Course: Bioterrorism and Weapons of Mass Destruction (Nevada requirement) | Copyright © 2009 CEUFast.com

Course Contents

	Purpose Statement    Objectives    The Nature of the Problem    Chemical Weapon Agents    Nerve Agents        Diagnosis        Treatment    Blister Agents        Diagnosis        Treatment    Blood Agents        Diagnosis        Treatment    Incapacitating Agents        Treatment    Pulmonary Agents        Diagnosis        Treatment    Biological Agents        Diagnosis        Anthrax        Plague        Smallpox        Botulism Toxin        Tularemia        Viral Hemorrhagic Fever        Ricin    Nuclear and Radioactive Agents        Diagnosis        Treatment    Explosive Agents        Traumatic Blast Injuries        Lung Blast Injuries        Ear Blast Injuries        Abdominal Blast Injuries        Brain Blast Injuries        Delayed Blast Injuries        Treatment    Triage    Decontamination    Personal Protective Equipment    System Supports        Health Alert Network        National Disaster Medical System        National Pharmaceutical Stockpile    Post traumatic Stress Disorder    Conclusion    References    Click any section in the index above to browse to the corresponding course section

Purpose Statement

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:

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 army was using a chemical agent, rye ergot (a hallucinogen), to poison the drinking wells of enemies. The army of the Tartar nations is recorded as having purposely provoked an outbreak of the black 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 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 as it is today. In this time of technology Weapons of Mass Destruction (WMD) are possible options that driven individuals or organizations may turn to in order to effect or inflict damage on the rest of us.

The instruments of mass destruction of today are known by the abbreviation CBRNE.

CBRNE Weapons of Mass Destruction

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

Figure 1: (Huebner, 2008).

As healthcare providers we have an obligation to be prepared, to be ready to recognize and treat those who may come in contact with 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 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 system to the point of breakdown.

WMD Induced Demands on the Health Care System

Shortfalls of ICU beds, ventilators, and other critical care needs       Shortages of chemotherapeutic agents       Needs for ancillary or nontradiational 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, 2008).

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, 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. Injuries produced from weapon grade chemicals can originate from a variety of causes. It 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 (Arnold, 2009).

	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 broad groupings or categories according to the type of primary effect they have on living humans or animals (Arnold, 2009), (Centers for Disease Control and Prevention Chemical Agents by Category, 2008).

"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 tend usually to be liquid or solid at normal temperatures.

"Non-persistent agents" are those 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 (mace, pepper spray), 2) droplets of a liquid (the sarin vapor used in the Tokyo subway attacks), or as 3) 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:

Depending on the agent, the method of delivery, and the amount (concentration) of exposure, chemical warfare agent effects may be immediate or 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, yet skin exposure to these chemicals are more dangerous than they seem at first. All individuals exposed to such agents need to be carefully observed for slowly developing or delayed effects.

First responders to a chemical warfare agent attack are at serious risk from an environment steeped with concentrations of the chemical contaminant, known as a hot zone. They 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, 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.

A Few Recent Chemical/Nerve Warfare Incidents

In 1983 Iraq used tabun against Iran, and Iran responded with a nerve agent of unidentified type. This exchange generated at least 10,000 deaths and casualties in the two armies.     On March 16, 1988, Iraq launched an attack on the Kurd population of Halabja, Iraq where there were 5000 deaths and a high number of casulaties from both sarin and from sulfur mustard.     A 1995 Tokyo subway attack by the religious cult Aum Shinrykio utilized sarin and caused 12 deaths and 5,000 casualties. One year earlier, the cult had conducted a test attack on an apartment building in Japan and killed seven people.

Figure 3: (Beary, Argonstein, Chines, 2009).

Currently there are five main chemical warfare nerve agents available. All are banned by international law and treaties and are considered to be exclusively military weapons. These five nerve agents are:

	Tabun (also referred to by the military designation "GA")
	Sarin (GB)
	Soman (GD)
	Cyclohexylsarin (GF)
	VX

Each of the five major nerve agents of the current generation possess a chemical structure similar to the common commercial organophosphate pesticide Malathion. In action these warfare agents initially stimulate and then paralyze nerve transmissions throughout the body, primarily by inhibiting acetylcholinesterase. This mechanism of action 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". This can be explained by their chemical nature. Being volatile means they tend 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 exposed on skin. All chemical warfare nerve agents are able to rapidly penetrate skin and clothing largely 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

Nerve Agent Onset	Sign	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 termors. High exposure:   Sudden loss of consciousness, seizures, flaccid paralysis
Figure 4: (Arnold, 2009) (Agency for Toxic Substances and Disease Registry, 2008).

