[Preparedness of Pomeranian Region hospitals for a possible attack with chemical weapons]

The aim of this study was to find out whether the medical staff in the emergency units in all Pomeranian Region hospitals were prepared for possible chemical weapon attack. Key medical personnel, senior doctors and nurses, in 24 hospitals were interviewed by the authors. None of the medical staff have received training in self-protection and management of mass casualties after accidental or terroristic chemical release. There were only four hospitals which had adequate space and special chambers for decontamination. None of the emergency units had special equipment needed for self-protection. The majority of the staff did not know their tasks and individual roles in the case of chemical contamination. None of the personnel had information about antidotes and place of their storage. Only 16.7% of the staff knew the source of quick information about specific treatment of casualties.

CONCLUSIONS

The emergency departments in Pomeranian Region hospitals are not prepared for a possible terroristic chemical attack. There is an urgent need for training the medical staff in self-protection and management of mass casualties after accidental or terroristic chemical release. It is important to make bank of antidotes which could be placed in the regional poison control centres. All these procedures could be carried out without too much expenditure.

Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear, biological, and chemical environment

OBJECTIVE

Intubation is a difficult skill under normal circumstances and more so with a limited visual field such as wearing a protective mask in a chemical or biological incident. This study sought to determine whether successful intubation using the intubating laryngeal mask airway (ILMA) under protective mask conditions was equivalent to standard endotracheal intubation.

METHODS

A pilot study was conducted using emergency medicine personnel. Participant's attempted intubation of a manikin while wearing a standard U.S. Army M-40 protective mask. Two attempts were performed with each method.

RESULTS

One hundred percent of the ILMA placements were successful with only 78% success with endotracheal intubation (p = 0.1). Time to successful intubation and ventilation was significantly less for the ILMA versus endotracheal intubation (p = 0.005).

CONCLUSION

This study suggests that under simulated chemical and biological conditions using an M-40 protective mask, intubation is accomplished faster and with more success with the ILMA.

Biological, chemical and radiological terrorism

After completing this overview of terrorism, readers should be able to: Describe the early signs and symptoms of a covert terrorist attack. Discuss the radiographic signs of exposure to bioterrorism agents. List likely chemical, biological and radiological agents of terrorism. Categorize biological agents of terror by their Centers for Disease Control (CDC) threat level. Explain the relevance of syndromic surveillance in terrorism preparedness.

[Neurological effects of chemical and biological weapons]

Neurological manifestations of chemical and biological weapons are reviewed. Nerve agents in current use, storage, or production include tabun, sarin, soman and VX. The initial effects of exposure to a nerve agent depend on the dose and on the route of exposure. Sarin, the agent studied most thoroughly in man in Matumoto and Tokyo attacked by Aum shinrikyo will cause miosis, rhinorrehea and shortness of breath are initial complaints immediately after inhalation exposure of the vapor. The severe cases showed loss of consciousness and convulsions. Respiratory arrest may occur. The most toxic of the nerve agents is VX. It is thought to be 100 times as toxic as sarin for humans by the percutaneous rout. The similar findings to sarin exposure are also observed in cases exposured to VX. Atropin and PAM will be effective in the early stage. BZ (benzilate) is a delayed onset incapacitation agent. It causes severe hallucination. The cyanide compounds are among the most rapidly acting of war gases, resulting in death. Anthrax has been the most attractive biological weapon for a long time. Anthrax is an acute bacterial infection of the skin and lungs in man and animals. Meningoencephalitis has been reported in the terminal stage in anthrax infection. In autopsy, it is really confirmed in the characteristic findings of the meningeal abnormality. The potential weaponization of variola virus continues to pose a military threat because the aerosol infectivity of the virus and the development of susceptible populations. A high rate of lethality, a staunch resistance to treatments and a rapid onset of severe generalised muscle weakness make botulinum toxin a suitable agent for biological warfare particularly by oral administration.

