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Weapons of Mass Destruction

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Author:    David Tilton (RN, BSN)

Purpose/Goals

To prepare healthcare providers to be ready to recognize, respond, and treat the victims of weapons of mass destruction.

Objectives

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

1. define Weapons of Mass Destruction,
   
2. identify Federal and CDC resources for communities after Weapon of Mass Destruction attacks,
   
3. differentiate between Nuclear and Radiological Weapons, and
   
4. discuss triage systems, and
   
5. discuss decontamination and choose the appropriate form of PPE for dealing with chemical weapons victims,
 

The Nature of the Problem

Weapons of mass destruction are by no means new. Historical accounts convey to us that during the 6th century BC the Assyrian’s army was using a chemical agent, rye ergot (a hallucinogen), to poison the drinking wells of enemies. The Tartar’s army is recorded as having purposely provoked an outbreak of plague in 1346 during its siege of the fortified city of Kaffa in the Crimea. They achieved this by purposely lobbing diseased and decaying bodies over the Kaffa city wall. Some historians speculate that the results of their efforts may have had a direct influence on the Black Death epidemic as survivors fleeing the siege provided a means by which disease could spread (Eitzen, 1997). 

This is an age of high-tech wonders and terrors. 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 as it is today. Weapons of Mass Destruction (WMD) have been and will continue to be the means by which sick individuals and groups spread their illness of the mind to the rest of us. The instruments of mass destruction of today are known by the abbreviation CBRNE.

CBRNE Weapons

Chemical

Biological

Radioactive

Nuclear

Explosive

(http://www.wmdfirstresponders.com)

As healthcare providers we have an obligation to be prepared, to be ready to recognize and treat the victims of these weapons. Front line medical staff can identify CBRNE weapons by being aware of abnormal surges in patient presentation patterns.

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 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 system to the point of breakdown.

Demands on the Healthcare System Include

 
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

(Luidvikas and Marcozzi, 2004)

Chemical Weapon Agents

Chemical Weapons Agents (CWAs) are compounds that pose a hazard to living tissues when they come in contact. CWAs produce incapacitation, serious injury, and death. Chemical 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 (Terrorism Preparedness and Public Health, 2003). Injury from weapon grade chemicals may be a result of an industrial accident, industrial sabotage, damage to a chemical storage area or stockpile, an act of war, or 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 (Arnold, 2004).

 
The components from which CWAs can be made are widely available.
  
 
Recipes for CWA production are easy to access worldwide on the internet.
  
 
CWAs are easily transported and 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 chemical terrorist attack.
  
 
Area hospitals would be quickly overwhelmed.

CWAs are placed in major categories according to the type of primary effect they have on living humans or animals (Arnold, 2004), (CDC Chemical Emergencies Overview, January 2005).

1.Vesicating or blistering agents - Chemicals that severely blister the eyes, respiratory tract, and skin on contact.
  
2.Blood agents – Toxins that affect the body by altering blood functions such as oxygen carrying capability.
  
3.Pulmonary agents - Chemicals that cause severe irritation or swelling of the respiratory tract (lining of the nose and throat, lungs).
  
4.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.
  
5.Nerve agents - Highly poisonous compounds that work by preventing the nervous system from working properly.

“Persistent agents” are those that remain dangerous for a considerable amount of time unless action is taken to destroy or neutralize them. These are usually liquid or solid at normal temperatures. “Non-persistent agents” are those that remain in effective concentrations for only a short time. They tend to be released as airborne particles of a solid (mace, pepper spray), droplets of a liquid (the sarin vapor used in the Tokyo subway attacks), or as true gases. Airborne particles are affected by prevailing weather conditions and are 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 3 routes:

1.Skin (liquid and 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, CWA effects may be immediate or delayed. Large inhalation exposures to nerve agents or mustards are likely to kill people immediately. Small exposures on the skin to the same nerve agents and mustards may initially only irritate, yet skin exposure to these chemicals are more dangerous than they seem at first. People exposed to such agents need to be carefully observed for slowly developing or delayed effects.

First responders to a chemical attack are at serious risk from the chemically contaminated environment, known as a hot zone. They can come into skin contact with the CWA or inhale the vapor. They are also at risk if they handle skin and clothing of victims if a liquid chemical agent was used. Ideally, emergency personnel will wear personal protective equipment, decontaminate the victims immediately, provide initial medical support and transport to the victims, and have access to specific antidotes to counteract harmful effects.

 

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 of time 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, yet death is rarely the main objective of their use.

Five main nerve agents are currently available. All are banned by international law and treaties and are considered to be exclusively military weapons. The Nerve agents are:

 
Tabun (GA)
  
 
Sarin (GB)
  
 
Soman (GD)
  
 
Cyclohexylsarin (GF)
  
 
VX

All of the current generation nerve agents have chemical structures similar to the common commercial organophosphate pesticide Malathion. These warfare agents initially stimulate and then paralyze nerve transmissions throughout the body, primarily by inhibiting acetylcholinesterase. This leads to hyperactivation of cholinergic pathways causing convulsive seizures and respiratory failure.

