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Bioterrorism and Weapons of Mass Destruction (FL Autonomous Practice INITIAL Differential Diagnosis)

4 Contact Hours
Only FL APRNs will receive credit for this course.
This course is only applicable for Florida nurse practitioners who need to meet the autonomous practice initial licensure requirement.
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP)
This course will be updated or discontinued on or before Sunday, February 20, 2033

To prepare healthcare providers to be ready to recognize, respond, and treat the victims of 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. Discuss common symptoms and methods of treatment 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. Discuss access and use of Federal and CDC resources for communities after Weapon of Mass Destruction attacks.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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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.)
Authors:    David Tilton (RN, BSN) , Susan Tilton (BSB BSMT)

The Nature of the Problem

Fear brought by the existence of weapons able to cause horrendous casualties and excessive destruction is not new. Historical accounts convey to us 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 death and terror. The army of the Islamic Tartar nations is recorded as having provoked an outbreak of the black plague (a.k.a. bubonic plague) in 1346 during its siege of the fortified city of Kaffa in the Crimea by purposely lobbing the diseased and decaying bodies of their own afflicted soldiers over the Kaffa city wall and into the packed citizens 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 of Kaffa provided a convenient vehicle for the disease spread. Before its end, the Black Death pandemic spread terror and destruction, slaughtering one-third of Europe’s population.1

Title 18 U.S.C. §2332a defines weapons of mass destruction (WMD) as2:
  • 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 similar to 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; and
  • 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 turn to in order to effect or inflict damage on the rest of us.

The instruments of mass destruction of today can be encompassed by the abbreviation CBRNE.

CBNE Weapons of Mass Destruction
  • C – Chemical
  • B – Biological
  • R – Radioactive
  • N – Nuclear
  • E – Explosive (high-yield)
Figure 1

As healthcare providers, we have an obligation to be prepared, to be ready to recognize and treat those who may be impacted by or exposed to these weapons. Frontline medical staff can identify CBRNE weapons by being aware of abnormal surges in patient presentation patterns.

Recognition of CBRNE weapons has great import as hospitals and medical facilities in our country, and throughout the industrialized world, are designed to handle patients who arrive singularly or in small numbers with intervals between new cases. 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 would strain even the best-designed health system to the point of breakdown.

WMD Induced Demands on the Health Care System3
  • Shortfalls of ICU beds, ventilators, and other critical care needs
  • Shortages of chemotherapeutic agents
  • Needs for ancillary or nontraditional treatment centers
  • High demand for mortuary and/or funeral services
  • High demand for social and counseling services
  • Shortages of healthcare workers due to absenteeism
  • Prolonged drain on medical care for weeks to months
  • Loss of essential staff (e.g., medical care personnel, police, firefighters, ambulance drivers, other first responders)
  • Elderly and others fearful of leaving their homes for chronic medical conditions
Figure 2: (Jagminas, 2011)

Chemical Weapon Agents

Chemical Weapons Agents (CWAs) are compounds that pose a hazard to living tissues when they come in contact. CWAs may produce incapacitation, serious injury, and/or death. Substances that may be pressed into service as chemical weapon agents are all around us. Common chemicals that can be used to cause injury are found in virtually every home. The more concentrated compounds used in business, in agriculture, and industry magnify the potential end-forms which can be produced. The type of injuries produced from weapon-grade chemicals can originate from a variety of causes. They might be the result of an industrial accident, industrial sabotage, damage to a chemical storage area or stockpile, an act of war, or even from a directed terrorist attack.

CWAs are a matter of high concern due to the following characteristics that increase the chances they may be used by terrorists 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 as well as through 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 quickly overwhelmed by casualty surge.

CWAs are placed in broad groupings or categories according to the primary effect they have on living humans or animals.4,5

  • 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 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 that cause an altered state of consciousness. 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 unless specific actions are taken to destroy or neutralize them. These substances usually tend to be a liquid or solid form 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 as 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 usually 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. Small exposures on the skin to the very same nerve agents and mustards may initially only irritate, in the manner of poison ivy or a very annoying insect bite, yet skin exposure to these chemicals is dangerous and 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 concentrations of the chemical contaminant. This area of high concentration, high danger, is known as a Hot Zone. Rescuers can come into skin contact with the particles of chemical, liquids in fluid or droplet form, or even inhale gaseous vapors. Responders are also at risk if they handle 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 to the victims, and have access to specific antidotes to counteract harmful effects.

Fast Fact:

Particularly for chemical events, a good rule for safety is to move quickly uphill, upwind, upstream, and upgrade from the hot zone area of danger.

Chemical Nerve Agents

Chemicals known as nerve agents are highly poisonous compounds that prevent the nervous system from working properly. The purpose of nerve agents is not so much to kill, but rather to rapidly incapacitate large numbers of people for extended periods, tying up resources and causing the collapse of support infrastructure. Many people exposed to nerve agents do die, however, depending on the agent used and amount of exposure, death is rarely the main objective of their use.

Under normal room temperature and atmospheric pressure, nerve agents tend to take the form of volatile liquids, which may seem contradictory as they are referred to by the common usage name of “nerve gases.” This can be explained by their chemical nature. 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 stairwells or basements.

The most volatile of the nerve agents is sarin, which evaporates at about the same rate and temperature as water. The least volatile agent, VX, has a consistency similar to 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 have the ability to rapidly penetrate both skin and clothing due to their high volatility.