The presentation and management of victims of chemical and biological agents: a survey of knowledge of UK clinicians

A survey was conducted among acute specialty clinicians in four centres in the UK to determine their levels of knowledge of the presentation and subsequent management of victims following deliberate release of chemical or biological agents. This revealed significant gaps in knowledge and training. Of the 102 respondents, more than half did not understand the decontamination process. More than a third were unsure of the presenting features of nerve agent release. Only a minority knew the recommended treatment and only one in five have participated in relevant exercises.

The challenges of deliberate chemical/biological attack

Major incident plans in many countries have recently been updated to address the issues surrounding the deliberate release of chemical and biological agents. Despite this, many 'front line' doctors who would be responsible for treating victims of such incidents are poorly integrated into the plans. This article examines some of the challenges that face clinicians in the pre-hospital and hospital phases of a deliberate release incident.

Ethical Resource Distribution after Biological, Chemical, or Radiological Terrorism

In situations with limited medical resources, be they personnel, equipment, or time (and it always boils down to a lack of time), clinicians use “triage” to determine which patients receive treatment. What type of treatment a patient receives depends on the triage “lottery” rules in place. Although these rules for sorting patients and distributing resources are standardized for most situations, they must be somewhat altered after overwhelming, nonstandard (i.e., biological, chemical, and radiological) disasters.

Evaluations over the medical emergency responding to chemical terrorist attack

The use of chemical warfare agents intentionally has become a great concern in the arena of the cold war. On the other hand, there has always been a threat on civilian population due to their mass destruction effects, including psychological damage and a great deal of discussion how to respond to it in terms of medical management. It is very important to provide the best lifesaving medical care and triage in a chemical-contaminated area. Mass casualties exposed to chemical agents require immediate medical intervention to save their lives and should be classified in accordance to medical care priorities and available medical sources, including antidotes and sophisticated health facilities. Establishing the decontamination area for chemical casualties where it is located at the suitable place with respect to the wind direction is necessary. To overcome the mass destruction effects of chemical warfare agents following the terrorist attack, we must have the emergency medical response plan involving experienced triage officers and medical care providers to be able to perform medical management in the chemical-contaminated area and health facilities.

The use of advanced simulation in the training of anesthesiologists to treat chemical warfare casualties

Training anesthesiologists to treat nerve gas intoxication in a mass casualty scenario is a complicated task. The scenario is an unfamiliar medical situation involving the need to decontaminate patients before providing definitive medical treatment, and the need for physical protection to the medical team before decontamination. We describe the development of a simulation-based training program. In one site of a virtual hospital, anesthesiologists were trained in initial airway and breathing resuscitation before decontamination while wearing full protective gear. In another site, they were trained in the treatment of critically-ill patients with combined conventional and chemical injuries or severe intoxication. Intubation simulators of newborn, pediatric, and adult patients, advanced full-scale simulators, and actors simulating patients were used. Initial airway, breathing, and antidotal treatment were performed successfully, with or without full protective gear. The gas mask did not interfere with orotracheal intubation, but limited effective communication within the medical team. Chemical protective gloves were the limiting factor in the performance of medical tasks such as fixing the orotracheal tube. Twenty-two participants (88%) pointed out that the simulated cases represented realistic problems in this scenario, and all 25 participants found the simulated-based training superior to previous traditional training they had in this field. Using advanced simulation, we were able to train anesthesiologists to treat nerve gas intoxication casualties and to learn about the limitations of providing medical care in this setting.

IMPLICATIONS

Advanced medical simulation can be used to train anesthesiologists to treat nonconventional warfare casualties. The limitations of medical performance in full protective gear can be learned from this training.

Operation Castle Cascade: managing multiple casualties from a simulated chemical weapons attack

In the wake of the recent terrorist attack on the United States, there is an ever-increasing need for the defense against weapons of mass destruction. The use of explosive devices in combination with chemical agents could result in a community disaster with multiple traumatic and medical injuries. Military medical personnel may be the first called upon due to their unique training and equipment. Operation Castle Cascade was a large-scale exercise on a military instillation involving the apprehension of hostages and detonation of an explosive device containing dimethyl sulfate. We will provide details on the medical management of 50 patients with simulated chemical and traumatic injuries. Issues relating to on-site chemical identification, triage, decontamination, treatment, casualty collection, and transportation of casualties are addressed in this article.

