Treating exposure to chemical warfare agents: implications for health care providers and community emergency planning

Decomposition of the Simulant 2-Chloroethyl Ethyl Sulfide Blister Agent under Ambient Conditions Using Metal-Organic Frameworks

Metal organic frameworks (MOFs) have been suggested as promising materials for application in the degradation of chemical warfare agents, with the majority of studies to date focusing on nerve agents. One of the most prominent MOFs used in the detoxification of nerve agents is UiO-66, which is of interest as a future nerve agent decontaminant. However, blister agents, which constitute one of the most toxic and highly reactive categories of chemical agents, are yet to be examined as gas-phase decontamination targets using MOF structures. In this study, a novel type of UiO-66 with a smaller particle size, namely, UiO-66S, was used as a decontaminant for the blister agent simulant, 2-chloroethyl ethyl sulfide (2-CEES). The gas-phase chemical adsorption and decomposition of 2-CEES were demonstrated for the first time, with an estimated t_1/2 of 1.34 h. This value is the highest reported value for an MOF in gas-phase reaction conditions. The obtained nontoxic degradation products were identified, and the reaction mechanism was studied using density functional theory calculations. Furthermore, the synthesized UiO-66S catalyst also exhibits superior catalytic ability toward nerve agent simulants (diisopropyl fluorophosphate).The results of the study provide a firm basis for the use of UiO-66S as a future decontaminant for both nerve and blister agents.

Decomposition of Chemical Warfare Agent Simulants Utilizing Pyrolyzed Cotton Balls as Wicks

A simple method to improve the thermal decomposition of chemical warfare agent simulants is reported. Utilizing pyrolyzed cotton balls as a substrate for the delivery of an incendiary agent into a bulk volume of chemical warfare agent simulants, significant enhancements in the burning rates were achieved with respect to either other wicks or the incendiary agent by itself. To perform the decomposition experiments and follow the reaction in real time, while still addressing the important safety considerations related to experiments involving chemical warfare agent simulants and incendiary agents, a simple instrument was assembled in a laboratory hood, where all experiments were performed. Under ambient conditions, this method was able to enhance the decomposition of simulants for both sulfur mustard (HD) and sarin (GB) chemical warfare agents. Overall, the proposed approach represents one of the simplest and more cost-effective ways to improve the decomposition of these dangerous substances, presenting options for field expedient and low-cost processes that could be applied in the near future to the safe destruction of an actual CWA.

Assessment of zebrafish embryo photomotor response sensitivity and phase-specific patterns following acute- and long-duration exposure to neurotoxic chemicals and chemical weapon precursors

Zebrafish are an attractive model for chemical screening due to their adaptability to high‐throughput platforms and ability to display complex phenotypes in response to chemical exposure. The photomotor response (PMR) is an established and reproducible phenotype of the zebrafish embryo, observed 24 h post‐fertilization in response to a predefined sequence of light stimuli. In an effort to evaluate the sensitivity and effectiveness of the zebrafish embryo PMR assay for toxicity screening, we analyzed chemicals known to cause both neurological effects and developmental abnormalities, following both short (1 h) and long (16 h+) duration exposures. These include chemicals that inhibit aerobic respiration (eg, cyanide), acetyl cholinesterase inhibitors (organophosphates pesticides) and several chemical weapon precursor compounds with variable toxicity profiles and poorly understood mechanisms of toxicity. We observed notable concentration‐responsive, phase‐specific effects in the PMR after exposure to chemicals with a known mechanism of action. Chemicals with a more general toxicity profile (toxic chemical weapon precursors) appeared to reduce all phases of the PMR without a notable phase‐specific effect. Overall, 10 of 20 chemicals evaluated elicited an effect on the PMR response and eight of those 10 chemicals were picked up in both the short‐ and long‐duration assays. In addition, the patterns of response uniquely differentiated chemical weapon precursor effects from those elicited by inhibitors of aerobic respiration and organophosphates. By providing a rapid screening test for neurobehavioral effects, the zebrafish PMR test could help identify potential mechanisms of action and target compounds for more detailed follow‐on toxicological evaluations.

