Vesicants

Vesicants (or blister agents) are cytotoxic alkylating compounds, which are chemical agents sometimes collectively known as mustard gas or simply as mustard. Other blister agents are nitrogen mustard; sulfur mustard; lewisite, a vesicant that contains arsenic; and phosgene oxime, a halogenated oxime that possesses different properties and toxicity from the other agents. This article discusses history, toxicity, clinical presentation, and common treatment for vesicants.

Organic Phosphorus Compounds—Nerve Agents

The organic phosphorous compounds (OPC) include both the military grade nerve agents and the organic phosphorous pesticides. The major mechanism of OPC toxicity is through inhibition of acetylcholinesterase in neuronal synapses leading to excess acetylcholine and overstimulation of target organs. Signs and symptoms depend on the affinity of the OPC for muscarinic versus nicotinic receptors, and are likely to include both. Muscarinic symptoms may include diarrhea, urination, bronchospasm, bronchorrhea, emesis, and salivation. Nicotinic symptoms such as paralysis and fasciculations may also occur. Central nervous system toxicity may include seizures, altered mental status, and apnea, and require prompt intervention. Treatment includes early airway and ventilatory support as well as antidotal therapy with atropine, pralidoxime, and diazepam. Goals of therapy include prevention and rapid treatment of hypoxia and seizures, as these are linked to patient outcome.

Decontamination

Decontamination is the removal or reduction of chemical, biologic, or radiologic agents from the patient's skin, mucosa, lungs, and gastrointestinal tract. Decontamination is an important step in decreasing the clinical effects of the agent on the patient, as well as protecting coworkers from exposure. For most agents and the vast majority of scenarios, the removal of clothing and a simple 5- to 6-minute shower with soap and water is sufficient to eliminate the risks to the patient and hospital staff. In rare circumstances, additional steps in decontamination including gastric lavage, broncho-alveolar lavage, surgical removal of wound foreign bodies, and administration of activated charcoal, polyethylene glycol electrolyte solution, and radioisotope binding agents, may be necessary.

Mechanistic studies of La3+ and Zn2+-catalyzed methanolysis of O-ethyl O-aryl methylphosphonate esters. An effective solvolytic method for the catalytic destruction of phosphonate CW simulants

The kinetics of methanolysis of six O-ethyl O-aryl methylphosphonates (6a-f) promoted by methoxide, La3+ and 1,5,9-triazacyclododecane complex of Zn2+(-OCH3) (5:Zn2+(-OCH3)) were studied as simulants for chemical warfare (CW) agents, and analyzed through the use of Brønsted plots. The beta(lg) values are, respectively, -0.76, -1.26 and -1.06, pointing to significant weakening of the P-OAr bond in the transition state. For the metal-catalyzed reactions the data are consistent with a concerted process where the P-OAr bond rupture has progressed to the extent of 84% in the La3+ reaction and ca. 70% in the Zn2+ catalyzed reaction. The catalysis afforded by the metal ions is remarkable, being about 10(6)-fold and 10(8)-fold for poor and good leaving groups, respectively, relative to the background reactions at pH 9.1. Solvent deuterium kinetic isotope studies for two of the substrates promoted by 5:Zn2+(-OCH3) give kH/kD = 1.0 +/- 0.1, consistent with a nucleophilic mechanism. A unified mechanism for the metal-catalyzed reactions is presented which involves pre-equilibrium coordination of the substrate to the metal ion followed by intramolecular delivery of a coordinated methoxide.

Unmasking Procedures following a Chemical Attack: A Critical Review with Recommendations

U.S. Marine Corp and Army doctrine specifies a process for troops to remove the field protective mask in the aftermath of a chemical weapon attack. At the company/battery level, this procedure culminates in exposure of the respiratory system of selected troops to potential gas vapor. Commanders in the field rely on front-line corpsman and medics to provide lifesaving first aid in the event that toxic exposures take place. After this initial stabilization, casualties would be evacuated to an Echelon I medical facility, typically a Battalion Aid Station. The current tactical unmasking procedure, as specified in doctrine, is critically analyzed from a field medical perspective. Easy to implement recommendations are made, both to prevent lethal exposures and to better treat toxicity should prevention fail.

