Chemical Agents of Opportunity for Terrorism: TICs & TIMs
Chemical Agents of Opportunity for Terrorism: TICs & TIMs Chemical Agents of Opportunity for Terrorism: TICs & TIMs
Chemical Agents of Opportunity for Terrorism: TICs & TIMs Non-Procedure Participant Guide December, 2008
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<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong><br />
<strong>Opportunity</strong> <strong>for</strong><br />
<strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Non-Procedure Participant Guide<br />
December, 2008
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong><br />
Training Support Package<br />
Participant Guide<br />
Table <strong>of</strong> Contents<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong> - Introduction..................... 1<br />
Module One Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons -<br />
Administration Page ..................................................................................................................... 2<br />
Duration ...................................................................................................................................... 2<br />
Scope Statement.......................................................................................................................... 2<br />
Terminal Learning Objective (TLO) .......................................................................................... 2<br />
Enabling Learning Objectives (ELO) ......................................................................................... 2<br />
Resources .................................................................................................................................... 2<br />
Instructor to Participant Ratio..................................................................................................... 3<br />
Reference List ............................................................................................................................. 3<br />
Practical Exercise Statement....................................................................................................... 3<br />
Assessment Strategy ................................................................................................................... 4<br />
Module One ................................................................................................................................... 5<br />
Icon Map ..................................................................................................................................... 5<br />
Module One Summary ............................................................................................................... 65<br />
Module Two The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong> - Administration Page<br />
....................................................................................................................................................... 66<br />
Duration .................................................................................................................................... 66<br />
Scope Statement........................................................................................................................ 66<br />
Terminal Learning Objective (TLO) ........................................................................................ 66<br />
Enabling Learning Objectives (ELO) ....................................................................................... 66<br />
Resources .................................................................................................................................. 66<br />
Instructor to Participant Ratio................................................................................................... 66<br />
Reference List ........................................................................................................................... 66<br />
Practical Exercise Statement..................................................................................................... 67<br />
Assessment Strategy ................................................................................................................. 67<br />
Module Two................................................................................................................................. 68<br />
Icon Map ................................................................................................................................... 68<br />
Module Two Summary............................................................................................................. 118<br />
Module Three Toxic Industrial Gases as Terrorist Threats - Administration Page ......... 120<br />
Duration .................................................................................................................................. 120<br />
Scope Statement...................................................................................................................... 120<br />
Terminal Learning Objective (TLO) ...................................................................................... 120<br />
Enabling Learning Objectives (ELO) ..................................................................................... 120<br />
Resources ................................................................................................................................ 120<br />
Instructor to Participant Ratio................................................................................................. 121<br />
Reference List ......................................................................................................................... 121<br />
Practical Exercise Statement................................................................................................... 123<br />
Assessment Strategy ............................................................................................................... 123<br />
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Training Support Package<br />
Participant Guide<br />
Module Three ............................................................................................................................ 124<br />
Icon Map ................................................................................................................................. 124<br />
Module Three Summary .......................................................................................................... 181<br />
Module Four Cyanide & Fumigants - Administration Page ............................................... 182<br />
Duration .................................................................................................................................. 182<br />
Scope Statement...................................................................................................................... 182<br />
Terminal Learning Objective (TLO) ...................................................................................... 182<br />
Enabling Learning Objectives (ELO) ..................................................................................... 182<br />
Resources ................................................................................................................................ 182<br />
Instructor to Participant Ratio................................................................................................. 182<br />
Reference List ......................................................................................................................... 182<br />
Practical Exercise Statement................................................................................................... 186<br />
Assessment Strategy ............................................................................................................... 186<br />
Module Four.............................................................................................................................. 187<br />
Icon Map ................................................................................................................................. 187<br />
Module Four Summary ............................................................................................................ 247<br />
Module Five <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, & Medication - Administration<br />
Page ............................................................................................................................................ 249<br />
Duration .................................................................................................................................. 249<br />
Scope Statement...................................................................................................................... 249<br />
Terminal Learning Objective (TLO) ...................................................................................... 249<br />
Enabling Learning Objectives (ELO) ..................................................................................... 249<br />
Resources ................................................................................................................................ 249<br />
Instructor to Participant Ratio................................................................................................. 249<br />
Reference List ......................................................................................................................... 250<br />
Practical Exercise Statement................................................................................................... 254<br />
Assessment Strategy ............................................................................................................... 254<br />
Module Five ............................................................................................................................... 255<br />
Icon Map ................................................................................................................................. 255<br />
Module Five Summary ............................................................................................................. 303<br />
Module Six <strong>Terrorism</strong> through Fear & Uncertainty: Delayed Toxic Syndromes -<br />
Administration Page ................................................................................................................. 304<br />
Duration .................................................................................................................................. 304<br />
Scope Statement...................................................................................................................... 304<br />
Terminal Learning Objective (TLO) ...................................................................................... 304<br />
Enabling Learning Objectives (ELO) ..................................................................................... 304<br />
Resources ................................................................................................................................ 304<br />
Instructor to Participant Ratio................................................................................................. 305<br />
Reference List ......................................................................................................................... 305<br />
Practical Exercise Statement................................................................................................... 307<br />
Assessment Strategy ............................................................................................................... 307<br />
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Training Support Package<br />
Participant Guide<br />
Module Six ................................................................................................................................. 308<br />
Icon Map ................................................................................................................................. 308<br />
Module Six Summary ............................................................................................................... 355<br />
Module Seven Radiation Emergencies - Administration Page............................................ 357<br />
Duration .................................................................................................................................. 357<br />
Scope Statement...................................................................................................................... 357<br />
Terminal Learning Objective (TLO) ...................................................................................... 357<br />
Enabling Learning Objectives (ELO) ..................................................................................... 358<br />
Resources ................................................................................................................................ 358<br />
Instructor to Participant Ratio................................................................................................. 358<br />
Reference List ......................................................................................................................... 358<br />
Practical Exercise Statement................................................................................................... 361<br />
Assessment Strategy ............................................................................................................... 361<br />
Module Seven ............................................................................................................................ 363<br />
Icon Map ................................................................................................................................. 363<br />
Module Seven Summary........................................................................................................... 421<br />
Module Eight Observed Behaviors during Mass <strong>Chemical</strong> Exposures- Administration<br />
Page ............................................................................................................................................ 423<br />
Duration .................................................................................................................................. 423<br />
Scope Statement...................................................................................................................... 423<br />
Terminal Learning Objective (TLO) ...................................................................................... 423<br />
Enabling Learning Objectives (ELO) ..................................................................................... 423<br />
Resources ................................................................................................................................ 423<br />
Instructor to Participant Ratio................................................................................................. 423<br />
Reference List ......................................................................................................................... 424<br />
Practical Exercise Statement................................................................................................... 426<br />
Assessment Strategy ............................................................................................................... 427<br />
Module Eight ............................................................................................................................. 428<br />
Icon Map ................................................................................................................................. 428<br />
Module Eight Summary ........................................................................................................... 468<br />
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Training Support Package<br />
Participant Guide<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong> -<br />
Introduction<br />
In recent years, there has been growing concern that many <strong>of</strong> the most likely threats <strong>of</strong> chemical<br />
terrorism involve so-called “agents <strong>of</strong> opportunity.” Both common and unusual industrial agents<br />
may pose a considerable threat as potential terrorist weapons. While an understanding <strong>of</strong> the<br />
traditional military chemical weapons (e.g. nerve agents) remains essential, an appreciation <strong>of</strong><br />
the myriad <strong>of</strong> other potential toxic chemicals readily available in our society is crucial if we are to<br />
optimally prepare, identify and defend against chemical threats. Many toxic industrial chemicals<br />
are easily obtainable from multiple sources in our communities and pose a serious threat to<br />
health if accidentally released or intentionally disseminated.<br />
The American College <strong>of</strong> Medical Toxicology (ACMT) has designed a 1-day course: “<strong>Chemical</strong><br />
<strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> (Toxic Industrial <strong>Chemical</strong>s) and <strong>TIMs</strong> (Toxic<br />
Industrial Materials)”. This course will utilize a symptom-based clinical approach to describe the<br />
medical impact <strong>of</strong> various chemical poisons. It will provide a framework to enhance recognition<br />
<strong>of</strong> the common health effects <strong>of</strong> apparently disparate chemical toxins, describe the risk to<br />
various healthcare workers, and introduce clinical and public health management strategies.<br />
The traditional military warfare chemical agents will not be covered in these lectures because<br />
in<strong>for</strong>mation on these agents is readily accessible through a number <strong>of</strong> other <strong>for</strong>ums such as the<br />
Internet.<br />
The central course topics are presented in eight modules and include:<br />
• Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
• The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
• Toxic Industrial Gases<br />
• Cyanide & Fumigants<br />
• <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, & Medications<br />
• <strong>Terrorism</strong> through Fear & Uncertainty: Delayed Toxic Syndromes<br />
• Radiation Emergencies<br />
• Observed Behaviors during Mass <strong>Chemical</strong>s Exposures<br />
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Training Support Package<br />
Participant Guide<br />
Module One<br />
Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong><br />
Weapons - Administration Page<br />
While the threat <strong>of</strong> conventional chemical warfare has received much attention, and is the<br />
subject <strong>of</strong> tight control measures and a program <strong>of</strong> planned chemical destruction, less interest<br />
has been paid to other chemical agents that have great potential to wreak havoc on the civilian<br />
sector and produce mass casualties. This module provides an introduction and overview <strong>of</strong> the<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> (Toxic Industrial <strong>Chemical</strong>s) and <strong>TIMs</strong><br />
(Toxic Industrial Materials) course and seeks to provide awareness-level training on a variety <strong>of</strong><br />
toxic syndromes likely to be encountered following exposures to <strong>TICs</strong>, <strong>TIMs</strong> and other chemical<br />
agents <strong>of</strong> opportunity.<br />
Duration<br />
45 minutes<br />
Scope Statement<br />
This module presents a broad overview <strong>of</strong> the potential toxic industrial chemicals and toxic<br />
metals readily available in our society, the most likely scenarios that might occur as the result <strong>of</strong><br />
terrorism, and historical examples <strong>of</strong> major chemical events. A framework <strong>for</strong> early detection<br />
and recognition <strong>of</strong> toxic chemicals is provided in order to optimally prepare, identify, and defend<br />
against chemical threats.<br />
Terminal Learning Objective (TLO)<br />
• Understand the concept <strong>of</strong> chemical agents <strong>of</strong> opportunity, including<br />
specific Toxic Industrial <strong>Chemical</strong>s (<strong>TICs</strong>) and Toxic Industrial<br />
Materials (<strong>TIMs</strong>)<br />
Enabling Learning Objectives (ELO)<br />
Resources<br />
• Define Toxic Industrial <strong>Chemical</strong>s and Toxic Industrial Materials<br />
• Describe the goals <strong>of</strong> toxic terrorism<br />
• Discuss prioritization and legislative response to chemicals <strong>of</strong> concern<br />
• Introduce the concept <strong>of</strong> using clinical findings to identify a terrorist<br />
chemical agent and event<br />
• Review historical examples <strong>of</strong> toxic terrorism<br />
Each <strong>of</strong> the eight course modules is deployed as an interactive, instructor-lead, MS PowerPoint<br />
presentation containing didactic content, historical examples, and selected case studies. All<br />
presentations are included in a printed participant guide (PG) containing the modules’ overview,<br />
scope statement, terminal and enabling learning objectives, PowerPoint slide handouts, and a<br />
summary section.<br />
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Training Support Package<br />
Participant Guide<br />
Instructor to Participant Ratio<br />
1:8 (minimum) and 1:25 (maximum)<br />
Reference List<br />
1. Acute Exposure Guideline Levels (AEGL): www.epa.gov/oppt/aegl/<br />
2. Army Office <strong>of</strong> the Surgeon General. Draft Medical NBC Hazard Analysis <strong>of</strong><br />
<strong>Chemical</strong>-Biological-Radiological-Nuclear-High Explosive Threat, Hospital Scenarios<br />
and Planning Requirements. Oct 2001.<br />
3. Bach LK and Walton B. “Las Vegas Dodged a Bullet: Chlorine-hauling tanker rolls<br />
free. Workers able to board, activate brake.” Las Vegas Review Journal, 30 Aug<br />
2007. Last accessed Dec 2008 from: http://www.lvrj.com/news/9466232.html<br />
4. Brodsky BH. “Industrial <strong>Chemical</strong>s as Weapons: Chlorine” Monterey Institute <strong>of</strong><br />
International Studies, 31 July 2007. Last access Dec 2008 from:<br />
http://www.nti.org/e_research/e3_89.html<br />
5. CDR Joseph L. Hughart and Mark M. Bashor. ATSDR: Industrial <strong>Chemical</strong>s And<br />
<strong>Terrorism</strong>: Human Health Threat Analysis, Mitigation And Prevention.<br />
6. “<strong>Chemical</strong> Time Bombs”. Editorial. New York Times, 10 May 2005. Last accessed<br />
Dec 2008 from: http://www.nytimes.com/2005/05/10/opinion/10tues1.html<br />
7. Congressional Research Service. “<strong>Chemical</strong> Plant Security” CRS Web, 23 Jan 2003.<br />
Last access Dec 2008 from:<br />
http://www.ncseonline.org/nle/crsreports/03Feb/RL31530.pdf<br />
8. Hauschild VD. Prioritizing industrial chemical hazards. J Toxicol Environ Health<br />
2005;68:857-76.<br />
9. International Task Force 25. “Hazard from Toxic Industrial <strong>Chemical</strong>s” 18 March<br />
1996. Last access Dec 2008 from: http://wikileaks.org/leak/us-uk-ca-mou-itf25-<br />
1996.pdf<br />
10. Khan AS and Sage MJ (2000) Biological and <strong>Chemical</strong> <strong>Terrorism</strong>: Strategic Plan <strong>for</strong><br />
Preparedness and Response, Recommendations <strong>of</strong> the CDC Strategic Planning<br />
Workgroup. MMWR, 49(RR04);1-14.<br />
11. Monterrey Institute: http://montrep.miis.edu/databases.html<br />
12. Okumura, T. et. al. The Tokyo Subway Sarin Attack: Disaster Management.<br />
Academic Emergency Medicine, Vol. 5. p. 613-628. 1998.<br />
13. Staten CL. “The Terrorist Threat <strong>of</strong> <strong>Chemical</strong> Attack” EmergencyNet News, 27 Apr<br />
2005. Last accessed Dec 2008 from:<br />
http://www.emergency.com/2005/chem_attk2005.htm<br />
14. Tucker, Jonathan (editor). Toxic Terror: Assessing Terrorist Use <strong>of</strong> <strong>Chemical</strong> and<br />
Biological Weapons. MIT Press, 2000.<br />
15. USA Patriot Act, HR 3162, 107th Congress, 1st Session (2001). Last accessed Dec<br />
2008 from: epic.org/privacy/terrorism/hr3162.html.<br />
Practical Exercise Statement<br />
Each module presentation contains one or more interactive audience response questions<br />
designed to drive discussion, promote participant engagement, and test knowledge. Through<br />
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Training Support Package<br />
Participant Guide<br />
the use <strong>of</strong> the Meridia® Audience Response system, participant responses can be collected,<br />
tabulated, and displayed within the presentation in real time. In order to use the interactive<br />
slides accompanying this presentation, the lecture hall must be equipped with the Meridia®<br />
Audience Response system and user keypads. In addition, a copy <strong>of</strong> the “Meridia® Q&A”<br />
s<strong>of</strong>tware component <strong>for</strong> MS PowerPoint must be installed on the presenter’s computer.<br />
Assessment Strategy<br />
Participant progress toward course learning objectives is monitored through in<strong>for</strong>mal discussion<br />
and responses to each module’s practical exercise questions. Overall mastery <strong>of</strong> module<br />
content and concepts is documented by means <strong>of</strong> a comprehensive, end-<strong>of</strong>-day posttest<br />
touching on key learning objectives from each module. Each participant must obtain a score <strong>of</strong><br />
80% or better to successfully complete the training and obtain a course completion certificate.<br />
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Training Support Package<br />
Participant Guide<br />
Module One<br />
Icon Map<br />
Knowledge Check: Used when it is time to assess the learners’ understanding<br />
Example: Used when there is a descriptive illustration to show or explain<br />
Key Points: Used to convey essential learning concepts, discussions and introduction <strong>of</strong><br />
supplemental material<br />
Hint: Used to cover administrative items or instructional tips that aid in the flow <strong>of</strong> the<br />
instruction<br />
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Training Support Package<br />
Participant Guide<br />
Slide 1<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Module One<br />
Toxic Warfare: Looking Beyond Conventional<br />
<strong>Chemical</strong> Weapons<br />
Training Support Package<br />
This module is entitled: Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons.<br />
1<br />
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Training Support Package<br />
Participant Guide<br />
Slide 2<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Course Overview<br />
• Why “<strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> ”<br />
• Neurotoxicology<br />
• Gases<br />
• Cyanide and Fumigants<br />
• Food/Water/Medications<br />
• Delayed Onset Toxins<br />
• Radiation<br />
• Psychological Aspects<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
2<br />
This course was developed by the American College <strong>of</strong> Medical Toxicology (ACMT) to<br />
prepare participants <strong>for</strong> chemical terrorism threats not traditionally discussed in other<br />
training courses.<br />
The topics that will be covered today start with an overview <strong>of</strong> the topic “Why <strong>Agents</strong> <strong>of</strong><br />
<strong>Opportunity</strong>”, followed by neurotoxins, then inhalational agents such as gases,<br />
systemic toxins such as cyanide, means <strong>of</strong> delivery such as food and water, toxins with<br />
delayed onset, the effects <strong>of</strong> radiation exposure, and finally the psychological aspects <strong>of</strong><br />
mass exposure to toxins.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 3<br />
The objectives <strong>of</strong> the agents <strong>of</strong> opportunity course are: to define toxic industrial<br />
chemicals (<strong>TICs</strong>) and toxic industrial materials (these are things such as explosives and<br />
radiologicals) (<strong>TIMs</strong>), describe the goals <strong>of</strong> toxic terrorism, discuss prioritization lists and<br />
the appropriate community response to chemicals <strong>of</strong> concern. This course will provide<br />
examples <strong>of</strong> terrorist events or chemical accidents to introduce the concept <strong>of</strong> using<br />
clinical findings to identify and respond to these events.<br />
The focus <strong>of</strong> the first module is to provide you with a broad overview and principles that<br />
will be developed throughout the rest <strong>of</strong> the day’s interactions.<br />
This module will use historical examples <strong>of</strong> toxic terrorism to explain how the prehospital,<br />
public health, law en<strong>for</strong>cement, and medical communities can be better prepared <strong>for</strong> the<br />
medical needs <strong>of</strong> patients.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 4<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Audience Response<br />
Which <strong>of</strong> the following best describes the type <strong>of</strong> work<br />
you do<br />
1. Clinical Medicine or Nursing<br />
2. First Responder<br />
3. Law En<strong>for</strong>cement<br />
4. Military<br />
5. Public Health<br />
6. Other<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
4<br />
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Training Support Package<br />
Participant Guide<br />
Slide 5<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Audience Response<br />
Which <strong>of</strong> the following best describes who you work<br />
<strong>for</strong><br />
1. Federal Government (incl. Military)<br />
2. State Government<br />
3. Local Government (incl. Police, Fire, EMS)<br />
4. Educational (University, High School, …)<br />
5. Hospital or Medical Facility<br />
6. Corporation<br />
7. Consulting Firm<br />
8. Other<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
5<br />
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Training Support Package<br />
Participant Guide<br />
Slide 6<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Official “Battlefield”<br />
<strong>Chemical</strong> Warfare <strong>Agents</strong><br />
• Purpose Designed Warfare<br />
<strong>Agents</strong><br />
• Dual Use Industrial<br />
<strong>Chemical</strong>s<br />
– Nerve ( eg. Sarin, VX)<br />
– Blister ( eg. Mustard)<br />
– Blood ( eg. CN)<br />
– Choking ( eg.Phosgene )<br />
– 1° focus <strong>of</strong> chemical defense<br />
programs in past<br />
– Less emphasis on industrial<br />
chemicals as a military threat<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
6<br />
This course covers <strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong>- a novel approach to this subject <strong>of</strong><br />
chemical terrorism. In general, these agents do not have any civilian use and are<br />
“purpose designed” <strong>for</strong> warfare or human harm, and they are very difficult to obtain.<br />
However, other battleground agents are actually dual use industrial chemicals. While the<br />
military has weaponized them and some <strong>of</strong> them have seen battlefield use in the past,<br />
they also have significant industrial applications. They are not the types <strong>of</strong> chemicals<br />
that can be solely restricted to military use and military stockpiles. Given their dual use,<br />
they are much more accessible than the military-use only agents.<br />
This module will not be covering the “select agent” chemicals. Sarin and VX are two<br />
potent organophosphorus compounds developed <strong>for</strong> use by the military. They are called<br />
nerve agents due to their ability to produce prominent neuromuscular weakness<br />
compared to the classical organophosphorus agents like parathion, which produces<br />
more muscarinic findings (e.g., salivation, bronchorrhea, miosis). Sulfur mustard is one<br />
example <strong>of</strong> a vesicant (blister <strong>for</strong>ming) agent, also developed <strong>for</strong> military use. The nerve<br />
agents and blister agents do not have any conventional or industrial use. Demilitarization<br />
programs are reducing the stockpiles <strong>of</strong> these agents.<br />
The blood agents include cyanide and cyanogen chloride. These have military use and<br />
also have industrial uses such as in mining and chemical syntheses.<br />
The choking agents include irritant gases such as phosgene and chlorine. These have<br />
proven military use in WWI and still have widespread industrial applications.<br />
These categorization terms, such as choking and blood agents, were developed by the<br />
military and not semantically medical in use. Blood agent, <strong>for</strong> example, is a vague term<br />
that could suggest that the toxin damages the blood. But in military use, it suggests that<br />
the toxin inhibits the oxygen carrying capacity <strong>of</strong> the blood. This too is incorrect, since<br />
cyanide affects oxygen utilization not its delivery.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 7<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
<strong>TICs</strong> and <strong>TIMs</strong><br />
• TIC = Toxic Industrial <strong>Chemical</strong><br />
• TIM = Toxic Industrial Material<br />
• <strong>Chemical</strong> substance that in sufficient available<br />
quantity produces a toxic effect through inhalation,<br />
ingestion, or other route <strong>of</strong> absorption<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
7<br />
<strong>TICs</strong> are toxic industrial chemicals and <strong>TIMs</strong> are toxic industrial materials. These are<br />
terms first introduced by the military to distinguish industrial chemicals <strong>of</strong> concern from<br />
the traditional weaponized battlefield agents such as sarin and mustard gas. <strong>TICs</strong> and<br />
<strong>TIMs</strong> are chemical substances, that delivered properly in sufficient quantity may produce<br />
a toxic effect. This effect may be via the exposure route <strong>of</strong> inhalation, ingestion, dermal<br />
absorption, or, more rarely, parenteral injection. These chemicals must be “delivered<br />
properly” in “sufficient quantity” to be problematic.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 8<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Audience Response<br />
Which <strong>of</strong> the following would best be characterized as<br />
a toxic industrial compound<br />
1. Ammonia<br />
2. Anthrax<br />
3. Sarin<br />
4. Mustard Gas<br />
5. Water<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
8<br />
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Participant Guide<br />
Slide 9<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Importance <strong>of</strong> DOSE<br />
“All substances are poisons: there is none which is not a poison.<br />
The right dose differentiates a poison and a remedy."<br />
Paracelsus (1493 -1541)<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
9<br />
It was the noted toxicologist Paracelsus who made the following observation in the 16 th<br />
century: “All substances are poisons: there is none which is not a poison. The right dose<br />
differentiates a poison and a remedy.”<br />
As you can see on this slide, along the X-axis (dose), as you increase the dose, the<br />
response, along the Y-axis (response) increases. The response could be response to a<br />
therapy (a good thing) or it could be lethality (not a good thing). Hence as you increase<br />
the dose, at some point you get some sort <strong>of</strong> response.<br />
“Dose response” is a tenet <strong>of</strong> toxicology. At sufficiently low doses everything is nontoxic,<br />
even things we think <strong>of</strong> as “really toxic.” As the dose goes up, everything, even water or<br />
oxygen, become toxic. The “toxicity” <strong>of</strong> a compound is in large part related to how much<br />
the dose must rise to get a response.<br />
This graph holds true <strong>for</strong> an individual or <strong>for</strong> a population. If used <strong>for</strong> a population,<br />
response is generally the percent <strong>of</strong> individuals who display the expected response.<br />
This curve shows a “ceiling effect” to the effect. If this were a lethality curve, the point at<br />
which it flattened out at the top would be the LD100, or the lethal dose <strong>for</strong> 100% <strong>of</strong> the<br />
population.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 10<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Sources <strong>of</strong> <strong>TICs</strong> and <strong>TIMs</strong> (1)<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
10<br />
Unlike the battlefield chemical agents which are highly secured and tightly controlled,<br />
<strong>TICs</strong> and <strong>TIMs</strong> are ubiquitous. Two seemingly innocuous sources <strong>of</strong> highly toxic<br />
chemicals are farm and garden supply stores and college laboratories. College<br />
laboratories, particularly those involved in research as opposed to education, contain<br />
many toxic chemicals, <strong>of</strong>ten in large volumes, and are another source <strong>for</strong> obtaining <strong>TICs</strong><br />
and TIMS.<br />
Examples <strong>of</strong> some <strong>of</strong> the agents found in these other sites include:<br />
o Airports use jet fuel, and transport toxic chemicals in the airplanes.<br />
o Farm and garden supply stores have pesticides.<br />
o<br />
o<br />
Toxic waste dumps are obvious sources <strong>of</strong> a variety <strong>of</strong> chemicals deemed to be<br />
hazardous to human health.<br />
Glass plants contain large amounts <strong>of</strong> arsenic and thallium.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 11<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Sources <strong>of</strong> <strong>TICs</strong> and <strong>TIMs</strong> (2)<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
11<br />
Other sources <strong>of</strong> <strong>TICs</strong> and <strong>TIMs</strong> include medical facilities which utilize a large number <strong>of</strong><br />
cancer chemotherapeutic agents which are highly toxic by design and also store and<br />
utilize a variety <strong>of</strong> radio nuclides diagnostically and therapeutically.<br />
A major concern about radiological terrorism involves the use <strong>of</strong> stolen hospital-based<br />
radio nuclides, given their extensive availability. Although the quantity may be small, the<br />
psychological impact <strong>of</strong> their use in a “dirty bomb” scenario is pr<strong>of</strong>ound.<br />
Many <strong>of</strong> these chemical threats involve chemicals that are routinely transported<br />
throughout our country by rail and other bulk transporter systems. If the chemicals <strong>of</strong><br />
concern were limited to fixed facilities, the challenges would be significant enough.<br />
Propane tank leaks lead to asphyxiation, and explosions can cause massive destruction.<br />
But understanding that highly toxic chemicals are moving all across our county through<br />
our towns and villages brings the specter <strong>of</strong> chemical toxic disasters - whether deliberate<br />
or accidental - into everyone’s backyard.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 12<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
<strong>Chemical</strong> <strong>Terrorism</strong><br />
• Definition – the use <strong>of</strong> chemicals to harm or alter the<br />
behavior <strong>of</strong> an adversary<br />
• Utilizes existing stored chemicals – exploiting<br />
weapons <strong>of</strong> opportunity<br />
• Who’s at risk<br />
– Civilians in U.S.<br />
• Wide availability <strong>of</strong> toxic materials throughout U.S.<br />
• Proximity <strong>of</strong> industrial operations to large urban centers<br />
– Military abroad<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
12<br />
Although there is no strict definition <strong>of</strong> “chemical terrorism”, it generally refers to the use<br />
<strong>of</strong> chemicals to harm or alter the behavior <strong>of</strong> an adversary. [CDC] Unlike conventional<br />
military warfare, chemical terrorists utilize readily available chemicals. By utilizing stored<br />
or other readily available chemicals reference to these chemicals as “weapons or<br />
chemicals <strong>of</strong> opportunity” is made more clear. US civilians remain at risk given the easy<br />
availability <strong>of</strong> many industrial and commercial chemicals, and particularly those civilians<br />
living near large urban areas where the terrorism targets are very dense. The military<br />
abroad, while at risk <strong>for</strong> conventional chemical weapons, is also at risk <strong>for</strong> agents <strong>of</strong><br />
opportunity. This was demonstrated by the use <strong>of</strong> chlorine gas released against the<br />
military in Iraq in 2007.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 13<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Goals <strong>of</strong> Toxic <strong>Terrorism</strong><br />
• Health Effects<br />
– Incapacitating vs killing<br />
• Damage / contamination <strong>of</strong> infrastructure<br />
• Psychological effects resulting from actual or<br />
threatened use <strong>of</strong> toxic substances - terrorizing<br />
– Asymmetrical<br />
– Create uncertainty, fear, and panic<br />
– Uncertainties provide tactical and/or psychological<br />
advantages<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
13<br />
Another difference between the battlefield military chemicals and many <strong>of</strong> the industrial<br />
chemicals <strong>of</strong> concern is that the <strong>for</strong>mer are meant to kill while the latter may not always<br />
be fatal except at very high doses. At lower doses, they may incapacitate – physically or<br />
emotionally or financially.<br />
As an example, the intended goal <strong>of</strong> the terrorist use <strong>of</strong> some chemicals, and certainly<br />
the radiologicals, is to damage or contaminate infrastructure. Such contamination by<br />
itself may create havoc and be extraordinarily disruptive.<br />
Even the intended threat <strong>of</strong> chemical exposure may prove terrorizing. Potential exposure<br />
may create uncertainty, fear, and panic. Such uncertainties provide the terrorist with an<br />
asymmetrical advantage, and provide tactical and psychological advantages. Tactical in<br />
this context mean short-term and supportive <strong>of</strong> the ultimate goal.<br />
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Participant Guide<br />
Slide 14<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Audience Response<br />
The goal <strong>of</strong> toxic terrorism is best accomplished by<br />
which <strong>of</strong> the following scenarios or releases<br />
1. Immediately lethal agent release in restaurant<br />
2. Disruption <strong>of</strong> a transportation corridor<br />
3. Creating fear leading to incapacity<br />
4. Occult insertion <strong>of</strong> a carcinogen<br />
5. Targeting a single factory component<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
14<br />
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Training Support Package<br />
Participant Guide<br />
Slide 15<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Scenarios<br />
• Large-scale outdoor release <strong>of</strong> toxic gas or fumes,<br />
and/or an explosion, from an attack on a mobile or<br />
fixed tank or vessel<br />
• Targeted release <strong>of</strong> a toxic gas into a confined<br />
space (e.g. a subway, theater, or building) or against<br />
specific individuals or groups<br />
• Acute or delayed poisoning by contamination <strong>of</strong><br />
food, water, or a highly trafficked venue<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
15<br />
There are a number <strong>of</strong> possible or probable scenarios that involve chemicals <strong>of</strong><br />
opportunity. Three such scenarios include: a large-scale outdoor chemical release from<br />
an attack on a mobile or fixed facility, a targeted release <strong>of</strong> a toxic gas into a small<br />
enclosed area or confined space, and acute or delayed poisoning by contamination <strong>of</strong><br />
food, water, or a highly trafficked venue.<br />
In the first scenario, a large scale outdoor release will potential affect the greatest<br />
number <strong>of</strong> people, depending on the nature <strong>of</strong> the agent (e.g., volatility, density) and the<br />
prevailing conditions. Even in an area without fixed facilities, vulnerability still exists due<br />
to the transportation <strong>of</strong> hazardous materials in large quantities (e.g., chlorine tank car, 90<br />
tons).<br />
In the second scenario, release in a closed space allows a smaller dose to be utilized to<br />
generate a similar clinical effect due to the lack <strong>of</strong> dilution by ambient air or wind.<br />
Recognize that the words ‘confined space’ here is not meant to be synonymous with the<br />
OSHA (Occupational Safety and Health Administration) definition, in which a confined<br />
space is one with limited egress. We use it to refer to a small space or one contained by<br />
walls and ceiling.<br />
In the third scenario, administration <strong>of</strong> the agent by contamination <strong>of</strong> a point source<br />
could still affect a large number <strong>of</strong> people, particularly if a delayed onset agent is utilized.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 16<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Why Use Industrial <strong>Chemical</strong>s<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
16<br />
This is a photograph <strong>of</strong> a large industrial plant that could be the target <strong>of</strong> a terrorist<br />
event. It would be considered a fixed facility.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 17<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Limitations with Purpose:<br />
Designed WMD<br />
Aum Shinrikyo – Matsumoto<br />
1994, Tokyo 1995 ( Sarin)<br />
• Spent ~$30 million on chemical<br />
weapons research<br />
• Employed many scientists<br />
• Killed only 19<br />
• Problems with<br />
– Production<br />
– Effective Delivery System<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
17<br />
One <strong>of</strong> the worst “chemical terrorism" incidents on civilians involved the release <strong>of</strong> the<br />
deadly nerve agent sarin in the Tokyo subway in 1995. This terrorist group – <strong>of</strong>ten<br />
referred to as a “sect” prior to this incident – was known as Aum Shinrikyo and was led<br />
by what some considered a god-like guru – Shoko Asahara. This group had a number<br />
<strong>of</strong> highly educated scientists as its members, and they apparently spent ~$30 million or<br />
more on chemical weapons research.<br />
Problems in producing truly weapon-grade sarin (estimates were that the product was<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong><br />
Training Support Package<br />
Participant Guide<br />
Slide 18<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
More Effective: Bhopal (1984)<br />
• Methyl isocyanate<br />
• > 2,500 deaths<br />
• 60,000 injuries<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
18<br />
Contrast the Sarin Tokyo subway release with what occurred in Bhopal India 11 years<br />
earlier. This accidental release <strong>of</strong> methyl isocyanate at a chemical production facility<br />
involved in the production <strong>of</strong> the carbamate pesticide, Sevin®, resulted in over 2,500<br />
deaths and 60,000 injuries. The Bhopal incident will be discussed in further detail in the<br />
module on toxic gases.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 19<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Should We Worry<br />
• ~ 850,000 U.S. businesses use, produce, or store<br />
<strong>TICs</strong><br />
• EPA report – 123 chemical plants across US have<br />
enough toxic chemicals to kill/injure 1 million people<br />
in terrorist attack<br />
• 750 other plants have enough chemicals to kill/injure<br />
at least 100,000 people in an attack<br />
• U.S. army study - terrorist attack on chemical plant<br />
in densely populated area could result in 2.4 million<br />
fatalities or injuries<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
19<br />
Should we worry<br />
Industrial facilities are omnipresent. According to one report, 850,000 U.S. businesses<br />
use, produce, or store toxic industrial chemicals. The EPA has suggested that 123<br />
chemical plants in 24 states across US have enough toxic chemicals to kill/injure 1<br />
million people in terrorist attack. [NYT] In addition, another 750 plants have enough<br />
chemicals to kill/injure at least 100,000 people. These are worst case estimates based<br />
on the EPA’s Risk Management Program.<br />
There is obviously no way to know conclusively the number who will die or be injured in<br />
the release <strong>of</strong> a chemical into the environment, and all <strong>of</strong> the models created to predict<br />
this suffer their own individual limitations. For example, wind dispersion and rain may<br />
result in a different outcome (with more or fewer injuries than predicted). Nonetheless,<br />
the numbers are numbing.<br />
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Participant Guide<br />
Slide 20<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
20<br />
This is a Toxic Release Inventory map prepared by ATSDR shows the location <strong>of</strong> high<br />
volume chemical production facilities in the U.S. that produce greater than 100,000<br />
pounds <strong>of</strong> chemicals from the year 2000.<br />
Each blue dot represents a facility containing more than 100,000 pounds, while the more<br />
darkly shaded areas represent the scale <strong>of</strong> danger based on density <strong>of</strong> available<br />
chemical(s).<br />
As you can see, these plants are in every state and virtually every locality. In some<br />
parts <strong>of</strong> the country - such as the heavily trafficked and populated northeast corridor and<br />
the Gulf coast - these chemical production plants are in great abundance, increasing the<br />
threat.<br />
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Participant Guide<br />
Slide 21<br />
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Participant Guide<br />
Slide 22<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
US Legislative Response to Major<br />
<strong>Chemical</strong> Accidents<br />
• Emergency Planning and Community Right -to-Know<br />
Act (EPCRA) 1986<br />
• Clean Air Act Amendments <strong>of</strong> 1990<br />
– Occupational Safety & Health Administration ’s (OSHA)<br />
Process Safety Management (PSM)<br />
– Environmental Protection Agency ’s (EPA) Risk<br />
Management Program (RMP) 1996<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
22<br />
There have been legislative responses to major chemical incidents including the EPCRA<br />
in response to Bhopal.<br />
The tragedy at Bhopal in December 1984, followed by a subsequent release <strong>of</strong> aldicarb<br />
oxime from a facility in Institute, West Virginia, resulted in great public concern in the<br />
United States about the potential danger posed by major chemical accidents. This public<br />
concern triggered the passage <strong>of</strong> three different legislative programs.<br />
The first law specifically intended to address the problem <strong>of</strong> chemical accidents in the<br />
US was the Emergency Planning and Community Right-to-Know Act <strong>of</strong> 1986 (EPCRA;<br />
Public Law 99-499). The other two legislative programs addressing chemical releases<br />
were enacted under sections 304 and 112(r), respectively, <strong>of</strong> the Clean Air Act<br />
Amendments <strong>of</strong> 1990 (Public Law 101-549). The first <strong>of</strong> these was the Occupational<br />
Safety and Health Administration’s (OSHA) Process Safety Management (PSM)<br />
standard (29CFR Part 1910), which required facilities having specified hazardous<br />
chemicals to implement accident prevention measures designed to protect workers.<br />
The most recent program, arising from section 112(r)(7) <strong>of</strong> the Clean Air Act<br />
Amendments, was the U.S. Environmental Protection Agency’s (EPA’s) Risk<br />
Management Program (40 CFR Part 68), issued on June 20, 1996.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 23<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Emergency Planning & Community<br />
Right-to-Know Act (EPCRA)<br />
• Required chemical facilities to provide<br />
– In<strong>for</strong>mation necessary <strong>for</strong> emergency planning to Local Emergency<br />
Planning Committees ( LEPCs)<br />
– annual hazardous chemical inventories to State Emergency Respons e<br />
Commissions (SERCs), LEPCs and local fire departments.<br />
• Required SERCs & LERCs to prepare emergency response<br />
plans <strong>for</strong> chemical accidents.<br />
• Established Toxics Release Inventory (TRI), which requires<br />
facilities to annually report quantities <strong>of</strong> their emissions <strong>of</strong><br />
toxic chemicals to TRI database.<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
23<br />
EPCRA requires states to create State Emergency Response Commissions (SERCs),<br />
and communities to <strong>for</strong>m Local Emergency Planning Committees (LEPCs) to prepare<br />
local emergency response plans <strong>for</strong> chemical accidents.<br />
It also requires chemical facilities to provide LEPCs with in<strong>for</strong>mation necessary <strong>for</strong><br />
emergency planning, and to submit to SERCs, LEPCs and local fire departments annual<br />
inventory reports (Tier 2 reports) and in<strong>for</strong>mation about hazardous chemicals.<br />
The statute also established the Toxics Release Inventory (TRI), which requires certain<br />
facilities to annually report the quantities <strong>of</strong> their emissions <strong>of</strong> toxic chemicals. The<br />
chemical inventory data are available to the public on a limited basis and EPA maintains<br />
a national database containing TRI reports.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 24<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
EPA: Risk Management Program<br />
• Aim: Prevent/minimize consequences <strong>of</strong> accidental<br />
chemical releases from fixed facilities.<br />
• Facilities that manufacture, process, use, store, or<br />
otherwise handle any <strong>of</strong> 140* listed substances at or<br />
above specified threshold quantities (range from<br />
500–20,000 pounds) must submit a Risk<br />
Management Plan (RMP).<br />
* The number <strong>of</strong> chemicals has been increased to 650<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
24<br />
Going beyond just reporting type and amount <strong>of</strong> chemicals at a site, the risk<br />
management plan (RMP) sought to have those facilities/companies provide a plan to<br />
respond to and mitigate an ACCIDENTAL release.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 25<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Risk Management Programs<br />
(61 CFR 31667, 06/20/96)<br />
• Hazard vulnerability assessment<br />
• Accident prevention program<br />
• Emergency response program<br />
• Specified facility in<strong>for</strong>mation<br />
• Make info available to: EPA, state & local<br />
governments, FD & public<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
25<br />
An accidental release prevention program is designed to detect, prevent, and minimize<br />
accidental releases. An emergency response program is designed to protect human<br />
health and the environment.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 26<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Worst-Case Scenario:<br />
Likelihood <strong>of</strong> Occurrence<br />
• WCS are considered unlikely because:<br />
– assume a very large release occurring during worst -case<br />
atmospheric conditions<br />
– does not include active release mitigation such as water<br />
deluge systems and automatic shut<strong>of</strong>f valves<br />
• passive mitigation ef<strong>for</strong>ts included, such as containment dikes a<br />
building enclosures<br />
• However, with terrorist attack, more than one<br />
process likely to be affected<br />
nd<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
26<br />
The EPA’s regulations require that Risk Management Plan (RMPs) be developed by all<br />
companies with large quantities <strong>of</strong> toxic chemicals on site. They should specify a worst<br />
case scenario (WCS). The modeling features <strong>of</strong> WCS include calm wind conditions<br />
(allowing uni<strong>for</strong>m spread <strong>of</strong> agent in all directions from a release), and release <strong>of</strong> all the<br />
substance involved in a single process or storage site without including any active<br />
mitigation steps (attempts to control spread).<br />
These conditions are all unlikely to occur, but as we will discuss later, the models are<br />
designed <strong>for</strong> accidental releases. A terrorist release may involve multiple processes or<br />
targets.<br />
The use <strong>of</strong> a worst-case scenario is standard practice in modeling hazardous material<br />
release responses and per<strong>for</strong>ming risk assessment. It allows an understanding <strong>of</strong> the<br />
potential <strong>for</strong> an event, with a realistic endpoint <strong>for</strong> response preparedness. In the<br />
situation <strong>of</strong> a real event, the response can be scaled as needed.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 27<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
AEGL Plumes<br />
Acute Exposure Guideline Levels (AEGL): www.epa.gov/oppt/aegl /<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
27<br />
One <strong>of</strong> the criteria used to assist in the determination <strong>of</strong> the response criteria is the<br />
plume model shown here. This takes into account ambient wind condition from a point<br />
release. EPA has developed a number <strong>of</strong> Acute Emergency Guideline Levels (AEGL) <strong>for</strong><br />
various chemical compounds and duration <strong>of</strong> exposure. AEGLs serve as a planning tool<br />
<strong>for</strong> response to chemical releases from chemical facilities. Note that AEGL-3 is more<br />
severe than AEGL-1.<br />
AEGL-1 is the airborne concentration (as parts per million, ppm) <strong>of</strong> a substance above<br />
which it is predicted that the general population, including susceptible individuals, could<br />
experience notable discom<strong>for</strong>t, irritation, or certain asymptomatic nonsensory effects.<br />
However, the effects are not disabling and are transient and reversible upon cessation <strong>of</strong><br />
exposure.<br />
AEGL-2 is the airborne concentration (ppm) <strong>of</strong> a substance above which it is predicted<br />
that the general population, including susceptible individuals, could experience<br />
irreversible or other serious, long-lasting adverse health effects or an impaired ability to<br />
escape.<br />
AEGL-3 is the airborne concentration (ppm) <strong>of</strong> a substance above which it is predicted<br />
that the general population, including susceptible individuals, could experience lifethreatening<br />
health effects or death<br />
December 2008 Version 2.0 Page 32
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Training Support Package<br />
Participant Guide<br />
Slide 28<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Reductions in Hazards &<br />
Vulnerabilities<br />
Safe Hometown Guide<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
28<br />
An ultimate goal <strong>of</strong> emergency planning, including legislative ef<strong>for</strong>ts, would be to reduce<br />
the risk to surrounding communities by encouraging “hardening” <strong>of</strong> facilities and<br />
decreasing the available “dose” <strong>of</strong> toxic compounds (Hardening implies increases the<br />
safety and security <strong>of</strong> a facility and the chemicals it stores).<br />
In this example, from “Safe Hometown Guide”, reducing the storage capacity, enclosing<br />
vulnerable storage vessels, or even relocating civilian populations can help to reduce the<br />
effect <strong>of</strong> an unexpected chemical release.<br />
Many <strong>of</strong> these are common sense maneuvers, but are avoided due to costs and the<br />
belief that such a release is unlikely. Had the shantytowns around the Union Carbide<br />
plant in Bhopal been relocated, <strong>for</strong> example, the devastation would have likely been<br />
substantially reduced.<br />
December 2008 Version 2.0 Page 33
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Training Support Package<br />
Participant Guide<br />
Slide 29<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
http://www.ncseonline.org/nle/crsreports/03Feb/RL31530.pdf<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
29<br />
Since 2001, chemical plant security has been subject to heightened scrutiny. A number<br />
<strong>of</strong> attempts have been made to address these issues and increase plant security. Given<br />
the large number <strong>of</strong> facilities, and the costs <strong>of</strong> increasing regulations, securing these<br />
facilities and decreasing the threat has been challenging...and has not yet been<br />
accomplished.<br />
December 2008 Version 2.0 Page 34
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Training Support Package<br />
Participant Guide<br />
Slide 30<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Not Just Fixed Facilities<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
30<br />
A fixed facility is an industrial building, yard, or storage tank.<br />
<strong>Chemical</strong> incidents occur regularly. The vast majority <strong>of</strong> these have been accidental.<br />
Few have been from industrial sabotage, and successful chemical releases by terrorists<br />
remain very few.<br />
This slide shows that the number <strong>of</strong> incidents is quite high, upwards <strong>of</strong> 60,000 during the<br />
period studied (1987- 1996). Of concern, about ½ <strong>of</strong> these incidents involved<br />
transportation incidents and did not occur at fixed facilities.<br />
December 2008 Version 2.0 Page 35
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Training Support Package<br />
Participant Guide<br />
Slide 31<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Rail links transporting chemical tanker<br />
cars travel through or near major cities<br />
<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
31<br />
This is a photo taken <strong>of</strong> a tanker car containing chlorine rolling through the nation’s<br />
capital in 2004. While attempts to change such vulnerable transportation routes have<br />
begun, as well as attempts to shift production to less toxic chlorine alternatives such as<br />
hypochlorites, a tanker spill by direct hostile action or otherwise remains a major<br />
concern. Chlorine tankers no longer travel on this rail line in D.C. However, other<br />
jurisdictions have not enacted similar legislation.<br />
December 2008 Version 2.0 Page 36
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Training Support Package<br />
Participant Guide<br />
Slide 32<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Railway Explosion<br />
• Power cables touch rail cars loaded with ammonium nitrate fertil izer<br />
• Buildings <strong>for</strong> several hundred meters were totally flattened<br />
• 129 public buildings destroyed or damaged including hospital, fo od processing<br />
plant, and college.<br />
• Rescue workers described utter devastation with damage extending <strong>for</strong> 4 km<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
32<br />
Explosive chemical are <strong>of</strong> great concern. This event in North Korea in 2004 provides a<br />
graphic picture. In this case, power cables ignited a nitrogen-based (ammonium nitrate)<br />
fertilizer in the rail cars. The <strong>for</strong>ce <strong>of</strong> the explosion destroyed building <strong>for</strong> several<br />
kilometers. The death toll in this event was 154.<br />
In the middle <strong>of</strong> the right hand third <strong>of</strong> the pre-explosion image is a school, which was<br />
just letting out at the time <strong>of</strong> the explosion. Of the 154 deaths there were 76 children.<br />
December 2008 Version 2.0 Page 37
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Training Support Package<br />
Participant Guide<br />
Slide 33<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Area Be<strong>for</strong>e Explosion<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
33<br />
This slide is an aerial view <strong>of</strong> the explosion site be<strong>for</strong>e the explosion.<br />
December 2008 Version 2.0 Page 38
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Training Support Package<br />
Participant Guide<br />
Slide 34<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Area After Explosion<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
34<br />
This slide is an aerial view <strong>of</strong> the identical site after the explosion.<br />
December 2008 Version 2.0 Page 39
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Training Support Package<br />
Participant Guide<br />
Slide 35<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
North Korean Railway Incident<br />
• Death toll: 154, including 76 schoolchildren<br />
– A primary school had just ended when the explosion<br />
happened<br />
– Some children were on their way home, while others were<br />
trapped in the building<br />
– Most people were injured when they were trapped or<br />
thrown from buildings.<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
35<br />
The death toll in this even was 154, including 76 children. School had just let out, and<br />
some <strong>of</strong> the children were already outside, and some <strong>of</strong> the children were trapped in the<br />
school building.<br />
December 2008 Version 2.0 Page 40
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Training Support Package<br />
Participant Guide<br />
Slide 36<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
School After Explosion<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
36<br />
In this aerial view you see the school in approximately the middle <strong>of</strong> the image.<br />
December 2008 Version 2.0 Page 41
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Training Support Package<br />
Participant Guide<br />
Slide 37<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Prioritizing <strong>Chemical</strong>s <strong>of</strong> Concern: NATO<br />
ITF-25 Definition <strong>of</strong> <strong>TICs</strong> – 1996<br />
