terror bombing. Akayed Ullah from Bangladesh detonated a bomb during morning rush hour at a major transit hub in Manhattan.
  • 2017, May – Manchester, England. Ariana Grande backpack bombing blast kills 22.
  • 2004, March – Madrid, Spain. Bombs placed on four commuter trains exploded, 190 were killed, and 1800 were injured.
  • 2001, September 11 – Concussive explosions from the impact of fully fueled hijacked jetliners destroy the New York World Trade Center Towers, 3350+ killed, 10,000+ injured.
  • 1996 – Khobar, Saudi Arabia. A tanker truck packed with explosives was driven into a US Family apartment complex and detonated.
And many, many more…
(Valle, 2021) (Vincent, 2021) (Pearson, 2021)

An explosive can consist of any material induced into a chemical reaction that converts rapidly from a solid (or a liquid) into an expanding gas. The damage created by explosives is mainly due to the tremendous atmospheric pressure increase created, which is forced outward from where the original substance has expanded. This brutal atmospheric expansion is referred to as a positive pressure wave, or blast wave, due to the almost instantaneous pressure force it yields. It is easy to forget that a negative pressure zone is created following rapid, forceful expansion. This negative pressure wave immediately follows the expanding blast wave causing displaced air in which myriads of small fragments displaced by the blast rush in to fill the void created by the initial positive pressure wave.

Few civilian medical personnel have experience handling the pattern of damage caused by a large explosive device. The ability to inflict mass casualties instantly makes explosives a nightmare for emergency services. Multiple levels of trauma are generated within a few seconds, and very few regions are set up to do the intense level of triage and transport necessary. This lack tends to result in what some refer to as “Triage Reversal” or “Upside-Down” care.

Triage reversal occurs immediately after any large explosive event; this is where the less severely wounded quickly find their way to emergency rooms and other medical facilities, clogging the care system hopelessly. When more severely wounded can be transported, local healthcare systems already waiver on the brink of collapse. This event is not a failure of emergency management services (EMS) personnel. The self-mobile, or walking wounded, simply “go around” heavily burdened first responders. They find their way to nearby hospitals and facilities, and it requires a fluid, well-rehearsed response by local staff to coordinate the delivery of care.

Explosive devices are often used as dispersal mechanisms for other acts or forms of weapons of mass destruction. An explosive can rupture chemical storage tanks, fling chemicals, biological agents, or radioactive materials into the air and surrounding environment. Therefore, any explosion must be the subject of scrutiny and treated as a crime scene. As a matter of health, let us take a closer look at explosives as a weapon of mass destruction and the impact on the care it delivers.

Diagnosis of Explosive Injuries

An explosion produces a unique pattern of injury. The injuries found after such events result from the composition and amount of chemically active materials involved, the surrounding environment, and the delivery method of the explosive. The delivery method may result from unfortunate circumstances like an electrical fire igniting highly flammable materials or the purposeful ignition. Other important factors are the distance between each victim and the blast source, any intervening protective barriers or environmental hazards, and secondary sources of injury such as flung debris, resulting fires, or structural collapse. Because large-scale explosions are rare, blast-related injuries present triage, diagnostic, and management challenges to those providing emergency care.

The HIGHS and LOWS of Explosives

High-order explosives (HE) produce a defining supersonic over-pressurization shock wave. HE examples include:
  • TNT – trinitrotoluene, a form of nitroglycerin, is an explosive in common use worldwide in the military and industry
  • C-4 is a stiff explosive putty that smells like motor oil and requires a detonating blasting cap. A preferred weapon of terrorists
  • Semtex – a wax-like explosive plastic that predates C-4 and is quite common in Europe. They are used in mining and underwater work, particularly in the destruction of concrete and metal structures
  • Nitroglycerin is a volatile liquid used to manufacture other explosives such as guncotton or nitrocellulose (a type of bullet propellant) and TNT
  • Dynamite – a mixture of nitroglycerin, clay, and originally antacids (sodium carbonate)
  • Ammonium nitrate fuel oil (ANFO) – as in the home-made Oklahoma Federal Building bombing, and available as bagged premade granules for heavy demolition work
Low-order (LE) explosives create a subsonic explosion and slower yet massive pressurization wave. Neither rocket ships nor fuel using vehicles could function without low-order explosive propellants. LE examples include:
  • Pipe bombs – tend to employ homemade explosives, many of which can be produced from household chemicals
  • Black gunpowder – from fireworks, gun shops, or sporting goods stores, also a popular pipe bomb component
  • Petroleum-based explosives – such as Molotov cocktails or aircraft/drones improvised as guided missiles
(Wightman, 2020)

High-order explosions shatter their point of impact and have a unique injury pattern compared to the bludgeoning power of low-order explosive blasts. The very force of the supersonic pressure wave can pick up and slam people, cars, basically any object not tethered to the ground into stationary or fixed materials. There is a dramatic increase in projectile injuries with HE explosions as large and small debris becomes a forceful hail of injury-producing items. Specific injury patterns are frequently seen in high-order explosive concussive events beyond the cascade of injury from debris or projectiles. These injuries patterns are referred to as traumatic, lung, ear, brain, and delayed injuries.

Traumatic Blast Injuries

Penetrating and blunt trauma to body surfaces are the most common injury seen among blast survivors. Wounds can be, and often are, grossly contaminated. Immediate concentration is on preventing blood loss, followed by later deep cleaning and debridement. Consider the use of delayed primary closure and assess tetanus status. Ensure close follow-up of wounds for infection.

Air embolism following a blast injury is common and can present as stroke, myocardial injury, acute abdomen, blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases of air embolism (RealFirstAid, 2020).