Recent Chemical/Nerve Warfare Incidents6,7,8:
  • April 2017, Sarin gas dropped on a Syrian village by the Syrian military kills over 100 children and families with over 500 more injured.
  • December 2016, Chlorine and Sarin gases were dropped on neighborhoods within the cities of Damascus, Hama, Idlib and Aleppo Syria by the Turkish military killing at least 64 and afflicting hundreds with symptoms.
  • 1995, Sarin gas attack on the Tokyo subway by the Aum Shinrikyo cult killed 12 and forced 5,500 to nearby hospitals.
  • 1988 March, Iraq forces attacked the Kurd population of Halabja, Iraq using both sarin and sulfur mustard gases. Deaths were estimated at 5000 civilians with vast numbers of injured.
  • 1983, Iraq used Tabun against neighboring country Iran, with Iran responding with the use of an unidentified nerve agent. The exchange generated at least 10,000 deaths and unknown casualties in both armies and many civilians.

Currently, there are five main chemical warfare nerve agents available. Nerve agents are then separated into two main groupings. The “G” series, whose first initial connotes the German scientists who researched and developed them, and the “V” series where the initial represents Venomous, who some authors credit as research branching from crop pesticide studies. All are banned by international law and treaties and are considered to be exclusively military weapons. These five 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)

A third series of chemical warfare nerve gas agents, referred to as 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 instead for 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 with it 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.9

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


Diagnostic testing is not reliable in identifying nerve agents in blood or urine. Health providers must make their treatment decisions based on the signs and symptoms a patient presents with and on information about the type of chemical exposure, if it is known.

Nerve Agents
Nerve Agent OnsetSignsSymptoms
Seconds to minutes

Minutes to hours
  • Pinpoint pupils, eye irritation
  • Bronchoconstriction
  • Respiratory arrest
  • Hypersalivation
  • Increased secretions
  • Diarrhea
  • Poor concentration
  • Seizures
Moderate exposure:
  • Diffuse muscle cramping, runny nose, difficulty breathing, eye pain, dim vision, sweating, muscle tremors.
High Exposure:
  • Sudden loss of consciousness, seizures, flaccid paralysis (late sign)
Figure 4: (Arnold, 2009) (Agency for Toxic Substances and Disease Registry, 2011)


Treatment of victims exposed to chemical warfare nerve agents is similar to the treatment of 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.

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 similar to 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 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 an “at 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 a 24-hour period. People who were 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 is not the yellow stuff found on hot dogs at the ballpark. Nitrogen mustard (HN 1-3), Sulfur mustard (H or HD, also referred to as “mustard gas”), Lewisite (L), and Phosgene oxime (CX) all 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 and leads to cell death. This chemical reaction is temperature dependent and is aided by the presence of 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 actually do possess an odor somewhat reminiscent to that of mustard greens, onion, garlic, or even horseradish. They are highly soluble in oils, fats, and organic solvents. They quickly penetrate skin and most covering materials or textiles, including rubber. Sulfur mustard, the nemesis of WWI trench warfare, 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.


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

A new topical product designed to neutralize the toxicity of blister agents, and to an extent, nerve agents, was 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.11 RSDL is a creamy lotion packaged on a foam applicator in a single-use pouch, or as tear open single-use towelettes, and is available for use by military and some civilian emergency services personnel. For best effect, the lotion should be applied within three minutes of skin contamination. The residue left by the lotion, which is non-toxic, should be washed away at the earliest convenience.

Treatment of blister agent exposure following decontamination is symptomatic. 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 known as dimercaprol or British anti-Lewisite works to bind the Lewisite compound, creating an effective antidote, when given as early as possible following 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.


Treatment of victims exposed to chemical warfare nerve agents is similar to the treatment of 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.

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 similar to 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 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 an “at 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 a 24-hour period. People who were 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 Blood Agents

Chemical warfare agents that affect the victim by being absorbed into the circulating bloodstream are referred to by the term Blood Agents. Many of these poisons contain cyanide ions, which once entered into the body and blood, chemically inactivate cytochrome oxidase, an essential component whose absence prevents cells from utilizing oxygen. This means that although the person’s blood is delivering oxygen to their tissues, the cells are poisoned and unable to take up the oxygen. The result is asphyxia with a small degree of cyanosis. Cyanide compounds act very 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 the form of a gas make a poor weapon. The gaseous form is very 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.


Due to the short time interval between exposure and death, diagnosis must be made by observation and any known 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 the presence of cyanide or thiocyanate in blood or urine are useful for later confirmation of the initial diagnosis.


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.12 The natural form of vitamin B12, hydroxocobalamin, is used intravenously in the treatment of cyanide toxicity and a rapid administer pack is marketed under the name Cyanokit. For hydroxocobalamin a standard dose of 5 gm. 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, 1 ampoule (0.2 ml) every 5 minutes, may 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 Action13,14,15
  • June 2017, CS tear gas used on protesters in Turkey. CS is a fine powder which when airborne irritates mucosal tissues such as the eyes.
  • May 2017, OC oleum capsicum spray (pepper spray) used to break up a high school riot in Guam.
  • 2002, 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.

An incapacitating agent known as 3-quinuclidinyl benzilate (QNB or BZ) may be the most commonly used compound of this nature currently in use. QNB has played a role in military, and even 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 extensive time and funding have been channeled into the Department of Defense Joint Non-Lethal Weapons Program.13 QNB has an ability to 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 traces of this chemical are present within some over-the-counter sleeping medications.

Lacrimating 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 very young and very old.

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.13 This 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.


Treatment of incapacitating agents is symptomatic, with irrigation of eyes and supplemental oxygen being the most common initial treatment. Those exposed require monitoring for individual effects to the chemical agent used.