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In an effort to evaluate the sensitivity and effectiveness of the zebrafish embryo photomotor response (PMR) assay for toxicity screening, we analyzed chemicals known to cause both neurological effects and developmental abnormalities, following both short‐ (1 h) and long‐duration (16 h+) exposures. Overall, 10 of 20 chemicals evaluated elicited an effect on the PMR assay and eight of those 10 chemicals were picked up in both the short‐ and long‐duration assays.

Nerve agents: a guide for emergency nurses. Part 1

Recent incidents in the UK and the alleged chemical attacks in Syria by the Bashar al-Assad regime have brought the subject of chemical weapons back into the public domain. To date these types of event have been relatively rare because terrorist plans to harm large numbers of people have mostly been thwarted. This is the first part of a two-part article on nerve agents. Part one gives an overview of these agents, their historical background and manufacture, and how the agents affect physiology. Part two, which will appear in the next issue, considers the pre-hospital response to the use of nerve agents, including effective triage and decontamination, and in-hospital treatment.

The possible role of intravenous lipid emulsion in the treatment of chemical warfare agent poisoning

Organophosphates (OPs) are cholinesterase inhibitors that lead to a characteristic toxidrome of hypersecretion, miosis, dyspnea, respiratory insufficiency, convulsions and, without proper and early antidotal treatment, death. Most of these compounds are highly lipophilic. Sulfur mustard is a toxic lipophilic alkylating agent, exerting its damage through alkylation of cellular macromolecules (e.g., DNA, proteins) and intense activation of pro-inflammatory pathways. Currently approved antidotes against OPs include the peripheral anticholinergic drug atropine and an oxime that reactivates the inhibited cholinesterase. Benzodiazepines are used to stop organophosphate-induced seizures. Despite these approved drugs, efforts have been made to introduce other medical countermeasures in order to attenuate both the short-term and long-term clinical effects following exposure. Currently, there is no antidote against sulfur mustard poisoning. Intravenous lipid emulsions are used as a source of calories in parenteral nutrition. In recent years, efficacy of lipid emulsions has been shown in the treatment of poisoning by fat-soluble compounds in animal models as well as clinically in humans. In this review we discuss the usefulness of intravenous lipid emulsions as an adjunct to the in-hospital treatment of chemical warfare agent poisoning.

Modeling the chelation of As(III) in lewisite by dithiols using density functional theory and solvent-assisted proton exchange

Dithiols such as British anti-lewisite (BAL, rac-2,3-dimercaptopropanol) are an important class of antidotes for the blister agent lewisite (trans-2-chlorovinyldichloroarsine) and, more generally, are chelating agents for arsenic and other toxic metals. The reaction of the vicinal thiols of BAL with lewisite through the chelation of the As(III) center has been modeled using density functional theory (DFT) and solvent-assisted proton exchange (SAPE), a microsolvation method that uses a network of water molecules to mimic the role of bulk solvent in models of aqueous phase chemical reactions. The small activation barriers for the stepwise SN2-type nucleophilic attack of BAL on lewisite (0.7-4.9kcal/mol) are consistent with the favorable leaving group properties of the chloride and the affinity of As(III) for soft sulfur nucleophiles. Small, but insignificant, differences in activation barriers were found for the initial attack of the primary versus secondary thiol of BAL and the R vs S enantiomer. An examination of the relative stability of various dithiol-lewisite complexes shows that ethanedithiols like BAL form the most favorable chelation complexes because the angles formed in five-membered ring are most consistent with the hybridization of As(III). More obtuse S-As-S angles are required for larger chelate rings, but internal As⋯N or As⋯O interactions can enhance the stability of moderate-sized rings. The low barriers for lewisite detoxification by BAL and the greater stability of the chelation complexes of small dithiols are consistent with the rapid reversal of toxicity demonstrated in previously reported animal models.

