tokyo sarin attack 1995 tareg bey, md, facep, abmt, deaa professor of emergency medicine department...
TRANSCRIPT
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Tokyo Sarin Attack 1995
Tareg Bey, MD, FACEP, ABMT, DEAAProfessor of Emergency Medicine
Department of Emergency MedicineDirector, International Emergency Medicine
University of California, Irvine, USA
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The Tokyo Incident
• 3 million workers and students arrive into Tokyo via the subway
• Monday morning 0755 on March 20, 1995 during rush hour
• The terrorist group organized the release of Sarin into 5 subway cars on 3 separate subway lines
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Timeline of Attack• 0755 Diluted form of Sarin released • 0816 St. Luke’s ED alerted• 0828 First subway victim arrived to ED
» C/O eye pain and dim vision
• 0920 approx. 500 additional patients had arrived; Hospital director activated hospital’s disaster plan
• Total patients at St. Luke’s ED = 640• More than 100 doctors & 300 nurses and
volunteers available to provide health care
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The Incident
• Largest documented civilian exposure to nerve agent
• Total of 12 commuters killed *• 2 deaths in the hospital • 5,000 persons required emergency medical
evaluation• 640 persons presented to the hospital• * Numbers may have increased.
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Sarin
• Developed in the 1930s for use in warfare by the German Dr. Gerhard Schrader
• Potent organophosphate compound• Blocks acetylcholinesterase effects at
myoneural junction• Sarin: Schrader, Ambrose, Rudringer, van der Linde
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Nerve Agents
• Are organophosphates
• Are similar to insecticides:– Malathion– Diazinon– Chlorpyrifos http://crdp.ac-paris.fr/cinevo_anglais/print/images/
poster_north.jpg
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Sarin
• Overstimulation of cholinergic receptors
• Effective in vapor form
• Lethal Dose: 1 mg
• Tokyo attack: diluted form of Sarin
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Expected Symptoms
• Miosis• Fasciculations• Convulsions• Weakness• Respiratory insufficiency• Decreased level of
consciousness
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Tokyo 1995
http://www.npa.go.jp/hakusyo/h16/hakusho/h16/image/ph200025.png
http://newsimg.bbc.co.uk/media/images/39504000/jpg/_39504695_attack203.jpg
http://www.semp.us/_images/biots/Biot171PhotoA.jpg
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Most prominent signs and symptoms of 111 moderate and severe cases
• Miosis 110 patients 99%• Headache 83 patients 74.8%• Dyspnea 70 patients 63.1%• Nausea 67 patients 60.4%• Eye pain 50 patients 45%
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How did the Sarin Victims Arrive to St. Luke’s Hospital?
• 640 patients to the hospital• 64 (10%) arrived by ambulance• 35 (5.5%) arrived by minivans belonging
to the Fire Defense Agency• 541 (84.5%) arrived by nonmedical
vehicles
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Cases
• Of the 641 patients seen at St. Luke’s International Hospital on the day of the disaster, five were in critical condition.
• Three patients had cardiopulmonary arrest and two were unconscious and had respiratory arrest soon after arrival.
• Of these five critically ill patients, three were successfully resuscitated and able to leave on hospital day 6.
• One of the patient who had cardiopulmonary arrest did not respond to cardiopulmonary resuscitation (CPR) and died with findings of very bizzare miosis.
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Decontamination of the Nerve Agents
•Outdoors is best
•Usually near ER
•Copious water
•Special drain considerations
•Hypochlorite not necessary
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Tokyo 1995
• Transport of sick patient out of subway
• With PPE of rescue staff
• No PPE in the hospital
http://publicsafety.com/article/photos/1129126846021_chemical1.jpg
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Tokyo: Hospital Response
• 5,500 victims• 641 presented to St.
