medical management of biochemical weapons casualties … · medical management of biochemical...
TRANSCRIPT
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Medical Management of Biochemical
Weapons Casualties:
An Introduction
William Schecter, M.D.
Professor of Clinical Surgery
University of California, San Francisco
Chief of Surgery
San Francisco General Hospital
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• When the drum beats to
quarters is now a time of
fearful expectation, and it
is now the surgeon feels
how much the nature of
the wounds which might
be brought to him ought
to have occupied his mind
in previous study.
Sir Charles Bell, 1855
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Objectives
• Review the history of biochemical weapons
• Understand the major types of chemical weapons
available and the principles of medical
management
• Understand the major types of biological weapons
available and the medical management of those
most likely to be employed in a civilian attack
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Terrorism: the use of violence or the
threat of violence to effect political change •
Osama bin Laden Sheikh Ahmed Yassin
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Von Clauswitz (1780-1831)
• ―War is a continuation of
‗Politik‘ (Policy or
Politics) – by other
means‖
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Delium 423 BCE
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Plague – Caffa 1346
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Smallpox and the French and Indian
War
•
General Jeffrey Amherst approved
Exchanging smallpox infested
Blankets with Huron Indians
In 1763 during Pontiac’s rebellion
Resulting in decimation of the
Indian foe.
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Fritz Haber (1868-1934)
• Introduced chlorine gas
• Introduced phosgene gas
• Following World War 1
developed Hydrogen cyanide
– Zyklon B
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World War 1 Casualties
• Phosgene
• 20, 015 casualties
• 1895 deaths (9.4%)
• Mustard
• 160, 970 casualties
• 4,167 deaths (2.5%)
• Phosgene
• 6834 casualties
• 66 deaths (1%)
• Mustard
• 27,711 casualties
• 599 deaths (2.1%)
United Kingdom United States
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World War 1 Casualties
• One third of the 5 million WW1 casualties due to
chemical weapons
• Pulmonary agents (chlorine and phosgene) were
the most lethal
• The largest number of chemical casualties were
due to mustard (all in the last year of the war)
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The Interwar Years
• 1925 Geneva Protocol- Use of chemical and biological weapons is forbidden
• 1935 Eritrea- Italy uses mustard bombs to defeat Ethiopian troops
• 1936 Germany-Gerhart Schrader at IG Farben synthesizes TABUN an organophosphate anticholinesterase
• 1938 Germany- Schrader synthesizes a new compound-SARIN- 10x as potent as TABUN
• 1943 Germany – Nerve agent SOMAN synthesized
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SS John Harvey Bari Mustard Disaster 2 Dec 1943
617 casualties with a 14% fatality rate
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Biological Warfare: Plague
• Ningpo, China Oct. 1940 Japanese plane released 5kg of fleas
• 99 bubonic deaths followed by rodent die-off
• Chang-the, China Nov 1941- lone Japanese plane released ―strange particles—thousands of plague deaths ensue
Dr. Shiro Ishii
Unit 731
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Vx
• Synthesized at Imperial Chemical Company 1953
• 1000 x more toxic than Sarin when applied to
skin—a drop the size of a pinhead could cause
death within 15 minutes
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Yemen Civil War
1962-1970 • Egyptians dropped mustard
gas on multiple occasions
• January 1967, Kitaf, bombs dropped upwind of town. 95% of population of Kitaf dead within 50 minutes. All animals dead. Probable nerve agent
• Additional attacks against Gahar, Gahas, Hofal, Gadr, Gadafa in 1967
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Iran-Iraq War 1980’s
• Mustard Agents used
extensively
• Severe casualties
evacuated to European
hospitals