Under normal temperature and atmospheric pressure all nerve agents are volatile liquids, which may seem contradictory as they are referred to by the common usage name of nerve gases. Being volatile means they tend to evaporate quickly. Nerve agent vapors are heavier than air and tend to sink into low places 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 exposed on skin. All nerve agents are able to rapidly penetrate skin and clothing due to their high volatility.

Diagnosis

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 person shows and on information about the type of chemical exposure, if it is known.

Nerve Agents Onset

Signs

Symptoms

Vapors: Seconds to minutes

Liquids: Minutes to hours

 
Pinpoint pupils, eye irritation
  
 
Bronchoconstriction
  
 
Respiratory arrest
  
 
Hypersalivation
  
 
Increased secretions
  
 
Diarrhea
  
 
Poor concentration
  
 
Loss of consciousness
  
 
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)


 

(Arnold, 2004), (CDC, 2005)

 

Treatment


Treatment of victims exposed to nerve gas 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 will have effects similar to the more readily available atropine and may also be given.

The Mark I kit is designed for military self-administration in the field. It consists of 2 spring-loaded devices for self-injection, containing atropine and pralidoxime chloride. These kits are 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 have a gradual onset.

Blister Agents

Vesicating or Blistering Agents are often referred to by the slang term “mustards”. This is not the yellow stuff found on hot dogs at the ball park. Nitrogen mustard, Sulfur mustard (H or HD), Lewisite (L), and Phosgene oxime (CX) all cause 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 causes 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 are oily liquids that actually do possess an odor similar 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 and textiles, including rubber. Sulfur mustard is a persistent agent with low volatility at cool temperatures that becomes a major vapor hazard at higher temperatures. Exposure to mustard vapor, not mustard liquid, is the 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) is lethal to half of those exposed.
 

Diagnosis

Diagnosis of vesicant / blister agent / mustard exposure is based on observations of the person’s signs and symptoms as well as reports from the time of exposure. No laboratory tests are diagnostic.

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

Treatment

Immediate decontamination within 2 minutes of exposure is the most important intervention for people who have skin exposure to mustard. Any effects on living tissue result in irreversible cell damage to that tissue. Even if an exposure takes place and a person shows no obvious sign and symptoms, decontamination is still urgent.

Treatment of blister agent exposure is symptomatic. For most blistering agents, there is no antidote. The blister agent Lewisite (chlorovinyldichloroar-sine) is the only agent in this grouping with a specific treatment. Lewisite is an arsenical vesicant that is a colorless to brown liquid with a fruity or geranium-like odor. A scavenger molecule, dimercaprol (British anti-Lewisite,) works to bind the Lewisite compound, creating an effective antidote, if given early (Smith, & Skelton, 2003).

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.

 

Blood Agents

Cyanide ions in the body and bloodstream inactivate cytochrome oxidase, which in turn prevents cells from utilizing oxygen. This means that although blood delivers oxygen to the tissues, the cells are poisoned and unable to take up the oxygen. The result is asphyxia with a small degree of cyanosis (Terrorism Preparedness and Public Health, 2003). Cyanide acts very rapidly, causing death within the first ten minutes of severe exposure. It can be fatal if either ingested or inhaled

Cyanide compounds are frighteningly easy to obtain. Industrial uses for hydrogen cyanide are numerous. The liquid form of Cyanide could be inserted into a water supply or disguised in a strongly flavored food or liquid (Terrorism Preparedness and Public Health, 2003).

Cyanide as a gas makes a poor weapon. The gaseous form is very volatile, disappearing rapidly into the environment. The gas poses a grave threat to anyone handling it, especially those releasing it. In addition, the gaseous form either kills or has no effect, making it an all-or-nothing agent (Arnold, 2004).

 

Diagnosis

Due to the short time interval between exposure and death, diagnosis must be made by observation and known available facts of exposure only. 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, headache, venous blood-O2 level above normal, and hypotension. The mucosal membranes and skin of casualties tend to appear dark red because the cells cannot utilize oxygen. Higher exposure levels provoke coma, convulsions, and cessation of respiration and heartbeat. The presence of cyanide or thiocyanate levels in blood or urine are useful for later confirmation of the initial diagnosis.

Treatment

Supplemental oxygen by mask followed by intubation with 100% FiO2 is the initial treatment. Both sodium nitrite and sodium thiosulfate are antidotes to cyanide when administered immediately. Sodium nitrite 300 mg IV over 5-10 minutes and sodium thiosulfate 12.5 g IV. IV sodium thiosulfate reacts with cyanide to form thiocyanate, which is excreted by the kidneys. Amyl nitrite inhalation, 1 ampule (0.2 ml) every 5 minutes, may be helpful as it generates methemoglobin that binds molecular cyanide (Terrorism Preparedness and Public Health, 2003). Full protection from cyanide vapors can be achieved with activated charcoal filters.

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.

3-quinuclidinyl benzilate (BZ) is reported to be the most commonly used, due to its ability to cause intense visual and aural hallucinations, 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 (UNODC, 2005).

Lacrimating Agents (tear gas) are incapacitating agents used primarily for riot control in order to cause 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 (Smith, K. and Skelton, H., July 2003).