Chlorine: State of the Art

Chlorine is a widely used industrial chemical. Individuals can be exposed to chlorine through transportation accidents, industrial exposures or misuse of domestic cleaners. While most exposed individuals recover normal pulmonary function, chlorine can cause a variety of lung injuries including pulmonary edema, restrictive lung disease, and obstructive disease, including Reactive Airways Dysfunction Syndrome. Residual effects of chlorine exposure are a function of intensity of exposure, minute ventilation during exposure, and host characteristics such as cigarette smoking and atopy. This monograph will summarize uses of chlorine, the potential for accidents, the mechanism of chlorine toxicity in the lung, and review acute and chronic effects of chlorine exposure on the lung, as well as systemic effects of massive chlorine exposure.

Nerve Agents

Nerve agents cause a rapidly fatal cholinergic crisis, but rapid, appropriate antidotal treatment saves lives. Survivors of nerve-agent poisoning generally are healthy, unlike survivors of some other chemical agent attacks. Neurologists can assist first responders and mass casualty planners materially by serving as resources for information on nerve agents and the syndromes they cause. They also can help their communities by reinforcing that treatment for nerve-agent poisoning is effective.

Neurological status of Australian veterans of the 1991 Gulf War and the effect of medical and chemical exposures

BACKGROUND

Since the 1991 Gulf War, concerns have been voiced about the effects on the health of veterans of Gulf War related medical and chemical exposures.

METHODS

Our cross-sectional study compared 1424 male Australian Gulf War veterans and a randomly sampled military comparison group (n = 1548). A postal questionnaire asked about the presence of current neurological type symptoms, medically diagnosed neurological conditions, and medical and chemical exposures. A neurological examination was performed as part of a physical assessment.

RESULTS

Veterans have a higher prevalence of neurological type symptoms (ratio of means 1.4, 95% confidence interval (CI) 1.2-1.5). Although the odds ratio (OR) of lower limb neurological type symptoms and signs in veterans compared with the comparison group was increased (OR = 1.6, 95% CI 1.0-2.7), it was of borderline significance, and there was no difference between groups according to a Neuropathy Score based on neurological signs alone (ratio of means 1.1, 95% CI 0.9-1.3). The increased OR of neurological type symptoms and signs suggestive of a central nervous system disorder (OR = 1.8, 95% CI 1.0-3.1) was also of borderline significance. Veterans were not more likely to have self-reported medically diagnosed neurological conditions, or to have neurological type symptoms and signs suggestive of an anterior horn cell disorder (OR = 0.9, 95% CI 0.5-1.6). The total number of neurological type symptoms reported by veterans, but not the Neuropathy Score, was associated with Gulf War related exposures including immunizations and pyridostigmine bromide in dose-response relationships, anti-biological warfare tablets, solvents, pesticides, and insect repellents.

CONCLUSIONS

This study shows increased reporting of neurological type symptoms in Gulf War veterans, but no evidence for increased neurological effects based on objective physical signs. There may be a number of factors, including information bias, relating to increased neurological type symptom reporting in veterans.

Prehospital management and medical intervention after a chemical attack

Chemical warfare agents are toxic weapons and emergency prehospital medical care providers should be well prepared, trained, and equipped to give response. Personnel need to be aware of the following medical issues regarding prehospital management of a chemical attack, event recognition, incident medical command and control, safety and protection, decontamination, isolation of the incident area (hot zone, warm zone, and cold zone), sampling and detection, psychological management, communication, triage, treatment, transportation, recovery activities and fatality management. During prehospital response, healthcare responders should provide self protection by wearing proper protective equipment and ensuring that the casualty is thoroughly decontaminated. Medical first responders are also responsible for performing triage in each zone of the incident area. Victims are triaged into four categories based on the need for medical care; immediate, delayed, minimal, and expectant. Finally, a medical emergency planning should be completed, and exercises conducted to test the system before an event occurs.

Trinitrotoluene (TNT)-induced cataract in Danish arms factory workers

PURPOSE

To compare the prevalence of cataract in workers exposed to trinitrotoluene (TNT) to the prevalence in a group of unexposed workers, matched on age and sex, using Tiukina's description and grading of TNT-induced cataract.

METHODS

A total of 23 TNT-exposed and 44 unexposed workers underwent an eye examination performed by an ophthalmologist who did not know the exposure status of the subjects. All lens opacities matching Tiukina's description were classified as TNT cataract and graded on Tiukina's scale of stages 1-4.