Lung Blast Injuries

“Blast lung” is a horrific direct consequence of a high explosive over-pressurization wave. It is the most common fatal primary blast injury among those who survive the initial concussive explosion event. Signs of blast lung are usually present at the time of initial evaluation but have been reported as late as 48 hours after the explosion. Blast lung is characterized by the clinical trio of apnea, bradycardia, and hypotension. Pulmonary injuries vary from scattered petechiae to confluent hemorrhages. Blast lung should be suspected for anyone with dyspnea, cough, hemoptysis, or chest pain following an explosion. Blast lung produces a characteristic “butterfly” pattern on chest X-ray. A chest X-ray is recommended for all persons exposed to a blast. A prophylactic chest tube (thoracotomy) is recommended before general anesthesia or air transport if a blast lung is suspected.

Ear Blast Injuries

Primary blast injuries to the auditory system frequently occur yet can be easily overlooked. The extent of acoustic injury depends on the orientation of the ear to the blast pressure wave. Tympanic membrane perforation or rupture is the most common injury to the middle ear. Signs of ear injury are usually present at the time of initial evaluation. They should be suspected of anyone presenting with hearing loss, tinnitus, otalgia (e.g., pain in the ear), vertigo, bleeding from the external canal, tympanic membrane rupture, or mucopurulent otorrhea. All patients exposed to a blast event should have an otologic assessment and audiometry as soon as they can be arranged.

Abdominal Blast Injuries

Gas-containing sections of the GI tract are vulnerable to the primary blast effect. Damage frequently seen includes immediate bowel perforation, hemorrhage ranging from small petechiae to large hematomas, mesenteric shear injuries, solid organ lacerations, and testicular rupture. Blast abdominal injury should be suspected in anyone exposed to an explosion with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, unexplained hypovolemia, or findings suggestive of an acute abdomen. Be aware that clinical findings may be absent until the onset of sepsis or other complications.

Brain Blast Injuries

Primary blast waves can cause concussions or traumatic brain injury (TBI) even without a physical object's direct blow to the head. Consider the victim's proximity to the blast, particularly when there are complaints of a headache, fatigue, poor concentration, lethargy, depression, anxiety, insomnia, or other constitutional symptoms.

Delayed Blast Injuries

Compartment syndrome, rhabdomyolysis, and acute renal failure are associated with structural collapse, prolonged extrication, severe burns, and poisonings. Consider the possibility of exposure to inhaled toxins and poisonings in both industrial and criminal explosions.

Treatment of Explosive Injuries

Time-related explosive incidents and local impact on emergency treatment facilities are a repeated frustration for medical care systems. It is not uncommon for the first trickle of “walking wounded” to arrive at nearby medical facilities in a matter of minutes from the occurrence of a large explosion, at times even before official notification of an explosive incident has been received. Area emergency services personnel must immediately implement local disaster planning measures upon arrival of the first responders to the scene. Prompt notification of all area healthcare facilities should create a “ripple effect” as each facility begins to place its prepared disaster plans. Be aware that the size or nature of events, especially those related to a WMD, may trigger the implementation of a regional disaster plan.

As a Health Professional, Can YOU?
  • Locate and identify your agency’s emergency response plan?
  • Describe your role in an emergency response involving mass casualties?
  • Describe the chain of command in emergency response?
  • Demonstrate your functional role in an emergency during regular drill participation?
  • Recognize deviations from the normal patient flow?
  • Identify the limits of your knowledge, skill, and authority?
  • Describe communication roles in emergency response?
  • Demonstrate the use of emergency equipment?

Hard-earned experience has shown that by the end of the first hour following the use of an explosive device as a weapon of mass destruction, approximately half of the “first-wave” of casualties will have already arrived at the nearest medical facilities. These tend to be the least injured survivors of the event. It is important not to allow medical services to become bogged down when dealing with these injuries. In many instances, the more severely injured survivors of an explosion will not even begin arriving at the closest facilities for 45 to 90 minutes after the blast occurs. This delay gives hospitals a small time window to implement their disaster response plan and begin arrangements to bolster staffing numbers. Use your first hour wisely!

Be sure to employ this window of time to obtain and record details concerning the nature of the explosion, any potential toxic exposures, and initial casualty estimates from police, fire, EMS, ICS (incident command system), the health department, or even reliable news sources. Should the report of a structural collapse occur, anticipate an increase in the severity of injuries and further time delays in the arrival of severe casualties.

Triage of Mass Casualties

Good efficient triage is both a blessing and a burden. The absolute, most critical thing needed on the scene of mass destruction is a reliable, uniform method for rapidly determining where the immediately available resources can best be applied.

Fast Fact:
Triage – This word of French origin, “trier,” emphasizes the context of sorting or sifting. A common use of the term is attributed to the Napoleonic battlefields of France where systematic sorting of wounded into those who available medical interventions could save, those who could be put quickly back into the battle, and those who could not easily be saved and who must, sadly, be left for later knowing that they might die in the meantime, was formalized.
(Torrey, 2021)

There is no uniform triage system in the United States. According to the American College of Emergency Physicians, one common triage practice currently in use is a 1-2-3 classification assignment system initiated at the time of patient entry into a hospital emergency department. Allocation decisions are made on an “as needed” basis, often by an experienced nurse, with the emphasis on ensuring that unstable or potentially unstable patients be seen rapidly while those deemed “not likely to deteriorate” wait for care. Evermore rapid response by EMS to disaster scenes has shown that these traditional triage systems have little use outside the emergency room.

The establishment of more in-the-field comprehensive systems has prompted several useful methodologies over the past decades. A good example is the simple, effective triage assessment system adopted and adapted by NATO forces known as the S.T.A.R.T. System (USHHS, 2021).

START stood for Simple Triage and Rapid Treatment and originated during the 1980s in Newport Beach, California, through the cooperative efforts of the local fire department and hospital personnel. The START system emphasizes the rapid classification of injury victims by senior on-site personnel using practiced rapid assessments, typically under one minute per victim. High visibility color-coded priority tags are then used to minimize confusion at the scene.