New incapacitating agents are cropping up all the time. In October 2002 Soviet security officials flooded a crowded Moscow theater with an aerosolized form of the common post surgical pain medication fentanyl. This resulted in 671 of the 800 hostages held by terrorists being rescued. Unfortunately, it also meant that 129 people perished with no accurate account of how many deaths were due to the incapacitating agent used (Robinson, J., 2005).
 

Treatment

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

 

Pulmonary Treatments

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 not concerned with breaking 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 initial exposure. This does not put them in the clear as tissue irritation and swelling can begin hours after exposure to the agent. Phosgene (CG) is primarily a pulmonary toxicant leading to injury of the respiratory tract and suffocation. Initially the effect of this agent is similar to tear gas with the onset of subsequent pulmonary edema developing approximately 4 hours after exposure (Smith, K. and Skelton, H., July 2003).

Diagnosis

Diagnosis

No specific tests are available, though a good history may help identify source and exposure characteristics. Chest x-rays may help confirm 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.

Treatment

No specific antidotes are available for the 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.

Biological Agents

Disease as a means of terror and mass destruction has been used since before written history. In modern times the ability to isolate a particular organism, and then replicate it in a controlled environment has promoted the use of disease as a living weapon. Most biological weapon agents are bacteria and viruses, along with some of the toxins they produce. However any living organism that is able to cause illness or death in humans or in the stock animals can conceivably be used as a biological weapon. The advantages of biological Agents are (Eitzen, 1997):

 
Death or incapacitation of the target population
  
 
Ability of some biological agents to continue proliferating in affected individuals and, potentially, in the local population and surroundings
  
 
The relatively low cost of producing many biological weapons
  
 
The 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)

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 (Bioterrorism Agents, 2004):

1.Can be easily disseminated or transmitted from person to person
  
2.Result in high mortality rates
  
3.Have the potential for major public health impact
  
4.Might cause public panic and social disruption
  
5.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 (Ebola, Marburg, Lassa, Machupo)

Category B Bio-agents are the second highest priority. These organisms pose a risk because they:

1.Are moderately easy to disseminate
  
2.Result in moderate morbidity rates and low mortality rates
  
3.Require CDC diagnostic and enhanced disease surveillance abilities

Category B Bio-agents include:

 
Brucellosis (Brucella species)
  
 
Epsilon toxin (from Clostridium perfringens)
  
 
Food Safety Threats (e.g., Salmonella, E. coli, Shigella)
  
 
Glanders (Burkholderia mallei)
  
 
Melioidosis (Burkholderia pseudomallei)
  
 
Psittacosis (Chlamydia psittaci)
  
 
Q fever (Coxiella burnetii)
  
 
Ricin toxin (from castor beans)
  
 
Staphylococcal enterotoxin B
  
 
Typhus fever (Rickettsia prowazekii)
  
 
Viral encephalitis
  
 
Water Safety Threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

Category C Bio-agents are pathogens that could be engineered for mass dissemination. These organisms pose a risk because of:

1.Availability
  
2.Ease of production
  
3.Potential for major health impact

Category C Bio-agents include:

 
Emerging infectious diseases (such as Nipah virus and hantavirus)

Biological warfare is the deliberate spreading of disease causing organisms among humans, animals, or plants. Disease results when the new, living microorganisms 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, this disease organism may spread to other available hosts, beginning the process anew. This process can be slow or blindingly fast. Even as the initial symptoms of quick spreading diseases become apparent those who are affected become incapacitated, creating a societal drain of resources as well as personnel able to give care. The incapacitation then continues until those infected begin to recover, become stabilized in their infirmity, or die. Biological weapons are living organisms that can adapt to new environments and to old treatments that use to work. Biological agents exposure routes are (Eitzen, 1997):

 
The Lungs as an aerosol (inhalational route)
  

   

The Digestive tract by being ingested in food or water (oral route)
  
   
The Skin by being absorbed through the skin or placed on the skin to cause damage to the integument (dermal route)
  
   
Into Tissue by being injected into the body (percutaneous route)

Toxins may also form the basis for biological weapons of mass destruction. These toxins themselves are non-living products of 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 agents of chemical warfare, can only affect those who are exposed to them, and have no ability to reproduce and produce transmissible disease.

Diagnosis

Symptomatic treatment is not enough when dealing with biological warfare agents. An exact diagnosis of the disease is essential, even beyond its normal importance in the treatment of an individual patient. The origin of the disease must be identified early in order to predict further spread of the organism, predict control needs, and isolate 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 critical.

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 will take. In the event a biological warfare agent is released, delays in instituting system level responses while waiting on “a definitive diagnosis” vastly increases the size and degree of the problem. It may be necessary to begin initial treatment in response to symptom type and patterns of location and exposure of involved individuals, even before a specific causative organism is determined. This method of early mass response goes against hard-learned habits for many practitioners; but, 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.

Signs of Bioterrorism

 
Abnormally high numbers of patients with similar symptoms of disease.
  
 
Large numbers of unexplained symptoms, diseases, or deaths.
  
 
Higher than expected morbidity and mortality in known disease.
  