• High Production Volume <strong>Chemical</strong>s ( HPVs)<br />
– produced in quantities > 30 tons (60,000 pounds) in a single fac ility<br />
• High Toxicity<br />
– LCt50 by inhalation < 100,000 mg/min/M3<br />
• Appreciable vapor pressure at 20 °C<br />
– Thus, airborne hazards only<br />
• Hazard Index = {(toxicity)x(state)x(distribution)x(producers)}<br />
– maximum value <strong>of</strong> 625<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
37<br />
How do we begin to prioritize among the hundreds <strong>of</strong> thousands <strong>of</strong> chemicals or<br />
chemical classes to determine which ones should receive our immediate attention and<br />
action<br />
One <strong>of</strong> the first attempts to come up with a prioritization list was undertaken by NATO<br />
(North Atlantic Treaty Organization) in 1996. Known as the NATO ITF-25 (International<br />
Task Force), this group per<strong>for</strong>med a Hazard Vulnerability Assessment prioritizing<br />
chemicals based on their production volume <strong>of</strong> >30 tons per year in a single facility and<br />
their inherent toxicity based on an LCt50 <strong>of</strong> < 100,000. This served as the original<br />
definition <strong>of</strong> a TIC.<br />
Those that met these criteria were then further investigated based on their Hazard Index<br />
(HI), which itself was based on four factors. These factors were global extent <strong>of</strong><br />
distribution, number <strong>of</strong> producers, inherent toxicity, and physical state (see Instructor<br />
Note <strong>for</strong> details)<br />
Toxicity is determined here as the concentration that kills 50% <strong>of</strong> animals (and<br />
extrapolated to humans). If the LCt50(LD50 in mg/m 3 x time in min) is less than 100,000<br />
it is considered in this <strong>for</strong>mula to be highly toxic. The lower the LCt50, the more toxic the<br />
agent, since a lower dose is lethal.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 38<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
NATO ITF-25: High Hazard <strong>TICs</strong><br />
• Tissue Irritants<br />
– ammonia<br />
– boron trichloride<br />
– chlorine<br />
– fluorine<br />
– <strong>for</strong>maldehyde<br />
– hydrogen bromide<br />
– hydrogen chloride<br />
– phosgene<br />
– phosphorus trichloride<br />
– nitric acid<br />
– sulfur dioxide<br />
– sulfuric acid<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
• Systemic Poisons<br />
– arsine<br />
– boron trifluoride<br />
– carbon disulfide<br />
– cyanide<br />
– diborane<br />
– ethylene oxide<br />
– hydrogen fluoride<br />
– hydrogen sulfide<br />
– tungsten hexafluoride<br />
38<br />
The NATO group came up with a list <strong>of</strong> 25 chemicals which they believed posed the<br />
highest hazard. The exact ranking <strong>of</strong> the chemicals are not important (and thus in<br />
alphabetical order). Note that many <strong>of</strong> these compounds are ones with which emergency<br />
responders have some familiarity (such as ammonia or chlorine). These <strong>TICs</strong> can be<br />
somewhat artificially divided into two groups: tissue irritants and systemic poisons.<br />
The list <strong>of</strong> tissue irritants is on the left. All produce upper and lower airway (throat and<br />
lung) irritation. There are no antidotes <strong>for</strong> this type <strong>of</strong> poisoning, and meticulous<br />
supportive care to prevent further lung injury is critical to survival. The evaluation,<br />
management and treatment is, <strong>for</strong> the most part, similar regardless <strong>of</strong> the specific irritant<br />
inhalant.<br />
We are able to respond initially to large scale incidents based on the symptoms<br />
displayed by people who have been exposed without necessarily knowing exactly which<br />
chemical is involved – knowing and finding out as soon as possible is still important!<br />
The systemic poisons are on the right. They are a more heterogeneous group <strong>of</strong><br />
chemicals. Some like cyanide, are specific cellular asphyxiants, and this has a specific<br />
antidote about which you will hear more about later today in the Cyanide and Fumigant<br />
module. Another systemic poison <strong>of</strong> interest to toxicologists is hydrogen fluoride.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 39<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
USACHPPM – 2002 Reevaluation<br />
• Also evaluated - corrosiveness, reactivity,<br />
flammability, less volatile chemicals<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
39<br />
In 2002, the USACHPPM (U.S. Army Center <strong>for</strong> Health Promotion and Preventive<br />
Medicine) group undertook a reassessment <strong>of</strong> the earlier NATO prioritization. Other lists<br />
(that appear in this complex Venn diagram) were also studied, and the chemicals <strong>of</strong><br />
concern were expanded to include less volatile chemicals as well as chemicals that were<br />
inherently reactive and flammable.<br />
It is easy to become overwhelmed by the thousands <strong>of</strong> chemical that exist. The process<br />
<strong>of</strong> prioritization and the prioritization lists that were produced help us as first responders<br />
to understand those that are most important and concerning.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 40<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Risk Assessment<br />
CHEMICAL<br />
HAZARD<br />
PROBABILITY<br />
RISK<br />
Hydrogen Cyanide<br />
Catastrophic<br />
Occasional<br />
High<br />
Sulfuric Acid<br />
Catastrophic<br />
Likely<br />
Extreme<br />
Acetylene<br />
Catastrophic<br />
Frequent<br />
Extreme<br />
Nitromethane<br />
Catastrophic<br />
Seldom<br />
High<br />
Phosgene<br />
Critical<br />
Occasional<br />
High<br />
Methanol<br />
Critical<br />
Occasional<br />
High<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
40<br />
This table from the 2002 USACHPPM exercise, provides a sampling <strong>of</strong> chemicals that<br />
underwent this assessment and which ultimately received a risk ranking <strong>of</strong> high or<br />
extreme. Several <strong>of</strong> these such as hydrogen cyanide and phosgene will be discussed in<br />
much more detail later in this course. They color coded and used appropriate words to<br />
describe the hazard, discussed earlier, along with the probability <strong>of</strong> use (based on<br />
historical use, availability, etc) and from this calculated a “risk” <strong>of</strong> the use <strong>of</strong> an agent as<br />
a weapon.<br />
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Participant Guide<br />
Slide 41<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Unusual but Easily Available <strong>Agents</strong><br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
41<br />
Despite these lists, not all chemicals <strong>of</strong> concern <strong>for</strong> terroristic use are identified by these<br />
lists. There are many chemicals out there. Some <strong>of</strong> these are very unfamiliar to those <strong>of</strong><br />
us not working directly with them or related industries. Some are in small volume<br />
production, and others just have not been considered. One example is osmium tetroxide,<br />
which is a very irritating chemical - corrosive to the eyes and lungs – used in NMR<br />
spectroscopy, a specialized analytical imaging technique. This was not on anyone’s<br />
“list” until a plot to use it was exposed.<br />
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Participant Guide<br />
Slide 42<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
42<br />
Accessibility is a key concept when it comes to how vulnerable we may be with regard to<br />
chemical X and chemical Y. Military warfare chemicals such as sarin or tabun are tightly<br />
secured by the military. While we may be concerned that a rogue State or large and<br />
well-financed terrorist enterprise may attempt to produce these extremely toxic warfare<br />
chemicals, their inaccessibility to most people makes their likelihood <strong>of</strong> use (particularly<br />
as an Agent <strong>of</strong> <strong>Opportunity</strong>) somewhat more remote.<br />
However, Osmium tetroxide, as seen in this example - and probably also discovered by<br />
the British terrorists - is sold by chemical supplies companies (sold at the time <strong>of</strong> the this<br />
episode).<br />
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Participant Guide<br />
Slide 43<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Osmium Tetroxide<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
43<br />
And, as you can see, OT is fairly inexpensive in the quantities use <strong>for</strong> NMR<br />
spectroscopy. A single gram could be purchased <strong>for</strong> $35, and is further discounted if<br />
you buy in bulk.<br />
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Participant Guide<br />
Slide 44<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Audience Response<br />
Which <strong>of</strong> the following is not a component <strong>of</strong> a hazard<br />
score or ranking<br />
1. Toxicity <strong>of</strong> a chemical<br />
2. Amount <strong>of</strong> a chemical on site<br />
3. Volatility <strong>of</strong> chemical<br />
4. Wind direction at time <strong>of</strong> release<br />
5. History <strong>of</strong> use in prior terrorist event<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
44<br />
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Participant Guide<br />
Slide 45<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
<strong>Chemical</strong> <strong>Agents</strong> Employed by Terrorists<br />
• Corrosives - Acid / alkalis<br />
• Metals<br />
• Cyanide<br />
• Rodenticides<br />
• Pesticides<br />
• Poison gas<br />
Monterey Institute Database, 2002<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
45<br />
It is important to study history. In the ongoing database <strong>of</strong> in<strong>for</strong>mation maintained by the<br />
Monterey Institute in Cali<strong>for</strong>nia, the agents that have actually been used were classified<br />
into several general categories. Some <strong>of</strong> the agents that have actually been employed<br />
including corrosives, metals, cyanide, pesticides, and poison gas. These chemicals will<br />
be discussed in much greater detail later throughout the day.<br />
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Participant Guide<br />
Slide 46<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
“Terrorists can make the 'unlikely' happen. ”<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
46<br />
The premise <strong>of</strong> today's discussion is that we need to prepare <strong>for</strong> the unlikely and the<br />
unknown. We need to think outside the box. Today we take crashing planes into<br />
buildings as a threat that we need to plan against. Prior to 9-11, the plan <strong>for</strong> responding<br />
to hijacked airplanes did not generally focus on this outcome.<br />
Similarly, there have been many anthrax hoaxes delivered through the mail since the<br />
mid 1990s. The likelihood <strong>of</strong> a true anthrax attack via the mail was thought to be<br />
remote, given the premise that “weaponized” anthrax would not be efficiently<br />
disseminated by mail transport. The events <strong>of</strong> 2001 and 2002 demonstrated those<br />
beliefs to be wrong.<br />
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Participant Guide<br />
Slide 47<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methods Used by Terrorists <strong>for</strong><br />
Delivery <strong>of</strong> <strong>Chemical</strong> (N=126)<br />
• Casual/direct contact 33 (30%)<br />
• Aerosol/spray 21 (19%)<br />
• Food/drink 13 (12%)<br />
• Unknown 12 (11%)<br />
• Product tampering 10 (9%)<br />
• Explosive 6 (5%)<br />
• Water supply 5 (4%)<br />
• Jug/jar/canister 1 (1%)<br />
• Mail/letter 4 (3%)<br />
• Reaction device 3 (2%)<br />
• Injection/projectile 1 (1%)<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
Monterey Institute Database, 2000<br />
47<br />
Further data can be obtained from the Monterey Institute Database in 2000. It provides<br />
in<strong>for</strong>mation on methods used by terrorists to inflict harm using chemical agents. As you<br />
can see a variety <strong>of</strong> delivery methods have been employed including direct contact,<br />
aerosols, product tampering, and injection devices.<br />
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Participant Guide<br />
Slide 48<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
<strong>Terrorism</strong> Preparedness<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
48<br />
At the same time, our response to a chemical terrorist event is based on what we do<br />
every day in responding to individual illness and injury and HazMat events. This course<br />
will help by providing a framework to prepare <strong>for</strong> and respond to the “extra” threat.<br />
The difference between an “everyday” chemical event and a terrorist event is<br />
represented by the NBC Delta (NBC means nuclear, biological, chemical and generally<br />
means “all hazards”, although others use CBRNE to encompass explosives and to<br />
differentiate). In other words, each person in the lower half <strong>of</strong> the pyramid has a role in<br />
day to day response and this is learned during their existing preparedness training.<br />
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Participant Guide<br />
Slide 49<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Unusual <strong>Agents</strong> <strong>of</strong> Historic Importance<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
49<br />
This course will address a number <strong>of</strong> toxins <strong>of</strong> historic importance. As we prepare <strong>for</strong> the<br />
future and ponder the new and unthinkable, we also need to heed the lessons <strong>of</strong> the<br />
past.<br />
Ricin, actually militarized in the past, had the notoriety <strong>of</strong> being extremely potent and<br />
toxic at a very small dose. Its actual use had been limited to cold war spy intrigues and<br />
U.S. militia groups planning. Hence the surprise <strong>of</strong> finding ricin in the Senate Office<br />
building in 2004. Its notoriety was clearly also known to terrorists and would-be terrorists.<br />
If nothing else, the discovery <strong>of</strong> ricin spread fear and uncertainty.<br />
Ricin is what is left over in the water-soluble “cake” after castor beans have the castor oil<br />
expressed by a cold press process.<br />
Ricin was found Feb 3, 2004 on an automatic mail sorter in a mailroom in the Dirksen<br />
Senate Office Building. This closed several Senate <strong>of</strong>fices <strong>for</strong> a few weeks <strong>for</strong><br />
decontamination.<br />
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Participant Guide<br />
Slide 50<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
50<br />
In 2004, a recipe <strong>for</strong> ricin was found in a London apartment occupied by would-be<br />
terrorists. In this case the ricin had not been used, and no one had become ill, but its<br />
discovery gave further credence to terrorists interest in this deadly substance.<br />
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Participant Guide<br />
Slide 51<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Unusual <strong>Agents</strong>: Characteristic Toxidromes<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
51<br />
There are other agents that have been used that are considered highly unusual chemical<br />
poisons, but their clinical effects are largely unmistakable. We will cover this poison – a<br />
chlorinated hydrocarbon – and its effects on Victor Yushenko, Ukrainian prime minister,<br />
in more detail later in the day.<br />
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Slide 52<br />
One such incident occurred in 1989 when it was alleged that Chilean grapes imported to<br />
the U.S. were deliberately contaminated with cyanide. In fact, an initial laboratory<br />
analysis one <strong>of</strong> these grapes we positive <strong>for</strong> a cyanide. This lab result turned out to be a<br />
false positive, and in fact, there was no cyanide contamination. In the meantime, the<br />
Chilean grape crop destined <strong>for</strong> import to the U.S. had to be destroyed at the cost <strong>of</strong> a<br />
loss <strong>of</strong> $100s <strong>of</strong> millions.<br />
No one died, no one was medically harmed, and in fact no one was contaminated, but<br />
the impact was still pr<strong>of</strong>ound.<br />
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Participant Guide<br />
Slide 53<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Challenges <strong>of</strong> <strong>Chemical</strong> Agent<br />
Identification<br />
• Symptoms similar to common disease (gastroenteritis)<br />
• Immediate symptoms might be mild or nonexistent<br />
• Staggered reports over long periods / different locations<br />
• Mixed clinical presentations<br />
• Health care providers may be less familiar with certain<br />
chemical induced presentations<br />
MMWR 10/3/03<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
53<br />
Given large variety <strong>of</strong> potential agents and <strong>of</strong>ten non-specific initial presentations, we<br />
need to look <strong>for</strong> additional clues to suspect the use <strong>of</strong> <strong>TICs</strong>/<strong>TIMs</strong>.<br />
Some <strong>of</strong> the clinical pearls appear on this slide. While some chemicals cause a typical<br />
toxidrome, more <strong>of</strong>ten the clinical presentation may not be diagnostic <strong>of</strong> any specific<br />
chemical agent. Often the symptoms are gastrointestinal in nature. At times the<br />
immediate symptoms might be mild or non-existent. Given the delay in some <strong>of</strong> these<br />
cases, we have devoted an entire lecture later in the day to these delayed syndromes.<br />
Many health care providers may be less familiar with chemical induced presentations <strong>of</strong><br />
patients since these cases are relatively uncommon. Medical toxicologists strive to stay<br />
current and maintain the most knowledge about these clinical findings because this is<br />
truly our area <strong>of</strong> specialization. Other physicians may rarely if ever encountered some <strong>of</strong><br />
these problems.<br />
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Participant Guide<br />
Slide 54<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clues to <strong>Chemical</strong> Exposure<br />
• Unusual number seeking care <strong>for</strong> chemical -related<br />
illness<br />
• Unexplained deaths among young, healthy people,<br />
plants, animals<br />
• Clusters <strong>of</strong> illness with common source (e.g. water)<br />
– Surveillance methods including PCC, pharmacy sales<br />
• Presence <strong>of</strong> a clinical pattern or toxidrome<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
54<br />
There are some key clues that may lead one to suspect a possible chemical exposure.<br />
These include patterns where an unusually large number <strong>of</strong> patients seeking care <strong>for</strong><br />
possible chemically related illnesses, unexplained deaths among people, animals or<br />
plants, and or the presence <strong>of</strong> a particular clinical pattern or toxidrome. Some <strong>of</strong> our<br />
surveillance ef<strong>for</strong>ts are directed at early identification <strong>of</strong> these clues. These utilize<br />
multiple resources including poison control centers (PCC) and pharmacy sales numbers<br />
<strong>of</strong> items like nonprescription cold medications.<br />
A toxidrome is a “toxicologic syndrome” which is a collection <strong>of</strong> clinical findings that<br />
suggest as specific etiology and treatment. An example <strong>for</strong> this lecture series would be<br />
the opioid toxidrome, discussed in the Neurotoxic syndromes talk. In this syndrome the<br />
finding <strong>of</strong> depressed mental status, respiratory depression, and miosis (small pupils)<br />
suggests the diagnosis and the therapy (ventilatory support and naloxone).<br />
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Participant Guide<br />
Slide 55<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Selected Toxidromes and Potential<br />
<strong>Chemical</strong> Etiologies<br />
Category<br />
Severe gastroenteritis<br />
Cholinergic crisis<br />
Cellular hypoxia<br />
Peripheral neuropathy<br />
Mouth pain / ulcerations<br />
MMWR 10/3/03<br />
Clinical Syndrome<br />
Abdominal pain, emesis<br />
pr<strong>of</strong>use diarrhea, shock<br />
SLUDGE symptoms,<br />
Fasciculations, weakness<br />
N/V, headache, AMS, shock,<br />
seizures, dec pH<br />
Muscle weakness, sensory<br />
loss<br />
Lip / mouth / pharyngeal<br />
ulcerations; burning pain<br />
Potential <strong>Chemical</strong><br />
Etiology<br />
Arsenic, Ricin, Colchicine<br />
OP insecticides, nicotine<br />
CN, SMFA, CO, Azide<br />
Hg, As, Thallium, Lead,<br />
Paraquat / diquat; caustics,<br />
Hg<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
55<br />
Some chemicals cause a characteristic clinical syndrome. These syndromes (or<br />
toxidromes) have symptoms/signs that are typical <strong>for</strong> that particular type <strong>of</strong> chemical<br />
exposure. Some <strong>of</strong> these toxidromes include severe gastroenteritis, cholinergic crisis,<br />
cellular hypoxia, neuropathy and mouth ulcerations. As you can see, a number <strong>of</strong><br />
chemicals can cause each toxidrome with the syndrome depicted on the slide. It is also<br />
important to realize that these are the textbook descriptions and not all patients follow<br />
the textbook script to the letter. These descriptions serve as guides and are not definitive<br />
confirmation <strong>of</strong> a cause, particularly given the use <strong>of</strong> unusual agents.<br />
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Participant Guide<br />
Slide 56<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
A Case<br />
49 yo man suddenly develops leg pain while walking<br />
• Day 1 - fever, nausea, vomiting<br />
• Day 2 - tachycardia, lymph node swelling and shock<br />
• Day 3 - kidney failure, vomited blood, heart block<br />
• Day 4 - death<br />
• Presumed Cause <strong>of</strong> Death – Septic Shock<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
56<br />
Let’s review a famous case <strong>of</strong> chemical terrorism. This only involved a single individual,<br />
and may be better called an assassination; it caused quite a sensation at the time.<br />
A 49 yo man in London suddenly develops right thigh pain while walking<br />
Day 1 - fever, nausea, vomiting<br />
Day 2 – tachycardia (fast heart beat), lymph node swelling and shock<br />
Day 3 - kidney failure, vomited blood, heart block (abnormal heart rhythm)<br />
Day 4 - death<br />
Presumed Cause <strong>of</strong> Death – Septic Shock (low blood pressure due to overwhelming infection)<br />
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Participant Guide<br />
Slide 57<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Selected Toxidromes and Potential<br />
<strong>Chemical</strong> Etiologies<br />
Category<br />
Severe gastroenteritis<br />
Cholinergic crisis<br />
Cellular hypoxia<br />
Peripheral neuropathy<br />
Mouth pain / ulcerations<br />
MMWR 10/3/03<br />
Clinical Syndrome<br />
Abdominal pain, emesis<br />
pr<strong>of</strong>use diarrhea, shock<br />
SLUDGE symptoms,<br />
Fasciculations, weakness<br />
N/V, headache, AMS, shock,<br />
seizures, dec pH<br />
Muscle weakness, sensory<br />
loss<br />
Lip / mouth / pharyngeal<br />
ulcerations; burning pain<br />
Potential <strong>Chemical</strong><br />
Etiology<br />
Arsenic, Ricin, Colchicine<br />
OP insecticides, nicotine<br />
CN, SMFA, CO, Azide<br />
Hg, As, Thallium, Lead,<br />
Paraquat / diquat; caustics,<br />
Hg<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
57<br />
Note that using the guide provided by the CDC leads to the suspicion <strong>of</strong> one <strong>of</strong> the<br />
cellular poisons, ricin, colchicine or arsenic because he had severe gastroenteritis and a<br />
shock presentation.<br />
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Participant Guide<br />
Slide 58<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Ricin Poisoning<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
58<br />
In fact on autopsy a tiny metallic sphere was retrieved from his posterior thigh. Pictured<br />
above, the sphere was ingeniously introduced through the tip <strong>of</strong> a specialized umbrella<br />
designed to implant such a metallic object. It was only later when there was a 2 nd case,<br />
that the mystery was solved and it became apparent the this dissident Bulgarian<br />
journalist (Georgi Markov) had died after have been injected with the metallic sphere<br />
which contained… ricin…derived from the castor bean plant.<br />
The modified umbrella is on the left. The metallic object with two tiny holes drilled<br />
through it, with a total volume <strong>of</strong> 0.2 microliters. The plant on the right is Ricinus<br />
communis, or the Castor Bean plant. The seeds come from the reddish pods, which are<br />
found in the autumn.<br />
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Participant Guide<br />
Slide 59<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
QUESTIONS<br />
Module One – Toxic Warfare: Looking Beyond Conventional <strong>Chemical</strong> Weapons<br />
59<br />
How real is the threat<br />
We need to be aware <strong>of</strong> <strong>TICs</strong> and <strong>TIMs</strong> and prepare <strong>for</strong> – or better yet – prevent their<br />
use as chemical weapons. To do this, at whatever level <strong>of</strong> preparation and response we<br />
are involved in, we can utilize the framework <strong>of</strong> historic examples, regional hazard<br />
vulnerability assessment and response, and clinical recognition <strong>of</strong> patterns consistent<br />
with various chemical classes.<br />
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Training Support Package<br />
Participant Guide<br />
Module One Summary<br />
This module provided a comprehensive introduction and overview <strong>of</strong> the <strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong><br />
<strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: The Medical and Psychological Consequences <strong>of</strong> <strong>TICs</strong> (Toxic<br />
Industrial <strong>Chemical</strong>s) and <strong>TIMs</strong> (Toxic Industrial Materials) course, sponsored by The American<br />
College <strong>of</strong> Medical Toxicology (ACMT). It presented a broad overview <strong>of</strong> the numerous<br />
potential toxic industrial chemicals and toxic metals readily available in our society, along with<br />
the most likely scenarios that might occur as the result <strong>of</strong> the intentional release <strong>of</strong> the agents<br />
by terrorists. The intentions <strong>of</strong> such a terrorist attack as critical analysis reveals, is to cause<br />
illness and injury and potentially large numbers <strong>of</strong> casualties but more over, to create social<br />
panic and chaos and substantial demands on our health care system’s ability to respond.<br />
Historical examples <strong>of</strong> major chemical events and the resultant pertinent legislation that was<br />
implemented in response to these occurrences governing the production, transportation, and<br />
storage <strong>of</strong> toxic chemicals were reviewed. A framework <strong>for</strong> first responders and first receivers<br />
<strong>for</strong> the early detection and recognition <strong>of</strong> toxic chemicals is provided in order to optimally<br />
prepare, identify and defend against chemical threats.<br />
Seeking to provide awareness-level training across several disciplines on a variety <strong>of</strong> toxic<br />
syndromes likely to be encountered following exposures to <strong>TICs</strong> and <strong>TIMs</strong> and other chemical<br />
agents <strong>of</strong> opportunity, this module introduced the concept <strong>of</strong> dose-response, the health<br />
implications resulting from the release <strong>of</strong> <strong>TICs</strong> and TIMS, it identified multiple sources available<br />
to obtain common industrial chemicals and the potential scenarios that might result from the<br />
use <strong>of</strong> these chemical agents by terrorists.<br />
First responders and first receivers are provided with a framework to enhance understanding<br />
and recognition <strong>of</strong> the common health effects <strong>of</strong> apparently disparate chemical toxins, and<br />
current and reliable in<strong>for</strong>mation regarding current policy and public health management<br />
strategies.<br />
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Training Support Package<br />
Participant Guide<br />
Module Two<br />
The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong> -<br />
Administration Page<br />
The underlying neurophysiology <strong>of</strong> the brain makes it a likely target <strong>for</strong> terrorism. Interruption <strong>of</strong><br />
the normal role <strong>of</strong> neurotransmitters in the brain will alter functionality and render the individual<br />
incapable <strong>of</strong> ‘fight or flight’. Because the potential exists <strong>for</strong> neurotoxins to be used in a terrorist<br />
attack it is imperative that clinicians and first responders are able to recognize the common toxic<br />
syndromes that affect the nervous system, including sedation, convulsions and hallucinations.<br />
Duration<br />
45 minutes<br />
Scope Statement<br />
This module provides a detailed overview <strong>of</strong> the major toxic syndromes along with examples <strong>of</strong><br />
chemical agents <strong>of</strong> opportunity <strong>for</strong> each clinical syndrome. Case studies are presented that<br />
highlight the historical use <strong>of</strong> these agents in terrorist attacks. Potential antidotes, initial<br />
treatment strategies and management <strong>of</strong> each clinical syndrome are reviewed.<br />
Terminal Learning Objective (TLO)<br />
• Recognize the common toxic syndromes that affect the nervous<br />
system, including sedation, convulsions and hallucinogens.<br />
Enabling Learning Objectives (ELO)<br />
Resources<br />
• Describe the role <strong>of</strong> neurotransmitters in brain function.<br />
• List examples <strong>of</strong> agents <strong>of</strong> opportunity <strong>for</strong> each clinical syndrome.<br />
• Describe initial treatment strategies <strong>for</strong> each clinical syndrome.<br />
• Identify antidotes where appropriate.<br />
Each <strong>of</strong> the eight course modules is deployed as an interactive, instructor-lead, MS PowerPoint<br />
presentation containing didactic content, historical examples, and selected case studies. All<br />
presentations are included in a printed participant guide (PG) containing the modules’ overview,<br />
scope statement, terminal and enabling learning objectives, PowerPoint slide handouts, and a<br />
summary section.<br />
Instructor to Participant Ratio<br />
1:8 (minimum) to 1:25 (maximum)<br />
Reference List<br />
1. Burns MJ, Linden CH, Graudins A, et al. A comparison <strong>of</strong><br />
physostigmine and benzodiazepines <strong>for</strong> the treatment <strong>of</strong><br />
anticholinergic poisoning. Ann Emerg Med 2001;37(2):239-41.<br />
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Participant Guide<br />
Practical Exercise Statement<br />
2. Centers <strong>for</strong> Disease Control and Prevention (CDC). Nicotine<br />
poisoning after ingestion <strong>of</strong> contaminated ground beef –Michigan,<br />
2003. MMWR May 9, 2003;52(18):413-16.<br />
3. Centers <strong>for</strong> Disease Control and Prevention (CDC). Poisoning by an<br />
illegally imported Chinese rodenticide containing<br />
tetramethylenedisulfotetramine--New York City, 2002. MMWR Morb<br />
Mortal Wkly Rep. 2003 Mar 14;52(10):199-201.<br />
4. H<strong>of</strong>fman JR et al. The empiric use <strong>of</strong> naloxone in patients with altered<br />
mental status: a reappraisal. Ann Emerg Med 1991;20:246-52.<br />
5. Lakoski JM, et al. The advantages and limitations <strong>of</strong> calmatives <strong>for</strong><br />
use as a non-lethal technique.<br />
nldt2.arl.psu.edu/documents/calamative_report.pdf<br />
6. McCarron MM et al. Acute phencyclidine intoxication: clinical patterns,<br />
complications and treatment. Ann Emerg Med 1981;6:290-7.<br />
7. Wax PM, et al. Unexpected "gas" casualties in Moscow: a medical<br />
toxicology perspective. Ann Emerg Med 2003;41:700-5.<br />
Each module presentation contains one or more interactive audience response questions<br />
designed to drive discussion, promote participant engagement, and test knowledge. Through<br />
the use <strong>of</strong> the Meridia® Audience Response system, participant responses can be collected,<br />
tabulated, and displayed within the presentation in real time. In order to use the interactive<br />
slides accompanying this presentation, the lecture hall must be equipped with the Meridia®<br />
Audience Response system and user keypads. In addition, a copy <strong>of</strong> the “Meridia® Q&A”<br />
s<strong>of</strong>tware component <strong>for</strong> MS PowerPoint must be installed on the presenter’s computer.<br />
Assessment Strategy<br />
Participant progress toward course learning objectives is monitored through in<strong>for</strong>mal discussion<br />
and responses to each module’s practical exercise questions. Overall mastery <strong>of</strong> module<br />
content and concepts is documented by means <strong>of</strong> a comprehensive, end-<strong>of</strong>-day posttest<br />
touching on key learning objectives from each module. Each participant must obtain a score <strong>of</strong><br />
80% or better to successfully complete the training and obtain a course completion certificate.<br />
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Training Support Package<br />
Participant Guide<br />
Module Two<br />
Icon Map<br />
Knowledge Check: Used when it is time to assess the learners’ understanding<br />
Example: Used when there is a descriptive illustration to show or explain<br />
Key Points: Used to convey essential learning concepts, discussions and introduction <strong>of</strong><br />
supplemental material<br />
Hint: Used to cover administrative items or instructional tips that aid in the flow <strong>of</strong> the<br />
instruction<br />
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Participant Guide<br />
Slide 1<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Module Two<br />
The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong><br />
<strong>Terrorism</strong><br />
Training Support Package<br />
1<br />
This module is the Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong>.<br />
Neurotoxicology is the study <strong>of</strong> toxins and other chemical on the nervous system.<br />
Clinical refers to the medical effects observed in people.<br />
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Participant Guide<br />
Slide 2<br />
Due to its complexity and the ease <strong>of</strong> disrupting its function, the human brain makes a<br />
great target <strong>for</strong> terrorism. The thought <strong>of</strong> someone interfering with our ability to function<br />
is very disturbing and highlights the power <strong>of</strong> the psychological effects <strong>of</strong> terrorism. The<br />
Central Nervous System is central to both our functionality and our thinking.<br />
Central nervous system is the organ system that includes the brain and spinal cord. Our<br />
ability to think, react and the control <strong>of</strong> many bodily functions are all coordinated by the<br />
brain. Disruption <strong>of</strong> brain function can be quite disabling and lead to all sorts <strong>of</strong> mental<br />
and psychological problems.<br />
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Participant Guide<br />
Slide 3<br />
Despite its complexity, the brain really only displays its dysfunction in a small number <strong>of</strong><br />
ways. There are basically three toxic syndromes that affect the central nervous system.<br />
This includes CNS depression (sedation), CNS excitation (seizure) and possibly altered<br />
thoughts, as with hallucinations.<br />
The objectives <strong>for</strong> today’s presentation include:<br />
o Review <strong>of</strong> the unique clinical effects <strong>of</strong> toxins that result in sedation syndromes<br />
o<br />
o<br />
List examples <strong>of</strong> agents <strong>of</strong> opportunity <strong>for</strong> each syndrome<br />
Describe the initial treatment strategy <strong>for</strong> each category <strong>of</strong> agent<br />
A syndrome refers to a constellation or grouping <strong>of</strong> signs and symptoms. A toxic<br />
syndrome refers to the signs and symptoms associated with exposure to a specific toxin<br />
or chemical. There are several different types <strong>of</strong> toxic syndromes. The three toxic<br />
syndromes which are most commonly seen are those that cause sedation or sleepiness,<br />
convulsion which are <strong>of</strong>ten referred to as seizures and hallucinations, which are<br />
distortions <strong>of</strong> reality. It is important to recognize that convulsions is an extreme<br />
manifestation <strong>of</strong> overstimulation, which is the opposite <strong>of</strong> sedation. People who have<br />
hallucinations may be awake and even alert but are not thinking clearly. A patient with<br />
hallucinations is <strong>of</strong>ten neither sedated nor agitated but they are clearly altered.<br />
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Participant Guide<br />
Slide 4<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
The Balance <strong>of</strong> the Brain<br />
• The brain is a fine balance <strong>of</strong> excitatory and inhibitory<br />
influences<br />
– Slight alterations in either direction are significant<br />
Excitation<br />
Glutamate<br />
Catecholamines<br />
Inhibition<br />
Gamma-aminobutyric acid<br />
(GABA)<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
4<br />
The normal state <strong>of</strong> the brain is maintained by balancing both excitation and inhibition,<br />
each mediated by a unique set <strong>of</strong> chemicals called neurotransmitters. We alter our<br />
neurotransmitters under normal conditions to suit our needs. For example, in order to<br />
sleep, you need to increase inhibition and reduce excitation.<br />
Neurotransmitters are chemicals in the nervous system including the brain that transmit<br />
in<strong>for</strong>mation from one neuron to the next (neurons are cells found in the nervous system<br />
and brain). There are a number <strong>of</strong> different types <strong>of</strong> neurotransmitters. These include<br />
adrenaline also known as epinephrine which belongs to the neurotransmitter class<br />
known as catecholamines. Some neurotransmitters cause stimulation and others cause<br />
inhibition or sedation. Catecholamines cause stimulation. Another neurotransmitter<br />
that causes stimulation is glutamate. An example <strong>of</strong> a neurotransmitter that causes<br />
inhibition is gamma-aminobutryic acid. This long chemical name is <strong>of</strong>ten abbreviated as<br />
GABA.<br />
The see-saw in the slide represents the delicate balance in the brain between excitation<br />
and inhibition. A person with a normal mental status is someone <strong>for</strong> whom these<br />
influences are in balance, while disorders are characterized by a tilt in favor <strong>of</strong> too much<br />
excitation (or too little inhibition) or too much inhibition.(or too little excitation).<br />
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Participant Guide<br />
Slide 5<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
The Balance <strong>of</strong> the Brain<br />
• In addition, other neurotransmitters influence our<br />
mood, our ability to think, remember, etc.<br />
Excitation<br />
Inhibition<br />
Modulators <strong>of</strong> Thought Processes<br />
Serotonin<br />
Acetylcholine<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
5<br />
Other neurotransmitters play a role in our functional abilities, or our ability to process<br />
in<strong>for</strong>mation smoothly. For example, Serotonin and Acetylcholine serve as modulators <strong>of</strong><br />
our thought processes.<br />
Some neurotransmitters do not excite and do not sedate (brain inhibition) but cause an<br />
alteration in thinking and mood. Two examples <strong>of</strong> neurotransmitters that may alter mood<br />
or thought are serotonin and acetylcholine. An increase or decrease in the amount <strong>of</strong><br />
these neurotransmitters may have a significant impact on mood and thought.<br />
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Participant Guide<br />
Slide 6<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clinical Syndromes <strong>of</strong> the CNS<br />
Too much inhibition = Sedation/coma<br />
Excitation Inhibition<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
6<br />
<strong>Chemical</strong>s (drugs) typically cause sedation or coma by enhancing our inhibitory tone, not<br />
by reducing excitation.<br />
Too much inhibition causes sedation. A person who is sedated is not alert. They are<br />
usually sleepy and may be difficult to arouse. With increasing sedation patients may be<br />
comatose. This may be confused <strong>for</strong> sleeping but the typical person who is sleeping can<br />
usually be awoken with some sort <strong>of</strong> stimulation. The comatose patient can not be<br />
awoken. If this coma is caused by a drug or chemical, the patient may not awaken until<br />
the chemical leaves the body or wears <strong>of</strong>f. In extreme cases someone who is comatose<br />
may slow down their breathing to such an extent that they are not longer getting enough<br />
oxygen. This may result in death and is a common cause <strong>of</strong> death after some drug<br />
overdoses.<br />
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Participant Guide<br />
Slide 7<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clinical Syndromes <strong>of</strong> the CNS<br />
Too much stimulation = Convulsions<br />
Excitation<br />
Inhibition<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
7<br />
While chemicals (and drugs) may cause convulsions by enhancing excitation, a more<br />
common mechanism <strong>for</strong> intoxicant-induced convulsions is diminished inhibition (known<br />
as “inhibition <strong>of</strong> inhibition”).<br />
A convulsion occurs when the patient has repetitive and uncontrolled jerking <strong>of</strong> the<br />
extremities. This is sometimes referred to as a seizure. However, a seizure refers to<br />
abnormal electrical activity in the brain, while convulsions refer to the abnormal muscle<br />
activity we are able to observe. Not all convulsions are seizures – the best example<br />
being the effects <strong>of</strong> strychnine, where the patient is awake and aware, but unable to<br />
control his muscle movements. Convulsions are <strong>of</strong>ten violent and may result in injury to<br />
the patient. In addition the intense muscle activity may result in an elevated body<br />
temperature and muscle damage. Prolonged seizures (those lasting more than 30<br />
minutes) or repetitive seizures without recovery <strong>of</strong> consciousness are termed status<br />
seizures. These can cause permanent brain injury and can lead to death.<br />
Patients having seizure are <strong>of</strong>ten unaware <strong>of</strong> their movements and may not even be<br />
aware that they are having a seizure. Prior to the onset <strong>of</strong> convulsions the patient may<br />
exhibit tremors and jitteriness. There are many different causes <strong>of</strong> seizures. Epilepsy is<br />
one <strong>of</strong> the most common causes. Epilepsy is not caused by specific drugs or toxins and<br />
usually develops in childhood. There are a large number <strong>of</strong> drugs and toxins that can<br />
also cause seizures.<br />
Note the see-saw is tilted towards excitation. The boxes depict both increased excitation<br />
and decreased inhibition (compared to baseline).<br />
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Participant Guide<br />
Slide 8<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clinical Syndromes <strong>of</strong> the CNS<br />
Altered Modulation <strong>of</strong> Thoughts = Hallucinations<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
8<br />
Alterations in the smooth flow <strong>of</strong> in<strong>for</strong>mation in our brain results in hallucinations.<br />
Sensory input is unfiltered resulting in sensory overload and altered modulation <strong>of</strong> our<br />
thoughts, causing hallucinations and delirium.<br />
Hallucinations are false perceptions that have no basis in the external environment.<br />
There are several different types <strong>of</strong> hallucinations. These include auditory hallucinations<br />
where one hears voices which are not present. Another type <strong>of</strong> hallucination is visual.<br />
People who experience visual hallucinations are seeing people or objects that are not<br />
present. Someone who is having hallucinations may not think clearly. For example, it<br />
would be very dangerous to drive a car or operate machinery at the same time one was<br />
experiencing hallucinations. A soldier on the battlefield might become ineffective and<br />
even dangerous to colleagues if he or she was experiencing hallucinations.<br />
The see-saw depicts wavy lines with upended boxes reflecting the altered thought<br />
process.<br />
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Participant Guide<br />
Slide 9<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clinical Syndrome: Sedation<br />
Excitation Inhibition<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
9<br />
Let’s talk about sedatives and their potential <strong>for</strong> use by terrorists.<br />
Recall that sedatives are going to enhance our inhibitory tone.<br />
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Participant Guide<br />
Slide 10<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Dose-Response<br />
Ethanol Intoxication:<br />
A Prototype <strong>for</strong> Calmatives<br />
– The more you drink, the drunker you get<br />
– 1 beer: buzz<br />
– 2 beers: intoxicated<br />
– 6 beers: uncoordinated, slurred speech,<br />
• Disinhibited<br />
– 24 beers: coma, respiratory arrest<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
10<br />
The term calmative refers to a drug or chemical that producing a calming state. Ethanol<br />
represents a nice example <strong>of</strong> a calmative and rein<strong>for</strong>ces a key concept in toxicology -<br />
dose response. The greater the exposure the more effect you see. For example, as you<br />
drink more bottles <strong>of</strong> beer, the neurologic effects progress from mild inebriation to coma.<br />
A larger dose or amount <strong>of</strong> a calmative may produce sedation, and an even larger dose<br />
may produce coma. There are a large number <strong>of</strong> drugs and chemicals that cause<br />
calming and sedation. One <strong>of</strong> the most commonly used chemicals that cause these<br />
symptoms is alcohol. The specific chemical name <strong>of</strong> the active ingredient in alcohol is<br />
ethanol. Different people have different responses to drinking the same amount <strong>of</strong><br />
ethanol. If someone doesn’t drink and then drinks one or two beers they may become<br />
intoxicated while others who drink many beers every day may not experience any<br />
obvious effect after only drinking one or two beers. However, <strong>for</strong> both individuals, if they<br />
drink enough they will develop more and more “inhibitory” effects. Eventually the patient<br />
who drinks a large number <strong>of</strong> beers may develop respiratory depression which is a<br />
decreased number <strong>of</strong> breaths each minute. Normal is about 12 to 20 breaths per<br />
minute. A respiratory arrest occurs when the number <strong>of</strong> breaths approaches no breaths<br />
per minute.<br />
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Participant Guide<br />
Slide 11<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case Study: Moscow Theatre Hostage<br />
Crisis (2002)<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
11<br />
Let’s look at an example <strong>of</strong> a mass poisoning using a calmative agent. The Moscow<br />
theater hostage crisis was the seizure <strong>of</strong> a crowded Moscow theatre on October 23,<br />
2002 by about 40 armed Chechen militants who claimed allegiance to the separatist<br />
movement in Chechnya. They took 850 hostages and demanded the withdrawal <strong>of</strong><br />
Russian <strong>for</strong>ces from Chechnya and an end to the Second Chechen War.<br />
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<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong><br />
Training Support Package<br />
Participant Guide<br />
Slide 12<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case Study: Moscow Theatre Hostage<br />
Crisis (2002)<br />
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12<br />
This is a photo <strong>of</strong> the ambulances that lined up outside the theatre awaiting casualties<br />
from the hostage takeover and the subsequent Russian military reentry into the theatre.<br />
Pandemonium resulted- panic and social disruption are among terrorism’s goals.<br />
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Participant Guide<br />
Slide 13<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case Study: Moscow Theatre Hostage<br />
Crisis (2002)<br />
• Russian Federal Security Service pumped<br />
unidentified “gas” into building<br />
• Security <strong>for</strong>ces raided building<br />
• 128 <strong>of</strong> 800 (16%) hostages died<br />
– All but one from gas<br />
• All 42 separatists died<br />
– 39-41 from gas<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
13<br />
After a 2 ½ day siege, Russian security services pumped an unidentified chemical agent<br />
into the building's ventilation system and raided it. Officially, 39 <strong>of</strong> the terrorists were<br />
killed by Russian <strong>for</strong>ces; at least 128 <strong>of</strong> the hostages died. Some estimates have put the<br />
civilian death toll at more than 200.<br />
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Participant Guide<br />
Slide 14<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
What happened<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
These images reveal how much confusion there was. Some victims were alive and<br />
appear well, others appear quite ill. The degree <strong>of</strong> Personal Protective Equipment use<br />
varied, but appears to have been inadequate in most images.<br />
14<br />
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Participant Guide<br />
Slide 15<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
15<br />
The events in the news media unfolded over several days. It was initially thought that the<br />
security services pumped an aerosol anesthetic into the theatre - later reported to be<br />
weaponized Fentanyl (possibly carfentanil) - through the air conditioning system. If it was<br />
an opioid, why was the military not prepared with antidote (naloxone)….would it have<br />
worked or helped anyway The amount <strong>of</strong> time to enter the building and administer the<br />
antidote naloxone makes it unlikely to have helped many.<br />
An opioid is a type <strong>of</strong> drug class that includes heroin and morphine. The drugs present<br />
in the poppy plant are termed opiates. There are other drugs that are synthesized or<br />
manufactured in pharmaceutical factories that resemble the active ingredients found in<br />
the poppy plants. These are referred to as synthetic opioids. Examples include<br />
meperidine and methadone. Another example is fentanyl which is very potent as will be<br />
described on the next slide.<br />
Opioids cause sedation, and in larger doses cause coma. They are also used to control<br />
pain. Deaths occur from respiratory arrest.<br />
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Participant Guide<br />
Slide 16<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Characteristics <strong>of</strong> Opioids<br />
Agent Potency<br />
(vs. morphine)<br />
Morphine 1<br />
Meperidine 0.5<br />
Methadone 4<br />
Fentanyl 300<br />
Sufentanil 4500<br />
Alfentanil 75<br />
Remifentani 220<br />
lCarfentanil 10,000<br />
Wax PM, Becker CE, Curry SC. Ann Emerg Med 2003;41:700 -5.<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
16<br />
Fentanyl has a very high potency, which means it is effective in very small (microgram)<br />
doses. Carfentanil is even more potent and would make an effective weapon if put into a<br />
respirable <strong>for</strong>m (e.g., aerosol). There are some suggestions that carfentanil was in fact<br />
the implicated toxin.<br />
This slide lists a number <strong>of</strong> chemicals or drugs which belong to the opioid class. They<br />
are all used medically except <strong>for</strong> carfentanil which is used as a veterinary anesthetic in<br />
large animals. The potency refers to how strong the drug is compared to another drug.<br />
The more potent a drug, the greater the effect at the same dose. A drug that has 10,000<br />
times the potency <strong>of</strong> another drug is essentially 10,000 times stronger at the same dose.<br />
Hence, to produce a similar effect one would give a much, much smaller dose <strong>of</strong> the<br />
more potent drug.<br />
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Participant Guide<br />
Slide 17<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
17<br />
Carfentanil is available as a large animal tranquilizer (<strong>for</strong> Moose or elk) sold under the<br />
brand name <strong>of</strong> “Wildnil”.<br />
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Participant Guide<br />
Slide 18<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Positive Purpose<br />
“The use <strong>of</strong> pharmacological agents<br />
to produce calm behavioral state ,<br />
particularly as relevant to<br />
management <strong>of</strong> individuals and/or<br />
groups that are agitated,<br />
aggressive and/or violent, is a<br />
topic with high relevance to<br />
achieving the mission <strong>of</strong> law<br />
en<strong>for</strong>cement and military<br />
communities ”<br />
(nldt2.arl.psu.edu/documents/calamative_report.pdf )<br />
October 3, 2000<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
18<br />
Sedatives can be put to positive use to overcome an aggressive person or group, the<br />
difference being the route <strong>of</strong> delivery. In the emergency department (ED) we frequently<br />
sedate people in order to produce a calm behavioral state. To sedate a group, the<br />
chemical sedative must be delivered in a different fashion, such as by inhalation. This<br />
has been studied, along with other techniques such as sticky foam and netting, as a<br />
non-lethal technique to replace bullets <strong>for</strong> law en<strong>for</strong>cement.<br />
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Participant Guide<br />
Slide 19<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Inhaled Calmatives/Sedatives<br />
• Aerosolized drugs<br />
– GABAergic agents<br />
• Benzodiazepine (e.g. diazepam)<br />
• Barbiturate (e.g. pentobarbital)<br />
– Opioids<br />
• Volatile agents<br />
– Hydrocarbons<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
19<br />
This slide describes some other examples <strong>of</strong> agents that would be useful as calmatives.<br />
They are all used in clinical medicine given their relative effectiveness and safety.<br />
Effective delivery is the challenge. Some hydrocarbons can be readily converted to<br />
gaseous <strong>for</strong>m (such as inhalational anesthetics (halothane)) while most drugs are solids<br />
that, once dissolved in water or another solvent, can be aerosolized (misted). However,<br />
even creating a respirable aerosol is quite difficult and requires sophisticated technology.<br />
Not all substances that are inhaled are true gases. Some chemicals are liquid particles<br />
that can be suspended in air. This appears as a fine mist. The process <strong>of</strong> producing<br />
this mist is known as aerosolization. This mist preparation may also be known as an<br />
aerosol. Some liquid chemicals that are calmatives or sedatives have been aerosolized<br />
<strong>for</strong> use. These include agents that act through the GABA neurotransmitters discussed<br />
previously. These agents cause sedation. Examples are two drug classes known as<br />
benzodiazepines and barbiturates. While one would not necessarily use aerosolized<br />
versions <strong>of</strong> these drugs to treat patients, such aerosolized versions might have other<br />
uses such as to sedate large crowds <strong>of</strong> people, hence their potential use by law<br />
en<strong>for</strong>cement and the military.<br />
Volatility generally refers to the ability <strong>of</strong> a liquid to convert to a gas <strong>for</strong>m (vapor) at<br />
relatively low temperatures. Unlike aerosols, vapors are not suspended liquid particles.<br />
Hydrocarbons refer to liquids which give <strong>of</strong>f vapors at a high enough temperature. For<br />
instance, gasoline is a liquid hydrocarbon. An open can <strong>of</strong> gasoline emits a vapor which<br />
has a distinctive odor. Hydrocarbon vapors may also cause sedation. Drugs used in<br />
anesthesia that put patients to sleep in the operating room are hydrocarbons such as<br />
halothane (and in the past, ether and chlor<strong>of</strong>orm).<br />
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Participant Guide<br />
Slide 20<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Calmatives/Sedatives<br />
• Suspect whenever clinical picture presents with predominant<br />
CNS depression<br />
– All produce dose dependent sedation<br />
• Major complication: RESPIRATORY DEPRESSION<br />
– Respiratory depressant effects vary<br />
• Specific Toxic Syndrome: CNS depression, pinpoint pupils,<br />
and respiratory depression = Opioid<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
20<br />
The sedative toxidrome is characterized by dose-dependent sedation with relatively<br />
preserved respiratory ef<strong>for</strong>t. However, most central nervous system depressants are<br />
associated with some degree <strong>of</strong> respiratory depression at higher doses. Some, like the<br />
opioids, are associated with pr<strong>of</strong>ound respiratory depression. This explains the high<br />
fatality rate in the Moscow theater.<br />
Respiratory depression, or a decrease number <strong>of</strong> breaths per minute, is the most serious<br />
problem associated with exposure to calmative or sedative agents. At high enough<br />
doses, this can result in a respiratory arrest and death.<br />
Opioids commonly cause respiratory depression. Toxicity from opioids also includes<br />
central nervous system depression and pinpoint pupils (also known as miosis).<br />
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Participant Guide<br />
Slide 21<br />
The opioid toxidrome (toxicological syndrome) is relatively easy to recognize, particularly<br />
<strong>for</strong> medical personnel, since it is commonly noted in heroin users. Treatment involves<br />
administration <strong>of</strong> an antidote called naloxone (Narcan).<br />
The opioid toxidrome consists <strong>of</strong> central nervous system depression, respiratory<br />
depression and pinpoint pupils (miosis). Looking <strong>for</strong> and recognizing these findings on a<br />
physical examination is very important since people with this condition require<br />
emergency treatment. The failure to treat may result in a patient’s death.<br />
The treatment <strong>of</strong> choice is naloxone, also known by its trade name as Narcan®. This<br />
drug can be administered by the intravenous (IV) route (through a vein) or through an<br />
endotracheal tube if the patient is already intubated. The usual dose <strong>for</strong> naloxone is 0.4<br />
mg. It is usually pushed rapidly through the IV. Some patients may not respond to this<br />
first dose and will require more naloxone. Typically patients respond to 2 mg <strong>of</strong><br />
naloxone although in some instances as much as 10 mg may be administered to reverse<br />
the effects <strong>of</strong> respiratory and CNS depression.<br />
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Slide 22<br />
Naloxone works by blocking the effect <strong>of</strong> the opioid on its inhibitory receptor. It basically<br />
knocks the drug <strong>of</strong>f the receptor and reduces the enhanced inhibition back to baseline.<br />
After administration patients wake up within seconds, and sometimes withdraw if they<br />
are chronic users (as with heroin)….not a terrorism issue.<br />
Realize that in many situations the toxic exposure results in toxicity that lasts longer than<br />
the antidote. Patient’s initial symptoms may then recur when the naloxone wears <strong>of</strong>f.<br />
The use <strong>of</strong> naloxone REVERSES the inhibition that is caused by an opioid drug. The<br />
onset <strong>of</strong> action after IV administration <strong>of</strong> naloxone is fast and generally occurs within 1-2<br />
minutes. Its duration <strong>of</strong> action is 20 to 90 minutes. Naloxone reverses the effects <strong>of</strong> the<br />
entire family <strong>of</strong> opioid drugs including heroin, morphine, fentanyl, methadone, and<br />
hydrocodone. For some opioids such as methadone and hydrocodone the dose<br />
necessary to reverse the drug effects is greater than 2 mg. Upwards <strong>of</strong> 10 mg may<br />
sometimes be required is some <strong>of</strong> these cases. This reflects the relative potency <strong>of</strong><br />
binding to the opioid receptors in the brain.<br />
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Slide 23<br />
In some cases, simply providing ventilation is sufficient, and the administration <strong>of</strong><br />
naloxone may not be necessary. The reason that opioids and most other sedatives kill is<br />
respiratory depression (assuming you are not driving a car or standing on the ledge <strong>of</strong> a<br />
cliff). Thus breathing <strong>for</strong> the person, either with mouth to mouth or by way <strong>of</strong> a bagvalve-mask<br />
as in the picture, is generally sufficient to save their life. Realize that you<br />
may have to ventilate <strong>for</strong> hours after exposure to some long acting sedative agents.<br />
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Slide 24<br />
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Participant Guide<br />
Slide 25<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clinical Syndrome: Convulsions<br />
Excitation Inhibition<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
25<br />
The second clinical syndrome to discuss is convulsions/seizures. A seizure really refers<br />
to brain activity whereas convulsion is what you see when you look at the patient - that is<br />
the movement itself. Some convulsant toxins are not seizure inducing. An example is<br />
strychnine.<br />
These words – seizure and convulsion – are sometimes used interchangeably – but as<br />
noted be<strong>for</strong>e – a seizure refers to the abnormal electrical activity that occurs in the brain<br />
and is usually manifested by violent rhythmic movements <strong>of</strong> the extremities while<br />
convulsions only refer to these abnormal movements. Strychnine does not cause<br />
abnormal electrical activity in the brain. Strychnine only effects neural impulse<br />
transmission in the spinal cord which also happens to cause convulsive movements <strong>of</strong><br />
the extremities. Hence strychnine poisoning causes convulsions without seizures.<br />
Robin Cook’s medical novel, Seizure, is used here just as a graphic depiction <strong>of</strong> a nerve<br />
synapse (nerve-to-nerve communication).<br />
The see-saw depicts a tilt towards the excitatory side. Note that the major reason <strong>for</strong> this<br />
imbalance is a decrease in inhibitory input.<br />
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Slide 26<br />
In coma, enhancement <strong>of</strong> inhibition is the predominant cause <strong>of</strong> depressed mental<br />
status. In seizure/convulsion it is inhibition <strong>of</strong> inhibition that is most important.<br />
Remember that different neurotransmitters can either cause excitation (glutamate), or<br />
inhibition (GABA). Any change that tips the balance in favor <strong>of</strong> excitation can produce<br />
convulsions/seizures. This can occur by increasing excitatory neurotransmitters, or by<br />
decreasing the levels <strong>of</strong> inhibitory neurotransmitters. The most common toxin-induced<br />
seizures are triggered by decreasing the levels <strong>of</strong> inhibitory neurotransmitters.<br />
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Participant Guide<br />
Slide 27<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Inhibition <strong>of</strong> inhibition<br />
Excitation Inhibition<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
27<br />
This slide depicts the in<strong>for</strong>mation stated on the previous slide. Decreasing or inhibiting<br />
the inhibition (smaller inhibition box) leads to increased excitation (larger excitation box).<br />
The scale is tipped in the excitation direction.<br />
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Slide 28<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
MMWR 2003;52:199 -201<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
28<br />
A report from NYC published in the CDC’s rapid turnaround journal (MMWR) discussed<br />
a case <strong>of</strong> a young girl in a Chinese immigrant family, who, in May 2002, developed<br />
status epilepticus unresponsive to conventional therapy after ingesting a powder from an<br />
apparent rodenticide packet marked with characters and purchased locally in Chinatown.<br />
At that time, despite intensive investigation, the nature <strong>of</strong> the powder could not be<br />
determined.<br />
A rodenticide is a chemical that is used to kill rodents such as rats and mice. These<br />
chemicals tend to be highly toxic. This slide depicts the rodenticide package in this case.<br />
The pictographs are easy to interpret as a rat or mouse poison, but the Chinese<br />
characters are not readily interpretable. Illegally imported <strong>for</strong>eign products can result in<br />