RESULTS

Four cases of TNT-induced cataract were identified among the 23 TNT-exposed workers and none in the unexposed group (p < 0.01).

CONCLUSION

Exposure to TNT may cause a unique type of cataract, which a general ophthalmologist, using Tiukina's description and grading scale, will be able to distinguish from other cataracts.

Chemical (VX) terrorist threat: public knowledge, attitudes, and responses

This article reports the results of a study of people's perceptions and reactions to a hypothetical terrorist attack involving a chemical agent (specifically, the nerve agent VX). Thirteen focus groups composed of 8 to 12 participants each were conducted using trained moderators. To achieve a broad representation of perspectives, the groups were conducted in several regions and included urban and rural locations. In addition, a variety of population groups, such as African Americans, Hispanics, American Indians, Asians, and people with English as a second language, were included in the study. Findings demonstrated fear, fatalism, and unfulfilled information needs related to the threat agent. To better prepare the public for VX threats or threats from other highly toxic chemical agents, it will be important to emphasize that VX exposure can be avoided or reduced, that VX effects can be treated, and that VX can be survived if appropriate protective measures are taken. Related findings from the focus groups are that participants preferred television, radio, and the Emergency Alert System for emergency messages and that people prefer to hear information about a chemical attack from a well-known, well-respected public figure or from a content expert on chemical attacks, protective actions, and health. In addition, local television meteorologists were identified as a category of trusted conveyers of important information in relation to chemical terrorist attacks.

Case definitions for chemical poisoning

When human illness results from an unintentional or intentional release of a toxin (chemicals produced by metabolism in an organism [e.g., ricin]) or a toxicant (natural or synthetic chemicals not metabolically produced by an organism [e.g., nerve agents]) into the environment, uniform reporting is necessary to direct appropriate resources, assess the extent of morbidity and mortality, track poisoned persons, and monitor response to intervention. In this report, CDC presents case definitions to facilitate uniform reporting among local, state, and federal public health agencies of illness resulting from a chemical release. The report also explains the rationale for the structure of the case definitions, the audience for whom it is intended, the setting in which the case definitions might be used, and reasons each chemical presented in the report was selected. Clinical knowledge and diagnostic tools (e.g., biologic laboratory tests) for detecting chemical poisoning are likely to improve over time. CDC will create new case definitions and revise existing definitions to meet the needs related to emerging threats and to enhance case definition sensitivity and specificity, when possible, with developing clinical information.

[In-hospital management of victims of chemical weapons of mass destruction]

Emergency situations caused by chemical weapons of mass destruction add a new dimension of risk to those handling and treating casualties. The fundamental difference between a hazardous materials incident and conventional emergencies is the potential for risk from contamination to health care professionals, patients, equipment and facilities of the Emergency Department. Accurate and specific guidance is needed to describe the procedures to be followed by emergency medical personnel to safely care for a patient, as well as to protect equipment and people. This review is designed to familiarize readers with the concepts, terminology and key operational considerations that affect the in-hospital management of incidents by chemical weapons.

The role of clinical neurophysiology in bioterrorism

Chemical and biological agents have been used as weapons of mass destruction for a long time and presents as a serious threat to mankind. They have been used in many great wars and terrorist attacks with devastating results. The knowledge about these weapons of mass destruction is crucial to health care providers. Early recognition of the clinical characteristics of poisoning as a result of these chemical and biological agents is important to initiate appropriate therapy and minimizing casualties. Neurophysiological investigations when integrated with clinical features are helpful in early identification of some of these agents, especially when serological confirmation is not rapidly available. In this review, we have focused on chemical and biological weapons, which affect the nervous system and the role of clinical neurophysiology in such conditions.

Micro-synthesis and electron ionization mass spectral analysis of O-alkyl N,N-dialkylphosphoramidocyanidates

This communication describes microsynthesis and GC/MS analysis of O-alkyl N,N-dialkylphosphoramidocyanidates (ADAPCs), which are analogues of chemical warfare agent, Tabun. The study was undertaken with a view to develop spectral data base of ADAPCs for verification purpose of Chemical Weapons Convention (CWC). Reported microsynthetic approach has advantages over traditional synthesis in terms of efficiency, synthetic waste, and exposure to toxic chemicals. GC/MS analysis of variety of these compounds (ADAPCs) was performed. Based on the obtained mass spectra of structurally diverse ADAPCs, the fragmentation routes are proposed, which explains most of the characteristic ions.