 
Failure of a known disease to respond to traditional therapy.
  
 
Single incidents of rare or uncommon disease.
  
 
Multiple unusual clinical syndromes in the same patient.
  
 
Out of season, out of region disease presentation.
  
 
Atypical patient distribution.
  
 
Atypical disease presentation.
  
 
Similar pathogen characteristics/genetics from distinctly different sources.
  
 
Unusual, atypical, genetically engineered or antiquated strains of pathogens.
  
 
Sudden, unexplained spikes in disease incidence.
  
 
Unusual clustering of similar illnesses in non-connected areas.
  
 
Induced transmission of toxins or organisms, i.e. by aerosol, food, water.
  
 
Multiple patients with same symptoms from same geographic area.
  
 
Abnormal animal death or illness congruent to death or illness in humans.

(Luidvikas and Marcozzi, 2004)

 

Anthrax

Apart from biological warfare, anthrax in humans is rare. In the United States an average of one naturally occurring case per year was reported during the 1990’s (Dire, 2005).

Bio-agent

Signs & Symptoms

Diagnosis

Handling

Inhalation Anthrax
 
Incubation of up to 6 weeks.
  
 
Flu like symptoms for 1-2 days, often followed by slight improvement before sudden respiratory failure occurs.
 
CXR
  
 
Blood and Sputum Cultures
  
 
ELISA
 
Standard Precautions
  
 Post exposure Prophylaxis available
  
Cutaneous Anthrax
 
Incubation 1-12 days.
  
 
Intense itching followed by painless papular lesions progressing into dark vesicular lesions, then eschar surrounded by edema.
  
 
Most common form of Anthrax
 
Gram positive bacilli may be seen on peripheral blood smear during sepsis
  
 
Blood and wound Cultures
  
 
ELISA
 
Contact Precautions
  
 
Post exposure Prophylaxis available
Gastrointestinal Anthrax
 
Incubation 1-7 days.
  
 
Abdominal pain, nausea, vomiting, severe diarrhea, GI bleeding, fever.
 
Blood and Stool cultures.
  
 
ELISA
 
Standard Precautions
  
 
Post exposure Prophylaxis available

(http://www.bt.cdc.gov),(Dire, 2005),(Freidlander, 1997).

Plague

Plague

Plague is an ancient enemy. It has been the cause of 3 great human pandemics in the 6th, 14th, and 20th centuries. Its ally, the rat flea, has greatly aided the spread of plague in the past. Military scientists have gone one better though, they have concentrated on the development of primary pneumonic plague (epidemic pneumonia). Air is now the vector of choice in this new and improved agent of mass destruction (Dire, 2005).

Bio-agent

Signs & Symptoms

Diagnosis

Handling

Plague

Swollen inguinal lymph glands
 
Incubation 2-6 days.
  
 
High fever, cough, bloody sputum, chest pain, nausea, vomiting, headache.
  
 
Purpuric skin lesions, copious sputum, respiratory failure.
 
Gram, Wayson or Wright stains.
  
 
Blood and Sputum cultures.
  
 
Characteristic painful lymph glands.
 
Droplet precautions until 48 hours of effective antibiotic treatment.
  
 
Post exposure Prophylaxis available

http://www.cdc.gov/ncidod/dvbid/plague/diagnosis.htm

Smallpox

Smallpox

Smallpox was declared “extinct in the wild” in a 1980 declaration issued by the World Health Organization. As a bioweapon in waiting it gets top scores. It is highly infectious and associated with a high death rate as well as secondary spread. Currently, the majority of the US population has no immunity, vaccine is in short supply, and no effective treatment exists for the disease.

Bio-agent

Signs & Symptoms

Diagnosis

Handling

Smallpox
 
Incubation 12-14 days.
  
 
Malaise, fever, vomiting, headache, backache.
  
 
Skin lesions after second day of symptoms. Progress from macules to papules, then to vesicles and pustules.
 
Synchronous lesion development.
  
 
Swab culture of lesions.
  
 
Electron microscopy.
 
Airborne N95 mask and Contact isolation.
  
 
Early post exposure vaccination.

(http://www.who.int/emc/diseases/smallpox/slideset)

Botulism

The seven subtypes of botulinum toxin are the most deadly toxins known. Botulinum toxin is so lethal, easy to manufacture and weaponize, that it is considered one of the most-likely-to-be-seen biological warfare agents for the next decade. As a weapon, exposure is likely to occur following inhalation of aerosolized toxin or ingestion of toxin contaminated food (Dire, 2005).

Bio-agent

Signs & Symptoms

Diagnosis

Handling

Botulism

  Incubation – None with Toxin. From 12-72 hours for spores.
   
  No fever, excess mucus, speech difficulty, dysphagia, dizziness, difficulty moving eyes, mild pupil dilatation, nystagmus.
   
  Unsteady gait, symmetric descending weakness, flaccid paralysis, respiratory failure.

  CDC testing available of Serum, stool, gastric aspirate.
   
  Test suspect foods.
   
  Nasal swabs for inhaled spores.
   
  Differentiate from CVA, neurological problems.