Photocatalytic oxidation of diethyl sulfide vapor over TiO2-based composite photocatalysts

Composite TiO₂/activated carbon (TiO₂/AC) and TiO₂/SiO₂ photocatalysts with TiO₂ contents in the 10 to 80 wt. % range were synthesized by the TiOSO₄ thermal hydrolysis method and characterized by AES, BET, X-ray diffraction and FT-IR ATR methods. All TiO₂ samples were in the anatase form, with a primary crystallite size of about 11 nm. The photocatalytic activities of the TiO₂/AC and TiO₂/SiO₂ samples were tested in the gas-phase photocatalytic oxidation (PCO) reaction of diethyl sulfide (DES) vapor in a static reactor by the FT-IR in situ method. Acetaldehyde, formic acid, ethylene and SO₂ were registered as the intermediate products which finally were completely oxidized to the final oxidation products – H₂O, CO₂, CO and SO₄²⁻ ions. The influence of the support on the kinetics of DES PCO and on the TiO₂/AC and TiO₂/SiO₂ samples’ stability during three long-term DES PCO cycles was investigated. The highest PCO rate was observed for TiO₂/SiO₂ photocatalysts. To evaluate the activity of photocatalysts the turnover frequency values (TOF) were calculated for three photocatalysts (TiO₂, TiO₂/AC and TiO₂/SiO₂) for the same amount of mineralized DES. It was demonstrated that the TOF value for composite TiO₂/SiO₂ photocatalysts was 3.5 times higher than for pure TiO₂.

Novel human butyrylcholinesterase variants: toward organophosphonate detoxication

Human butyrylcholinesterase (hBChE) is currently being developed as a detoxication enzyme for stoichiometric binding and/or catalytic hydrolysis of organophosphates. Herein, we describe the use of a molecular evolution method to develop novel hBChE variants with increased resistance to stereochemically defined nerve agent model compounds of soman, sarin, and cyclosarin. Novel hBChE variants (Y332S, D340H, and Y332S/D340H) were identified with an increased resistance to nerve agent model compounds that retained robust intrinsic catalytic efficiency. Molecular dynamics simulations of these variants revealed insights into the mechanism by which these structural changes conferred nerve agent model compound resistance.

A clinicopathological approach to sulfur mustard-induced organ complications: a major review

CONTEXT

Sulfur mustard (SM), with an old manufacturing history still remains as potential threat due to easy production and extensive effects.

OBJECTIVES

Increasing studies on SM indicates the interest of researchers to this subject. Almost all human body organs are at risk for complications of SM. This study offers organ-by-organ information on the effects of SM in animals and humans.

METHODS

The data sources were literature reviews since 1919 as well as our studies during the Iraq-Iran war. The search items were SM and its all other nomenclatures in relation to, in vivo, in vitro, humans, animals, eye, ocular, ophthalmic, lungs, pulmonary, skin, cutaneous, organs and systemic. Amongst more than 1890 SM-related articles, 257 more relevant clinicopathologic papers were selected for this review.

RESULTS

SM induces a vast range of damages in nearly all organs. Acute SM intoxication warrants immediate approach. Among chronic lesions, delayed keratitis and blindness, bronchiolitis obliterans and respiratory distress, skin pruritus, dryness and cancers are the most commonly observed clinical sequelae.

CONCLUSION

Ocular involvements in a number of patients progress toward a severe, rapid onset form of keratitis. Progressive deterioration of respiratory tract leads to "mustard lung". Skin problems continue as chronic frustrating pruritus on old scars with susceptibility to skin cancers. Due to the multiple acute and chronic morbidities created by SM exposure, uses of multiple drugs by several routes of administrations are warranted.

Changing the Scale and Efficiency of Chemical Warfare Countermeasure Discovery Using the Zebrafish

As the scope of potential chemical warfare agents grows rapidly and as the diversity of potential threat scenarios expands with non-state actors, so a need for innovative approaches to countermeasure development has emerged. In the last few years, the utility of the zebrafish as a model organism that is amenable to high-throughput screening has become apparent and this system has been applied to the unbiased discovery of chemical warfare countermeasures. This review summarizes the in vivo screening approach that has been pioneered in the countermeasure discovery arena, and highlights the successes to date as well as the potential challenges in moving the field forward. Importantly, the establishment of a zebrafish platform for countermeasure discovery would offer a rapid response system for the development of antidotes to the continuous stream of new potential chemical warfare agents.