domestic exposures to unusual toxic chemicals, and health-care providers might not be<br />
able to provide appropriate therapy because the chemical ingredients might not be listed<br />
or recognized even after translation <strong>of</strong> the product label.<br />
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Participant Guide<br />
Slide 29<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
29<br />
Four months later, on September 14, 2002 a snack shop owner in China poisoned food<br />
in a competitor's snack shop with a rodenticide identified as Dushuqiang, resulting in 38<br />
deaths. Although it has been banned <strong>for</strong> sale since the mid-1980s, it was still widely<br />
available in China. Dushuqiang contains tetramine, sometimes known as TETS. TETS is<br />
a little-known, <strong>of</strong>ten unrecognized, and highly lethal neurotoxic rodenticide that once was<br />
used widely.<br />
Following news reports <strong>of</strong> this incident, the New York City Poison Control Center<br />
conducted additional laboratory testing <strong>of</strong> the product associated with the poisoning in<br />
New York City in May 2002 and confirmed TETS in the product.<br />
TETS is an odorless, tasteless, and water-soluble white crystalline powder that acts as a<br />
-amino butyric acid (GABA) antagonist (China Center <strong>for</strong> Disease Control and<br />
Prevention [CDC], unpublished data, 2002), TETS, like picrotoxin, binds<br />
noncompetitively and irreversibly to the GABA receptor on the neuronal cell membrane<br />
and blocks chloride channels. The most common routes <strong>of</strong> exposures are through<br />
ingestion and inhalation (China CDC, unpublished data, 2002). TETS is not registered<br />
by the U.S. Environmental Protection Agency <strong>for</strong> use in the United States, and its<br />
importation, manufacture, and use in the United States are illegal.<br />
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Participant Guide<br />
Slide 30<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Tetramine<br />
• Du-shu-quiang (“very strong poison ”)<br />
• Used as a rodenticide in China<br />
– Banned in 1984<br />
• Like many substances used as rodenticides,<br />
tetramine is highly toxic to humans<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
30<br />
This is the first known case <strong>of</strong> TETS poisoning in the United States. The chemical's<br />
morbidity and lethality and the lack <strong>of</strong> a known antidote present a danger to human<br />
health in areas where TETS might be imported illegally. Just as it was used to poison the<br />
rice in China, concern <strong>for</strong> use as a terrorist agent in the US is obvious.<br />
While the term tetramine is generally used to refer to this toxin it also refers to several<br />
nontoxic chemicals which can make the use <strong>of</strong> this term confusing. It causes<br />
convulsions and over-excitation which leads to the death <strong>of</strong> rodents which is the desired<br />
outcome; but un<strong>for</strong>tunately causes the same symptoms in humans. There are a wide<br />
variety <strong>of</strong> substances used as rodenticides and many <strong>of</strong> them act by causing over<br />
excitation, convulsions, and seizures. Strychnine is another example <strong>of</strong> a rodenticide<br />
that is highly toxic and causes convulsions.<br />
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Slide 31<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Rat Poison<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
31<br />
Tetramine has been reportedly used several times in epidemic poisoning in China.<br />
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Slide 32<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Some <strong>Chemical</strong> Causes <strong>of</strong> Convulsions<br />
• Organophosphate & Carbamate Insecticides<br />
• Nicotine<br />
• Hydrazines<br />
• Camphor<br />
• Organochlorines<br />
• Strychnine<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
32<br />
Other convulsant poisons that are relatively easy to access include the chemicals listed<br />
here. Nicotine was used by a supermarket clerk in Michigan to poison ground beef<br />
patties. Hydrazines are used as rocket propellants. Organophosphate and carbamate<br />
insecticides, camphor, organochlorines, and strychnine all are used as pesticides <strong>for</strong><br />
different animal species. The use <strong>of</strong> any <strong>of</strong> these agents in an act <strong>of</strong> terrorism is a<br />
distinct possibility.<br />
Nicotine is widely available from tobacco and a variety <strong>of</strong> other nicotine-containing<br />
plants, ingestion can lead to severe vomiting and diarrhea, high blood pressure, anxiety,<br />
and a rapid heart rate. At high doses nicotine stimulates muscle spasm (twitching).<br />
After a period <strong>of</strong> stimulation the muscle can become fatigued and subsequently lead to<br />
muscle weakness or even paralysis.<br />
Hydrazines are compounds found within certain poisonous mushroom species and is a<br />
component <strong>of</strong> rocket fuel. Ingestion leads to seizures that are <strong>of</strong>ten resistant to standard<br />
anti-seizure therapy. It works by inhibiting the normal function <strong>of</strong> vitamin B-6<br />
(pyridoxine) in the brain..<br />
Camphor is used in mothballs. In the United States camphor is limited to 11% <strong>of</strong> the<br />
mothball, however older mothballs or those from other countries can have very high<br />
concentrations <strong>of</strong> camphor. Ingestion <strong>of</strong> camphor can lead to early onset <strong>of</strong> seizures.<br />
Organochlorines are a wide variety <strong>of</strong> compounds which can have differing effects<br />
depending on the exact chemical. Many result in overexcitation and convulsions. A<br />
common treatment <strong>for</strong> scabies (a mite that burrows in the skin) is lindane, an<br />
organochlorine insecticide, that has caused seizure when ingested or over-applied to the<br />
skin.<br />
Strychnine is still found in rat poisons, and poisons <strong>for</strong> larger animals such as coyote. It<br />
prevents the normal relaxation <strong>of</strong> muscles. This leads to extremely painful convulsions<br />
that closely resemble seizures. It has no effect on the brain so victims are conscious<br />
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during these severe episodes which are very painful and can lead to death from<br />
impairment <strong>of</strong> respiratory muscle function.<br />
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Slide 33<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Convulsions: Management<br />
• Benzodiazepines<br />
• Barbiturates, prop<strong>of</strong>ol<br />
• Pyridoxine<br />
– Empiric dose, 5 gms (70 mg/kg)<br />
Excitation<br />
Inhibition<br />
Excitation<br />
Inhibition<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
33<br />
The clinical management <strong>of</strong> seizures attempts to balance the loss <strong>of</strong> inhibitory tone by<br />
supplying a sedative that enhances inhibitory tone. Examples <strong>of</strong> sedatives that are<br />
given to control excitation and seizures include benzodiazepines, barbiturates and<br />
prop<strong>of</strong>ol.<br />
In selected circumstances, pyridoxine is also used, although it is not a sedative. It is a<br />
critical co-vitamin whose administration along with a benzodiazepine may be required in<br />
poisoning by monomethylhydrazine (rocket fuel) or INH (an anti-tuberculosis<br />
medication).<br />
Excitatory toxins cause convulsions and seizures which if prolonged can be rapidly fatal.<br />
The best way to treat this is to give inhibitory drugs or agents to stop the convulsions<br />
and seizures. Overly excited states are generally much more dangerous than overly<br />
inhibited states. In addition to the seizures and convulsions many excitatory agents<br />
cause changes in heart rate and blood pressure and other bodily functions that are <strong>of</strong>ten<br />
difficult to manage. In some cases the best treatment <strong>for</strong> an overly excited state is to<br />
use inhibitory agents to place the patient in a comatose and overly inhibited state which<br />
is easier to manage and can be maintained until the excitatory toxin effect has worn <strong>of</strong>f.<br />
Benzodiazepines, barbiturates, and prop<strong>of</strong>ol are all examples <strong>of</strong> available<br />
pharmaceutical agents that can be used to produce inhibition and at high doses can be<br />
used to place the patient in a comatose state. Pyridoxine refers to vitamin B-6 which as<br />
described in the previous slide may be needed to treat convulsions and seizures from<br />
hydrazines or other compounds that interfere with normal vitamin B-6 usage in the brain.<br />
Although we give sedative agents to patients presenting with excitation, we never give<br />
excitation agents to patients with coma because the complications <strong>of</strong> causing undue<br />
excitation in these previously comatose patients outweighs the benefits <strong>of</strong> suddenly<br />
waking them up. Naloxone which is not a stimulant awakens opioid intoxicated patients<br />
NOT by stimulating them but by actually BLOCKING the opioid receptors and preventing<br />
continuing opioid effects.<br />
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Slide 34<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
www.squidy.150m.com<br />
“Playing with Our Mind ”<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
34<br />
Let’s turn to the last concept – alteration <strong>of</strong> thought, <strong>of</strong>ten manifested as hallucinations.<br />
These screen shots are from Nightmare at 20,000 feet, a classic episode from the 1960s<br />
television series Twilight Zone. Bob Wilson (played by William Shatner), the character<br />
on this slide, is a salesman on a plane <strong>for</strong> the first time since his nervous breakdown six<br />
months ago. He spots a gremlin on the wing <strong>of</strong> the plane. Every time someone else<br />
looks out the window the gremlin moves out <strong>of</strong> view, so nobody believes Bob. Although<br />
at the end he is whisked away in a straitjacket, this was not drug-induced modulation <strong>of</strong><br />
thought. However, if you have seen the show, it sends a chill up and down your spine<br />
knowing what he went through - both the difficulty in convincing others <strong>of</strong> what he had<br />
seen and dealing with his own fear.<br />
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Slide 35<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Hallucinogens<br />
• Alter modulation <strong>of</strong> thought processes<br />
– Serotonergic<br />
– Sympathomimetic<br />
– Anticholinergic<br />
– Anesthetic (PCP and ketamine)<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
35<br />
Although the actual mechanisms by which hallucinogens act on our brain vary, the<br />
clinical syndrome produced is qualitatively similar. We lose the ability to interpret and<br />
interact with our environment. There are a number <strong>of</strong> different classes <strong>of</strong> drugs which<br />
alter the modulation <strong>of</strong> the thought process. This slide lists 4 classes <strong>of</strong> drugs or<br />
chemicals that alter thought processes: serotonergic, sympathomimetic, anticholinergic<br />
and anesthetic. We will discuss examples <strong>of</strong> two <strong>of</strong> these (serotinergic and<br />
anticholinergic) in greater depth.<br />
Four <strong>of</strong> the classes <strong>of</strong> drugs or chemicals that alter modulation <strong>of</strong> thought processes are<br />
the following:<br />
1. Seroternergic – These drugs/chemicals after the transmission <strong>of</strong> the neurotransmitter<br />
serotonin. An example <strong>of</strong> an hallucinogenic agent which affects serotonin<br />
neurotransmission is LSD.<br />
2.Sympathomimetic – These drugs/chemicals stimulate the sympathetic nervous<br />
system. Norepinephrine (also known as adrenaline) is one <strong>of</strong> the neurotransmitters<br />
which serves as a modulator in the sympathetic nervous system. The street drug –<br />
methamphetamine – is an example <strong>of</strong> a sympathomimetic compound. Use <strong>of</strong> this drug<br />
can cause hallucinations.<br />
3.Anticholinergic – Drugs or chemicals that are anticholinergic block the neurotransmitter<br />
known as acetylcholine. Acetycholine is involved in a wide variety <strong>of</strong> bodily functions<br />
including muscle activity, heart (cardiac) activity and central nervous system (brain)<br />
activity. Anticholinergic drugs block the receptors which acetylcholine stimulate. By<br />
blocking these receptors anticholinergic drugs prevent normal function <strong>of</strong> the brain (and<br />
other target organs such as the heart and muscles). Hallucinations may result. An<br />
example <strong>of</strong> an anticholenergic drug is atropine. A plant with anticholinergic chemicals is<br />
jimson weed.<br />
4.Anesthetics – Some anesthetics – drugs used in anesthesia – also cause<br />
hallucinations. Ketamine is an anesthetic drug which at high doses frequently causes<br />
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hallucinations. PCP (phencyclidine) is similar in structure to ketamine and causes<br />
hallucinations as well.<br />
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Slide 36<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Serotonergic Hallucinogens<br />
• LSD<br />
• Tryptamines (DMT, 5 -MeO-<br />
DMT, psilocybin)<br />
• Ololiuqui (morning glory<br />
seeds)<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
36<br />
Serotonin is a widely distributed neurotransmitter in the brain. Excess serotonin in<br />
certain regions <strong>of</strong> the brain leads to delirium and hallucinations. A number <strong>of</strong> intoxicants<br />
and drugs <strong>of</strong> abuse enhance the effects <strong>of</strong> serotonin including LSD, tryptamines, and<br />
some amphetamines.<br />
Many <strong>of</strong> these compounds have been abused <strong>for</strong> their hallucinogenic effects. LSD or<br />
“acid” is probably the most famous <strong>of</strong> these.<br />
Psilocybin is found in hallucinogenic mushrooms. DMT (dimethyl tryptamine) and 5-<br />
MEO-DMT (5-methoxy dimethyl tryptamine) are “designer drugs.” These drugs are<br />
chemical modifications <strong>of</strong> other drugs. Such modifications may enhance their<br />
hallucinogenic effects.<br />
Morning glory seeds (also known as ololiuqui) and other plant hallucinogens such as<br />
mushrooms and certain cacti are used recreationally <strong>for</strong> their effects. While they are<br />
unlikely to cause any permanent or serious harm to people exposed in a terrorist<br />
situation – they can incapacitate a large number <strong>of</strong> people and prevent them from<br />
responding rationally or appropriately to a given situation.<br />
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Slide 37<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Serotonergic Hallucinogens<br />
• 1968 - The Yippies (Youth<br />
International Party)<br />
• Threatened to “space-out” or<br />
“turn on” the delegates to the<br />
Democratic National Convention<br />
in Chicago, and everyone else in<br />
Chicago as well, by dumping<br />
LSD into Lake Michigan.<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
37<br />
In 1968 the Yippies threatened to “space out” delegates to the Democratic Convention<br />
by dumping LSD into Lake Michigan. Although highly potent, the amount <strong>of</strong> water in<br />
Lake Michigan would dilute the drug to the point <strong>of</strong> having no effect on people who drank<br />
it. Water contamination and dilutional effects will be discussed in greater detail in the<br />
Food/Water/Medication Module.<br />
LSD is potent at very small doses. However, given the tremendous volume <strong>of</strong> water in<br />
Lake Michigan, contaminating the Lake with enough LSD to produce a concentration <strong>of</strong><br />
LSD in the water that would have caused any noticeable effect was very far-fetched.<br />
The dilutional effects <strong>of</strong> the water would have limited the LSD concentration to a<br />
negligible amount.<br />
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Slide 38<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Anticholinergic Hallucinogens<br />
Atropine, Scopolamine and Hyoscyamine<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
38<br />
Anticholinergic drugs can also cause hallucinations. At low doses they have beneficial<br />
therapeutic uses. At higher doses they may cause hallucinations. Cruise ship<br />
passengers <strong>of</strong>ten use scopolamine, an anticholinergic drug, in the <strong>for</strong>m <strong>of</strong> a transdermal<br />
patch, to prevent sea sickness. Occasionally, passengers, who excessively absorb the<br />
scopolamine through their skin, begin to hallucinate.<br />
Teenagers may read on the Internet about a “free, natural, and safe” high that can be<br />
obtained if they brew a tea, or sometimes smoke seeds from the Thornapple or<br />
Jimsonweed plant (shown to the right). These plants have scopolamine and atropine<br />
(another anticholinergic agent) as their main ingredients and exposure to these<br />
chemicals may result in potent anticholinergic hallucinations –that may last <strong>for</strong> days.<br />
Anticholinergics chemicals are found in a wide range <strong>of</strong> drugs and plants. These include<br />
not only the plants mentioned above, but also a number <strong>of</strong> pharmaceutical agents<br />
including many antihistamines such as diphenhydramine.<br />
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Slide 39<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Mad as a hatter<br />
• Red as a beet<br />
• Dry as a bone<br />
• Hot as Hare<br />
• Blind as a bat<br />
• Full as a flask<br />
(Also decreased GI motility)<br />
Clinical Effects<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
39<br />
The clinical effects produced by an anticholinergic drug or chemical can be remembered<br />
by recalling the first letter <strong>of</strong> this alliteration/poetic mnemonic: "blind as a bat, mad as a<br />
hatter, red as a beet, hot as a hell, dry as a bone, the bowel and bladder lose their tone,<br />
and the heart runs alone."<br />
The clinical effects from anticholinergic exposure include the following:<br />
1. Altered mental status – abnormal and <strong>of</strong>ten bizarre behavior where the patient may<br />
appear very agitated and <strong>of</strong>ten simply “delirious” or “mad.” These patients are <strong>of</strong>ten<br />
pr<strong>of</strong>oundly altered and may exhibit bizarre movements and appear to be picking at<br />
things. They are usually awake but <strong>of</strong>ten do not respond appropriately to questions and<br />
commands. Their speech is slurred and difficult to understand and their answers <strong>of</strong>ten<br />
have nothing to do with the questions asked <strong>of</strong> them. This type <strong>of</strong> delirium can be very<br />
disabling and may last <strong>for</strong> hours even to days depending on the particular anticholinergic<br />
compound and on the dose consumed. The “hatter” reference refers to workers who<br />
were exposed to mercury during the production <strong>of</strong> felt hats. While mercury is not an<br />
anticholinergic chemical, exposure to mercury could also result in an altered mental<br />
status.<br />
2. Red – patients appear quite flushed in appearance, almost as red as a beet<br />
3. Dry – patients suffering from anticholinergic effects <strong>of</strong>ten have very dry skin and do<br />
not perspire or sweat despite their agitation<br />
4. Hot – because <strong>of</strong> the agitation and the inability to sweat, patients <strong>of</strong>ten have elevated<br />
body temperature and fever<br />
5. Another anticholinergic effect is the presence <strong>of</strong> dilated pupils. The pupil size is <strong>of</strong>ten<br />
much larger than normal with each pupil measuring as much as 7 or 8 mm in diameter<br />
(normal pupil diameter is 3-4 mm). The dilation <strong>of</strong> the pupils is referred to as mydriasis.<br />
Patients with large pupils have difficulty focusing and because <strong>of</strong> their inability to focus –<br />
they may appear “blind”<br />
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6. Anticholinergics also cause severe constipation and an inability to urinate. Hence<br />
these patients may appear very “full” and have a large distended bladder and their colon<br />
may be full <strong>of</strong> stool.<br />
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Slide 40<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Modern History<br />
• 1676: a group <strong>of</strong> men led by Captain John Smith were sent<br />
to Jamestown, Virginia to quell the Bacon rebellion.<br />
• Gathered the plant now<br />
known as “Jamestown<br />
weed” (or Jimsonweed),<br />
Datura stramonium , <strong>for</strong> a<br />
salad.<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
40<br />
An example <strong>of</strong> a mass poisoning with an anticholinergic compound occurred in<br />
Jamestown Virginia in 1676 during a colonial uprising known as Bacon’s rebellion.<br />
Of great toxicological interest, the British soldiers who were sent by the Colonial<br />
government to put down the rebellion ate a salad which mistakenly included<br />
Jimsonweed as one <strong>of</strong> its ingredients. The jimsonweed plant’s leaves (depicted an this<br />
slide) look like a more typical salad leaf (arugula), with scalloped edges and dark green<br />
color, and this is probably how the error occurred.<br />
Jimson weed contains the anticholinergic chemicals atropine and scopolamine. The<br />
picture on the slide also displays the characteristic tubular flower (not present in<br />
arugula).<br />
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Slide 41<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Bacon Rebellion<br />
1676, Bacon Rebellion:<br />
The soldiers presented a “very pleasant comedy, <strong>for</strong> they turned<br />
natural fools upon it <strong>for</strong> several days: one would blow a feather in the<br />
air; another would dart straws at it with much fury; and another , stark<br />
naked, was sitting up in a corner like a monkey, grinning and ma king<br />
mows at them. …. A thousand such simple tricks they played, and<br />
after 11 days returned themselves again, not remembering anythin g<br />
that had passed. ”<br />
Robert Beverly, The History and Present State <strong>of</strong> Virginia (1705)<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
41<br />
This is a description excerpted from a book written in 1705 about the Bacon rebellion.<br />
Of note, the anticholinergic hallucinations lasted 11 days. This is likely dose-related as<br />
the soldiers may have continued to eat the plant, and related to the long-lasting effects<br />
on the brain from repetitive administration.<br />
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Slide 42<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
July 1995<br />
Bosniaks fleeing Srebrenica during the war in Bosnia and Hercegovina .<br />
“Survivors gave consistent descriptions <strong>of</strong> mortar shells that pro duced a<br />
‘strange smoke ’ <strong>of</strong> various colors which did not rise but spread out<br />
slowly. Following these attacks, some <strong>of</strong> the marchers - the numbers<br />
are unclear - began to hallucinate and behave in an irrational manner,<br />
Human Rights Watch<br />
with some even killing their friends or themselves. . . . ”<br />
BZ: 3-Quinuclidinyl benzilate (QNB)<br />
Hay A. Surviving the impossible: the long march from Srebrenica. An in vestigation <strong>of</strong><br />
the possible use <strong>of</strong> chemical warfare agents. Med Confl Surviv 1998;14:120 -55.<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
42<br />
BZ is a chemical warfare agent with anticholinergic features, which has been<br />
weaponized by the military <strong>for</strong> possible battlefield use. Its use was implicated in the<br />
activities described above during the Bosnian exodus from Srebrenica in 1995. People<br />
exposed to BZ would be expected to develop an alteration in their mental status and<br />
exhibit hallucinations and act “mad.”<br />
BZ’s <strong>of</strong>ficial chemical name is 3-Quinuclidinyl benzilate. Generally referred to as BZ, this<br />
chemical is also an anticholinergic agent. Exposure to BZ would result in anticholinergic<br />
effects such as those described in the previous slides.<br />
While BZ would not serve as a lethal weapon, the delirium that would result would<br />
render the adversary confused and disoriented and quite ineffectual to fight back.<br />
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Participant Guide<br />
Slide 43<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Anticholinergic Hallucinogens<br />
• Qualitatively similar<br />
Atropine<br />
Scopolamine<br />
BZ<br />
Dose (70 kg)<br />
8-14 mg<br />
2 mg<br />
0.5 mg<br />
Duration<br />
4-8 h<br />
2-4 h<br />
48-72 h<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
43<br />
Although these agents act generally the same, their potency (dose to have an effect)<br />
and the duration <strong>of</strong> effect is quite different.<br />
As can be seen on this slide, BZ is more potent than atropine and scopolamine because<br />
a lower dose is required to cause a comparable effect to those obtained with higher<br />
doses <strong>of</strong> the other anticholinergic agents. This slide also demonstrates that some<br />
anticholinergics have a much longer duration <strong>of</strong> action than others. The effects from BZ<br />
would be expected to last upwards <strong>of</strong> 2-3 days while the effects <strong>of</strong> atropine and<br />
scopolamine are much shorter acting lasting just a few hours.<br />
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Participant Guide<br />
Slide 44<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong><br />
<strong>Terrorism</strong>: <strong>TICs</strong> &<br />
<strong>TIMs</strong><br />
Treatment<br />
strategy<br />
Excitatio<br />
n<br />
Inhibitio<br />
n<br />
Module<br />
Two<br />
- The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong><br />
<strong>Terrorism</strong><br />
4<br />
4<br />
Although the hallucinogenic agents disrupt our thought processes, our treatments<br />
usually focus on enhancing the inhibitory activity <strong>of</strong> the brain.<br />
In other words, we focus on sedation to counter delirium. As depicted on the slide, this<br />
treatment alters the individual’s balance <strong>of</strong> inputs - however, it is easier to provide care<br />
<strong>for</strong> and protect a sedated person than a delirious person.<br />
In the case <strong>of</strong> anticholinergic delirium, a specific antidote is available. The use <strong>of</strong> the<br />
cholinergic drug, physostigmine, can reverse all <strong>of</strong> the anticholinergic effects. This drug<br />
is a useful diagnostic – and therapeutic – tool. However, its duration <strong>of</strong> action is shor<br />
The see-saw depicts the effects <strong>of</strong> treating a hallucinating or delirious patient with a<br />
sedative, thus enhancing the inhibition <strong>of</strong> brain function. Note that this will result in a<br />
sedated patient, with all the potential downside <strong>of</strong> CNS and respiratory depression.<br />
However, it removes the potentially injurious effects seen in patients with altered thought<br />
processes due to unexpected and unpleasant hallucinations.<br />
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Participant Guide<br />
Slide 45<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Concluding Thoughts<br />
• The CNS is a unique target organ <strong>for</strong> terrorism<br />
• Limited number <strong>of</strong> acute clinical consequences<br />
• Management is generally symptomatic although<br />
“antidotes” may be available <strong>for</strong> certain agents.<br />
Module Two - The Clinical Neurotoxicology <strong>of</strong> <strong>Chemical</strong> <strong>Terrorism</strong><br />
45<br />
In conclusion, the central nervous system is a unique target <strong>for</strong> terrorism and there are<br />
many historical examples <strong>of</strong> its use to create social panic and fear. The use <strong>of</strong><br />
neurotoxins as agents <strong>of</strong> terrorism however, will result in a limited number <strong>of</strong> acute<br />
clinical syndromes. Management <strong>of</strong> these syndromes is predominately symptomatic<br />
although antidotes may be available <strong>for</strong> certain agents.<br />
Global brain function can be altered in a limited number <strong>of</strong> ways (inhibition leading to<br />
sedation and coma; excitation leading to agitation and seizures; and altered thought<br />
processes leading to hallucinations and delirium). Recognizing these major toxidromes<br />
will allow better assessment <strong>of</strong> the chemical class(es) involved and allow appropriate<br />
treatment to be initiated.<br />
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Participant Guide<br />
Slide 46<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Questions<br />
Training Support Package<br />
46<br />
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Participant Guide<br />
Module Two Summary<br />
The Central Nervous System is a unique target organ <strong>for</strong> chemical terrorism. Despite its<br />
complexity, the brain really only displays its dysfunction in a limited number <strong>of</strong> ways. This<br />
includes CNS depression (sedation), CNS excitation (seizure) and possibly altered thoughts, as<br />
with hallucinations. There<strong>for</strong>e, the use <strong>of</strong> certain chemicals as agents <strong>of</strong> terrorism will result in a<br />
limited number <strong>of</strong> acute clinical consequences. Management is generally symptomatic although<br />
“antidotes” may be available <strong>for</strong> certain agents.<br />
The normal state <strong>of</strong> the brain is maintained by balancing both excitation and inhibition, each<br />
mediated by a unique set <strong>of</strong> chemicals called neurotransmitters. We alter our neurotransmitters<br />
under normal conditions to suit our needs. For example, in order to sleep we increase inhibition<br />
and reduce excitations. Other neurotransmitters play a role in our functional abilities, or our<br />
ability to process in<strong>for</strong>mation smoothly. For example, Serotonin and Acetylcholine serve as<br />
modulators <strong>of</strong> our thought processes. <strong>Chemical</strong> (drugs) typically cause sedation or coma by<br />
enhancing our inhibitory tone, not by reducing excitation. <strong>Chemical</strong>s (drugs) typically cause<br />
seizures by enhancing excitation or reducing inhibition. The alteration <strong>of</strong> the flow <strong>of</strong> in<strong>for</strong>mation<br />
in our brain results in hallucinations. Sensory input is unfiltered resulting in sensory overload,<br />
causing hallucinations.<br />
Sedatives have the potential to be used by terrorists. The Moscow theater hostage crisis was<br />
the seizure <strong>of</strong> a crowded Moscow theatre on October 23, 2002 by about 40 armed Chechen<br />
militants. They took 850 hostages and demanded the withdrawal <strong>of</strong> Russian <strong>for</strong>ces from<br />
Chechnya and an end to the Second Chechen War. After a two-and-a-half day siege, Russian<br />
special <strong>for</strong>ces pumped weaponized Fentanyl (maybe carfentanil)- into the building's ventilation<br />
system and raided it. Officially, 39 <strong>of</strong> the terrorists were killed by Russian <strong>for</strong>ces, along with at<br />
least 129 <strong>of</strong> the hostages. Some estimates have put the civilian death toll at more than 200<br />
people.<br />
Most central nervous system depressants are associated with some degree <strong>of</strong> respiratory<br />
depression. Some like the opioids are associated with pr<strong>of</strong>ound respiratory depression,<br />
explaining the high fatality rate in the Moscow theater. The opioid toxidrome (toxicological<br />
syndrome) is relatively easy to recognize, particularly <strong>for</strong> medical personnel, since it is<br />
commonly noted in heroin users. Treatment involves administration <strong>of</strong> an antidote called<br />
naloxone (Narcan). Ventilatory support may be necessary and <strong>for</strong> extended periods <strong>of</strong> time.<br />
The use <strong>of</strong> toxic convulsants creates another clinical syndrome that may appear convulsions or<br />
seizure. The term seizure refers to the underlying brain activity whereas convulsion is what you<br />
see when you look at the patient; the movement. Some convulsant toxins are not seizure<br />
inducing, such as strychnine.<br />
Tetramine (rat poisoning) has been reportedly used several times in epidemic poisoning in<br />
China. Other convulsant poisons that are relatively easy to access include organophosphorus<br />
and carbamate insecticides, along with nicotine, hydrazines, camphor, and organochlorines and<br />
strychnine.. Their use in an act <strong>of</strong> terrorism is a distinct possibility. The clinical management <strong>of</strong><br />
seizures attempts to balance the loss <strong>of</strong> inhibitory tone by supplying a sedative that enhances<br />
inhibitory tone.<br />
Hallucinogens. Although the actual mechanisms by which hallucinogens act on our brain vary,<br />
the clinical syndrome produced is qualitatively similar. We lose the ability to interpret and<br />
interact with our environment. Hallucinogens may be used by terrorists as incapacitating agents.<br />
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Participant Guide<br />
The anticholinergic hallucinogens have a long history <strong>of</strong> use, and drugs such as scopolamine<br />
are in current use as transdermal patches. A common occurrence on cruise ships is an elderly<br />
passenger who is using a transdermal scopolamine patch who begins hallucinating due to<br />
excessive absorption through their thin skin. The treatment <strong>for</strong> hallucinations is generally<br />
supportive with the additional use <strong>of</strong> sedatives (enhancing inhibition) to allow the drug to be<br />
eliminated.<br />
In conclusion, The CNS is a unique target organ <strong>for</strong> terrorism yet there are a limited number <strong>of</strong><br />
acute clinical consequences that may result from the deliberate exposure to toxins.<br />
Management is generally symptomatic although “antidotes” may be available <strong>for</strong> certain agents.<br />
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Participant Guide<br />
Module Three<br />
Toxic Industrial Gases as Terrorist Threats - Administration<br />
Page<br />
<strong>Chemical</strong> compounds are produced in massive quantities as part <strong>of</strong> America's industrial<br />
complex. Many <strong>of</strong> these compounds are amenable to use as large scale terrorist weapons.<br />
These chemicals are produced, transported, and stored in communities across our nation and<br />
are easily accessible by all. These chemicals pose a significant health risk to individuals and<br />
populations should they be released either intentionally or accidentally. Exposure to toxic gases<br />
will create serious health implication <strong>for</strong> victims. Many <strong>of</strong> these irritive gases, such as chlorine,<br />
phosgene, and ammonia, exert their effects by the production <strong>of</strong> corrosive agents, such as<br />
hydrochloric acid and ammonium hydroxide. Other agents, such as hydr<strong>of</strong>luoric acid, also<br />
produce systemic effects. Individual characteristics <strong>of</strong> each gas will determine its toxicity and<br />
health effects. Quick response and appropriate clinical management will be critical to reducing<br />
morbidity and mortality. Prevention includes methods to decrease the likelihood <strong>of</strong> exposure and<br />
mitigation ef<strong>for</strong>ts will be important. Current legislation under the community right to know act<br />
mandates disclosure <strong>of</strong> the presence <strong>of</strong> toxic chemicals within communities.<br />
Duration<br />
45 minutes<br />
Scope Statement<br />
This module will address a number <strong>of</strong> chemicals, such as phosgene, chlorine, and anhydrous<br />
ammonia, which might be disseminated as inhalational threats. Historical examples <strong>of</strong> the<br />
release <strong>of</strong> these gases and their impact on the community will be reviewed. Their<br />
pathophysiology, treatment, and potential sources in the community and in the transportation<br />
system will be discussed.<br />
Terminal Learning Objective (TLO)<br />
• Understand the threat posed by toxic industrial gases and the<br />
recognition, assessment and management <strong>of</strong> exposed patients.<br />
Enabling Learning Objectives (ELO)<br />
Resources<br />
• Review the history <strong>of</strong> industrial gas exposures and regulatory<br />
response<br />
• Identify major compounds <strong>of</strong> interest<br />
• Understand the varying clinical picture created by the gases, based<br />
on their physical properties and toxicity<br />
• Address methods to decrease likelihood <strong>of</strong> exposure and illness<br />
Each <strong>of</strong> the eight course modules is deployed as an interactive, instructor-lead, MS PowerPoint<br />
presentation containing didactic content, historical examples, and selected case studies. All<br />
presentations are included in a printed participant guide (PG) containing the modules’ overview,<br />
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Training Support Package<br />
Participant Guide<br />
scope statement, terminal and enabling learning objectives, PowerPoint slide handouts, and a<br />
summary section.<br />
Instructor to Participant Ratio<br />
1:8 (minimum) to 1:25 (maximum)<br />
Reference List<br />
1. AEGL List <strong>of</strong> <strong>Chemical</strong>s:<br />
http://earth1.epa.gov/oppt/aegl/pubs/chemlist.htm<br />
2. ATSDR ToxFAQs (choose by chemical):<br />
http://www.atsdr.cdc.gov/toxfaq.html<br />
3. ATSDR Medical Management Guidelines:<br />
http://www.atsdr.cdc.gov/MHMI/mmg.html#bookmark03<br />
4. Bardana EJ Jr. Reactive airways dysfunction syndrome (RADS):<br />
guidelines <strong>for</strong> diagnosis and treatment and insight into likely<br />
prognosis. Ann Allergy, Asthma, Immunol 1999; 83(6 Pt 2):583-586.<br />
5. Belke JC. <strong>Chemical</strong> accident risks in U.S. industry -A preliminary<br />
analysis <strong>of</strong> accident risk data from U.S. hazardous chemical facilities.<br />
Last accessed Dec 2008 from:<br />
http://www.epa.gov/ceppo/pubs/stockholmpaper.pdf<br />
6. Bosse GM. Nebulized sodium bicarbonate in the treatment <strong>of</strong> chlorine<br />
gas inhalation. J Tox Clin Tox 1994;32(3):233-241.<br />
7. BP Facilities Lead Nation in <strong>Chemical</strong> and Refinery Accidents Since<br />
1990, Despite Industry-Touted Safety Measures” (Report by Texas<br />
Public Interest Research Group on HF Release). Last accessed Dec<br />
2008 from: http://www.commondreams.org/news2005/0324-09.htm<br />
8. CDC. Public Health Consequences from Hazardous Substances<br />
Acutely Released During Rail Transit ---South Carolina, 2005;<br />
Selected States, 1999-2004. MMWR 54(3):64-67. Last accessed Dec<br />
2008 from:<br />
http://iier.isciii.es/mmwr/preview/mmwrhtml/mm5403a2.htm<br />
9. <strong>Chemical</strong> Safety and Hazard Investigation Board (listing <strong>of</strong> chemical<br />
company events and investigations): http://www.chemsafety.gov/<br />
10. Chin S-M, Hwang H-L, Peterson BE. “A Tool <strong>for</strong> Railroad Hazmat<br />
Routing Under Shipment Bans In Major Cities” [PowerPoint<br />
presentation from Oak Ridge Laboratory at Transportation Research<br />
Board 85th Annual Meeting, 2006]. Last accessed Dec 2008 from:<br />
http://projects.battelle.org/trbhazmat/Presentations/TRB2006-LH.ppt<br />
11. Dhara VR, Dhara R. The Union Carbide disaster in Bhopal: a review<br />
<strong>of</strong> health effects. Arch Environ Health 2002;57:391-404.<br />
12. EPA’s Acute Exposure Guideline Levels (AEGL) Definitions:<br />
http://earth1.epa.gov/oppt/aegl/pubs/define.htm<br />
13. EPA’s High Production Volume In<strong>for</strong>mation System (characterizing<br />
chemicals produced or imported at > 1 million pounds):<br />
http://www.epa.gov/hpvis/<br />
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Training Support Package<br />
Participant Guide<br />
14. EU Health & Safety Executive report from Control <strong>of</strong> Major Accidental<br />
Hazards- COMAH. Last accessed Dec 2008 from:<br />
http://www.hse.gov.uk/comah/sragtech/caseuncarbide84.htm<br />
15. Klasner A, Scalzo A, Blume C, Johnson P, Thompson M. Marked<br />
hypocalcemia and ventricular fibrillation in two pediatric patients<br />
exposed to a fluoride-containing wheel cleaner. Ann Emerg Med<br />
1996;28(6):713-718.<br />
16. Lapierre D and Moro J. Five Past Midnight in Bhopal: The Epic Story<br />
<strong>of</strong> the World’s Deadliest Industrial Disaster. Hatchett Book Group,<br />
Grand Central Publishing, New York; 2002.<br />
17. Lee DC, Wiley JF 2nd, Synder JW 2nd.Treatment <strong>of</strong> inhalational<br />
exposure to hydr<strong>of</strong>luoric acid with nebulized calcium gluconate. J<br />
Occup Med 1993;35:470.<br />
18. Military Textbook <strong>of</strong> Medicine: Medical Aspects <strong>of</strong> <strong>Chemical</strong> and<br />
Biological Warfare. Last accessed Dec 2008 from:<br />
http://www.bordeninstitute.army.mil/published_volumes/chemBio/Ch9.<br />
pdf<br />
19. Muller, R. A Significant Toxic Event: The Union Carbide Pesticide<br />
Plant Disaster in Bhopal, India, 1984. Last accessed Dec 2008 from:<br />
http://www.tropmed.org/rreh/vol1_10.htm<br />
20. National Library <strong>of</strong> Medicine ChemIdLite Site (choose by chemical;<br />
access to databases):<br />
http://chem.sis.nlm.nih.gov/chemidplus/chemidlite.jsp<br />
21. National Research Council. Emergency and Continuous Exposure<br />
Limits <strong>for</strong> Selected Airborne Contaminants, V2;National Academy<br />
Press, Washington D.C.; 2000. Last accessed Dec 2008 from:<br />
http://books.nap.edu/openbook.phprecord_id=690&page=69<br />
22. National Transportation Safety Board Graniteville SC crash accident<br />
report. Last accessed Dec 2008 from:<br />
http://www.ntsb.gov/publictn/2005/RAR0504.pdf<br />
23. Noltkamper D, Burgher SW, Toxicity, Phosgene. eMedicine from<br />
WebMD. Last accessed Dec 2008 from:<br />
http://www.emedicine.com/emerg/topic849.htm<br />
24. Sriramachari S, Chandra H. Pathology and toxicology <strong>of</strong> methyl<br />
isocyanate and MIC derivatives in Bhopal disaster. Last accessed<br />
Dec 2008 from:<br />
www.anchem.su.se/isocyanate2000/abstracts/abs_chandra.html<br />
25. Wibbenmeyer LA, Morgan LJ, Robinson BK, et al. <strong>Chemical</strong> burn<br />
injuries: exposing the dangers <strong>of</strong> anhydrous ammonia. Journal <strong>of</strong> Burn<br />
Care & Rehabilitation 1999;20 (vol 3):226-232.<br />
26. Woodward JL, Woodward HZ. “Analysis <strong>of</strong> hydrogen fluoride release<br />
at Texas city.” Process Safety Progress 2004;17(3):213-218.<br />
27. World Health Organization. Health and Safety Guide No. 106:<br />
Phosgene. International Programme on <strong>Chemical</strong> Safety (IPCS);<br />
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Participant Guide<br />
Practical Exercise Statement<br />
Geneva, 1998. Last accessed Dec 2008 from:<br />
http://www.inchem.org/documents/hsg/hsg/hsg106.htm<br />
Each module presentation contains one or more interactive audience response questions<br />
designed to drive discussion, promote participant engagement, and test knowledge. Through<br />
the use <strong>of</strong> the Meridia® Audience Response system, participant responses can be collected,<br />
tabulated, and displayed within the presentation in real time. In order to use the interactive<br />
slides accompanying this presentation, the lecture hall must be equipped with the Meridia®<br />
Audience Response system and user keypads. In addition, a copy <strong>of</strong> the “Meridia® Q&A”<br />
s<strong>of</strong>tware component <strong>for</strong> MS PowerPoint must be installed on the presenter’s computer.<br />
Assessment Strategy<br />
Participant progress toward course learning objectives is monitored through in<strong>for</strong>mal discussion<br />
and responses to each module’s practical exercise questions. Overall mastery <strong>of</strong> module<br />
content and concepts is documented by means <strong>of</strong> a comprehensive, end-<strong>of</strong>-day posttest<br />
touching on key learning objectives from each module. Each participant must obtain a score <strong>of</strong><br />
80% or better to successfully complete the training and obtain a course completion certificate.<br />
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Training Support Package<br />
Participant Guide<br />
Module Three<br />
Icon Map<br />
Knowledge Check: Used when it is time to assess the learners’ understanding<br />
Example: Used when there is a descriptive illustration to show or explain<br />
Key Points: Used to convey essential learning concepts, discussions and introduction <strong>of</strong><br />
supplemental material<br />
Hint: Used to cover administrative items or instructional tips that aid in the flow <strong>of</strong> the<br />
instruction<br />
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Training Support Package<br />
Participant Guide<br />
Slide 1<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Module Three<br />
Toxic Industrial Gases as Terrorist Threats<br />
Training Support Package<br />
1<br />
This lecture will focus on high production volume industrial gases that are present<br />
throughout the country, the threat they pose as terroristic agents, and the measures<br />
taken to reduce that threat.<br />
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Participant Guide<br />
Slide 2<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Learning Objectives<br />
• Review history <strong>of</strong> industrial gas exposures and<br />
regulatory response<br />
• Identify major compounds <strong>of</strong> interest<br />
• Understand the varying clinical picture created by<br />
the gases, based on their physical properties and<br />
toxicity<br />
• Address methods to decrease likelihood <strong>of</strong> exposure<br />
and illness<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
2<br />
Beyond just identification <strong>of</strong> some <strong>of</strong> the major compounds in this group, this<br />
presentation will provide the participant with an understanding <strong>of</strong> the characteristic<br />
toxidromes associated with these gases, and familiarity with the national legislative and<br />
regulatory framework and local implementation that encourages threat reduction.<br />
The learning objectives <strong>for</strong> this module are as follows:<br />
Review history <strong>of</strong> industrial gas exposures and regulatory response<br />
Identify major compounds <strong>of</strong> interest<br />
Understand the varying clinical picture created by the gases, based on their physical<br />
properties and toxicity. We will discuss the physical properties in detail with each gas.<br />
Of note, the type <strong>of</strong> clinical injury seen is dependant not only on dose and inherent<br />
toxicity, but also water solubility.<br />
Address methods to decrease likelihood <strong>of</strong> exposure and illness<br />
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Participant Guide<br />
Slide 3<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Key Learning Points<br />
• Legislation to regulate <strong>TICs</strong>/<strong>TIMs</strong> was generated by concerns<br />
regarding toxic gases<br />
• Releases <strong>of</strong> large volumes <strong>of</strong> compressed gas is the most<br />
likely TIC/TIM scenario<br />
• Toxicity <strong>of</strong> a gas is determined by<br />
– Dose<br />
– Inherent toxicity<br />
– Volatility<br />
– Water solubility<br />
– Warning properties<br />
– pH<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
3<br />
Recognize that much <strong>of</strong> the chemical legislation in this country and elsewhere grew out<br />
<strong>of</strong> concern following large-scale exposures. We will present several major chemical<br />
releases in this module.<br />
By far, releases <strong>of</strong> these agents <strong>for</strong>m the most likely TIC/TIM scenario. These are the<br />
physical characteristics <strong>of</strong> an irritant gas that predict its specific toxicity – in particular,<br />
water solubility.<br />
Toxicity <strong>of</strong> a gas is determined:<br />
Dose<br />
Inherent toxicity<br />
Volatility<br />
Water solubility<br />
Warning properties<br />
pH<br />
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Participant Guide<br />
Slide 4<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
The Bhopal Disaster (1984)<br />
• Methyl isocyanate (MIC)<br />
release<br />
Union Carbide plant in<br />
Bhopal, India (December 3,<br />
1984)<br />
http://www.lenntech.com/environmental<br />
-disasters.htm<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
4<br />
Releases <strong>of</strong> toxic industrial gases <strong>for</strong>m the most likely TIC/TIM scenario.<br />
Much <strong>of</strong> the chemical legislation in this country and elsewhere grew out <strong>of</strong> concern<br />
following large-scale exposures.<br />
The release <strong>of</strong> more than 40 tons <strong>of</strong> methyl isocyanate (MIC) from the Union Carbide<br />
plant in Bhopal, India in December 1984 is the best example <strong>of</strong> a large-scale industrial<br />
release <strong>of</strong> a gas. Although this is generally considered to be an industrial accident, it<br />
highlights many key features <strong>of</strong> a terrorist event, including the scope <strong>of</strong> injury – both<br />
acute and chronic, the failure <strong>of</strong> control measures, and the inadequacy <strong>of</strong> medical<br />
response. There were considerably more casualties and more deaths from this<br />
industrial event than any terrorist event to date.<br />
This slide depicts some <strong>of</strong> the features <strong>of</strong> the methyl isocyanate release and failures <strong>of</strong><br />
intended control measures at the Union Carbide plant in Bhopal, India. This plant was in<br />
the process <strong>of</strong> being shut down and staffing and maintenance were not at their usual<br />
levels.<br />
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Slide 5<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Bhopal Disaster<br />
• Water entered tank containing 57,000 L MIC<br />
– sabotage<br />
• Exothermic reaction<br />
• Release <strong>of</strong> >40 tons MIC over 2 hrs<br />
• Multiple safety system failures<br />
– unreliable pressure gauges<br />
– nonfunctional refrigeration unit<br />
– inoperable gas scrubber<br />
– alarm failure<br />
– Inadequate spray “knock -down”<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
5<br />
During this event, which occurred in the middle <strong>of</strong> the night, water entered a tank that<br />
was supposed to be empty, but actually contained about 57,000 liters <strong>of</strong> MIC, resulted in<br />
an exothermic reaction with the massive release <strong>of</strong> more than <strong>for</strong>ty tons <strong>of</strong> MIC over a<br />
couple <strong>of</strong> hours, which then drifted downwind over the slums <strong>of</strong> Bhopal. The release<br />
itself involved multiple system failures in terms <strong>of</strong> plant based operations that were<br />
supposed to prevent or mitigate against this type <strong>of</strong> event. Pressure gauges were not<br />
functioning, the refrigeration unit was not functioning, there was an inoperable scrubber<br />
that should have reduced or knocked down some <strong>of</strong> the ascending plume, and alarms<br />
failed, resulting in a large release over this area.<br />
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Slide 6<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Bhopal Disaster<br />
• Gas plume drifted over shanty -<br />
town exposing 250,000 people<br />
• Temperature inversion reduced<br />
plume dilution<br />
• Extent <strong>of</strong> risk:<br />
– Modeled mean MIC ambient<br />
concentration: 27 ppm (range<br />
0.12 -85.6 ppm)<br />
– Median MIC concentration: 1.8<br />
ppm<br />
– 30 minute Acute Emergency<br />
Guideline Level -3 (AEGL3) 0.40<br />
ppm<br />
http:// www.bhopal.org/whathappened.html<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
6<br />
Approximately 250,000 people were exposed to the MIC gas fume. A temperature<br />
inversion in the local area reduced the extent <strong>of</strong> a plume dilution effect that would have<br />
occurred under normal weather conditions. After the fact, modeling suggested a median<br />
air concentration <strong>of</strong> MIC <strong>of</strong> 1.8 ppm. This exceeded the AEGL-3 <strong>of</strong> 0.40 ppm which was<br />
the predicted airborne concentration above which people are likely to experience life<br />
threatening health effects or death.<br />
Temperature inversions occur when the temperature <strong>of</strong> the atmosphere increases with<br />
height. During a temperature inversion, warm air traps cool air below, acting like a lid.<br />
Pollutants below the inversion are trapped, allowing them to build up. In the Bhopal<br />
case the temperature inversion limited the usual dilutional effect <strong>of</strong> the chemical plume<br />
increasing the airborne concentration <strong>of</strong> the MIC.<br />
AEGLs are “acute exposure guideline levels” which have been developed <strong>for</strong> a number<br />
<strong>of</strong> chemicals. The modeled concentrations after this release were quite a bit above the<br />
threshold <strong>for</strong> devastating health effects, consistent with the actual events.<br />
The map on the slide depicts the modeled distribution <strong>of</strong> the methyl isocyanate plume<br />
following this release. The darker shading indicates higher gas concentration. The extent<br />
<strong>of</strong> heavy concentration represents the lack <strong>of</strong> dilutional effect from the temperature<br />
inversion and low wind speed. Note the extension in all directions with more prominence<br />
towards the south, also representing the effects <strong>of</strong> a low wind speed.<br />
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Slide 7<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Bhopal Disaster<br />
• 2500 fatalities within 1 week<br />
• Long term mortality<br />
estimated ≥ 6000<br />
• Chronic disability <strong>for</strong> ><br />
100,000 ()<br />
– chronic pulmonary complaints<br />
– ocular inflammation<br />
Dhara et al, Arch Environ Health 2002; 57:391 -404<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
7<br />
The numbers <strong>of</strong> deaths and injuries from this disaster had never previously been seen<br />
from an industrial accident. Within the first week more than 2000 residents <strong>of</strong> Bhopal<br />
died from the acute toxic effects <strong>of</strong> this chemical release. Additional thousands died in<br />
the ensuing weeks and months. Long term pulmonary and eye injuries were thought to<br />
have affected at least 100,000 people.<br />
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Slide 8<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methyl Isocyanate (MIC):<br />
H3C–N=C=O<br />
• Used as a chemical intermediary <strong>for</strong> many products,<br />
including carbamate insecticides, polyurethane foam<br />
and a variety <strong>of</strong> plastics<br />
• Usually produced by reacting methylamine and<br />
phosgene with release <strong>of</strong> hydrochloric acid<br />
• A high production volume chemical, as are its<br />
reagents<br />
• Combustion products from MIC may include cyanide<br />
and carbon monoxide<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
8<br />
Prior to the Bhopal disaster, relatively little was known about methyl isocyanate. The<br />
Bhopal plant was producing a carbamate pesticide called carbaryl (Sevin). Methyl<br />
isocyanate was a chemical intermediate that was produced in the production <strong>of</strong> this<br />
pesticide. Although MIC has the term “cyanate” in its name, a release <strong>of</strong> MIC does not<br />
produce cyanide. Only when MIC undergoes combustion or pyrolysis (when it is burned)<br />
does cyanide (and carbon monoxide) get produced. The exothermic reaction in the<br />
Bhopal event likely produced some <strong>of</strong> these other toxic gases, although a fire did not<br />
occur with the MIC release at Bhopal.<br />
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Slide 9<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methyl Isocyanate :<br />
Physical Properties<br />
• Colorless, flammable liquid at room temperature, but<br />
easily vaporizes<br />
– Vapor pressure 348 mm Hg<br />
– Boiling point 39.5 °C<br />
• Has a pungent odor; inadequate warning<br />
• Water soluble, but with exothermic reaction<br />
• Vapor density: 1.4<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
9<br />
This slides illustrates some <strong>of</strong> the chemical properties <strong>of</strong> methyl isocyanate. The high<br />
vapor pressure and low boiling point mean this is a highly volatile liquid. It has a pungent<br />
odor but detection <strong>of</strong> this odor does not adequately warn someone who is exposed to<br />
MIC to immediately leave the source <strong>of</strong> exposure. The vapor density means it is<br />
somewhat heavier than air (which has a vapor density <strong>of</strong> 1).<br />
Vapor densities are compared to that <strong>of</strong> air.<br />
MIC odor threshold is in the range <strong>of</strong> 2ppm – this does not provide an adequate warning<br />
<strong>of</strong> potentially harmful exposure (the Occupational Health and Safety Administration has<br />
set the Permissible Exposure Limit – <strong>for</strong> a 40 hour work week <strong>for</strong> a working lifetime:<br />
OSHA PEL 0.02ppm)<br />
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Slide 10<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methyl Isocyanate : Clinical Effects<br />
• Dermal/ocular<br />
– Irritation and ulceration<br />
• Respiratory<br />
– Mucosal irritation <strong>of</strong> upper and lower respiratory tract<br />
– Life-threatening pulmonary edema<br />
– Residual chronic lung disease<br />
• Reactive Airways Dysfunction Syndrome (RADS)<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
10<br />
The clinical effects <strong>of</strong> methyl isocyanate predominantly involve 3 organ systems: skin<br />
(dermal), eyes (ocular) and lungs (respiratory). In each <strong>of</strong> these cases, methyl<br />
isocyanate acts as a potent irritant. Although the eye and skin manifestations may cause<br />
significant discom<strong>for</strong>t and distress and chronic disability, the life threatening effects<br />
occur from the pulmonary effects. A chemical pneumonia and pulmonary edema may<br />
result causing decreased oxygenation and air hunger. Overwhelming pulmonary<br />
compromise may result in death.<br />
RADS is a chronic pulmonary problem that may develop after an acute exposure to MIC.<br />
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Slide 11<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Reactive Airways Dysfunction<br />
Syndrome (RADS)<br />
• Non-immunologic asthmatic condition following large<br />
exposure to certain irritants<br />
• Syndrome diagnosis requiring:<br />
– No prior chronic respiratory illness (including asthma)<br />
– Documented exposure to chemical irritant in significant amount<br />
– Onset <strong>of</strong> symptoms (cough, dyspnea , wheezing) within 24 hours and<br />
persistence <strong>for</strong> >3 months<br />
– Demonstrated airway obstruction and bronchial hyper -responsiveness<br />
by pulmonary function testing<br />
– Lack <strong>of</strong> other competing pulmonary diagnosis<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
11<br />
Reactive airways dysfunction syndrome (RADS) is a chronic condition that sometimes<br />
develops after an exposure to a “sensitizing” irritant such as methyl isocyanate. The<br />
symptoms resemble asthma. Prior to the exposure to the irritant, the patient may not<br />
have had any preexisting pulmonary condition such as asthma. The symptoms <strong>of</strong> RADS<br />
– cough, shortness <strong>of</strong> breath and/or wheezing – typically develop within 24 hours <strong>of</strong> the<br />
exposure. These symptoms may last <strong>for</strong> months (or even longer).<br />
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Slide 12<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
SARA<br />
• Emergency Planning and Community Right -to-Know<br />
Act <strong>of</strong> 1986 (SARA Title III)<br />
• State Emergency Response Commissions<br />
• Local Emergency Planning Committees<br />
• <strong>Chemical</strong> facilities submit annual inventory reports<br />
about hazardous chemicals<br />
http://www.access.gpo.gov/nara/cfr/waisidx_04/40cfr372_04.html<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
12<br />
In response to the Bhopal tragedy and increasing community concern regarding<br />
hazardous materials, the US Congress passed several laws intended to minimize the<br />
likelihood and consequences <strong>of</strong> catastrophic chemical events<br />
The SARA Title III is the first <strong>of</strong> several laws that were passed by Congress. This law is<br />
known as the “Emergency Planning and Community Right-to-Know Act (EPCRA).” It<br />
requires states to create State Emergency Response Commissions (SERCs) and<br />
communities to <strong>for</strong>m Local Emergency Planning Committees (LEPCs) <strong>for</strong> the goal <strong>of</strong><br />
preparing emergency response plans <strong>for</strong> chemical accidents. It also requires chemical<br />
facilities to provide annual inventory reports and in<strong>for</strong>mation about hazardous chemicals<br />
<strong>for</strong> use in emergency planning. The focus <strong>of</strong> these laws is on ACCIDENTAL releases.<br />
SARA Title III: The Emergency Planning and Community Right-to-Know Act (EPCRA)<br />
establishes requirements <strong>for</strong> Federal, State and local governments, Indian Tribes, and<br />
industry regarding emergency planning and “Community Right-to-Know” reporting on<br />
hazardous and toxic chemicals. The Community Right-to-Know provisions help increase<br />
the public’s knowledge and access to in<strong>for</strong>mation on chemicals at individual facilities,<br />
their uses, and releases into the environment. States and communities, working with<br />
facilities, can use the in<strong>for</strong>mation to improve chemical safety and protect public health<br />
and the environment.<br />
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Slide 13<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clean Air Act Amendments <strong>of</strong> 1990: Risk<br />
Management Plans (RMP)<br />
• Businesses required to prepare RMP if greater than threshold<br />
amount present <strong>of</strong> any <strong>of</strong> 77 toxic or 63 flammable<br />
substances<br />
• EPA reviews <strong>for</strong> completeness, NOT accuracy<br />
• RMP must include<br />
– Identity <strong>of</strong> type and amounts <strong>of</strong> hazardous materials<br />
– Accident history during past 5 years<br />
– Hazards associated with chemical processes<br />
– Process controls, mitigation systems, detection systems<br />
• Off-site consequence analysis (OCA)<br />
• No in<strong>for</strong>mation on site security is included<br />
http://www.epa.gov/fedrgstr/EPA -AIR/2004/April/Day -09/a7777.htm<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
13<br />
While the SARA Title III laws mandated that industry provide in<strong>for</strong>mation on the<br />
inventory <strong>of</strong> hazardous chemicals used at their facilities, these laws contained no<br />
provisions <strong>for</strong> the prevention <strong>of</strong> chemical accidents.<br />
The 1990 Clean Air Act Amendments addressed this “prevention” issue and contains<br />
two provisions <strong>for</strong> the prevention and minimization <strong>of</strong> chemical accidental releases. This<br />
is the basis <strong>of</strong> the EPA’s “Risk Management Plans” (RMP) <strong>for</strong> <strong>Chemical</strong> Accidental<br />
Release Prevention. This slide details the requirements <strong>of</strong> these Risk Management<br />
Plans.<br />
Off-site Consequence Analysis (OCA) is the process <strong>of</strong> determining the worst case<br />
scenario <strong>for</strong> an ACCIDENTAL release. This is defined as a release <strong>of</strong> the maximum<br />
amount <strong>of</strong> a chemical involved in a single process or storage vessel, using models that<br />
define calm environmental conditions, equal spread in all directions. No active release<br />
mitigation steps are included, although passive ef<strong>for</strong>ts such as building enclosures are<br />
included.<br />
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Slide 14<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
DHS <strong>Chemical</strong> Facility Antiterrorism<br />
Standard (Interim Final Rule 2007)<br />
• Risk-based focus on facility security and<br />
improvements<br />
• Security Vulnerability Assessments and Site<br />
Security Plans<br />
• Mandates audits and inspections<br />
• Penalties <strong>for</strong> non -compliance<br />
• Confidential in<strong>for</strong>mation – preventing “inappropriate<br />
public disclosure ”<br />
http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.ac cess.gpo.gov/2007/E7 -6363.htm<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
14<br />
Under the 2007 <strong>Chemical</strong> Facility Anti-<strong>Terrorism</strong> Standards, Congress directed the<br />
Department <strong>of</strong> Homeland Security (DHS) to issue regulations "establishing risk-based<br />
per<strong>for</strong>mance standards <strong>for</strong> the security <strong>of</strong> chemical facilities." Many states have initiated<br />
Hazard Vulnerability Assessments <strong>of</strong> their chemical facilities.<br />
According to DHS, security risk is a function <strong>of</strong> the following:<br />
o the consequence <strong>of</strong> a successful attack on a facility (consequence),<br />