Regional pharmaceutical preparation for biological and chemical terrorism

BACKGROUND

The United States National Office of Domestic Preparedness has determined that the threat of a biological or chemical attack is very real. As an active participant of a 13-county regional task force, one of the roles of the poison center was to determine the pharmaceutical needs of the community in the event of a terrorist action and develop a financially responsible method of acquisition and storage.

METHODS

Working with local health officials, an extensive literature review was conducted to identify possible biological and chemical poisons. Treatment recommendations were identified and an estimated amount to treat 5,000 people for 24hrs was determined. Instead of purchasing the medications, a unique solution utilizing a regional pharmacy wholesaler was used.

DISCUSSION

An important element in a biological or chemical terrorist event is the availability of the pharmaceuticals and the capability of delivering them rapidly. The poison center is the ideal agency to help coordinate this endeavor since it is familiar with contemporary therapy and will be aware of the number, location, and status of casualties. Based on the expense involved in the purchase and storage of a large quantity of medications, utilizing a local pharmaceutical distribution company is fiscally responsible. Rotation through normal stock and being readily accessible is another benefit.

CONCLUSION

The poison center serves a number of roles in the surveillance, recognition, and treatment of biological and chemical terrorism. Assisting in the development, implementation, and procurement of a pharmaceutical cache is yet another role.

Olfactory functioning in Gulf War-era veterans: relationships to war-zone duty, self-reported hazards exposures, and psychological distress

To explore possible neurotoxic sequelae of Gulf War (GW) participation, olfactory identification performance, neurocognitive functioning, health perceptions, and emotional distress were assessed in 72 veterans deployed to the GW and 33 military personnel activated during the GW but not deployed to the war zone. Findings revealed that war-zone-exposed veterans reported more concerns about health, cognitive functioning, and depression than did their counterparts who did not see war-zone duty. There was no evidence that performances on olfactory or neurocognitive measures were related to war-zone duty or to self-reported exposure to GW toxicants. However, symptoms of emotional distress were positively correlated with self-report of health and cognitive complaints. Results do not provide support for the hypothesis that objectively-measured sensory (i.e., olfactory) or cognitive deficits are related to war-zone participation but do underscore the increasingly demonstrated association between self-reported health concerns and symptoms of emotional distress.

Chemical, biological, and radiological weapons: implications for optometry and public health

BACKGROUND

Because of growing concerns of terrorist attacks using chemical, biological, radiological, and nuclear weapons, appropriate diagnosis and management of ocular and systemic effects are important issues for eye care practitioners.

OVERVIEW

The literature on the ocular and systemic effects of chemical, biological, radiological, and nuclear weapons is reviewed to provide practicing optometrists with an overview of the issues involved in incident management. A discussion of the public health issues and implications is also presented. Chemical, biological, radiological, and nuclear weapons can exert serious consequences on the eye and the entire body. Acts of terrorism can pose unique challenges to patient care and to the healthcare system infrastructure. The clinician must be familiar with signs of potential terrorist activities to aid in appropriate patient care and in the containment of illness in the community.

CONCLUSIONS

Knowledge of the signs and symptoms of exposure to potential agents used by terrorists and a review of the public health concerns of managing terrorist events can provide the necessary background to help the eye care provider make the appropriate diagnosis and understand the role of the clinician in the hierarchy of disaster preparedness, surveillance, and response.

Neurotoxinas con actividad anticolinesterásica y su posible uso como agentes de guerra

Anatoxin-a(s), onchidal and fasciculins are neurotoxins with anticholinesterase activity. An intoxication by these neurotoxins is characterized by cholinergic syndromes similar to organophosphate insecticide and nerve agent intoxications. Anticholinesterase neurotoxins, as well as other toxins, have some disadvantages if used as weapons of mass destruction. Drawbacks include difficulties to produce them in big quantities and their dissemination in form of aerosols. However, other properties such as high toxicity, improbable identification with common commercial portable detectors for chemical warfare agents and toxic industrial chemicals, as well as the lack of effectiveness of antidotal treatments with oximes may make them attractive in order to be used in military operations or terrorist attacks. For these reasons, it should be necessary to control these neurotoxins through international treaties which have real verification measures such as the Chemical Weapons Convention.