Simple Triage and Rapid Treatment:
Casualties are quickly sorted into four color-coded groups:
  • Red (Immediate) – Life-threatening injuries are present that require immediate medical treatment if they are to survive. Must be carried from the staging area.
  • Yellow (Delayed) – Injuries requiring treatment are present; however, they will not die if care is delayed. Non-ambulatory and those who require a stretcher or direct aid to mobilize.
  • Green (Ambulatory) – Minor or limited injuries and self-mobile. The walking wounded.
  • Black (Terminal) – They are so heavily injured that they are not expected to survive given the available treatment resources. Give what comfort is quickly available when time allows and transport last.
(Torrey, 2021) (Shertz, 2020)

Regardless of the triage system employed, all emergency service and first response hospital staff must be familiar with the system that is in place locally and participate in periodic drills to exercise knowledge and skills.

Decontamination as Part of Triage

Decontamination is the physical process of removing the chemicals, biological agents, or radioactive materials from people, equipment, and eventually the environment. Residual hazardous materials covering those exposed directly are a source of ongoing exposure to others. These residuals pose a risk of secondary exposure to first responders and healthcare personnel. Immediate decontamination is a major treatment priority for those with chemical or radiologic weapon agent exposure.

Initial decontamination involves removing all contaminated clothes and items from the affected person and then washing the body thoroughly with warm water and soap. Be aware that hot water and vigorous scrubbing may worsen the effects by increasing chemical absorption into the skin.

Vapor exposure alone may not require decontamination. If it is not known whether the exposure was to a vapor or an aerosolized liquid, decontamination is recommended. Be safe, decontaminate.

Make sure victims can breathe as respiratory effects are common with chemical warfare agents and blast lungs from an explosive event. Ideally, decontamination will take place as close as safely possible to the exposure site to minimize the duration of exposure and prevent further spread. Hospitals receiving contaminated people may establish an area outside the Emergency Department to perform initial decontamination. Portable decontamination equipment with showers and run-off water collection systems are commercially available. All hospitals should have the capacity to decontaminate at least one person at a time safely.

Immediate decontamination within 2 minutes of exposure is the most critical intervention for people who have skin exposure to mustard agents. Any effects on living tissue caused by the chemical mustard will result in irreversible cell damage to that tissue. If an exposure takes place and a person shows no obvious signs or symptoms, decontamination is still urgent. If exposure is suspected, immediately remove garments, and wash the skin with soap and water. Eye exposure requires immediate irrigation with copious amounts of saline or water. Even delayed decontamination serves a purpose as it prevents the spread of the chemical to other parts of the body and protects emergency care personnel from further exposure. Liquid blister agent contamination poses a high risk for emergency care personnel. The use of PPE (personal protective equipment) impervious to the highly soluble agents is necessary.

Radiological contamination can be readily confirmed by passing a radiation detector (radiac dosimetry device or Geiger counter) over a person’s body. The need for radiological decontamination should not interfere with emergent medical care. Unlike chemical weapon agents, the presence of radioactive particles will not cause acute injury to caregivers. Decontamination measures that are sufficient to remove chemical agents are more than adequate to remove superficial radiological contamination.

Please be aware that it is important to initiate decontamination of victims exposed to a radiation weapon as soon as possible. Usually, decontamination will be done before arrival at a medical facility. Decontamination of multiple casualties resulting from a radiological weapon is an enormous task. Be aware that the process will require a considerable amount of time. Therefore, initial life-sustaining medical interventions such as intubation for respiratory distress, emergent control of bleeding, or the initiation of intravenous access should be done before full decontamination efforts.

Open wounds should be carefully covered before decontamination, as radioactive particles may move onto the exposed tissue, especially when there is blood or serous fluid to adhere. Contaminated clothing, jewelry, and other items should be carefully removed, placed in sealed, labeled plastic bags, and removed to a secure location marked as a contaminated holding area. Bare skin and hair should be thoroughly washed with soap, and if possible, all fluid and soilage from the washing process should be gathered, contained, and labeled. It should then be stored in an area clearly marked as contaminated and later handled appropriately.

Should the seriousness of injuries mandate radiation decontamination be delayed, the simple removal of outer clothing and shoes along with a rapid washing of exposed skin and hair will, in most instances, affect a significant reduction in the patient’s contamination. Before the patient's initial decontamination, the provider should wear anti-contamination protective clothing, such as coveralls. Still, standard universal precautions are adequate for those treating limited numbers of radiologically contaminated patients. After treating and decontaminating the patient, providers themselves should undergo decontamination.

The provider should take special care not to irritate the skin. Experience with victims of radiological contamination has shown that should the skin become erythematous, small particles of radionuclides may be absorbed directly through it. Standard surgical irrigation solutions should be used in liberal amounts in all open wounds, including the abdomen and chest, as alpha and beta-emitting particles left in wounds will continue to cause extensive local damage and may even be absorbed into the systemic circulation, where they become redistributed as internal contaminants. If possible, all irrigation solutions should be removed by suction instead of sponging and wiping. The contained solution is saved, labeled, and moved to an area marked as contaminated. Copious amounts of water, normal saline, or eye solutions are recommended for suspected eye contamination.

Frequently a second, more deliberate decontamination will be conducted upon the arrival of victims at a medical care facility. The second decontamination is initiated to prevent the transfer of any residual radiological particulate to areas of the previously uncontaminated body and to limit possible particulate contamination of personnel. During this second, less emergent decontamination, it is common to obtain moist cotton swabs of the nasal mucosa from each side of the nose. These should be carefully labeled, emphasizing the exact time the sample was obtained and sealed in separate bags for later determination of radioactive particle inhalation.

Be aware that if decontamination wash water and soilage cannot be contained and collected, local water and sanitation authorities must be notified to take appropriate action.

All wound dressings, tourniquets, and pressure pads initially applied must be replaced with clean ones after general decontamination is complete. The original items were placed before the body wash process to protect open wounds and must now be bagged, labeled, and stored in an area marked as contaminated.