o the likelihood that an attack on a facility will be successful (vulnerability)<br />
o the intent and capability <strong>of</strong> an adversary in respect to attacking a facility (threat).<br />
There are also provisions within this act addressing audits, inspections, and penalties <strong>for</strong><br />
non-compliance, as well as security <strong>of</strong> the data generated in complying with the act.<br />
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Slide 15<br />
EPA has published the results from the first five years <strong>of</strong> data collection under the Risk<br />
Management Plans.<br />
There were 1,913 reported accidents, with a TOTAL <strong>of</strong> 2,038 injuries and 75 deaths<br />
during this five year period. This is an abbreviated list <strong>of</strong> the most commonly spilled<br />
chemicals. We will spend the remainder <strong>of</strong> this module focusing on the highlighted<br />
compounds, which constitute the vast majority <strong>of</strong> releases to date or – in the case <strong>of</strong><br />
phosgene – have both historical and toxic significance. These agents are commonly<br />
present in the community, present a real threat, and typify gas inhalational injury.<br />
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Slide 16<br />
Be<strong>for</strong>e we cover some <strong>of</strong> these other major industrial gases, it is important to increase<br />
our understanding <strong>of</strong> the determinants <strong>of</strong> inhalation exposure. There are several key<br />
factors that determine the toxicity associated with a gas exposure. These factors include<br />
the underlying health <strong>of</strong> the individual exposed, the exposure circumstances and the<br />
specific properties <strong>of</strong> the chemical agent. The DOSE <strong>of</strong> the inhalational exposure is<br />
determined by the concentration, respiratory rate, and duration <strong>of</strong> chemical exposure.<br />
Ultimately the dose, along with the chemical properties and the health <strong>of</strong> the individual<br />
exposed will determine the severity <strong>of</strong> injury. The DOSE is critically important as<br />
something that may be only irritating (sneeze, “tickle in the throat”, uncom<strong>for</strong>table) at low<br />
concentration or short-term exposure may become injurious (tissue damage, edema,<br />
inflammation and scarring) at much higher doses.<br />
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Slide 17<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clinical Effects Based on<br />
Properties <strong>of</strong> Agent<br />
High<br />
Solubility<br />
Low<br />
Solubility<br />
Onset <strong>of</strong><br />
Symptoms<br />
Warning<br />
Properties<br />
Airway<br />
Injury<br />
Rapid<br />
Good<br />
Upper with<br />
irritation<br />
Delayed<br />
Poor<br />
Lower with lung<br />
injury<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
17<br />
The anatomic site <strong>of</strong> injury depends on the water solubility <strong>of</strong> the substance inhaled.<br />
High water solubility gases tend to have a rapid onset <strong>of</strong> symptoms and predominantly<br />
affect the upper airways. Low water solubility gases tend to have a delayed onset <strong>of</strong><br />
symptoms and predominantly affect the lower airways.<br />
Simplistically, these gases can be separated into their usual effects based on water<br />
solubility. Individual exposure characteristics may modify this, but – when <strong>for</strong>ming a<br />
case definition – these characteristics provide a reliable framework. Exposure to a very<br />
water soluble irritant substance will <strong>for</strong>ce someone to flee (if possible) be<strong>for</strong>e a sufficient<br />
dose (concentration x duration) reaches the lower airways because <strong>of</strong> the irritation<br />
caused by it being dissolved in tear film and saliva/mucous <strong>of</strong> the upper airways. Of<br />
course, these distinctions may not hold true in an overwhelming situation (massive<br />
exposure) or where escape is not possible. At high doses (prolonged exposure or very<br />
high concentrations or both), the distinction between irritation and injury will become<br />
blurred or lost.<br />
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Slide 18<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Irritancy<br />
Comparative Toxicity Of Likely<br />
Terrorist Industrial Gases<br />
• Danger/Lethality<br />
Ammonia > Phosgene<br />
Phosgene > Ammonia<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
18<br />
Given the same dose – concentration and duration <strong>of</strong> exposure – ammonia (to be<br />
discussed next) which is water soluble –tends to be much more irritating then phosgene<br />
which is poorly water soluble. However, phosgene (to be discussed later in this talk)<br />
which is far less irritating in the acute exposure setting, is far more lethal given similar<br />
exposure concentrations.<br />
The fact that phosgene is far more lethal at equivalent concentration is borne out by the<br />
different 30 minute AEGL3 (major or life threatening impact) <strong>for</strong> these two compounds.<br />
For ammonia the 30 minute AEGL3 is 1600 ppm while <strong>for</strong> phosgene the equivalent<br />
value is 1.5 ppm. This data suggest that at equivalent airborne concentrations phosgene<br />
is 1000 times as potent as ammonia.<br />
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Slide 19<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Railway Accident: Minot, ND 2002<br />
• Derailment <strong>of</strong> 31 cars<br />
• Immediate release <strong>of</strong><br />
~150,000 gallons <strong>of</strong><br />
anhydrous ammonia<br />
from 5 <strong>of</strong> 15 cars<br />
• One car airborne _ mile<br />
striking a house<br />
• Plume 300 feet high<br />
spreading 5 miles<br />
downwind<br />
http://www.ntsb.gov/publictn/2004/RAR0401.pdf<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
19<br />
This next case study demonstrates the toxicity associated with an ammonia exposure.<br />
On January 18, 2002 at 1:37AM, a major train derailment (secondary to a rail break from<br />
fractured joint bars) occurred approximately 0.5 mile west <strong>of</strong> Minot, ND. A total <strong>of</strong> 31<br />
cars derailed, 15 <strong>of</strong> which contained anhydrous ammonia. Five <strong>of</strong> these 15 lost all <strong>of</strong><br />
their contents, immediately releasing an estimated 146,700 gallons <strong>of</strong> anhydrous<br />
ammonia which created a visible plume spreading <strong>for</strong> 5 miles. Six other cars leaked<br />
contents (74,000 gallons) over the next 5 days.<br />
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Slide 20<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Response and Outcomes<br />
• Shelter-in-place order<br />
• Difficulty with communication<br />
• Exposed population: 11,600<br />
– Minor symptoms: 322<br />
– Serious symptoms: 11<br />
– Fatal: 1<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
20<br />
Initial calls to 911 resulted in local activity, but there was a problem getting messages to<br />
the community, as the designated emergency broadcast TV station did not have an<br />
overnight crew. Although the population at risk <strong>for</strong> exposure exceeded 10,000, only 3%<br />
<strong>of</strong> those who were at risk <strong>for</strong> exposure developed symptoms and less than 0.1%<br />
developed serious symptoms. There was one death.<br />
In addition, power outages from the crash and siren positioning affected message<br />
dissemination. The one death was a man who was driving away from the area <strong>of</strong> the<br />
crash, became overcome by the ammonia, and struck a house. He then got out <strong>of</strong> the<br />
vehicle and collapsed. Rescuers were unable to extract him and neighbors were unable<br />
to go outside to help because <strong>of</strong> the noxious gas. Yet they were relatively unaffected<br />
“sheltering in place.”<br />
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Slide 21<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Anhydrous Ammonia (NH3)<br />
• Used mainly in manufacture <strong>of</strong> fertilizer as nitrogen source<br />
(>80%)<br />
• Other uses include plastics, fibers and resins, explosives,<br />
cleaning disinfectants, refrigeration<br />
• Third highest production volume chemical in U.S.<br />
– ~9 million metric tons<br />
• Transported as liquefied gas under pressure via pipeline,<br />
railcar, tanker truck, and refrigerated barge<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
21<br />
Anhydrous ammonia is the third most produced chemical in the US. The term<br />
anhydrous emphasizes the absence <strong>of</strong> water in commercial strength ammonia. Most <strong>of</strong><br />
the anhydrous ammonia produced worldwide is used <strong>for</strong> fertilizer. Its high nitrogen<br />
content makes it one <strong>of</strong> the best fertilizers available commercially. It is also used as an<br />
intermediary or component in a number <strong>of</strong> other industrial processes. Because <strong>of</strong> its<br />
widespread use in large quantities, it is also transported long distances by a variety <strong>of</strong><br />
mechanisms.<br />
Anhydrous ammonia is applied either by injection <strong>of</strong> the anhydrous gas directly into the<br />
soil, or as an aqueous solution or various salts. It is used in the manufacturing <strong>of</strong><br />
plastics, pesticides, explosives and pharmaceuticals. It is found as a refrigerant gas in<br />
commercial installations.<br />
In contradistinction to commercial strength ammonia, household ammonia used <strong>for</strong><br />
disinfecting and cleaning in the house is actually ammonium hydroxide. Ammonium<br />
hydroxide is ammonia and water. The typical ammonia concentration is about 5-10% in<br />
this household product.<br />
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Slide 22<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Ammonia: Physical Properties<br />
• Colorless gas with pungent odor<br />
• Low odor threshold; good warning properties<br />
• Highly water soluble<br />
• Boiling point – 33°C<br />
• Vapor density 0.6 (lighter than air)<br />
• Combustible in narrow range<br />
• Highly reactive gas<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
22<br />
Anhydrous ammonia at standard atmospheric pressure and temperature is a colorless<br />
gas with an extremely pungent odor. It has high water solubility causing irritation on<br />
contact. This combined with its low odor threshold (5-50 ppm) result in good warning<br />
properties. (NIOSH TWA 25ppm). When anhydrous ammonia escapes from a<br />
pressurized system, it may appear as a white plume. It is combustible at a concentration<br />
<strong>of</strong> 15-25%; but pressured canisters can easily explode in heat and fires or with impact –<br />
as occurs in railroad crashes. Note that it is lighter than air, but the density <strong>of</strong> a recently<br />
released pressurized liquid is higher, so it may continue to “hug the ground” near site <strong>of</strong><br />
release.<br />
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Slide 23<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clinical Effects<br />
• Damage from alkali burn and thermal reaction<br />
NH 3 + H 2 O NH 4 OH<br />
• Low concentration: irritant to nose, throat, upper respiratory<br />
tract<br />
• Higher concentrations or more prolonged contact<br />
– Skin burns: 30% <strong>of</strong> admitted chemical burns attributed to ammonia<br />
(variable by extent <strong>of</strong> clandestine drug labs)<br />
– Lower airway inflammation with pneumonitis and pulmonary edema<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
23<br />
Ammonia is an irritant at low concentrations and a corrosive at higher concentrations.<br />
Given that ammonia is a water-soluble gas, typical symptoms seen at lower<br />
concentrations affect the upper airways including the nose, throat, and trachea. At higher<br />
concentrations, or with more prolonged contract, anhydrous ammonia acts as a<br />
corrosive and may cause burns to tissues exposed to concentrated amounts.<br />
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<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Anhydrous Ammonia<br />
• Concentration and duration <strong>of</strong> exposure determines clinical<br />
effect<br />
– From minor irritation to blindness with extensive scar <strong>for</strong>mation<br />
• Center picture shows fluorescein uptake indicating diffuse<br />
corneal injury<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
24<br />
This slide demonstrated what happens when anhydrous ammonia comes in contact with<br />
the eye. The cornea which covers the eye is very sensitive to minor irritation. A<br />
corrosive exposure (higher concentration and/or more prolonged contact) may cause a<br />
chemical burn to the cornea and result in irreversible scarring. These photos illustrate<br />
what may occur after such a corneal injury. The intense fluorescein staining (a greenish<br />
dye under UV light) shown in the middle at the time <strong>of</strong> injury led in this case to<br />
irreversible scarring and blindness.<br />
The photo on the left demonstrates inflammation <strong>of</strong> the conjunctiva and cornea – the<br />
epithelial layer covering the eye (conjunctival “injection” or vascular congestion, and<br />
corneal clouding – appears as opaqueness – secondary to corneal edema). The middle<br />
photo shows what occurs when the green fluorescein dye is applied to the cornea and<br />
viewed with an ultraviolet light. With a normal cornea there should be no uptake with the<br />
fluorescein. The uptake <strong>of</strong> fluorescein in this middle photo suggests widespread injury to<br />
the cornea.<br />
The photo on the right shows the long term results <strong>of</strong> a chemical burn to the eye and<br />
subsequent scar <strong>for</strong>mation. In the scarred eye, blood vessels grow into the tissue. The<br />
scarring results in a permanent opacity in what is suppose to be a translucent cornea.<br />
Such an opacity results in blindness.<br />
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Slide 25<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Next Gas:<br />
Homemade WWI Warfare Agent<br />
• 29 yr old man with acute respiratory distress after<br />
cleaning toilet<br />
• RR 36/min, HR 128/min, BP 148/76<br />
• Lip and throat swelling<br />
• Diffuse wheezing<br />
• Required intubation<br />
and positive pressure<br />
ventilation<br />
• Hypoxia with CXR<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
25<br />
The next toxic gas we will discuss has a long history <strong>of</strong> use as a chemical warfare agent.<br />
This young man developed symptoms while at home cleaning his bathroom. The rapid<br />
onset <strong>of</strong> mucous membrane irritation, rapid respirations, upper airway and lower airway<br />
injury suggests exposure to an intermediate water-soluble irritant. The low oxygenation<br />
and Chest X-ray abnormalities (shown on next slide) indicate the degree <strong>of</strong> lung injury.<br />
The patient presents with a number <strong>of</strong> abnormalities as a result <strong>of</strong> his exposure to<br />
chlorine. These include a rapid respiratory rate (RR). Normal respiratory rate is 16-20.<br />
This patient has a much faster respiratory rate suggesting some type <strong>of</strong> respiratory<br />
distress. In addition the HR (heart rate) is also increased to 128 (normal 60-100). This<br />
occurs from the stress – physiologic and psychologic (pain, hypoxia, sympathomimetic<br />
response) - that develops after a significant toxic gas inhalation.<br />
Given the irritating effects <strong>of</strong> the chlorine, tissues that are in contact with the chlorine<br />
such as the lips and throat will become edematous (swell up) as a part <strong>of</strong> the<br />
inflammatory response. In a more significant exposure the lungs can be affected and<br />
the patient can develop wheezing which may resemble asthma.<br />
Patients with significant lung involvement may develop hypoxia. Hypoxia refers to a<br />
condition <strong>of</strong> inadequate oxygenation – in this case due to lung injury and the inability to<br />
transfer oxygen from the lungs to the blood. Patients that develop hypoxia require<br />
supplemental oxygen. For those who develop significant hypoxia (and airway edema),<br />
intubating the patient with an endotracheal tube and placing them on a ventilator that<br />
delivers positive pressure ventilation may be required.<br />
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Slide 26<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
What Toxic Gas Did He Inhale<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
Chlorine<br />
26<br />
This case illustrates a typical finding from a severe chlorine gas exposure. This is a<br />
typical chest X-ray picture <strong>of</strong> chemical lung injury response: the presence <strong>of</strong> fluffy white<br />
infiltrates bilaterally is consistent with non-cardiogenic pulmonary edema or lung injury –<br />
i.e. not from fluid overload or heart failure.<br />
There are a number <strong>of</strong> medical conditions where the lungs become congested with fluid.<br />
The chest xray reveals the presence <strong>of</strong> infiltrates which take on a whitish appearance as<br />
opposed to the black radiographic appearance that appears with clear lung fields. If the<br />
lung congestion is thought to be from a failing heart, this is usually referred to as<br />
pulmonary edema. When the heart is not the culprit, the edema (or fluid congestion) is<br />
thought to be non-cardiogenic. An overwhelming infection can cause a non-cardiogenic<br />
edema. Consequential gas inhalation that results in a diffuse injury may also take on the<br />
appearance <strong>of</strong> non-cardiogenic edema.<br />
The radiograph on the slide has the appearance <strong>of</strong> a toxic gas exposure that may result<br />
after exposure to a number <strong>of</strong> toxic gases discussed in this presentation including<br />
chlorine, phosgene and methyl isocyanate.<br />
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Slide 27<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Audience Response<br />
Mixing together which <strong>of</strong> the following is most likely to<br />
<strong>for</strong>m chlorine gas<br />
1. Ammonia and acidic toilet bowl clearer<br />
2. Bleach and acidic toilet bowl clearer<br />
3. Cyanide and bleach<br />
4. Acidic toilet bowl clearer and a dirty toilet<br />
5. Unable to make chlorine gas in the house<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
27<br />
.<br />
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Slide 28<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Dangerous Mixture<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
28<br />
Chlorine gas exposures are probably the most common toxic gas exposure we see in<br />
the emergency department. The most common chlorine exposure we encounter<br />
involves the mixture <strong>of</strong> bleach (sodium hypochlorite) and an acid (toilet bowl cleaner).<br />
These two household chemicals are sometimes mixed together – either in an attempt to<br />
strengthen the disinfection process or at times when the chemicals are separately<br />
discarded into a common disposal reservoir such as a toilet or bathtub. The combination<br />
<strong>of</strong> sodium hypochlorite and acid produces chlorine gas and water. Other large scale<br />
chlorine exposures occur when chlorine is inadvertently released at a swimming pool<br />
during a misstep in the swimming pool disinfection process.<br />
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Slide 29<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chlorine Gas<br />
• Multiple Uses<br />
– Manufacturing <strong>of</strong> non -agricultural<br />
chemicals<br />
– Pulp and paper industry<br />
– Commercial & household bleaching<br />
agents<br />
– Water purification & waste treatment<br />
• 1998 US production > 14 million<br />
tons<br />
– Shipped as liquefied compressed<br />
gas<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
29<br />
Chlorine is among the 10 most produced chemical in the US; in 1998, US production<br />
exceeded 14 million tons. Today, it is used <strong>for</strong> nonagricultural chemical manufacturing -<br />
including the production <strong>of</strong> chlorinated hydrocarbons (CCl4-carbon tetrachloride, vinyl<br />
chloride, chlor<strong>of</strong>orm) - pulp and paper industry as an oxidizing bleaching agent; as<br />
commercial and household bleaching agents; & in water purification and waste treatment<br />
systems as a disinfectant. Similar to ammonia, chlorine is shipped in large quantities<br />
over long distances as a liquefied compressed gas.<br />
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Slide 30<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chlorine: Physical Properties<br />
• Green -yellow, pungent gas<br />
• Low odor threshold;<br />
moderate warning properties<br />
• Intermediate water solubility<br />
• Boiling point –31 oF<br />
• Vapor density 2.5 (heavier than<br />
air)<br />
• Reacts explosively with many<br />
compounds<br />
http://www.amazingrust.com/Experiment<br />
show_to/Images/Chlorine_gas.jpg<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
30<br />
Chlorine is a gas at standard temperature and pressure. Its presence is recognizable by<br />
a yellow-green color and pungent odor. Its vapor density is 2.5 (2.5 times as heavy as<br />
air).<br />
Chlorine has intermediate water solubility. Its solubility is between that <strong>of</strong> ammonia and<br />
phosgene (300 times less soluble than ammonia). As such, it can cause upper and<br />
lower airway symptoms after exposure.<br />
Though it has a low odor threshold <strong>of</strong> 3 ppm, the noxious odor does not necessarily<br />
serve as a reliable warning. Irritative symptoms can occur after exposure to chlorine gas<br />
at 1ppm <strong>for</strong> several hours which would be below the odor threshold (i.e. one would<br />
develop irritation prior to detecting the chlorine odor).<br />
Chlorine is a very reactive substance. When released, it does not exist <strong>for</strong> long in the<br />
molecular gas (Cl 2 ) <strong>for</strong>m, but combines – <strong>of</strong>ten explosively – with other compounds.<br />
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Slide 31<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chlorine: Clinical Effects<br />
• Intermediate water -solubility<br />
• Low concentrations:<br />
– irritant to eyes, nose, throat,<br />
upper respiratory tract<br />
• Higher concentrations:<br />
– acute pulmonary edema,<br />
chemical pneumonitis<br />
• Chronic sequelae:<br />
– RADS<br />
Cl 2 + H 2 O ↔ HCl + HOCl<br />
http://www.aliciapatterson.org/APF1403/Borg/Borg04.jpg<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
31<br />
The types <strong>of</strong> symptoms associated with a chlorine gas exposure are determined in part<br />
by chlorine’s intermediate water solubility. At lower concentrations chlorine exposure<br />
results in upper airway irritation and usually serves as a warning, preventing continued<br />
voluntary exposure. People complain <strong>of</strong> mucous membrane irritation: watery eyes,<br />
corneal irritation, runny nose, throat irritation, wheezing, and cough.<br />
However, at relatively low concentration, mild symptoms may be tolerated to some<br />
extent. If the exposed individual does not leave the source <strong>of</strong> exposure, continued low<br />
level exposure may ultimately increase the delivered dose, since dose is the product <strong>of</strong><br />
both concentration and time. Continued low does exposure may result in a delayed<br />
onset <strong>of</strong> lower respiratory symptoms and potential injury to the lower respiratory tract,<br />
with bronchospasm-associated wheezing and inflammation.<br />
Similar to what may occur after methyl isocyanate exposure, RADS may also develop<br />
after chlorine exposure.<br />
Chlorine gas dissolves in water to <strong>for</strong>m hydrochloric acid and hypochlorous acid.<br />
Hypochlorous acid subsequently dissociates into hydrochloric acid and oxygen free<br />
radicals, prolonging and exacerbating the injury.<br />
A chemical pneumonitis refers to the pneumonia (lung injury) that develops after certain<br />
chemical exposures. Unlike a bacterial pneumonitis, the chemical pneumonitis is not<br />
the result <strong>of</strong> an infection but is the direct result <strong>of</strong> the chemical injury to the lung tissue.<br />
Since it is not caused by in infectious agent, antibiotic treatment is not needed.<br />
The picture is a depiction <strong>of</strong> a World War I training poster emphasizing the steps soldiers<br />
could take (awareness, proper use <strong>of</strong> personal protection equipment) in response to the<br />
threat <strong>of</strong> a gas attack.<br />
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Slide 32<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chlorine: 1st Successful <strong>Chemical</strong><br />
Warfare Agent, WW I<br />
Wind -borne Chlorine Attack, WWI<br />
http://www.germannotes.com/hist_ww1_poison.jpg<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
Chlorine Gas Respirators<br />
32<br />
The first successful use <strong>of</strong> a gas as a chemical warfare agent in modern times was the<br />
German canister deployment <strong>of</strong> chlorine at the (Second) Battle <strong>of</strong> Ypres (Belgium) in<br />
April 1915. 168 tons <strong>of</strong> chlorine gas were released from 5700 canisters, resulting in<br />
10,000 French troops being affected (50% mortality) and resulting in a 4 mile breach in<br />
the front lines, <strong>of</strong> which the Germans were unprepared to take advantage.<br />
The British retaliated with chlorine at the Battle <strong>of</strong> Loos (Belgium) in September 1915,<br />
but unfavorable winds minimized the impact <strong>of</strong> that attack.<br />
<strong>Chemical</strong> warfare preparation at that time included 1) protective devices <strong>for</strong> the troops 2)<br />
development <strong>of</strong> toxic gases armamentarium 3) improvement in delivery system.<br />
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Slide 33<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chlorine from Train Accident (Graniteville,<br />
SC; Jan 6, 2005 02:40)<br />
http:// www.hazmatteam.com<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
33<br />
Much more recently, this train derailment <strong>of</strong> freight cars containing chlorine<br />
demonstrates current vulnerabilities and potential threats from this compound. In this<br />
2005 incident, as the result <strong>of</strong> an improperly-aligned switch, a Norfolk Southern freight<br />
train was diverted onto a track, striking a parked train. One <strong>of</strong> three 90 ton chlorine<br />
tankers ruptured, releasing gas <strong>for</strong> ¼ to ½ mile in all directions (light wind).<br />
Note that this accident, like so many industrial accidents, occurred in the middle <strong>of</strong> the<br />
night. While that may hinder communications and response because <strong>of</strong> staffing and the<br />
presence <strong>of</strong> fewer bystanders, this timing may also decrease casualties because <strong>of</strong><br />
fewer people being in –or traveling through – the area. The magnitude <strong>of</strong> the event was<br />
also minimized both by single tank rupture and the cooling <strong>of</strong> contents by rapid<br />
expansion.<br />
The picture shows an aerial view <strong>of</strong> the crash scene involving a road, a parking lot and<br />
power lines.<br />
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Slide 34<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Consequences <strong>of</strong> Graniteville Train<br />
Accident (MMWR January 28, 2005)<br />
• 9 deaths<br />
– 1 train engineer, 6 mill workers,<br />
1 in home, 1 in truck<br />
• 529 sought medical care<br />
– 69 hospitalized, 11 critical<br />
– 18 were treated at area physicians ’ <strong>of</strong>fices<br />
• 5,400 evacuated in 1 mile radius <strong>of</strong> crash<br />
• Initial report : "sodium nitrate"<br />
• Chlorine was not reported to ED <strong>for</strong> 1 hour<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
34<br />
As the result <strong>of</strong> this derailment and chlorine release, over 5000 people were evacuated,<br />
500 sought medical attention, 69 were hospitalized and there were 9 deaths. Of interest<br />
the initial report detailing the nature <strong>of</strong> the release was erroneous and misleading.<br />
December 2008 Version 2.0 Page 158
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Slide 35<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chlorine Transport in the US<br />
Rail transportation <strong>of</strong> chlorine and other toxic gases is<br />
common in highly populated cities<br />
<br />
<br />
<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
35<br />
This scary-looking photo depicts the transport <strong>of</strong> a freight car loaded with chlorine gas<br />
making its way through our nation’s capital, literally in sight <strong>of</strong> the U.S. Capital. The<br />
impact <strong>of</strong> disruption <strong>of</strong> this railcar (equivalent to the release from the Graniteville SC<br />
accident) in this large, crowded city would be severe. Since this photo was taken in<br />
2004, hazardous rail transportation through Washington, DC has been curtailed<br />
precisely because <strong>of</strong> this potential transportation threat and the inability to contain this<br />
danger without rescheduling freight routes <strong>of</strong> hazardous chemicals.<br />
Making such route change carries its own significant economic and<br />
commerce/scheduling implications <strong>of</strong> re-routing. The decision in Washington D.C. was<br />
contentious, even post – 9/11. Rerouting <strong>of</strong> hazardous substances has been limited in<br />
scope and does not apply to most other U.S. cities. This vulnerability continues to be a<br />
major impediment to planning <strong>for</strong> all communities.<br />
December 2008 Version 2.0 Page 159
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Slide 36<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chlorine Gas Attack by Truck Bomber<br />
Kills Up to 30 in Iraq<br />
BAGHDAD, April 6 (NY Times) — A<br />
suicide truck bomb loaded with<br />
chlorine gas exploded in Ramadi<br />
on Friday, killing as many as 30<br />
people, many <strong>of</strong> them children, a<br />
security <strong>of</strong>ficial said.<br />
The explosion burned victims ’ lungs,<br />
eyes and skin. Dr. Ali Abdullah<br />
Saleh, <strong>of</strong> the main Ramadi<br />
hospital, said 30 people had been<br />
admitted with shrapnel wounds<br />
and 15 had been sent to a second<br />
hospital in the city. He said 50<br />
people had been admitted <strong>for</strong><br />
breathing problems .<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
36<br />
Actual terrorist uses <strong>of</strong> chlorine have occurred during the Iraqi War. In Iraq in 2007,<br />
terrorist groups began to use suicidal truck bombs loaded with chlorine. Since this time<br />
chlorine canisters have been incorporated into several improvised explosive device<br />
(IED) bombings.<br />
The news photograph shows the remains <strong>of</strong> the car bomb. The narrative describes the<br />
water-soluble irritant symptoms experienced by the victims. There were as many people<br />
injured by the chlorine gas as there were by shrapnel.<br />
December 2008 Version 2.0 Page 160
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Slide 37<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosgene: Cl 2 C=O<br />
• Used in the manufacture <strong>of</strong><br />
– Organic chemicals: dyestuffs, isocyanates<br />
– Plastics<br />
– Insecticides<br />
– Pharmaceuticals<br />
• 80% used <strong>for</strong> isocyanate production<br />
• US production: estimated 1 million tons/year<br />
• Also <strong>for</strong>med as a combustion product when chlorine -<br />
containing compounds are burned<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
37<br />
Phosgene is a common chemical intermediate used in the manufacture <strong>of</strong> organic<br />
chemicals (dyestuffs, isocyanates), plastics and polyurethanes, insecticides, and<br />
pharmaceuticals. 80% <strong>of</strong> phosgene production is used <strong>for</strong> isocyanate manufacture.<br />
Phosgene is also a combustion product, potentially produced anytime a chlorinated<br />
product (e.g. plastic) is burned.<br />
A chlorinated compound as used here is a hydrocarbon with chlorine substitution(s).<br />
Many <strong>of</strong> these compounds are heavily used in industry. When burned, such chlorinated<br />
compounds as methylene chloride and chlor<strong>of</strong>orm release phosgene.<br />
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Slide 38<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Synthesized in 1812<br />
• First used in WWI against<br />
the British at Ypres,<br />
Belgium (December 1915)<br />
Phosgene: History<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
38<br />
Phosgene was first synthesized in 1812. During WWI, phosgene was extensively used in<br />
gas warfare. Its first wartime use was in Dec 1915 when the Germans shelled British<br />
troops with 88 tons <strong>of</strong> phosgene. This one attack resulted in ~1100 casualties and 120<br />
deaths.<br />
The top picture depicts buried gas cylinders used in attacks. The bottom picture is <strong>of</strong> a<br />
British machine gun crew in CG (referring to phosgene) helmets (site reported as Battle<br />
<strong>of</strong> Somme, July 1916, the bloodiest day <strong>of</strong> the war <strong>for</strong> the British Army).<br />
December 2008 Version 2.0 Page 162
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Slide 39<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosgene: Community Threat<br />
Assessment<br />
• 99.9% <strong>of</strong> production is<br />
“used on-site”<br />
• Storage and transport as<br />
liquefied compressed gas<br />
http:// www.chemicaldesign.com/Phosgene.htm<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
39<br />
Ammonia and chlorine are transportation, as well as fixed facility threats, given the need<br />
to move large volumes <strong>of</strong> these chemicals to their industrial sites. In contrast, the threat<br />
<strong>of</strong> phosgene is mostly limited to a fixed facility. More then 99% <strong>of</strong> phosgene production<br />
is used in the manufacture <strong>of</strong> other chemicals within a plant boundary,<br />
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Slide 40<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosgene<br />
• BASF Plant Ascension<br />
Parish, LA<br />
– 1981: Plant operator killed<br />
– 1982: 28 workers injured<br />
– 1986: phosgene plume<br />
over unpopulated parts<br />
<strong>of</strong> Ascension Parish<br />
http://commons.wikimedia.org/wiki/Image:Map_<strong>of</strong><br />
_Louisiana_highlighting_Ascension_Parish.svg<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
40<br />
During the 1980s there were several releases <strong>of</strong> phosgene from an industrial plant in<br />
Ascension Parish, LA. During one release the plant operator was killed and during<br />
another release, 28 workers were injured. During another event, phosgene was released<br />
with the wind carrying a plume outside the plant, <strong>for</strong>tunately over an unpopulated area.<br />
Ascension Parish (shown in red in the map <strong>of</strong> Louisiana on the slide) accounted <strong>for</strong> ~1/4<br />
<strong>of</strong> all the TRI (Toxic Release Inventory) chemical releases from the 64 parishes in LA at<br />
that time. A very small fraction <strong>of</strong> that 120,000,000 pounds was phosgene (1,493<br />
pounds). Despite the small amount, the local area effect <strong>of</strong> a release is still significant.<br />
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Slide 41<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosgene: Physical Properties<br />
• Colorless gas with odor <strong>of</strong> musty hay<br />
• Higher odor threshold; poor warning properties<br />
• Low water solubility<br />
• Boiling point 8.2 ºC<br />
• Vapor density 3.5 (heavier than air)<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
41<br />
Phosgene is a highly reactive gas <strong>of</strong> historical interest and current industrial importance.<br />
Because <strong>of</strong> its low water solubility, there are no immediate irritive effects to serve as<br />
warning properties <strong>of</strong> exposure. It is colorless and described as having a “musty hay” or<br />
“green corn” odor. The odor threshold is above the concentration that would result in<br />
lower airway & lung toxicity.; thus this compound has inadequate warning properties. It<br />
is a gas at room temperature with a vapor density 3.5 times that <strong>of</strong> air. As mentioned<br />
earlier, when shipped <strong>of</strong>f-site, it is in liquid <strong>for</strong>m in pressurized steel cylinders.<br />
December 2008 Version 2.0 Page 165
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Slide 42<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosgene<br />
Odor threshold:<br />
0.5 - 1.5 ppm<br />
10 min AEGL -2:<br />
0.60 ppm<br />
10 min AEGL -3: 3.6<br />
ppm<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
42<br />
The colorless gas, phosgene, has the odor <strong>of</strong> moldy hay or green corn. However,<br />
recognition <strong>of</strong> odor is reliable only around a concentration <strong>of</strong> 1.5 ppm, a concentration at<br />
which injury is already occurring.<br />
Severe, but delayed-onset, pulmonary injury can be expected after a relatively short<br />
duration <strong>of</strong> exposure at levels that may not be appreciated by smell. Additionally,<br />
olfactory fatigue can occur, further impairing odor recognition.<br />
AEGL-2 is the concentration above which exposure would be expected to result in<br />
increasingly severe symptoms as exposure continued, with impairment <strong>of</strong> self-rescue.<br />
Above AEGL-3 concentrations, life-threatening symptoms are expected.<br />
Olfactory fatigue is a common, normal experience. It is an adaptive response in humans<br />
– to both noxious and non-noxious agents. As an example, the aroma <strong>of</strong> fresh-baked<br />
bread is more noticeable when first entering a room than several minutes later. With<br />
some chemical agents, it is thought that the cellular toxicity <strong>of</strong> the compound itself (e.g.<br />
hydrogen sulfide) contributes to the loss <strong>of</strong> odor recognition.<br />
The posters on the slide were used in World War II military training to increase awareness <strong>of</strong><br />
soldiers, medical providers, and the general community <strong>of</strong> various aspects <strong>of</strong> chemical warfare.<br />
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Slide 43<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosgene: Clinical Effects<br />
• Limited initial symptoms<br />
– Irritation <strong>of</strong> eyes, nose, upper airways<br />
– Higher concentrations cause airway spasm<br />
• Low water solubility – slow hydrolysis to HCl<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
43<br />
Because <strong>of</strong> its low water solubility, a victim will continue to inhale phosgene, with<br />
increased contact time deeper into the lungs, causing lower airway and lung damage.<br />
Immediate symptoms are usually mild and are due to irritation <strong>of</strong> the mucous<br />
membranes from slow release <strong>of</strong> hydrochloric acid as shown in the chemical equation on<br />
the slide. These symptoms include eye irritation, throat irritation, and mild cough.<br />
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Slide 44<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosgene: Delayed Effects<br />
• Latent development <strong>of</strong> pulmonary edema<br />
– Onset 1 to 24 hours after exposure<br />
– Pulmonary function abnormalities<br />
– May be fatal<br />
• Chronic airway disease<br />
COCl 2<br />
+ 2 R-NH 2<br />
CO(NH-R) 2<br />
+ 2HCl<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
44<br />
Delayed onset symptoms are due to deep tissue damage and associated with fluid<br />
collection in the lungs and lung function abnormalities. The fluid collection can occur<br />
within minutes, but usually there is a latent period <strong>of</strong> hours; symptoms can be delayed<br />
up to 72 hours.<br />
Following significant exposure, death due to pulmonary edema can occur after a delay <strong>of</strong><br />
24-48 hours.<br />
Exposed persons can have chronic airway disease with permanently abnormal<br />
pulmonary function.<br />
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Slide 45<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosgene: Delayed Lung Injury<br />
6 hrs post-exposure<br />
10 hrs post-exposure<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
45<br />
These Chest X-ray pictures <strong>of</strong> delayed-onset pulmonary edema after phosgene<br />
exposure shows the progression <strong>of</strong> peripheral pulmonary infiltrates over time, as is<br />
typical <strong>of</strong> non-cardiogenic pulmonary edema.<br />
Chest X-ray appearances can lag behind clinical symptoms, but the accumulation <strong>of</strong><br />
lung water – and inflammatory cells – as depicted by the increased whiteness <strong>of</strong> the<br />
normally black lung fields on X-ray is one indication <strong>of</strong> the degree <strong>of</strong> injury occurring in<br />
this case.<br />
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Slide 46<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Hydr<strong>of</strong>luoric Acid (HF)<br />
• HF is used <strong>for</strong> a variety <strong>of</strong> industrial<br />
processes and consumer products (dilute),<br />
including<br />
– Catalyst in oil refineries<br />
– Manufacture <strong>of</strong> silicon semiconductor chips<br />
– Separating uranium isotopes<br />
– Etching glass or enamel<br />
– Cleaning brass, crystal and as a rust<br />
remover<br />
• Production in U.S. is < 1 million tons/year<br />
• Transported as pressurized anhydrous<br />
liquid by rail<br />
http:// www.viewimages.com/Search.aspx <br />
mid=1307009&epmid=1&partner=Google<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
46<br />
Hydr<strong>of</strong>luoric Acid (HF) is a relatively low production volume chemical in the US, but it<br />
has multiple industrial and household uses. Along with hydrogen sulfide (a cellular<br />
poison somewhat similar to cyanide), it is a major concern at oil refineries. It is also<br />
used in the semiconductor industry, and <strong>for</strong> a number <strong>of</strong> other specialty purposes listed<br />
on the slide. HF (and related compounds) are available in dilute solution (
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong><br />
Training Support Package<br />
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Slide 47<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
HF: Physical Properties<br />
• Colorless, non -flammable, fuming liquid or gas with<br />
irritating odor<br />
• Low odor threshold; good warning property<br />
• Highly water soluble - with release <strong>of</strong> heat<br />
• Weak acid<br />
– Not highly dissociated, but penetrates tissue well<br />
• Boiling point 20 °C<br />
• Vapor density 0.7<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
47<br />
HF is a very toxic substance, but at the same time it is a relatively weak acid. It has a<br />
low odor threshold and is irritating as a concentrated vapor, providing good warning<br />
properties <strong>of</strong> exposure. At the same time, dermal exposure to dilute solutions does not<br />
cause immediate symptoms, as do other acids.<br />
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Slide 48<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
HF: Clinical Effects<br />
• Highly corrosive depending on concentration and<br />
irritating to all tissues<br />
• Onset <strong>of</strong> pain and skin changes may be delayed <strong>for</strong><br />
hours with dilute (
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong><br />
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<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Texas City, TX Industrial Accident<br />
Releasing HF (October 31, 1987)<br />
• ~30,000 pounds <strong>of</strong> hydr<strong>of</strong>luoric acid leaked from an HF<br />
alkylation reactor drum when a 50 foot long convection unit<br />
was dropped on the vessel<br />
• Vapors emitted under pressure <strong>for</strong> 2 hours<br />
• Estimate <strong>of</strong> AEGLS 3 at ~3/4 mile away<br />
• ~4000 residents evacuated <strong>for</strong> 3 days<br />
• >1000 people to hospital with skin, eye, nose/throat irritation<br />
and pulmonary symptoms<br />
• No fatalities<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
49<br />
The last gas we will cover in this module is hydr<strong>of</strong>luoric acid (HF). In concentrated <strong>for</strong>m,<br />
HF is a gas. The largest industrial accident related to HF occurred about 20 years ago<br />
when a piece <strong>of</strong> equipment was dropped by a crane onto a reactor vessel at an oil<br />
refinery in TX, releasing HF under pressure. The leak continued <strong>for</strong> 2 hours. It is<br />
estimated that life-threatening concentrations <strong>of</strong> the gas (AEGL 3) extended nearly one<br />
mile from the site. More than 1000 people were evaluated <strong>for</strong> symptoms and 4000<br />
residents were evacuated <strong>for</strong> 3 days, at which point the leak had been plugged and<br />
remaining diluted HF drained.<br />
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Participant Guide<br />
Slide 50<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
50<br />
The importance <strong>of</strong> plant security, “hardening” <strong>of</strong> containment measures, and minimizing<br />
on-site storage <strong>of</strong> <strong>TICs</strong> is illustrated by this example <strong>of</strong> a chemical plant which<br />
maintained 500,000 lbs <strong>of</strong> Hydrogen Fluoride on-site (year 2004 -mean maximum<br />
amount on a daily basis).<br />
This Google map aerial photo identifies an industrial plant in Oakland, CA. This amount<br />
<strong>of</strong> HF is ~10 times the amount released in the Texas City accident.<br />
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Participant Guide<br />
Slide 51<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
51<br />
An intentional (or accidental) release <strong>of</strong> 10 times the amount <strong>of</strong> HF released in the Texas<br />
City accident, given “favorable” wind conditions, would impact a major highway and large<br />
sports arena, or industrial and residential property. While this could be mitigated by<br />
early communication <strong>of</strong> a “shelter-in-place” order, that would not be helpful to attendees<br />
at the open-air coliseum less than ½ mile away.<br />
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Participant Guide<br />
Slide 52<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Community threat<br />
assessment<br />
• Emergency response<br />
planning<br />
• Prevention through zoning<br />
and/or substitution <strong>of</strong> less<br />
hazardous processes<br />
HF: Preparedness<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
52<br />
Prevention and planning may decrease the need <strong>for</strong> mitigation and recovery. All <strong>of</strong><br />
these aspects are important and should be done in partnership with other public health,<br />
responder, industry, citizen, and government groups, using the expertise <strong>of</strong> each.<br />
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Slide 53<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Summary: Toxic Gas Characteristics<br />
AGENT<br />
PHYSICAL PROPERTIES<br />
EXPECTED CLINICAL EFFECTS<br />
H 2<br />
O<br />
Solubility<br />
Odor /<br />
Warning<br />
Vapor<br />
Density<br />
Mucosal /<br />
Upper Airway<br />
Lower<br />
Airway<br />
Systemic<br />
MIC<br />
High<br />
Pungent /<br />
Inadequate<br />
1.4<br />
Yes<br />
Possible<br />
No<br />
NH 3<br />
High<br />
Pungent /<br />
Good<br />
0.5<br />
Yes<br />
Possible<br />
No<br />
Cl 2<br />
Interm .<br />
Pungent / Fair<br />
2.5<br />
Yes<br />
Yes<br />
No<br />
COCl 2<br />
Low<br />
Mown Hay/<br />
Inadequate<br />
3.5<br />
Unlikely<br />
Yes<br />
No<br />
HF<br />
High<br />
Pungent /<br />
Good<br />
0.7<br />
Yes<br />
Possible<br />
Electrolyte &<br />
Cardiac<br />
Rhythm<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
53<br />
This table summarizes some <strong>of</strong> the material covered up to this point.<br />
The major feature to remember is that <strong>for</strong> those agents with high water solubility,<br />
mucous membrane (eye, nose, throat) and upper airway symptoms would be expected<br />
to predominate, while low water solubility gas exposure victims will <strong>of</strong>ten demonstrate<br />
a predominance <strong>of</strong> lower respiratory symptoms, except in cases with high dose (amount<br />
x time) exposure.<br />
Certain agents (such as HF) can cause systemic effects that may be more important<br />
than the local irritant/corrosive effects.<br />
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Slide 54<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Treatment <strong>for</strong> Irritive Gas Exposure<br />
• Remove from exposure<br />
• Irrigation <strong>of</strong> eyes or skin if<br />
involved<br />
– Extensive decontamination<br />
usually not necessary unless<br />
liquid exposure<br />
• Oxygen<br />
• Nebulized beta-agonists (e.g.<br />
albuterol ) <strong>for</strong> wheezing or<br />
dyspnea<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
54<br />
Despite the significant toxicity <strong>of</strong> all <strong>of</strong> these gases, there are no specific antidotes to<br />
reverse the effects. However, there are steps and treatments that are important <strong>for</strong><br />
management <strong>of</strong> these patients.<br />
As with almost all toxic situations, removal from ongoing exposure – with attention to<br />
safety <strong>of</strong> rescuers – is most important.<br />
Water-soluble agents will lead to significant eye symptoms and appropriate irrigation <strong>of</strong><br />
exposed tissue is very important <strong>for</strong> both com<strong>for</strong>t and long-term outcome. However,<br />
extensive ef<strong>for</strong>ts at decontamination (e.g. stripping all clothing and full “wet decon”) is<br />
usually inappropriate <strong>for</strong> gas/vapor exposure. In an industrial setting with exposure to<br />
liquid, full decon may be important. Certainly HazMat technicians would require<br />
chemical protective clothing and self-contained breathing apparatus to enter such a<br />
scene.<br />
Many <strong>of</strong> these compounds cause hypoxia (directly or indirectly), so oxygen<br />
administration is important; administration <strong>of</strong> albuterol (a bronchodilator) will address<br />
some <strong>of</strong> the bronchial hyper-reactivity common to these chemical exposures. Once<br />
stabilized, corticosteroids may also be appropriate in modifying the inflammatory<br />
pulmonary response.<br />
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Slide 55<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Special Considerations<br />
• Consider adding sodium bicarbonate to nebulizer in<br />
chlorine gas exposures<br />
• Intravenous and inhaled calcium gluconate, and<br />
continuous cardiac monitoring are important <strong>for</strong><br />
hydrogen fluoride exposure<br />
• Observe patients <strong>for</strong> late pulmonary effects,<br />
particularly in those with severe early symptoms<br />
Module One – Toxic Industrial Gases as Terrorist Threats<br />
55<br />
There are some situations where specialized treatment may provide some incremental<br />
benefit. As an example, the use <strong>of</strong> sodium bicarbonate in nebulizer treatments may<br />
provide some treatment <strong>for</strong> the acid generation following chlorine inhalation.<br />
In other situations, specific treatment is definitely indicated. As examples, multiple<br />
administrations <strong>of</strong> calcium gluconate may be necessary depending on the dose and<br />
delivery route <strong>of</strong> a hydrogen fluoride exposure; and continued observation <strong>of</strong> relatively<br />
asymptomatic patients <strong>for</strong> delayed-onset pulmonary symptoms is indicated following<br />
phosgene exposure.<br />
The importance <strong>of</strong> accurate identification <strong>of</strong> the <strong>of</strong>fending agent and<br />
monitoring/treatment <strong>of</strong> “special agents” should be emphasized (and pointed out on the<br />
following summary slide). This would also be an opportunity to remind the participants <strong>of</strong><br />
the importance <strong>of</strong> correlating or comparing identification in<strong>for</strong>mation provided, with the<br />
clinical toxidromes observed. As an example, hydr<strong>of</strong>luoric acid exposure is <strong>of</strong>ten initially<br />
misidentified as hydrochloric acid exposure, but the relative predominance <strong>of</strong> systemic<br />
effects with the <strong>for</strong>mer vs. dermal effects should point out the error.<br />
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Slide 56<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Questions<br />
Training Support Package<br />
56<br />
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Module Three Summary<br />
This module presented a detailed overview <strong>of</strong> chemical compounds that are produced in large<br />
quantities as part <strong>of</strong> America’s industrial complex. Many <strong>of</strong> these compounds are amenable <strong>for</strong><br />
use as large scale terrorist weapons and may be released in the <strong>for</strong>m <strong>of</strong> toxic gases. Exposure<br />
to these toxic gases will create serious health implications <strong>for</strong> its victims. The clinical symptoms<br />
created by exposure to toxic gases will be determined by the dose (concentration <strong>of</strong> chemical<br />
and duration <strong>of</strong> exposure), the unique properties <strong>of</strong> the agent (e.g. water solubility), and the<br />
underlying health status <strong>of</strong> the exposed individual. Clinical management <strong>of</strong> these patients<br />
includes immediate removal from the exposure and the initiation <strong>of</strong> appropriate management<br />
strategies. Care must be taken to ensure that rescuers and other first receivers do not become<br />
victims as well. Because <strong>of</strong> the major role these compounds play in modern industry, community<br />
hazard vulnerability assessment using the expertise <strong>of</strong> a variety <strong>of</strong> responsible individuals within<br />
the public health, emergency planning, responder, medical care provider, industry and lay public<br />
is critical to prepare <strong>for</strong> accidental and intentional releases.<br />
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Module Four<br />
Cyanide & Fumigants - Administration Page<br />
Cyanide and fumigants constitute a threat to the general population because they are easily<br />
weaponized, highly toxic when inhaled, and widely available due to their extensive use in the<br />
agriculture and pest-control industries. While accidental exposure is not uncommon, there is<br />
significant concern about their potential use as weapons <strong>of</strong> mass destruction. Though public<br />
attention has focused on past incidents <strong>of</strong> drug tampering, a more substantial danger is these<br />
agents’ suitability <strong>for</strong> dispersal as a gas through ventilation systems.<br />
Duration<br />
45 minutes<br />
Scope Statement<br />
This module reviews commercial applications, characteristics, and treatment guidelines relating<br />
to hydrogen cyanide gas and to the three most common fumigants regulated by the US<br />
Department <strong>of</strong> Agriculture: Vikane (sulfuryl fluoride), methyl bromide, and phosphine.<br />
Terminal Learning Objective (TLO)<br />
• Recognize and provide appropriate initial therapy <strong>for</strong> individuals<br />
exposed to cyanide and to fumigant gases.<br />
Enabling Learning Objectives (ELO)<br />
Resources<br />
• Indicate the sources and uses <strong>of</strong> cyanide and fumigants<br />
• Describe therapies used to treat cyanide poisoning<br />
• List the four most common fumigant gases<br />
• Describe the clinical effects <strong>of</strong> exposure to these gases<br />
• Explain how to treat victims exposed to these gases<br />
Each <strong>of</strong> the eight course modules is deployed as an interactive, instructor-lead, MS PowerPoint<br />
presentation containing didactic content, historical examples, and selected case studies. All<br />
presentations are included in a printed participant guide (PG) containing the modules’ overview,<br />
scope statement, terminal and enabling learning objectives, PowerPoint slide handouts, and a<br />
summary section.<br />
Instructor to Participant Ratio<br />
[Enter the instructor to participant ratio(e.g., 1:25).]<br />
Reference List<br />
1. Sperry P. Al-Qaida terrorists to gas US subways DHS memo warns<br />
<strong>of</strong> device that uses cyanide to asphyxiate its victims. WorldNetDaily,<br />
25 November 2003.<br />
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2. Baud FJ, Barriot P, T<strong>of</strong>fis V, et al. Elevated blood cyanide<br />
concentrations in victims <strong>of</strong> smoke inhalation. NEJM 1991;325:1761-<br />
1766.<br />
3. BBC News. Romania’s poison dump. May 19 2000. Accessed Dec<br />
2008 from:<br />
http://news.bbc.co.uk/1/hi/programmes/correspondent/755780.stm<br />
4. Bogle RG, Theron P, Brooks P, Dargan PI, Redhead J. Aluminium<br />
phosphide poisoning. Emerg Med J. 2006 Jan;23(1):e3.<br />
5. Burgess JL. Phosphine exposure from a methamphetamine laboratory<br />
investigation. J Toxicol Clin Toxicol. 2001;39(2):165-8.<br />
6. Burgess JL, Morissey B, Robertson WO. Fumigant related illnesses:<br />
Washington State’s five year experience. J Toxicol Clin Toxicol<br />
1998: 36(5):465 (abstract).<br />
7. Burkhart K. Methyl Bromide and Other Fumigants, in Goldfrank’s<br />
Toxicological Emergencies; Goldfrank LR, Flomenbaum N, H<strong>of</strong>fman<br />
RS, et al (eds.) McGraw-Hill Pr<strong>of</strong>essional, 8th edition, 2006.<br />
8. Centers <strong>for</strong> Disease Control and Prevention. Epidemiologic Notes and<br />
Reports Fatalities Resulting From Sulfuryl Fluoride Exposure After<br />
Home Fumigation—Virginia. MMWR 1987;36(36):602-604,609-611.<br />
9. Centers <strong>for</strong> Disease Control and Prevention: National Institute <strong>for</strong><br />
Occupational Safety and Health. NIOSH Alert: preventing phosphine<br />
poisonings and explosions during fumigation. NIOSH Publication No.<br />
99-126;1999. Accessed Dec 2008 from: http://cdc.gov/niosh/99-<br />
126.html<br />
10. Centers <strong>for</strong> Disease Control and Prevention: Agency <strong>for</strong> Toxic<br />
Substances and Disease Registry. Medical Management Guidelines<br />
<strong>for</strong> Phosphine. Accessed Dec 2008 from:<br />
http://www.atsdr.cdc.gov/mhmi/mmg177.html<br />
11. Centers <strong>for</strong> Disease Control and Prevention: National Institute <strong>for</strong><br />
Occupational Safety and Health. Acetonitrile. NIOSH Pocket Guide to<br />
<strong>Chemical</strong> Hazards. Accessed Dec 2008 from:<br />
http://www.cdc.gov/niosh/npg/npgd0006.html<br />
12. Centers <strong>for</strong> Disease Control and Prevention: National Institute <strong>for</strong><br />
Occupational Safety and Health. Acrylonitrile. NIOSH Pocket Guide to<br />
<strong>Chemical</strong> Hazards. Accessed Dec 2008 from:<br />
http://www.cdc.gov/niosh/npg/npgd0014.html<br />
13. Centers <strong>for</strong> Disease Control and Prevention: National Institute <strong>for</strong><br />
Occupational Safety and Health. Cyanogen Chloride The Emergency<br />
Response Safety and Health Database. Accessed Dec 2008 from:<br />
http://www.cdc.gov/niosh/ershdb/EmergencyResponseCard_2975003<br />
9.html<br />
14. Centers <strong>for</strong> Disease Control and Prevention: National Institute <strong>for</strong><br />
Occupational Safety and Health. NIOSH Pocket Guide to <strong>Chemical</strong><br />
Hazards: Sulfuryl fluoride. 2005. Accessed Dec 2008 from:<br />
http://www.cdc.gov/niosh/npg/npgd0581.html<br />
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15. Centers <strong>for</strong> Disease Control and Prevention: National Institute <strong>for</strong><br />
Occupational Safety and Health. Phosphine. The Emergency<br />
Response Safety and Health Database. Accessed Dec 2008 from:<br />
http://www.cdc.gov/niosh/ershdb/EmergencyResponseCard_2975003<br />
5.html<br />
16. Cyanokit package insert. Access Dec 2008 from:<br />
http://www.cyanokit.com<br />
17. Dunea G. Death over the counter. Br Med J 1983; 286:211-2.<br />
18. Eckstein M, Manistalco PM. Focus on smoke inhalation – the most<br />
common cause <strong>of</strong> acute cyanide poisoning. Prehosp Disast Med<br />
2005;21(2):s49-s55. Accessed Dec 2008 from:<br />
http://pdm.medicine.wisc.edu/21-2%20PDFs/eckstein.pdf<br />
19. Ellison NM, Byar DP, Newell GR Special report on Laetrile:the NCI<br />
Laetrile review. Results <strong>of</strong> the National Cancer Institute’s retrospective<br />
Laetrile review. NEJM 1978;299:549-552. Accessed Dec 2008 from:<br />
http://content.nejm.org/cgi/content/abstract/299/10/549<br />
20. Environmental Protection Agency. Overview <strong>of</strong> the Use and Usage <strong>of</strong><br />
Soil Fumigants, 2005. Accessed Dec 2008 from:<br />
http://www.epa.gov/oppsrrd1/reregistration/soil_fumigants/soil_fumiga<br />
nt_use.pdf<br />
21. Ferrari LA, Arado MG, Giannuzzi L, et al.. Hydrogen cyanide and<br />
carbon monoxide in blood <strong>of</strong> convicted dead in a polyurethane<br />
combustion: a proposition <strong>for</strong> the data analysis. Forensic Sci<br />
International 2001;121(1-2):140-143.<br />
22. Gill JR, Goldfeder LB, Stajic M. The Happy Land homicides: 87<br />
deaths due to smoke inhalation. J Forensic Sci 2003;48(1):161-163.<br />
Accessed Dec 2008 from:<br />
http://www.astm.org/JOURNALS/FORENSIC/PAGES/JFS2002227_4<br />
81.htm<br />
23. González ER. Cyanide evades some noses, overpowers others.<br />
JAMA 1982 Nov 12;248(18):2211.<br />
24. Gupta, S. Maryland Teen Facing First Degree Murder Charges For<br />
Poisoning Friend. CNN, American Morning. Originally broadcast: Jan<br />
10, 2003. Transcript accessed Dec 2008 from: http://wwwcgi.cnn.com/TRANSCRIPTS/0301/10/ltm.12.html<br />
25. Holstege CP, Isom GE, Kirk MA, et al. Cyanide and Hydrogen Sulfide.<br />
In: Flomenbaum NE, Goldfrank LR, H<strong>of</strong>fman RS, Howland MA, Lewin<br />
N, Nelson LS. Goldfrank’s Toxicologic Emergencies, 8th Edition.<br />
McGraw-Hill. New York, NY. 2006.<br />
26. Horowitz BZ, Albertson TE, O'Malley M, Swenson EJ. An unusual<br />
exposure to methyl bromide leading to fatality. J Toxicol Clin Toxicol.<br />
1998;36(4):353-7.<br />
27. Keim MJ: <strong>Terrorism</strong> involving cyanide: The prospect <strong>of</strong> improving<br />
preparedness in the prehospital setting. Prehosp Disast Med<br />
2006;21(2):s56–s60.<br />
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Participant Guide<br />
28. Lance P. 1000 Years For Revenge: International <strong>Terrorism</strong> and the<br />
FBI: The Untold Story. HarperCollins Publishers, 2004.<br />
29. Layton, Deborah. Seductive Poison. Doubleday/Anchor. 1998.<br />
30. Lee J, Mukai D, Kreuter K et al. Potential interference by<br />
hydroxocobalamin on cooximetry hemoglobin measurements during<br />
cyanide and smoke inhalation treatments. Ann Emerg Med<br />
2007;49(6):814-6.<br />
31. Litovitz TL, Klein-Schwartz W, White S, et al. 2000 Annual report <strong>of</strong><br />
the American Association <strong>of</strong> Poison Control Centers Toxic Exposure<br />
Surveillance System. Am J Emerg Med 2001;19(5):337-395<br />
[Appendix, Case #175].<br />
32. Madrzykowski D, Bryner N, Kerber SI. The NIST Station Nightclub<br />
Fire Investigation: Physical Simulation <strong>of</strong> the Fire. Fire Protection<br />
Engineering; 2006 Summer. Accessed Dec 2008 from:<br />
http://www.fpemag.com/archives/article.aspissue_id=37&i=245<br />
33. Michnea A, Gherheş, J. Impact <strong>of</strong> metals on the environment due to<br />
technical accident at aurul baia mare, romania. Int J Occ Med Environ<br />
Health. 2001;14:255-59.<br />
34. Montreal Protocol. Wikipedia. Access Dec 2008 from:<br />
http://en.wikipedia.org/wiki/Montreal_Protocol<br />
35. Mui, YQ. Maryland Teen Gets Life For Poisoning Friend. Washington<br />
Post. July 21, 2004. Accessed Dec 2008 from:<br />
http://www.washingtonpost.com/wp-dyn/articles/A114-2004Jul20.html<br />
36. National Institute <strong>for</strong> Occupational Safety and Health (NIOSH).<br />
Hydrogen Cyanide IDLH Documentation. Accessed Dec 2008 from:<br />
http://www.cdc.gov/Niosh/idlh/74908.html<br />
37. North Dakota Department <strong>of</strong> Agriculture. Timeline <strong>for</strong> sodium cyanide<br />
case. February 23, 2005. Accessed Dec 2008 from:<br />
http://www.agdepartment.com/2005Press/TimelineSodiumCyanideCa<br />
se2-11-05.pdf<br />
38. Olsen, Gregg. Bitter Almonds. St. Martin’s True Crime. 2006.<br />
39. Palatnick W, Tennebein M. Methyl bromide poisoning treated with<br />
hemodialysis. J Toxicol Clin Toxicol 1998; 36(5):464.<br />
40. Peddy SB, Rigby MR, Shaffner DH. Acute cyanide poisoning. Pediatr<br />
Crit Care 2006;7(1):79-82.<br />
41. Pesticide Action Network (PAN) Pesticide Database. Access Dec<br />
2008 from: http://www.pesticideinfo.org/<br />
42. Phosphine. Wikipedia. Accessed Dec 2008 from:<br />
http://en.wikipedia.org/wiki/Phosphine<br />
43. Polk, J. Jones plotted cyanide deaths years be<strong>for</strong>e Jonestown.<br />
Accessed Dec 2008 from:<br />
http://www.cnn.com/2008/US/11/11/jonestown.cyanide/<br />
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Practical Exercise Statement<br />
44. Regional Environmental Center <strong>for</strong> Central and Eastern Europe.<br />
Death <strong>of</strong> a river. The Bulletin 2000 9(2). Access Dec 2008 from:<br />
http://greenhorizon.rec.org/bulletin/Bull92/deathriver.html<br />
45. Sodium Thiosulfate at Drugs.com. Accessed Dec 2008 from:<br />
http://www.drugs.com/mmx/sodium-thiosulfate.html<br />