Neurological aspects of biological and chemical terrorism: a review for neurologists

The Centers for Disease Control and Prevention urge physicians to become familiar with chemical and biological weapons. Preparedness among neurologists is especially important because several of these agents affect the nervous system. This article reviews 4 agents that have a history of military or terrorist use: cyanide poisons, organophosphate poisons, botulinum toxin, and anthrax. Cyanide and organophosphate poisons are characterized by dose-dependent impairment of neurological function with nonspecific symptoms such as headache or dizziness at one end of the spectrum and convulsions and coma at the other. Neurological examinations help clinicians to differentiate these agents from other intoxications. Botulinum toxin has a delayed onset of action and results in descending paralysis and prominent cranial nerve palsies. Anthrax frequently causes fulminating hemorrhagic meningitis. Early recognition of these chemical and biological weapons is key to instituting specific therapy and preventing casualties within the health care team and the community at large.

Chemical weapon functional exercise--Cincinnati: observations and lessons learned from a "typical medium-sized" city's response to simulated terrorism utilizing Weapons of Mass Destruction

In the wake of the September 11, 2001, attacks and the subsequent anthrax scare, there is growing concern about the United States' vulnerability to terrorist use of Weapons of Mass Destruction (WMD). As part of ongoing preparation for this terrible reality, many jurisdictions have been conducting simulated terrorist incidents to provide training for the public safety community, hospitals, and public health departments. As an example of this national effort to improve domestic preparedness for such events, a large scale, multi-jurisdictional chemical weapons drill was conducted in Cincinnati, Ohio, on May 20, 2000. This drill depicted the components of the early warning system for hospitals and public health departments, the prehospital medical response to terrorism. Over the course of the exercise, emergency medical services personnel decontaminated, triaged, treated, and transported eighty-five patients. Several important lessons were learned that day that have widespread applicability to health care delivery systems nationwide, especially in the areas of decontamination, triage, on-scene medical care, and victim transportation. As this training exercise helped Cincinnati to prepare for dealing with future large scale WMD incidents, such drills are invaluable preparation for all communities in a world increasingly at risk from terrorist attacks.

Abrin Poisoning

Abrin is a toxic protein obtained from the seeds of Abrus precatorius (jequirity bean), which is similar in structure and properties to ricin. Abrin is highly toxic, with an estimated human fatal dose of 0.1-1 microgram/kg, and has caused death after accidental and intentional poisoning. Abrin can be extracted from jequirity beans using a relatively simple and cheap procedure. This satisfies one criterion of a potential chemical warfare agent, although the lack of large scale production of jequirity seeds means that quantity is unavailable for ready mass production of abrin for weapons. This contrasts with the huge cultivation of Ricinus seeds for castor oil production. At the cellular level, abrin inhibits protein synthesis, thereby causing cell death. Many of the features observed in abrin poisoning can be explained by abrin-induced endothelial cell damage, which causes an increase in capillary permeability with consequent fluid and protein leakage and tissue oedema (the so-called vascular leak syndrome). Most reported cases of human poisoning involve the ingestion of jequirity beans, which predominantly cause gastrointestinal toxicity. Management is symptomatic and supportive. Experimental studies have shown that vaccination with abrin toxoid may offer some protection against a subsequent abrin challenge, although such an approach is unlikely to be of benefit in a civilian population that in all probability would be unprotected.

Pulmonary manifestations of intentionally released chemical and biological agents

Recent events have underscored the importance of knowledge and understanding of biological and chemical agents that are intentionally released on civilian populations. Preparedness of the medical community to recognize and manage the resulting clinical syndromes will be a major determinant in the outcome of such attack, or a community's 'prognosis' for survival. The biological and chemical agents that have been weaponized produce diseases and toxidromes that are not commonly seen by clinicians in most parts of the United States. Patients or clusters of patients who present with febrile syndromes that are unusual for the geographic or seasonal setting should trigger notification of public health authorities and the use of state or national reference lab systems for augmented diagnostic support. In many cases, early, empiric therapy, administered before definitive diagnosis, is required for survival. The basic principles in the management of exposure to chemical agents include containment, prevention of secondary exposure, rapid decontamination, implementation of supportive and symptomatic care, and specific antidotes as indicated and available.