Chemical Pulmonary Agents

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

Pulmonary agents are chiefly gaseous compounds or aerosolized liquids. Onset of effects are often immediate, yet may be delayed as long as 24 hours, and rarely, up to 72 hours. Individuals may be asymptomatic following an initial low exposure. Lack of symptoms does not put them in the 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 is used in the synthesis of 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 similar to tear gas and a somewhat delayed extremely serious onset of subsequent pulmonary edema developing around 4 hours after exposure.16


No specific tests are readily available, though a good history may 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 spasm. Acute Respiratory Distress Syndrome (ARDS) is common, leading to non-cardiogenic pulmonary edema.


No specific antidotes are available for pulmonary or choking agents. Aggressive pulmonary lavage has not been shown to be effective at this time. Treatment must center on aggressively maintaining the airway along with management of the secretions. High dose steroids may be employed in an effort 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.

Case Study

The Urgent Care Clinic next to City Center where Wallace works has been frantically busy. Rush hour adults from the mass transit station began to pour in, eyes streaming, coughing hoarsely. Several reported toy drones trailing a white, gray cloud circling over the 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, a staff member leads ambulatory clients away from 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 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 to establish triage areas. Hospital and care centers in an expanding zone were notified by EMS to activate their emergency plans and prepare for incoming, with updates given as more information was gathered.

Simultaneously, the city emergency center became activated to coordinate efforts and direct the flow of assistance into the needed area while bringing the injured out. Less severe cases going to more distant hospitals, keeping capacity for 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 a chain of car
  • 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 a little while to find the correct next step then to rush blindly in an unsafe direction.

Chemical Caustic Agents

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

Phosphoric acid, sulfuric acid, or the most weaponized caustic, hydrofluoric acid is unfortunately easy to obtain due to their common use in industry. Hydrofluoric acid, or hydrogen fluoride, is often a favorite due to a secondary effect wherein as 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 somewhat tricky to handle due to their tendency to corrode or make unusable containers or delivery devices, however, their effect when dispersed can be significant.

Delivery/dissemination of caustics17:

  • 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 prior to consumption.

Caustics exposure can be by skin contact, ingestion, or inhalation.


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

Skin Contact:

  • Pain and tissue destruction is immediate 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 with less concentrated exposure delayed up to 36 hours.
  • Cough, shortness of breath, and possibly pulmonary edema.


  • Corrosiveness to tissues increases with both amount and concentration of the agent. Be alert for severe bloody emesis, abdominal pain, chemical burns to 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.


Immediate decontamination is a must. Flush the affected areas with large amounts of room temperature water to dilute and carry aware as much of the caustic agent as possible. Closely monitor and correct blood electrolytes and ph levels as well as airway management.

Biological Agents

Disease as a means of terror and widespread destruction has been used since before written history. In modern times, the ability to isolate or modify a particular organism, then replicate it in a controlled environment has encouraged the use of 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, along with the toxins they produce. However, any living organism able to cause illness or death in humans or stock animals can conceivably be a biological weapon. The advantages of biological agents include:

Death or incapacitation of the target population

  • Ability of certain biological agents to continue proliferating 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 onset of illness (or the slow onset of symptoms)
  • High incidence of panic associated with biological weapon use
  • Preservation of property and physical surroundings (compared with conventional or nuclear weapons)

Agents of Biologic Warfare are categorized 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.18

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

Can be easily disseminated or transmitted from person to person

  1. Result in high mortality rates
  2. Have the potential for major public health impact
  3. Might cause public panic and social disruption
  4. 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:

  1. Availability
  2. Ease of production and/or dissemination
  3. 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
  • Coccidiodes 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, animals, or plants. Disease results when these new pathologies enter into the target population and begin to multiply, usually after an incubation period. During this incubation period, and even afterward during the time 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 quick spreading disease becomes apparent those affected become incapacitated, creating a societal drain of resources as well as 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 that tend to have an 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 the products of plants such as ricin from castor beans and even products of shellfish, like saxitoxin. Toxins, like the synthetic agents of chemical warfare, can only affect those who are exposed to them and have no ability to reproduce or produce any form of transmissible.


Symptomatic treatment is not enough when dealing with biological warfare agents. An exact diagnosis of the disease is essential and has consequences beyond its normal importance in the treatment of any individual patient. The origin of the disease outbreak must be identified quickly in order to predict 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 Facts:
  • Isolation is the restriction of an infected person
  • Quarantine is the restriction of an exposed person

Even when everything runs smoothly, the gathering of necessary information along with diagnostic testing requires time. The more sophisticated the test, the more time results tend to take. In the event 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 the determination of whether aggressive treatment of large populations is needed can be made as early as possible.

Indications of Possible Biologic Weapons Event 19
  • Abnormally high numbers of patients with similar symptoms.
  • Unusually large numbers of unexplained symptoms, disease, or deaths.
  • Presence of a disease (or strain) not locally endemic.
  • Greater than anticipated morbidity and mortality in known disease.
  • New resistance in known disease 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 large, non-motile, gram-positive, spore-forming, aerobic bacillus that can be found worldwide in both 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.19

Bio-Agent19Signs & SymptomsHandling
Cutaneous Anthrax
(most common form of anthrax)
  • Incubation 1-12 days.
  • Intense itching followed by painless papular lesions.
  • Lesions progress into dark vesicular lesions then eschar surrounded by edema.
  • Contact Precautions
  • Post exposure prophylaxis for care personnel.
Inhalation Anthrax
(aka Woolsorter's Disease)
  • Incubation has a latent period up to 60 days.
  • Flu-like symptoms for 1-2 days followed by slight improvement proceeding sudden respiratory failure
  • Standard Precautions
  • Post exposure prophylaxis for care personnel.
Gastrointestinal Anthrax
  • Incubation 1-7 days.
  • Abdominal pain, nausea, diarrhea, GI bleeding, fever.
  • Standard Precautions
  • Post exposure prophylaxis for care personnel.