46. Sperry P. Al-Qaida terrorists to gas US subways DHS memo warns<br />
<strong>of</strong> device that uses cyanide to asphyxiate its victims. WorldNetDaily<br />
25 November 2003.<br />
47. Status Report <strong>for</strong> Fumigant Pesticides. Department <strong>of</strong> Pesticide<br />
Regulation, April 2003. Access Dec 2008 from:<br />
http://www.cdpr.ca.gov/docs/emon/methbrom/stat0403.pdf<br />
48. Sulfuryl fluoride. Wikipedia. Accessed Dec 2008 from:<br />
http://en.wikipedia.org/wiki/Sulfuryl_fluoride<br />
49. “The Gas Chamber”. Accessed Dec 2008 from:<br />
http://www.capitalpunishmentuk.org/gascham.html<br />
50. Tucker JB. Toxic Terror. Monterey Institute <strong>of</strong> International Studies.<br />
MIT Press, 2000.<br />
51. United States Army Center <strong>for</strong> Health Promotion and Preventive<br />
Medicine. Detailed Facts about Blood Agent Hydrogen Cyanide (AC).<br />
Accessed Dec 2008 from: http://chppmwww.apgea.army.mil/dts/docs/detac.pdf<br />
52. United States Fire Administration. “Fire Statistics”. Accessed Dec<br />
2008 from: http://www.usfa.dhs.gov/statistics/<br />
53. Willers-Russo LJ. Three fatalities involving phosphine gas, produced<br />
as a result <strong>of</strong> methamphetamine manufacturing. J Forensic Sci. 1999<br />
May;44(3):647-52.<br />
54. Wilson B. The Rise and Fall <strong>of</strong> Laetrile, at Quackwatch.org; 2004.<br />
http://www.quackwatch.org/01QuackeryRelatedTopics/Cancer/laetrile.<br />
html<br />
Each module presentation contains one or more interactive audience response questions<br />
designed to drive discussion, promote participant engagement, and test knowledge. Through<br />
the use <strong>of</strong> the Meridia® Audience Response system, participant responses can be collected,<br />
tabulated, and displayed within the presentation in real time. In order to use the interactive<br />
slides accompanying this presentation, the lecture hall must be equipped with the Meridia®<br />
Audience Response system and user keypads. In addition, a copy <strong>of</strong> the “Meridia® Q&A”<br />
s<strong>of</strong>tware component <strong>for</strong> MS PowerPoint must be installed on the presenter’s computer.<br />
Assessment Strategy<br />
Participant progress toward course learning objectives is monitored through in<strong>for</strong>mal discussion<br />
and responses to each module’s practical exercise questions. Overall mastery <strong>of</strong> module<br />
content and concepts is documented by means <strong>of</strong> a comprehensive, end-<strong>of</strong>-day posttest<br />
touching on key learning objectives from each module. Each participant must obtain a score <strong>of</strong><br />
80% or better to successfully complete the training and obtain a course completion certificate.<br />
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Training Support Package<br />
Participant Guide<br />
Module Four<br />
Icon Map<br />
Knowledge Check: Used when it is time to assess the learners’ understanding<br />
Example: Used when there is a descriptive illustration to show or explain<br />
Key Points: Used to convey essential learning concepts, discussions and introduction <strong>of</strong><br />
supplemental material<br />
Hint: Used to cover administrative items or instructional tips that aid in the flow <strong>of</strong> the<br />
instruction<br />
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Participant Guide<br />
Slide 1<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Module Four<br />
Cyanide & Fumigants<br />
Training Support Package<br />
1<br />
Cyanide and fumigants constitute a threat to the general population because they are<br />
easily weaponized, highly toxic when inhaled, and widely available due to their extensive<br />
use in the agriculture and pest-control industries. While unintentional exposure can<br />
occur, the US Department <strong>of</strong> Homeland Security is concerned about their potential <strong>for</strong><br />
use as weapons <strong>of</strong> mass destruction. Though public attention has focused on past<br />
incidents <strong>of</strong> drug tampering, a more imminent danger is these agents’ suitability <strong>for</strong><br />
dispersal through <strong>for</strong>ced air ventilation systems.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 2<br />
The components <strong>of</strong> the learning objectives can be summarized as: becoming familiar<br />
with the sources and uses <strong>of</strong> cyanide and fumigants, the clinical impact <strong>of</strong> exposure to<br />
these, and available treatment modalities.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 3<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Cyanide<br />
– Salts (solids)<br />
– Gas<br />
• Fumigant gases<br />
Cyanide & Fumigants<br />
– Vikane (sulfuryl fluoride)<br />
– Methyl bromide<br />
– Phosphine<br />
Module Four – Cyanide & Fumigants<br />
3<br />
In 2003, the US Department <strong>of</strong> Homeland Security (DHS) issued a bulletin warning <strong>of</strong><br />
the possibility <strong>of</strong> terrorists using ventilation systems to disperse cyanide gas. Although<br />
not part <strong>of</strong> the bulletin, fumigants could be similarly deployed.<br />
This module reviews commercial applications, characteristics, and treatment guidelines<br />
relating to cyanide and to the three most common fumigants regulated by the US<br />
Department <strong>of</strong> Environmental Protection (regulation/use) and the Department <strong>of</strong><br />
Agriculture (application): Sulfuryl fluoride, methyl bromide, phosphine, and chloropicrin.<br />
Cyanide under standard temperature conditions is a gas and it is used as a gas in<br />
certain industrial uses, but it is widely available in salt (powdered) <strong>for</strong>m as well. The<br />
fumigants are all gases and are stored in high pressure cylinders.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 4<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide<br />
• Notoriety well deserved<br />
• Historical relevance<br />
– Mass poisoning<br />
• Pharmaceutical terrorism<br />
• Weapon <strong>of</strong> Mass Destruction<br />
Module Four – Cyanide & Fumigants<br />
4<br />
Public conceptions <strong>of</strong> cyanide have been strongly influenced by its <strong>of</strong>ten fanciful<br />
depiction in popular culture (murder mysteries, TV show “24”, etc.) and through realworld<br />
crises (Tylenol tampering, Jonestown massacre, poisonings). Misconceptions<br />
regarding cyanide abound. Fictional depictions <strong>of</strong> cyanide usually refer to a white<br />
powder or clear liquid, smelling strongly <strong>of</strong> bitter almonds, that brings about almost<br />
instantaneous death when taken orally. As we will see through the course <strong>of</strong> this<br />
module, real-world scenarios involving cyanide challenge these preconceived notions.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 5<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide (CN): Properties<br />
• Small molecule (26 Dalton)<br />
• Boiling Point 27.7 °C<br />
• Colorless<br />
• Bitter Almonds Myth<br />
• Water soluble<br />
Module Four – Cyanide & Fumigants<br />
5<br />
Cyanide is commonly encountered in one <strong>of</strong> two <strong>for</strong>ms: as a solid salt (sodium cyanide,<br />
potassium cyanide) or as a gas (hydrogen cyanide). While solid cyanide salts are usually<br />
white, in aqueous solution (ie. water soluble) or as a gas, cyanide is colorless. Its<br />
relatively low boiling point means that it would exist as a gas at room temperature unless<br />
kept in solution. Cyanide remains in aqueous solution at an alkaline (basic) pH.<br />
Hydrogen cyanide gas cannot be easily detected by its odor. The scent <strong>of</strong> bitter almonds<br />
is faint and many exposed people (who live to tell about it) do not report having smelled<br />
anything.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 6<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Two Common Forms<br />
Hydrogen Cyanide Gas<br />
Solid Cyanide Salts<br />
(sodium cyanide,<br />
potassium cyanide,<br />
calcium cyanide)<br />
Toxic when Inhaled<br />
Toxic when Ingested<br />
Module Four – Cyanide & Fumigants<br />
6<br />
This lecture will primarily be devoted to inhalation exposures to hydrogen cyanide gas<br />
because that constitutes the more significant threat. Hydrogen cyanide gas is readily<br />
absorbed through the lungs and results in rapid onset (seconds) after exposure and<br />
more severe clinical effects.<br />
The salt <strong>for</strong>ms <strong>of</strong> cyanide (such as sodium cyanide) require dissolution in stomach water<br />
delaying the onset <strong>of</strong> symptoms after ingestion compared to when inhaled. Also, the<br />
kinetics <strong>of</strong> gastrointestinal uptake are slower than following inhalation. Thus symptoms<br />
following ingestion may be delayed about 20 minutes, as opposed to nearly immediately<br />
after inhalation.<br />
Sodium and potassium salts are widely available from chemical supply companies and<br />
industry. Calcium cyanide is sometimes used to clean the brass buttons used on<br />
traditional Korean costumes.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 7<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Generating HCN Gas from Salts<br />
Module Four – Cyanide & Fumigants<br />
7<br />
Using a simple chemical reaction, cyanide salts can be mixed with an acid (or even just<br />
with water which has some acid in it naturally) to produce hydrogen cyanide gas.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 8<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Sources <strong>of</strong> cyanide (solid)<br />
Cyanide<br />
– Industrial applications (electroplating, hardening steel,<br />
mining, fumigation, …)<br />
– Sodium, potassium and calcium cyanide are all readily<br />
purchased on the internet<br />
• Other sources<br />
– Cyanogen chloride<br />
– Acetonitrile, acrylonitrile<br />
– Natural occurring cyanogens (laetrile)<br />
Module Four – Cyanide & Fumigants<br />
8<br />
Given its abundant legitimate uses in industry, cyanide, particularly in salt <strong>for</strong>m can be<br />
easily purchased in a variety <strong>of</strong> <strong>for</strong>ms – most commonly sodium cyanide, potassium<br />
cyanide, and calcium cyanide.<br />
Cyanide has many industrial applications and potential availability from many sources.<br />
Some <strong>of</strong> these include:<br />
1. Sodium and potassium salts are widely available from chemical supply companies and<br />
industry.<br />
2. Cyanogen chloride, also known as CK when used as a war agent, is a extremely toxic<br />
chemical compound with the <strong>for</strong>mula CNCl; it is a colorless gas.<br />
3. Acetonitrile, CH3CN, is a colorless liquid and the simplest organic nitrile; it is widely used<br />
as a solvent. It can be metabolised to produce hydrogen cyanide if ingested.<br />
4. Acrylonitrile, CH2CHCN, is a pungent-smelling colorless liquid that <strong>of</strong>ten appears yellow<br />
due to impurities. It is an important monomer <strong>for</strong> the manufacture <strong>of</strong> useful plastics.<br />
5. Laetrile, or amygdalin, is a naturally occurring compound found in peach and apricot pits<br />
that when ingested, is metabolized by the body to cyanide. It was used in the past<br />
(1970’s) as an anticancer agent in Mexico, and is used by alternative practitioners as<br />
“vitamin B17” in the US.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 9<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Mechanism <strong>of</strong> Action<br />
• Readily enters cells<br />
• Inhibits mitochondrial<br />
respiration<br />
Module Four – Cyanide & Fumigants<br />
9<br />
Cyanide is a systemic poison with no single target organ. Cyanide acts by inhibiting<br />
enzymes within the mitochondria (or powerhouse) <strong>of</strong> all cells. This results in the<br />
complete arrest <strong>of</strong> cellular respiration and chemical asphyxiation <strong>of</strong> affected cells. In<br />
simple terms, the cells suffocate. The heart and CNS system, being the most oxygensensitive<br />
organs in the human body, are most affected by cyanide poisoning.<br />
Cyanide is an inhibitor <strong>of</strong> the enzyme cytochrome c oxidase (also known as aa3) in the<br />
fourth complex <strong>of</strong> the electron transport chain (found in the membrane <strong>of</strong> the<br />
mitochondria <strong>of</strong> eukaryotic cells.) It attaches to the iron within this protein and prevents<br />
oxygen from acting as the final electron acceptor in the chain. Thus the cell can no<br />
longer aerobically produce ATP <strong>for</strong> energy. Tissues that mainly depend on aerobic<br />
respiration, such as the central nervous system and the heart, are particularly affected.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 10<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide<br />
Other Cytochrome Oxidase Inhibitors:<br />
• Hydrogen sulfide<br />
– “sewer gas”<br />
• Sodium azide<br />
– Component <strong>of</strong> airbags<br />
• Carbon monoxide<br />
– minor mechanism<br />
Module Four – Cyanide & Fumigants<br />
10<br />
There are other cytochrome oxidase inhibitors, such as hydrogen sulfide, sodium azide,<br />
and carbon monoxide. Exposure to these other cytochrome oxidase inhibitors, due to<br />
their similar mechanism <strong>of</strong> action, may produce systemic clinical effects similar to<br />
cyanide poisoning. Hydrogen sulfide, also called sewer gas, is found in manure pits, but<br />
also has use in industry. Sodium azide is a colorless azide salt commonly used in<br />
organic synthesis, and it is a component in many car airbag systems. Carbon monoxide<br />
is readily generated by burning organic matter. When a victim presents with rapid loss <strong>of</strong><br />
consiousness that is considered to be related to an inhalational exposure, the likely <strong>of</strong> a<br />
“knock down gas” is raised. The differential diagnosis boils down to the following “knock<br />
down gases”: cyanide gas, hydrogen sulfide gas, carbon monoxide, and oxygendeficient<br />
air.<br />
Hydrogen sulfide, H2S, is colorless, toxic and flammable gas is partially responsible <strong>for</strong><br />
the foul odor <strong>of</strong> rotten eggs. It is irritating and has good warning properties due to its<br />
sulfury odor; however at high concentrations this chemical’s odor paradoxically fades<br />
and poisoning is likely.<br />
Azide is the anion with the <strong>for</strong>mula N 3 - ; Sodium azide is the sodium salt NaN 3 This latter<br />
compound is colorless and is a common reagent in organic synthesis, and is a<br />
component in many car airbag deployment systems because <strong>of</strong> its explosive nature (it<br />
<strong>for</strong>ces out the airbag).<br />
Carbon monoxide, or CO, is a colorless, odorless gas that is produced during incomplete<br />
combustion <strong>of</strong> organic compounds. It inhibits mitochondria similarly to the way that CN<br />
does, but it has other more consequential toxic effects on the red blood cells.<br />
Poisoning by each is preventable with proper safety systems or personal protective<br />
equipment.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 11<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Cyanide salts<br />
Cyanide: Toxic Quantities<br />
– Lethal dose: 200 -300 mg (3 mg/kg)<br />
• Hydrogen Cyanide (HCN) gas<br />
– Lethal dose: 50 -100 mg<br />
• 10 ppm <strong>for</strong> 2 -hours = headache<br />
• 100-200 ppm = death in 1 -hour<br />
• 200-300 ppm = death in several minutes<br />
Module Four – Cyanide & Fumigants<br />
11<br />
As previously mentioned cyanide is more readily absorbed and considerably more lethal<br />
in gaseous <strong>for</strong>m. While 200-300 mg <strong>of</strong> constitute a lethal oral dose <strong>of</strong> cyanide salts, only<br />
50-100mg <strong>of</strong> hydrogen cyanide is needed to produce a similar effect.<br />
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Participant Guide<br />
Slide 12<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Clinical Manifestations<br />
• “Gasp poison”<br />
• Central Nervous System<br />
– Headache, confusion, agitation, syncope, convulsions,<br />
coma, death<br />
• Cardiovascular<br />
– Tachycardia, hypertension<br />
– Bradycardia, hypotension<br />
– Cardiac arrest<br />
• GI<br />
– nausea, vomiting, abdominal pain<br />
Module Four – Cyanide & Fumigants<br />
12<br />
Cyanide is a systemic poison; there is no specific target organ. It is sometimes called a<br />
“blood agent” because it is carried by the blood <strong>for</strong> distribution to the body. As a result<br />
there is no reliable clinical “toxidrome” <strong>for</strong> low level cyanide poisoning; no specific<br />
constellation <strong>of</strong> signs and symptoms. The heart and central nervous system are<br />
generally most susceptible because they are the most oxygen-sensitive organs. Thus at<br />
high level exposures, coma and cardiac arrest make up the toxidrome. The word gasp<br />
poison suggests that when inhaled the onset is very rapid that the victim literally gasps<br />
<strong>for</strong> breath.<br />
CNS manifestations include syncope, or loss <strong>of</strong> consciousness, which rapidly resolves,<br />
though most <strong>of</strong> the time the patient does not rapidly recover and remains comatose.<br />
Cardiovascular manifestations include rapid (tachycardia) and (bradycardia), slow heart<br />
rates as well as high (hypertension) and low (hypotension) blood pressures.<br />
The term "blood agent" is a misnomer because these agents do not really affect the<br />
blood. Blood agents may act upon all tissues in the body once distributed by the blood.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 13<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Some possible suspects:<br />
• Hydrogen cyanide<br />
• Hydrogen sulfide<br />
• Carbon monoxide<br />
• Oxygen-deficient air<br />
Knock-Down Gases<br />
Module Four – Cyanide & Fumigants<br />
13<br />
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Training Support Package<br />
Participant Guide<br />
Slide 14<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Onset <strong>of</strong> Symptoms<br />
Time to Onset <strong>of</strong> Symptoms<br />
• Cyanide salt and cyanide gas (HCN)<br />
– Minutes<br />
– Inhalation <strong>of</strong> gas >> ingestion >> dermal<br />
– Survival > 10 minutes, most likely will survive<br />
• All or Nothing<br />
• Aliphatic cyanogens & Natural cyanogens<br />
– Hours – must be metabolized<br />
Module Four – Cyanide & Fumigants<br />
14<br />
The amount <strong>of</strong> time until the onset <strong>of</strong> symptoms is relatively short – usually on the order<br />
<strong>of</strong> a few minutes – with both solid and gaseous cyanide exposure. Onset is faster <strong>for</strong><br />
inhalation <strong>of</strong> hydrogen cyanide gas than <strong>for</strong> the ingestion <strong>of</strong> cyanide salts or <strong>for</strong> dermal<br />
exposures. Cyanide poisoning tends to be an all or nothing in terms <strong>of</strong> outcome; those<br />
who survive the first 10 minutes after the onset <strong>of</strong> symptoms will likely survive in the<br />
long-term.<br />
The salt <strong>for</strong>ms <strong>of</strong> cyanide (such as sodium cyanide) require dissolution in stomach water<br />
delaying the onset after ingestion compared to when inhaled. Also, the kinetics <strong>of</strong><br />
gastrointestinal uptake are slower than following inhalation, further explaining why it<br />
takes about 20 minutes to get sick after ingestion as opposed to nearly immediately after<br />
inhalation.<br />
Cyanogens are compounds that generate cyanide after metabolism. Examples include<br />
linamarin from cassava and amygdalin from peach pits (sold in the 1970’s and still today<br />
as Laetrile)<br />
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Participant Guide<br />
Slide 15<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Diagnostic Testing<br />
• ABG<br />
– Anion gap metabolic acidosis<br />
• VBG<br />
– “Arteriolization ” <strong>of</strong> venous blood gas<br />
• Lactate<br />
– Elevated<br />
• Blood cyanide levels<br />
– Whole blood or serum<br />
– 2-3 day turn around time<br />
Module Four – Cyanide & Fumigants<br />
15<br />
The clinical laboratory can be useful in making the diagnosis <strong>of</strong> cyanide poisoning. Anion<br />
gap metabolic acidosis is usually present and is due to the presence <strong>of</strong> large amounts <strong>of</strong><br />
lactate (L-lactate).<br />
Arteriolization <strong>of</strong> the venous blood gas may be present. That means that the arterial<br />
blood, when passing through the capillaries, does not have its oxygen removed by the<br />
tissues (since their mitochondrial electron transport chain is blocked by cyanide) and the<br />
blood passes into the venous system with lots oxygen.<br />
Blood cyanide levels from either whole blood or serum can also be obtained but these<br />
are usually per<strong>for</strong>med outside the hospital setting and have a 2-3 day turnaround time.<br />
One characteristic <strong>of</strong> cyanide poisoning is the “arteriolization” <strong>of</strong> the venous blood gas.<br />
This is due to a very poor oxygen extraction ratio from the capillary blood as it passes<br />
from artery to vein, and a very high content <strong>of</strong> oxyhemoglobin in the venous blood. It is<br />
generally felt that O2 saturation on a venous blood gas (VBG) over 80% is suggestive <strong>of</strong><br />
cyanide (or other mitochondrial enzyme) poisoning. One simple assessment <strong>for</strong> cyanide<br />
poisoning is to look at the color <strong>of</strong> the venous blood: arterial blood is bright red while<br />
venous blood should be deep red. Arteriolization is when the venous blood looks bright<br />
red like arterial blood.<br />
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Participant Guide<br />
Slide 16<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Real World Scenarios<br />
• Battlefield<br />
• Mass Murder<br />
• Mass Suicide<br />
• Homicide<br />
• Pharmaceutical <strong>Terrorism</strong><br />
• Environmental <strong>Terrorism</strong><br />
• Economic <strong>Terrorism</strong><br />
Module Four – Cyanide & Fumigants<br />
16<br />
While cyanide is primarily a compound used in various industrial applications, the<br />
compound has a long history <strong>of</strong> use as a weapon. This section discusses some potential<br />
and historical misuses <strong>of</strong> cyanide. Of current concern, someone gaining access to an air<br />
intake handler <strong>of</strong> a building can easily put cyanide gas into the <strong>for</strong>ced air ventilation<br />
system.<br />
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Participant Guide<br />
Slide 17<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Battlefield<br />
• WMD<br />
– Researched as a weapon in<br />
WW I<br />
– Used in concentration camps<br />
in WW II and in caves<br />
(Adjimushkaiskye)<br />
• Zyklon B<br />
Module Four – Cyanide & Fumigants<br />
17<br />
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Slide 18<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Mass Murder<br />
Nazi Death Camps<br />
• Millions <strong>of</strong> Jews, gypsies, and<br />
others died<br />
in CN gas chambers<br />
• Gas chambers disguised as<br />
communal showers<br />
• Some suffering more than<br />
20 min be<strong>for</strong>e death<br />
Module Four – Cyanide & Fumigants<br />
18<br />
Cyanide is an extremely toxic and rapidly acting poison. During WWI and WWII, cyanide<br />
gas was employed as a chemical warfare agent; and, under the name Zyklon B, it was<br />
used as part <strong>of</strong> Hitler’s “Final Solution”.<br />
Zyklon B was the trade name <strong>of</strong> a cyanide-based insecticide infamous <strong>for</strong> its use by Nazi<br />
Germany against Jews and other minorities in the gas chambers <strong>of</strong> extermination (such<br />
as Auschwitz-Birkenau) camps during the Holocaust. This genocide resulted in the<br />
deaths <strong>of</strong> over 6 million people be<strong>for</strong>e the end <strong>of</strong> WWII. Death camp gas chambers were<br />
frequently disguised as communal showers.<br />
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Participant Guide<br />
Slide 19<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Execution by Cyanide Gas Chamber<br />
• CN salts dropped into sulfuric<br />
acid HCN<br />
• Few states now use it<br />
• 1930 to 1980 (11 states):<br />
– 945 men<br />
– 7 women<br />
• 1960 Caryl Chessman told<br />
reporters he would nod his head<br />
if it hurt. He nodded his head <strong>for</strong><br />
several minutes be<strong>for</strong>e he died.<br />
Module Four – Cyanide & Fumigants<br />
19<br />
Execution by cyanide gas chamber, now seldom used in the United States, continues to<br />
be practiced to this day. Typically, the gas used in US execution chambers is produced<br />
by dropping a sachet <strong>of</strong> cyanide salts into a vat <strong>of</strong> sulfuric acid.<br />
Increasing recognition <strong>of</strong> the gas chamber as a needlessly cruel and painful means <strong>of</strong><br />
execution has lead many states to ban its use or provide inmates with more humane<br />
options (e.g., lethal injection). Ironically, even lethal injection has been criticized as being<br />
inhumane. Three states, Arizona, Maryland, and Missouri, retain the gas chamber as a<br />
secondary method <strong>of</strong> execution <strong>for</strong> inmates sentenced to death or having committed<br />
capital crimes be<strong>for</strong>e certain dates, though they have lethal injection as the primary<br />
method<br />
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Participant Guide<br />
Slide 20<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Other Sources<br />
The most common source <strong>of</strong><br />
cyanide exposure is<br />
incomplete combustion <strong>of</strong>:<br />
– Wood<br />
– Plastic<br />
– Rubber<br />
– Polyurethane<br />
– Wool<br />
– Silk<br />
Module Four – Cyanide & Fumigants<br />
20<br />
While numerous and dramatic cases <strong>of</strong> deliberate or accidental release <strong>of</strong> cyanide<br />
provide an important foundation <strong>for</strong> terrorism planning, the most common source <strong>of</strong><br />
cyanide exposure is the incomplete combustion <strong>of</strong> construction materials and textiles<br />
(wood, plastic, rubber, polyurethane, wool, silk). Responders should be on the lookout<br />
<strong>for</strong> cases <strong>of</strong> cyanide poisoning among victims <strong>of</strong> fire and smoke inhalation.<br />
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Participant Guide<br />
Slide 21<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Incomplete Combustion<br />
Happy Land Social Club Fire Bronx 1990: 87 deaths<br />
Module Four – Cyanide & Fumigants<br />
21<br />
The Happy Land Social Club fire was an arson fire which killed 87 people trapped in an<br />
unlicensed social club called "Happy Land" in the Bronx, New York City, on March 25,<br />
1990. Most <strong>of</strong> the victims were ethnic Hondurans celebrating Carnival. Unemployed<br />
Cuban refugee Julio González was arrested shortly after and ultimately convicted <strong>of</strong><br />
arson and murder.<br />
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Participant Guide<br />
Slide 22<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Incomplete Combustion<br />
The Station Nightclub Fire Providence 2003: 100 deaths<br />
Module Four – Cyanide & Fumigants<br />
22<br />
The Station nightclub fire occurred in West Warwick, Rhode Island on the evening <strong>of</strong><br />
February 20th, 2003. This event, the fourth-deadliest nightclub fire in U.S. history, killed<br />
100 people and injured more than 200 others. Ninety-six perished on the night <strong>of</strong> the fire,<br />
and four died later from their injuries at local hospitals. Many died without burns or<br />
significant smoke inhalation, suggestive <strong>of</strong> a role <strong>for</strong> cyanide in causing or contributing to<br />
some <strong>of</strong> the deaths.<br />
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Participant Guide<br />
Slide 23<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Homicide<br />
Module Four – Cyanide & Fumigants<br />
23<br />
Given its reputation and availability via the Internet, cyanide is a common weapon <strong>of</strong><br />
choice <strong>for</strong> many would-be poisoners. In the story described on this slide, an 18 year old<br />
Maryland teen purchased 2 grams <strong>of</strong> potassium cyanide on the internet using his<br />
mother’s credit card. He poisoned and killed his best friend because <strong>of</strong> rivalry over a<br />
<strong>for</strong>mer girlfriend. The compound was administered by lacing his friend’s beverage while<br />
the two were playing video games.<br />
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Participant Guide<br />
Slide 24<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Homicide<br />
Timeline:<br />
• 17 yr old male drinks KCN spiked soda<br />
• Feels unwell and goes to the bathroom<br />
• Emerges from the bathroom and collapses<br />
• EMS intubate <strong>for</strong> apnea. Vital signs present.<br />
• Cardiac arrest in hospital. ACLS and recovery.<br />
• Transfer to tertiary care center.<br />
• Dx made. Steps 2 & 3 <strong>of</strong> antidote kit administered.<br />
• No neurologic recovery.<br />
Module Four – Cyanide & Fumigants<br />
24<br />
This slide provides a timeline <strong>of</strong> events <strong>for</strong> the case study described on the previous<br />
slide. An indeterminate period after ingesting the cyanide spiked soda provided by his<br />
friend, the subject reported feeling unwell. Upon emerging from the bathroom the subject<br />
collapsed and emergency services were called. EMS responders intubated the subject<br />
due to the appearance <strong>of</strong> apnea (respiratory arrest) and determined that vital signs were<br />
present. While cyanide poisoning was not yet suspected, the patient was hospitalized<br />
and underwent standard testing. While in the Radiology suite <strong>for</strong> a CT scan, the subject<br />
went into cardiac arrest necessitating ACLS (Advanced Cardiac Life Support). The<br />
subject recovered and was subsequently transferred to a tertiary care center. A<br />
diagnosis <strong>of</strong> cyanide poisoning was reached and antidote steps 2 and 3 were<br />
administered. No neurologic recovery was noted. The victim went into respiratory arrest<br />
and died soon after.<br />
The antidote kit has 3 parts. Part 2 is sodium nitrite, given IV, and part 3 is sodium<br />
thiosulfate, also given IV. Part 1, not used in this case, is amyl nitrite, given by inhalation.<br />
Details about treatment <strong>for</strong> cyanide poisoning will be covered in subsequent slides.<br />
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Slide 25<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Suicide<br />
• 55 yr old male ingests KCN tablets at sentencing<br />
hearing.<br />
• Subject tells lawyer who tells judge<br />
• In minutes: lethargy > collapse > shock<br />
• No antidote kit at scene<br />
• Subject received antidote kit at hospital<br />
(~15 min post -ingestion)<br />
• No neurological recovery.<br />
Module Four – Cyanide & Fumigants<br />
25<br />
Given its reputation, cyanide is also a common choice among people wishing to poison<br />
themselves. In the case described above, a 55 year old man consumed cyanide tablets<br />
during his sentencing hearing. The defendant in<strong>for</strong>med his lawyer who in turn reported to<br />
the judge what he had done. A few minutes after the situation became known the<br />
individual became lethargic, went into shock, and collapsed. Though he received an<br />
antidote kit approximately 15 minutes after ingestion, no neurological recovery occurred<br />
and the patient subsequently died.<br />
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Participant Guide<br />
Slide 26<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Mass Murder<br />
The Jonestown Massacre<br />
– Jonestown, Guyana (1978)<br />
– CN-laced Kool -Aid<br />
– 913 Deaths<br />
Module Four – Cyanide & Fumigants<br />
Jim Jones, a cult leader from the San Francisco area, established a commune <strong>for</strong> his<br />
followers in Jonestown, Guyana. In 1978, Jones, fearing extradition to the US <strong>for</strong> a<br />
variety <strong>of</strong> crimes, exhorted his disciples to drink Kool-Aid laced with potassium cyanide<br />
as part <strong>of</strong> a mass-murder/suicide pact. Over 900 men, women, and children were killed.<br />
While most succumbed to the effect <strong>of</strong> potassium cyanide, autopsy reports noted that<br />
many victims died <strong>of</strong> gunshot wounds or poisoning by other substances.<br />
26<br />
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Slide 27<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Drug Tampering<br />
• Pharmaceutical <strong>Terrorism</strong><br />
– 1982 – Acetaminophen<br />
– 1991 – Pseudoephedrine<br />
Module Four – Cyanide & Fumigants<br />
27<br />
In 1982, Tylenol capsules adulterated with cyanide were implicated in the deaths <strong>of</strong> 7<br />
Chicago-area residents. While the original perpetrator was never apprehended, this<br />
crisis lead to a federal mandate (“The Tylenol Bill”) <strong>for</strong> more stringent anti-tampering<br />
safeguards and closer oversight <strong>of</strong> the US drug supply. Since that time there have been<br />
several similar “copy-cat” cases <strong>of</strong> drug tampering. While the risk <strong>of</strong> exposure has been<br />
greatly reduced, the surreptitious introduction <strong>of</strong> cyanide (and other toxins) into<br />
pharmaceuticals remains a serious source <strong>of</strong> concern.<br />
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Participant Guide<br />
Slide 28<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: <strong>Terrorism</strong><br />
Appearance at incidents:<br />
• NY WTC (1993)<br />
– Ingredients <strong>for</strong> HCN in the<br />
truck<br />
• Tokyo Subway (1995)<br />
– Sarin<br />
– Ingredients <strong>for</strong> HCN in<br />
bathroom<br />
Module Four – Cyanide & Fumigants<br />
28<br />
While neither <strong>of</strong> the two terrorist events (1993 World Trade Center bombing and the<br />
1995 Tokyo Sarin release) primarily involved cyanide, in both circumstances, the<br />
perpetrators appeared to be prepared to do so. This suggests that while radical groups<br />
may have more lethal means at their disposal, cyanide, by virtue <strong>of</strong> its availability and<br />
ubiquity, may provide a fall-back alternative and a supplemental means <strong>of</strong> attack.<br />
The 1993 World Trade Center bombing occurred on February 26, 1993, when a car<br />
bomb was detonated below Tower One <strong>of</strong> the World Trade Center in New York City. The<br />
1,500 lb (680 kg) urea nitrate-hydrogen gas enhanced device was intended to knock the<br />
North Tower (Tower One) into the South Tower (Tower Two), bringing both towers down<br />
and killing thousands <strong>of</strong> people. It failed to do so, but did kill six people and injured<br />
1,042. Ramzi Yousef and a Jordanian friend, Eyad Ismoil, drove a yellow Ryder van into<br />
Lower Manhattan, and pulled into the public parking garage beneath the World Trade<br />
Center around noon. There remains a popular belief that there was cyanide in the bomb,<br />
which is rein<strong>for</strong>ced by Judge Duffy's statement at sentencing, "[y]ou had sodium cyanide<br />
around, and I’m sure it was in the bomb." However, the bomb's true composition was not<br />
able to be ascertained from the crime scene and Robert Blitzer, a senior FBI <strong>of</strong>ficial who<br />
worked on the case, stated that there was "no <strong>for</strong>ensic evidence indicating the presence<br />
<strong>of</strong> sodium cyanide at the bomb site." Furthermore, Yousef is said only to have<br />
considered adding cyanide to the bomb, and to have regretted not doing so in Peter<br />
Lance's book 1000 Years For Revenge.<br />
The Sarin (nerve agent) attack on the Tokyo subway was an act <strong>of</strong> domestic terrorism<br />
perpetrated by members <strong>of</strong> Aum Shinrikyo on March 20, 1995. In five coordinated<br />
attacks, the perpetrators released sarin on several lines <strong>of</strong> the Tokyo Metro, killing at<br />
least a dozen people, severely injuring fifty and causing temporary vision problems <strong>for</strong><br />
nearly a thousand others. The bottom image shows the clean up crew on the subway car<br />
in Japan.<br />
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Participant Guide<br />
Slide 29<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Environmental <strong>Terrorism</strong><br />
• Cyanide spill into Tisza River, Romania (2000)<br />
• 100,000 cubic meters <strong>of</strong> cyanide containing water released<br />
when a gold mine dam overflowed<br />
• All river life killed <strong>for</strong> miles downriver<br />
Module Four – Cyanide & Fumigants<br />
29<br />
One <strong>of</strong> cyanide’s main industrial uses is in the processing <strong>of</strong> ore during the metal refining<br />
process. Accidental or deliberate release <strong>of</strong> the large amounts <strong>of</strong> cyanide used in the<br />
mining industry has the potential to cause serious and widespread environmental and<br />
economic damage.<br />
Several environmental disasters have occurred in Europe and South American when the<br />
tailing ponds where cyanide waste water is kept breach the banks.<br />
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Slide 30<br />
Claims in 1989 that imported Chilean grapes contained cyanide resulted in a massive<br />
downturn in the Chilean fruit industry and caused irreparable harm to that nation’s<br />
economy. Based on phone calls placed to US, Canadian, and Japanese embassies<br />
threatening to poison Chilean fruit exports and the discovery <strong>of</strong> two cyanide-laden<br />
grapes, FDA <strong>of</strong>ficials seized all the country’s fruit exports and recommended that<br />
consumers destroy any fruit they had at home. While subsequent testing and<br />
investigation proved the risk to be minimal and the threat a likely hoax, the event had an<br />
undeniable impact on the Chilean economy ($333 million USD lost) and consumer<br />
purchasing habits.<br />
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Participant Guide<br />
Slide 31<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: Missing Cyanide (2004)<br />
• 15-gallon drum <strong>of</strong> sodium cyanide<br />
was lost from a delivery truck<br />
• Located after 1 -week search in N.<br />
Dakota<br />
– Was being hauled <strong>for</strong> delivery to<br />
beekeepers<br />
– Used to fumigate and kill excess<br />
bees<br />
– Not legally registered <strong>for</strong> this use<br />
• Became a multi -state<br />
investigation<br />
Module Four – Cyanide & Fumigants<br />
31<br />
In 2004 in North Dakota a 15 gallon drum <strong>of</strong> cyanide was “lost” from a delivery truck, and<br />
was found almost 2 weeks later. It was being transported to be used in beekeeping,<br />
which is not a registered use <strong>of</strong> cyanide. Obviously this was a concern to DHS and FBI<br />
given the possible use <strong>of</strong> this chemical against a population, and it became a multistate<br />
investigation. But this really demostrates just how easy it is to get, and to lose, cyanide.<br />
The case first came to light on Sept. 30, 2004, when passing motorists found two drums<br />
<strong>of</strong> sodium cyanide along ND Highway 1, north <strong>of</strong> Lakota, North Dakota. A trucker<br />
admitted that three barrels had fallen <strong>of</strong>f his vehicle, and a search was launched to find<br />
the missing barrel. The missing barrel was found October 12 th , in a water-filled ditch<br />
along Highway 1 near Brocket, ND. The case initially drew the attention <strong>of</strong> the U.S.<br />
Department <strong>of</strong> Homeland Security and the FBI. After it was learned that the chemical<br />
was intended <strong>for</strong> beekeeping, it became an agricultural regulatory matter and NDDA<br />
took the lead role. Since the incident was first reported, NDDA investigators determined<br />
that 54 containers <strong>of</strong> sodium cyanide had been sold in North Dakota over the past two<br />
years. All have been traced to the same <strong>of</strong>fender: EnviroKem. Eleven locations in North<br />
Dakota and six locations in other states were involved. Sodium cyanide is legally used in<br />
extracting precious metals, case-hardening steel and electroplating. It has no registered<br />
agricultural use.<br />
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Participant Guide<br />
Slide 32<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Prehospital Care<br />
Cyanide: Treatment<br />
• Safely remove victims from source<br />
• Restore or maintain airway patency<br />
• Maximize oxygenation<br />
– 100% NRBM or BVM<br />
• Cardiopulmonary support to maintain VS<br />
– IVF and/or dopamine, norepinephrine<br />
• Decontamination<br />
Module Four – Cyanide & Fumigants<br />
32<br />
Given all these potential sources and nefarious uses <strong>of</strong> cyanide, let’s look at some<br />
treatment issues. In any setting with multiple people incapacitated or “found down”, one<br />
should always consider the surroundings potentially hazardous.<br />
After removal from the scene (with appropriate attention to rescuer safety), the treatment<br />
<strong>of</strong> cyanide poisoning starts with oxygenation and supportive care.<br />
Intubation and manual ventilation are <strong>of</strong>ten required to provide an airway and<br />
oxygenation. Specific antidotes exist and need to be given as soon as possible after<br />
exposure in order to save lives. Currently two different antidote kits are available in the<br />
US: the traditional 3-step (“Eli Lilly” or Taylor) kit or the more recently approved one-step<br />
Cyanokit® (Merck). We will discuss these in the next few slides.<br />
Once the patient has been stabilized decontamination procedures may be initiated, if<br />
indicated (more appropriate <strong>for</strong> ingested cyanogenic compounds or dermal contact with<br />
powder or liquid).<br />
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Training Support Package<br />
Participant Guide<br />
Slide 33<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide Antidote Kit (CAK)<br />
• 3-steps<br />
– Amyl nitrite<br />
– Sodium nitrite<br />
– Sodium thiosulfate<br />
• Converts cyanide to<br />
thiocyanate<br />
• One kit treats two people<br />
Module Four – Cyanide & Fumigants<br />
33<br />
The first and oldest antidote is the 3-step cyanide antidote kit, still referred to as the “Lilly<br />
kit”. The first step involves the inhalation <strong>of</strong> amyl nitrite in the nares <strong>of</strong> the victim to<br />
induce a methemoglobinemia. Step two involves intravenous administration <strong>of</strong> sodium<br />
nitrite another methemoglobin inducer. Methemoglobin can bind cyanide to <strong>for</strong>m<br />
cyanomethemoglobin. The third and last step involves the intravenous administration <strong>of</strong><br />
sodium thiosulfate which binds the cyanide from methemoglobin <strong>for</strong>ming thiocyanate, a<br />
renally excretable substrate. Sodium thiosulfate has a somewhat delayed onset <strong>of</strong><br />
action, which is why the methemoglobin inducers are used. One kit treats two adults, or<br />
one adult twice, but full prescribing in<strong>for</strong>mation is written on the box inside cover.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 34<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide: CAK<br />
CAK Dosing<br />
• Amyl nitrite - inhale if no IV access yet<br />
• Sodium nitrite (3% solution)<br />
– Adults 300 mg (10 ml) IV over 15-20 min<br />
– Peds Hgb based<br />
• Sodium thiosulfate (50 ml 25% solution)<br />
– Adults 12.5 g (50 ml) IV<br />
– Peds 1.65 ml/kg IV<br />
• May repeat if large cyanide exposure<br />
Module Four – Cyanide & Fumigants<br />
34<br />
Amyl nitrite is best used in the pre-hospital setting and should be administered by<br />
inhalation only. The application <strong>of</strong> amyl nitrite induces methemoglobinemia which begins<br />
the process <strong>of</strong> binding free cyanide. This process is continued in the hospital setting by<br />
the application <strong>of</strong> sodium nitrite in 3% solution. Adults should receive 300mg (10ml) IV<br />
infusion over the course <strong>of</strong> 15-20 minutes, while pediatric dosing should be determined<br />
based on hemoglobin values. The process <strong>of</strong> eliminating the bound cyanide is started by<br />
the application <strong>of</strong> sodium thiosulfate in 25% solution. Adults should receive 12.5g (50 ml)<br />
IV while pediatric dosing be 1.65 ml/kg IV. Thiosulfate converts cyanohemoglobin to<br />
thiocyanate which can then be renally excreted.<br />
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Participant Guide<br />
Slide 35<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Effective<br />
• Safe<br />
• Side Effects<br />
– Nitrite<br />
• Hypotension<br />
• MetHb<br />
– Sodium Thiosulfate<br />
• vomiting<br />
Cyanide: CAK<br />
Module Four – Cyanide & Fumigants<br />
35<br />
While generally safe and effective several undesirable adverse effects are associated<br />
with CAK therapy. The administration <strong>of</strong> nitrite may induce hypotension and<br />
methemoglobinemia, while sodium thiosulfate may induce vomiting.<br />
.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 36<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanokit<br />
• Hydroxocobalamin<br />
• Converts cyanide to<br />
cyanocobalamin<br />
(vitamin B12)<br />
Cyanide: Cyanokit<br />
Dosing<br />
• 5g IV<br />
• 10g IV in cardiac arrest<br />
Module Four – Cyanide & Fumigants<br />
36<br />
The newer antidote is the one-step “Cyanokit®” which contains hydroxocobalamin. This<br />
antidote has been in use in Europe <strong>for</strong> decades and was introduced in the US in 2006.<br />
Hydroxocobalamin is administered intravenously and binds with cyanide to <strong>for</strong>m<br />
cyanocobalamin (i.e. vitamin B12) which is renally excretable. The dose is 5 grams<br />
intravenously if the patient is symptomatic and 10 grams if the patient is suffering from<br />
cardiac arrest.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 37<br />
Compared to the CAK, hydroxocobalamin has a fast onset <strong>of</strong> action and is associated<br />
with minor adverse effects such as red discoloration <strong>of</strong> skin and urine. Because <strong>of</strong> its<br />
intense color, it can interfere with cooximeter readings. Hydroxocobalamin was given an<br />
expedited review and was approved <strong>for</strong> use in the treatment <strong>of</strong> cyanide poisoning in<br />
December 2006. Its main advantage is its ease <strong>of</strong> use and the lack <strong>of</strong> methemoglobin<br />
<strong>for</strong>mation (which would be problematic in the setting <strong>of</strong> concomitant carbon monoxide<br />
poisoning)<br />
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Training Support Package<br />
Participant Guide<br />
Slide 38<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide as a Weapon<br />
An Ideal Terrorist Weapon<br />
• Plentiful<br />
• Readily available<br />
• Special knowledge not required<br />
• Capable <strong>of</strong> causing mass casualties<br />
• Capable <strong>of</strong> causing social disruption<br />
• Requires large quantities <strong>of</strong> resources to combat its<br />
effects<br />
Module Four – Cyanide & Fumigants<br />
38<br />
Since cyanide is easy to obtain, plentiful, and easily converted into gaseous <strong>for</strong>m, it is<br />
capable <strong>of</strong> causing mass casualties and social disruption. It requires large quantities <strong>of</strong><br />
resources to control its effects (rapid response, ventilation, and specific antidotes, which<br />
may not be readily available). Thus, it is ideally suited <strong>for</strong> use as a weapon.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 39<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Any terrorist attack that involves explosions or fire<br />
will likely result in HCN release<br />
Module Four – Cyanide & Fumigants<br />
39<br />
Any event which produces fire will invariably generate cyanide as a combustion byproduct.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 40<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Fumigant Gases<br />
• Sulfuryl fluoride ( Vikane 7)<br />
• Methyl bromide<br />
• Phosphine<br />
Module Four – Cyanide & Fumigants<br />
40<br />
The three most common fumigants regulated by the US Department <strong>of</strong> Environmental<br />
Protection and the Department <strong>of</strong> Agriculture are sulfuryl fluoride (Vikane 7), methyl<br />
bromide, and phosphine. Although fumigants are very toxic and their distribution<br />
regulated, they remain surprisingly easy to obtain. While not generally available through<br />
retail locations or Internet ordering sites, these agents can be purchased directly from<br />
chemical supply companies.<br />
Fumigation is a method <strong>of</strong> pest control that completely fills an area with gaseous<br />
pesticides to suffocate or poison the pests within. It is utilized <strong>for</strong> control <strong>of</strong> pests in<br />
buildings (structural fumigation), soil, grain, and produce, and is also used during<br />
processing <strong>of</strong> goods to be imported or exported to prevent transfer <strong>of</strong> exotic organisms.<br />
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Participant Guide<br />
Slide 41<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Fumigants<br />
Applications<br />
• Insect or rodent control in grain storage<br />
• Insect or rodent control in structures<br />
• Eradication <strong>of</strong> soil pests in farming<br />
Module Four – Cyanide & Fumigants<br />
41<br />
Fumigants are agents used in the home and numerous agricultural and industrial<br />
industries <strong>for</strong> the extermination and control <strong>of</strong> a variety <strong>of</strong> pests (termites, fungi,<br />
nematodes, etc.). A substantial number <strong>of</strong> exposures to fumigants reported to Poison<br />
Centers are due to the fact that civilians reenter a dwelling be<strong>for</strong>e it is safe to do so. A<br />
substantial number <strong>of</strong> exposures to fumigants reported to Poison Centers are due to the<br />
fact that civilians reenter a dwelling be<strong>for</strong>e it is safe to do so.<br />
Structural fumigating techniques differ from building to building, but in houses a rubber<br />
tent is <strong>of</strong>ten placed over the entire house while the pesticides are being released into the<br />
residence. This concentrates the gases and prevents them from escaping and doing<br />
harm to people in the neighborhood. During this time the residents <strong>of</strong> the house must<br />
find an alternate residence <strong>for</strong> up to a week depending on the fumigant used, which in<br />
turn depend on the severity <strong>of</strong> infestation and size <strong>of</strong> the house.<br />
The picture on the left is <strong>of</strong> a grain storage silo on a farm (potential site <strong>for</strong> phosphine<br />
use)<br />
The middle photograph shows a house that has been completely tented in preparation<br />
<strong>for</strong> injection <strong>of</strong> a fumigant (typically sulfuryl fluoride with a tearing agent, such as<br />
chloropicrin)<br />
The photograph on the right shows a pressurized cylinder and injection apparatus <strong>for</strong><br />
soil application in farming (previously usually using methyl bromide).<br />
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Participant Guide<br />
Slide 42<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Fumigant Gases<br />
• Like HCN, could be introduced into a closed space<br />
through ventilation system or other conduits<br />
Module Four – Cyanide & Fumigants<br />
42<br />
In 2003, the US Department <strong>of</strong> Homeland Security (DHS) issued a bulletin warning <strong>of</strong><br />
the possibility <strong>of</strong> terrorists using ventilation systems to disperse cyanide gas. Although<br />
not part <strong>of</strong> the bulletin, fumigants could be similarly deployed.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 43<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Used in 85% <strong>of</strong> building<br />
fumigations<br />
• Colorless<br />
• Odorless<br />
• Irritating<br />
• 3.5 times heavier than air<br />
• Exposure to fatal<br />
concentrations possible<br />
without warning odor<br />
• No re-entry until air levels <<br />
5 ppm<br />
Sulfuryl Fluoride<br />
O<br />
F<br />
S<br />
O<br />
F<br />
Module Four – Cyanide & Fumigants<br />
43<br />
Popular <strong>for</strong> over 50 years in the extermination industry, sulfuryl fluoride is the most<br />
frequently used fumigant in the United States. It is usually obtained in canisters and<br />
sprayed into vacant buildings <strong>for</strong> the purposes <strong>of</strong> pest-control. Because <strong>of</strong> its lack <strong>of</strong><br />
color and odor, it is <strong>of</strong>ten admixed at the scene with a small amount <strong>of</strong> chloropicrin (a<br />
potent lachrymator) to enhance detection.<br />
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Participant Guide<br />
Slide 44<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Clinical Manifestations<br />
– High concentrations<br />
• Seizures<br />
• Syncope / dysrhythmias<br />
• Respiratory arrest<br />
– Lower concentrations:<br />
• Vomiting<br />
• Diarrhea<br />
• Salivation<br />
• Lung injury<br />
Sulfuryl Fluoride<br />
Module Four – Cyanide & Fumigants<br />
44<br />
Clinical signs <strong>of</strong> sulfuryl fluoride exposure are concentration dependent and may include<br />
vomiting, diarrhea, salivation, and lung injury at lower concentrations and, in higher<br />
doses, may lead to seizures, syncope/dysrhythmias, and respiratory arrest.<br />
Acute and delayed symptoms <strong>of</strong> poisoning may also include depression, slowed gait,<br />
slurred speech, stomach pain, drunkenness, itching, numbness, twitching, and seizures.<br />
Skin contact with sulfuryl fluoride normally poses no hazard, but contact with liquid<br />
sulfuryl fluoride can cause pain and frostbite due to rapid vaporization.<br />
Sulfuryl fluoride gas is odorless and colorless, does not cause tears or immediately<br />
noticeable eye irritation, and lacks any other warning property. Thus, chloropicrin is<br />
added.<br />
.<br />
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Participant Guide<br />
Slide 45<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Management<br />
Sulfuryl Fluoride: Treatment<br />
• Removal from source <strong>of</strong> exposure<br />
• Ventilation<br />
• Oxygen<br />
• Monitor <strong>for</strong> hypocalcemia<br />
– ECG (prolonged QTc)<br />
– Serum or ionized Ca2+<br />
• Administer calcium as needed<br />
Module Four – Cyanide & Fumigants<br />
45<br />
As with all fumigants and gases the first step is to remove the patient from the exposure<br />
source. Treatment should include ventilation and oxygen and the patient should be<br />
monitored <strong>for</strong> hypocalcemia (usually identified on the ECG as a prolonged QT interval or<br />
by obtaining a Serum or ionized Ca 2+ measurement).<br />
Intravenous calcium is the treatment <strong>for</strong> this complication.<br />
There is no specific antidote <strong>for</strong> sulfuryl fluoride itself.<br />
The fluoride ion may be released from the compound in the body. This fluoride can bind<br />
blood calcium and cause hypocalcemia, which results in neurologic and cardiac<br />
abnormalities, which can be fatal if not treated. If patients develop fluoride-induced<br />
hypocalcemia, the treatment is large doses <strong>of</strong> intravenous calcium chloride or calcium<br />
gluconate.<br />
Depending on the background <strong>of</strong> the participants, many will not be familiar with<br />
electrocardiograms (ECG) monitoring or the specific intervals, such as the period <strong>of</strong><br />
cardiac electrical repolarization, as represented by the QT interval. A simple notation<br />
that this interval is prolonged by many factors, including a very low blood calcium, is<br />
sufficient.<br />
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Participant Guide<br />
Slide 46<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Sulfuryl Fluoride<br />
Elderly couple reenter fumigated home be<strong>for</strong>e Vikane<br />
had fallen to a safe levels:<br />
• Husband:<br />
– Shortness <strong>of</strong> breath, seizures<br />
– Death 48 hrs after reentry<br />
• Wife:<br />
– Weakness, nausea, vomiting<br />
– Death 72 hrs after reentry (lung damage)<br />
Module Four – Cyanide & Fumigants<br />
46<br />
This case study demonstrates the typical presentation in cases <strong>of</strong> sulfuryl fluoride<br />
poisoning. An elderly couple reentered their recently fumigated home be<strong>for</strong>e the<br />
concentration <strong>of</strong> Vikane had fallen to a safe level. The husband experienced shortness<br />
<strong>of</strong> breath, developed seizures, and died 48 hours later. The wife experienced weakness,<br />
nausea, and vomiting. She died 3 days later from lung damage.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 47<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methyl Bromide<br />
• Odorless, colorless gas<br />
• Chloropicrin (lachrymator) added as<br />
warning agent<br />
• MeBr heavier than air<br />
• Broad spectrum <strong>of</strong> activity<br />
– Alkylating agent<br />
• Penetrates rubber and neoprene<br />
• Being phased out due to environmental<br />
concerns<br />
Module Four – Cyanide & Fumigants<br />
Br<br />
CH 3<br />
47<br />
Methyl bromide, another fumigant gas, is less commonly used in the United States<br />
currently because <strong>of</strong> adverse effects on the environment (ozone depletion). However, it<br />
remains popular in many <strong>for</strong>eign countries. It is both colorless and odorless. Because <strong>of</strong><br />
its lack <strong>of</strong> color and odor, (like sulfuryl fluoride) it is <strong>of</strong>ten pre-prepared and shipped with<br />
chloropicrin (a potent lachrymator) to enhance its detection.<br />
Methyl bromide, sometimes called bromomethane, is an organic halogen compound with<br />
<strong>for</strong>mula CH 3 Br. It is a colorless, nonflammable gas with no distinctive smell. Its chemical<br />
properties are quite similar to those <strong>of</strong> chloromethane. It is a recognized ozone-depleting<br />
chemical. It was used extensively as a pesticide until being phased out by most<br />
countries in the early 2000s per the Montreal Protocol.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 48<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methyl Bromide: Clinical Signs<br />
• Acute high -level exposure rapid onset <strong>of</strong> sxs<br />
– CNS depression, delirium, seizures, pulmonary edema<br />
– Skin injury, burns, blistering reported with high -level dermal exposure<br />
• Lower level exposure<br />
– Delayed onset toxicity well -documented<br />
– Mucosal irritation<br />
– Headache, dizziness, Nausea, vomiting<br />
– Progression (hours) to visual symptoms, ataxia, tremor, delirium ,<br />
seizures<br />
• Sxs reversible with mild intoxication<br />
– Permanent effects have been reported in severe cases<br />
Module Four – Cyanide & Fumigants<br />
48<br />
Acute high level exposure results in the rapid onset <strong>of</strong> clinical symptoms. These include<br />
coma and irritant injury <strong>of</strong> the skin and airways. Lower level acute exposures results in<br />
less severe effects, with a slightly delayed onset <strong>of</strong> several hours. Many <strong>of</strong> the effects,<br />
particularly those involving the central nervous system, are not reversible.<br />
The liquid burns the skin, producing itching and reddening, then blisters several hours<br />
after contact. Both liquid and vapour severely damage the eyes.<br />
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Participant Guide<br />
Slide 49<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methyl Bromide: Case Study<br />
• Adult female occupying a guest house rapidly developed<br />
headache, flu -like symptoms<br />
• Within 24 hours, found in status epilepticus<br />
• Initial labs remarkable <strong>for</strong> severe liver, kidney injury<br />
• Expired 19 days post -exposure<br />
• A building next door had undergone fumigation with methyl<br />
bromide. Seven 1 -2 inch underground conduits connected<br />
the buildings.<br />
• Methyl bromide had traveled from the adjacent building into<br />
the cottage.<br />
Module Four – Cyanide & Fumigants<br />
49<br />
This case report from the Cali<strong>for</strong>nia Poison Center shows a typical course <strong>for</strong> high level<br />
methyl bromide exposure. An adult woman developed headache and severe<br />
neurological findings (seizure) and subsequently died after exposure to methyl bromide<br />
used to fumigate a nearby house.<br />
It was not known at the time that the two houses were connected by an undergound<br />
conduit, which allowed the methyl bromide to enter the victims home.<br />
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Participant Guide<br />
Slide 50<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosphine (PH 3 )<br />
• Forms<br />
– Gas (vapor density 1.17)<br />
– Aluminum and Zinc phosphide<br />
pellets<br />
• Smells like garlic and rotten fish<br />
• Many uses in agriculture & structural<br />
pest control<br />
• Used in semiconductor industry<br />
• Concentration effects<br />
– 400-600 ppm - severe toxicity in<br />
30 min<br />
– 1000 ppm - immediate death<br />
Module Four – Cyanide & Fumigants<br />
50<br />
Phosphides, typically distributed in pellet <strong>for</strong>m, are commonly used in agricultural<br />
settings <strong>for</strong> the fumigation <strong>of</strong> grain and widely used in the semiconductor industry. In<br />
gaseous <strong>for</strong>m phosphine is heavier than air and produces severe toxic effects above 400<br />
ppm. Exposures exceeding 1000ppm usually lead to immediate death.<br />
Phosphine is the common name <strong>for</strong> phosphorus hydride (PH3). It is a colorless,<br />
flammable gas with a boiling point <strong>of</strong> -88 °C at standard pressure. Pure phosphine is<br />
odorless, but technical grade phosphine has a highly unpleasant odor like garlic or<br />
rotting fish, due to the presence <strong>of</strong> substituted phosphine and diphosphine (P2H4).<br />
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Participant Guide<br />
Slide 51<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Generating Phosphine Gas<br />
Module Four – Cyanide & Fumigants<br />
51<br />
Phosphides break down (on contact with water, oxygen, acid) to yield phosphine gas,<br />
the active pesticidal agent.<br />
Phosphine should not be confused with phosgene which is discussed in the Toxic Gases<br />
module.<br />
Aluminum phosphide is used as a rodenticide, insecticide and fumigant <strong>for</strong> stored cereal<br />
grains. It is used to kill small verminous mammals such as moles, rabbits, and rodents.<br />
Once wet, either in the environment or the GI tract <strong>of</strong> a rodent, phosphine is liberated. In<br />
some parts <strong>of</strong> the world, aluminum or zinc phosphide ingestion is a leading cause <strong>of</strong><br />
suicide by overdose.<br />
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Participant Guide<br />
Slide 52<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Clinical<br />
Phosphine : Treatment<br />
• Early/mild cases<br />
– Non-specific<br />
– GI effect, cough, chest tightness, eye irritation<br />
• Late/serious exposure<br />
– Pulmonary edema, coma, seizures, death<br />
– Knock-down gas<br />
• Rapid progression and deterioration in fatal cases<br />
Module Four – Cyanide & Fumigants<br />
52<br />
Shortly after exposure or following very low-dose exposure, patients will present with<br />
non-specific symptoms that may include GI effects (nausea, vomiting), cough, tightness<br />
<strong>of</strong> the chest, and eye irritation. If treatment is delayed or the exposure is heavier,<br />
subjects may experience pulmonary edema, coma, and seizure leading to death.<br />
Typically symptoms progress rapidly in cases <strong>of</strong> fatal exposure.<br />
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Participant Guide<br />
Slide 53<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Phosphine: Case Study<br />
• 5-year-old girl suddenly develops difficulty breathing at home<br />
• Has a cardiac arrest - Unable to resuscitate<br />
• Family members were ill as well<br />
– Developed acutely after a period <strong>of</strong> heavy rainfall<br />
– Odor noted in basement<br />
• Investigation: a cupful <strong>of</strong> aluminum phosphide pellets had<br />
been placed in a hole adjacent to the basement foundation<br />
• Child’s father was a pr<strong>of</strong>essional exterminator<br />
Module Four – Cyanide & Fumigants<br />
53<br />
As indicated by this case study, mishandling and misuse are the most common causes<br />
<strong>of</strong> phosphine exposure. In this case a young girl developed difficulty breathing and<br />
suffered a cardiac arrest, and several other family members were ill. The investigation<br />
identified aluminum phosphide pellets, which had been placed by the father (an<br />
exterminator) in a potential site <strong>of</strong> rodent entry in the basement had become wet, and<br />
likely released the phosphine gas.<br />
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Slide 54<br />
The illicit synthesis <strong>of</strong> methamphetamine also produces phosphine and has resulted in<br />
toxic exposures <strong>for</strong> both the “cooks” and first responders. The Willers paper describes<br />
three dead victims in a hotel room where methamphetamine was being synthesized. The<br />
Burgess paper detailed a law en<strong>for</strong>cement agent who was exposed to phosphine during<br />
a methamphetamine raid. He developed chronic lung disease following this initial<br />
exposure.<br />
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Participant Guide<br />
Slide 55<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Treating Fumigant Poisoning<br />