Treatment

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 also be given.

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 2 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 have a gradual onset.

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 ball park. 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 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 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 and 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 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 agent / 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 primarily injure the skin, eyes, respiratory tract, GI tissues, and blood system. Wherever tissue is exposed to the agent the symptom pattern will reflect corrosive irritation of that area. Skin exposure commonly results in an initial rash followed by blistering similar to a partial-thickness burn. Vapor exposure 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

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. RSDL is a creamy lotion currently packaged on a foam applicator in a single use pouch 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 (Beary, Argonstein, Chines, 2009).

Treatment of blister agent exposure beyond decontamination is symptomatic. For most blistering agents, there is no agent specific 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 known as dimercaprol or British Anti-Lewisite works to bind the Lewisite compound, creating an effective antidote, if given early.

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

Chemical warfare agents that affect the victim by being absorbed into the circulating blood stream 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. It can be fatal if either ingested or inhaled

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. The gaseous form of cyanide 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.

Diagnosis

Due to the short time interval between exposure and death, diagnosis must be made by observation and any known available facts of 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, 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.

Treatment

Supplemental oxygen by mask followed by intubation with 100% FiO2 is the preferred initial treatment. Both sodium nitrite and sodium thiosulfate are antidotes to cyanide when administered immediately. 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 cyanide vapors can be achieved with activated charcoal filters (Schraga & Pennardt, 2008).

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.

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 civil unrest actions in several countries such as Mozambique and Bosnia. There are no reports of its use in the United States. 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 (Holstege & Boyle, 2008).

Lacrimating Agents (tear gas) are incapacitating agents used in the United States and other countries used 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. 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 directly to the incapacitating agent used (Robinson, 2005).

Treatment

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.

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 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. Initial 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. Primarily phosgene is a pulmonary toxicant. Exposure to it leads quickly 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 (Wethern & Huebner, 2009).

Diagnosis

No specific tests are readily 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 include:

	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 surrounding areas
	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)

Agents of Biologic Warfare are categorized into three levels categories A, B, and C. based on how easily they can be dispersed into a target population as well as the severity of illness or death that they can be expected to cause.

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 (Centers for Disease Control and Prevention, Bioterrorism Agents by Category, 2008).

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 level of concern. These organisms pose a risk because they (Centers for Disease Control and Prevention. Bioterrorism Agents by Category, 2008):

Category B Bio-agents include:

	Brucellosis (Brucella species)
	Epsilon toxin (from Clostridium perfringens)
	Food Safety Threats (e.g., Salmonella, E. coli select strains, Shigella)
	Glanders (Burkholderia mallei)
	Melioidosis (Burkholderia pseudomallei)
	Psittacosis (Chlamydia psittaci)
	Q fever (Coxiella burnetii)
	Ricin toxin (extract 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 have the potential to be engineered for mass dissemination. These organisms pose a risk because of (Centers for Disease Control and Prevention. Bioterrorism Agents by Category, 2008):

Category C Bio-agents include:

Emerging infectious diseases (such as Nipah virus and Hantavirus)

The weapons of mass destruction of biological warfare focus on the deliberate spread of disease causing organisms or organic toxins among humans, animals, or plants. Disease results when these new, pathologic 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, these disease organisms may have the ability to self-spread into other available hosts, beginning the process anew. This self dissemination process can be slow or blindingly fast. With many of the biological warfare agents as the initial symptoms of quick spreading disease becomes apparent, those who are affected become incapacitated, creating a societal drain of resources as well as rapid loss of personnel able to contain the outbreak or give care to those affected. Incapacitation continues until those infected begin to recover, become stabilized in their infirmity, or die.

Biological weapons are living organisms that have an ability to adapt to new environments and to old treatments that used to work. Biological agent exposure routes are (Eitzen & Takafuji, 1997):

	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 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 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 any individual patient. The origin of the disease must be identified quickly in order to predict further spread of the organism, estimate control needs, 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 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 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 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 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.