Biologic and chemical weapons of mass destruction

Weapons of mass destruction (WMDs) are capable of producing massive casualties and are typically grouped into nuclear, biologic, and chemical weapons. In the wake of the September 11th disasters, attention to terrorist groups and the potential for use of WMDs has increased. Biologic and chemical weapons are relatively accessible and inexpensive to develop, and are thought to be the most available to foreign states and subnational terrorist groups. This article reviews various biologic and chemical weapons, including emergency diagnosis and management of selected agents.

Knowledge and Awareness Concerning Chemical and Biological Terrorism: Continuing Education Implications

BACKGROUND

A survey on knowledge and awareness concerning chemical and biological terrorism was used to assess the knowledge base of health care providers at an urban medical center in preparation for developing a workshop on domestic terrorism preparedness. A second survey assessing domestic terrorism preparedness of infection control personnel and nurse educators also was conducted.

METHOD

A total of 291 nurses, physicians, nursing students, and medical students completed the knowledge and awareness survey. A total of 24 infection control personnel and nurse educators completed the second survey on domestic terrorism preparedness.

FINDINGS

The knowledge scores of the respondents were low, with less than one fourth of the knowledge questions answered correctly. In addition, less than 23% of the respondents reported confidence to provide health care in a hypothetical chemical terrorism situation.

CONCLUSION

These findings indicate a need for nurses in continuing education and staff development to develop, implement, and evaluate innovative domestic terrorism preparedness programs.

Therapeutic effects of cooling swine skin exposed to sulfur mustard

Recent world events have highlighted the need for effective medical therapies for chemical weapon injuries. Of the chemical weapon agents, perhaps one of the most widely used, both historically and most recently in the Iran-Iraq War, is sulfur mustard (HD). No effective antidotes exist for this vesicant agent and, to this day, HD casualties are treated entirely symptomatically. Previous work carried out in this laboratory has indicated that cooling HD-exposed tissue may ameliorate the resultant injury. To further examine this, an anesthetized domestic swine model was used to investigate whether alteration of skin temperature had any effect either visually or histopathologically on the development and progression of HD-induced skin lesions over 7 days. Exposure of swine skin to HD vapor resulted in lesions whose severity was exposure time related (4, 8, 12, and 16 minutes). Postdecontamination heating of skin above ambient temperature (approximately 39 degrees C) resulted in worsening of the lesion, whereas postdecontamination cooling (approximately 15 degrees C) for between 2 to 4 hours postexposure lessened the severity of HD-induced injury. The authors conclude that the early, noninvasive and simplistic act of cooling HD-exposed skin may have a salutary effect on the severity of HD-induced cutaneous lesions.

Evaluation of a virtual reality simulator in sustainment training

Is there a better way to train and prepare our health care personnel to function in a chemical biological environment while continuing to provide for patient care in a variety of healthcare settings? The purpose of this pilot work was to compare the effectiveness and user satisfaction of the Cath-Sim Intravenous Training System to the traditional IV arm model for teaching and achieving competence at IV insertion while in Mission-Oriented Protective Posture level 4 for Army medical personnel. Grounded in adult psychomotor learning principles and in an established evaluation model, participants were tested on both the traditional IV arm and Cath-Sim models and then allowed to practice on each model while at Mission-Oriented Protective Posture level 4. One week later, participants were again tested on both models. Outcome measures included (1) a computer-generated score sheet measuring time to success and criterion success/nonsuccess on the Cath-Sim; (2) time and success rating for IV insertion on the IV arm model; and (3) satisfaction evaluations completed by the participants. There were conflicting evaluation scores for recommending one model over the other. Participants felt that there was some benefit to each model depending on user, setting, and purpose.