• No antidotes available<br />
• Remove victim from source<br />
• Thorough decontamination<br />
• Oxygenation<br />
• Symptomatic and supportive care as indicated<br />
Module Four – Cyanide & Fumigants<br />
55<br />
All exposures to fumigants should be treated with immediate removal from source,<br />
thorough skin and eye decontamination, oxygenation, supplemented by symptomatic<br />
and supportive care. No specific antidote is available <strong>for</strong> any <strong>of</strong> these exposures.<br />
Treatment <strong>of</strong> hypocalcemia sometimes seen with sulfuryl fluoride poisoning may be<br />
necessary.<br />
Supportive care is indicated. This includes oxygen and decontamination <strong>of</strong> exposed skin<br />
and eyes. A full “wet decon” is not usually necessary <strong>for</strong> a vapor or gas exposure alone.<br />
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Participant Guide<br />
Slide 56<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Fumigants: Summary<br />
Gas<br />
Vikane<br />
Methyl<br />
Bromide<br />
Properties<br />
Poorly<br />
detectable<br />
(occasionally<br />
mixed with<br />
chloropicrin)<br />
Poorly<br />
detectable<br />
(occasionally<br />
mixed with<br />
chloropicrin)<br />
Clinical manifestations<br />
Neurologic<br />
Gastrointestinal<br />
Potentially delayed onset<br />
Mucous membranes irritation<br />
Neurologic<br />
Seizures <br />
Lung<br />
Management<br />
Remove from<br />
exposure<br />
Flush skin/eyes<br />
100% O2<br />
Supportive care<br />
Same<br />
Phosphine<br />
Fishy / garlic<br />
odor<br />
Neurologic, Cardiac, Lung<br />
Same<br />
Module Four – Cyanide & Fumigants<br />
56<br />
This chart is a reminder and comparison <strong>of</strong> the different fumigants that we have<br />
discussed today. It shows some <strong>of</strong> the sensory warning properties (or lack there<strong>of</strong>), the<br />
clinical signs <strong>of</strong> poisoning, and management strategies, which are essentially supportive.<br />
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Participant Guide<br />
Slide 57<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Audience Response<br />
Which <strong>of</strong> the following is added to fumigants to<br />
make them more easily detectable<br />
1. Mercaptans<br />
2. Hydrogen sulfide<br />
3. Chloropicrin<br />
4. Organophosphates<br />
5. Yellow dye number 20<br />
Module Four – Cyanide & Fumigants<br />
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Participant Guide<br />
Slide 58<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Summary<br />
• Forced air ventilation systems could be used by terrorists to<br />
disperse toxic gases or aerosols.<br />
• Cyanide gas and fumigants are easily obtained and well -<br />
suited <strong>for</strong> airborne dispersal.<br />
• Cyanide gas exposure should be treated with oxygenation,<br />
supportive care, and antidotal therapy.<br />
• No antidote is available <strong>for</strong> the fumigants discussed in this<br />
module. Treatment should focus on decontamination and<br />
supportive therapy.<br />
Module Four – Cyanide & Fumigants<br />
58<br />
Cyanide and fumigants constitute a threat to the general population because they are<br />
widely available, easily weaponized, and can be highly toxic if inhaled. In a 2003 bulletin,<br />
the US Department <strong>of</strong> Homeland Security warned <strong>of</strong> the possible use <strong>of</strong> cyanide gas as<br />
a weapon and the threat <strong>of</strong> its introduction into <strong>for</strong>ced air ventilation systems. Fumigants,<br />
while more tightly controlled, could easily be used in a similar fashion.<br />
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Slide 59<br />
Any Questions<br />
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Module Four Summary<br />
Cyanide and fumigants constitute a threat to the general population because they are widely<br />
available, easily weaponized, and can be highly toxic if inhaled. In a 2003 bulletin, the US<br />
Department <strong>of</strong> Homeland Security warned <strong>of</strong> the possible use <strong>of</strong> cyanide gas as a weapon and<br />
the threat <strong>of</strong> its introduction into <strong>for</strong>ced air ventilation systems. Fumigants, while more tightly<br />
controlled, could easily be used in a similar fashion.<br />
Cyanide is an extremely toxic and rapidly acting poison. Discovered in 1782 by the noted<br />
Swedish chemist Carl Wilhelm Scheele [1742 – 1786], prussic acid (hydrogen cyanide) was<br />
found to have numerous industrial applications. During WWI and II, cyanide gas was employed<br />
as a chemical warfare agent and, under the name Zyklon B, used as part <strong>of</strong> Hitler’s “Final<br />
Solution”. Popular conceptions <strong>of</strong> cyanide have been shaped by its frequent appearance as a<br />
murder weapon in detective fiction and by tragic real-world mass poisonings.<br />
Given its abundant legitimate uses, cyanide can be easily purchased in a variety <strong>of</strong> <strong>for</strong>ms –<br />
most commonly sodium cyanide, potassium cyanide, and calcium cyanide. Using a simple<br />
chemical reaction, cyanide salts can be mixed with an acid to produce hydrogen cyanide gas.<br />
The dose <strong>of</strong> cyanide required to produce toxicity varies with type <strong>of</strong> exposure. About 200 mg <strong>of</strong><br />
potassium cyanide is lethal if ingested, whereas airborne concentrations <strong>of</strong> >110ppm <strong>for</strong> 30<br />
minutes are generally considered fatal.<br />
Cyanide acts by inhibiting specific enzymes – predominantly cytochrome aa3 in the<br />
mitochondrial electron transport chain – resulting in the complete arrest <strong>of</strong> cellular respiration<br />
and chemical asphyxiation <strong>of</strong> cells. The heart and CNS system, being the most oxygensensitive<br />
organs in the human body, are most affected by cyanide poisoning. Cyanide may also<br />
impact myocardial cells but this effect is, as yet, not well established.<br />
The clinical effects <strong>of</strong> cyanide poisoning include: gasping, syncope, and cardiac arrest. There is<br />
no specific constellation <strong>of</strong> signs and symptoms; no toxidrome. The <strong>of</strong>t-discussed bitter almond<br />
scent is not a reliable indicator <strong>of</strong> the presence <strong>of</strong> cyanide gas. Cyanide poisoning should be<br />
suspected whenever a group <strong>of</strong> people seem to have collapsed following an unknown inhalation<br />
exposure.<br />
The clinical laboratory can be useful in making the diagnosis <strong>of</strong> cyanide poisoning. Anion gap<br />
metabolic acidosis is usually present and it is due to the presence <strong>of</strong> large amounts <strong>of</strong> lactate<br />
(L-lactate). Arteriolization (i.e., inability <strong>of</strong> peripheral tissues to use oxygen) <strong>of</strong> the venous blood<br />
gas may be present. This leads to a very poor oxygen extraction ratio and a very high content <strong>of</strong><br />
oxyhemoglobin in the venous blood. Oxygen saturations <strong>of</strong> >80% in venous blood are highly<br />
suggestive <strong>of</strong> arteriolization phenomenon. Blood cyanide levels can also be obtained but these<br />
are usually per<strong>for</strong>med outside the hospital setting and have a 2-3 day turnaround time.<br />
The treatment <strong>of</strong> cyanide poisoning starts with oxygenation and supportive care. Intubation and<br />
ventilation are <strong>of</strong>ten required. Specific antidotal therapies exist and need to be applied as soon<br />
as possible after exposure. Currently two different antidote kits are available in the US: the<br />
traditional 3-step (“Eli Lilly”) kit or the more recently approved one-step Cyanokit® (Merck).<br />
The first and oldest antidote is the 3-step cyanide antidote kit, still affectionately still referred to<br />
as the Eli Lilly kit. The first step involves the insufflation <strong>of</strong> amyl nitrite capsules in the nares <strong>of</strong><br />
the victim to induce a methemoglobinemia. Step two involves intravenous administration <strong>of</strong><br />
sodium nitrite another methemoglobin inducer. Methemoglobin can bind cyanide to <strong>for</strong>m<br />
cyanomethemoglobin. The third and last step involves the intravenous administration <strong>of</strong> sodium<br />
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thiosulfate which binds the cyanide from methemoglobin <strong>for</strong>ming thiocyanate, a renally<br />
excretable substrate. Sodium thiosulfate has a delayed onset <strong>of</strong> action, which is why the<br />
methemoglobin inducers are used. The adverse effects associated with the administration <strong>of</strong><br />
both <strong>for</strong>ms <strong>of</strong> nitrites include hypotension and methemoglobin <strong>for</strong>mation.<br />
The newer antidote is the one-step “Cyanokit®” which contains hydroxocobalamin. This<br />
antidote has been in use in Europe <strong>for</strong> decades and was introduced in the US in 2006.<br />
Hydroxocobalamin is administered intravenously and binds with cyanide to <strong>for</strong>m<br />
cyanocobalamin (i.e. vitamin B12) which is renally excretable. The dose is 5 grams<br />
intravenously if the patient is symptomatic and 10 grams if the patient is suffering from cardiac<br />
arrest. It has a fast onset <strong>of</strong> action and is associated with minor adverse effects such as red<br />
discoloration <strong>of</strong> skin and urine. Because <strong>of</strong> its intense color, it can interfere with cooximeter<br />
readings.<br />
Fumigants are agents used in the home and numerous agricultural and industrial industries <strong>for</strong><br />
the extermination and control <strong>of</strong> a variety <strong>of</strong> pests (termites, fungi, nematodes, etc.). The four<br />
most common fumigants regulated by the US Department <strong>of</strong> Agriculture are Vikane (sulfuryl<br />
fluoride), methyl bromide, phosphine, and chloropicrin. Although fumigants are very toxic and<br />
their distribution regulated, they remain surprisingly easy to obtain. While not generally<br />
available, through retail locations or Internet ordering sites, these agents can be purchased<br />
directly from chemical supply companies.<br />
Popular <strong>for</strong> over 50 years in the extermination industry, Vikane (sulfuryl fluoride) is the most<br />
frequently used fumigant in the United States. It is usually obtained in canisters and sprayed<br />
into vacant buildings <strong>for</strong> the purposes <strong>of</strong> pest-control. Monitors are used to determine when it is<br />
safe <strong>for</strong> occupants to return. Vikane has no warning properties as it is both colorless and<br />
odorless. Exposure produces respiratory symptoms, seizures, coma, and death.<br />
Methyl Bromide, being more toxic to humans, is less commonly used in the United States,<br />
however, it remains popular in many <strong>for</strong>eign countries. It is both colorless and odorless. The<br />
clinical effects can be delayed and may include: respiratory symptoms, seizures, and coma.<br />
Seizures from methyl bromide are specifically associated with poor outcomes.<br />
Phosphides, typically distributed in pellet <strong>for</strong>m, are commonly used in agricultural settings <strong>for</strong><br />
the fumigation <strong>of</strong> grain. Pellets are mixed with water or an acid to produce phosphine gas.<br />
Phosphine is colorless and has a fishy or sometimes garlicky odor. Clinical effects include<br />
lethargy, coma, and lung injury.<br />
All exposures to fumigants should be treated with immediate removal from source, thorough<br />
skin and eye decontamination, oxygenation, supplemented by symptomatic and supportive<br />
care. No specific antidote is available <strong>for</strong> any <strong>of</strong> these exposures.<br />
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Participant Guide<br />
Module Five<br />
<strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, & Medication -<br />
Administration Page<br />
Safe food and water are among the basic necessities <strong>of</strong> life. Pharmaceuticals are widely used<br />
and generally considered safe in the United States. However, as past domestic and <strong>for</strong>eign<br />
crises have demonstrated, modern centralized production and distribution systems <strong>for</strong> these<br />
critical resources provide a tempting target to would-be terrorists.<br />
Duration<br />
45 minutes<br />
Scope Statement<br />
This module provides an overview <strong>of</strong> US food, drug, and water production systems with a view<br />
towards identifying potential threats and vulnerabilities. Past incidents are discussed and used<br />
to contextualize existing preventive measures and regulations.<br />
Terminal Learning Objective (TLO)<br />
• Identify potential vulnerabilities in relation to the properties <strong>of</strong> selected<br />
chemical agents in our water, food, and drug supply systems.<br />
Enabling Learning Objectives (ELO)<br />
Resources<br />
• Describe how US drinking water is produced and protected<br />
• Identify system vulnerabilities and potential chemical agents <strong>of</strong><br />
concern, using past incidents <strong>of</strong> water, food, and drug contamination<br />
or terrorism<br />
• Describe significant episodes <strong>of</strong> water, food, and medication<br />
contamination that have resulted in system-wide changes or<br />
legislation<br />
• Identify resources detailing measures used to protect the US water,<br />
food, and drug supplies<br />
Each <strong>of</strong> the eight course modules is deployed as an interactive, instructor-lead, MS PowerPoint<br />
presentation containing didactic content, historical examples, and selected case studies. All<br />
presentations are included in a printed participant guide (PG) containing the modules’ overview,<br />
scope statement, terminal and enabling learning objectives, PowerPoint slide handouts, and a<br />
summary section.<br />
Instructor to Participant Ratio<br />
1:8 (minimum) to 1:25 (maximum)<br />
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Reference List<br />
1. An Introduction to Cross-Connection Control. Foundation <strong>for</strong> Cross-<br />
Connection Control and Hydraulic Research. University <strong>of</strong> Cali<strong>for</strong>nia<br />
Viterbi School <strong>of</strong> Engineering, 2005. Accessed Dec 2008 from:<br />
http://www.usc.edu/dept/fccchr/intro.html<br />
2. Arnon SS, Schechter R, Inglesby TV. Botulinum toxin as a biological<br />
weapon: medical and public health management. JAMA. Feb<br />
28 2001;285(8):1059-70.<br />
3. Bell R. The Tylenol Terrorist. truTV, Turner Broadcasting System, Inc.<br />
Accessed Dec 2008 from:<br />
http://www.trutv.com/library/crime/terrorists_spies/terrorsts/tylenol_mu<br />
rders/4.html<br />
4. Burrows WD and Renner SE. Biological warfare agents as threats to<br />
potable water. Environ Helath Perspect 1999;107(12):975-984.<br />
5. Centers <strong>for</strong> Disease Control and Prevention. Chlorine Residual<br />
Testing Fact Sheet, SWS Project. Accessed Dec 2008 from:<br />
http://www.cdc.gov/safewater/publications_pages/chlorineresidual.pdf<br />
6. Centers <strong>for</strong> Disease Control and Prevention. Fatalities Associated<br />
with Ingestion <strong>of</strong> Diethylene Glycol-Contaminated Glycerin Uesd to<br />
Manufacture Acetaminophen Syrup—Haiti, November 1995-June<br />
1996. MMWR 1996;45(30):649-650.<br />
7. Centers <strong>for</strong> Disease Control and Prevention. BioSense. Accessed<br />
Dec 2008 from: http://www.cdc.gov/BioSense/<br />
8. Chertow DS, Tan ET, Maslanka SE, et al. Botulism in 4 adults<br />
following cosmetic injections with an unlicensed highly concentrated<br />
botulinum preparation. JAMA 2006;296(20):2476-9.<br />
9. Clark RM, Deininger RA. Protecting the nation’s critical infrastructure:<br />
the vulnerability <strong>of</strong> U.S. water supply system. J Contingencies Crisis<br />
Management 2000;8(2):73-80.<br />
10. Cockburn R, Newton PN, Agyarko EK, et al. The global threat <strong>of</strong><br />
counterfeit drugs: why industry and governments must communicate<br />
the dangers. PLoS Med 2005;2(4):e100.<br />
medicine.plosjournals.org/archive/1549-<br />
1676/2/4/pdf/10.1371_journal.pmed.0020100-L.pdf<br />
11. Denileon GP. The Who, What, Why and How <strong>of</strong> Counterterrorism<br />
Issues. J Amer Water Works Assoc 2001;93(5):78-85.<br />
12. Diethylene Glycol. Health Council <strong>of</strong> the Netherlands; 2007. Accessed<br />
Dec 2008 from: www.gezondheidsraad.nl/pdf/phpID=1606&p=1<br />
13. Dunea G. Death over the counter. Br Med 1983;286(6360):21-212.<br />
14. Environmental Protection Agency. Drinking Water Treatment.<br />
Accessed Dec 2008 from:<br />
http://www.epa.gov/ogwdw/sdwa/30th/factsheets/pdfs/fs_30ann_treat<br />
ment_web.pdf<br />
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15. Environmental Protection Agency. Potential Contamination Due to<br />
Cross-connections and Backflow and Associated Health Risks. Issue<br />
Paper US EPA Office <strong>of</strong> Ground Water and Drinking Water<br />
(OGWDW); Aug 2002.<br />
16. Environmental Protection Agency. Response Protocol Toolbox:<br />
planning <strong>for</strong> and responding to drinking water contamination threats<br />
and incidents. Accessed Dec 2008 from:<br />
http://www.epa.gov/safewater/security.<br />
17. Environmental Protection Agency. Safe Drinking Water Act. Accessed<br />
Dec 2008 from:<br />
http://www.epa.gov/OGWDW/sdwa/basicin<strong>for</strong>mation.html<br />
18. Faircloth JM. Dechlorination Procedure using Sodium Thiosulfate.<br />
DEP/State <strong>of</strong> Florida. Accessed Dec 2008 from:<br />
ftp.dep.state.fl.us/pub/labs/lds/sops/4032.pdf<br />
19. Farre ML, Garcia M-J, Tirapu L et al. Wastewater toxicity screeing <strong>of</strong><br />
non-ionic surfactants by Toxalert and Microtox bioluminescence<br />
inhibition assays. Analyt chim acta 2001;427(2):181-189.<br />
20. FDA Finds Hazardous Levels <strong>of</strong> Selenium in Samples <strong>of</strong> "Total Body<br />
Formula" and "Total Body Mega Formula“ - Dietary supplement<br />
products linked to adverse reactions. FDA Press Release. April 9,<br />
2008. Accessed Dec 2008 from:<br />
www.fda.gov/bbs/topics/news/2008/new01818.html<br />
21. Food and Drug Administration. Dietary Supplement Health and<br />
Education Act <strong>of</strong> 1994. FDA; Center <strong>for</strong> Food Safety and Applied<br />
Nutrition; 1995. Accessed Dec 2008 from:<br />
http://www.cfsan.fda.gov/~dms/dietsupp.html<br />
22. Food and Drug Administration. Food Safety: A Team Approach.<br />
Accessed Dec 2008 from:<br />
http://www.cfsan.fda.gov/~lrd/foodteam.html<br />
23. Food and Drug Administration. Grade “A” Pasteurized Milk Ordinance<br />
(2005 Revision). Accessed Dec 2008 from:<br />
http://www.cfsan.fda.gov/~ear/pmo05-2.html<br />
24. Food and Drug Administration. Questions and answers on heparin<br />
sodium injection (Baxter). FDA Center <strong>for</strong> Drug Evaluation and<br />
Research. 2008. Accessed Dec 2008 from:<br />
http://www.fda.gov/cder/drug/infopage/heparin/heparinQA.htm<br />
25. Food and Drug Administration. Risk Assessment <strong>for</strong> Food <strong>Terrorism</strong><br />
and Other Food Safety Concerns Accessed Dec 2008 from:<br />
http://www.cfsan.fda.gov/~dms/rabtact.html<br />
26. Food and Drug Administration. Standards For Grade “A” Pasteurized,<br />
Ultra-Pasteurized and Aseptically Processed Milk and Milk Products.<br />
Accessed Dec 2008 from: http://www.cfsan.fda.gov/~ear/pmo03-<br />
4.html<br />
27. Food and Drug Administration, Office <strong>of</strong> Regulatory Affairs:<br />
Compliance. Tamper-Resistant Packaging Requirements <strong>for</strong> Certain<br />
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Participant Guide<br />
Over-the-Counter (OTC) Human Drug Products (CPG 71321.17).<br />
Accessed Dec 2008 from:<br />
http://www.fda.gov/ora/compliance_ref/cpg/cpgdrg/cpg450-500.html<br />
28. Gelpi E, de la Paz MP, Terracini B, et al. The Spanish toxic oil<br />
syndrome 20 years after its onset: a multidisciplinary review <strong>of</strong><br />
scientific knowledge. Environ Health Perspect 2002;110(5):457-464.<br />
29. Gerhardt A, Ingram MK, Kang IJ, Ulitzur S. In situ on-line toxicity<br />
biomonitoring in water: recent developments. Environ Toxicol Chem<br />
2006;25(9):2263-2271.<br />
30. Government Accounting Office (GAO). Federal Oversight <strong>of</strong> Food<br />
Safety: high-risk designation can bring attention to limitations in the<br />
government’s food recall programs. Accessed Dec 2008 from:<br />
http://www.gao.gov/new.items/d07785t.pdf<br />
31. Haas CN. Benefits <strong>of</strong> using a disinfectant residual. J Amer Water<br />
Works Assoc 1999;91(1):65-69.<br />
32. Kalluri P, Crowe C, Reller M, et al. An outbreak <strong>of</strong> foodborne botulism<br />
ssociated with food sold at a salvage store in Texas. Clin Inf Dis<br />
2003;37:1490-1495. http://cdc.gov/enterics/publications/429-<br />
Kalluri2003.pdf<br />
33. Kishimoto TK, Viswanathan K, Ganguly T, et al. Contaminated<br />
heparin associated with adverse clinical events and activation <strong>of</strong> the<br />
contact system. NEJM 2008;358(23)2457-2467.<br />
34. Ko RJ. Adulterants in Asian patent medicines. NEJM 1998;339:847.<br />
35. Krouse M. Backflow incident sparks improvements. Opflow<br />
2001:27(2):1,4-5,7,14.<br />
36. Lechelt M, Blohm W, Kirschneit B, et al. Monitoring <strong>of</strong> surface water<br />
by ultra-sensitive Daphnia Toximeter. Environ Toxicol (Symposium<br />
ISTA 9) 2000;15(5):390-400.<br />
37. Lerner I. “Gold Pushing Cyanide” in ISIS News, December 18 2006.<br />
Accessed Dec 2008 from:<br />
http://www.icis.com/Articles/2006/12/15/2017988/gold-pushingcyanide.html<br />
38. McKay CA. Risk Assessment and Communication. in Flomembaum<br />
NE, Goldfrank LR, H<strong>of</strong>fman RS, Howland MA, Lewin NA, Nelson LS<br />
(eds.) Goldfrank’s Toxicologic Emergencies. McGraw-Hill Publishers,<br />
NYC, 8th edition, 2006.<br />
39. Meinhardt PL. Physician Preparedness <strong>for</strong> Acts <strong>of</strong> Water <strong>Terrorism</strong>:<br />
Recognizing waterborne disease and the health effects <strong>of</strong> water<br />
pollution. www.waterhealthconnection.org.<br />
40. Morgenstern LB, Viscoli CM, Kernan WN, et al. Use <strong>of</strong> ephedracontaining<br />
products and risk <strong>for</strong> hemorrhagic stroke. Neurology<br />
2003;60(1):132-135.<br />
41. Morrison J, Mancl K. Water System Pressure Sources. In Manel K<br />
(ed.) Water systems <strong>for</strong> small communities. The Ohio State University<br />
Extension Bulletin 910;2003.<br />
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Participant Guide<br />
42. National Research Council. Public Water Supply Distribution Systems:<br />
Assessing and Reducing Risks—First Report. National Academies<br />
Press, Washington D.C. 2005.<br />
43. Nickels G. Reservoir Covering Program. Seattle.gov. Accessed Dec<br />
2008 from:<br />
http://www.seattle.gov/util/About_SPU/Water_System/Projects/Reserv<br />
oir_Covering_Program/index.asp<br />
44. Notermans S and Havelaar AH. Removal and inactivation <strong>of</strong><br />
botulinum toxins during production <strong>of</strong> drinking water from surface<br />
water. Antonie van Leeuwenhoek 1980;46(5):511-514.<br />
45. Quimby B. “Three years later, church still feeling effects <strong>of</strong> poisoning;<br />
Its pastor says the Gustaf Adolph church, which some members have<br />
left, needs more time to heal.” Portland Press Herald, April 20 2006.<br />
Accessed Dec 2008 from: http://www.encyclopedia.com/doc/1P1-<br />
122178383.html<br />
46. Scalzo AJ. Diethylene glycol toxicity revisited: the 1996 Haitian<br />
epidemic. J Toxicol Clin Tox 1996;34(5):513-516.<br />
47. Seamon MJ, Clauson KA. Ephedra:yesterday, DSHEA, and<br />
tomorrow—a ten year perspective on the Dietary Supplement Health<br />
and Educatioin Act <strong>of</strong> 1994. J Herbal Pharmacother 2005;5(3)67-86.<br />
48. Schwartz RA. Eosinophilia-Myalgia Syndrome. eMedicine 2008.<br />
Accessed Dec 2008 from:<br />
http://www.emedicine.com/derm/topic891.htm<br />
49. Turnipseed S, Casey C, Nochetto C, Heller DN. Determination <strong>of</strong><br />
melamine and cyanuric acid residue in infant <strong>for</strong>mula using LC-<br />
MS/MS. Laboratory In<strong>for</strong>mation Bulletin No 4421. FDA Laboratory<br />
In<strong>for</strong>mation Bulletin 2008;24.<br />
50. United States Department <strong>of</strong> Agriculture. Food Safety and Inspection<br />
Service. Accessed Dec 2008 from:<br />
http://www.fsis.usda.gov/Food_Defense_&_Emergency_Response/in<br />
dex.asp<br />
51. United States Department <strong>of</strong> Defense. Crisis Communication<br />
Strategies. Analysis: Case Study: The Johnson & Johnson Tylenol<br />
Crisis. DoD Joint Course in Communication Class 02-C, Team 1.<br />
Accessed Dec 2008 from:<br />
http://www.ou.edu/deptcomm/dodjcc/groups/02c2/Johnson%20&%20<br />
Johnson.htm<br />
52. Wein LM, Liu Y. Analyzing a bioterror attack on the food supply: the<br />
case <strong>of</strong> botulinum toxin in milk. Proc Natl Acad Sci<br />
2005;102(28):9984-9989.<br />
http://www.pnas.org/content/102/28/9984.full<br />
53. Zernike K. “Arsenic Case Is Considered Homicide, Maine Police Say.”<br />
The New York Times, May 2 2003.<br />
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Practical Exercise Statement<br />
54. de Zwart D, Kramer KJM, Jenner HA. Practical experiences with the<br />
biological early warning system “mosselmonitor”. Environ Toxicol<br />
Water Quality 2006;10(4):237-247.<br />
Each module presentation contains one or more interactive audience response questions<br />
designed to drive discussion, promote participant engagement, and test knowledge. Through<br />
the use <strong>of</strong> the Meridia® Audience Response system, participant responses can be collected,<br />
tabulated, and displayed within the presentation in real time. In order to use the interactive<br />
slides accompanying this presentation, the lecture hall must be equipped with the Meridia®<br />
Audience Response system and user keypads. In addition, a copy <strong>of</strong> the “Meridia® Q&A”<br />
s<strong>of</strong>tware component <strong>for</strong> MS PowerPoint must be installed on the presenter’s computer.<br />
Assessment Strategy<br />
Participant progress toward course learning objectives is monitored through in<strong>for</strong>mal discussion<br />
and responses to each module’s practical exercise questions. Overall mastery <strong>of</strong> module<br />
content and concepts is documented by means <strong>of</strong> a comprehensive, end-<strong>of</strong>-day posttest<br />
touching on key learning objectives from each module. Each participant must obtain a score <strong>of</strong><br />
80% or better to successfully complete the training and obtain a course completion certificate.<br />
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Participant Guide<br />
Module Five<br />
Icon Map<br />
Knowledge Check: Used when it is time to assess the learners’ understanding<br />
Example: Used when there is a descriptive illustration to show or explain<br />
Key Points: Used to convey essential learning concepts, discussions and introduction <strong>of</strong><br />
supplemental material<br />
Hint: Used to cover administrative items or instructional tips that aid in the flow <strong>of</strong> the<br />
instruction<br />
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Participant Guide<br />
Slide 1<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Module Five<br />
<strong>Chemical</strong> Contamination <strong>of</strong><br />
Food, Water, and Medication<br />
Training Support Package<br />
1<br />
This module will focus on the delivery mechanism <strong>of</strong> industrial toxins disseminated<br />
through water, food, or medication.<br />
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Participant Guide<br />
Slide 2<br />
This module provides an overview <strong>of</strong> the US food, drug, and water production systems<br />
with a view towards identifying potential threats and vulnerabilities. Past incidents <strong>of</strong><br />
contamination or terrorism are discussed and used to contextualize existing or possible<br />
preventive measures and regulations.<br />
By the end <strong>of</strong> this module, participants should be able to:<br />
Describe how US drinking water is produced and protected<br />
Describe significant episodes <strong>of</strong> water, food, and medication contamination; noting<br />
potential agents <strong>of</strong> concern, system vulnerabilities, and resulting system-wide changes<br />
or legislation<br />
Identify resources detailing measures used to protect the US water, food, and drug<br />
supplies<br />
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Participant Guide<br />
Slide 3<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Water Treatment<br />
• State / federal EPAs regulate public drinking water<br />
safety (Safe Drinking Water Act) in US<br />
• Common treatment steps:<br />
– Coagulation / Flocculation<br />
– Sedimentation<br />
– Filtration<br />
– Disinfection<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
3<br />
This module will present the steps involved <strong>for</strong> most <strong>of</strong> the U.S. population in bringing<br />
water from a reservoir or aquifer to the home or business.<br />
Federal and state Environmental Protection Agency (EPA) regulate pubic drinking water<br />
safety via the Safe Drinking Water Act. There are a number <strong>of</strong> water characteristics (e.g.<br />
turbidity – a measure <strong>of</strong> clarity) and contaminants (e.g. lead) that are regulated by<br />
maximum contaminant levels (MCLs). Although assays <strong>for</strong> nearly 100 contaminants are<br />
per<strong>for</strong>med, there are many elements and compounds that are not regulated or<br />
measured.<br />
Some common steps used in the treatment <strong>of</strong> water to make it safe <strong>for</strong> drinking are<br />
coagulation/flocculation, sedimentation, filtration, and disinfection.<br />
The Safe Drinking Water Act was first passed in 1974, with the latest revision in 1996.<br />
This statute defines water qualities that are mandated <strong>for</strong> public drinking water. All<br />
“states” except Wyoming, the District <strong>of</strong> Columbia, and most tribal nations have<br />
“primacy”, meaning that the states take responsibility <strong>for</strong> complying with water safety<br />
standards. Federal EPA provides oversight and monitoring <strong>for</strong> the others.<br />
There are more than 170,000 community drinking water systems in the U.S.,<br />
approximately 1/3 <strong>of</strong> those use ground water (wells/aquifers), while 2/3 originate from<br />
surface water (rivers, lakes, reservoirs).<br />
Each <strong>of</strong> the water treatment steps will be expanded in the next slides, but a basic<br />
definition includes:<br />
1. Coagulation/Floculation: adding alum or other agglomerating agents that cause large<br />
particulates to clump together<br />
2. Sedimentation: removal <strong>of</strong> larger particles by gravity<br />
3. Filtration: removal <strong>of</strong> small particles (potentially down to the micrometer size or smaller<br />
4. Disinfection: (usually with a chlorine containing compound in this country). The chlorine<br />
kills viruses/bacteria well, but spores & protozoa such as Giardia & Cryptosporidium are<br />
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relatively resistant. In Europe, disinfection is done with ozone which is very effective but<br />
unlike chlorine, has no residual effects since it doesn’t stay in the water. This can lead to<br />
re-contamination during water storage or final routing to the tap.<br />
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Participant Guide<br />
Slide 4<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Typical Public Drinking Water System<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
4<br />
This slide shows a schematic or overview <strong>of</strong> a typical water system <strong>of</strong> the steps typically<br />
involved in the water treatment process from source to tap. Beginning from a water<br />
source, the water is first treated to remove large particles, then filtered <strong>for</strong> smaller<br />
particles, then disinfected.<br />
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Participant Guide<br />
Slide 5<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Coagulation/Flocculation<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
5<br />
Coagulation removes dirt and other particles suspended in water. Alum and other<br />
chemicals are added to water to <strong>for</strong>m tiny particles called “floc” which attract the dirt<br />
particles. The combined weight <strong>of</strong> the dirt and alum (floc) become heavy enough to sink<br />
to the bottom during sedimentation.<br />
This step is the “first pass” at removal <strong>of</strong> contaminants and is important both <strong>for</strong> water<br />
clarity and safety.<br />
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Participant Guide<br />
Slide 6<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Sedimentation<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
6<br />
The heavy particles (floc) settle to the bottom and the clear water moves to the filtration<br />
stage.<br />
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Slide 7<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Filtration<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
7<br />
Water passes through filters, some made <strong>of</strong> layers <strong>of</strong> sand, gravel, and charcoal that<br />
help removes even smaller particles.<br />
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Slide 8<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Disinfection<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
8<br />
A small amount <strong>of</strong> chlorine, bleach, or chloramine is added (or some other disinfection<br />
method is used) to kill any bacteria or microorganisms that may be in the water. Once<br />
disinfecting agents have been added, the water is held in storage to allow disinfection to<br />
take place. The water then flows through pipes, to homes and businesses in the<br />
community.<br />
After chlorine is added to the water, some free residual chlorine remains. This provides<br />
continued antimicrobial action. A significant drop in free residual chlorine indicates either<br />
a lack <strong>of</strong> disinfectant input or a high chlorine demand – suggesting the presence <strong>of</strong><br />
nitrates or other material in the water.<br />
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Participant Guide<br />
Slide 9<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Water System Vulnerabilities<br />
The Water System,<br />
• Is essential <strong>for</strong> health & safety<br />
• Comprises spatially diverse elements<br />
• Is susceptible to intrusion<br />
• Provides numerous attack sites<br />
• Is difficult to protect against backflow attacks<br />
• Contamination is difficult to trace<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
9<br />
The US public drinking water system is vitally necessary.<br />
It is spatially diverse providing numerous possible attack vectors and targets.<br />
Distribution systems are quite complex and the low pressure flow patterns are highly<br />
variable and difficult to predict.<br />
Many <strong>of</strong> the water pumps are custom built and, if damaged, would takes months to<br />
replace. Apart from providing potable drinking water, in most cities fire fighters depend<br />
on the public water system <strong>for</strong> fire control and suppression.<br />
These reasons, among others, make the US public drinking water system a tempting<br />
target <strong>for</strong> would be terrorists. Compared to other kinds <strong>of</strong> community assault, an attack<br />
on the water system would be particularly troubling.<br />
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Participant Guide<br />
Slide 10<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Maple Leaf Reservoir (Seattle, WA)<br />
• Sept 10th, 2002<br />
• Breach <strong>of</strong> fence around<br />
60,000,000 gal finished water<br />
reservoir reported.<br />
• 15 foot garden hose found near<br />
cut in fence.<br />
• First noted 2 days earlier but not<br />
reported to supervisors.<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
10<br />
On September 10 th <strong>of</strong> 2002 a breach in the fence surrounding the Maple Leaf Reservoir<br />
– a 60 million gallon reservoir serving the Seattle, WA area – was noted. A hose was<br />
found at the scene, near a cut section <strong>of</strong> perimeter fence. Despite the damage having<br />
been noted 2 days previously, no one had thought to report the incident to supervisors.<br />
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Participant Guide<br />
Slide 11<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Questions<br />
When water supply adulteration is suspected,<br />
– What chemicals should we test <strong>for</strong><br />
– Who can run STAT tests <strong>for</strong><br />
significant chemical contaminants<br />
– What criteria do you use to say<br />
the water is safe to drink<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
11<br />
In circumstances such as these, certain basic questions arise.<br />
How should a public health entity respond<br />
Should the reservoir be put <strong>of</strong>f-line<br />
Should there be a PSA (public service announcement)<br />
Should a health survey (100,000’s people) be per<strong>for</strong>med<br />
Should lab testing be done<br />
What should be tested<br />
What chemicals should we test <strong>for</strong><br />
Who can run STAT tests <strong>for</strong> significant chemical contaminants<br />
What criteria do you use to say the water is safe to drink<br />
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Participant Guide<br />
Slide 12<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Maple Leaf Reservoir (Seattle, WA)<br />
• Tests on hose and reservoir water negative<br />
• No claims <strong>of</strong> responsibility<br />
• No clusters <strong>of</strong> illness identified<br />
• Reservoir water disinfected and reprocessed<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
12<br />
Despite extensive testing by HazMat and state health department <strong>of</strong>ficials, no<br />
contaminants were found in the reservoir water supply or on the hose. In addition no one<br />
sought to claim responsibility <strong>for</strong> the event and no unusual clusters <strong>of</strong> illness were<br />
identified in the reservoir’s catchment area.<br />
As a precautionary measure the reservoir was emptied, the water treated with chlorine,<br />
and refilled.<br />
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Slide 13<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
The Ideal Drinking Water Contaminant<br />
• Resists water treatment<br />
• Is difficult to detect<br />
• Is difficult to clean<br />
– Pipes, reservoirs, etc<br />
• Causes illness:<br />
– Delayed onset<br />
– Difficult to diagnose<br />
• Readily available<br />
• No odor & taste<br />
• Colorless<br />
• Water soluble<br />
• Stable in water<br />
(i.e., resistant to hydrolysis)<br />
• Unexpected<br />
• Low LD50<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
13<br />
There are many features that could be used to define an ideal water contaminant. Some<br />
<strong>of</strong> them are common-sense, in order to avoid early detection. Most are important in order<br />
to evade some component <strong>of</strong> the water purification systems that are in place. Apart from<br />
simple accessibility, an ideal contaminant should:<br />
Be resistant to existing water treatment methods<br />
Be difficult to detect through routine surveillance/monitoring<br />
Be difficult to clean contaminated equipment<br />
Be colorless, odorless, and without taste<br />
Water soluble and water stable<br />
Should cause illness that is both unexpected, delayed in onset, and difficult to diagnose<br />
(i.e., non-specific symptoms/signs)<br />
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Slide 14<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Relative Water Toxicity<br />
R = Solubility/Lethal Dose x 1000<br />
Compound<br />
R<br />
Botulinum Toxin<br />
10,000<br />
VX<br />
300<br />
Sarin<br />
100<br />
Nicotine<br />
20<br />
Cyanide<br />
9<br />
Amiton (OP)<br />
5<br />
Na Fluoroacetate<br />
1<br />
Arsenite, arsenate<br />
1<br />
Clark: J Contingencies Crisis Management 2000<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
14<br />
Relative water toxicity is calculated as a ratio <strong>of</strong> an agent’s solubility to the dose required<br />
to cause death. A higher relative water toxicity value (R) indicates it would be easier to<br />
dissolve a toxic dose in water.<br />
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Slide 15<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cyanide Calculations<br />
Cyanide salts as potential contaminants:<br />
• Individual:<br />
– 250 mg Lethal Human Dose (oral)<br />
(250 mg/0.5 L = 500 mg/L = 0.5 g/L)<br />
• Water System:<br />
– 0.0005 kg/L x 200,000,000 L = 100,000 kg = 220,000 lb =<br />
110 tons<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
15<br />
This is an estimated oral (not inhalational) lethal dose. Assuming that everyone drank a<br />
½ liter, 110 tons is the amount <strong>of</strong> cyanide salt that would be necessary to contaminate<br />
200,000,000 liters (60 million gallons) <strong>of</strong> water – obviously, this is a lot <strong>of</strong> cyanide and a<br />
somewhat impractical means <strong>of</strong> attack.<br />
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Slide 16<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
NaCN Tanker<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
16<br />
Cyanide is a very commonly used industrial chemical and is widely available <strong>for</strong> use in<br />
the mining and metal refining industries. A tanker truck (as depicted here with the driver<br />
wearing protective clothing and a face shield, holding the large hose used to transfer<br />
cyanide) that is loaded with 30,000 gallons <strong>of</strong> 24-32% aqueous sodium cyanide solution<br />
carries roughly 8 tons <strong>of</strong> cyanide salt.<br />
While this is considerably less than the amount calculated to be necessary <strong>for</strong><br />
contaminating an entire water system, the tanker company shown above delivers 39,000<br />
tons/year with a capacity more than double that amount.<br />
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Slide 17<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Botulism Calculations<br />
• 0.00003 µg/kg LD50 Mice<br />
• 70 µg Lethal Human Dose<br />
• 70 µg/0.5 L = 140 µg/L<br />
• 140 µg/L x 200,000,000 L = 28,000 g<br />
• 28 kg <strong>for</strong> 200,000,000 L Reservoir!<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
17<br />
Contrast the amount <strong>of</strong> cyanide necessary to poison a reservoir (110 tons) with the<br />
amount <strong>of</strong> extremely toxic botulinum toxin required. Roughly 60 pounds <strong>of</strong> botulinum<br />
toxin would be required to contaminate 200 millions liters (60 million gallons) <strong>of</strong> drinking<br />
water.<br />
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Slide 18<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Filtration Spectrum<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
18<br />
There are other <strong>for</strong>ms <strong>of</strong> filtration beyond “particle level” filtration. This slide, provided by<br />
a General Electric subsidiary, shows relative particle size in relationship to filtration<br />
efficiency. The most effective method <strong>of</strong> filtering water <strong>for</strong> contaminants is reverse<br />
osmosis. This process can effectively remove even metals and dissolved salts.<br />
However, it is also expensive, requires frequent changes <strong>of</strong> the filters, must be used in<br />
association with other filtration methods (to minimize fouling <strong>of</strong> the membrane) and may<br />
be inefficient in terms <strong>of</strong> waste water generation.<br />
This chart provides in<strong>for</strong>mation on relative particle size <strong>of</strong> different filtration methods.<br />
Examples <strong>of</strong> contaminants cleared at different levels include:<br />
1. gross contaminants (e.g. sand in the millimeter size range or coal dust and other air<br />
pollutants <strong>of</strong> the micrometer size) which are removed by particle-level filtration<br />
2. suspended or dissolved compounds (such as latex or other emulsions [globules <strong>of</strong> liquid<br />
suspended in the water], bacteria, tobacco smoke) which are removed by micr<strong>of</strong>iltration<br />
techniques<br />
3. proteins (such as virus particles and albumin in the fractions <strong>of</strong> micrometer range) which<br />
are removed by ultrafiltration<br />
4. water-soluble molecules (such as sugars at the nanometer range) which are removed by<br />
nan<strong>of</strong>iltration<br />
5. dissolved elements (such as metals and salts at the fraction <strong>of</strong> a nanometer [equivalent<br />
to angstrom] range) which are removed by reverse osmosis.<br />
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Slide 19<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cross-Connections<br />
• Mix <strong>of</strong> non potable with potable water<br />
• Distribution system pressure ≥ 20 psi<br />
• Backpressure: external>system pressure<br />
• 1970-01: 459 events, 12,093 illnesses<br />
– Avg 1 line break/yr 1,000 person system<br />
(Potential Contamination Due to Cross -connections and Backflow and Associated Health Risks.<br />
Issue Paper US EPA OGW & DW Aug 2002)<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
19<br />
Let’s turn our attention to another potential vulnerability in the drinking water system.<br />
This vulnerability occurs during water distribution, namely cross-connections. These<br />
represent opportunities to introduce contaminants into the potable water system by<br />
exceeding the pressure within the system (minimum <strong>of</strong> 20 psi, usually 2-3 x that<br />
pressure).<br />
A survey <strong>of</strong> 30 years <strong>of</strong> reporting to the EPA identified 459 events with over 12,000<br />
associated illnesses. These were predominantly infectious diseases from contaminated<br />
water leaking into water systems from old water pipes, valves or other connections.<br />
Nonetheless, these numbers point out the potential vulnerability <strong>of</strong> an aging water<br />
distribution system and the ease with which someone could intentionally contaminate a<br />
water supply.<br />
Unintentional water main breaks are reported to occur at a rate <strong>of</strong> approximately one<br />
incident per year <strong>for</strong> every 1000 persons served..<br />
Over 50% <strong>of</strong> the drinking water pipes in the U.S. are over 30 years old and some<br />
systems use pipes that are more than 150 years old. Cross-connections can lead to<br />
contamination <strong>of</strong> the drinking water supply as pressures within the system fluctuate.<br />
Intentional cross-connections can occur by applying backpressure to a water system,<br />
introducing a toxin by tapping into the distribution line. Backsiphoning, another <strong>for</strong>m <strong>of</strong><br />
backflow, can occur when the water pressure in the system drops because <strong>of</strong> lowered<br />
input or excessive use at some point in the system.<br />
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Slide 20<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cross Connection / Backflow Threats<br />
One sociopath who understands hydraulics and<br />
has access to a drum <strong>of</strong> toxic chemicals could<br />
inflict serious damage pretty quickly to a water<br />
supply system in a neighborhood or a<br />
pressure zone without detection in most<br />
communities. - Denileon : JAWWA 2001<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
20<br />
The vulnerabilities <strong>of</strong> the distribution system are highlighted by this statement in the<br />
Journal <strong>of</strong> The American Water Works Association. In this article, written be<strong>for</strong>e the<br />
2001 U.S. terrorist attacks, Ms. Denileon discusses several potential types <strong>of</strong> terrorists,<br />
their funding, and potential targets. She reaches a conclusion, shared by the EPA, that<br />
the cross-connection issue is the highest priority vulnerability within our water system.<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cross Connection Example<br />
North Carolina (1997)<br />
• 60 gal. retardant foam pumped into hydrant<br />
• No local labs <strong>for</strong> testing<br />
• Water use ban on 40,000 households<br />
• 90 million gallons used to flush system<br />
• No drinking water <strong>for</strong> 39 hrs<br />
Krouse: Opflow 2001<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
21<br />
In 1997, a mistaken cross-connection made by fire fighters in North Carolina caused 60<br />
gallons <strong>of</strong> fire retardant foam to be pumped into the local drinking water system. Firemen<br />
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immediately began flushing nearby hydrants, a valve team was dispatched, and<br />
attempts were made to isolate contaminated part <strong>of</strong> distribution system. This incident<br />
impacted the water supply <strong>for</strong> some 40,000 households and caused foam to flow from<br />
fire station faucets. No local labs were available <strong>for</strong> testing and water usage had to be<br />
banned <strong>for</strong> the entire local area. Ninety million gallons <strong>of</strong> water was used to flush the<br />
system and, after 39 hours, the “all clear” was given to begin using the water again.<br />
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Slide 22<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Drinking Water: <strong>Terrorism</strong> Detection<br />
Detection Scenarios:<br />
• Caught in the act<br />
(cameras, security, or eye witness reports)<br />
• Online/Field detection & monitoring<br />
• Water quality observations (odor, color, …)<br />
• Mass Illnesses (<strong>of</strong>ten nonspecific)<br />
– ED/Public Health Surveillance Systems<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
22<br />
Currently there is no systematic evaluation <strong>of</strong> drinking water other than routine periodic<br />
testing required by the EPA. As should be clear from this presentation, there is no<br />
analytic test (and certainly no readily available test) to answer all questions about water<br />
quality or potential water contaminants.<br />
Since most water treatment and distribution facilities have some measure <strong>of</strong> security,<br />
many incidents may be detected by eye witness report, surveillance cameras, or – as<br />
with the potential Seattle case – detected by a perimeter breach. Barring the possibility<br />
<strong>of</strong> catching a culprit in the act <strong>of</strong> contaminating the water supply, detection <strong>of</strong> a terrorist<br />
attack would be dependent on noting obvious abnormalities <strong>of</strong> the water or an illness<br />
cluster detected by a public health surveillance system.<br />
Increases in over-the-counter sales <strong>for</strong> anti-diarrheals is one <strong>of</strong> the many components <strong>of</strong><br />
BioSense, a public health surveillance system. Emergency Department or Poison Center<br />
syndrome/diagnosis tracking is another surveillance activity. Although rapid recognition<br />
<strong>of</strong> disease onset potentially provides early detection <strong>of</strong> disease clusters, this surveillance<br />
(secondary preventive measure) is obviously not an ideal preventive or mitigation<br />
measure.<br />
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Slide 23<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Early Detection<br />
• Online Phys/Chem Monitors<br />
– Chlorine, pH, Turbidity, Total Organic Carbon, Pressure,<br />
Radioactivity<br />
• Rapid Field Testing Kits<br />
• Online Biosensors<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
23<br />
There are devices that can be used to detect water contamination. However, they are<br />
not routinely used unless there is suspicion that something is wrong.<br />
Some biological and chemical contaminants may cause a drop in residual chlorine levels<br />
but a much more likely cause is a failure <strong>of</strong> the chlorination system. While a drop in<br />
residual chlorine, if detected, may provide evidence <strong>of</strong> a failure in disinfection, it is<br />
unlikely that changes in the physical or chemical properties <strong>of</strong> water could be used to<br />
detect chemical contamination.<br />
There is an ongoing discussion about ways to implement additional safeguards on a<br />
routine basis that could detect at least some agents with the potential to be used by<br />
terrorists.<br />
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Slide 24<br />
A variety <strong>of</strong> biologically based sensors exist that capitalize on the sensitivity <strong>of</strong> organic<br />
systems (living organisms) to detect the presence <strong>of</strong> dangerous chemicals. Like the<br />
proverbial canary in a coalmine, observing these organisms’ reactions can provide<br />
valuable in<strong>for</strong>mation regarding water-borne contaminants. Since the organisms used in<br />
these tests would be adversely affected by disinfecting chemicals, the tests must be<br />
per<strong>for</strong>med on raw (untreated) water or after the disinfectant is chemically removed.<br />
In contrast to the field sensors mentioned in the prior slide (which would only be<br />
implemented when abnormalities were suspected), these on-line biosensors serve as<br />
active monitors, used continuously and alerting staff as soon as water quality issues are<br />
detected. Further investigation as to the specific chemical (or other) cause would be<br />
necessary, but precautions regarding use <strong>of</strong> the water could be taken immediately.<br />
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Slide 25<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
More In<strong>for</strong>mation<br />
Available Online at:<br />
www.epa.gov/safewater/security<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
25<br />
For more in<strong>for</strong>mation regarding water quality and planning <strong>for</strong> response to threats to the<br />
US drinking water system, the US Environmental Protection Agency provides a<br />
“Response Protocol Toolbox: Planning <strong>for</strong> and Responding to Drinking Water<br />
Contamination Threats and Incidents”.<br />
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Slide 26<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Physician Preparedness <strong>for</strong> Acts <strong>of</strong><br />
Water <strong>Terrorism</strong><br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
26<br />
In addition, there is physician-oriented continuing medical education available on-line in<br />
the area <strong>of</strong> preparing <strong>for</strong> water-delivered chemical terrorism. This course is accessible to<br />
all at www.waterhealthconnection.org<br />
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Slide 27<br />
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Slide 28<br />
Turning to the U.S. food system, we should first note that the regulatory structure is not<br />
as clear as it is with the regulated drinking water system. The U.S. Food and Drug<br />
Administration (FDA) regulates roughly 80% (by number <strong>of</strong> items) <strong>of</strong> the U.S. food<br />
supply, including all foods except meat, poultry, and processed egg products. These<br />
latter items are regulated by The U.S. Department <strong>of</strong> Agriculture (USDA).<br />
The FDA and USDA have conducted a vulnerability assessment, identifying 4 factors<br />
that are consistently associated with foods at a higher risk <strong>for</strong> terrorism: large batches,<br />
uni<strong>for</strong>m mixing, short shelf life, and ease <strong>of</strong> access.<br />
Slide 29<br />
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<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Factors Enhancing Food System<br />
Vulnerability<br />
• Concentration <strong>of</strong> primary production in large,<br />
monoculture farms/stockyards<br />
• Raw goods from small suppliers combined<br />
• Concentration <strong>of</strong> commodity food -processing in<br />
large centralized facilities<br />
• Quality control not designed to detect unanticipated<br />
contaminants/poisons<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
29<br />
The rationale <strong>for</strong> the food supply vulnerability assessment is highlighted here. Because<br />
raw foods including fruits, vegetables and meats are <strong>of</strong>ten shipped from all over the USA<br />
(and overseas) and, particularly in the case <strong>of</strong> meat products or milk, combined into<br />
large batches prior to shipping, any contamination could become widespread.<br />
Identification <strong>of</strong> abnormalities would be potentially impeded by sampling techniques<br />
(laboratory limits <strong>of</strong> detection as well as small samples) and the exact source may be<br />
difficult to identify, highlighting the vulnerability <strong>of</strong> the food system.<br />
Although no test can detect “everything”, the lack <strong>of</strong> quality control inspections <strong>for</strong><br />
chemicals not anticipated to be present is a vulnerability that is highlighted by the 2007-<br />
2008 epidemic <strong>of</strong> melamine/cyanuric acid adulteration <strong>of</strong> pet food and infant <strong>for</strong>mula.<br />
Identification and detection <strong>of</strong> these compounds did not occur until after repeated<br />
illnesses. The delay to distributing quality control instructions and laboratory methods,<br />
and uncertainty regarding “safe” levels, further complicated this situation.<br />
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Slide 30<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Botulism Threat<br />
• Potency: “Most Lethal Substance ”<br />
– 70 ug Lethal Oral Dose<br />
– 70 gm Could Kill 1,000,000 People<br />
• Prolonged ICU Requirement<br />
– May Exhaust Supply <strong>of</strong> Ventilators<br />
• Easy to Mass Produce<br />
– Russia, Iraq, Iran, Syria, North Korea<br />
– 1991 “Iraqi Stockpile ”: 19,000 L<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
30<br />
Let’s use botulinum toxin (produced by the bacterium, Clostridium botulini) as an<br />
example <strong>of</strong> a potent toxin being introduced into the food supply. Although not an<br />
industrial material (and considered as a Class A biological weapon by the CDC), it is<br />
produced in large quantities and available as a medication (Botox – botulinum A toxin).<br />
Because <strong>of</strong> the muscle paralysis (particularly respiratory muscle failure) that occurs with<br />
botulism, it has been estimated that 60% <strong>of</strong> botulinum poisoned individuals would<br />
require mechanical ventilation. Given the small number <strong>of</strong> ventilators and limited amount<br />
<strong>of</strong> antitoxin in the national stockpile, the death rate from a large attack would likely be<br />
closer to the pre-1950s mortality rate <strong>of</strong> 60%, or perhaps the 25% rate that occurred in<br />
the 1950s, rather than to the 6% death rate experienced in the 1990s.<br />
This agent has been weaponized by a number <strong>of</strong> nation-states, so we will use it as an<br />
example <strong>of</strong> a potential food contaminant similar to its use in the water portion <strong>of</strong> this<br />
module.<br />
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Slide 31<br />
This slide depicts the mechanism <strong>of</strong> action <strong>of</strong> botulinum toxin – the end result being<br />
inhibition <strong>of</strong> acetylcholine (neurotransmitter) release. The toxin, once taken up by the<br />
nerve fibre (axon) ending, prevents the fusion <strong>of</strong> presynaptic vesicles containing<br />
acetylcholine (the neurotransmitter responsible <strong>for</strong> sending signals between the brain<br />
and the muscle) with the nerve membrane at the synapse (connection point between<br />
nerve and muscle). If no acetylcholine is released, then coordinated muscle activity does<br />
not occur. Thus patients with botulism have paralysis, and this paralysis lasts a long time<br />
(weeks - months) even with use <strong>of</strong> the botulinum antidote (antitoxin antibodies).<br />
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Slide 32<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
32<br />
Several years ago, a terror attack using botulinum in the milk supply was modeled, as an<br />
example <strong>of</strong> introducing a potent toxin into the food supply.<br />
The Cali<strong>for</strong>nia dairy industry was chosen because this system produces 20% <strong>of</strong> the nation’s<br />
milk.<br />
Instructor Note:<br />
The pasteurized milk delivery system is characterized by the rapid distribution <strong>of</strong> 20 billion<br />
gallons per year in the U.S. There have been previous infectious disease outbreaks in the dairy<br />
industry including two natural Salmonella outbreaks, each infecting ~200,000 people.<br />
The findings from this National Academy <strong>of</strong> Science mathematical model <strong>for</strong>m the basis <strong>for</strong> the<br />
next several slides.<br />
The major focus <strong>for</strong> the discussion in this portion <strong>of</strong> the module is the extent <strong>of</strong> poisoning that<br />
can occur with introduction <strong>of</strong> a small amount <strong>of</strong> a very toxic substance at the producer end <strong>of</strong> a<br />
“bow-tie” supply chain. By extension, introduction <strong>of</strong> larger amounts <strong>of</strong> a less toxic substance at<br />
the early part <strong>of</strong> the distribution side <strong>of</strong> the supply chain can have similar effects. This would be<br />
the case <strong>for</strong> most industrial chemicals that would be introduced into the food supply.<br />
Reference:<br />
Wein LM, Liu Y.Analyzing a bioterror attack on the food supply: the case <strong>of</strong> botulinum toxin in<br />
milk. Proc Natl Acad Sci 2005;102(28):9984-9989.<br />
http://www.pnas.org/content/102/28/9984.full<br />
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Slide 33<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
33<br />
This slide depicts the model used in this study. Many food products, such as milk, fruit<br />
and vegetable juices, canned foods (e.g., processed tomato products), grain-based and<br />
other foods follow the bow-tie-shaped supply chain pictured above.<br />
Introduction <strong>of</strong> a chemical at any point in the manufacture/collection and processing<br />
system to the left has the potential to contaminate all <strong>of</strong> the finished goods.<br />
Introduction <strong>of</strong> a chemical at any point in the distribution and sales portion <strong>of</strong> the food<br />
chain on the right hand side will contaminate less <strong>of</strong> the product and poison fewer<br />
individuals. This situation also allows easier identification <strong>of</strong> the site <strong>of</strong> adulteration and<br />
potential culprit.<br />
Adulteration at a “downstream” (distribution/sales) site allows effective use <strong>of</strong> a less<br />
potent chemical agent (than botulinum toxin).<br />
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Slide 34<br />
In the model just depicted, the authors note that infiltration <strong>of</strong> the system anywhere on<br />
the “left-hand side <strong>of</strong> the bow-tie” with only 1-10 grams <strong>of</strong> botulinum toxin has the<br />
potential to poison 100,000 people to more than 5 times that number (i.e. all <strong>of</strong> the<br />
tainted milk consumers), if undetected.<br />
If a clinical surveillance system notes a signal and is correctly interpreted, 2/3 <strong>of</strong> the<br />
cases could be prevented by public notification and milk recall, yet 100,000 people could<br />
still be poisoned.<br />
The authors estimate the cost to care <strong>for</strong> 100,000 botulinum poisoned patients (even if<br />
that number <strong>of</strong> ICU-equivalent beds, ventilators, and anti-toxin were available) would be<br />
17.2 million dollars<br />
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Slide 35<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Inactivating Botulinum Toxin<br />
• Botulinum toxin cannot be completely inactivated by<br />
radiation or any heat treatment that does not<br />
adversely affect the milk ’s taste.<br />
• Ultrahigh -temp pasteurization (UHT) can inactivate<br />
botulinum toxin but has not been embraced by U.S.<br />
consumers.<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
35<br />
Botulinum toxin is difficult to destroy. Remember- in this model - it is not the bacteria<br />
(Clostridium botulini ) that needs to be killed, but the toxin itself that was maliciously<br />
added to the milk.<br />
In Ultra High temperature processing, the milk is heated using commercially sterile<br />
equipment and then placed into hermetically-sealed (airtight) containers under aseptic<br />
conditions. This high temperature is sufficient to inactivate practically all botulinum toxin.<br />
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Slide 36<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Maine Arsenic Poisonings<br />
• 1 died, 15 others were sickened<br />
following Sunday services in<br />
2003<br />
• Next day, maintenance man died<br />
<strong>of</strong> gunshot wound to chest<br />
• Victims shared c<strong>of</strong>fee and food<br />
• Arsenic was found in the c<strong>of</strong>fee<br />
pot.<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
36<br />
This event is an example <strong>of</strong> inserting a toxin at the point-<strong>of</strong>-use (end <strong>of</strong> the distribution<br />
chain). A dispute amongst members <strong>of</strong> a church resulted in one death and 15 others<br />
sickened after drinking c<strong>of</strong>fee contaminated with arsenic and served after Sunday<br />
services.<br />
An individual with maintenance duties at the church (including making the c<strong>of</strong>fee)<br />