Indications of Possible Biologic Weapon Event

Abnormally high numbers of patients with similar symptoms.       Large numbers of unexplained sympotoms, disease, or deaths.       Presence of disease (or strain) not locally endemic.       Higher than expected mortbidity and mortality in known diesease.       Failure of a known diease to respond to traditional therapy.       Out of season, out of region diesease presentation.       Atypical patient distribution.       Atypical disease presentation.       Similar pathogen characteristics/genetics from distrinctly different sources.       Unusual clustering of similar illnesses in non-connected areas.       Induced transmission of toxins or organisms, (i.e. by aerosol, food, water).       Abnormal animal death or illness congruent to death or illness in humans.

Figure 5:( Dire, 2008)

Anthrax

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 very rare. In the United States an average of one naturally occurring case per year has been reported during the last twenty years (Dire, 2008).

Anthrax

Bio-Agent	Signs & Symptoms	Handling
Cutanuous Anthrax (most common form of anthrax)	Incubation 1-12 days.       Intense itching followed by painless papular lesions progressing into dark vesicular lesions, then eschar surrounded by edema.	Contact Precautions       Post exposure prophylaxis for care personnel available
Inhalation Anthrax (aka Woolsorter's Disease)	Incubation with latent period of up to 60 days       Flu like symptoms for 1-2 days, often followed by slight improvement before sudden respiratory failure occurs.	Standard Precautions       Post exposure prophylaxis for care personnel available
Gastrointestinal Anthrax	Incubation 1-7 days.       Abdominal pain, nausea, vomiting, severe diarrhea, GI bleeding, fever.	Standard Precautions       Post exposure prophylaxis for care personnel available
Figure 6:( Dire, 2008).

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

Plague (Yersinia pestis, a gram negative, non-motile, nonsporulating coccobacillus) is an ancient enemy of civilization. It has been the cause of 3 great human pandemics in the 6th, 14th, and 20th centuries. Its ally, the oriental 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 which if untreated has a reported mortality rate of near 100-percent. Air is now the vector of choice in this new and improved biologic agent of mass destruction (Dire, 2008).

Plague

Bio-Agent	Signs & Symptoms	Handling
Plague	Incubation 2-6 days.       Swollen inguinal lymph glands.       High fever, cough, bloody sputum, chest pain, nausea, vomiting, headache.       Purpuric skin lesions, copious sputum, respiratory failure.	Droplet precautions until 48 hours of effective anitibiotic treatment.       Post exposure prophylaxis for care personnel available.
Figure 7:( Dire, 2008).

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 will demonstrate results in 48 hours. PCR (Polymerase Chain Reaction) testing is specific for the presence of plague, however may not be available in all regions.

Smallpox

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 however it gets top marks. It 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 has no immunity, vaccine is in short supply, and no effective treatment exists for the disease.

Smallpox

Bio-Agent	Signs & Symptoms	Handling
Plague	Incubation 7-17       Malaise, fever, vomiting, headache, backache.       Skin lesions (pox) begin to form after second day of symptoms.       Simultaneous progress from macules to papules, then to vesicles and pustules.	Use of N95 repiratory mask and Contact isolation.       Early post exposure vaccination.
Figure 8: (Dire, 2008)

Diagnosis of smallpox falls largely on alertness of medical personnel to the differences of smallpox 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) 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 may be taken of formed lesions in order to confirm 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 hyperimmune serum may be used.

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 the number-one, most deadly toxins that we know of. 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 foreseeable future. As a weapon, exposure is likely to occur following inhalation of aerosolized toxin or ingestion of toxin contaminated food (Dire, 2008).

All 7 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 Toxin

Bio-Agent	Signs & Symptoms	Handling
Botulism ( all 7 subtypes)	Incubation - None with refined toxin. From 12-72 hours for spores       Excess muscus, 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.
Figure 10: (Dire, 2008).

Diagnosis of botulism toxin exposure relies heavily on clinical examination skills. Some initial signs include blurred vision, speech difficulty, dysphagia, dizziness, difficulty moving eyes, and nystagmus. An unsteady gait with symmetric descending muscular weakness is a strong indication of exposure. This generally proceeds into flaccid paralysis and respiratory failure. Nasal swabs can be obtained for PCR and toxin assays, and toxin serum assays can be ran (Woods, 2009).

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.

Tularemia

Bio-Agent	Signs & Symptoms	Handling
Tularemia	Incubation 3-6 days.       Enlarged lymph nodes, fever, headache, cough, muscle aches.       In the skin form at least one large skin chancre-like ulceration is common.       In the respiratory form pneumonia pneumnia, chest pain, vomiting, joint pain, sore throat, abdominal pain, diarrhea.	Standard precautions with droplet precautions for both pulmonary presentations and lab workers.       Post exposure prophylaxis is available.
Figure 11: (Dire, 2008).