  Standard precautions.
   
  No post exposure prophylaxis available.

(http://www.websters-online-dictionary.org ‘six’ -photo credit CDC.)(Dire, 2005.)

Tularemia

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 very excellent reasons. It is very incapacitating and very easy to contract when in a weapons 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-agent

Signs & Symptoms

Diagnosis

Handling

Tularemia
 
Incubation 3-6 days.
  
 
Enlarged lymph nodes, fever, headache, cough, muscle aches.
  
 
In the skin form least one large skin ulceration is common.
  
 
In the respiratory form pneumonia, chest pain, vomiting, joint pain, sore throat, abdominal pain, diarrhea.
 
Culture of blood, wounds, or sputum.
  
 
Serologic tests.
  
 
Agglutination tests.
  
 
ELISA.
 
Standard precautions with droplet precautions for both pulmonary presentations and lab workers.
  
 
Post exposure prophylaxis is available.

(Photo http://www.imcworldwide.org)

Viral Hemorrhagic Fever

Viral hemorrhagic fevers (VHFs) refer to a group of illnesses characterized by hemorrhage and fever. They are caused by five distinct families of viruses. Some VHFs cause relatively mild illness. Most however are severe and life-threatening involving multiple organ systems damage. All of the VHFs, with the exception of dengue, are potentially transmitted via aerosol. This capability, combined with their ability to cause serious illness has resulted in their consideration as biological weapons.

Bio-agent

Signs & Symptoms

Diagnosis

Handling

Viral hemorrhagic fevers - Ebola, Marburg, Lassa, Machupo along with Hantavirus, Nipah virus.

  Incubation days to months.
   
  Fever, flushing, red eyes, muscle aches, dizziness, and fatigue.
   
  Bleeding into the skin (petechae, purpura, and ecchymoses).
   
  Bleeding in internal organs, or from the mouth, eyes, or ears.
   
  Delirium, seizures, and coma.
   
  Kidney failure, shock, multiple organ system failure, and death.

  Distinctive bleeding due to damage to the vascular endothelium (lining cells of the blood vessels).
   
  Serologic testing, CDC testing.

  Airborne and Contact precautions pending definite identification.
   
  Maximum containment measures for all lab specimens!
   
  Only Crimean-Congo VHF and Lassa fever have effective post exposure prophylaxis.

(http://www.imcworldwide.org)(Photo CDC)

Ricin

Ricin is a plant toxin derived from a protein in the beans of the castor plant. It has been one of the most widely used bio weapons of the last several decades. 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-agent

Signs & Symptoms

Diagnosis

Handling

Ricin Inhalation
 
Sudden onset nasal & throat congestion, nausea and vomiting, itching of eyes, tightness in the chest, difficulty breathing progressing to possible death.
 
Is made on the basis of symptoms and possibility of exposure.
  
 
Inhalation of toxin aerosol victims may have signs on a chest x-ray as well as nasal swab traces.
 
Ricin is not contagious, though standard precautions should be maintained.
  
 
No post exposure prophylaxis is available.
Ricin Ingestion
 
Nausea, vomiting, severe cramping, bloody stools &/or emesis, shortness of breath, tachycardia, diaphoresis.
  
Ricin Injection
 
Flu like symptoms, body aches, nausea, vomiting, pain and swelling at the injection site. Severe exposure results in tissue death and GI bleeding, as well as widespread liver, spleen, and kidney damage.
  

(Dire, 2005.)(Tainted mail scare, www.homelandsecurity.org)
(Ricin container from mail www.reviewjournal.com)

Biological weaponry possesses a uniquely mobile feature (human carriers) that circumvents logical prediction and response methods. People don’t 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 point of contact before becoming aware there is a problem. This results in secondary infections from carriers.

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.

 

Nuclear and Radioactive Agents

The threat of nuclear and radioactive weaponry is just as real today as it was during the cold war with those annoying “fallout drills”. Some terrorism experts believe the risk for use of radiological weapons of mass destruction is actually higher now then it has ever been before! The very real possibility of such an event here inside of 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; but, are related. Nuclear weapons are instruments of mass destruction that have a primary focus related to explosive impact and physical damage. Radioactive weapons however are all about fallout. The focus is to frighten people and make buildings or land unusable for a long period 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 would be added when, and if it was needed.

Radiological dispersion devices (RDD) can be used to spread radioactive material over a wider area. A RDD might not kill a large number of people; but, the degree of terror and societal disruption caused by its use would be almost indescribable. A RDD known as a "dirty bomb," consists of conventional explosives wrapped in some sort of container containing low-grade fissionable material or radioactive waste. It 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.

Some experts believe that the concern over being ‘contaminated’ by a radiation producing substance is one of those things that will spark fear far beyond the actual potential for injury. This could lead to a “rush” on local hospitals and health facilities, as well intentioned yet fearful people seek reassurance and assistance. This would keep staff from those who truly need their services (Moller, 2003).

Radioactive weapons of mass destruction may not be an explosion at all! It can be distributed by a passive radiological dispersion device. The can be as simple as radioactive powders or waste products used to contaminate an area or product, such as a playground or a batch of cosmetics. Radiation emitting matter could slowly accumulate in the 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.

