Chemical, Biological and Radiological Weapons An Appropriate Response Jay L. Schauben, Schauben, PharmD, PharmD, DABAT, FAACT Director, Florida/USVI Poison Information Center – Jacksonville Director, Florida Poison Information Center Network Data Center Clinical Professor, Department of Emergency Medicine, College of Medicine, and Department of Pharmacy Practice, College of Pharmacy University of Florida Health Science Center

Overview • Unique features of terrorism and response • HAZMAT zones, PPE, and decontamination • Biological terrorism agents review • Chemical terrorism agents review • Nuclear/radiation threats review • Action and resources

Epidemiology of Disasters • Natural Disasters • ManMan-made Disasters • Terrorism

Epidemiology of Disasters • Natural Disasters • ManMan-made Disasters • Terrorism

1

Disaster Epidemiology

What is Terrorism?

• Most victims arrive within

•

• • • •

1.5 hours of the disaster Arrival is uncoordinated Closest hospital is typically overwhelmed Medical care of unaffected community adds to burden Civilian rescue increases injuries

Unique Features of an NBC Terrorist Attack • Involve mass casualties • Responding personnel are at risk for personal injury

• EMS and HCF’ HCF’s easily become overwhelmed • Psychogenic casualties probable • Instantaneous or delayed effects possible • Could involve exotic or common materials

Social psychology “...the indirect strategy that wins or loses only in terms of how you respond to it… it….Terrorism wins only if you respond to it in the way the terrorist wants you to: which means that its fate is in your hands and not in theirs” theirs” Franklin, 1975

Most Likely Methods of Terrorist Attack • Use of a conventional explosive • Release of an industrial chemical agent • Release of a military chemical agent • Use of a conventional bomb laced with • •

chemical, biological, or radiologic agents Release of a biological agent Detonation of a nuclear device

Sharp et al: Ann Emerg Med 1998; 32; 214-223

Other Considerations • Controlled vs. uncontrolled event • Delayed onset • Lack of information/verification of substance • Staff/facility contamination • Resources overwhelmed • HCF must stand alone • Unfamiliarity leads to chaos

Nuclear Terrorism Name

Example

Simple radiological device

Dispersal of plutonium through a building’s ventilation system

Radiological dispersal device

Spreading radioactive material with a conventional explosion

Nuclear reactor sabotage

Disabling a nuclear reactor’s cooling system

Improvised nuclear device

Terrorist detonation of a homemade nuclear device in a city

Nuclear weapon

Detonating a one kiloton, suitcasesize, nuclear weapon obtained by piracy from one of the nuclear powers of the world

2

Chemical Terrorist Events • 1985 - Covenant Group found to possess 33 • • •

gallons of cyanide 1992 - Police prevent NeoNeo-Nazis from using cyanide in synagogue 1994 - Aum Shinrikyo uses sarin in Matsumoto – 7 dead, 280 injured 1995 - Aum Shinrikyo uses sarin in Tokyo subway – 12 dead, 5,500 injured

Impact of a Chemical Agent Release • In immediate aftermath of Tokyo sarin nerve agent attack

– Over 650 patients presented to St. Luke’ Luke’s Hospital within several hours – 50% of staff affected within few hours due to offoff-gassing of vaporvapor-exposed patients – 5500 sought medical care – 1000 hospitalized – 135 first responders injured

Nerve Agents Liquid Exposure

• Copycat attacks in Japan using cyanide, phosgene, and pepper spray

• FBI thwarts possible sarin attack in Disneyland • 1997 - Sydney, Australia – chlorine bombs in shopping centers injure 14 - 500 evacuated

5 Main Classes of Chemical Terrorism Agents Classification

Specific Names

Main Clinical Effects

Antidotes

Nerve Agents

Tabun; Sarin; Soman; VX

Cholinergic crisis; Paralysis; Ventilatory failure; Coma

Pralidoxime; Atropine

Vesicants

Lewisite; Sulfur mustard; Phosgene oxime

Vesiculation; Chemical burns of the skin and mucous membranes

British-Anti-Lewisite (BAL) for Lewisite only

Cyanides

Cellular asphyxia; Anaerobic Hydrogen cyanide; metabolism; Lactic acidosis; Cyanogen chloride Cardiovascular collapse; Shock; CNS dysfunction; Seizures; Coma

Amyl nitrite; Sodium nitrite; Sodium thiosulfate

Pulmonary Agent

Phosgene

Noncardiogenic pulmonary edema; Hypoxemia; Respiratory failure; Hypovolemic shock

None

Riot Control Agents

CN; CS (Mace®)

Mucous membrane & skin irritation; Lacrimation

None

Chemical Warfare Agents

• Large amount of VX nerve

agent (LD50) (8 Gy) Gy)

Vomiting Onset Incidence (%)

≥2h 10-50

1-2h 70-90