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 is effective, and culture of Francisella tularensis can be obtained from specimens of blood, sputum, 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 (Dire, 2008).

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 damage. 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 Hemorrahagic Fevers

Bio-Agent	Signs & Symptoms	Handling
Viral hemorrhagic fevers (e.g., Ebola, Marburg, Lassa, Machupo, Hantavirus, Nipah virus)	Incubation days to months.       Fever, flushing, red eyes, muscle aches, dizziness, fatigue.       Distinctive bleeding into the skin (petechae, purpura, ecchymoses) due to damage to the vascular endothelium (lining cells of the blood vessels).     Bleeding in internal organs, or from the mouth, eyes, or ears.     Delirium, seizures, and coma.     Kidney failure, shock, mutiple organ system failure.	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.
Figure 13: (Bray, 2009).

Diagnosis of any of the viral hemorrhagic fevers relies primarily on initial provider awareness of observable symptoms, as well as 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 as while detection can be made of early immunoglobulin antibody response during the acute phase, test results tend to take from 3 to 10 days (Dire, 2008).

Ricin

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.

Ricin

Bio-Agent	Signs & Symptoms	Handling
Ricin Inhalation	Sudden onset nasal & throat congestion, nausea and vomiting, itching of eyes, tightness in the chest, difficulty breathing progressing to severe respiratory distress and possible death.	Ricin is not contagious, though standard precautions should be maintained.       No post exposure prophylaxis is available.
Ricin Ingestion	Nausea, vomiting, severe cramping, bloody stolls &/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 both local and diffuse tissue death and GI bleeding, as well as widespread liver, spleen, and kidney damage.
Figure 14: (Dire, 2008).

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 are 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 (Dire, 2008).

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. This 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.

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 than 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 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 however differ in that they are all about radiation fallout. With radioactive weapons the primary focus is to frighten people and make buildings or land unusable for long 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 would be added when, and if it was needed.

Radiological dispersion devices (RDD) are used to spread radioactive material over a wider area. An 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. An RDD often referred to 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.

Prevalence of Radiologic Materials

According to the United States Federal accounting office, approximately 10 million "sealed sources" of radioactive material exist in 50 countries, including the United States       Of the 612 sealed sources reported lost of stolen since 1995, 254 have not been recovered. Many additional sealed sources may be unaccounted for as well. Such refined sources of radioactive material might be used by terrorist for making a Radiologic Dispersion Device.

Figure 15: (Wingard & Dainiak, 2009).

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. 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.

Radioactive weapons of mass destruction may not incorporate an explosion at all! Material can be distributed by means of 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 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.

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.

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 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 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 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 some general syndromes related to the physiological response to radiation exposure have been identified (Dainiak, 2009).

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 (Dainiak, 2009).

The Four Stages of Acute Radiation Syndrome

Prodromal stage: Classic symptoms are nausea, vomiting, anorexia, and possibly diarrhea. Symptoms occuer 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.       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, with life-long follow-up required due to chronic effects of radiation exposure.

Figure 16: (Dainiak, 2009)

Cutaneous Syndrome often occurs in conjunction with ARS. Skin damage from the radiation exposure may develop early, within one to two days, or it may take years to fully manifest. Early damage may even start to show within a few hours after exposure and can include swelling, itching, and redness of the skin (like severe sunburn). The area and body region showing damage will be related to the localized dose of the skin that comes in contact with the radiation, and can provide important early clues as to the nature of the exposure which has occurred. 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, 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 Syndrome

The early presence (within minutes of exposure) of fever, hypotension, and major impairment of cognitive function, along with severe prodromal symptoms (eg, anorexia, nausea, vomiting) suggests exposure to a supralethal dose of radiation.       Lesser, but still fatal, exposures to the central nervous system present with persisten and severe nausea and vomiting, accompanied by headache, neurologic deficits, and abnoral cognition. Signs and sumptoms include disoreintation, confusion, loss of balance and seizures. Physical examination may show papilledema, ataxia, and reduced or absent deep tendon and corneal reflexes. A latent period of a few hours of apparent improvement is common, but within five to six hours watery diarrhea, respiratory distress, fever, and cariovascular collapse ensue. The final picture may mimic that of sepsis with hpyotension, cerebrak edema, increased intracranial pressure, cerebral anoxia, with death typically in about two days time.