Diagnosis

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

Exposure to high amounts of 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 that releases 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 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 radiological weapons. Involved tissues begin to display disruption in mitosis, motility, cell growth, and permeability. Actively dividing cells are the most effected. The systems most vulnerable include gastrointestinal mucosal cells and hematopoetic tissues (especially lymphocyte 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 in sterility and three general syndromes related to the hematopoetic, gastrointestinal and neurovascular systems (Medical Management of Radiological Casualties, 2003).

Acute Radiation Syndrome (ARS) is also referred to as radiation toxicity or radiation sickness. 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 a matter of minutes. The major cause of this syndrome is depletion of immature parenchymal stem cells in tissues (Acute Radiation Syndrome: A Fact Sheet for Physicians, 2005). The four stages of ARS are:

1.Prodromal stage: The classic symptoms for this stage are nausea, vomiting, anorexia, and possibly diarrhea (depending on amount of radiation exposure). Symptoms occur from minutes to days following exposure. The symptoms may last (episodically) for minutes up to several days. Hair loss often occurs.
  
2.Latent stage: In this stage, the patient looks and feels generally healthy for a few hours or even up to a few weeks.
  
3.Manifest illness stage: In this stage the symptoms depend on the specific syndrome and last from hours up to several months.
  
4.Recovery or death: Most patients who do not recover will die within several months of exposure. The recovery process lasts from several weeks up to two years.

Those who have ARS also typically display skin damage. This damage may start to show within a few hours after exposure and can include swelling, itching, and redness of the skin (like severe sunburn). The skin may heal for a short time, followed by the return of swelling, itching, and redness days or weeks later. Complete healing of the skin may take from several weeks up to a few years depending on the radiation dose the person’s skin received.

Neurovascular 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 (Terrorism Preparedness and Public Health, 2003).

Gastrointestinal syndrome results from ionizing radiation damaging the 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, and 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 with gastrointestinal syndrome will also face hematopoetic syndrome (Terrorism Preparedness and Public Health, 2003).

Hematopoetic or Bone Marrow syndrome results from stem cell destruction due to radiation in the bone marrow and lymphatic organs. Symptoms include bleeding, infection, and anemia. Significant drops in blood cell counts may be seen anywhere from an hour to two days post exposure. The drop 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 in the slow process of recovery (Terrorism Preparedness and Public Health, 2003).

Treatment

When radiation exposure is suspected:

 
Secure ABCs (airway, breathing, circulation) and physiologic monitoring (blood pressure, blood gases, electrolyte and urine output) as appropriate.
  
 
Treat major trauma, burns, and respiratory injury if evident.
  
 
In addition to the blood samples required to address the trauma, obtain blood samples for CBC (complete blood count), with attention to lymphocyte count, and HLA (human leukocyte antigen) typing prior to any initial transfusion and at periodic intervals following transfusion.
  
 
Treat contamination as needed.
  
 
If exposure occurred within 8 to 12 hours, repeat CBC, with attention to lymphocyte count, 2 or 3 more times (approximately every 2 to 3 hours) to assess lymphocyte depletion.

(Medical Management of Radiological Casualties, 2003)

 

When internal contamination is suspected action can be taken to minimize damage by reducing the absorption of material and promoting rapid excretion from the body using binding agents and cathartics. Strategies include (Terrorism Preparedness and Public Health, 2003):

 
Oral potassium iodide (KI) for appropriate populations, if, and only if, radioiodine is suspected as a potential contaminant.
  
 
Gastric washing to remove radioactive material is only 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 biscodyl will rapidly increase intestinal transit time, taken orally or as an enema.
  
 
Pharmacologic doses of sodium bicarbonate, orally or intravenously, are useful and safe countermeasures for uranium exposure; however, 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. Calcium chelators for plutonium compounds are similarly being evaluated.

If exposure levels hint that a hematopoetic event is likely, any open wound repairs, severe burn debridements, 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 occur (Medical Management of Radiological Casualties, 2003), (Neal & Moores, 2002).

 

C Agents

Explosives often fail to be listed among Weapons of Mass Destruction due to their ready availability worldwide. 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 (CNN Oklahoma City Tragedy, 1996), (Terrorism Preparedness and Public Health, 2003).

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 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. The less severely wounded find their way to emergency rooms and other medical facilities, clogging them hopelessly. By the time the more severely wounded can be transported, local healthcare systems border on 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 devises are often associated with other forms of WMD. An explosive can rupture chemical storage tanks, fling chemicals, biologicals, or radioactive materials into the air and surrounding environment. Any explosion must therefore be the start of scrutiny and treated as a crime scene. As a matter of health, let’s 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 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 resulting fires or structural collapse. Because explosions are infrequent, blast-related injuries present triage, diagnostic, and management challenges to those providing emergency care.

High-order explosives (HE) produce a defining supersonic over-pressurization shock wave. Examples of HE include:

 
TNT,
  
 
C-4,
  
 
Semtex,
  
 
nitroglycerin,
  
 
dynamite, and
  
 
ammonium nitrate fuel oil (ANFO).