Identification of human butyrylcholinesterase organophosphate-resistant variants through a novel mammalian enzyme functional screen

Human butyrylcholinesterase (hBChE) is currently being developed as a detoxication enzyme for the catalytic hydrolysis or stoichiometric binding of organophosphates (OPs). Previously, rationally designed hBChE mutants (G117H and E197Q) were reported in the literature and showed the feasibility of engineering OP hydrolytic functional activity into hBChE. However, the OP hydrolysis rate for G117H is too low for clinical utility. Additional OP-resistant hBChE variants with greater hydrolysis rates are needed as OP nerve-agent countermeasures for therapeutic utility. As described herein, a directed molecular evolution process was used to identify amino acid residues that contribute to OP-resistant functional activity of hBChE variants. In this article, we describe the development and validation of a novel method to identify hBChE variants with OP-resistant functional activity (decreased rate of OP inhibition). The method reported herein used an adenoviral protein expression system combined with a functional screening protocol of OP nerve-agent model compounds that have been shown to have functional properties similar to authentic OP nerve-agent compounds. The hBChE screening method was robust for transfection efficiency, library diversity, and reproducibility of positive signals. The screening approach not only identified the previously reported hBChE G117H variant, but also identified a series of additional hBChE variants, including hBChE G117N, G117R, E197C, and L125V, that exhibited OP-resistant functional activities not reported previously. The mammalian functional screening approach can serve as a cornerstone for further optimization and screening for OP-resistant hBChEs for potential therapeutic applications.

An in vivo zebrafish screen identifies organophosphate antidotes with diverse mechanisms of action

Organophosphates are a class of highly toxic chemicals that includes many pesticides and chemical weapons. Exposure to organophosphates, either through accidents or acts of terrorism, poses a significant risk to human health and safety. Existing antidotes, in use for over 50 years, have modest efficacy and undesirable toxicities. Therefore, discovering new organophosphate antidotes is a high priority. Early life stage zebrafish exposed to organophosphates exhibit several phenotypes that parallel the human response to organophosphates, including behavioral deficits, paralysis, and eventual death. Here, we have developed a high-throughput zebrafish screen in a 96-well plate format to find new antidotes that counteract organophosphate-induced lethality. In a pilot screen of 1200 known drugs, we identified 16 compounds that suppress organophosphate toxicity in zebrafish. Several in vitro assays coupled with liquid chromatography/tandem mass spectrometry-based metabolite profiling enabled determination of mechanisms of action for several of the antidotes, including reversible acetylcholinesterase inhibition, cholinergic receptor antagonism, and inhibition of bioactivation. Therefore, the in vivo screen is capable of discovering organophosphate antidotes that intervene in distinct pathways. These findings suggest that zebrafish screens might be a broadly applicable approach for discovering compounds that counteract the toxic effects of accidental or malicious poisonous exposures.

Toxicity of Organophosphates and Carbamates

Organophosphate (OP) and carbamate (CM) compounds are commonly used as insecticides around the world. Some of them are extremely toxic to non-target species, including mammals. OP and CM insecticides are acetylcholinesterase (AChE) inhibitors and are commonly referred to as anticholinesterase agents. In addition to their cholinergic mechanisms, these insecticides exert toxicity through non-cholinergic mechanisms, thereby affecting several vital organs and body systems. The brain and skeletal muscles are the major target organs. Cardiovascular, respiratory and immune systems are also affected. There are similarities and differences between and among the toxicity profiles of OPs and CMs. This is due in part to variability in the interaction of each OP or CM with target and non-target receptors, enzymes and proteins. Treatment of CM poisoning rests with atropine, while the treatment of OP poisoning includes atropine in combination with an oxime.

Interactive effect of arsenic and fluoride on cardio-respiratory disorders in male rats: possible role of reactive oxygen species