Gas chromatography/mass spectrometric analysis of methyl esters of N,N-dialkylaminoethane-2-sulfonic acids for verification of the Chemical Weapons Convention

This paper describes the synthesis and gas chromatography/electron ionization mass spectrometric (GC/EI-MS) analysis of methyl esters of N,N-dialkylaminoethane-2-sulfonic acids (DAESAs). These sulfonic acids are important environmental signatures of nerve agent VX and its toxic analogues, hence GC/EI-MS analysis of their methyl esters is of paramount importance for verification of the Chemical Weapons Convention. DAESAs were prepared by condensation of 2-bromoethane sulfonic acid with dialkylamines, and by condensation of dialkylaminoethyl chloride with sodium bisulfite. GC/EI-MS analysis of methyl esters of DAESAs yielded mass spectra; based on these spectra, generalized fragmentation routes are proposed that rationalize most of the characteristic ions.

Mass spectral analysis of synthones of nerve agents for verification of the Chemical Weapons Convention

This communication describes the synthesis and gas chromatography/mass spectrometric (GC/MS) analysis of N,N-dialkylphosphoramidic dihalides and alkylphosphonic difluorides, which are synthones of nerve agents. The study was undertaken with a view to developing a spectral database of these compounds for verification purposes of the Chemical Weapons Convention (CWC). The modified synthetic approach reported here has advantages over traditional syntheses in terms of time and yield. GC/MS analysis of these synthones yielded electron ionization (EI) mass spectra and, based on these spectra, generalized fragmentation routes are proposed that rationalize most of the characteristic ions.

Gas chromatography–mass spectrometry analysis of trifluoroacetyl derivatives of precursors of nitrogen and sulfur mustards for verification of chemical weapons convention

Trifluoroacetylation reactions were optimized for gas chromatography-mass spectrometric (GC-MS) analysis of precursors of nitrogen and sulfur mustards using newly developed N-trifluoroacetylbenzimidazole (TFABI) and known N-trifluoroacetylimidazole (TFAI) and N-trifluoroacetylbenzotriazole (TFABT) reagents. TFAI and TFABI gave the best results in terms of yields and reaction time. Trifluoroacetyl derivatives showed clean total ion chromatograms in GC-MS analysis than trimethylsilyl (TMS) derivatives. The negative ion chemical ionization analysis of these derivatives gave pseudo molecular weight information, with low limit of detection.

Hospital response to chemical terrorism: personal protective equipment, training, and operations planning

BACKGROUND

Hospitals distant from the immediate site of an incident involving a hazardous materials (HAZMATs) release which could include chemical warfare agents, must develop emergency response plans (ERPs) to protect healthcare professionals if they receive potentially contaminated victims. The ERP must address OSHA, EPA, and JCAHO requirements.

METHODS

The VHA convened groups to develop a hazard and exposure assessment, identify actions for compliance with existing regulatory standards, and review site and operational planning issues. Exposure modeling results were used to derive relationships between operational parameters (time and distance from sites/sources) and potential exposure for healthcare workers.

RESULTS

According to exposure modeling, level C personal protective equipment is adequate to protect hospital staff distant from the chemical release site. Decontamination runoff and contaminated clothing should also be controlled to limit exposure.

CONCLUSIONS

Development and coordination of ERPs must include the local emergency planning committee, with clear assignment of tasks, locations, and training in order to prevent exposures to healthcare workers.

Minimizing casualties in biological and chemical threats (war and terrorism): the importance of information to the public in a prevention program