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


Plague (Yersinia pestis, a gram-negative, non-motile, non-sporulating coccobacillus) is an ancient enemy of civilization. It has been the cause of three great human pandemics in the 6th, 14th, and 20th centuries. Its preferred means of transport, the oriental rat flea, has greatly aided the spread of plague in the past. Military scientists have gone one better however; they have concentrated on the development of a primary pneumonic plague, which if untreated has a reported mortality rate of close to 100-percent. Air is now the vector of choice in this new and improved biologic agent of mass destruction.19

Bio-AgentSigns & SymptomsHandling

Bubonic plague (most common form)

  • Incubation 1-7 days.
  • Skin lesion at site of flea bite.
  • Sudden onset chills, fever, weakness, headache.
  • Swollen painful lymph glands (bubo).
  • Edema, erythema above and surrounding buboes.
  • Droplet precautions.
  • Post exposure prophylaxis for care personnel.

Septicemic plague 

  • Incubation 1-7 days.
  • Lack of buboes or localizing lesions.
  • Fever, chills, nausea, vomiting, diarrhea.
  • Hypotension, disseminated intravascular coagulation, multi-organ failure.
  • Droplet precautions.
  • Post exposure prophylaxis for care personnel.

Pneumonic plague

  • Incubation hours to days.
  • Sudden onset dyspnea, high fever, pleuritic chest pain, cough with bloody sputum.
  • Droplet precautions.
  • Post exposure prophylaxis for care personnel.

Diagnosis of plague may be made by the clinical presentation of painful buboes (lymph node swelling, especially evident in the groin), fever, severe malaise, and exposure to rodents or fleas. Cultures of blood, bubo aspirate, sputum or cerebrospinal fluid can demonstrate results in 48 hours. PCR (Polymerase Chain Reaction) testing is specific for the presence of plague; however, it may not be available in all regions.


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, on the other hand, it gets top marks. Smallpox is highly infectious when spread in an aerosolized form and is associated with a high death rate as well as good secondary spread. In 2003, the United States began vaccination of military personnel. However the majority of the US population currently has no immunity, the vaccine is in short supply, and no effective treatment exists for the disease. 

Bio-AgentSigns & SymptomsHandling
  • Incubation 7-17 days.
  • High fever, headache, rigors, backache, malaise.
  • Spreading skin rash starting on face, forearms and hands.
  • Rash progresses to form small macules, which grow into papules by the second day.
  • Papules form into vesicles around day 4 or 5, then pustules around day 7.
  • Pustules are round, deep-seated, firm, well-circumscribed nodules.
  • Crusts begin to form on pustules by day 14.
  • The height of infectiveness is generally days 3-6 after onset of fever.
  • Death usually occurs in the second week from general toxemia,
  • Consider patient infectious until all scabs have separated from the depressed scars remaining from pustular healing. 
  • Use of N95 respiratory mask and Contact isolation.
  • Early post exposure vaccination for care personnel.

Diagnosis of smallpox falls largely on alertness of medical personnel for the differences of lesion development from their more benign counterparts found in chickenpox or allergic contact dermatitis. In smallpox, the rash from which pustules arise has a centrifugal distribution (greatest concentration of lesions on the face and distal extremities far from the center of the body) 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 all of the lesions are in the same development stage). Swab cultures can be taken of formed lesions in order to confirm the diagnosis, and observation of the characteristic viral particles with electron microscopy is definitive. For more rapid testing, a Gispen modified silver stain is available yet rather insensitive, and a gel diffusion test in which vesicular fluid antigen from one of the pustule lesions can be incubated with vaccine hyper immune serum may be used. 
Smallpox lesions

Figure 9: (CDC, Smallpox lesions on skin of trunk, 2006)

Botulism Toxin

Clostridium botulinum is an anaerobic spore-forming, gram-positive bacillus. The seven subtypes of botulinum toxin are most deadly toxins known. Botulinum toxin is so incredibly lethal, easy to manufacture and weaponize that it is considered one of the most-likely-to-be-seen biological warfare agents for the near future. As a weapon, exposure is likely to occur following inhalation of aerosolized toxin or ingestion of toxin-contaminated food.19

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

Botulism Toxin19
Bio AgentSigns & SymptomsHandling
all 7 subtypes)
  • Incubation - None with refined toxin. From 12-72 hours for spores.
  • Excess mucus, speech difficulty, dysphagia, dizziness, difficulty moving eyes, mild pupil dilatation, nystagmus.
  • Unsteady gait, symmetric descending weakness, flaccid paralysis, respiratory failure
  • Standard Precautions.
  • No post exposure prophylaxis available.

Diagnosis of botulinum 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 is a strong indication of exposure. These symptoms generally proceed into flaccid paralysis and respiratory failure. Nasal swabs can be obtained for PCR and toxin assays, and toxin serum assays can be ordered.


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 biologic weapons for two excellent reasons. It is incredibly incapacitating and very easy to contract when in a weaponized form. Tularemia can be distributed by aerosol. It can pass 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. Added to that, those recovering from tularemia’s effects can anticipate a protracted recovery, creating a drain on available health resources.