Epidemiological evidence demonstrates positive correlation between environmental and occupational arsenic or fluoride exposure and risk to various cardio-respiratory disorders. Arsenic-exposure has been associated with atherosclerosis, hypertension, cerebrovascular diseases, ischemic heart disease, and peripheral vascular disorders, whereas Fluoride-exposure manifests cardiac irregularities and low blood pressure (BP). Present study aims to study the combined effects of these toxicants on various cardio-respiratory variables in male rats. Single intravenous (i.v.) dose of arsenic (1, 5, 10 mg/kg) or fluoride (5, 10, 20, 36.5 mg/kg) either alone or in combination were administered. Individual exposure to arsenic or fluoride led to a significant depletion of mean arterial pressure, heart rate (HR), respiration rate and neuromuscular (NM) transmission in a dose-dependent manner. These changes were accompanied by increased levels of blood reactive oxygen species (ROS) and decreased glutathione (GSH) concentrations. An increase in the blood acetyl cholinesterase (AChE) activity was observed in both arsenic or fluoride exposed rats. These changes were significantly more pronounced in arsenic-exposed animals than in fluoride. During combined exposure to arsenic (5 mg/kg) + fluoride (20 mg/kg) or arsenic (10 mg/kg) + fluoride (36.5 mg/kg) the toxic effects were more pronounced compared to individual toxicities of arsenic or fluoride alone. However, combined exposure to arsenic (5 mg/kg) + fluoride (36.5 mg/kg) resulted in antagonistic effects on variables suggestive of altered cardio-respiratory function and oxidative stress. The results from the present study suggest that arsenic or fluoride individually demonstrate cardio-respiratory failure at all doses whereas during combination exposure these toxins show variable toxicities; both synergistic and antagonistic effects depending upon the dose. Moreover, it may be concluded that arsenic and/or fluoride cardio-respiratory toxicity may be mediated via oxidative stress. However, these results are new in the discipline thus requires further exploration.

A role for mitochondrial oxidative stress in sulfur mustard analog 2-chloroethyl ethyl sulfide-induced lung cell injury and antioxidant protection

Sulfur mustards (SMs) have been used as warfare agents since World War I and still pose a significant threat against civilian and military personnel. SM exposure can cause significant blistering of the skin, respiratory injury, and fibrosis. No antidote currently exists for SM exposure, but recent studies, using the SM analog 2-chloroethyl ethyl sulfide (CEES), have focused on the ability of antioxidants to prevent toxicity. Although antioxidants can prevent CEES-induced toxicity, the mechanisms by which these compounds are effective against SM agents are largely unknown. Using human bronchial epithelial (16HBE) cells and primary small airway epithelial cells, we show that CEES causes a significant increase in mitochondrial dysfunction as early as 4 h, which is followed by increases in mitochondrial reactive oxygen species (ROS), peaking 12 h after exposure. We also have identified a catalytic antioxidant metalloporphyrin that can rescue airway cells from CEES-induced toxicity when added 1 h after CEES exposure. In addition, the cytoprotective effects of the catalytic antioxidant are associated with correcting mitochondrial dysfunction ROS, DNA oxidation, and decreases in intracellular GSH. These findings suggest a role for oxidative stress in CEES toxicity and provide a rationale to investigate antioxidants as rescue agents in SM exposures.

Protective effects of mecamylamine and atropine against α(4)β(2) nicotinic receptor expression and functional toxicity in paraoxon-treated rats

Chronic and acute exposure to organophosphate pesticides or related nerve agents may lead to persistent neurological and neurobehavioral effects, which cannot be explained by acetylcholinesterase (AChE) inhibition alone. In the present study, the effects of mecamylamine (2mg/kg), or atropine (10mg/kg) alone, or in combination, on the expression of nicotinic acetylcholine receptors (nAChRs) subunits, functional signs of toxicity and lethality in paraoxon-treated rats were investigated. Surviving animals were sacrificed after 48h of paraoxon administration. Paraoxon, at dosage of 1× LD50, significantly reduced expression of α(4) and β(2) nAChR subunits mRNA and protein in rat brain homogenates. Mecamylamine, efficiently prevented reduction of the α(4) and β(2) nAChR mRNA and protein in paraoxon exposed rat brains, but atropine was not efficient. Concurrent treatment with mecamylamine and atropine restored nAChRs mRNA and protein level and prevented lethality and severe involuntary movements induced by paraoxon. Nicotinic receptors antagonists may be included in the cocktail of therapeutic agents targeting the various mechanisms for neuronal injury by organophosphates.

Mustard Gas: Imminent Danger or Eminent Threat?

Objective:

To increase awareness of the widespread environmental prevalence of the chemical warfare agent mustard gas, examine the acute and chronic toxic effects to exposed humans, and discuss medical treatment guidelines for mustard gas exposures.