• UN panel estimated that
45,000 Iranians injured by
Iraqi chemical weapons
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Halabja - 1983
• Saddam Hussein gassed
Kurdish villagers in
Northern Iraq
• > 5,000 casualties
• Gas was a fast acting
vapor – either cyanide or
a nerve agent
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Major Chemical Threats
• Pulmonary Agents
• Cyanide Agents
• Vesicants
• Nerve Agents • Riot control and incapacitating agents
• Toxic industrial chemicals
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Pulmonary Agents
• Chlorine
• Phosgene
• PFIB (perfluoroisobutylene)
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Pulmonary Agents - Pathophysiology
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Clinical Considerations
• Pulmonary Agents cause pulmonary edema
• Latent period- onset delayed by hours, objective
signs appear later than symptoms
• Sudden death may occur due to airway
obstruction or bronchospasm
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Clinical Considerations
• Pneumonia common 3-5 days after injury
• Effects exacerbated by exertion
• No specific therapy
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Clinical Considerations
• Mild exposure: Chest tightness, cough, exertional
dyspnea
• Moderate exposure: above symptoms plus
hoarseness, stridor and pulmonary edema within
2-4 hours
• Severe exposure: Massive pulmonary edema
within 1 hour
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Cyanide
Zyklon B (hydrocyanic acid) Cremation Pits Auschwitz
1944
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Cyanide - Military Operations
• Difficult to weaponize
• Very volatile - blows away
• Weapons inefficient – cyanide payload destroyed
in 50% of munition delivery explosions
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Current Threats
• Focused Targets: Terrorist attacks, homicides,
suicides
• Household products: silver polish, rodenticides
• Industrial Hazards: chemical processing industry,
metal plating, iron and steel mills, gold and silver
mines
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Hydrogen Cyanide
• Colorless liquid or gas
• Odor of bitter almonds
• Vapor density lighter than air
• Boils at 70 degrees F and freezes at 7
degrees F
• Highly water soluble
• Nonpersistent
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• Colorless liquid or gas
• Odor of bitter almonds
• Vapor density lighter than
air
• Boils at 70 degrees F and
freezes at 7 degrees F
• Highly water soluble
• Nonpersistent
• Colorless gas or liquid
• Pungent, biting odor
• Vapor density heavier
than air
• Boils at 59 degrees F,
freezes at 20 degrees F
• Slightly water soluble
• Nonpersistent
Hydrogen Cyanide Cyanogen Chloride
HCN H+ + CN- CNCl CN- + Cl2
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Chemistry of CN-
• High affinity for ions of transitional metals
– Cobalt
– Iron
• Cytochromes (Fe 2+, Fe 3+)
• Heme in Methemoglobin (Fe 3+)
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Pathophysiology
CN- interrupts oxidative phosphorylation by
binding to cytochome a3 in cytochrome oxidase
• Stable but not irreversible binding
• CN- has higher affinity for Fe 3+ in metHb
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Antidote to Cyanide Poisoning
Hg02 (Fe2+)
Nitrite MetHgb (Fe3+)
CN- Cyt a3
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Antidote to Cyanide Poisoning
MetHgb (Fe3+)
CN-
Thiosulfate
CN- thiocyanates sulfites +
Urine
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Classic Clinical Presentation
Hydrogen Cyanide
Moderate Exposure
• Bright red venous blood and skin
• Odor of bitter almonds
• Profound metabolic acidosis
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Hydrogen Cyanide
Severe Exposure
• Tachypnea
• Rapid Loss of Consciousness
• Apnea
• Cardiac Arrest
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Treatment of Cyanide Poisoning
• Amyl Nitrite – 0.3 ml ampules for inhalation –
marked vasodilation – do not use if casualty
conscious and able to stand
• Sodium Nitrite – comes in a 3% solution; give 10
cc (300mg) iv over a 3 minute period in adults.
0.2 ml/kg in children not to exceed 10 ml.