Bio AgentSigns & SymptomsHandling
  • Incubation 3-6 days.
  • Fever, enlarged lymph nodes, headache, cough, muscle aches.
  • Skin form will show at least one large chancre-like ulceration.
  • Respiratory form resembles pneumonia with additional chest pain, joint pain, sore throat nausea, vomiting diarrhea.
  • Droplet plus standard precautions for both forms, and especially for laboratory workers.
  • Post exposure prophylaxis for care personnel

Diagnosis of tularemia, in the absence of a known outbreak, 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, a lesion, or a wide variety of exudates.



Figure 12: (CDC Tularemia, 2005)


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 in a cutaneous tularemia infection, which will often be found on an extremity. While these chancre-like ulcerations are the most commonly observed sign of tularemia, they will be absent in clients whose infection does not involve the skin.


Viral Hemorrhagic Fever

The term viral hemorrhagic fevers (VHFs) refer to a group of loosely related illnesses characterized by hemorrhage and fever. They are caused by several distinct families of viruses and are related mainly by the symptoms that they manifest. Some VHFs cause relatively mild illness. Most, however, are severe and life-threatening, involving multiple organ system damages. All of the VHFs, with the exception of dengue, can potentially be transmitted via airborne aerosol. This capability, combined with their ability to cause serious illness has resulted in their consideration as biological weapons.

Viral Hemorrhagic Fevers19
Bio AgentSigns & SymptomsHandling
Viral hemorrhagic fevers
  • Ebola
  • Marburg
  • Lassa
  • Hantavirus
  • Nipah virus
  • Crimean-Congo fever
  • Dengue
  • Yellow fever
  • Rift Valley fever
  • (etc.)
  • Incubation days to months.
  • Fever, flushing of skin, red eyes, muscle aching, fatigue, dizziness.
  • Distinctive bleeding into the skin (petechiae, purpura, ecchymoses). 
  • Bleeding in internal organs, or from mouth, eyes, or ears.
  • Delirium, seizures, coma.
  • Shock, multiple organ failure.
  • Airborne and Contact precautions.
  • Maximum containment measures for all lab specimens!
  • Only Crimean-Congo and Lassa fever have effective post-exposure prophylaxis.

All of fevers grouped as viral hemorrhagic target the infected person’s vascular beds. Microvascular damage and enhanced vascular permeability lead to a sort of weeping of bloody fluid throughout organs and mucous tissues. Hemorrhagic viruses are all simple RNA viral strands with lipid shells that are resiliently stable in blood, leading to a heightened risk infection amongst livestock processing workers, and the ready ability to spread in an aerosolized droplet weapon. VHFs include members of the viral families Arenaviridae, Bunyaviridae, Filoviridae, and Flaviviridae.

Diagnosis of any of the viral hemorrhagic fevers relies primarily on initial provider awareness of observable symptoms, as well as the available history that can be provided by patient or family. 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 Disease located in Frederick, Maryland. Even ELISA testing is of limited aid. While detection can be made of early immunoglobulin antibody response during the acute phase, test results tend to take from 3 to 10 days.


Ricin is a plant toxin derived from a protein found in the beans of the castor plant. It has been one of the most widely used biologic weapons of the last several decades due in great part to the combination of high toxicity and relative ease of production. Ricin is extremely toxic to cells and acts by inhibiting protein synthesis. The effects of ricin exposure center on its method of delivery. Inhalation exposure causes primarily breathing and lung problems. If ingested, ricin causes symptoms in the GI tract. If injected, cell death occurs at the area of injection, and the toxin affects any tissues and organ systems taking it up.

Bio AgentSigns & SymptomsHandling
Ricin Inhalation
  • Sudden onset nasal and throat congestion.
  • Nausea, vomiting, itching eyes, chest tightness, breathing difficulty progressing to severe respiratory distress and possible death.
  • Standard precautions, though not contagious.
Ricin Ingestion
  • Nausea, vomiting, severe abdominal cramping, bloody stools, bloody emesis, shortness of breath, tachycardia, diaphoresis.
  • Standard precautions.
Ricin Injection
  • Flu like symptoms, body ache, nausea, vomiting, pain.
  • Swelling at injection site.
  • Severe exposure leads to tissue death at injection site as well as in diffuse locations.
  • GI bleeding, liver, spleen, kidney damage.
  • Standard precautions.

Diagnosis of ricin poisoning relies on a combination of clinical and epidemiologic factors. Ricin does not occur naturally but must be produced; therefore, exposure history is essential to providing a setting for contamination such as may occur in a terror event where a group of people is purposely exposed to the toxin. Awareness of numbers of clients being admitted with similar symptoms should spark a high level of suspicion in health care facilities. Confirmation of ricin poisoning can be made by either ELISA analysis or by PCR (Polymerase Chain Reaction) testing which is able to detect the presence of castor bean DNA.

Weapons of mass destruction that are 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 the vast majority of 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 results in secondary spread of the warfare agent from the movement of those initially exposed.

Identification of the disease that is spreading is of utmost importance since the transmissibility of infection must be known in order 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, whereas 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.

Radioactive and Nuclear Agents

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

Nuclear and Radioactive agents are categorized separately, nevertheless are closely related. Nuclear weapons are by definition instruments of mass destruction that have a primary focus related to 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 of time.

A nuclear explosion creates destruction and demolition by means of a huge concussion wave created by the explosion. The heat and debris spray of radioactive particles (fallout) associated with a nuclear explosion are secondary effects. 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.

Radiological dispersion devices (RDDs) are used specifically for the spread of radiation emitting material over a wide area. An RDD might not directly kill large numbers of 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 tends to consist of conventional (e.g., non-nuclear) explosives wrapped in some sort of container containing low-grade fissionable material or radioactive waste. As a weapon, an RDD is simple to produce 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 effect of conventional explosives.