Data Sources:

Literature retrieval of medical case reports and clinical studies was accomplished using PubMed and the Cochrane Database (1919–March 2007). Search terms included mustard, mustard gas, sulfur mustard, chemical warfare, blister agents, vesicants, and war gas. Historical information and current events were accessed through military field manuals and Internet searches.

Study Selection and Data Extraction:

All articles in English identified from the data sources were evaluated. Adult and pediatric populations were included in the review.

Data Synthesis:

Mustard gas and other chemical weapons are feared for their use as weapons of terror; however, the major threat of mustard gas lies elsewhere. Tons of this chemical agent were produced for war, then subsequently buried in landfills, disposed of at sea, or teft to decay in storage lacrlities. There are documented and anecdotal reports of chemical weapon buriat sites and ocean dumps across the globe spanning from the Arctic Circle to Australia. Numerous accidental exposures have occurred over the past decade. Mustard gas is corrosive to the skin, eyes, and respiratory tract. Extensive exposures can also affect other organ systems. Its ability to cause harm to multiple organ systems at extremely low doses in virtually any environmental condition makes it an extremely dangerous agent. Immediate decontamination of people exposed to mustard gas liquids and vapors is paramount. Supportive care and long-term followup is necessary for exposed persons. Research is under way to find antidotes or treatment methods for mustard gas exposure, but currently there are no definitive treatment guidelines.

Conclusions:

Mustard gas is a weapon, but also a prevalent environmental threat. Recognizing the immense environmental presence of mustard gas disposal sites and the signs and symptoms of exposure will help speed treatment to those accidentally or purposefully exposed.

Respiratory agents: irritant gases, riot control agents, incapacitants, and caustics

There are many chemical respiratory agents suitable for use by terrorists. They are the oldest chemical agents used and have caused the most casualties throughout the 20th century. Many are available in large quantities for industrial use and are susceptible to potential sabotage. This paper will concentrate on respiratory agents that are readily available and have the potential to cause a large number of casualties and panic. These agents have a lower rate of lethality when compared to other chemical agents but could produce many casualties that may overwhelm the emergency medical system.

Aquatic toxicity of nitrogen mustard to Ceriodaphina dubia, Daphnia magna, and Pimephales promelas

Investigation of toxicity of mustard compounds to aquatic organisms has been limited although their effects on terrestrial mammal species have been well studied. In this study, the 48-h LC50 values of nitrogen mustard (HN2) are reported for two aquatic invertebrate species (Daphnia magna and Ceriodaphnia dubia) and for one fish species (Pimephales promelas). Mean LC50 values to C. dubia, D. magna, and P. promela were 1.12, 2.52, and 98.86 mg/L, respectively. C. dubia was the species most sensitive to HN2. Seven-day lethal and sublethal tests with P. promelas and C. dubia were also conducted. In chronic tests, fathead minnow growth was significantly reduced by 2.50 mg/L HN2, while C. dubia reproduction was significantly affected by 7.81 mug/L HN2. These adverse effects on aquatic organisms caused by lower-level concentrations of HN2 indicate that a possible aquatic ecosystem disaster could occur either after a chemical spill or during chemical warfare.

Biochemical terrorism: the medical threat in the twenty-first century

September 11, 2001, forever changed the landscape surrounding terrorism. The oceans no longer protected the United States from terrorists. And as incidences in the Philippines, Spain, Iraq, and other corners of the globe have found, no place on the planet can be considered risk-free. Unfortunately, not only must the world be concerned with acts of violence and destruction, but also with the threat of a more insidious nature-chemical and biological terrorism. According to a March 29, 2004, article in the New York Times, the Pentagon released parts of an unclassified document suggesting that the United States is "woefully ill-prepared to detect and respond to a bioterrorist assault." In this article, our authors offer us a first-hand window into an important and regrettably necessary area of medicine that could affect us both as physicians and citizens in the twenty-first century.Fig 1 -The Editors Biochemical terrorism-the deliberate dispersion of viruses, bacteria, fungi, and organic or inorganic toxin agents, to kill, mutilate, and create chaos-is a real threat that all countries must cope with today. Both sovereign nations and terror organizations now have the capability to produce and use biochemical agents, and some of them have already demonstrated their eagerness to do so. The development of instant communication has been a further inducement to the terrorists. Each event is reported almost immediately in the media, bringing recognition and reputation to the executors (1-3).