Case Study:
Walking wounded are arriving at your facility from the Conference Center explosion, having made their way around street closures and points set up for triage processing, decontamination, and transport. Emergency Command has notified all care centers that the biological risk contaminants were released using an explosive blast as a spreading mechanism. Instructions are to decontaminate all leaving the blast scene and quarantine them pending further instructions.
No patients were supposed to arrive without processing! Yet here they are, limping in, holding makeshift dressings to lacerations and injuries, covered with debris from the blast and who knows what weaponized organism. Worse yet, all mobile decontamination units were already rushed to the edge of the hot zone where decontamination and triage were supposed to occur. What to do?
Following written protocols, staff members quickly establish a facility-specific triage area in a parking garage using plastic sheeting retrieved from storage and water hoses to provide warm water for decontamination. More water lines serve to remove used water runoff into a plastic drop cloth makeshift holding pond. Folding privacy screens are set outside the quickly established decontamination corridor, and staff in waterproof PPE and N-95 masks assist patients in placing all clothing and personal possessions into sealed, clearly marked bags for storage in a marked area. Wounds are covered, and soap with plenty of warm water is used to decontaminate skin and hair. Nasal swabs are taken as a part of the process and carefully conveyed to laboratory services. After drying, clean clothing is provided. Processed patients are escorted to quarantine or further treatment as warranted.
After Action Notes:
  • Routine “pinch-nose” surgical masks are designed to be sneeze and droplet guards, not infection barriers. N-95 face contoured masks are designed to filter out 95% of all airborne contaminants such as smoke, dust, bacteria, and virus particles. They are not oil-resistant, so use around oily aerosols will require a different type of PPE.
  • Experience working with people during disasters has shown that alert citizens always find ways around help stations! Always anticipate some “walking wounded” to arrive from a near disaster and have a fallback plan to deal with a possible surge of individuals.
  • Post decontamination, incident debriefings reveal a small number of individuals unwilling to part with sentimental jewelry or completely disrobe can create a full stop to the time-sensitive process. Have a plan for moving discussions out away from the decontamination line. Often “can’t part with” jewelry can be sealed into a rip-proof plastic bag and kept “in hand” during decontamination, then opened and cleaned under controlled conditions later. Same-sex staff can accompany bashful individuals, or reliable family members can be enlisted to assist. However, if personnel resources are tight, defer dilemmas to the last line, so those willing to be aided can progress through without delay.

Personal Protective Equipment

Routine hospital issue personal protective equipment (PPE) will not be adequate for most events involving chemical weapon agents. Surgical masks, for example, are designed to protect the sterile surgical field of a patient from contaminants generated by the wearer sneezing, not protect the wearer. While surgical masks are adequate to catch most large-size particles in the air, they offer no respiratory protection against chemical vapors and little against most biologicals. Surgical or hospital issue barrier gowns do not provide adequate skin or mucous membrane protection against warfare grade chemicals. Latex gloves are also inadequate against most weapon-grade chemicals. What is needed during the receiving of chemical weapon victims is clothing designed for the task.

The US Environmental Protection Agency (EPA) has graded PPE into four levels based on protection. Each level consists of a combination of respiratory equipment and clothing, which protects against varying degrees of inhalational, eye, or skin exposure.

Level A PPE

Level A protection consists of a self-contained breathing apparatus and a completely encapsulating chemical protective (TECP) suit. Level A personal protective equipment provides the highest level of the respiratory, eye, mucous membrane, and skin protection and is universally used at Level 4 biological laboratories mentioned earlier.

Image 7: Level A PPE such as used in Biosafety Level 4 Laboratories:


A CDC scientist in the Biosafety Level 4 laboratory, Atlanta, GA

Level B PPE

Level B protection consists of a positive-pressure respirator (self-contained breathing apparatus or supplied-air respirator) and non-encapsulated chemical-resistant garments, gloves, and boots. When wearing, be sure to tape airtight all garment seams with the chemically resistant tape supplied for this purpose. Be sure there is a means for allowing the positive pressure atmosphere to vent. A vent should be inbuilt into the garments. Level B PPE provides the highest level of respiratory protection with a lower level of skin protection.

Level C PPE

Level C protection consists of an air-purifying respirator (APR) and non-encapsulated chemical-resistant clothing, gloves, and boots. Level C personal protective equipment provides the same level of skin protection as Level B, with a lower level of respiratory protection.

Level D PPE

Level D protection consists of formal work clothes without a respirator. In hospitals, level D consists of a surgical gown, N95 mask, and latex gloves. Be aware that level D provides poor respiratory protection and only minimal skin protection.

PPE for Chemical Weapons

Primary exposure to chemical warfare agents occurs by inhaling chemical gas or vapor, though direct contact of the eyes or skin with chemical vapor or liquid is also common. Because victims from the “hot zone” or area where the weapon of mass destruction was used may have had minimal or no decontamination, healthcare staff may be required to take extra precautions to minimize the spread of residual Chemical Weapons Agents (CWA) onto themselves or others.

Chemical-protective clothing consists of garments made from varying layers of materials. Each layer serves to protect against different hazards. At the highest protection level, aluminum-lined vapor-impermeable garments are available.

Incoming victims exposed to a CWA vapor from a volatile liquid (such as a nerve or blistering agent) warrant a higher level of protection for staff, as low levels of chemical agents may continue to be exhaled and exuded. In most instances, a small number of staff members with level C PPE and air-purifying respirators will assume the task of conducting decontamination. Once decontamination is complete and the threat level assessed, standard level D precautions (universal precautions) may be adequate.