Fun Fact22
Material that emits radiation is used every day in medical centers, laboratories, food irradiation plants, and for many industrial uses. Many of these materials, or their waste products, could be used in radiological dispersal devices, RDD’s, 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 staff from those who truly need their services.

Explosions are not necessary for radioactive weapons of mass destruction. Radiation-emitting material can be distributed by means of 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 occurring. Paradigms need to be changed, segregating the horror of a nuclear explosion from the insidious poisoning that might be caused by the use of radiological weaponry. Healthcare professionals need to be aware of signs of radioactive weapons.


Medical effects from radiation fall into two general categories, acute and chronic. Effects 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, such as 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. For those who survive the initial radiation release, advanced medical treatments and supportive care can be lifesaving.

Should exposure to radiation occur over a prolonged period of time, at lower levels, or without a single catastrophic event to mark the presence of radiation, it may well be very 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 very 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.23

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 to 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 very short period of time, usually exposure for a mere matter of minutes. One of the lead factors in this syndrome is depletion of immature parenchymal stem cells in tissues.

The Four Stages of Acute Radiation Syndrome (ARS)23
  • Prodromal state: Classic symptoms are nausea, vomiting, anorexia, and possibly diarrhea. Symptoms occur from minutes to days following exposure. The symptoms may be episodic. Hair loss often occurs.
  • Latent stage: The patient looks and feels generally 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 at this time.
  • Recovery or death: Death generally occurs several months post exposure unless the body rallies and recovery occurs. The process of recovery may be several weeks up to two years, with life-long follow-up due to chronic radiation exposure effects.

Neurovascular Radiation Syndrome, sometimes called cerebrovascular syndrome or CNS (Central Nervous System) syndrome, results from the damage caused by ionizing radiation to cells in the central nervous system. Typically, it is the result of very high radiation doses. Symptoms may begin after only a few hours, or may not start for days. A steady, severe deterioration of mental status is generally first noticed, followed by coma and often death.

Neurovascular Radiation Syndrome23
  • The early presence (within minutes of the exposure event typically) of fever, hypotension, and often major cognitive impairment with severe prodromal symptoms (nausea, vomiting) suggest exposure to a supralethal dose of radiation.
  • Lesser yet still fatal exposures to central nervous system tissues present with persistent and severe nausea and vomiting, accompanied by headache, disorientation, confusion, loss of balance, and seizures. Physical examination may show papilledema, ataxia, reduced or absent deep tendon and corneal reflexes. 
  • A latent period of a few hours of apparent improvement is common for both levels of exposure, yet within a few hours watery diarrhea, respiratory distress, fever, and cardiovascular collapse ensue. 
  • The final picture of neurovascular radiation syndrome may mimic that of sepsis with hypotension, cerebral edema, an increase in intracranial pressure, cerebral anoxia, and death. Typically, at around two days post exposure.

Gastrointestinal 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. In most cases, those suffering from gastrointestinal syndrome will also face hematopoietic syndrome. When gastrointestinal symptoms are mild, generally limited to one or two episodes of diarrhea with associated abdominal pain, prognosis for an eventual recovery is very encouraging.

Hematopoietic Radiation Syndrome, sometimes referred to as 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.24 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 time for the diminished stem cells to be replaced, and even in those individuals who suffer from complete stem cell die off; bone marrow and stem cell transplants can aid the slow process of recovery.

Cutaneous Radiation Syndrome focuses on the complex pathological processes resulting from radiation exposure to the skin.24 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 occurs. Cutaneous exposure healing eventually occurs, 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.


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, by physical radioactive material on the skin or have absorbed contaminants by ingestion or inhalation. Preliminary decontamination such as removal of clothing and washing of skin should decrease external contamination by 90 to 95 percent. Persons at the scene of a radiologic incident who show no, or minor, injuries should be relocated to a staging area upwind of the site (but not at a hospital, in order to decrease congestion of emergency facilities). Evaluation and decontamination can then proceed at a more controlled pace.23

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 the presence of 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 when the estimation of the degree of radiation exposure is made, 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 to play in care. Careful collection of bodily excretions can be helpful, for example, the collection of bilateral nasal swabs within the first hour post incident can provide a measure by which amounts of radioactive particles inhaled can be estimated. Blood tests such as a CBC with white blood cell differential and platelet count is important, as are routine chemistry profiles. Please note the time of collection carefully because of time sensitive changes that may occur 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:23,24

  • Blocking organ uptake by use of oral potassium iodide (KI) if radioiodine is suspected as a potential contaminant. 
  • Gastric washing to remove radioactive material. This tends to be most effective within 1–2 hours of ingestion of 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. They 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. 

If exposure levels hint that a hematopoietic event is likely, 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 is due to the anticipated blood cell count changes that will drastically affect granulation and healing once they set in.

Explosive Agents

Explosives often 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 we have seen 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
  • 1995, April - Oklahoma City Federal Building bombed with home-made explosive device, 168 killed.
  • 2001, September 11 - Concussive explosions from the impact of hijacked jetliners destroy the New York World Trade Center Towers, 3,350+ killed, 10,000+ injured.
  • 2004, March - Madrid, Spain. Bombs placed on 4 commuter trains explode, 190 killed, 1,800+ injured.
  • 2017, May – Manchester, England. Ariana Grande backpack bombing blast kills 22.

    And many, many more...