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.

Microbiological, biological, and chemical weapons of warfare and terrorism

Microbiological, biological, and chemical toxins have been employed in warfare and in terrorist attacks. In this era, it is imperative that health care providers are familiar with illnesses caused by these agents. Botulinum toxin produces a descending flaccid paralysis. Staphylococcal enterotoxin B produces a syndrome of fever, nausea, and diarrhea and may produce a pulmonary syndrome if aerosolized. Clostridium perfringens epsilon-toxin could possibly be aerosolized to produce acute pulmonary edema. Ricin intoxication can manifest as gastrointestinal hemorrhage after ingestion, severe muscle necrosis after intramuscular injection, and acute pulmonary disease after inhalation. Nerve agents inhibit acetylcholinesterase and thus produce symptoms of increased cholinergic activity. Ammonia, chlorine, vinyl chloride, phosgene, sulfur dioxide, and nitrogen dioxide, tear gas, and zinc chloride primarily injure the upper respiratory tract and the lungs. Sulfur mustard (and nitrogen mustard) are vesicant and alkylating agents. Cyanide poisoning ranges from sudden-onset headache and drowsiness to severe hypoxemia, cardiovascular collapse, and death. Health care providers should be familiar with the medical consequences of toxin exposure, and understand the pathophysiology and management of resulting illness.

The sources, fate, and toxicity of chemical warfare agent degradation products

We include in this review an assessment of the formation, environmental fate, and mammalian and ecotoxicity of CW agent degradation products relevant to environmental and occupational health. These parent CW agents include several vesicants: sulfur mustards [undistilled sulfur mustard (H), sulfur mustard (HD), and an HD/agent T mixture (HT)]; nitrogen mustards [ethylbis(2-chloroethyl)amine (HN1), methylbis(2-chloroethyl)amine (HN2), tris(2-chloroethyl)amine (HN3)], and Lewisite; four nerve agents (O-ethyl S-[2-(diisopropylamino)ethyl] methylphosphonothioate (VX), tabun (GA), sarin (GB), and soman (GD)); and the blood agent cyanogen chloride. The degradation processes considered here include hydrolysis, microbial degradation, oxidation, and photolysis. We also briefly address decontamination but not combustion processes. Because CW agents are generally not considered very persistent, certain degradation products of significant persistence, even those that are not particularly toxic, may indicate previous CW agent presence or that degradation has occurred. Of those products for which there are data on both environmental fate and toxicity, only a few are both environmentally persistent and highly toxic. Major degradation products estimated to be of significant persistence (weeks to years) include thiodiglycol for HD; Lewisite oxide for Lewisite; and ethyl methyl phosphonic acid, methyl phosphonic acid, and possibly S-(2-diisopropylaminoethyl) methylphosphonothioic acid (EA 2192) for VX. Methyl phosphonic acid is also the ultimate hydrolysis product of both GB and GD. The GB product, isopropyl methylphosphonic acid, and a closely related contaminant of GB, diisopropyl methylphosphonate, are also persistent. Of all of these compounds, only Lewisite oxide and EA 2192 possess high mammalian toxicity. Unlike other CW agents, sulfur mustard agents (e.g., HD) are somewhat persistent; therefore, sites or conditions involving potential HD contamination should include an evaluation of both the agent and thiodiglycol.

Emergency department management of nerve agent exposure

Nerve agents are toxic chemicals developed for use by the military, but used by terrorists against civilian populations. As threats of terrorism increase, it is possible that health care providers will be confronted with multiple victims of nerve agent exposure. Nerve agents are highly toxic forms of organophosphate poisons that potentially could cause harm to anyone who comes in contact. Emergency personnel need to be familiar with the agents, know how to prepare for encountering and treating victims, and know how to protect all people involved from further poisoning.

Toxicology and terrorism

Images

The surgical management in war of penetrating wounds contaminated with chemical warfare agents

Military surgeons in a future conflict may face the problem of wounds contaminated with chemical warfare (CW) agents. No useful guidelines for this eventuality exist-nor any assessment of the specific CW risk to such casualties or to the surgical teams operating on them. The principal hazard to surgeons is direct contact with contaminated clothing in the wound. Practices are recommended to reduce this threat significantly. Thorough wound excision augmented by lavage with a specific proprietary hypochlorite solution will provide effective wound decontamination without producing unacceptable tissue damage. The vapour hazard at surgery is very low-respirators are unnecessary but goggles or glasses should be worn to prevent conjunctival splashes of potentially contaminated body fluids.