System Supports

Health Alert Network

In response to biological and chemical terrorism threats, the Center for Disease Control has implemented an internet Health Alert Network (HAN). The online address of HAN is

Health Alert Network Objectives:
Ensure that each community has rapid and timely access to emergent health information, a cadre of highly trained professional personnel, and evidence-based practices and procedures for effective public health preparedness, response, and service on a 24/7 basis.
Function as the Public Health Information Network’s (aka PHIN’s) Health Alert component. This includes collaborating with federal, state, and city/county partners to develop protocols and relationships to ensure a robust, interoperable platform for rapidly exchanging public health information.
(CDC, 2020b)

The HAN website notes the status relative to the risk of a bioterrorism event. It has a direct link to procedures for interim recommended notification for local and state public health department leaders in the event of a bioterrorist incident.

National Disaster Medical System

The National Disaster Medical System (NDMS) has been established to provide medical care and transportation for disaster victims. Any state can enlist the services of the NDMS, which can assist with care at the event site, evacuate individuals affected, and find beds for those evacuated. A quick deployment design of response teams allows them to go anywhere in the country within hours following an event of mass destruction.

The National Disaster Medical System:
At a state’s request, NDMS provides personnel, equipment, supplies, and a system of partner hospitals that work together with state and local personnel to provide care when needed most. NDMS is a federally coordinated asset that can support disaster medical response at the state and local level, such as through Disaster Medical Assistance Teams.
(DHHS, 2021a)

The idea for NDMS was formed during Cold War days to have a ready response in case of catastrophic casualties. Since then, NDMS has been rebuilt and primarily assists state and local agencies dealing with medical care during major disasters. State and community resources are supported by FEMA, the military, and the Department of Veterans Affairs (VA) medical systems.

Strategic National Stockpile

The Strategic National Stockpile (SNS), formerly known as the National Pharmaceutical Stockpile (NPS) program advocated by the Center for Disease Control (CDC), is now in place. The SNS is a standing emergency reserve of supplies for use in times of emergency. It is structured to provide both an immediate response at any moment of need and a delayed response targeted toward specific tasks. The initial response consists of ready-for-delivery pharmaceuticals and supplies able to arrive at the scene of an emergency within 12 hours of a federal decision to aid. These packages allow for both the treatment and prevention of most manufactured diseases and are constantly updated.

Strategic National Stockpile:
The Strategic National Stockpile's role is to supplement state and local medical supplies and equipment during public health emergencies. The supplies, medicines, and devices for lifesaving care contained in the stockpile can be used as a short-term stopgap buffer when the immediate supply of these materials may not be available or sufficient.
(DHHS, 2021b)

The National Pharmaceutical Stockpile was created in 1999 to ensure the nation’s readiness against potential bioterrorism agents like botulism, anthrax, smallpox, plague, viral hemorrhagic fevers, and tularemia. The mission was to assemble large quantities of essential medical supplies that could be delivered to states and communities during an emergency within 12 hours of the federal decision to use the stockpile.

The September 11, 2001, terrorist attacks prompted federal legislation and directives to strengthen public health emergency readiness. In 2003, the National Pharmaceutical Stockpile was broadened to supply frequent medical needs other than just medications. It was then renamed the Strategic National Stockpile.

SNS available supplies include medications, PPE, ventilator resources, support materials, and the hard-to-obtain Emergency Use Authorization granted by the U.S. Food and Drug Administration (FDA). This authorization allows for the emergency use of an unapproved medical product (e.g., drugs, vaccines, and devices) or unapproved use of an approved medical product to diagnose, treat, or prevent serious or life-threatening diseases or conditions for which no adequate, FDA-approved alternative is available (DHHS, 2021).

Post-Traumatic Stress Disorder

After traumatic events, it is normal for victims, families, and caregivers to experience acute symptoms of anxiety that typically dissipate over time. However, some may develop psychiatric disorders, most commonly post-traumatic stress disorder (PTSD).

The cardinal features of PTSD include:

  • Intrusive re-experiencing of the trauma in the form of nightmares or flashbacks
  • Avoidance of reminders of the trauma along with emotional numbing
  • Persistent symptoms of autonomic hyperarousal

The best predictor of PTSD risk is the degree of exposure to the traumatic event. Those whose lives are directly threatened, physically injured, or exposed to extremely horrifying or grotesque events are at greatest peril. However, all who have exposure to an extreme event are in potential jeopardy, including family members and friends, rescue workers, healthcare providers, and others in the local community.

As a healthcare worker, you, just like those survivors you care for, are at risk of experiencing what psychologists refer to as a traumatic incident, that is, an incident that may involve exposure to catastrophic events, severely injured children or adults, dead bodies, body parts, or even the loss of someone you know or work. Often first responders and initial care staff fail to acknowledge the need to take care of themselves and ignore the need to monitor their own emotional and physical health. Taking care of oneself is especially true when recovery efforts stretch into days or weeks.

Indications of Traumatic Incident Stress in Care Givers:
  • Chest pain
  • Difficulty breathing
  • Shock symptoms
  • Fatigue
  • Nausea/Vomiting
  • Dizziness
  • Profuse sweating
  • Rapid heart rate
  • Thirst
  • Headaches
  • Visual issues
  • Clenching jaw
  • Nonspecific aches
  • Confusion
  • Nightmares
  • Disorientation
  • Changes in alertness
  • Poor concentration
  • Memory problems
  • Poor problem solving
  • Difficulty identifying familiar people or objects
  • Anxiety
  • Guilt
  • Grief
  • Denial
  • Panic attack
  • Fear
  • Irritability
  • Loss of emotion control
  • Depression
  • Sense of Failure
  • Overwhelmed
  • Blaming self or others
  • Intense anger
  • Withdrawal
  • Emotion outbursts
  • Appetite loss or increase
  • Alcohol increase
  • Pacing
  • Inability to rest
  • Change in sexual function
(CDC, 2020a)

There are ways to ease the strain. Seek professional help as soon as possible; you are not alone! There are also simple, effective methods for helping yourself. Ways to begin to ease the stress, to start to heal.