The most effective means of defending against biological or chemical warfare, whether in war or as a result of terror, is the use of primary prevention. The main goal of such a prevention program is to minimize the human loss by reducing the number of casualties (fatalities, physical wounds, and psychological injury). A secondary objective is to prevent the widespread sense of helplessness in the general population. These two aims complement each other. The more the public is active in defending itself, rather than viewing itself as helpless, the lesser the expected number of casualties of any kind. In order to achieve these two goals, educating the civilian population about risk factors and pointing out appropriate defensive strategies is critical. In the absence of an effective prevention program and active participation by the public, there is a high risk for massive numbers of physical and psychological casualties. An essential ingredient of any preventive program, which ultimately may determine the success or failure of all other protective actions, is early, gradual dissemination of information and guidance to the public, so that citizens can become active participants in the program. The public needs to be given information concerning the nature of the threat and effective methods of coping with it, should an unconventional attack occur. Lack of such adaptive behavior (such as wearing protective gear) is likely to bring about vast numbers of physical and psychological casualties. These large numbers may burden the medical, political, and public safety systems beyond their ability to manage. Failure to provide reasonable prevention and effective interventions can lead to a destruction of the social and emotional fabric of individuals and the society. Furthermore, inadequate preparation, education, and communication can result in the development of damaging mistrust of the political and military leadership, disintegration of social and political structures, and perhaps, even risk the collapse of the democracy.

[Perspectives in the treatments of poisonings by organophosphorus insecticides and warfare nerve agents]

INTRODUCTION AND DEVELOPMENT

Organophosphorus compounds are worldwide employed as insecticides and are yearly responsible of several millions of poisonings. The chemical structure of most of the warfare nerve agents also corresponds with an organophosphorus compound. Organophosphorus insecticides and warfare nerve agents exert their main toxicological effects through inhibition of acetylcholinesterase. Current treatments of patients poisoned with organophosphorus compounds include atropine (in order to protect muscarinic receptors), oximes (in order to accelerate the reactivation of the inhibited acetylcholinesterase) and benzodiazepines (in order to avoid convulsions). The administration of phosphotriesterases (enzymes involved in the detoxication of organophosphorus compounds through hydrolysis) is a very effective treatment against poisonings by organophosphorus insecticides and warfare nerve agents. There are experimental preventive treatments based on the simultaneous administration of carbamates and certain antimuscarinic drugs, different from atropine, which notably improve the efficacy of the classical treatments applied after poisonings by warfare nerve agents.

CONCLUSIONS

The treatments based in the administration of phosphotriesterases might be the response to the call of the World Health Organization for searching new treatments with capability to reduce the high mortality recorded in the cases of poisonings by organophosphorus compounds. These treatments can be applied in a preventive way without the intrinsic neurotoxicity associated to the preventive treatments based on carbamates and antimuscarinic drugs. Therefore, these treatments are specially interesting for people susceptible to suffer severe exposures, i.e. sprayers in the farms.

How Would Military Hospitals Cope with a Nuclear, Biological, or Chemical Disaster?

In any nuclear, biological, or chemical (NBC) attack, it is clear that the hospitals may be overwhelmed with casualties. In these deliberate accidents, there will be an additional problem of contamination. Military hospitals must be prepared for NBC disasters with a detailed incident plan. Within this plan, decontamination facilities and shower systems are needed primarily to protect the hospital from self-contamination. Physical and collective protection measures of the staff should be taken into account, with evacuation routes under such an attack. Within this conjunction, the required equipment, including protective suits, detection means, drugs, antidotes, and vaccines, should be provided and stored properly. Qualified personnel should be assigned to the NBC first-aid and rescue team organized within the hospital, equipped, and trained according to such a possible task. Medical staff must be aware of the effects of the agents, and must be experienced in decontamination and first-aid to victims exposed to these agents. Therefore, this information must be put into practice by giving attack scenarios and responses to the hospital administration. It can be conclusively pointed out that military hospitals especially should be better prepared than any other civilian health unit to such attacks of weapons of mass destruction.

Long-term respiratory disorders of claimers with subclinical exposure to chemical warfare agents

It is well documented that inhalation of sulfur mustard causes injury of the respiratory system. While all of the reports and surveys thoroughly document long-term pulmonary effects after significant exposure to mustard, there is no direct evidence that addresses the issue of long-term respiratory effects in individuals who were exposed to very low level of mustard and suffered no acute respiratory tract injury. Our subjects were selected among all those who were in chemically contaminated areas with chemical warfare agents (CWA) and had been registered for an annual checkup. Subclinical exposure's definition is the absence of any acute symptoms at the time of exposure. We used standard respiratory questionnaires, and chest HRCT examinations and a pulmonary function test were done. Based on exclusion criteria from total of 200 patients claiming respiratory problems, just 77 veterans entered the study. After performing HRCT for all our patients there were 13 (38.23%) veterans with no observable defect, 13 (38%) of them had just significant air trapping in their HRCTs. All the others had at least air trapping (AT), which added to other defects. Septal wall thickening was seen in five veterans (14.7%) and bronchiectasis was seen in three (8.8%) cases. This study suggest that exposure to CWA was responsible for the occurrence of the bronchiolitis obliterans syndrome observed in our patients. There are many civilian and military people who have been present in contaminated area without signs and symptoms at the time of exposure, and early detection of such a population could be lifesaving.