A serious skin sulfur mustard burn from an artillery shell

Despite the Geneva Protocol of 1925 and the Paris Conference on Prohibition of Chemical Weapons in 1989, sulfur mustard and other chemical weapons continue to pose a hazard to both civilians and soldiers. The presence of artillery shells containing sulfur mustard, both in waters where these shells were dumped and in old battlefields, presents a problem in times of peace, especially for those who collect wartime memorabilia. Past literature has reported several hundred incidents involving fishermen who inadvertently pulled leaking shells aboard their fishing vessels, thereby exposing themselves to the vesicant chemical. Other literature reports exposure to children who found the chemical shells in old battlefields. The purpose of this article is to report the first case of a serious sulfur mustard burn that occurred after removing the detonator from an old artillery shell in a historic battle field near Verdun, France. The circumstances surrounding the injury, the diagnosis and management of injuries secondary to sulfur mustard, and the long-term consequences to the patient are presented and discussed. Although skin grafting has been used in the management of other chemical burn injuries, this report is the first to describe the need for split-thickness skin grafts in the management of a patient with sulfur mustard burns.

Toxicity of the organophosphate chemical warfare agents GA, GB, and VX: implications for public protection

The nerve agents, GA, GB, and VX are organophosphorus esters that form a major portion of the total agent volume contained in the U.S. stockpile of unitary chemical munitions. Congress has mandated the destruction of these agents, which is currently slated for completion in 2004. The acute, chronic, and delayed toxicity of these agents is reviewed in this analysis. The largely negative results from studies of genotoxicity, carcinogenicity, developmental, and reproductive toxicity are also presented. Nerve agents show few or delayed effects. At supralethal doses, GB can cause delayed neuropathy in antidote-protected chickens, but there is no evidence that it causes this syndrome in humans at any dose. Agent VX shows no potential for inducing delayed neuropathy in any species. In view of their lack of genotoxicity, the nerve agents are not likely to be carcinogens. The overreaching concern with regard to nerve agent exposure is the extraordinarily high acute toxicity of these substances. Furthermore, acute effects of moderate exposure such as nausea, diarrhea, inability to perform simple mental tasks, and respiratory effects may render the public unable to respond adequately to emergency instructions in the unlikely event of agent release, making early warning and exposure avoidance important. Likewise, exposure or self-contamination of first responders and medical personnel must be avoided. Control limits for exposure via surface contact of drinking water are needed, as are detection methods for low levels in water or foodstuffs.

Toxicity of vesicant agents scheduled for destruction by the Chemical Stockpile Disposal Program

The vesicant agents of the unitary chemical munitions stockpile include various formulations of sulfur mustard [bis-(2-chloroethyl) sulfide; agents H, HD, and HT] and small quantities of the organic arsenical Lewisite [dichloro(2-chlorovinyl) arsine; agent L]. These agents can be dispersed in liquid, aerosol, or vapor form and are capable of producing severe chemical burns upon direct contact with tissue. Moist tissues such as the eyes, respiratory tract, and axillary areas are particularly affected. Available data summarizing acute dose response in humans and laboratory animals are summarized. Vesicant agents are also capable of generating delayed effects such as chronic bronchitis, carcinogenesis, or keratitis/keratopathy of the eye under appropriate conditions of exposure and dose. These effects may not become manifest until years following exposure. Risk analysis derived from carcinogenesis data indicates that sulfur mustard possesses a carcinogenic potency similar to that of benzo[a]pyrene. Because mustard agents are alkylating compounds, they destroy individual cells by reaction with cellular proteins, enzymes, RNA, and DNA. Once begun, tissue reaction is irreversible. Mustard agents are mutagenic; data for cellular and laboratory animal assays are presented. Reproductive effects have not been demonstrated in the offspring of laboratory rats. Acute Lewisite exposure has been implicated in cases of Bowen's disease, an intraepidermal squamous cell carcinoma. Lewisite is not known to generate reproductive or teratogenic effects.