An explosive can consist of any material that when induced into a chemical reaction 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 they create, 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 following such a rapid, forceful expansion a negative pressure zone is created. 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 in handling the pattern of damage caused by the use of 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 time, and very few regions are set up to do the intense level of triage and transport necessary. This 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. By the time more severely wounded can be transported, local healthcare systems already waiver on the brink of collapse. This 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 own 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. Any explosion must, therefore, 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 care it delivers.

An explosion produces a unique pattern of injury. The injuries found after such events are the result of the composition and amount of the chemically active materials involved, what was in the surrounding environment, and the delivery method of the explosive. The delivery method may be the product of unfortunate circumstances like an electrical fire igniting highly flammable materials or the purposeful ignition of a bomb. 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 HIGH's and LOW's of Explosives25
High-order explosives (HE) produce a defining supersonic over-pressurization shock wave. Examples of HE include:
  • TNT– trinitrotoluene, a form of nitroglycerin, an explosive in common use worldwide in both military and industry.
  • C-4– a stiff explosive putty that smells like motor-oil and requires a blasting cap to detonate. A preferred weapon of terrorists.
  • Semtex– a wax-like explosive plastic that predates C-4 and is very common in Europe. Used in mining and underwater work, particularly the destruction of concrete and metal structures.
  • Nitroglycerin - volatile liquid used in the manufacture of 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 also available as bagged premade granules for heavy demolition work.
Low-order explosives (LE) explosives create a subsonic explosion and slower yet massive pressurization wave. Neither rocket ships or fuel using vehicles could function without low-order explosive propellants. LE examples include:
  • Pipe bombs– tend to employee home-made explosives, many types of which can be produced from household chemicals.
  • Black gunpowder– from fireworks, gun shops or sporting goods stores, also a popular pipe bomb component.
  • Most petroleum– such as Molotov cocktails or aircraft/drones improvised as guided missiles.

High order explosions have a unique injury pattern as compared to low order explosive blasts in that 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 debris, both large and small, becomes a forceful hail of injury producing items. Beyond the cascade of injury from debris or projectiles are specific injury patterns frequently seen in high order explosive concussive events. 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 prevention of 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.

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 trial 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, and a prophylactic chest tube (thoracotomy) is recommended before general anesthesia or air transport if blast lung is suspected.

Ear Blast Injuries

Primary blast injuries of the auditory system frequently occur yet can be easily overlooked. The extent of auditory injury tends to be dependent 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 and should be suspected for 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 can be arranged.

Abdominal Blast Injuries

Gas-containing sections of the GI tract are areas that are very vulnerable to 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 direct blow to the head by a physical object. Consider the proximity of the victim 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 some poisonings. Consider the possibility of exposure to inhaled toxins and poisonings in both industrial and criminal explosions.


Timing related to explosive incidents and local impact on emergency treatment facilities is 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 be able to 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 put into place their own prepared disaster plans. Be aware that the size or nature of particular events, especially those related to a WMD, may trigger the implementation of a regional disaster plan.

As a Health Professional, Can YOU?
  • Identify and locate your agency's emergency response plan?
  • Describe your role in an emergency response involving mass casualties?
  • Describe the chain of command in emergency response?
  • Describe your functional role in an emergency and demonstrate your role by regular drill participation?
  • Recognize deviations from the norm in patient flow?
  • Identify the limits of your own knowledge, skill, and authority?
  • Demonstrate 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 window of time in which 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, be sure to anticipate an increase in the severity of injuries as well as further time delays in the arrival of severe casualties.


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

Fast Fact
Triage26– A word of French origin “trier” that emphasizes the context of sorting, or shifting. Common use of the term is attributed to the Napoleonic battlefields of France where systematic sorting of wounded into those who could be saved by available medical interventions, and those who could not was formalized.

There is no uniform triage system in the United States. One common triage practice currently in use, according to the American College of Emergency Physicians, is a 1-2-3 classification assignment system initiated at the time of patient entry into a hospital emergency department. Allocation decisions are at that time 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. Ever more rapid response by EMS to disaster scenes has shown that traditional triage systems have little use outside of the emergency room setting.

The establishment of more in-the-field comprehensive systems has prompted creation of several useful methodologies over the past decades, a good example of which is the simple, effective triage assessment system adopted and adapted for their use by NATO forces known as the S.T.A.R.T. System.26 

START stands for Simple Triage and Rapid Treatment and originated during the 1980’s in Newport Beach, California by the cooperative efforts of local fire department and hospital personnel. The START system emphasizes 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 Treatment26,27
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 stretcher or direct aid to mobilize.
  • Green (Ambulatory)– Minor or limited injuries and self-mobile. The walking wounded.
  • Black (Terminal)– So heavily injured they are not expected to survive given the treatment resources currently available. Give what comfort is quickly available when time allows and transport last.

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 in order to exercise knowledge and skills.


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 who have been exposed directly are themselves 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 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.

Make sure victims are able to breathe, as respiratory effects are common with the majority of chemical warfare agents. Ideally, decontamination will take place as close as possible to the site of exposure to minimize the duration of exposure and prevent further spread. Hospitals receiving contaminated people may establish an area outside the Emergency Department in which 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 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 clothing 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 spread of the chemical to other parts of the body as well as protecting emergency care personnel from further contact exposure. Liquid blister agent contamination poses a high risk for emergency care personnel. The use of PPE (personal protective equipment) that is impervious to the highly soluble agents is necessary.

The presence of 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 suffi¬cient to remove superficial radiological contamination.23

That said, please be aware that it is important to initiate decontamination of victims exposed to a radiation weapon as soon as possible, and usually, this will be done prior to 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 prior to full decontamination efforts.