committed suicide the next day, leaving a note implicating himself and possibly another<br />
individual.<br />
A tentative diagnosis <strong>of</strong> heavy metal poisoning was confirmed within a day and<br />
treatment with a chelating agent (dimercaptopropane sulfonate) begun <strong>for</strong> the affected<br />
individuals, who presented to the hospital hours after ingesting the c<strong>of</strong>fee with stomach<br />
pain, nausea and vomiting, diarrhea, and low blood pressure. This event has had a<br />
lasting effect on this small community (population ~650), with the loss <strong>of</strong> a “sense <strong>of</strong><br />
innocence” (suspicion, locking doors) documented in news articles years later.<br />
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Slide 37<br />
In 1981, 20,000 people were poisoned by consuming adulterated rapeseed oil.<br />
This epidemic occurred because <strong>of</strong> adulteration <strong>of</strong> a falsely labeled cooking oil with an<br />
industrial dye (aniline) in the processing portion <strong>of</strong> the food chain <strong>for</strong> a large area <strong>of</strong><br />
Spain.<br />
This poisoning resulted in 12,000 hospital admissions and over 300 deaths. Based on<br />
clinical reports the acute phase was a respiratory illness with patients exhibiting<br />
eosinophilic pneumonia, hypertension, and scleroderma-like changes.<br />
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Slide 38<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
How Safe are US Medications<br />
• Drug production is a complex process<br />
– Synthesis Delivery to the patient<br />
– Multiple steps <strong>for</strong> interference<br />
• Depending on the circumstances, the results can be<br />
devastating:<br />
– Primary Impact (fatalities, illness)<br />
– Fear/Uncertainty<br />
– Economic Impact<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
38<br />
As a last potential mechanism <strong>for</strong> a terrorist attack in this module, let’s turn to our<br />
medication system. The US drug production system is large and complex involving<br />
multiple production and distribution phases; each providing many opportunities <strong>for</strong><br />
interference. A terror attack could occur anywhere from the production <strong>of</strong> the raw<br />
materials to the packaging and distribution <strong>of</strong> the final product.<br />
An attack in this sector would certainly have devastating results including decreased<br />
availability <strong>of</strong> potentially lifesaving medication, fear <strong>of</strong> using medications, and an<br />
economic impact on many levels.<br />
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Slide 39<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Tylenol Murders (Chicago, 1982)<br />
• 7 died from KCN laced<br />
Tylenol<br />
• 1-2 bottles per store<br />
•
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong><br />
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Slide 40<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Copycat (1986)<br />
• Woman in WA state killed her husband with cyanide -laced<br />
pain killer<br />
• Attempted to cover her tracks by placing packages <strong>of</strong><br />
poisoned Excedrin and Anacin capsules on the shelves <strong>of</strong> 3<br />
stores<br />
• Nickell was sentenced to 90 years in prison.<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
40<br />
In 1986, Stella Nickell <strong>of</strong> Washington state killed her husband with cyanide-laced<br />
Excedrin in a plot to collect on his life insurance. Attempting to cover her tracks she<br />
placed similarly poisoned packages Excedrin and Anacin at three local stores.<br />
Based on video evidence, eye witness reports, and a particular contaminant found in all<br />
<strong>of</strong> the contaminated capsules, Nickell was apprehended and sentenced to 90 years in<br />
prison.<br />
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Slide 41<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
1983<br />
The Tylenol Bill<br />
"Tylenol Bill ” made malicious tampering with consumer<br />
products a federal <strong>of</strong>fense.<br />
1989<br />
FDA established a national requirement <strong>for</strong> tamper<br />
packaging <strong>of</strong> over -the-counter products.<br />
• Triple-seal, tamper -resistant packaging now the<br />
norm.<br />
-resistant<br />
Module One - <strong>Chemical</strong> Contamination <strong>of</strong> Food, Water, and Medication<br />
41<br />
After these prominent events, Congress, the Food and Drug Administration, and<br />
pharmaceutical manufacturers turned to the problem <strong>of</strong> packaging non-prescription<br />
drugs to prevent tampering and restore the public's faith in the products.<br />
In May 1983, Congress approved the "Tylenol Bill," making malicious tampering with<br />
consumer products a federal <strong>of</strong>fense.<br />
By 1989, the FDA had established compliance language and posted final rules requiring<br />
at least one <strong>of</strong> several possible packaging modifications.<br />
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Slide 42<br />
This is just one example <strong>of</strong> many, reflecting medication tampering during the<br />
manufacture or processing stage <strong>of</strong> production.<br />
In 1996 an unusual cluster <strong>of</strong> renal failure cases was noted among children in Haiti. This<br />
lead to an investigation (described on the next slide) that eventually identified DEGcontaminated<br />
acetaminophen elixir as the cause.<br />
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Slide 43<br />
In late 2007, reports began to come by MedWatch and other reporting mechanisms<br />
identifying severe allergic reactions and decreased blood pressure with more than 80<br />
deaths associated with administration <strong>of</strong> one brand <strong>of</strong> heparin (a blood thinning agent).<br />
Laboratory identification <strong>of</strong> a contaminant that had some anticoagulant activity led to the<br />
recall <strong>of</strong> this product.<br />
As with many recent events, a source <strong>of</strong> raw material from China, was found to be<br />
responsible.<br />
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Slide 44<br />
In an ef<strong>for</strong>t to give consumers more input into their health management, President<br />
Clinton signed the Dietary Supplement Health and Education Act (DSHEA) in 1994,<br />
removing dietary supplements from any treatment as food (or drugs). While the FDA<br />
could still investigate reports <strong>of</strong> harm, all aspects <strong>of</strong> manufacture, claims and advertising<br />
were now left to the product producers. A notation was required that “this statement<br />
[regarding the use <strong>of</strong> the product] has not been evaluated by the FDA. This product is<br />
not intended to diagnose, treat, cure, or prevent any disease.”<br />
Since that time a number <strong>of</strong> dietary supplements, most notably ephedra-containing<br />
products, have been investigated or removed from the market because <strong>of</strong> documented<br />
safety concerns and/or adulteration.<br />
Asian patent medicines (traditional Chinese medicines) have been studied in market<br />
sampling surveys. 1/3 contain undeclared pharmaceutical agents, including some<br />
medications banned <strong>for</strong> human use. A variety <strong>of</strong> heavy metals (lead, mercury, arsenic)<br />
occur in these and other ethnic medicines.<br />
In 2008, the FDA received reports <strong>of</strong> illness attributed to excess selenium and chromium<br />
in one brand <strong>of</strong> dietary supplement through incorporation <strong>of</strong> too much <strong>of</strong> these<br />
ingredients in the manufacturing process.<br />
The unregulated <strong>for</strong>eign market and internet as a source <strong>of</strong> medication is another<br />
potential mechanism <strong>for</strong> introduction <strong>of</strong> contaminated products.<br />
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Slide 45<br />
Due to the large number <strong>of</strong> individuals who depend on them, modern large-scale<br />
production and distributions systems <strong>for</strong> food, water, and medication provide a tempting<br />
target to would-be terrorists.<br />
The use <strong>of</strong> potent toxins or common industrial solvents can occur at multiple sites in the<br />
manufacturing, processing or distribution/sales chain.<br />
Past cases <strong>of</strong> tampering have resulted in closer government oversight and strict product<br />
safety and distribution standards <strong>for</strong> the US.<br />
Unusual case clusters or increased incidence <strong>of</strong> illness or disease out <strong>of</strong> keeping with<br />
local norms can be an indication <strong>of</strong> point source exposure to a toxic agent. While this is<br />
not the ideal method <strong>of</strong> detection (because <strong>of</strong> the delay to recognition), it is historically<br />
the only method that has been used to identify contamination.<br />
As we have shown in this module, there are a number <strong>of</strong> monitoring and safety steps<br />
that are being used to drastically limit the likelihood <strong>of</strong> large-scale terrorist attacks using<br />
the food, water or medication delivery system. Continued attention to safety and<br />
security <strong>of</strong> raw materials and processes will have benefits in preventing accidental<br />
contamination as well.<br />
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Slide 46<br />
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Module Five Summary<br />
Due to the large number <strong>of</strong> individuals who depend on them, modern large-scale production and<br />
distributions systems <strong>for</strong> food, water, and medication provide a tempting target to would-be<br />
terrorists.<br />
State and federal EPAs bear the primary responsibility <strong>for</strong> safeguarding the US public water<br />
supply. Water treatment steps commonly employed in the US include coagulation/flocculation,<br />
sedimentation, filtration, and disinfection. While chlorine used during the disinfection process<br />
kills viruses and bacteria, other biological contaminants and many chemical agents may remain<br />
unaffected.<br />
Due to their size and complexity, US water distribution systems are vulnerable at multiple sites.<br />
Though numerous layers <strong>of</strong> protection exist (testing, physical security, public reporting, health<br />
surveillance), US public water systems remain susceptible to contamination through adulteration<br />
or cross-connection/backflow.<br />
While not routinely used in day-to-day monitoring, a wide variety <strong>of</strong> tools exist <strong>for</strong> the early<br />
detection <strong>of</strong> chemical and biological contaminants in drinking water. Improved water supply<br />
safety will depend, in part, on the judicious application <strong>of</strong> these tools as part <strong>of</strong> a broader water<br />
quality surveillance plan.<br />
The US food supply is largely overseen by the FDA with some agricultural products, such as<br />
meat, milk and eggs, monitored by the USDA. The combined trend toward large monoculture<br />
farms, mixing <strong>of</strong> raw goods from multiple sources, and centralization <strong>of</strong> production increases the<br />
reach and potential impact <strong>of</strong> an attack. More rigorous and uni<strong>for</strong>m quality control standards are<br />
being implemented to ensure the continued safety <strong>of</strong> the US food supply.<br />
Past cases <strong>of</strong> drug tampering have resulted in closer FDA oversight and strict product safety<br />
packaging standards <strong>for</strong> the US pharmaceutical industry. While historical examples <strong>of</strong><br />
accidental drug contamination point to the potential impact <strong>of</strong> such events, the numerous<br />
safeguards enacted in recent years drastically limit the viability <strong>of</strong> a large-scale terrorist attack.<br />
However, the potential <strong>for</strong> an attack via other routes, such as the unregulated “dietary<br />
supplement” or internet-based/international medication market is increasing.<br />
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Module Six<br />
<strong>Terrorism</strong> through Fear & Uncertainty: Delayed Toxic<br />
Syndromes - Administration Page<br />
Exposure to some chemicals is characterized by a delayed onset <strong>of</strong> toxicity which may make<br />
them attractive <strong>for</strong> use as a covert weapon. This delay <strong>of</strong> onset <strong>of</strong> symptoms complicates the<br />
epidemiology <strong>of</strong> the event, making detection and identification <strong>of</strong> the chemical (figuring out the<br />
cause <strong>of</strong> the problem and source), response and clinical management significantly more<br />
difficult.<br />
More people may be exposed to delayed-onset toxins and the individual’s dose may be larger,<br />
given the relative absence <strong>of</strong> warning properties to indicate exposure. In acute-onset toxins,<br />
most people will escape when they realize that others around them are developing symptoms. If<br />
however, no one is becoming ill, no one realizes they are being poisoned…and thus, no one<br />
takes the necessary measures to limit exposure.<br />
<strong>Chemical</strong> agents with a delayed onset can be organized and separated based on route/scenario<br />
<strong>of</strong> exposure. Some are airborne (phosgene), food and waterborne (thallium, organomercurials,<br />
radionuclides/radioactive metals), and environmental/biopersistent agents (dioxin, PCBs).<br />
Treatment depends on rapid identification and intervention and strategies will vary based on the<br />
class <strong>of</strong> chemical agent used.<br />
Duration<br />
45 minutes<br />
Scope Statement<br />
This module will introduce industrial chemical toxins which, due to their delayed onset <strong>of</strong><br />
symptoms, may make them likely to be used as a covert weapon by terrorists. A framework is<br />
provided <strong>for</strong> organizing and separating these chemical agents based on their route <strong>of</strong> delivery<br />
and likely scenarios <strong>of</strong> exposure, as well as relevant toxidromes.<br />
Terminal Learning Objective (TLO)<br />
• Understand the unique threat posed by exposure to chemicals which<br />
are manifested by delayed onset <strong>of</strong> symptoms.<br />
Enabling Learning Objectives (ELO)<br />
Resources<br />
• Recognize that exposure to some chemical agents does not result in<br />
the immediate onset <strong>of</strong> symptoms.<br />
• Describe the major chemical agents that may cause delayed toxic<br />
syndromes.<br />
• Differentiate between clinical presentations <strong>of</strong> various delayed-onset<br />
syndromes from these chemicals.<br />
Each <strong>of</strong> the eight course modules is deployed as an interactive, instructor-lead, MS PowerPoint<br />
presentation containing didactic content, historical examples, and selected case studies. All<br />
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Training Support Package<br />
Participant Guide<br />
presentations are included in a printed participant guide (PG) containing the modules’ overview,<br />
scope statement, terminal and enabling learning objectives, PowerPoint slide handouts, and a<br />
summary section.<br />
Instructor to Participant Ratio<br />
1:8 (minimum) to 1:25 (maximum)<br />
Reference List<br />
1. Amin-Zaki L, Elhassani S, Majeed MA, et al. Intra-uterine<br />
methylmercury poisoning in Iraq. Pediatrics 1974;54(5):587-595.<br />
2. Agency <strong>for</strong> Toxic Substances and Disease Registry. Medical<br />
Management Guideline <strong>for</strong> Mercury. Accessed Dec 2008 from:<br />
http://www.atsdr.cdc.gov/MHMI/mmg46.html<br />
3. Agency <strong>for</strong> Toxic Substances and Disease Registry. ToxFAQs <strong>for</strong><br />
Thallium. Accessed Dec 2008 from:<br />
http://www.atsdr.cdc.gov/tfacts54.html<br />
4. Bakir F, Damluji SF, Amin-Zaki L, et al. Methylmercury poisoning in<br />
Iraq. Science 1973;181(96):230-241.<br />
5. Bertazzi PA, Bernucci I, Brambilla G, et al. The Seveso studies on<br />
early and long-term effects <strong>of</strong> dioxin exposure: a review. Env Health<br />
Persp 1998;106 (S2):625-633.<br />
6. Centers <strong>for</strong> Disease Control and Prevention. Third National Report on<br />
Human Exposure to Environmental <strong>Chemical</strong>s. Atlanta (GA): CDC,<br />
2005. Accessed Dec 2008 from:<br />
http://www.cdc.gov/exposurereport/pdf/thirdreport.pdf<br />
7. Clarkson TW, Vyas JB, Ballatori N. Mechanisms <strong>of</strong> mercury<br />
disposition in the body. Am Industrial Medicine 2007; 50(10):757-764.<br />
8. Cavanagh JB. What have we learned from Graham Frederick Young<br />
Reflections on the mechanism <strong>of</strong> thallium neurotoxicity. Neuropath<br />
Appl Neurobio 2007;17(1):3-9.<br />
9. Coenraads PJ, Olie K, Tang NJ. Blood lipid concentrations <strong>of</strong> dioxins<br />
and dibenz<strong>of</strong>urans causing chloracne. Br J Dermatol<br />
1999;141(4):694-697.<br />
10. Conradi P. “Prisoners were used to test poisons”. TimesOnLine,<br />
October 10 2004. Accessed Dec 2008 from:<br />
http://www.timesonline.co.uk/tol/news/world/article492686.ece<br />
11. Emsley J. Elements <strong>of</strong> Murder: A History <strong>of</strong> Poisons. Ox<strong>for</strong>d<br />
University Press, USA; 2005.<br />
12. Hoque A, Sigurdson AJ, Burau KD, et al. Cancer among a Michigan<br />
cohort exposed to polybrominated biphenyls in 1973. Epidemiol<br />
1998;9(4):373-378.<br />
13. Houts PS, McDougall MS. Importance <strong>of</strong> evaluating the context in<br />
which notification occurs. AM J Industr Med 2007;23(1):205-210.<br />
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Participant Guide<br />
14. Hsu J-F, Guo Y-L, Yang S-Y, Liao P-C. Congener pr<strong>of</strong>iles <strong>of</strong> PCBs<br />
and PCDD/Fs in Yucheng victims fifteen years after exposure to ricebran<br />
oils and their implications <strong>for</strong> epidemiologic studies.<br />
Chemosphere 2005;61(9):1231-1243.<br />
15. International Agency <strong>for</strong> Research on Cancer. Overall Evalutions <strong>of</strong><br />
Carcinogenicity in Humans: List <strong>of</strong> all agents, mixtures, and<br />
exposures evaluated to date. Accessed Dec 2008 from:<br />
http://monographs.iarc.fr/ENG/Classification/crthalllist.php<br />
16. “Iranian Refugees at Risk” in Iranian Refugees’ Alliance Quarterly<br />
Newsletter (Summer/Fall 1997). Accessed Dec 2008 from:<br />
http://www.irainc.org/text/nletter/su97fa97/su97fa97.html<br />
17. Kulig K. A tragic reminder about organic mercury. N Engl J Med 1998;<br />
338(23):1692-1694.<br />
18. Kuratsune M, Yoshimura T, Matsuzaka J, Yamaguchi A. Epidemiolgic<br />
study on yusho, a poisoning caused by ingestion <strong>of</strong> rice oil<br />
contaminated with a commercial brand <strong>of</strong> polychlorinated biphenyls.<br />
Env Health Persp 1972;1:119-128.<br />
19. Landrigan PJ, Wilcox KR Jr, Silva J Jr, et al. Cohort study <strong>of</strong> Michigan<br />
residents exposed to polybrominated biphenyls: epidemiologic and<br />
immunologic findings. Ann New York Acad Sci 1979; 320:284-294.<br />
20. Leung HW, Kerger BD, Paustenbach DJ, et al. Concentration and<br />
age-dependent elimination kinetics <strong>of</strong> polychlorinated dibenz<strong>of</strong>urans<br />
in Yucheng and Yusho patients. Toxicol Industr Health<br />
2007;23(8):493-501.<br />
21. Masuda Y. The Yusho rice oil poisoning incident in Dioxins and<br />
Health. Schecter A and Gasiewica TA (eds), 2nd ed; John Wiley &<br />
Sons, Inc., Dallas TX 2003.<br />
22. Meggs WJ, H<strong>of</strong>fman RS, Shih RD, Weisman RS, Goldfrank<br />
LR.Thallium poisoning from maliciously contaminated food. J Toxicol<br />
Clin Toxicol 1994;32(6):723-30.<br />
23. Nierenberg DW, Nordgren RE, Chang MB, et al. Delayed cerebellar<br />
disease and death after accidental exposure to dimethylmercury.<br />
NEJM 1998; 338(23):1672-6.<br />
24. OSHA. Hazard In<strong>for</strong>mation Bulletin – Dimethylmercury. February 15<br />
1991. Accessed Dec 2008 from:<br />
http://www.osha.gov/dts/hib/hib_data/hib19980309.html<br />
25. Reich MR. Environmental politics and science: the case <strong>of</strong> PBB<br />
contamination in Michigan. Am J Pub Health 1983;73(3):302-313.<br />
26. Schecter A, Birnbaum L, Ryan JJ, Constable JD. Dioxins: an<br />
overview. Environ Res 2006;101(3):419-28.<br />
27. Schwartz LM, Woloshin S, Fowler FJ, Welch HG. Enthusiasm <strong>for</strong><br />
cancer screening in the United States. JAMA 2004;291:71-78.<br />
28. Steenland K, Bertazzi P, Baccarelli A, Kogevinas M. Dioxin revisited:<br />
developments since the 1997 IARC classification <strong>of</strong> dioxin as a<br />
human carcinogen. Env Health Persp 2004;112(13):1265-1268.<br />
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Training Support Package<br />
Participant Guide<br />
Practical Exercise Statement<br />
29. United Nations Environment Programme. Dioxins, Furans, Pose<br />
Concerns <strong>for</strong> Health and Environment World-Wide. 1999. Accessed<br />
Dec 2008 from:<br />
http://portalserver.unepchemicals.ch/Publications/InfDioxinsJuly99.pdf<br />
Each module presentation contains one or more interactive audience response questions<br />
designed to drive discussion, promote participant engagement, and test knowledge. Through<br />
the use <strong>of</strong> the Meridia® Audience Response system, participant responses can be collected,<br />
tabulated, and displayed within the presentation in real time. In order to use the interactive<br />
slides accompanying this presentation, the lecture hall must be equipped with the Meridia®<br />
Audience Response system and user keypads. In addition, a copy <strong>of</strong> the “Meridia® Q&A”<br />
s<strong>of</strong>tware component <strong>for</strong> MS PowerPoint must be installed on the presenter’s computer.<br />
Assessment Strategy<br />
Participant progress toward course learning objectives is monitored through in<strong>for</strong>mal discussion<br />
and responses to each module’s practical exercise questions. Overall mastery <strong>of</strong> module<br />
content and concepts is documented by means <strong>of</strong> a comprehensive, end-<strong>of</strong>-day posttest<br />
touching on key learning objectives from each module. Each participant must obtain a score <strong>of</strong><br />
80% or better to successfully complete the training and obtain a course completion certificate.<br />
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Training Support Package<br />
Participant Guide<br />
Module Six<br />
Icon Map<br />
Knowledge Check: Used when it is time to assess the learners’ understanding<br />
Example: Used when there is a descriptive illustration to show or explain<br />
Key Points: Used to convey essential learning concepts, discussions and introduction <strong>of</strong><br />
supplemental material<br />
Hint: Used to cover administrative items or instructional tips that aid in the flow <strong>of</strong> the<br />
instruction<br />
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Training Support Package<br />
Participant Guide<br />
Slide 1<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Module Six<br />
<strong>Terrorism</strong> by Fear and Uncertainty:<br />
Delayed Toxic Syndromes<br />
Training Support Package<br />
1<br />
This module will introduce industrial chemicals that cause delayed onset <strong>of</strong> symptoms<br />
following exposure, making them an attractive covert weapon to terrorists.<br />
A framework is provided <strong>for</strong> organizing and separating these chemical agents based on<br />
their route <strong>of</strong> delivery and likely scenarios <strong>of</strong> exposure, as well as by their toxidromes.<br />
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Participant Guide<br />
Slide 2<br />
This module introduces a very interesting group <strong>of</strong> chemicals – those that do not cause<br />
immediate symptoms. The concept <strong>of</strong> delayed onset chemicals may be particularly<br />
attractive to some terrorists as they mimic the time course <strong>of</strong> some biological agents.<br />
This module will go through examples <strong>of</strong> toxic industrial chemicals that present in very<br />
characteristic fashion, but days, weeks or even years following exposure, rather than<br />
those with immediate onset as we have been discussing <strong>for</strong> much <strong>of</strong> the morning.<br />
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Participant Guide<br />
Slide 3<br />
Unlike the general concept <strong>of</strong> chemical poisoning, in which the onset <strong>of</strong> symptoms is<br />
rapid and the source identifiable, exposure to some chemicals present with a delayed<br />
onset <strong>of</strong> symptoms. This unique property could contribute to their use as a covert<br />
weapon.<br />
Allowing time to escape may not have an immediate impact (as is commonly seen with<br />
explosive terrorist events)., However, this delayed onset complicates the epidemiology<br />
(figuring out the cause <strong>of</strong> the problem and source) and makes clinical management more<br />
difficult.<br />
More exposures may occur because there are no warning properties <strong>of</strong> exposure. In<br />
acute onset toxins, most people will escape when everyone around them develops<br />
symptoms. But if nobody gets ill….nobody realizes they are being poisoned….and<br />
nobody escapes.<br />
For toxins with particularly long latency (delay to onset <strong>of</strong> symptoms or disease), such as<br />
those chemicals that may cause cancer, the long-term psychological effects may be very<br />
consequential, even in the absence <strong>of</strong> any physical disease. This is a reasonably good<br />
definition <strong>of</strong> terror.<br />
Delayed onset toxins may mimic biological agents (particularly non-contagious ones<br />
such as anthrax), both because <strong>of</strong> the time to symptom development (<strong>of</strong>ten measured in<br />
days-weeks) and the somewhat non-specific nature <strong>of</strong> initial symptoms. This further<br />
complicates the diagnosis.<br />
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Participant Guide<br />
Slide 4<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Thallium salts<br />
• Qualities <strong>for</strong> unintentional and malicious use<br />
– Tasteless and odorless<br />
– Salts are water -soluble<br />
– Rapidly absorbed (oral, inhalation, dermal)<br />
– Not detected on routine toxicological screening<br />
– Highly toxic and easily concealable<br />
– Lethal dose ~10 -20 mg/kg (about 1 gram in an adult)<br />
– Inexpensive (~$1 -2 per gram)<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
4<br />
Thallium has many qualities that allow it to be used as a terrorist weapon, as well as a<br />
long history <strong>of</strong> use as a homicidal toxin.<br />
In addition to being easy to conceal because <strong>of</strong> its water solubility and lack <strong>of</strong> taste and<br />
odor, it is rapidly absorbed by all routes <strong>of</strong> exposure and is not detected on any<br />
routinely-per<strong>for</strong>med screening test; a specific thallium determination must be ordered<br />
and run on specialized instruments. It is toxic in very low quantities and very<br />
inexpensive.<br />
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Participant Guide<br />
Slide 5<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Thallium Poisoning<br />
• Classic Triad:<br />
– Gastrointestinal distress (N/ V/ D) within a few hours, mild<br />
– Painful polyneuropathy (severe pain in the extremities)<br />
• About 24 hours after exposure, dose dependent<br />
– Hair loss; usually 2(+) weeks after exposure<br />
– Other: constipation, hypertension, EKG changes<br />
• Diagnostic testing<br />
– Abdominal x -rays may show metal<br />
– Blood thallium > 100 µg/L, urine thallium greater than 200 µg/L<br />
considered toxic<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
5<br />
The “classic triad” <strong>of</strong> thallium poisoning is gastrointestinal symptoms, followed in a day<br />
or two by very painful distal extremities (especially soles <strong>of</strong> the feet), and after a delay <strong>of</strong><br />
another 1-2 weeks, hair loss (alopecia). A history <strong>of</strong> recent severe nausea, vomiting,<br />
and diarrhea is an important clue to thallium (or arsenic) in patients who present with<br />
acute painful neuropathy and/or progressive diffuse hair loss.<br />
Thallium is a metal; there<strong>for</strong>e it may appear as a radiopaque density on an x-ray <strong>of</strong> the<br />
abdomen. However, from a practical point <strong>of</strong> view, patients rarely present early enough<br />
<strong>for</strong> this to be a useful diagnostic tool..<br />
Blood thallium can be measured in reference laboratories. The test is not available in<br />
most hospital labs.<br />
.<br />
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Participant Guide<br />
Slide 6<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Thallium-Tainted Marzipan<br />
• Four young adults in NYC<br />
share premium marzipan<br />
candies recieved by mail<br />
from an “unknown admirer ”<br />
• The next day they<br />
developed diarrhea,<br />
vomiting, abdominal cramps<br />
and constipation<br />
J Toxicol Clin Toxicol. 1994;32:723 -30.<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
6<br />
This is one example <strong>of</strong> the thallium poisoning.<br />
Four young adults received a box <strong>of</strong> candy from an unidentified “admirer”. They shared<br />
3 candies (as can be seen in the photo <strong>of</strong> the uneaten portion above). The following<br />
day, they developed significant gastrointestinal distress, although somewhat varied in<br />
nature and severity. They came to an Emergency Department <strong>for</strong> evaluation.<br />
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Participant Guide<br />
Slide 7<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Thallium-Tainted Marzipan (cont.)<br />
• After 2 days the two who ate most (a whole candy<br />
each) developed pain in the palms and soles worse<br />
with touch<br />
– Hypertension in and EKG changes in two<br />
– Three <strong>of</strong> 4 developed alopecia (hair loss)<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
7<br />
Gastrointestinal symptoms resolved, but a very painful paresthesia (abnormal sensation)<br />
developed – so intense as to be painful with any pressure (even bed linen) against the<br />
distal extremity skin. After about one week, symptoms progressed to involve diffuse hair<br />
loss, with additional cardiovascular signs in the two who had consumed the most.<br />
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Participant Guide<br />
Slide 8<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Thallium Poisoning<br />
• X-rays <strong>of</strong> the candies showed abnormal radioopacity<br />
• Lethal dose <strong>of</strong> thallium in each candy<br />
– Lab confirmed that each candy contained 810 to 1090 mg<br />
thallium<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
8<br />
Routine X-Ray <strong>of</strong> the remaining candies showed variable amounts and lack <strong>of</strong> uni<strong>for</strong>mity<br />
<strong>of</strong> radiodense material (opaque on X-Ray) that would be unusual in normal candy.<br />
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Participant Guide<br />
Slide 9<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Jilted admirer, Filip Semey, arrested in Belgium<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
9<br />
One <strong>of</strong> the involved women had been harassed by a man who had a history <strong>of</strong> stalking<br />
women. Investigators found he had left the country. A couple weeks later, he was<br />
arrested at his home in Belgium, tried and convicted.<br />
The newspaper clipping (New York Times) above shows an investigator holding a<br />
display <strong>of</strong> the adulterated candy and X-Rays and an inset photograph <strong>of</strong> the poisoner,<br />
Filip Semey. He had also sent a box <strong>of</strong> candy to another woman on the West Coast,<br />
and as mentioned above, had a history <strong>of</strong> stalking women.<br />
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Participant Guide<br />
Slide 10<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Malicious Thallium Poisoning<br />
Other cases<br />
• 1971: Graham Frederick Young kills two co -workers<br />
– Liked to poison people<br />
• 1988: George Trepal kills Peggy Carr<br />
– Tainted Coca -Cola; 7 others poisoned, 2 became ill<br />
– Kids playing loud music, and dogs chasing his cats<br />
• 1988 and 1995: Iraqi dissidents poisoned<br />
– 1988: Abdullah Rahim Sharif Ali killed<br />
– 1995: Maj Safa al-Battat; presumably recovered<br />
• 1997: Kurds poisoned by Iranian agents<br />
– 60 sickened; presence <strong>of</strong> thallium confirmed<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
10<br />
Thallium has a long history <strong>of</strong> use by both “crazy” people like Graham Frederick Young,<br />
who poisoned his friends and coworkers in England (he is the basis <strong>of</strong> the Young<br />
Poisoner’s Handbook - a book and a movie) and by “crazed” people who per<strong>for</strong>m<br />
political or military assassinations. Graham Frederick Young was hospitalized as a<br />
teenager as criminally insane after fatally poisoning his pets and step-mother, and<br />
poisoning his father and sister, and classmates. He was released after convincing an<br />
examining psychiatrist <strong>of</strong> his mental health, then went on to poison co-workers with<br />
thallium added to tea. The workplace used thallium in the manufacturing <strong>of</strong> camera<br />
lenses (John Hadland Laboratories in Bovington, Hert<strong>for</strong>dshire). A consulting toxicologist<br />
became suspicious. When arrested by police, they found incriminating diaries tracking<br />
the progression <strong>of</strong> symptoms in his victims. He died in prison, reportedly <strong>of</strong> a heart<br />
attack, at the age <strong>of</strong> 42.<br />
George Trepal, a member <strong>of</strong> Mensa, after becoming angry at his noisy neighbors,<br />
poisoned them with thallium added to soda. He is currently on death row in Florida.<br />
Thallium was also used to kill Iraqi dissidents. These two individuals represent some <strong>of</strong><br />
the many killed under Saddam Hussein’s reign. Some were poisoned by beverages or<br />
food given as a “token <strong>of</strong> reconciliation” at the time <strong>of</strong> their release from prison, only to<br />
die days-weeks.later.<br />
Cross-border chemical terrorism in the Persian Gulf region has occurred on a large<br />
scale. Smaller-scale events via poisoned food supplies occurred in the last decade, and<br />
as seen on the next slide, continue to occur now.<br />
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Participant Guide<br />
Slide 11<br />
In March 2007 a mother and daughter, born in Russia but living in the US, were<br />
“accidentally” poisoned by thallium during a trip to Russia.<br />
They returned to the US <strong>for</strong> therapy and did well.<br />
This came on the heels <strong>of</strong> the Litvenenko case (by Polonium-210 poisoning) which was<br />
originally thought to be a case <strong>of</strong> thallium poisoning; and demonstrating the ongoing use<br />
<strong>of</strong> stealth (delayed-onset) agents in assassination plots.<br />
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Participant Guide<br />
Slide 12<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Treatment<br />
• Multi-dose activated charcoal<br />
– Prevents absorption<br />
– Enterohepatic circulation<br />
• Prussian Blue ( Radiogardase )<br />
– Prevents absorption from GI tract<br />
– Undefined efficacy<br />
• Unclear role <strong>for</strong> chelators once thallium is absorbed<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
12<br />
Treatment <strong>for</strong> thallium poisoning involves ef<strong>for</strong>ts to prevent its absorption or hasten<br />
elimination. Thallium can be bound to either activated charcoal or Prussian Blue<br />
preventing its absorption through the GI tract.<br />
In addition, there is some recycling <strong>of</strong> thallium back into the gastrointestinal tract via the<br />
bile, where it can be bound to these therapeutic agents, if they are present in the<br />
duodenum, preventing reabsorption.<br />
Once thallium has been distributed to the rest <strong>of</strong> the body, it is unclear if any chelating<br />
agents would play a role in hastening elimination.<br />
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Participant Guide<br />
Slide 13<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Three <strong>for</strong>ms <strong>of</strong> Mercury<br />
Elemental<br />
(Hg 0 ; quicksilver)<br />
Liquid: essentially nontoxic by ingestion<br />
Vapor: brain and lung toxicity<br />
Inorganic salt<br />
(Hg 2+ )<br />
Organic<br />
(Methyl-Hg)<br />
Typically rapid onset <strong>of</strong> GI effects when ingested<br />
Aryl (cyclic): behave like inorganic<br />
Alkyl (short -chain): methylmercury , ethylmercury ,<br />
dimethylmercury<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
13<br />
Mercury provides an example <strong>of</strong> an agent to use to raise fear and concern. Mercury<br />
exists in several <strong>for</strong>ms. The particular physical state <strong>of</strong> mercury determines its toxicity<br />
and how the body handles it.<br />
Elemental mercury is <strong>of</strong> minimal toxicity in liquid <strong>for</strong>m, but when inhaled following<br />
volatilization it can produce lung damage and neurotoxicity. Although low level exposure<br />
to a vapor over a long period <strong>of</strong> time can produce neurotoxicity without pulmonary<br />
abnormalities, this would not be as useful to a terrorist as would organic mercury (see<br />
below).<br />
Mercury salts produce corrosive gastrointestinal effects when ingested. There are no<br />
other realistic routes <strong>of</strong> poisoning than the oral route <strong>for</strong> mercury salts. Although this has<br />
been used in individual cases, it would not be effective in a large scale release.<br />
Organic mercury is the most concerning <strong>for</strong>m <strong>of</strong> mercury, from a terrorism perspective.<br />
The neurotoxicity that it causes is similar to that <strong>of</strong> inhaled elemental mercury, but the<br />
ability <strong>of</strong> the short chain organic mercury compounds to be absorbed orally, to be<br />
inhaled, and to cross the dermal barrier raise concerns <strong>for</strong> its nefarious use.<br />
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Participant Guide<br />
Slide 14<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• Uses:<br />
Organomercurials<br />
– Bactericidal, fungicides, paper manufacture, laboratory<br />
standard<br />
• Generally well absorbed by all routes<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
14<br />
Organic mercury compounds (those in which Hg is bound to a carbon backbone) have<br />
been widely used in industry and science in very small concentrations. At a sufficient<br />
dose, organic mercury is the most toxic <strong>for</strong>m <strong>of</strong> mercury...<br />
Depending on the specific organic mercury compound, absorption can occur by virtually<br />
every route, including dermal.<br />
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Slide 15<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Dimethymercury<br />
Properties<br />
• Colorless, dense, volatile liquid<br />
• Readily absorbed through the skin<br />
• Rapidly penetrates latex gloves<br />
• Lethal dose approx 400 mg (5 mg/kg)<br />
• 10 grams = $183.80<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
15<br />
This is one example <strong>of</strong> an organic mercury compound that is <strong>of</strong> extremely high toxicity.<br />
Dimethylmercury is used as a nuclear magnetic resonance standard in industry and<br />
research laboratories.<br />
Although less volatile than water, vapor exposure to methylmercury is still a significant<br />
route <strong>of</strong> exposure, particularly in settings <strong>of</strong> elevated temperature.<br />
This short-chain alkyl <strong>for</strong>m <strong>of</strong> mercury passes through several types <strong>of</strong> glove material<br />
(latex, vinyl, neoprene), and the skin very easily.<br />
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Participant Guide<br />
Slide 16<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
16<br />
.<br />
Case Study: A 48 year old chemistry pr<strong>of</strong>essor at Dartmouth College spilled a drop <strong>of</strong><br />
methylmercury on her gloved hand while working under a hood in August 1996. She<br />
removed the glove, washed her hands, and noted the incident in her logbook. She<br />
presented about 5 months later with a progression <strong>of</strong> symptoms.<br />
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Slide 17<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Dimethylmercury Toxicity<br />
Dr. Karen Wetterhahn<br />
• Day 0 : Spills few drops on latex -gloved hand<br />
– Initially asymptomatic and continued normal activities. She deli vered a<br />
paper at an overseas conference 3 months later.<br />
• Day 154: Onset <strong>of</strong> symptoms<br />
– Balance, gait and speech problems<br />
• Day 159: Admitted to hospital; symptoms progress<br />
– Paresthesias; visual field changes; bilateral high -pitched tinnitus;<br />
deterioration <strong>of</strong> speech, hearing, gait, mental status<br />
• Day 176: Persistent vegetative state<br />
• Day 298: Dies<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
17<br />
Dr. Wetterhahn presented <strong>for</strong> evaluation in Jan 1997 (159 days after exposure) with a<br />
five-day history <strong>of</strong> progressive deterioration in balance, gait, and speech. A preliminary<br />
laboratory report indicated that the whole-blood mercury concentration was more than<br />
1000 µg per liter.<br />
Chelation therapy with oral succimer (10 mg per kilogram orally every eight hours) was<br />
begun on day 168 after exposure.<br />
She had aggressive chelation therapy and other treatments, but she died on June 8,<br />
1997, 298 days after exposure.<br />
The delay to onset <strong>of</strong> symptoms is remarkable in this case, presumably reflecting the<br />
time to distribution to the blood from an amount absorbed through the skin.<br />
The symptom complex described – affecting the brain, including the cerebellum (balance<br />
and gait), the cerebral cortex – higher level functioning (speech, hearing, “coning in” <strong>of</strong><br />
visual fields – loss <strong>of</strong> peripheral vision, and change in mental status – vegetative state<br />
being unable to communicate or respond to stimuli) as well as peripheral nerves<br />
(paresthesias – abnormal sensation) is characteristic <strong>of</strong> the effects <strong>of</strong> mercury on the<br />
nervous system.<br />
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Participant Guide<br />
Slide 18<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Dimethylmercury Toxicity<br />
Dr. Karen Wetterhahn<br />
• Initial blood mercury level:<br />
– 4,000 mcg/L<br />
– nl 1-5 mcg/L; toxic > 200<br />
• Chelated with DMSA<br />
• Exchange transfusion<br />
• No other Hg source identified<br />
http://www.dartmouth.edu/~toxmetal/TXQAcr.shtml<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
18<br />
Laboratory values returned 169 days after exposure from sampling a week earlier:<br />
whole-blood mercury, 4000 µg per liter (normal range, 1 to 8; toxic level, >200);<br />
urinary mercury, 234 µg per liter (normal range, 1 to 5; toxic level, >50).<br />
An intensive investigation including sequential sampling <strong>of</strong> hair to identify the time <strong>of</strong><br />
exposure, identified no other plausible source <strong>of</strong> mercury exposure.<br />
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Participant Guide<br />
Slide 19<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
N Engl J Med 1998; 338:1672 -1676<br />
Dr Wetterhahn ’s<br />
Cerebellum<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
Age-Matched Woman<br />
19<br />
The effects <strong>of</strong> dimethylmercury toxicity are visible at the gross anatomy level. These<br />
autopsy pictures depict the volume loss in the cerebellum <strong>of</strong> Pr<strong>of</strong>essor Wetterhahn (on<br />
the left) compared to a normal cerebellum <strong>of</strong> an age-matched woman (on the right).<br />
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Participant Guide<br />
Slide 20<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methylmercury Poisoning<br />
Iraq, 1971-1972<br />
• Wheat crop failure in 1970<br />
• Sept to Nov, 1971 govt distrib mercury treated crops<br />
– 73,201 metric tons wheat<br />
– 22,262 tons barley seed<br />
• Seed intended <strong>for</strong> planting<br />
– Methylmercury added to grain seeds as an antifungal<br />
– Warning in English<br />
– Shipment received after planting<br />
• Grain used to make flour rather than plant it<br />
– MeHg content 9.1 mg/kg (range 4.8 -14.6)<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
20<br />
Other <strong>for</strong>ms <strong>of</strong> organic mercury may also be toxic in a delayed fashion following acute<br />
short term exposure.<br />
A famous example is this unintentional poisoning event in Iraq in the 1970s.<br />
USAID (United States Agency <strong>for</strong> International Development) supplied seed grain to<br />
Iraqi farmers following a couple <strong>of</strong> wheat crop failures.<br />
Methylmercury was added to the grain as a fungicide to protect it from deterioration prior<br />
to planting. However, the grain was not distributed until after the planting season.<br />
Although there was a warning on the bags not to eat the grain, the warning was in<br />
English and Spanish, not Arabic.<br />
The hungry population ground the unplanted seeds to make flour <strong>for</strong> bread and were<br />
exposed to about 9 mg <strong>of</strong> methylmercury per kilogram <strong>of</strong> flour.<br />
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Participant Guide<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methylmercury Poisoning<br />
Iraq, 1971-1972<br />
• Mean exposure period was 32 days.<br />
• ∼40,000 exposed over several months<br />
– Est. total MeHg dose was 80 to 250 mg.<br />
• 6530 hospital admissions / 459 hospital deaths<br />
• Latency to onset <strong>of</strong> ≈ 2 to 6 weeks<br />
• Initial lack <strong>of</strong> symptoms among animals fed grain<br />
may have instilled false sense <strong>of</strong> security that it was<br />
safe to eat<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
21<br />
The contaminated bread was eaten by the population <strong>for</strong> an average time period <strong>of</strong> one<br />
month.<br />
Approximately 1% <strong>of</strong> those exposed (and 6% <strong>of</strong> those ill enough to be admitted to the<br />
hospital) died.<br />
Onset <strong>of</strong> symptoms was several weeks after consumption began.<br />
.<br />
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Participant Guide<br />
Slide 22<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methylmercury Poisoning<br />
Clinical Findings in Adults<br />
• Numbness around the mouth and in a stocking -glove<br />
distribution<br />
• Classic Triad<br />
– Ataxia - slight unsteadiness to inability to walk<br />
– Visual changes ranging from blurred or decreased vision to blind ness<br />
– Dysarthria - Slurring <strong>of</strong> speech<br />
• Mental deterioration<br />
• Severity <strong>of</strong> signs and symptoms are dose -dependent<br />
– Mild/moderate symptoms: 2.4 mg/kg<br />
– Severe symptoms: 3.6 mg/kg<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
22<br />
The symptoms developed by Iraqi adults follow the typical progression <strong>for</strong> organic<br />
mercury poisoning.<br />
Initial numbness (paresthesias) around the mouth and distal extremities was followed by<br />
the triad <strong>of</strong> gait abnormalities, visual, and speech changes.<br />
Most toxins exhibit a dose-response relationship. Comparing clinical effects with<br />
estimates <strong>of</strong> methylmercury consumption from contaminated grain were consistent with<br />
a dose-response relationship.<br />
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Participant Guide<br />
Slide 23<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Methylmercury Poisoning<br />
Developmental Toxicity<br />
• Crosses placenta and accumulates in child<br />
• Transmitted mother to child via breast milk<br />
• Severe developmental delay / Cerebral -<br />
palsy-like syndrome<br />
• Mother may have minimal or no symptoms<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
23<br />
The developing nervous system <strong>of</strong> the fetus and infant is particularly vulnerable to shortchain<br />
organic mercury compounds. . As a toxin that interferes with cellular, particularly<br />
neuronal, development, the presentations in neonates who had been exposed included<br />
severe developmental delays and cerebral palsy – like syndromes <strong>of</strong> incoordination and<br />
weakness/spasticity.<br />
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Participant Guide<br />
Slide 24<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Organomercurials – Potential<br />
Advantages in Toxic <strong>Terrorism</strong><br />
• Toxic to humans in small amounts<br />
• Symptoms occur days to weeks after ingestion,<br />
depending on the dose<br />
• Highly fetotoxic, cross the placenta most readily <strong>of</strong><br />
all <strong>for</strong>ms <strong>of</strong> mercury, enter breast milk<br />
• Enter the body via ingestion <strong>of</strong> contaminated<br />
foodstuffs, inhalation and dermal exposure<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
24<br />
Features <strong>of</strong> organomercurials that would be appealing <strong>for</strong> terrorist use include its toxicity<br />
in small amounts (1/2 gram or less), its impact on the very young and not yet born<br />
(“second generation impact”), the delay to detection because <strong>of</strong> delayed-onset<br />
symptoms and possible diagnostic uncertainty, and the possibility <strong>of</strong> using a variety <strong>of</strong><br />
routes <strong>of</strong> exposure – making it both more difficult to identify the source, and there<strong>for</strong>e to<br />
eliminate it.<br />
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Participant Guide<br />
Slide 25<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Seveso, Italy<br />
July 10,1976<br />
www.chm.bris.ac.uk<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
25<br />
The last group <strong>of</strong> industrial chemicals with delayed onset toxicity that we will discuss<br />
today can be loosely grouped as complex halogenated aromatic hydrocarbons that are<br />
only very slowly broken down or eliminated from the human body once absorbed. These<br />
include such compounds as dioxin, a contaminant <strong>of</strong> “Agent Orange”.<br />
A chemical plant explosion and fire in 1976 released a massive amount <strong>of</strong> the<br />
biopersistent chemical dioxin into the environment.<br />
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Slide 26<br />
This plant was involved in the chemical oxidation <strong>of</strong> a chlorinated aromatic hydrocarbon<br />
to trichlorophenol, an agricultural biocide and pr<strong>of</strong>essional disinfectant. In the setting <strong>of</strong> a<br />
run-away reaction with increased temperature and pressure, a portion <strong>of</strong> the product<br />
released was a condensation product, usually known as dioxin.<br />
The mayor <strong>of</strong> the city was not notified immediately and the nature <strong>of</strong> the contaminating<br />
product generated was not known <strong>for</strong> days.<br />
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Participant Guide<br />
Slide 27<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Unintentional Dioxin Release<br />
Immediate Events<br />
• Some residents with HA, nausea, eye irritation<br />
• Plants turn yellow; rabbits and chickens die<br />
• Day 6: 14 children to hospital “chemical burns ”<br />
• Day 10: Confirmed that dioxin was released<br />
• Day 16-23: Zone A evacuated<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
27<br />
It took several days to understand the implications <strong>of</strong> the explosion and related health<br />
effects, even though the explosion was a known, overt event. The more than 2 week<br />
delay in response in terms <strong>of</strong> decreasing exposure by precautionary evacuation is<br />
notable.<br />
What if this chemical had been released in a covert fashion A presentation <strong>of</strong> the listed<br />
(in slide) delayed and dissimilar diagnostic features (other than the initial irritating effects<br />
<strong>of</strong> the smoke) affecting plants, animals, and children would not have an obvious unifying<br />
source and would be a source <strong>of</strong> great concern and potential panic.<br />
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Participant Guide<br />
Slide 28<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chloracne, Seveso, Italy<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
28<br />
Despite the concern regarding dioxin and cancer initiation in animal models, the most<br />
consequential effect in humans appears to be severe cystic acne, known as chloracne.<br />
This disorder is not unique to dioxin, but can be caused by other halogenated aromatic<br />
hydrocarbons (e.g. aromatic organochlorine compounds).<br />
The acne is likely related to the release <strong>of</strong> dioxin into sweat glands following absorption,<br />
resulting in irritation and severe inflammation and infection. Scarring is common.<br />
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Participant Guide<br />
Slide 29<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Seveso <strong>Chemical</strong><br />
Plume<br />
Zone Size*<br />
Pop.<br />
A 0.3 804<br />
B 1.0 5941<br />
R 5.5 38,624<br />
Ref 28.8 182,843<br />
*Size in square miles<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
29<br />
This map detail <strong>of</strong> the affected region <strong>of</strong> Italy pinpoints the ICMESA chemical plant, and<br />
provides an estimate <strong>of</strong> the areas <strong>of</strong> greatest contamination (A), lesser contamination<br />
(B), minimally affected areas (R), and an uninvolved area (Ref), with the size <strong>of</strong> the<br />
region (square miles) and population depicted in the chart .<br />
The zones are depicted in a plume model developed based on the meteorlogical<br />
conditions at the time <strong>of</strong> the release supplemented by data from soil sampling well after<br />
the release. Subsequent epidemiological studies attempted to correlate health outcomes<br />
with the areas in which people resided, until improved laboratory techniques allowed<br />
blood TCDD testing <strong>of</strong> these individuals.<br />
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Participant Guide<br />
Slide 30<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Seveso, Italy: The Aftermath<br />
• Zone A cleaned and soil removed<br />
• Thousands <strong>of</strong> soil and blood<br />
samples collected<br />
• Surveillance Programs<br />
– Liver enzyme induction, lipid<br />
metabolism, congenital<br />
mal<strong>for</strong>mation,<br />
immunosuppression , chloracne<br />
(193 cases)<br />
– 20 years later TCDD blood levels<br />
still high<br />
– Increased female:male birth ratio<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
Despite the limited human toll acutely (chloracne in about 200 people), and even with<br />
intensive follow-up demonstrating minimally statistically significant changes in other<br />
health effects, the financial (and psychological) toll was severe. Extensive environmental<br />
testing (depicted in top picture) and millions <strong>of</strong> tons <strong>of</strong> soil were carted away in cylinders<br />
(bottom picture) and stored.<br />
30<br />
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Slide<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Unintentional Dioxin Release<br />
Controversial human effects<br />
• Many <strong>of</strong> the reported relationships between dioxin exposure<br />
and human toxicity have come under epidemiologic scrutiny<br />
• Carcinogenicity<br />
– Known carcinogen in mice and rats<br />
– In humans reported association with some cancers such as Non -<br />
Hodgkin ’s Lymphoma and s<strong>of</strong>t tissue sarcomas but causation has not<br />
been established<br />
• Undisputed link between dioxin exposure and chloracne<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
31<br />
The fear <strong>of</strong> carcinogenicity is the most important sociopolitical issue. However there is<br />
really no solid link <strong>of</strong> dioxins to human cancer despite its highly defined carcinogenicity<br />
in animal models.<br />
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Slide 32<br />
Victor Yushchenko, while running <strong>for</strong> the Presidency <strong>of</strong> Ukraine, developed severe<br />
gastroenteritis after a dinner with political rivals.. It was later determined that he was<br />
likely poisoned at that time. The toxin was confirmed as dioxin by measuring tissue (fat)<br />
and blood levels. He had the second highest levels ever reported.<br />
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Slide 33<br />
Notice the marked difference be<strong>for</strong>e (smooth skin) and after the exposure (pockmarked<br />
face), with significant recovery (but some persistent scarring) 3 years later.<br />
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Slide 34<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
“Yusho” Poisoning<br />
Japan, 1968<br />
• Kanemi rice oil contaminated with Kanechlor 400<br />
– Mixture <strong>of</strong> polychlorinated biphenyls (PCB) & polychlorinated<br />
dibenz<strong>of</strong>urans (PCDF)<br />
• 1788 certified exposures by end <strong>of</strong> 1982<br />
• Subacute symptoms: acne -like eruptions<br />
• Growth retardation in school children one year later<br />
– Triglyceride, immune & endocrine disturbances<br />
• PCDF may have played the greater role<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
34<br />
Getting an organochlorine compound into the food supply on a larger scale is not<br />
unprecedented. This event involved nearly 1800 people in southern Japan. Although the<br />
rice oil (Yusho in Japanese) contamination was unintentional, it reminds us that an<br />
intentional poisoning could occur via a similar mechanism.<br />
This large scale disaster occurred 40 years ago when rice cooking oil was accidentally<br />
contaminated with a mixture <strong>of</strong> chlorinated hydrocarbons including PCBs and PCDFs.<br />
The major physical effect noted was an acne-like eruption (chloracne) preceded by<br />
eyelid swelling and increased eye discharge. Dark brown pigmentation <strong>of</strong> the skin and<br />
nails was also noted. Some lipid abnormalities and possible growth effects consistent<br />
with hormonal disruption were also noted in follow-up studies.<br />
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<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Yusho Effects<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
35<br />
In addition to the findings typical <strong>of</strong> chloracne, nail and gum changes were also noted<br />
after the Yusho event.<br />
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Slide 36<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Chlorinated hydrocarbon<br />
Dioxin, PCB<br />
• Intentional mass exposure to dioxin or PCBs would<br />
be difficult to detect, induce wide -spread fear, and<br />
tax our resources <strong>for</strong> decades at an enormous cost<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
36<br />
As mentioned, an intentional large-scale exposure to these biopersistent (slowly<br />
eliminated) compounds with potential or claimed long-term effects would be difficult to<br />
detect (other than the clue provided by those exposed to large amounts manifesting<br />
chloracne).<br />
A terrorist attack <strong>of</strong> this nature would have enormous financial and psychological impact<br />
<strong>for</strong> years; though few, if any, fatalities.<br />
The unintentional releases we have covered thus far are from other countries.<br />
Has such an event ever happened in the United States<br />
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Slide 37<br />
Slide 39<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Forewarned Is Forearmed<br />
• Given a new willingness by terrorists in the 21st Century to<br />
use previously unthinkable means to meet their ends, we<br />
must prepare:<br />
– Limit access to highly toxic agents<br />
– Protections <strong>of</strong> food and water supplies, toxic substances in indu strial<br />
plants and in transport<br />
• Raise awareness <strong>of</strong> potential clinical effects to:<br />
– Hasten recognition<br />
– Limit exposure<br />
– Speed response<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
39<br />
There has been an increase in terrorist activities over the last few decades in the setting<br />
<strong>of</strong> internal strife and in international settings. In an ef<strong>for</strong>t to prevent and prepare <strong>for</strong> the<br />
use <strong>of</strong> industrial chemicals as terrorist weapons:<br />
1. We must limit access to toxic agents, both those with rapid- and delayed-onset <strong>of</strong><br />
symptoms.<br />
2. As has been increasingly recognized, hazard vulnerability analyses and system-wide<br />
protective measures must be developed and en<strong>for</strong>ced.<br />
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3. Improving our public health and medical response/care system is critical to prevent<br />
illness and save lives. One <strong>of</strong> the features <strong>of</strong> this response is the recognition <strong>of</strong><br />
syndromes characteristic <strong>of</strong> exposure to chemicals and distinguishing those from other<br />
more common entities.<br />
Early recognition <strong>of</strong> illness clusters will limit the extent and number <strong>of</strong> exposures and<br />
allow <strong>for</strong> an earlier, appropriate response.<br />
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Slide 40<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Lessons Learned<br />
• Highly toxic substances are currently readily available whose<br />
onset <strong>of</strong> toxicity is delayed<br />
• Toxins with delayed effects can be used to affect large<br />
numbers <strong>of</strong> people be<strong>for</strong>e it is discovered<br />
• The delay in onset <strong>of</strong> toxicity aids a would -be terrorist in<br />
avoidance <strong>of</strong> detection and escape<br />
• Widespread exposure and uncertainty re: long -term effects<br />
maximizes the fear factor – serves the purpose <strong>of</strong> the terrorist<br />
• Even less toxic compounds which are biopersistent and<br />
whose detection is delayed have enormous potential to<br />
cause fear and overwhelm health care resources<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
40<br />
The examples covered in this module should make it clear that there are a number <strong>of</strong><br />
available industrial chemicals that cause delayed-onset illness, allowing widespread<br />
exposure and potentially complicating clinical and epidemiologic evaluation. The more<br />
uncertain the source and long-term consequences <strong>of</strong> an exposure are, the more public<br />
fear (terror) will result.<br />
Because <strong>of</strong> the delay to onset <strong>of</strong> toxicity from a variety <strong>of</strong> available substances with<br />
significant potential to cause harm, many people may be affected – physically and/or<br />
psychologically, with significant impact on individuals and systems. In particular, concern<br />
about possible effects many years in the future (i.e. cancer and second generation<br />
effects), even if poorly supported by data or <strong>of</strong> little significance to any one individual,<br />
causes fear and initiated requests <strong>for</strong> monitoring. These considerations should be<br />
included in planning <strong>for</strong> response and communication post-event.<br />
As has been discussed in other modules today, identification <strong>of</strong> responsible individuals<br />
and even the source <strong>of</strong> a toxin may be challenging. This can be seen even with rapidonset<br />
toxins (e.g. Chicago cyanide contamination <strong>of</strong> over-the-counter analgesics is still<br />
an unsolved crime); identification <strong>of</strong> the culprit or extent <strong>of</strong> exposure following<br />
surreptitious use <strong>of</strong> a delayed-onset toxin will be much more difficult, leading to yet more<br />
fear and uncertainty.<br />
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Slide 41<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Questions<br />
Training Support Package<br />
41<br />
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Slide 42<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Supplemental Slides<br />
Training Support Package<br />
42<br />
Instructor Note: If time permits you may include following slides in your presentation.<br />
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Slide 43<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Polybrominated Biphenyl (PBB) Exposure<br />
through Contaminated Food<br />
Michigan (1973)<br />
• <strong>Chemical</strong> plant packaged FireMaster<br />
flame retardant (PBB) and<br />
NutriMaster (MgO dairy cattle feed<br />
supplement) in similar brown paper<br />
bags due to a shortage <strong>of</strong> pre -printed<br />
bags.<br />
• Ten to twenty 50lb bags <strong>of</strong> PBB were<br />
included in a truckload <strong>of</strong> NutriMaster<br />
sent to a cattle feed mill during the<br />
summer <strong>of</strong> 1973.<br />
• PBB contaminated cattle feed was<br />
sold to dairy farms throughout the<br />
state<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
43<br />
A chemical plant that manufactured both FireMaster flame retardant (containing<br />