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Treatment of Cyanide Poisoning
• Sodium Thiosulfate: give 50 cc of a 25% solution
(250 mg/cc) = 12.5 grams. Administer over a 10
minute period immediately after nitrite
administration
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Vesicants
• Mustards
• Lewisite
• Phosgene oxime
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Mustards
• Oily liquid
• Light yellow to brown in color
• Vapor heavier than air
• Liquid heavier than water
• Low volatility-persistent
• Causes bone marrow suppression
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Treatment - Decontamination
• Early decontamination
protects casualty
• Late decontamination
protects medical
personnel and facility
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Nerve Agents
• Anti-cholinesterase
• Acetylcholine accumulates
• Effects due to excess Acetylcholine
– Cholinergic crisis
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Physical Properties of Nerve Agents
• Clear colorless liquid
– Not nerve gas
• Boils > 150 o C
• Penetrates skin and
clothing
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Acetylcholine crossing
synapse
Acetylcholine binding to
Receptor initiating post
Synaptic transmission
Cholinesterase binding to
acetylcholine Cholinesterase inactivated
Due to binding with nerve
agent
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Effects of Cholinergic Crisis
• Muscarinic
– Smooth muscles
• Bronchoconstriction
• Miosis
• GI smooth muscle constriction – nausea, diarrhea
– Glands - increased secretions from
• Eyes, nose, mouth, airway, GI tract
– Heart - Bradycardia
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Effects of Cholinergic Crisis
• Nicotinic
– Skeletal muscle
• Fasciculations, twitching, fatigue, flaccid paralysis
– Preganglionic
• Tachycardia, hypertension
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Heart Rate
• Muscarinic (vagal) - decrease
• Nicotinic (preganglionic) - increase
• May be high, low or normal
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CNS Effects of Nerve Agents
• Large exposure
– Loss of consciousness
– Seizures
– Apnea
– Death
• Minor Exposure
– Slowness in thinking, decision making
– Poor concentration
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Antidote to Organophosphates:
Atropine for Muscarinic Receptors
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Atropine
• Starting dose 2-6 mg
• 2 mg every 5 minutes until
– Secretions dry
– Ventilation improved
• Usual dose (severe casualty) 15 – 20 mg
– 1000s of mgs in insecticide poisoning
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Antidote to Organophosphates: Oximes at
Nicotinic Receptors
• Effects at Nicotinic receptors
– Increase skeletal muscle strength
• No effects at muscarinic receptors
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Oximes
• Remove agent from enzyme unless aging has
occurred
• Aging: agent-enzyme complex changes
• Oximes cannot reactivate enzyme after aging
• Aging times: Soman 2 minutes, Sarin 3-4 hours,
others longer
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Dose of Pralidoxime Cl
• 1 gram iv over 20-30 minutes
• To be given immediately after atropine
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Aum Shinrikyo Sarin Attack
Tokyo subway 1995
30% solution of Sarin
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Numbers seeking care
278 Tokyo medical facilities
• 5510 total
• Mild 984
• Moderate 37
• Severe 17
• Deaths 12
• Status unknown >300
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Major Chemical Threats
• Pulmonary Agents
• Cyanide Agents
• Vesicants
• Nerve Agents • Riot control and incapacitating agents
• Toxic industrial chemicals
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Biological Weapons
• Pathogens
• Toxins
• Biomodulators (e.g. Agent Orange)
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Bioterrorism Pathogens
• Bacteria
– B. anthracis
– S. typhi
– S. typhimurium
– Shigella species
– Y. pestis
– V cholerae
– Rickettsia prowazekii
• Toxins
– Botulinum toxin
– Mycotoxins
– SEB
– Ricin
• Viruses
– Variola (smallpox)
– VHF
• Ebola/Marburg
• Lassa Fever
• CCHF
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Portals of Entry of Biological Agents
• Respiratory Tract
• GI Tract
• Skin/Mucus Membranes
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Disease from Aerosolized Biologic
Agents of most concern
• Aerosolized droplets 1-5 microns optimal for
reaching lower respiratory tract
• Aerosols of some agents produce pulmonary
syndromes (anthrax, plague, Q fever, SEB)
• Aerosols of most agents produce systemic illness
(botulinum, most viruses)
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Agents of Greatest Concern
Anthrax
Smallpox
Plague
Tularemia
Botulinum Toxin
VHF
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Anthrax
•Gram positive spore forming non-motile rod
•1876 Robert Koch – germ theory of disease
•1881 Louis Pasteur – first live bacterial vaccine
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Epidemiology
• Reservoir: Soil
• Herbivores infected during grazing
• Transmission to humans
– Contact with infect animals and products
– Ingestion of contaminated meat
– Inhalation – industrial and weapons settings
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Cutaneous Anthrax
• Malignant pustule
• 95% of all Anthrax
infections
• 80-90% complete
resolution
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Anthrax Case 4 October 19, 2001
• 56 y.o. male postal
worker
• 3 day history of fever,
chills, malaise, chest
heaviness, productive
cough
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Anthrax Case 4 October 19, 2001
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Anthrax Case 4 October 23, 2001
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Anthrax Treatment • Post exposure prophylaxis: Ciprofloxacin 500 mg po bid
4-8 weeks
• Initial Inhalation Anthrax Treatment Protocol
– Cipro 400 mg iv q 12h
– or Doxycycline 100 mg iv q 12 h
– Additional antimicrobials: Rifampin, Vanco, Imipenum, Clinda
• Vaccine: not available for civilian use
CDC. Update: Investigation of Bioterrorism-Related Anthrax and Interim Guidelines
For Exposure Management and Antimicrobial Therapy, October 2001. MMWR 2001;
50:909-919.