Heat and mass transfer from a baby manikin: impact of a chemical warfare protective bag

A chemical warfare (CW) protective bag for babies, younger than 1 year, has been evaluated in respect of thermal load. Heat and water vapour dissipating from the baby make the climate in the protective bag more demanding than outside. The thermal strain on a baby was estimated from heat and mass transfer data using an electrically heated baby manikin and a water-filled tray. Furthermore, a theoretical baby model was developed based on relations valid for heat and mass transfer rates from a cylinder and flat surface. Convective and radiative (dry) and evaporative heat transfer coefficients calculated from this model agreed well with the measured values. The maximum heat dissipation from a baby was calculated for combinations of air temperatures (22-30 degrees C) and relative humidities (70-90% rh). The results indicate that a naked baby can dissipate about 100% more heat than is produced during basal conditions when the bag is ventilated (70 1 min(-1)) and the ambient climate is 30 degrees C and 90% rh. If the ventilation rate is 40 1 min(-1), the margin is reduced to 50%. Clothing reduces the margin further. Ventilating the bag with 70 1 min(-1), a dressed baby can dissipate only 10-20% more heat than is produced during basal conditions in a climate (27 degrees C and 80% rh) that is obtained in a crowded shelter after about 24 h of occupation.

General disaster psychiatry

This article attempts to make further sense of disasters and specifically terrorism as one particular form of disaster from the perspective of psychology and mental health.

The chemical disaster response system in Japan

During the last decade, Japan has experienced the largest burden of chemical terrorism-related events in the world, including the: (1) 1994 Matsumoto sarin attack; (2) 1995 Tokyo subway sarin attack; (3) 1998 Wakayama arsenic incident; (4) 1998 Niigata sodium-azide incident; and (5) 1998 Nagano cyanide incident. Two other intentional cyanide releases in Tokyo subway and railway station restrooms were thwarted in 1995. These events spurred Japan to improve the following components of its chemical disaster-response system: (1) scene demarcation; (2) emergency medical care; (3) mass decontamination; (4) personal protective equipment; (5) chemical detection; (6) information-sharing and coordination; and (7) education and training. Further advances occurred as result of potential chemical terrorist threats to the 2000 Kyushu-Okinawa G8 Summit, which Japan hosted. Today, Japan has an integrated system of chemical disaster response that involves local fire and police services, local emergency medical services (EMS), local hospitals, Japanese Self-Defense Forces, and the Japanese Poison Information Center.

Intraosseous Vascular Access in the Treatment of Chemical Warfare Casualties Assessed by Advanced Simulation: Proposed Alteration of Treatment Protocol

Current treatment protocols for chemical warfare casualties assume no IV access during the early treatment stages. Time constraints in mass casualty scenarios, impaired manual dexterity of medical personnel wearing protective gear, and victims' complex clinical presentations render standard IV access techniques impractical. A newly developed spring-driven, trigger-operated intraosseous infusion device may offer an effective solution. Sophisticated simulators were developed and used to mimic scenarios of chemical warfare casualties for assessing the feasibility of intraosseous infusion delivery. We evaluated the clinical performance of medical teams in full protective gear. The success rate in intraosseous insertion, time to completion of treatment goals, and outcome were measured in a simulated setting. Medical teams from major hospitals in Israel, designated for emergency response in a real chemical warfare mass casualty scenario, were trained in a simulated setting. All 94 participating physicians were supplied with conventional treatment modalities: only the 64 study group physicians received intraosseous devices. The simulated survival rate was 73.4% for the study group and 3.3% for the controls (P < 0.001). Treatment goals were achieved within 3.5 min (range, 1-9 min) in the study group and within >10 min for controls (P < 0.001), and the complication rate for intraosseous use was 13.8%. Personnel satisfaction with the intraosseous device was unanimous and high. New-generation intraosseous infusions have great potential value in the early treatment stages of chemical warfare casualties.