Open wounds should be carefully covered prior to decontamination, as radioactive particles may move onto the exposed tissue, especially when there is blood or serous fluid to adhere to. Contaminated clothing, all jewelry, and other items should be carefully removed, placed in sealed, labeled plastic bags and re-moved to a secure location clearly marked as a contaminated holding area. Bare skin and hair should be thoroughly washed with soap, and if at all possible, all of the 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 disposed of in an appropriate manner.

Should the seriousness of injuries mandate 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, effect a significant reduction in the patient’s contamination. Anti-contamination protective clothing, such as coveralls, should be worn by the provider prior to the patient's initial decontamination, but 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.

Special care must be taken 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 the chest as al¬pha and beta-emitting particles left in wounds will continue to cause extensive local damage and may even be absorbed into the systemic circu¬lation where they become redistributed as internal contaminants. If at all possible, all irrigation solutions should be removed by suction instead of sponging and wiping, with the contained solution being saved, labeled and moved to an area clearly marked as contaminated. Copious amounts of water, normal sa¬line, or eye solutions are recommended for suspected eye contamination.

Frequently a second, more deliberate decontamination will be conducted on arrival of victims to a medical care facility. A second decontamination is initiated to prevent the transfer of any residual radiological particulate to areas of the body pre¬viously uncontaminated, as well as 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 both sides of the nose. These should be carefully labeled with an emphasis on documentation of 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 so that appropriate action can be taken.

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 prior to the body wash process for protection of 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 of the risk that biologic contaminants were released using an explosive blast as a spread 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 have already been 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 lines ran to provide warm water for decontamination. More water lines serve to remove used water runoff into a 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 to place all of their clothing and personal possessions into sealed, clearly marked bags for storage in a clearly 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 air-borne contaminants such as smoke, dust, bacteria and virus particles; they are not oil resistant, so use around oily aerosols will require another type of PPE.
  • Experience working with people in 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 for dealing with the possible surge of individuals arriving.
  • Past decontamination, incident debriefings reveal that 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 bringing time requiring 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 of the 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 field of the patient from contaminants generated by the wearer, 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 biological aerosols. 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 the degree of protection provided. Each level consists of a combination of respiratory equipment and clothing, which protects against varying degrees of inhalational, eye, or skin exposure.

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 respiratory, eye, mucous membrane, and skin protection.

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. Tape off all garment seams! Level B PPE provides the highest level of respiratory protection with a lower level of skin protection.

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 protection consists of standard work clothes without a respirator. In hospitals, level D consists surgical gown, mask, and latex gloves. Be aware that level D provides no true respiratory protection and only minimal skin protection.

Primary exposure to chemical warfare agents occurs by inhaling chemical gas or vapor as well as by direct contact of the eyes or skin to chemical vapor or liquid. 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 known to have been 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 or exuded. In most instances, a small number of staff members with level C PPE and air-purifying respirators can 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 the threats of biological and chemical terrorism, the Center for Disease control has implemented an internet Health Alert Network (HAN). The online address of HAN is

The objectives of HAN include28:

  • 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 Networks (aka PHINs) Health Alert component. This includes collaborating with federal, state, and city/county partners to develop protocols and relationships that will ensure a robust interoperable platform for the rapid exchange of public health information.

The HAN website notes the current status in relative to risk of a bioterrorism event, and 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 in order to provide medical care and transportation for disaster victims. Any state can enlist the services of the NDMS, which is able to assist with care at the event site, can evacuate individuals affected, and is able to 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.

National Pharmaceutical Stockpile

The National Pharmaceutical Stockpile (NPS) program advocated by the Center for Disease Control (CDC) is now in place. The NPS is a standing emergency reserve of supplies for use in times of emergency. It is structured to be able to provide both an immediate response at any moment of need and a delayed response more targeted toward specific task needs. 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 provide assistance. These packages allow for both treatment and prophylaxis of most man-made diseases and are constantly being updated.

A second phase of the NPS program is known as the ‘Vendor-Managed Inventory.' This program consists of providing additional pharmaceuticals and supplies specifically targeted toward the needs of local healthcare workers so that they can better serve their patients during the emergency. The Vendor-Managed Inventory is capable of arriving at the incident scene from 24-36 hours after notification of a biological attack.

Post-traumatic Stress Disorder

After traumatic events, it is normal for victims, families, and caregivers to experience acute symptoms of anxiety that dissipate over time. However, some may go on to 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, who are physically injured, or who are exposed to extremely horrifying or grotesque events are at greatest peril. However, all who have exposure to the event are at potential jeopardy, including family members and friends, rescue workers, healthcare providers, as well as 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 or body parts, or even the loss of someone you know or work with. 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. The need to take care of one's self is especially true when recovery efforts stretch into days or weeks.

Symptoms of Traumatic Incident Stress29, 30
  • Fatigue
  • Dyspnea
  • Dizziness
  • High heart rate
  • Thirst
  • Headaches
  • Sweating
  • Confusion
  • Disorientation
  • Nightmares
  • Poor concentration, memory
  • Fear
  • Anger
  • Guilt
  • Grief
  • Depression
  • Overwhelm
  • Restless
  • Withdrawal
  • Rage
  • Appetite changes

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 you 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 own comfort level.
  • If your employer provides you with formal 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 had to deal with several instances of mass casualties. We have learned 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 the part of all healthcare providers.

We know that the quick implementation of a prepared, practiced response plan can save many lives. An awareness of what injuries might result from each of the 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, and all personnel who have any dealings with a large-scale emergency must be aware of what triage means and how to best aid in timely, effective care for both their patients and themselves.

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