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Sverdlovsk – April 4-May 15, 1979
• < 1 gram of anthrax
spores released via air
vent without filter
• 77 patients infected
• 66 deaths (87%)
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Smallpox - Variola
• Infectious via aerosol
• No routine Vaccination
• Decreased potency
• Limited supply
• Transmissible
• 30% mortality
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Smallpox - Treatment
• Vaccination within 3-4 days of exposure can
prevent the disease in many patients and prevent
death in most
• After 7 days of exposure, most ―experts‖ would
give vaccinia immunoglobulin as well
• No specific antiviral therapy
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Dark Winter War Game
June 22-23, 2001
• Scenario: Al Qaida terrorists spray smallpox from
aerosol cans in 3 shopping malls in Oklahoma
City, Atlanta and Philadelphia.
• By day 13 of the scenario, smallpox had spread to
25 cities in the US and 15 countries.
• 11,000 individuals infected and 2600 dead by Day
13.
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Plague
• Reservoir >200 species of
mammals
– Rattus rattus
– Squirrels, cats
• Vector > 80 species of
fleas
• Person to person
transmission via aerosol
Yersinia Pestis: Gram negative
Non-motile coccobacillus
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Plague
Bubonic Septicemic Pneumonic
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Pneumonic Plague
• Primary or secondary (incubation 2-3 days)
• High fever, chills, malaise
• Hemoptysis
– Pneumonia progresses rapidly
– Respiratory failure and circulatory collapse
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Plague: Diagnosis
Otherwise healthy young person
Hemoptysis
Think Plague
Especially if GNCB in sputum
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Plague: Treatment
• Streptomycin 15 mg/kg IM or IV qd x 10 days or
• Doxycycline 200 mg iv x1 then 100 mg iv q 12 h
• Cipro 500 mg po/iv bid should also be effective
• Chloramphenicol for meningitis
• No vaccine
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Tularemia – Rabbit Fever
• Gram negative non-motile coccobaccillus
• Reservoir:
– Rabbits, squirrels, muskrats, cats
• Vectors:
– Ticks, deerflies
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Tularemia: Clinical Presentation
• Ulceroglandular:
• Glandular
• Occuloglandular
• Pharyngeal
• Typhoidal: nonspecific febrile illness without
localization
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Pneumonic Tularemia
• After inhalation
(biological weapon)
• Secondary hematogenous
spread after typhoidal
form
• Vaccine available
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Tularemia: Treatment
• Post exposure prophylaxis
– Doxycycline 100mg po bid or
– Ciprofloxacin 500mg po bid
• For treatment of established infection
– Gentamycin 5 mg/kg iv qd
• Vaccine available but not currently recommended for
prophylaxis
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Toxins Relevant to Biological
Warfare
• Botulinum Toxin
• Staph Enterotoxin B (SEB)
• Ricin
• T3 Mycotoxins (Yellow Rain)
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Mechanism of Action
• Enters pre-synaptic nerve terminal
• Prevents release of Acetylcholine
– Neuromuscular junction-flaccid paralysis
– Cholinergic autonomic blockade
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Botulism: Clinical Features
• Latent period: 24-36 hours after inhalation
• Symmetrical descending bulbar paralysis
– Blurred vision, diplopia, ptosis, photophobia
– Dysphonia, dysphagia
– Flaccid paralysis
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Botulism: Treatment
• Antitoxin
• Ventilatory support
• Intensive Care
• Recovery may be prolonged (months)
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Viral Hemorrhagic Fevers
• Acute febrile illness
• Malaise, myalgia