Low-order explosives (LE) create a subsonic explosion and pressurization wave. Examples of LE include:

 
pipe bombs,
  
 
gunpowder, and
  
 
most petroleum-based bombs such as Molotov cocktails or aircraft improvised as guided missiles.

(CDC Explosions and Blast Injuries, 2003)

 

HE explosions have a unique injury pattern as compared to LE blasts, in that the very force of the supersonic pressure wave created can pick up and slam people, cars, any object, 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. Specific HE injuries are traumatic, lung, ear, brain, and delayed injuries (CDC Explosions and Blast Injuries, March 2003)

Traumatic Injuries

Traumatic Injuries

Penetrating and blunt trauma to any body surface is the most common injury seen among survivors. Wounds can be grossly contaminated. Immediate concentration is on blood loss followed by later cleaning and debridement. Consider delayed primary closure and assess tetanus status. Ensure close follow-up of wounds for infection. Air embolism is common, and can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases.

Lung Injuries


“Blast lung” is a direct consequence of a high explosive over-pressurization wave. It is the most common fatal primary blast injury among those who survive the initial explosion. 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 triad of apnea, bradycardia, and hypotension. Pulmonary injuries vary from scattered petechae 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 exposed persons and a prophylactic chest tube (thoracostomy) is recommended before general anesthesia or air transport if blast lung is suspected. 

Ear Injuries

Primary blast injuries of the auditory system are common yet easily overlooked. The extent of the injury is dependent on the orientation of the ear to the blast pressure wave. TM perforation is the most common injury to the middle ear. Signs of ear injury are usually present at time of initial evaluation and should be suspected for anyone presenting with hearing loss, tinnitus, otalgia, vertigo, bleeding from the external canal, TM rupture, or mucopurulent otorhea. All patients exposed to blast should have an otologic assessment and audiometry as soon as can be arranged.

Abdominal Injuries

Gas-containing sections of the GI tract are the most vulnerable to primary blast effect. Damage 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 Injuries

Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) even without a direct blow to the head by an object occurring. Consider the proximity of the victim to the blast particularly given complaints of headache, fatigue, poor concentration, lethargy, depression, anxiety, insomnia, or other constitutional symptoms.

Delayed 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 like CO or CN, MetHgb in both industrial and criminal explosions. 

Treatment

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. Area emergency services personnel must immediately implement local disaster planning measures upon arrival of the first responders to the scene. Prompt notification of all area healthcare facilities should create a “ripple effect” as each facility begins to 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.

Can YOU?

1.Identify and locate your agency's emergency response plan.
  
2.Describe your role in an emergency response involving mass casualties.
  
3.Describe the chain of command in emergency response.
  
4.Describe your functional role in an emergency and demonstrate your role by regular drill participation.
  
5.Recognize deviations from the norm.
  
6.Identify the limits of your own knowledge, skill, and authority.
  
7.Describe communication roles in emergency response.
  
8.Demonstrate use of emergency equipment.

At 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 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 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 use 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 Commander, regional EMA, health department, or even reliable news sources. Should the report of structural collapse occur, be sure to anticipate an increase in the severity of injuries as well as further time delays in the arrival of casualties (CDC Explosions and Blast Injuries, 2003).

 

Triage

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

Triage is a French word that emphasizes the context of sorting, or sifting. It was on the battlefields of France that the practice of triage first became formalized, with an effort to systematically sort the wounded into those who could be saved by medical interventions, and those who could not.

(Peterson T., Mello M., Broderick K., Lane P., Prince L., Jones A., and Goodman P., 2003)

 

There is no uniform triage system in the United States. The most 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 and their need to make field decisions according to the acuity of trauma victims have shown that these traditional triage systems have little use outside of the ER (Fernandes C, Groth S, Johnson L, et al, June 1999).

One example of a simple, effective triage assessment system that is gaining in popularity is the S.T.A.R.T. System. START stands for Simple Triage and Rapid Treatment and was originated during the 1980’s in Newport Beach California by 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 (Streger, 1998).

The START system categorizes patients into four groups: Red, Yellow, Green and Black.

 
Red (Immediate) patients are critically injured, with problems that will require immediate intervention to correct
  
 
Yellow (Delayed) patients are injured and will require some medical attention, yet will not die if care is delayed for other patients. Individuals placed in this category have respirations under 30 per minute, capillary refill of less than 2 seconds and can follow simple commands. Yellow patients are not ambulatory and will require a stretcher for transportation
  
 
Green (Ambulatory) patients are not critically injured and can walk and care for themselves
  
 
Black-tagged patients have such catastrophic injuries that they are not expected to survive to be transported or already deceased.

 

Decontamination

Decontamination is the physical process of removing the remaining chemicals from people, equipment, and the environment. Residual hazardous chemicals on 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 CWA 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 actually 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, decontaminate.

Make sure victims are able to breathe, as respiratory effects are common with the majority of CWAs. Ideally decontamination will take place as close as possible to the site of exposure to minimize 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 safely decontaminate at least one person at a time.