  • Pace yourself. The injured will continue to trickle in for a considerable time after a WMD incident. Be aware that rescue and recovery efforts may continue for days or even weeks.
  • Take frequent rest breaks. As little as two minutes of downtime can significantly help. Mental fatigue over long shifts can place staff at significantly increased risk for errors or injury.
  • Watch out for each other. Co-workers may be intently focused on a particular task and may not see what they can.
  • Be conscious of those around you. Personnel who are exhausted, feeling stressed, or even temporarily distracted may place themselves and others at risk.
  • Maintain as normal a schedule as possible – regular eating and sleeping are crucial! Make sure that you drink plenty of fluids such as water and juices.
  • Whenever possible, take breaks away from the work area. Eat and drink in the cleanest area available.
  • Recognize and accept what you cannot change - the chain of command, organizational structure, waiting, equipment failures, etc.
  • Talk to people when YOU feel like it. You decide when you want to discuss your experience. Talking about an event may be reliving it. Choose your comfort level.
  • If your employer provides you with proper mental health support, use it!
  • Permit yourself to feel rotten: You are in a difficult situation.
  • Recurring thoughts, dreams, or flashbacks are normal - do not try to fight them. They will decrease over time.
  • Communicate with your loved ones at home as frequently as possible


Weapons of mass destruction come in many forms. The damage they inflict may occur at any time, in any place. What is shared by these devastating weapons is the large scale of damage, injury, and death, all stemming from one incident, one source. In recent years, health services have dealt with several instances of mass casualties. We have learned, and the Covid pandemic has emphasized, how little it takes for local resources to be stressed in their abilities to cope. The possibility that such agents of destruction might be used in any of our neighborhoods mandates a heightened level of preparation and vigilance on all healthcare providers.

We have learned that the quick implementation of a prepared, practiced response plan can save many lives. An awareness of what injuries might result from various types of destructive agents, or CBRNE of mass destruction - Chemical, Biological, Radioactive, Nuclear, Explosive – allows healthcare and rescue personnel to tackle the task of dealing with the emergency in the most efficient manner possible. Early triage of survivors will make a huge impact on the success of overall care efforts. All personnel who have any dealings with a large-scale emergency must know what triage means and how to best aid in timely, effective care for their patients themselves.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
No TestDescribe how this course will impact your practice.