• Petechiae, ecchymoses
• Diffuse hemorrhage
• Shock
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Pathogens
• Areaviridae
– Lassa Virus
• Phlebovirus
– Rift Valley Fever
• Nairovirus
– Crimea-Congo
Hemorrhagic Fever
• Hantavirus
• Filoviridae
– Ebola HF
– Marburg HF
• Flaviviridae
– Yellow Fever
– Dengue HF
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Mode of Transmission in Biological
Weapon
Aerosol
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Treatment of VHF
• Strict Isolation
• Supportive Care
• Ribavirin (available from the CDC on a
compassionate use basis) otherwise
• No specific treatment
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Chem-Bio Casualties
• Immediate Pulmonary
– Phosgene
– SEB
– Vesicants
– Cyanide
• Immediate Neurologic
– Nerve Agents
– Cyanide
• Delayed Pulmonary – Anthrax, Plague, Tularemia
– Q Fever
– Phosgene
– SEB, Ricin, Vesicants
– Phosgene
• Delayed Neurologic
– Botulism
– VEE
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Further Study • http://ccc.apgea.army.mil/Documents/HTML_Restricted/
index.htm (Textbook of biochemical weapons)
• http://ccc.apgea.army.mil/ (US Army Institute of Chemical Defense)
• http://www.usamriid.army.mil/education/instruct.html (US Army Research Institute for Infectious Disease)
• http://www.medletter.com/freedocs/bioweapons.pdf (Medical Letter: Rx of Biological Weapons Pathogens)
• http://www.bt.cdc.gov/ (CDC homepage for bioterrorism)
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In War, Resolution
In Defeat, Defiance
In Victory, Magnanimity
In Peace, Good Will
Winston S. Churchill
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God Bless America
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When you're wounded and left
on Afghanistan's plains,
And the women come out to
cut up what remains,
Jest roll to your rifle and
blow out your brains
An' go to your Gawd like
a soldier.
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Anticholinesterases
• Carbamates
– Physostigmine (Antilirium)
– Pyridostigmine (Mestinon)
– Neostigmine (Prostigmine)
• Organophosphates
– ―Nerve Agents‖
– Malathion
– Diazinon
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Unusual presentation of number or
Type of patients to ER with unfamiliar
Symptom complex
Duration of symptoms
Less than 24 hours
Yes No Consider exposure
To toxin or chemical
Algorithm 2
Consider exposure
To infection
Algorithm 3
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Algorithm 2A
Many deaths within
The first hour? yes
No
Nerve agent, cyanide,
Fast acting toxin
Fever, septic shock within
The first 24 hours?
yes
No
Algorithm
2B
Is the skin red, painful or
Blistered? Yes
Mycotoxins Do most die within 2-3 days?
No
Ricin
No SEB
Yes
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Algorithm 2B
No deaths in 1st hour
No fever in 1st day
Paralysis?
yes no Rapid appearance of
Stridor, secretions,
Fasciculations, coma
Seizures?
Cough, sob,
High wbc?
yes no no yes
Nerve agent botulism phosgene
Skin red
Blistered?
Mustard,
mycotoxin
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Algorithm 3A
Sx > 24 hours
Dominant clinical
signs
diarrhea respiratory Headache
meningismus rash
bloody
no yes
cholera
E. coli, Shigella,
Salmonella
Ebola, Marburg
CXR findings?
See next slide VEE See algorithm
3B
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Algorithm 3A (continued)
Resp sx . 24 hrs
CXR?
Segmental or
Subsegmental
Infiltrate? ARDS
Hilar
Adenopathy
Widened
Mediastinum
Tularemia
Plague
Q fever
P mallei
SEB
Hantavirus Anthrax
Plague
Tularemia
Anthrax
Plague
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Algorithm 3B
Dominant sign rash > 24 hours
ecchymotic pustular macuolopapular
Ebola/Marburg
Smallpox
Crimean-Congo HF
Smallpox
P. Mallei
Pseudomallei
Smallpox
P. Mallei
P. Pseudomallei
Ebola/Marburg
Lassa fever
Crimean-Congo HF