Luke’s International Hospital
• No decontamination was the norm
• No EMS involvement for most patients
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Tokyo Events – VideoHospital Receiving Area
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Nerve Agents - Therapy
• Blocks the enzyme acetylcholinesterase• Protection: PPE, evacuated, undress, avoid
cross contamination, off gassing?• Decontamination • Airway, ventilation, supportive care, (seizure
control, suctioning, IV fluids) • Antidotes (atropine, obidoxime, HI-6)• Anticonvulsants (valium, midazolam)
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Usual Treatment
• Decontamination• Anticholinergics
– Atropine sulfate
• Reverse block of acetylcholinesterase– 2-pyridine aldoxime methiodide (2-PAM)
• Supportive treatment– Ventilatory support
• Rescuscitative– CPR, intubation
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Categorization Of Victims- Triage
• MILD – only eye signs or symptoms» 528 patients (82.5%)» Released after 12 hrs of observation
• MODERATE – presence of systemic signs without needing mechanical ventilation
» 107 patients (16.7%)
• SEVERE – require emergency ventilation» 5 patients (0.78%)
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Examples When Early Detection Can Make
a Difference
• Radiological: Radionuclides- N-95 respirators, type of decontamination, delay of decontamination early trauma care
• Chemical:
- Mustard gas: Isobutyl rubber protection versus latex gloves
- Sarin gas versus Soman or Tabun: Half-life, antidotes versus mass ventilation --- Tokyo: Lack of PPE , difficulties with early detection
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Key Points
• Detection, awareness
• PPE, protection
• Decontamination
• Mass treatment, proper triage of a chemical incident
• Chemical versus radiological versus biological triage
• Supportive Care and Antidotes
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TechnologyExample: Europe
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Origin: Military Light Armored Vehicle (LAV) – Fuchs -
http://www.uebersetzerportal.de/bilder/fuchs-spuerpanzer.jpg
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Technical Capabilities
• Automatic and continuous measurements (online measurements) in conjunction with geopositioning and sotrage of data –online graphic visualization-
• Measurement and transmission of meterological data
• Soil, water and air sampling • Data transission to central dispatch
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Standardized CBRN Explorers
• Uniformly equipped “CBRN Explorers” assure more timely and consistent analytic capabilities in all geographic areas during HAZMAT disasters.
• In the United States the fire departments’ HAZMAT teams and other agencies own a great variety of different nonstandardized analytical CBRN tools across the country
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Dose Rate- Time (Location) Rad-xy-Diagramm600
http://www.bbk.bund.de/cln_007/nn_400552/SharedDocs/Bilder/ABC-Schutz/RadxyDiagramm600.html
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Mapping of a Dose Rate with GPS
http://www.bbk.bund.de/cln_007/nn_400552/SharedDocs/Bilder/ABC-Schutz/Karte_20ODL_20Bonn600.html
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Examples Chemical Detection
Photoionization detector (PID), Ionmobility spectrometry (IOS): Measurement of HAZMAT and chemical warfare agent
http://www.bbk.bund.de/cln_007/nn_400552/DE/02__Themen/08__ABCSchutz/01__ABCErkundung/02__Messtechnik/05__Ionenmobilitaetsspektrometer/Ionenmobilitaetsspektrometer__node.html__nnn=true
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Ionmobility Spectrometry: Rapid Alarm and Identification Device (RAID 1)
CWA• Lewisite• Sarin, Soman, Tabun, VX• Sulfur and nitrogen
mustard
Industry: • Ammonia, cyanide,
chlorine, chlorinated halogens, acetic acid, SO2, Toluene diisocyanate
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Problems in Tokyo
• Delay in confirmation of the nature of toxic substance
• No personal protective equipment at hospital entrance
• Delay in organizing a mass casualty plan• Poor ventilation in waiting area of ED• Secondary contamination of medical staff
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Tokyo: Hospital Response
• 5,500 victims• 641 presented to St.
Luke’s International Hospital
• No decontamination was the norm
• No EMS involvement for most patients
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Summary
• For nerve agents avoidance of exposure is an important issue.
• Evacuation of closed environment is a key measure.
• Personal protective equipment• Decontamination prevents further exposure and
ongoing absorption with further toxicity.• Supportive care saves lives.• Antidotes: Atropine, obidoxime, benzodiazepines