Figure 17: (Dainiak, 2009).

Gastrointestinal Syndrome results from the ionizing effect of radiation damaging the 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, 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. 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.

Hematopoetic 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. 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 the slow process of recovery.

Treatment

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, either by physical radioactive material on skin or absorbed 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 (Wingard & Dainiak, 2009).

Signs and symptoms of radiation exposure can be initially quite vague. Special attention should be placed on history taking, emphasizing location of 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 during the estimation of degree of radiation exposure is made, around which much of the later 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 the amount 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 (Wingard & Dainiak, 2009):

	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 biscodyl 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; 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.

If exposure levels hint that a hematopoetic 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 availability 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.

Remember Explosive Weapons Attacks

1995, April - Oaklahoma City Federal Building bombed with a 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. 3350+ killed, 10,000+ injured.       2004, March - Madrid, Spain. Bombs placed on 4 commuter trains explode. 190 killed, 1800+ injured.       And many, many other incidents...

Figure 18: (Stephens, 2008)

An explosive is simply 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, and 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 holds. 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, and myriads of small fragments displaced by the blast, to 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 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 first, 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 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 infrequent, blast-related injuries present triage, diagnostic, and management challenges to those providing emergency care.

The HIGH's and LOW's of Explosives

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,       Black gunpowder, and       Most petroluem-based bombs such as Molotov cocktails or aircraft imporivsed as guided missles.

Figure 19: (CDC, Explosion and Blast Injuries, 2006).

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 created can pick up and slam people, cars, basically 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. Beyond the cascade of injury from debris 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 is the most common injury seen among survivors. Wounds can be, and often are, grossly contaminated. Immediate concentration is on prevention of blood loss followed by later 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 triad 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 exposed persons and a prophylactic chest tube (thoracostomy) is recommended before general anesthesia or air transport if blast lung is suspected.

Ear Blast Injuries

Primary blast injuries of the auditory system occur frequently yet 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 time of initial evaluation and should be suspected for anyone presenting with hearing loss, tinnitus, otalgia, vertigo, bleeding from the external canal, tympanic membrane rupture, or mucopurulent otorhea. All patients exposed to blast 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 the most 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 mild traumatic brain injury (MTBI) even without a direct blow to the head by a physical 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 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.

Treatment

Timing related to explosive incidents and emergency treatment facility impact 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 aency's emergency response plan?     Describe your role in an emergency reponse involving mass casualties?     Describe the chain of command in emergency reponse?     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?     Describe communication roles in emergency reponse?     Demonstrate use of emergency equipment?

Figure 20

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 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 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) Commander, 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.

 

Triage

Good 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.

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 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 emergency room setting.

Establishment of more in-the-field comprehensive systems has prompted creation of several useful methodologies over the past two decades, a good example of which is the simple, effective triage assessment system known as 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.

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

Decontamination is the physical process of removing the chemicals, biological agents, or radioactive materials from people, equipment, and the environment. Residual hazardous materials 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 chemical warfare agents. 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 caused by chemical mustard will 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. Liquid blister agent contamination poses a high risk for emergency care personnel. The use of PPE (personal protective equipment) impervious to the highly soluble agents is a must.

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 (Wingard & Dainiak, 2009).

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 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 for latter disposal in an appropriate manner.

Should the seriousness of injuries mandate that 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. This is initiated to prevent 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 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 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 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.

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 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 http://www2a.cdc.gov/han/Index.asp.

The objectives of HAN are to (CDC, 2009, pg, 1):

	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 PHIN's Health Alert component. This includes collaborating with federal, state, and city/county partners to develop protocols and stake holder relationships that will ensure a robust interoperable platform for the rapid exchange of public health information.

The website notes the current status in relationship to bioterrorism, 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 can 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 allow them to go anywhere in the country within a short time 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 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.

A 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.

Post traumatic Stress Disorder

After traumatic events most people will experience acute symptoms of anxiety 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       Visiual difficulties       Clenching of jaw       Nonspecific aches and pains	Confusion       Nightmares       Disorientation       Heightened or lowered alertness       Poor concentration       Memory 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     Feels 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
Figure 23: (National Institute for Occupational Safety and Health, Traumatic Incident Stress, 2008)

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. 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!
	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 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.

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