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


  • Acosta, R. (2021, June 5). Radiation Syndrome. (S. Warrington, Editor) Retrieved July 10, 2021, from StatPearls. Visit Source.
  • Army Technology. (2020, January 20). The world’s most dangerous bioweapons. Retrieved July 3, 2021, from Army Technology. Visit Source.
  • Buckley, R. (2020, April 23). Top Military Leaders Know COVID-19 is a Bioweapon. Retrieved July 6, 2021, from The Independent. Visit Source.
  • Burns, D. (2021, June 14). Industrial Chemical Incidents. (A. Boyle, Editor) Retrieved June 26, 2021, from RCEM. Visit Source.
  • CDC. (2020, December 16). Dealing with Stress. Retrieved July 15, 2021, from Centers for Disease Control and Prevention. Visit Source.
  • CDC. (2020, January 22). Health Alert Network. Retrieved July 12, 2021, from Centers for Disease Control and Prevention. Visit Source.
  • CDC. (2021, February 26). Ebola (Ebola Virus Disease). Retrieved July 3, 2021, from Centers for Disease Control and Prevention. Visit Source.
  • CDC. (2021, March 19). Tularemia for Clinicians. Retrieved June 29, 2021, from Centers for Disease Control and Prevention. Visit Source.
  • CDC ERB. (2019, July 29). Emergency Response Branch. Retrieved June 18, 2021, from Centers for Disease Control and Prevention. Visit Source.
  • Cennimo, D. J. (2021, April 5). What is the prevalence of anthrax in the US? (M. S. Bronze, Editor) Retrieved June 27, 2021, from Medscape. Visit Source.
  • Coelho, C., & Foltynova, K. (2020, November 23). Everything You Need To Know About Novichok. (R. Liberty, Producer) Retrieved June 13, 2021, from Radio Free Europe. Visit Source.
  • Dachir, S., Cohen, M., & Buch, H. (2021, February 25). Skin decontamination efficacy of sulfur mustard and VX in the pig model: A comparison between Fuller's earth and RSDL. Retrieved June 14, 2021, from Science Direct. Visit Source.
  • Davis, C. P. (2021, January 14). Smallpox. (M. C. Stoppler, Editor) Retrieved June 28, 2021, from MedicineNet. Visit Source.
  • Dhakal, A. (2021, May 24). Aflatoxin Toxicity. (E. Sbar, Editor) Retrieved July 5, 2021, from StatPearls. Visit Source.
  • DHHS. (2021, July 1). National Disaster Medical System. Retrieved July 13, 2021, from Public Health Emergency. Visit Source.
  • DHHS. (2021, February 26). Strategic National Stockpile. Retrieved July 13, 2021, from Public Health Emergency. Visit Source.
  • Durden, T. (2021, May 29). Virologists Say Genetic “Fingerprints” Prove COVID-19 Man-Made, ‘No Credible Natural Ancestor.’ Retrieved July 3, 2021, from Medicalveritas. Visit Source.
  • Edet, U. (2019, August 23). Corrosive substance – Examples, safety precaution & emergency plan. Retrieved June 26, 2021, from HSE Watch. Visit Source.
  • FBI. (2021, April 28). Weapons of Mass Destruction. Retrieved May 25, 2021, from Visit Source.
  • FDA. (2021, June 21). FDA approves drugs to treat smallpox. Retrieved June 27, 2021, from RDA Drug Safety and Availability. Visit Source.
  • Floridatimesdaily. (2021, June 3). Should Scientists Be Allowed To Enhance Pandemic Pathogens? Retrieved June 27, 2021, from Florida Times Daily. Visit Source.
  • Global Biodefense Staff. (2020, February 11). Army Medical Department Board Tests Nerve Agent Antidote Auto-Injectors. Retrieved June 13, 2021, from Global Biodefense. Visit Source.
  • GUWS. (2020, February 18). Irritant Gases. Retrieved June 26, 2021, from GUWS Medical Emergency Medicine. Visit Source.
  • Hamdani, I. (2021, March 31). Engineered Viruses: Deadly Era of Biological War. Retrieved July 3, 202, from Say Pakistan. Visit Source.
  • Harding, A., & Lanese, N. (2020, March 4). The deadliest viruses in history. Retrieved July 5, 2021, from Live Science. Visit Source.
  • Editors. (2021, March 18). Tokyo subways are attacked with sarin gas. (A. T. Networks, Producer) Retrieved June 12, 2021, from History. Visit Source.
  • Hodgson, L. (2021, April). How Violent Attacks Are Changing The Demands of Mass Casualty Incidents: A Review of The Challenges Associated with Intentional Mass Casualty Incidents. Homeland Security Affairs(17), 5-40. Retrieved June 6, 2021. Visit Source.
  • Holstege, C. P. (2020, January 27). CBRNE - Vomiting Agents - Dm, Da, Dc Workup. (Z. F. Dembek, Editor) Retrieved June 20, 2021, from Medscape. Visit Source.
  • Holstege, C. P. (2021, February 22). 3-Quinuclidinyl Benzilate Poisoning. (D. C. Caneva, Editor) Retrieved June 19, 2021, from Medscape. Visit Source.
  • Hooker, E. (2020, October 16). What Is Biological Warfare? Agents Use. (W. C. Shiel, Editor) Retrieved June 26, 2021, from EmedicineHealth. Visit Source.
  • Ishak, N. (2020, April 8). The Black Death Was The Worst Pandemic In Human History, So How Did It Finally End? Retrieved May 22, 2021, from Allthatsinteresting. Visit Source.
  • Jabbour, C. R., Parker, L. A., Hutter, E. M., & Weckhuysen, B. M. (2021, May 5). Chemical targets to deactivate biological and chemical toxins using surfaces and fabrics. doi. Visit Source.
  • John Hopkins. (2020, January 21). Coronaviruses: SARS, MERS, and COVID-19. Retrieved July 6, 2021, from Johns Hopkins Center for Health Security. Visit Source.
  • Koblentz, G., & Stricker, A. (2020, September 25). Hold Russia accountable for the latest chemical weapons attack. Retrieved June 12, 2021, from MSN. Visit Source.
  • Kortepeter, M. (2020, August 21). A Defense Expert Explores Whether The Covid-19 Coronavirus Makes A Good Bioweapon. Retrieved July 5, 2021, from Forbes. Visit Source.
  • Kronman, C. (2021, May 3). USAMRICD Develops ChemDx Field Diagnostic System to Detect Chemical Exposure. Retrieved June 16, 2021, from USAMRICD. Visit Source.
  • Malikyte, E. (2021, April 26). The World's Deadliest Biological Weapons. Retrieved June 27, 2021, from TopTenz. Visit Source.
  • Mayo Clinic Staff. (2020, November 7). Radiation Sickness. Retrieved July 6, 2021, from Mayo Clinic. Visit Source.
  • Mayo Staff. (2020, July 22). Q Fever. Retrieved June 28, 2021, from Mayo Clinic. Visit Source.
  • McCranor, B., & et al. (2020, August 22). Assessment of naloxone as a therapeutic for inhaled carfentanil in the ferret. Retrieved June 16, 2021, from Toxicology Reports: 10.1016/j.toxrep.2020.08.019.
  • Means, G. (2020, March 9). The coronavirus: Blueprint for bioterrorism. Retrieved July 5, 2021, from The Hill. Visit Source.
  • Mills, A. F., & Helm, J. E. (2020, March 16). Medical Surge: Lessons for a Pandemic from Mass-Casualty Management. Retrieved June 6, 2021, from HMPI Health Management Policy & Innovation. Visit Source.