Immediate decontamination within 2 minutes of exposure is the most important intervention for people who have skin exposure to mustard agents. Any effects on living tissue result in irreversible cell damage to that tissue. Even if an exposure takes place and a person shows no obvious sign and 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 (Arnold, 2004.) Liquid blister agent contamination poses a risk for emergency care personnel. The use of PPE impervious to the highly soluble agents is a must.

The presence of radiological contamination can be readily confirmed by passing a radiation detector (radiac or Geiger counter) over a person’s body. The need for radiological decontamination should never interfere with 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 suffi­cient to remove radiological contamination (Medical Management of Radiological Casualties, 2003).

That said, 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 the 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 intra venous access should be done prior to full decontamination efforts (Medical Management of Radiological Casualties, 2003).

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 re­moved to a secure location clearly marked as a contaminated 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 for latter disposal in an appropriate manner.

Should the seriousness of injuries mandate that decontamination be delayed, in the simple removal of outer clothing and shoes along with a rapid washing of exposed skin and hair will, in most instances, effect a 95% reduction in the patient’s contamination (Medical Management of Radiological Casualties, 2003). “Anti-contamination 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” (Neal & Moores, 2002).

Special care must be taken not to irritate the skin. Experience with victims of radiological contamination has shown that should the skin become erythematous, some 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 al­pha and beta emitters left in wounds will continue to cause extensive local damage and may be absorbed into the systemic circu­lation 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 sa­line, 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. This is initiated to prevent transfer of any residual radiological particulate to areas of the body pre­viously 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 labeled, and sealed in separate bags for latter 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 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.

 

Personal Protective Equipment

The US Environmental Protection Agency (EPA) has graded PPE into 4 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 totally 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 of surgical gown, mask, and latex gloves. 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 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 (CWAs) onto themselves, or others.

Routine hospital issue personal protective equipment (PPE) will probably not be adequate. Surgical masks, for example, are designed to protect the sterile field of the patient from contaminants generated by the wearer. While surgical masks are adequate at filtering 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 (Arnold, 2004).

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

When initially handling victims contaminated with chemical warfare agents (CWA) both respiratory and skin protection is needed. Victims exposed to a CWA gas with known properties (chlorine, phosgene, oxides of nitrogen, cyanide) may be handled with standard hospital issue equipment (Level D PPE), as these victims cannot breathe out the hazardous gas and harm others.

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 with level C PPE and air-purifying respirators will be required to conduct decontamination. Once decontamination is complete and the threat level assessed, standard level D precautions (universal precautions) may be adequate (Arnold, 2004).

 

System Supports

National Medical Response Teams were established by the Federal Office of Emergency Preparedness. Teams are organized so that they are available to assist with sudden medical needs following a chemical or biological terrorist event. The quick deployment design of response teams allow them to go anywhere in the country within six hours of an attack. They are supplied with sufficient equipment and specialized pharmaceuticals to treat as many as 1000 patients.

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 a combination response at any moment of need. The initial response consists of ready for delivery of pharmaceuticals and supplies designed 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.

The second phase of the NPS program is known as the ‘Vendor-Managed Inventory’. This 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 (Luidvikas and Marcozzi, 2004).

 

Post Traumatic Stress Disorder

After traumatic events most people will experience acute symptoms that dissipate over time. However, some may go on to develop psychiatric disorders, most commonly posttraumatic 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, and
  
 
persistent symptoms of autonomic hyperarousal.

The best predictor of PTSD 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 risk. However, all who have exposure to the event are at potential risk, including immediate victims, 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 to monitor their own emotional and physical health. This is especially true when recovery efforts stretch into days or weeks.

Symptoms of Traumatic Incident Stress

Physical

Cognitive

Emotional

Behavioral

 
 
Chest pain
  
 
Difficulty breathing
  
 
Shock symptoms
  
 
Fatigue
  
 
Nausea/vomiting
  
 
Dizziness
  
 
Profuse sweating
  
 
Rapid heart rate
  
 
Thirst
  
 
Headaches
  
 
Visual difficulties
  
 
Clenching of jaw
  
 
Nonspecific aches and pains
 
Confusion
  
 
Nightmares
  
 
Disorientation
  
 
Heightened or lowered alertness
  
 
Poor concentration
  
 
Memory problems
  
 
Poor problem solving
  
 
Difficulty identifying familiar objects or people

 

 
Anxiety
  
 
Guilt
  
 
Grief
  
 
Denial
  
 
Severe panic (rare)
  
 
Fear
  
 
Irritability
  
 
Loss of emotional control
  
 
Depression
  
 
Sense of failure
  
 
Feeling overwhelmed
  
 
Blaming others or self

 

 
Intense anger
  
 
Withdrawal
  
 
Emotional outburst
  
 
Temporary loss or increase of appetite
  
 
Excessive alcohol consumption
  
 
Inability to rest, pacing
  
 
Change in sexual functioning

(Traumatic Incident Stress, 2001)

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 down time can greatly help. Mental fatigue over long shifts can place staff at greatly 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. Staff 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!
  
 
Give yourself permission 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

Conclusion

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 that they cause damage, injury, and death to many; 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 beyond 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, allow 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.

 

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