IMPLICATIONS

In a chemical warfare mass casualty scenario, the protective gear worn by medical personnel, the time constraints, and the casualties' medical condition impose limitations on the establishment of IV access during early treatment of the victims. A spring-driven, trigger-operated intraosseous infusion delivery system may offer an effective solution.

Chemical warfare agents: their past and continuing threat and evolving therapies. Part I of II

Chemical warfare agents are potentially accessible to even underdeveloped nations because they are easily and inexpensively produced. This means that they are ideal for use by terrorists and in military operations against civilian populations and troops. In terms of cutaneous injury, vesicants-mainly sulfur mustard-are the most significant chemical warfare agents. Advances in understanding the pathophysiology of the lesions produced by sulfur mustard have led to the research and development of barrier creams as well as pre- and post-exposure therapies to moderate the damage and accelerate healing. Part I of this paper will discuss the history and classification of chemical agents; Part II, which will appear in the September/October 2003 issue of SKINmed, will discuss characteristic manifestations of exposure to chemical agents, as well as prevention and therapy.

Pediatric considerations in chemical exposures: are we prepared?

Manmade disasters have risen over the past decaFde. Specifically, chemical weapons used in acts of aggression pose an increasing threat to our society. These potential disaster situations raise concerns regarding preparedness for both adults and children. This article's purpose is to review general principles of chemical exposure and treatment of specific chemical agents, and to identify specific pediatric considerations involved.

Role of the pulmonary provider in a terrorist attack: resources and command and control issues

Hospital-based pulmonologists, intensivists, respiratory therapists, and others are trained in the triage of limited ICU assets and function well in the chaos this environment often entails. Additionally, many intensivists and other providers often participate in hospital disaster planning and drills. Their education, training, and utility outside this setting are often limited,however. Managing the turbulence surrounding a disaster outside an ICU requires special training and skills to optimize safety, security, and effectiveness of the response effort. Failure to orchestrate the many parties that arrive at the scene risks having various types of providers independently seeking to do good but failing to cooperate or share limited resources of people and equipment. The result may be endangerment of personnel and the in-completion of critical tasks. Health care providers who normally work in a health care facility must participate in disaster planning activities to prepare themselves and the irinstitutions better for disasters that may occur. Critical to that preparation is an understanding of the organizational framework of disaster management, both inside and outside the hospital. This preparation ensures safety if the individual leaves the hospital to support the disaster scene (an action that is not recommended, as discussed previously) and quality care. Understanding whom to ask for resources and the constraints surrounding multidisciplinary disaster response can only improve the care ultimately provided at the bedside.

Credible threat: assessing the likelihood of a chemical or biologic attack

Threat assessment for weapons of mass destruction is a complex task,requiring many assumptions. As a general rule, weapons of mass destruction are expensive, complex, and difficult-to-use weapons. It is not likely that any current terrorist group has the capability to strike the United States with a weapon capable of producing millions of casualties. Smaller-scale attacks with weapons of mass destruction, however. may result in significant disruption from social and psychologic changes. even though actual casualty rates would probably be quite low. It is., however, highly unlikely that any terrorist attack on the United States could completely undermine national security or threaten the survival of the United States as a nation.

Chemical agents and chemical terrorism

Chemical terrorism is a new threat to the security of mankind, which scale essentially exceeds the impact of use of the most modem firearms. At present time all over the world threats from different radical elements to use radioactive materials, potent poisonous substances and pathogenic microorganisms for terrorist purposes became more frequent. High-toxic chemical substances can fall in terrorist hands through wide range of sources. Potentially misused types of chemical compounds are discussed in this article.

Biomaterials for mediation of chemical and biological warfare agents

Recent events have emphasized the threat from chemical and biological warfare agents. Within the efforts to counter this threat, the biocatalytic destruction and sensing of chemical and biological weapons has become an important area of focus. The specificity and high catalytic rates of biological catalysts make them appropriate for decommissioning nerve agent stockpiles, counteracting nerve agent attacks, and remediation of organophosphate spills. A number of materials have been prepared containing enzymes for the destruction of and protection against organophosphate nerve agents and biological warfare agents. This review discusses the major chemical and biological warfare agents, decontamination methods, and biomaterials that have potential for the preparation of decontamination wipes, gas filters, column packings, protective wear, and self-decontaminating paints and coatings.