  • Moore, S. (2021, June 15). What are Bioterrorism Agents? (E. Henderson, Editor) Retrieved June 26, 2021, from News Medical. Visit Source.
  • Mukhtar, A., & Aziz, A. (2021, May 20). India: Radioactive Quandary. Retrieved July 10, 2021, from Eurasia Review. Visit Source.
  • Mulhern, R. (2021, June 3). Polonium And The Piano Player: Lives of Litvinenko and musician 'forever intertwined' after poisoning. Retrieved July 10, 2021, from Sky News. Visit Source.
  • NCEZID. (2020, November 20). Anthrax. Retrieved June 27, 2021, from CDC. Visit Source.
  • NIH. (2021, March 8). Phosgene - Emergency Department/Hospital Management. Retrieved June 26, 2021, from Chemical Hazards Emergency Management. Visit Source.
  • NIH Staff. (2021, January 21). NITHIODOTE- sodium nitrite and sodium thiosulfate kit. (National Institute of Health) Retrieved June 16, 2021, from U.S. National Library of Medicine. Visit Source.
  • Oakes, M. (2021, March 13). Tear gas used at Montreal anti-lockdown protest. Retrieved June 16, 2021, from Canadian News. Visit Source.
  • O'Brein, C., Varty, K., & Ignaszak, A. (2021, February 10). The electrochemical detection of bioterrorism agents: a review of the detection, diagnostics, and implementation of sensors in biosafety programs for Class A bioweapons. doi. Visit Source.
  • OLRC. (2021, May 24). 18 USC 2332a: Use of weapons of mass destruction. Retrieved May 25, 2021, from Office of the Law Revision Counsel. Visit Source.
  • Olson, E. G. (2020, February 4). ToxCard: Caustic Eye Injuries. Retrieved June 26, 2021, from Amdocs. Visit Source.
  • Pacific Institute. (2019, January 1). Pacific Institute (2019) Water Conflict Chronology. Retrieved May 22, 2021, from Pacific Institute. Visit Source.
  • Pearson, E. (2021, June 18). Khobar Towers bombing of 1996. Retrieved July 11, 2021, from Britannica. Visit Source.
  • Planas, O. (2021, May 7). Hisashi Ouchi, a Victim of Nuclear Radiation from Tokaimura, Japan. Retrieved July 10, 2021, from Nuclear Energy. Visit Source.
  • RealFirstAid. (2020, August 6). Blast Injury. Retrieved July 11, 2021, from RealFirstAid. Visit Source.
  • Rice, P. L., & Orgill, D. P. (2021, February 25). Assessment and classification of burn injury. (M. G. Jeschke, Editor) Retrieved June 26, 2021, from UpToDate. Visit Source.
  • Salameh, N. (2019, September 9). Terrorism and Weapons of Mass Destruction Refresher. Retrieved June 14, 2021, from Fire Engineering. Visit Source.
  • Sapkota, A. (2020, October 16). Biosafety Levels (BSL-1, BSL-2, BSL-3 and BSL-4). Retrieved July 3, 2021, from MicrobeNotes. Visit Source.
  • Sawe, E. (2020, February 9). Chemical And Biological Warfare: Major Threat In The 21st Century? (World Facts) Retrieved June 13, 2021, from World Atlas. Visit Source.
  • Shertz, M. (2020, December 1). START, SALT, and RAMP Triage in a Mass Casualty Event. Retrieved July 12, 2021, from Crisis Medicine. Visit Source.
  • Shi, Z.-L. (2021, April 1). Origins of SARS-CoV-2: Focusing on Science. (W. Zhao, Editor, & I. t. Immunity, Producer) doi:doi: 10.1097/ID9.0000000000000008.
  • Slawson, L. (2021, June 30). The 10 Deadliest and Most Dangerous Viruses in the World. (Maven Media) Retrieved July 2, 2021, from Owlcation. Visit Source.
  • Smith, A. (2020, October 15). What is pepper spray, and is it dangerous? (D. Weatherspoon, Editor) Retrieved June 19, 2021, from Medical News Today. Visit Source.
  • Smith, J. (2020, June 1). Here’s What to Do if You’ve Been Exposed to Tear Gas, According to an Expert. Retrieved June 19, 2021, from Prevention. Visit Source.
  • Stieb, M. (2019, August 19). It Appears Russia Is Covering Up a Nuclear Accident Again. Retrieved July 10, 2021, from New York Intelligencer. Visit Source.
  • Stoppler, M. C. (2021, March 29). Medical Definition of Acute radiation syndrome. Retrieved July 6, 202, from MedicineNet. Visit Source.
  • The Weekend Australian. (2021, May 13). COVID-19: What is the bioweapon theory all about? Retrieved July 5, 2021, from Times Now News. Visit Source.
  • Theen, A. (2020, July 31). ‘Unprecedented’ use of tear gas against Portland protesters prompts state regulators to call for environmental testing. Retrieved June 16, 2021, from Oregon Live. Visit Source.
  • Tompkins, A. (2020, June 4). There are many types of ‘tear gas.’ Here’s how to tell the difference. Retrieved June 19, 2021, from Poynter. Visit Source.
  • Torrey, T. (2021, February 19). What Medical Triage Is in a Hospital. (A. Hall, Editor) Retrieved July 12, 2021, from Verywellhealth. Visit Source.
  • Trista. (2019, September 3). 48 Terrifying Times Deadly Chemicals Were Used During Biological Warfare. Retrieved June 12, 2021, from History Collection. Visit Source.
  • USHHS. (2021, March 8). START Adult Triage Algorithm. Retrieved July 12, 2021, from Chemical Hazards Emergency Medical Management. Visit Source.
  • Vachhatani, J. (2021, May 10). COVID 'good Material For Non-traditional Bioweapon' To Ruin Economies: Chinese Virologist. Retrieved July 6, 2021, from Republic World. Visit Source.
  • Valle, L. d. (2021, April 22). NYC subway bomber sentenced to life in prison for terror attack. Retrieved July 11, 2021, from CNN. Visit Source.
  • Velez-Daubon, L. I. (2021, January 21). CBRNE - Nerve Agents, Binary - GB2, VX2 Clinical Presentation. (D. C. Caneva, Editor) Retrieved June 13, 2021, from Medscape. Visit Source.
  • Vincent, I. (2021, July 10). Suicide bomb in Mogadishu kills nine in government convoy. Retrieved July 11 2021, from New York Post. Visit Source.
  • Warfare History Network. (2019, September 16). The Iran-Iraq War Was a Special Kind of Hell (A Million Dead?). (C. f. Interest, Producer) Retrieved June 12, 2021, from National Interest. Visit Source.
  • WHO. (2021, February 5). Cholera. Retrieved June 29, 2021, from World Health Organization Fact Sheets. Visit Source.
  • Wightman, J. (2020, July 4). Operational and Medical Management of Explosive and Blast Incidents. doi. Visit Source.
  • Winter, R. (2020, May 18). Cancer from Radiation Widespread Among 9/11 Responders. Retrieved July 10, 2021, from Winter Watch. Visit Source.
  • Yan, L.-M., Shu, K., Guan, J., & Hu, S. (2020, October 8). SARS-CoV-2 Is an Unrestricted Bioweapon: A Truth Revealed through Uncovering a Large-Scale, Organized Scientific Fraud. (R. o. Foundation, Producer) Retrieved July 6, 2021, from Zenodo. Visit Source.
  • Zanders, J. (2020, June 13). ‘Tear-gas’: authorized at home, banned in war? Not so for the USA. Retrieved June 18, 2021, from Visit Source.
  • Zayed, A. (2020, June 10). Marburg Virus in Africa. Retrieved July 3, 2021, from Ghana Medical. Visit Source.