polybrominated biphenyls (structure shown in graphic) and Nutrimaster (magnesium<br />
oxide feed supplement) mistakenly included 10-20 50 pound bags <strong>of</strong> the flame retardant<br />
in a shipment to a cattle feed mill in 1973.<br />
The mistake occurred because <strong>of</strong> a shortage <strong>of</strong> pre-printed bags.<br />
PBB contaminated cattle feed was sold to dairy farms throughout the state.<br />
A simple error in the distribution process led to this mass poisoning event.<br />
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Slide 44<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Polybrominated Biphenyl (PBB) Exposure<br />
through Contaminated Food<br />
• Weight loss, decreased milk<br />
production, and nonspecific illness<br />
noted among dairy herds in Fall<br />
1973, Spring 1974<br />
• After months <strong>of</strong> analysis, PBB<br />
detected in feed in April, 1974.<br />
• Quarantine <strong>of</strong> dairy herds and other<br />
farm animals started in May, 1974.<br />
• By 1975, 500 farms quarantined:<br />
– 30,000 cattle<br />
– 4500 swine<br />
– 1500 sheep,<br />
– 1.5 million chickens destroyed and<br />
buried.<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
44<br />
Weight loss, decreased milk production, and nonspecific illness were noted among dairy<br />
herds in the fall <strong>of</strong> 1973 and spring <strong>of</strong> 1974. The cause was not known until PBB was<br />
detected in feed in April, 1974.<br />
Quarantine <strong>of</strong> dairy herds and other farm animals started in May, 1974. By 1975, 500<br />
farms quarantined: 30000 cattle, 4500 swine, 1500 sheep, and 1.5 million chickens were<br />
destroyed and buried.<br />
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<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Polybrominated Biphenyl (PBB) Exposure<br />
through Contaminated Food<br />
• Widespread, low level human exposure to PBB occurred<br />
throughout Michigan. E.g. 51 <strong>of</strong> 53 (96%) <strong>of</strong> random breast<br />
milk samples in 1976 had detectable levels.<br />
• Exposure most intense among dairy farm families, and<br />
persons obtaining dairy foods directly from quarantined<br />
farms.<br />
• High dose animal studies revealed PBB could cause<br />
multisystemic effects, including liver neoplasms<br />
• Between 1976 - 1979, state and federal agencies assembled<br />
a cohort <strong>of</strong> ≈ 4000 people, mainly farm families, to study<br />
long-term human health effects.<br />
Module One - <strong>Terrorism</strong> by Fear and Uncertainty: Delayed Toxic Syndromes<br />
45<br />
Widespread, low level human exposure to PBB occurred throughout Michigan.<br />
Practically all sampled human breast milk in 1976 had detectable levels. Exposure was<br />
most intense among dairy farm families, and persons obtaining dairy foods directly from<br />
quarantined farms. High dose animal studies revealed PBB could cause multisystemic<br />
effects, including liver neoplasms.<br />
Between 1976 and 1979, state and federal agencies assembled a cohort <strong>of</strong> ≈ 4000<br />
people, mainly farm families, to study long-term human health effects.<br />
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Slide 46<br />
Similar to other organohalide compounds discussed in the last 1/3 <strong>of</strong> this module, PBB is<br />
highly lipophilic and extremely persistent.<br />
The apparent elimination half-life, measured in the blood, is approximately 10.8 years.<br />
The initial results reported on the cohort <strong>of</strong> exposed individuals (at about 4 years after<br />
exposure) did not identify any relationship between serum levels and symptoms; in fact<br />
the highest symptom prevalence occurred in subjects with lowest serum PBB.<br />
Because <strong>of</strong> concern about potential immunologic impact, lymphocyte count and function<br />
were also evaluated. No relationship was identified.<br />
An epidemiologic study reported in 1998 raised a question <strong>of</strong> carcinogenesis, but the<br />
study had many limitations. The findings have not been confirmed.<br />
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Slide 47<br />
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Module Six Summary<br />
Unlike the general concept <strong>of</strong> chemicals poisoning, in which the onset is rapid and the source<br />
identifiable, some toxins may have a delayed onset <strong>of</strong> symptoms. This could be beneficial to its<br />
use as a covert weapon from the perspective <strong>of</strong> a terrorist. Allowing time <strong>for</strong> victims to leave<br />
may seem like a “bad thing” to a terrorist, but in reality this complicates the epidemiology<br />
(figuring out the cause <strong>of</strong> the problem and source) and makes clinical management more<br />
difficult. More exposures may occur because there are no warning properties <strong>of</strong> exposure. In<br />
acute onset toxins, most people will escape when those around them start to get sick. But if<br />
nobody gets sick….nobody realizes they are being poisoned….and nobody escapes.<br />
<strong>Chemical</strong> agents with a delayed toxicity onset can be organized and separated based on<br />
route/scenario <strong>of</strong> exposure. Some are airborne (phosgene), food and waterborne (thallium,<br />
organomercurials, radionuclides/radioactive metals), and environmental/ biopersistent agents<br />
(dioxins, PCBs and PBBs).<br />
Choice <strong>of</strong> a toxin with delayed onset not only allows time <strong>for</strong> the perpetrator to escape and<br />
complicates diagnosis and response, but creates the potential <strong>for</strong> a large number <strong>of</strong> victims<br />
which may result in overwhelming the health care system with large numbers <strong>of</strong> patients with<br />
“medically unexplainable symptoms” presenting in dispersed fashion. This will contribute to<br />
creating chaos and social terror. The delayed onset <strong>of</strong> these agents may mimic some biological<br />
agents (anthrax, smallpox).<br />
Thallium has many qualities that allow it to be used as a terrorist weapon and has a long history<br />
<strong>of</strong> use as a homicidal toxin. The “classic triad” <strong>of</strong> gastrointestinal symptoms, paresthesias, and<br />
alopecia is obvious only if you know about it. Most physicians are not aware <strong>of</strong> this syndrome<br />
and will likely go looking in the wrong direction…..many other things cause painful neuropathy<br />
(e.g., diabetes, HIV) but none are as acute in onset as that from thallium (days).<br />
Organomercurials are examples <strong>of</strong> an agent used to raise fear and concern. It is widely believed<br />
to be extremely toxic, although the majority <strong>of</strong> us are exposed to small doses on a daily basis. It<br />
provides the opportunity to highlight the importance <strong>of</strong> physical state and chemical <strong>for</strong>m in<br />
determining toxicity. While elemental mercury is <strong>of</strong> minimal toxicity in is liquid <strong>for</strong>m, when<br />
inhaled following volatilization it can produce both irritant lung syndrome and neurotoxicity.<br />
Although low level exposure to a vapor over a long period can produce neurotoxicity without<br />
pulmonary abnormalities, this would not be a very effective terrorist weapon. Organic mercury<br />
compounds (those in which Hg is bound to a carbon backbone) are widely used in industry and<br />
science, and vary in toxicity from virtually none (as in organic mercury present in vaccines) to<br />
devastating, as is the case with dimethylmercury. Depending on the specific organic mercury<br />
compound, they can be absorbed by virtually every route, including dermal.<br />
Even less toxic compounds which are biopersistent and whose detection is delayed (such as<br />
the dioxins and other halogenated hydrocarbons) have enormous potential to cause fear and<br />
overwhelm health care resources<br />
Highly toxic substances whose onset <strong>of</strong> toxicity is delayed are currently readily available; these<br />
delayed effects can be used to affect large numbers <strong>of</strong> people be<strong>for</strong>e an event is discovered.<br />
The delay in onset <strong>of</strong> toxicity aids a would-be terrorist in avoidance <strong>of</strong> detection and escape<br />
while serving the purpose <strong>of</strong> creating uncertainty and panic. Due to the dramatic increase in<br />
terrorist activities both in internal strife and in international settings and a new willingness by<br />
terrorists in the 21st Century to use previously unthinkable means to meet their ends, we must<br />
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prepare to limit access to highly toxic agents, ensure greater protections <strong>of</strong> food and water<br />
supplies, and more closely monitor toxic substances in industrial plants and in transport. Access<br />
to toxic agents must be stringently monitored and limited, both those with rapid onset and those<br />
that are delayed in onset <strong>of</strong> toxicity. Improving our public health and medical response/care<br />
system is critical to prevent sickness and save lives.<br />
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Module Seven<br />
Radiation Emergencies - Administration Page<br />
The concept <strong>of</strong> terrorists using radiation as a weapon is extremely concerning. Ionizing or<br />
“nuclear” radiation has the clear potential to “terrify” the public as it is associated in the public<br />
mind with the destructive <strong>for</strong>ce <strong>of</strong> nuclear weapons, it is invisible and acutely undetectable to the<br />
senses, and is associated with the “dread <strong>of</strong> cancer”; with other effects not well understood by<br />
general public. Clinicians can play a vital role in minimizing fear and panic.<br />
Several potential scenarios involving the use <strong>of</strong> radiation by terrorists include the surreptitious<br />
placement <strong>of</strong> a radiation source, the stealth dispersal <strong>of</strong> radioactive material, an explosive<br />
radiation dispersal device (“dirty bomb”), a deliberate attack on a nuclear power plant, or the<br />
detonation <strong>of</strong> a nuclear weapon.<br />
Medical personnel may be called upon to care <strong>for</strong> patients who have been exposed to high<br />
levels <strong>of</strong> radiation or who have been contaminated with radioactive materials. Some <strong>of</strong> these<br />
patients may be gravely ill with radiation sickness or may have radiation burns, while others may<br />
have no radiological medical problems other than minor skin contamination. It is essential that<br />
medical personnel be able to recognize radiation injury and provide appropriate treatment. It is<br />
also essential that medical personnel understand that patients who are merely contaminated<br />
may be treated without risk <strong>of</strong> radiation injury to the medical staff, although contamination<br />
control measures may be prudent if the medical condition permits.<br />
Acute radiation syndrome is a constellation <strong>of</strong> signs and symptoms that develop after total body<br />
irradiation. The initial signs and symptoms <strong>of</strong> radiation illness are nonspecific, and could be<br />
misdiagnosed as a viral syndrome, or gastroenteritis. It is important in triage to attempt to<br />
ascertain the time interval between a person’s acute radiation exposure and the onset <strong>of</strong><br />
gastrointestinal signs and symptoms. Individuals who become symptomatic in less than 4 hours,<br />
and certainly in less than 2 hours after exposure are likely to have absorbed a lethal dose <strong>of</strong><br />
radiation and cannot be saved. In a mass casualty incident, they might have to be triaged to<br />
palliative care rather than intensive supportive care.<br />
Duration<br />
45 minutes<br />
Scope Statement<br />
This module presents the major potential scenarios involving the release <strong>of</strong> radiation by<br />
terrorists and reviews the basic fundamentals <strong>of</strong> radiation biology and concepts <strong>of</strong> exposure,<br />
contamination and containment. Decontamination and treatment strategies are presented <strong>for</strong><br />
managing victims <strong>of</strong> radiation exposure.<br />
Terminal Learning Objective (TLO)<br />
• Understand the concepts <strong>of</strong> radiation poisoning to assess and provide<br />
clinical care to patients who have been exposed to or contaminated<br />
with radioactive material.<br />
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Participant Guide<br />
Enabling Learning Objectives (ELO)<br />
Resources<br />
• Describe five potential terrorist scenarios involving the use <strong>of</strong><br />
radiation.<br />
• Describe the basic types <strong>of</strong> radiation.<br />
• Distinguish between radiation and radioactive contamination.<br />
• Recognize common types <strong>of</strong> radiological incidents and emergencies.<br />
• Describe the clinical signs <strong>of</strong> radiation exposure.<br />
• Understand the importance <strong>of</strong> treating significant medical and<br />
psychological problems in patients with radioactive contamination.<br />
• Explain basic radiological control methods.<br />
Each <strong>of</strong> the eight course modules is deployed as an interactive, instructor-lead, MS PowerPoint<br />
presentation containing didactic content, historical examples, and selected case studies. All<br />
presentations are included in a printed participant guide (PG) containing the modules’ overview,<br />
scope statement, terminal and enabling learning objectives, PowerPoint slide handouts, and a<br />
summary section.<br />
Instructor to Participant Ratio<br />
1:8 (minimum) to 1:25 (maximum)<br />
Reference List<br />
1. Andrews GA, Auxier JA, Lushbaugh CC. The Importance <strong>of</strong> Dosimetry to the<br />
Medical Management <strong>of</strong> Persons Exposed to High Levels <strong>of</strong> Radiation. In<br />
Personal Dosimetry <strong>for</strong> Radiation Accidents. Vienna : International Atomic<br />
Energy Agency; 1965.<br />
2. Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. Hyperbaric<br />
oxygen therapy <strong>for</strong> late radiation tissue injury. Cochrane Database <strong>of</strong><br />
Systematic Reviews 2005, Issue 3. Art. No.: CD005005.<br />
3. Cable News Network (CNN). Sentence in Radiation Poison Case.<br />
CNN.com/World, October 2, 2003. Accessed Dec 2008 from:<br />
http://www.cnn.com/2003/WORLD/asiapcf/east/10/02/china.radiation/<br />
4. Centers <strong>for</strong> Disease Control and Prevention. Acute Radiation Syndrome:<br />
Physician Fact Sheet. CDC Emergency Preparedness and Response.<br />
Accessed Dec 2008 from:<br />
http://www.bt.cdc.gov/radiation/arsphysicianfactsheet.asp<br />
5. Centers <strong>for</strong> Disease Control and Prevention. Cutaneous Radiation Injury:<br />
Fact Sheet <strong>for</strong> Physicians. CDC: Emergency Preparedness and Response.<br />
Accessed Dec 2008 from:<br />
http://www.bt.cdc.gov/radiation/criphysicianfactsheet.asp<br />
6. Centers <strong>for</strong> Disease Control and Prevention. Emergency Preparedness and<br />
Response. Fact Sheet: Prussian Blue. Accessed Dec 2008 from:<br />
http://www.bt.cdc.gov/radiation/prussianblue.asp<br />
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7. Centers <strong>for</strong> Disease Control and Prevention. Emergency Preparedness and<br />
Response: Radiation Emergencies. Accessed Dec 2008 from:<br />
http://www.bt.cdc.gov/radiation/<br />
8. Centers <strong>for</strong> Disease Control and Prevention. Possible Health Effects <strong>of</strong><br />
Radiation Exposure on Unborn Babies. CDC: Emergency Preparedness and<br />
Response. Accessed Dec 2008 from:<br />
http://www.bt.cdc.gov/radiation/prenatal.asp<br />
9. Centers <strong>for</strong> Disease Control and Prevention. Radioisotope Brief: Iodine-131.<br />
Accessed Dec 2008 from:<br />
http://www.bt.cdc.gov/radiation/isotopes/pdf/iodine.pdf<br />
10. Centers <strong>for</strong> Disease Control and Prevention. Radioisotope Brief: Cesium-137.<br />
Accessed Dec 2008 from:<br />
http://www.bt.cdc.gov/radiation/isotopes/cesium.asp<br />
11. Clinical Response <strong>of</strong> Normal Tissues in Radiobiology <strong>for</strong> the Radiologist. Hall<br />
EJ, Giaccia AJ (eds). Lippincott Williams & Wilkins, Philadelphia PA, 6th<br />
edition, 2006.<br />
12. Cutaneous Radiation Syndrome. Radiation Event Medical Management:<br />
Guidance on Diagnosis & Treatment <strong>for</strong> Health Care Providers. Accessed<br />
Dec 2008 from: http://www.remm.nlm.gov/cutaneoussyndrome.htm<br />
13. Ferguson CD, Kazi T, Perera J. Commercial radioactive sources: surveying<br />
the security risks. Occasional Paper No. 11, Center <strong>for</strong> Nonproliferation<br />
Studies, Monterey Institute <strong>of</strong> International Studies, CA; 2003.<br />
14. Holt M, Andrews A. Nuclear Power Plant Security and Vulnerabilities. CRS<br />
Report <strong>for</strong> Congress, Congressional Research Service; 2008. Accessed Dec<br />
2008 from: http://www.fas.org/sgp/crs/homesec/RL34331.pdf<br />
15. International Atomic Energy Agency. “The Radiological Accident in Goiania.”<br />
IAEA, STI/PUB/815 (ISBN 92-0-129088-8);Vienna, 1988.<br />
16. International Atomic Energy Agency. Goiânia’s Legacy Two Decades On:<br />
Accident led to review <strong>of</strong> international safety standards <strong>for</strong> radiation; March 7<br />
2008. Accessed Dec 2008 from:<br />
http://www.iaea.org/NewsCenter/News/2008/goiania.html<br />
17. Ionizing Radiation During Pregnancy. Exposure to radiation and physical<br />
agents during pregnancy. Accessed Dec 2008 from:<br />
www.perinatology.com/exposures/Physical/Xray.htm<br />
18. Isotopes <strong>for</strong> Medicine and the Life Sciences. Adelstein SJ, Manning FJ (eds)<br />
Instititute <strong>of</strong> Medicine. National Academy Press, Washington D.C.; 1995.<br />
19. Jordan M, Finn P. “Radioactive Poison Killed Ex-Spy”. Wasingtonpost.com;<br />
November 25, 2006. Accessed Dec 2008 from:<br />
http://www.washingtonpost.com/wpdyn/content/article/2006/11/24/AR2006112400410.html<br />
20. Kuniak M, Azizova T, Day R, et al. The radiation injury severity classification<br />
system: an early injury assessment tool <strong>for</strong> the frontline healthcare provider.<br />
Br J Radiol 2008;81:232-243.<br />
21. Managing Radiation Emergencies: Guidance <strong>for</strong> Hospital Medical<br />
Management. REAC/TS Guidance <strong>for</strong> Radiation Accident Management –<br />
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Participant Guide<br />
Decontamination. Accessed Dec 2008 from:<br />
http://orise.orau.gov/reacts/guide/emergency.htm#Decontamination<br />
22. McFee R. “Exclusive: the death <strong>of</strong> Litvinenko – two years later and what have<br />
we learned” Family Security Matters 2008. Accessed Dec 2008 from:<br />
www.familysecuritymatters.org/publications/id.1969/pub_detail.asp<br />
23. Mettler FA Jr, Voelz GL. Major radiation exposure – what to expect, how to<br />
respond. N Engl J Med 2002;346:1554-1561.<br />
24. Nuclear Energy Advisory Committee. Nuclear Energy: Policies and<br />
Technology <strong>for</strong> the 21st Century. Department <strong>of</strong> Energy, November 2008.<br />
25. Ortiz P, Friedrich V, Wheately J, Oresugun M. Lost and found dangers:<br />
orphan radiation sources raise global concerns. IAEA Bulletin 1999; 413:18-<br />
21.<br />
26. Osborn A. “Now traces <strong>of</strong> polonium 210 are found in Russian businessman’s<br />
flat”. The Independent; December 10, 2006. Accessed Dec 2008 from:<br />
http://www.independent.co.uk/news/world/europe/now-traces-<strong>of</strong>-polonium-<br />
210-are-found-in-russian-businessmans-flat-427862.html<br />
27. Parker DD, Parker JC. Estimating radiation dose from time to emesis and<br />
lymphocyte depletion. Health Physics. The Radiation Safety Journal<br />
2007;93(6):701-704.<br />
28. Pastel RH. Fear <strong>of</strong> radiation in U.S. military medical personnel. Military Med<br />
2001. Accessed Dec 2008 from:<br />
http://findarticles.com/p/articles/mi_qa3912/is_200112/ai_n9008782<br />
29. Patterson AJ. Ushering in the era <strong>of</strong> nuclear terrorism.[editorial] Crit Care<br />
Med 2007;35(3):953-954.<br />
30. Public Broadcasting Service. Frontline. Nuclear Reaction: Why do Americans<br />
Fear Nuclear Power Accessed Dec 2008 from:<br />
http://www.pbs.org/wgbh/pages/frontline/shows/reaction/interact/facts.html<br />
31. Radiation Event Medical Management: Dose Estimator (Biodosimetry Tools).<br />
National Library <strong>of</strong> Medicine. Accessed Dec 2008 from:<br />
http://www.remm.nlm.gov/ars_wbd.htm#vomit<br />
32. Radiation Event Medical Management: Explaining Biodosimetry. National<br />
Library <strong>of</strong> Medicine. Accessed Dec 2008 from:<br />
http://www.remm.nlm.gov/explainbiodosimetry.htm<br />
33. Radiological <strong>Terrorism</strong> Tutorial: Iridium-192. Nuclear Threat Initiative.<br />
Accessed Dec 2008 from:<br />
http://www.nti.org/h_learnmore/radtutorial/iridium192.html<br />
34. Rubin GJ, Page L, Morgan O, et al. Public in<strong>for</strong>mation needs after the<br />
poisoning <strong>of</strong> Alexander Litvinenko with polonium-210 in London: cross<br />
sectional telephone survey and qualitative analysis. BMJ 2007;335:1143.<br />
35. Shope TB. Radiation-induced skin injuries from fluoroscopy. FDA: Center <strong>for</strong><br />
Devices and Radiological Health. Accessed Dec 2008 from:<br />
http://www.fda.gov/cdrh/RSNAii.html<br />
36. United States Department <strong>of</strong> Health and Human Services. Radiation Event<br />
Medical Management (REMM): Guidance on Diagnosis & Treatment.<br />
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Dictionary <strong>of</strong> Radiological Terms. Accessed Dec 2008 from:<br />
http://www.remm.nlm.gov/dictionary.htm<br />
37. United States Department <strong>of</strong> Homeland Security. Radiation Portal Monitors.<br />
Homeland Security TechNote; System Assessment and Validation <strong>for</strong><br />
Emergency Responders (SAVER); April 2006.<br />
38. United States Department <strong>of</strong> Labor: OSHA. Safety and Health Topics: Non-<br />
Ionizing Radiation. Accessed Dec 2008 from:<br />
http://www.osha.gov/SLTC/radiation_nonionizing/index.html<br />
39. United States Department <strong>of</strong> Labor: Occupational Safety & Health<br />
Administration (OSHA). Safety and Health Topics: Ionizing Radiation.<br />
Accessed Dec 2008 from: http://www.osha.gov/SLTC/radiationionizing/<br />
40. United States Nuclear Regulatory Commission. Fact Sheet <strong>of</strong> Dirty Bombs.<br />
Accessed Dec 2008 from: http://www.nrc.gov/reading-rm/doc-collections/factsheets/dirty-bombs.html<br />
41. United Nations. Chernobyl’s Legacy: Health, Environmental and Socio-<br />
Economic Impacts and Recommendations to the Governments <strong>of</strong> Belarus,<br />
the Russian Federation and Ukraine. The Chernobyl Forum: 2003-2005; 2nd<br />
edition, rev.<br />
42. United States Environmental Protection Agency. Radiation Protection.<br />
Accessed Dec 2008 from: http://www.epa.gov/rpdweb00/<br />
43. Waselenka JK, MacVittie TJ, Blakely WF, Pesik N, Wiley AL, Dickerson WE,<br />
Tsu H, Confer DL, Coleman N, Seed T. Medical Management <strong>of</strong> the Acute<br />
Radiation Syndrome: Recommendations <strong>of</strong> the Strategic National Stockpile<br />
Radiation Working Group, Annals <strong>of</strong> Internal Medicine 2004; 140:1037-1051.<br />
44. World Health Organization. Health Effects <strong>of</strong> the Chernobyl Accident and<br />
Special Health Care Programs. Bennett B, Repacholi M, Carr Zhanat (eds.);<br />
Geneva, 2006.<br />
45. Yard, CR. Lost radiation sources: Raising public awareness about the<br />
hazards associated with industrial and medical radiography sources. J<br />
Environ Health 1996;58.<br />
Practical Exercise Statement<br />
Each module presentation contains one or more interactive audience response questions<br />
designed to drive discussion, promote participant engagement, and test knowledge. Through<br />
the use <strong>of</strong> the Meridia® Audience Response system, participant responses can be collected,<br />
tabulated, and displayed within the presentation in real time. In order to use the interactive<br />
slides accompanying this presentation, the lecture hall must be equipped with the Meridia®<br />
Audience Response system and user keypads. In addition, a copy <strong>of</strong> the “Meridia® Q&A”<br />
s<strong>of</strong>tware component <strong>for</strong> MS PowerPoint must be installed on the presenter’s computer.<br />
Assessment Strategy<br />
Participant progress toward course learning objectives is monitored through in<strong>for</strong>mal discussion<br />
and responses to each module’s practical exercise questions. Overall mastery <strong>of</strong> module<br />
content and concepts is documented by means <strong>of</strong> a comprehensive, end-<strong>of</strong>-day posttest<br />
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touching on key learning objectives from each module. Each participant must obtain a score <strong>of</strong><br />
80% or better to successfully complete the training and obtain a course completion certificate.<br />
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Module Seven<br />
Icon Map<br />
Knowledge Check: Used when it is time to assess the learners’ understanding<br />
Example: Used when there is a descriptive illustration to show or explain<br />
Key Points: Used to convey essential learning concepts, discussions and introduction <strong>of</strong><br />
supplemental material<br />
Hint: Used to cover administrative items or instructional tips that aid in the flow <strong>of</strong> the<br />
instruction<br />
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Slide 1<br />
This module presents the major potential scenarios involving the release <strong>of</strong> radiation by<br />
terrorists and reviews the basic fundamentals <strong>of</strong> radiation biology and concepts <strong>of</strong><br />
exposure, contamination and containment. Decontamination and treatment strategies<br />
are presented <strong>for</strong> managing victims <strong>of</strong> radiation exposure.<br />
While the science dealing with generation <strong>of</strong> energy sufficient to disrupt elements<br />
(ionizing radiation)and the release <strong>of</strong> radiation from radioactive isotopes (high-energy<br />
<strong>for</strong>ms <strong>of</strong> some elements) seems distant from medical toxicology (the science <strong>of</strong> human<br />
poisoning), there are many areas <strong>of</strong> overlap or similarity.<br />
The principles <strong>of</strong> dose response, specificity <strong>of</strong> effect (toxidromes), and the importance <strong>of</strong><br />
supportive care with appropriate use <strong>of</strong> antidotes during treatment are exactly the same<br />
in the evaluation <strong>of</strong> a terrorist event involving radiation or the typical industrial chemical<br />
release. In addition, the principles <strong>of</strong> risk communication are very important (perhaps <strong>of</strong><br />
primary importance) in most potential radiation terrorist events.<br />
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Slide 2<br />
The objectives <strong>for</strong> this presentation include:<br />
- Identify the settings where radioactive materials may be used or obtained <strong>for</strong> terrorist<br />
attacks<br />
- Describe five potential major terrorist scenarios involving radiation<br />
- Review key concepts including the clinical effects <strong>of</strong> the various types <strong>of</strong> radiation,<br />
such as alpha particles and gamma rays. Other key concepts include differentiation<br />
between radiation and radioactive materials, radiation contamination and incorporation,<br />
and how the human body manifests evidence <strong>of</strong> significant radiation poisoning.<br />
- Describe clinical response strategies including personal protection, decontamination,<br />
and antidotal therapy<br />
The most important concept to remember is that:<br />
1. we are all exposed to ionizing radiation daily<br />
2. exposure to ionizing radiation may cause injury in sufficient dose<br />
3. exposure to ionizing radiation does not make a person “radioactive”<br />
4. radioactive material on the skin is external contamination, while inhaled, ingested, or<br />
penetrating injuries with radioactive particles marks internal contamination or<br />
incorporation; assessment and treatment should address these differences and prevent<br />
any further internal contamination<br />
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Slide 3<br />
Nuclear (radioactive) materials are found in a number <strong>of</strong> locations, including:<br />
Irradiation facilities, used <strong>for</strong> treating food products and other materials<br />
Nuclear reactors used <strong>for</strong> generating power<br />
Materials testing devices such as those used to test metal frame (bridge) or pipeline<br />
integrity<br />
X-ray devices in healthcare settings<br />
isotope production facilities <strong>for</strong> use in many applications including in medicine/research.<br />
Other locations such as in-transit or junkyards or abandoned or transported material<br />
used in pre-regulatory days (pre-1960s) are in sites that we may not know about.<br />
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Slide 4<br />
There are an estimated 2 million devices in the USA contain licensed radioactive<br />
sources, but there is no comprehensive national inventory.<br />
Companies have reported losing track <strong>of</strong> almost 1700 sources since 1998. More than<br />
half have yet to be found. While some sources, such as those <strong>for</strong> irradiating food, are<br />
meters in size, others, such as those in industrial radiography cameras, are small,<br />
measuring only millimeters in size.<br />
In particular, some <strong>of</strong> these sources could become detached from their connections and<br />
be lost on a worksite or picked up by someone thinking it was a random piece <strong>of</strong> metal,<br />
leading to significant exposure, severe local tissue injury, and in some cases, death.<br />
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Slide 5<br />
We will briefly describe five major potential terrorist scenarios involving the use <strong>of</strong><br />
radiation. These scenarios include the:<br />
Surreptitious placement <strong>of</strong> a radiation source which would radiate those in proximity.<br />
Stealth dispersal <strong>of</strong> radioactive material which would spread exposure over a larger area<br />
Explosive radiation dispersal (“dirty bomb”) which, <strong>of</strong> course, would not be subtle – if<br />
radiation monitoring were conducted at every explosive event.<br />
Attack on a nuclear power plant, which would potentially release a large number <strong>of</strong><br />
fission products over a widespread area.<br />
Detonation <strong>of</strong> a nuclear weapon, which would make <strong>for</strong> a very bad day. While much <strong>of</strong><br />
the impact <strong>of</strong> such a release are outside the scope <strong>of</strong> toxicology, some <strong>of</strong> the<br />
management issues that incorporate dose and fallout (downwind drift <strong>of</strong> radioactive<br />
material from an explosive release) will be discussed.<br />
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Slide 6<br />
How would you know if someone placed a radioactive source in your vicinity<br />
As shown, some <strong>of</strong> these sources are very small – such as the source (usually Iridium-<br />
192) in the tips <strong>of</strong> these pigtail catheters, housed in shielded containers (known as<br />
“pigs”) shown at the top <strong>of</strong> the slide.<br />
These pigtails can become disconnected. They are unmarked and have been pocketed<br />
or carried about the worksite – resulting in severe local radiation tissue injury, and<br />
systemic poisoning, including death.<br />
Yet radiation is the easiest to detect <strong>of</strong> all <strong>of</strong> the terrorist weapons – if it is sought using a<br />
radiation detector.<br />
Of course, all agents (biologic, chemical, radiologic/nuclear) can also be identified by the<br />
toxidrome displayed once people become ill, but that can be non-specific and also takes time to<br />
develop.<br />
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Slide 7<br />
In this case, a nuclear medicine expert placed some illegally obtained iridium-192 above<br />
the ceiling tiles <strong>of</strong> his partner’s <strong>of</strong>fice, with whom he had had a dispute. Within days, the<br />
partner developed typical acute radiation sickness, as did seventy-four other hospital<br />
employees, be<strong>for</strong>e the surreptious placement <strong>of</strong> these sources was identified. Note the<br />
tiny size <strong>of</strong> iridium disks (2mm diameter) in the graphic. The perpetrator was arrested<br />
and sentenced to death.<br />
Slide 8<br />
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Turning to an example <strong>of</strong> the next potential scenario, the Goiânia Brazil tragedy is<br />
probably the best-known example <strong>of</strong> surreptitious (though unintentional) dispersal <strong>of</strong> a<br />
radioactive source in a community, although there have been other cases over the<br />
years.<br />
In 1987, a radiotherapy device was found in an abandoned clinic by a few young men.<br />
They broke it open and found a blue glowing powder, which, unknown to them, was<br />
Cesium-137. These individuals sold it to a junkyard dealer. He broke it fully open and<br />
brought the glowing object into his home, and gave some <strong>of</strong> the powder to friends and<br />
family. The young daughter <strong>of</strong> the dealer rubbed some <strong>of</strong> this glowing powder onto her<br />
face. Once several <strong>of</strong> them started to get sick, the connection to the source was<br />
suspected, and a large public health response began.<br />
Note that it took nearly 2 weeks from the time <strong>of</strong> initial Cesium dispersal to discovery <strong>of</strong><br />
the cause <strong>of</strong> illness in the affected individuals.<br />
Luminescence, or “blue glow” from the powder represents the presence <strong>of</strong> Tschenkov<br />
radiation. This occurs when high energy Beta particles released by the Cesium<br />
temporarily ionize water vapor molecules in the air. Some energy is released as visible<br />
blue light in the process.<br />
Lessons drawn from this accident in Brazil are still helping shape actions on radiation<br />
safety and security decades later. It was the worst accident involving a small radioactive<br />
source that the world has seen.<br />
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Slide 9<br />
There was widespread concern about potential environmental contamination because <strong>of</strong><br />
the delay in discovery <strong>of</strong> radiation poisoning, disruption <strong>of</strong> the shielding <strong>of</strong> the device,<br />
and potential run-<strong>of</strong>f from the area. In addition to environmental surveys, ~112,000<br />
people were surveyed <strong>for</strong> contamination by having them walk through radiation portal<br />
monitor in a soccer stadium. More detailed screening was done <strong>for</strong> those demonstrating<br />
contamination.<br />
Note that in almost half the contamination incidents (only 0.2% <strong>of</strong> those screened),<br />
contamination was confined to clothing. 46 people received chelation therapy with<br />
Prussian Blue (to bind cesium in the bowel), and 14 suffered bone marrow failure, a<br />
classic sign <strong>of</strong> radiation poisoning. 8 <strong>of</strong> these received GM-CSF. 4 died.<br />
One <strong>of</strong> the people who died included the daughter <strong>of</strong> the junk yard dealer.<br />
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Slide 10<br />
The next scenario involves incorporating a small amount <strong>of</strong> radioactive material (“dirty”)<br />
to a conventional explosive. This allows the dispersion <strong>of</strong> radiation over a fairly large<br />
area (typically in the range <strong>of</strong> thousands <strong>of</strong> square yards). Given the ready detectability<br />
<strong>of</strong> radiation, if monitoring is per<strong>for</strong>med, few individuals are likely to absorb a lethal dose<br />
be<strong>for</strong>e they can evacuate the area. Some may be impaled with contaminated shrapnel<br />
or inhale radioactive dust and develop radiation sickness (poisoning), but human<br />
casualties are likely to be low.<br />
A “dirty bomb” is one type <strong>of</strong> a “radiological dispersal device” (RDD) that combines a<br />
conventional explosive, such as dynamite, with radioactive material. Most RDDs would<br />
not release enough radiation to kill people or cause severe illness. The energy <strong>of</strong> a dirty<br />
bomb explosion is derived from the amount <strong>of</strong> conventional explosive used and is much,<br />
much less than that <strong>of</strong> a nuclear bomb; the energy <strong>of</strong> a nuclear bomb is derived from<br />
fission, releasing a number <strong>of</strong> fission products that are not present with a dirty bomb.<br />
There is no radioactive iodine generated by a dirty bomb – and thus no role <strong>for</strong> the <strong>of</strong>ten<br />
mischaracterized “anti-radiation pill” potassium iodide.<br />
Depending on the scenario, an RDD explosion could create fear and panic, contaminate<br />
property, and require potentially costly cleanup. A dirty bomb is not a “Weapon <strong>of</strong> Mass<br />
Destruction” but a “Weapon <strong>of</strong> Mass Disruption,” where contamination and anxiety are<br />
the terrorists’ major objectives.<br />
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Slide 11<br />
A deliberate attack on a nuclear power plant is a possibility <strong>of</strong> grave concern, particularly<br />
after September 11 2001, as questions about the ability <strong>of</strong> containment or control room<br />
structures to withstand an airliner crash were raised.<br />
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Slide 12<br />
On 26 April 1986, the most serious accident in the history <strong>of</strong> the nuclear industry<br />
occurred in the Chernobyl nuclear power plant in the <strong>for</strong>mer Ukrainian Republic <strong>of</strong> the<br />
Soviet Union. Explosions damaged the reactor vessel and the subsequent fire dispersed<br />
large amounts <strong>of</strong> radioactive materials into the environment (estimated at 400 times the<br />
fallout <strong>of</strong> the Hiroshima atomic bomb). Iodine and cesium were the major radionuclides<br />
released. Two people died in the initial steam explosion, but most deaths from the<br />
accident were attributed to radioactive fallout. Initially there were 134 victims <strong>of</strong> acute<br />
radiation poisoning, but several thousand cancer cases from radiation exposure<br />
(primarily thyroid cancer in young children) have occurred; more cancer cases and<br />
deaths are expected over the next few decades. Psychological effects have also been<br />
documented among the exposed population, attributed to both poor communication<br />
about risk and the social disruption in the region.The greatest deposition <strong>of</strong> radionuclides<br />
occurred over large areas <strong>of</strong> the Soviet Union surrounding the reactor in what are now<br />
the countries <strong>of</strong> Belarus (60% <strong>of</strong> fallout), the Russian Federation and Ukraine. Initial<br />
identification <strong>of</strong> the event actually came from a Swedish nuclear power plant radiation<br />
alarm 1000 miles away that detected the drifting radioactive fallout “cloud” from the<br />
event. Initial evacuation and potassium iodide treatment <strong>of</strong> downwind residents was also<br />
markedly delayed.<br />
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Slide 13<br />
Radiation is energy in the <strong>for</strong>m <strong>of</strong> electromagnetic waves or subatomic particles.<br />
Radiation is usually thought <strong>of</strong> as either rapidly propagating waves or individual particles<br />
emitted by the nucleus (or other component) <strong>of</strong> an atom as it changes from a higher<br />
energy state to a lower energy state.<br />
Radiation can be classified as ionizing or non-ionizing, depending on its effect on atomic<br />
matter. "Radiation" usually refers to ionizing radiation, which is radiation that has<br />
sufficient energy to ionize atoms or molecules; non-ionizing radiation does not.<br />
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Slide 14<br />
Ionizing radiation has sufficient energy to strip electrons <strong>of</strong>f <strong>of</strong> atoms. In biological<br />
systems this raises the potential <strong>for</strong> both acute and chronic effects.<br />
People are very concerned about ionizing radiation in large part related to its association<br />
with nuclear bombs and a limited understanding <strong>of</strong> what ionizing radiation can and<br />
cannot do. Furthermore, radiation is undetectable by our innate senses, though readily<br />
detected, unlike biological or chemical agents, with widely available equipment (e.g.<br />
Geiger-Mueller counter).<br />
The figure shows the electromagnetic spectrum, which depicts how radiation is broken<br />
into types according to the frequency (or wavelength) <strong>of</strong> the wave. These types, in order<br />
<strong>of</strong> increasing frequency (or decreasing wavelength) and increasing danger, include radio<br />
waves, microwaves, infrared radiation, visible light, ultraviolet radiation, X-rays and<br />
gamma rays. Of these, radio waves have the longest wavelengths and Gamma rays<br />
have the shortest. The visible spectrum includes the frequencies sensed by the eye and<br />
depicted by the color spectrum in the figure.<br />
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Slide 15<br />
Non-ionizing radiation refers to any type <strong>of</strong> radiation that does not carry enough energy<br />
to ionize atoms or molecules. These are represented in the electromagnetic spectrum by<br />
waves <strong>of</strong> longer wavelength (lower frequency).<br />
Examples include UV (ultraviolet) light, radio waves, microwaves, visible light. This does<br />
not mean that these <strong>for</strong>ms <strong>of</strong> radiation have no physical effects, but rather that they don’t<br />
produce their physical effects (e.g. activating cells in the retina to transmit signals<br />
interpreted by the brain as sight <strong>for</strong> the visible light spectrum) via the highly injurious<br />
method <strong>of</strong> ionization.<br />
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Slide 16<br />
In order to understand radiation, we need to briefly review the structure <strong>of</strong> matter. An<br />
atom consists <strong>of</strong> a nucleus, made up <strong>of</strong> protons (positively charged) and neutrons (no<br />
charge, neutral), surrounded by a cloud <strong>of</strong> rapidly moving electrons (negatively charged).<br />
Electrons are tiny compared to protons and neutrons, which are approximately the same<br />
size.<br />
The four basic types <strong>of</strong> ionizing radiation include:<br />
alpha particles are essentially helium nuclei (2 protons and 2 neutrons), ejected from the<br />
nucleus <strong>of</strong> a larger atom and moving with high energy. Following an alpha emission, the<br />
atom trans<strong>for</strong>ms from one element into another (since an element is defined by its<br />
number <strong>of</strong> protons, the atomic number).<br />
A beta particle is an electron that is ejected from the electron cloud around the nucleus.<br />
Gamma radiation is not particulate, but rather electromagnetic rays that are emitted from<br />
the nucleus. X-rays are similar to gamma rays, but have an origin outside the nucleus.<br />
Neutrons are uncharged particles ejected from the nucleus.<br />
Beta release, gamma ray, X-ray, or neutron release do not change the atom into another<br />
element.<br />
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Slide 17<br />
One way to differentiate the potential effects <strong>of</strong> external radiation is by their ability to<br />
penetrate the body.<br />
Alpha particles do not penetrate even the dead layer <strong>of</strong> skin and can be stopped by a<br />
thin layer <strong>of</strong> paper or clothing. However, if one ingests or inhales an alpha emitting<br />
radioactive material the radiation can cause damage to the tissue it is next to, such as<br />
the lung cells.<br />
Beta particles are only moderately penetrating, though energy varies by the element.<br />
Some beta radiation can penetrate human skin to the layer where new skin cells are<br />
produced. If beta emitting contaminants remain on the skin <strong>for</strong> a prolonged period <strong>of</strong><br />
time, they may cause skin injury resembling sunburn. They may also be harmful if<br />
deposited internally.<br />
Gamma rays and x-rays are able to travel into or through human tissue (thus the use <strong>of</strong><br />
x-rays in medical imaging). Lead is needed to stop these.<br />
Neutrons also penetrate most materials. They are able to travel many feet in concrete,<br />
yet may be stopped by large amounts <strong>of</strong> water. Neutrons are not likely to be<br />
encountered in dirty bomb events, but would be seen after a nuclear bomb detonation.<br />
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Slide 18<br />
It is important to differentiate between radiation and radioactive material. Radiation is the<br />
energy released from a source and is in the <strong>for</strong>m <strong>of</strong> waves or particles (i.e alpha, beta,<br />
gamma, or x-rays).<br />
Radioactive material is the substance that emits ionizing radiation. A radioisotope is a<br />
radioactive material that emits radiation.<br />
Differentiate that radiation sources may either be intrinsically radioactive and continually<br />
emit radiation (as with radioisotopes), or may be able to generate radiation on demand<br />
by an electric current releasing electrons (as from the tungsten filament in a hospital X-<br />
ray machine).<br />
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Slide 19<br />
A person may be exposed to radiation at a distance, particularly with X-rays and gamma<br />
rays. When that happens, the person has been irradiated and can suffer serious<br />
sequelae if the radiation dose absorbed by the body is sufficient.<br />
However, that person, if tested with a Geiger counter would not be emitting radiation;<br />
that is, the person would not be radioactive.<br />
Exposure to radiation equals irradiation. There is no residual radioactivity once the<br />
person leaves the exposure.<br />
This is different than having radioactive material on or in the body. This is contamination<br />
and is discussed next.<br />
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To become contaminated, radioactive material must get on a person’s skin or clothing,<br />
or inside the body. For example, people could become contaminated if they were near<br />
an explosion such as a ‘dirty bomb’.<br />
Radioactive material sitting on the clothes or skin is called external contamination.<br />
Simply removing the clothing and washing the hair and skin will remove the majority <strong>of</strong><br />
the contamination.<br />
Radioactive material inside the body is called internal contamination, and is more difficult<br />
to remove. If the radioisotope is taken up by tissue, it is said to be incorporated into the<br />
body. Medical therapy may be required to help clear this material.<br />
These patients are themselves giving <strong>of</strong>f radiation and require more caution than those<br />
who are simply irradiated.<br />
Washing the skin with a mild soap is generally recommended to decontaminate patients<br />
with external contamination.<br />
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Slide 21<br />
There are commonly used radiation terms to describe the energy released and its effect<br />
on the body. These terms and their derivation is somewhat complex; memorization is not<br />
required. Manhyy <strong>of</strong> the terms are based on important person in radiation science<br />
history, such as Marie Curie (who coined the term radioactivity and discovered radium<br />
and polonium). A general understanding is fine <strong>for</strong> most clinical needs.<br />
The activity <strong>of</strong> an isotope is the number <strong>of</strong> disintegrations that occur per second. A<br />
disintegration is what happens in the nucleus, causing the release <strong>of</strong> radiation. The more<br />
disintegrations per second, the more radioactive (all other things being equal). The units<br />
are the Curie or Becquerel.<br />
The amount <strong>of</strong> radiation deposited onto or into the person, or the dose, is measured in<br />
rads or Grays. But more importantly is the amount <strong>of</strong> biological damage done by that<br />
amound <strong>of</strong> absorbed radiation. This is measured in rem or Seivert, and is basically the<br />
deposited dose multiplied by a factor that differs based on the type <strong>of</strong> radiation (ie.,<br />
alpha vs beta vs gamma, etc).<br />
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Slide 22<br />
This slide shows some common examples <strong>of</strong> ionizing radiation exposures, including<br />
background levels coming from the sun, releases from rocks, food, and water that are<br />
experienced by everyone. Each year the average person is exposed to a dose <strong>of</strong> 360<br />
mrem <strong>of</strong> ionizing radiation (or about 1mrem/day). These amounts on a continuous basis<br />
or with single exposures, such as to an X-ray, can be compared with the amounts<br />
needed <strong>for</strong> a single exposure to cause acute radiation symptoms.<br />
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Slide 23<br />
The injuries that can be caused by or associated with exposure to large amounts <strong>of</strong><br />
radiation or radioactive materials are listed here. Acute radiation syndrome is the most<br />
consequential life threat, though each <strong>of</strong> the others results in significant physical and/or<br />
psychological concerns. Acute radiation syndrome generally follows whole body high<br />
dose irradiation. Localized radiation injuries are most commonly seen with a small<br />
gamma (or potentially beta) source in sustained contact with the body (such as being<br />
carried in a pocket). We will describe the increased sensitivity <strong>of</strong> the developing fetus to<br />
radiation in the setting <strong>of</strong> maternal exposure. .<br />
Contamination – and the importance <strong>of</strong> limiting internal contamination in the setting <strong>of</strong><br />
radiological materials or a “dirty bomb” explosion will be covered. Of course, significant<br />
trauma from shrapnel in this situation should always be considered; missed injuries will<br />
be <strong>of</strong> more problematic than a short delay in assessment <strong>of</strong> radiation injury.<br />
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Slide 24<br />
Many people have unrealistic perceptions <strong>of</strong> what radiation can do. This is related to our<br />
innate fear <strong>of</strong> what we do not understand – and are unable to see, as well as the media<br />
portrayal <strong>of</strong> radiation effects (as in Godzilla movies and comic books). Although the<br />
blast <strong>of</strong> a dirty bomb (or nuclear bomb) may kill, radiation itself does not cause<br />
immediate death or immediate burns or wounds. Instead, radiation exposure sets in<br />
motion a series <strong>of</strong> events in various body tissues that may ultimately lead to death in<br />
hours to days to years following exposure. These organ system effects will be described<br />
in the next several slides.<br />
While radiation exposure and/or contamination with radioactive material should be<br />
addressed in the early management <strong>of</strong> a patient, there is absolutely no risk to healthcare<br />
providers who are treating a patient who has been irradiated. A few simple procedures<br />
reduce healthcare worker exposure when caring <strong>for</strong> contaminated patients. Treat the<br />
patient first!<br />
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Slide 25<br />
Radiation sickness, known as acute radiation syndrome (ARS), is a serious illness that<br />
occurs when the entire body (or most <strong>of</strong> it) receives a high dose <strong>of</strong> radiation, usually over<br />
a short period <strong>of</strong> time. ARS generally requires a whole body exposure to a type <strong>of</strong><br />
radiation that passes the skin, such as gamma; or is delivered directly to the entire body,<br />
as with inhalation or ingestion <strong>of</strong> a large quantity <strong>of</strong> alpha particles.<br />
Radiation sickness, known as acute radiation syndrome (ARS), is a serious illness<br />
resulting from a total body dose <strong>of</strong> radiation over a short period <strong>of</strong> time. As examples,<br />
many survivors <strong>of</strong> the Hiroshima and Nagasaki atomic bombs in the 1940s and many <strong>of</strong><br />
the firefighters who first responded after the Chernobyl Nuclear Power Plant accident in<br />
1986 became ill with ARS.<br />
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Slide 26<br />
This chart shows the time course <strong>of</strong> ARS. The higher the dose, the shorter the time to<br />
symptom onset and the more severe the symptoms. Radiation symptoms follow a typical<br />
pattern (toxidrome). Typically, the first symptoms <strong>of</strong> ARS are nausea, vomiting, and<br />
diarrhea. The delay to onset is very important in predicting the dose. Symptom onsets <<br />
1 hour after exposure indicates a large radiation dose. Lower doses are associated with<br />
delays up to 48 hours. These symptoms will last <strong>for</strong> hours up to several days, and may<br />
come and go. Many <strong>of</strong> the initial signs and symptoms <strong>of</strong> radiation illness are<br />
nonspecific, and could be misdiagnosed as a viral syndrome, or gastroenteritis. The<br />
person may improve (particularly with supportive treatment) during what is termed the<br />
latent stage, after which he or she may become sick again with fatigue, fever from<br />
infection due to bone marrow toxicity (which also causes thrombocytopenia), recurrent<br />
gastrointestinal symptoms, and even seizures and coma in very high dose exposures.<br />
This seriously ill stage may last from a few hours up to several months with lower doses.<br />
Recovery depends on the dose and can be improved with advanced medical care.<br />
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Slide 27<br />
Dosimetry is a method to gauge the severity <strong>of</strong> radiation exposure. Based on the specific<br />
syndrome that develops, the clinician and health physicist can determine the dose range<br />
to which a patient was exposed. In general, the higher the dose, the greater the severity<br />
<strong>of</strong> early effects and the greater the possibility <strong>of</strong> life threatening effects. Each <strong>of</strong> these<br />
syndromes represents an increasing exposure to radiation and carries a greater risk <strong>of</strong><br />
adverse or fatal outcomes. We will discuss a few <strong>of</strong> them in more detail.<br />
1. Subclinical – while tissue damage may occur, no overt symptoms are expected and the body<br />
should be able to repair damage that has been done.<br />
2. Hematopoietic syndrome - characterized by bone marrow dysfunction with decreased<br />
lymphocyte, polymorphonuclear (PMN) white blood cells, and platelets, resulting in immunodeficiency,<br />
increased infectious complications, bleeding, anemia, and impaired wound healing.<br />
3. Cutaneous (Skin) syndrome - can occur with other syndromes; characterized by loss <strong>of</strong><br />
epidermis (and possibly dermis) with "radiation burns."<br />
4. Gastrointestinal syndrome - characterized by loss <strong>of</strong> cells lining intestinal crypts and loss <strong>of</strong><br />
mucosal barrier, with alterations in intestinal motility, fluid and electrolyte loss with vomiting and<br />
diarrhea, loss <strong>of</strong> normal intestinal bacteria, sepsis, and damage to the intestinal microcirculation,<br />
along with the hematopoietic syndrome.<br />
5. Cerebrovascular/Central Nervous System (CNS) syndrome - primarily associated with effects<br />
on the vasculature and resultant fluid shifts. Signs and symptoms include vomiting and diarrhea<br />
within minutes <strong>of</strong> exposure, confusion, disorientation, cerebral edema, hypotension, and<br />
hyperpyrexia. Requires massive exposure and is fatal in short time.<br />
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Slide 28<br />
The hematopoietic syndrome (Bone marrow syndrome) will usually predominate with a<br />
dose between 1 and 5 Gy (100 – 500 rads) though mild symptoms may occur as low as<br />
0.3 Gy or 30 rads. Irradiation <strong>of</strong> the bone marrow results in a fall in lymphocytes,<br />
although some <strong>of</strong> the early fall in lymphocyte count (the first 2 days) is related to<br />
migration <strong>of</strong> lymphocytes out <strong>of</strong> the bloodstream in response to tissue injury. The degree<br />
and rate <strong>of</strong> fall serve as markers <strong>for</strong> the extent <strong>of</strong> exposure. Serial measurement <strong>of</strong> the<br />
lymphocyte count can be used prognostically. The survival rate <strong>of</strong> patients with this<br />
syndrome decreases with increasing dose. The primary cause <strong>of</strong> death is infection (no<br />
white blood cells) and hemorrhage (no platelets).<br />
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Slide 29<br />
The clinical syndromes associated with a predominance <strong>of</strong> early onset <strong>of</strong> vomiting<br />
(gastrointestinal or GI syndrome) or early confusion, seizures or coma (central nervous<br />
system or CNS syndrome) indicate larger radiation doses and suggest a poor prognosis.<br />
Exposure above 6 Gray makes survival unlikely; this is approximately the same dose<br />
that causes the GI syndrome.<br />
Patients with early onset nausea and vomiting may die within the week <strong>of</strong> hemorrhagic diarrhea,<br />
or may survive to die within several weeks <strong>of</strong> bone marrow failure- related infection.<br />
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Slide 30<br />
The diagnosis <strong>of</strong> Acute Radiation Syndrome requires a history <strong>of</strong> possible radiation<br />
exposure, in<strong>for</strong>mation about the onset <strong>of</strong> early symptoms (nausea and vomiting) and<br />
serial complete blood counts (CBC) looking at the absolute lymphocyte count.<br />
In the setting <strong>of</strong> an earlier occult radiation exposure, the diagnosis is more difficult.<br />
However, similar to the situation described with heavy metal poisoning in the Delayed<br />
Onset Toxin Module, a history <strong>of</strong> preceding gastrointestinal symptoms should be sought<br />
in patients who present with skin changes, hair loss, or patterns <strong>of</strong> blood cell line<br />
deficiencies that may suggest radiation as a potential cause.<br />
The onset time <strong>of</strong> signs and symptoms (in particular vomiting and diarrhea) following<br />
exposure correlates with the severity <strong>of</strong> exposure (more rapid onset equals larger<br />
radiation dose) and with the prognosis (more rapid onset equals worse outcome).<br />
The CBC is an assessment <strong>of</strong> the white blood cell (WBC), red blood cell, and platelet<br />
count. The diff, or differential count, is a slightly advanced analysis that looks at the<br />
types <strong>of</strong> white blood cells present. The WBC type <strong>of</strong> most importance is the lymphocyte<br />
(other types <strong>of</strong> WBCs are the neutrophils, monocytes, and eosinophils – which are not<br />
as sensitive to radiation effects as are the lymphocytes). Lymphocytes will drop quickly,<br />
followed by neutrophils, platelets, then red blood cells.<br />
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Slide 31<br />
There are several algorithms that can be used to guide management and treatment<br />
decisions based on likely radiation dose received. One example is shown here where<br />
time to onset <strong>of</strong> vomiting is correlated with radiation dose. However, note that not all<br />
people will vomit, particularly at lower doses. In these situations it is helpful to have<br />
additional measurements, such as the lymphocyte depletion rate shown on the next<br />
slide.<br />
The need <strong>for</strong> early specialized care is to optimize chances <strong>for</strong> survival, which will entail<br />
strict attention to fluid and electrolyte balance, early operative care if indicated,<br />
preparation <strong>for</strong> neutropenia and use <strong>of</strong> reverse isolation procedures and specialized<br />
medications to increase bone marrow response (cytokines). The National Library <strong>of</strong><br />
Medicine site has an interactive algorithm that is very useful.<br />
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Slide 32<br />
The Andrews nomogram depicts early lymphocyte depletion following radiation exposure<br />
and can also be used to estimate dose (exposure to radiation). The lymphocyte count is<br />
derived from the complete blood count mentioned in a prior slide.<br />
The left axis is the lymphocyte count, and the bottom axis is the time since exposure.<br />
The green lines represent dose estimates which relates on the right to prognosis. The<br />
more rapid the lymphocyte fall (depletion), the higher the likely radiation dose; and the<br />
more severe the ensuing clinical course.<br />
A fall <strong>of</strong> the lymphocyte count below 1000 cells/milliliter <strong>of</strong> blood within 24 hours after<br />
exposure suggests a dose over 6 Gy and a very severe course, while a drop below 1000<br />
cells/ml within 12 hours may indicate a lethal exposure <strong>of</strong> over 8 Gy range. .<br />
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Slide 33<br />
Localized radiation injury occurs when one part <strong>of</strong> the body receives a high dose <strong>of</strong><br />
radiation. It can accompany the acute radiation syndrome (ARS) or occur in isolation. As<br />
with all radiation exposure, diagnosis is difficult without a good history <strong>of</strong> exposure. The<br />
cables (shown previously) contain radiation sources <strong>for</strong> use in a number <strong>of</strong> devices, such<br />
as assessing structural integrity <strong>of</strong> a weld.<br />
Inadvertent pocketing <strong>of</strong> items such as these can lead to severe local injury.<br />
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Slide 34<br />
Localized radiation injury can also occur with therapeutic radiation <strong>for</strong> cancer treatment,<br />
although this is minimized by fractionated treatment and the use <strong>of</strong> multiple radiation<br />
“windows” and shielding.<br />
Findings are related to dose and generally follow a more severe course as the dose<br />
increases. For example 300 rads or 0.3 Gy will result in localized hair loss after a couple<br />
weeks, while doses above 1000 rads or 1 Gy will damage deeper skin structures,<br />
leading to tissue loss, and the possibility <strong>of</strong> poor wound healing. .<br />
Lesions may not appear <strong>for</strong> days or weeks, particularly with relatively low doses.<br />
The procedures used in radiation therapy units include targeting a tumor via multiple<br />
angles (windows), delivering the total dose over a period <strong>of</strong> daily treatments over weeks<br />
(fractional), and shielding uninvolved areas <strong>of</strong> the body.<br />
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Slide 35<br />
In the absence <strong>of</strong> a history <strong>of</strong> exposure to a gamma source (such as the iridium-192<br />
containing radiography sources shown), the picture on the left could be <strong>of</strong> a wound from<br />
a variety <strong>of</strong> causes (including a traumatic injury, insect bite, or bacterial or fungal<br />
infection). This small wound, shown on the left, with significant surrounding redness<br />
(erythema) and swelling (edema) eventually became a significant ulceration (shown on<br />
the right).<br />
Radiation experts can use the eventual amount <strong>of</strong> tissue injury to calculate an<br />
approximate radiation dose (retrospective dosimetry). Alternatively, a known time <strong>of</strong><br />
exposure to a known source can be used to develop a prediction <strong>of</strong> the likely extent <strong>of</strong><br />
injury <strong>for</strong> prospective wound and surgical planning purposes.<br />
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Slide 36<br />
Treatment <strong>for</strong> local radiation injury includes providing <strong>for</strong> the patients com<strong>for</strong>t with<br />
adequate pain control. They should avoid nicotine, which reduces blood flow to the skin.<br />
It is critical to prevent or rapidly treat infections that develop. Surgery to debride<br />
devitalized/dead tissue will help prevent infection, but the remaining tissue heals slowly<br />
and poorly. Hyperbaric oxygen therapy may have a role in improving blood vessel<br />
migration into this damaged tissue.The image shows the chronic wound that can follow<br />
localized radiation injuries.<br />
Erythema and dry desquamation can be treated symptomatically. Lotions or sprays<br />
containing hydrocortisone can be used to relieve the symptoms associated with severe<br />
erythema accompanied by edema. To treat moist desquamation, daily dressings and<br />
bathing <strong>of</strong> the affected skin in antiseptic solutions is helpful. Antibiotic creams can also<br />
be used.<br />
For ulceration, moist dressings and daily cleansing is recommended. Systemic<br />
antibiotics should be utilized <strong>for</strong> verified secondary infection. Surgical debridement can<br />
be problematic because <strong>of</strong> the poor vascularization and integrity <strong>of</strong> the surrounding<br />
tissue. Hyperbaric oxygen treatment has been demonstrated to improve new blood<br />
vessel growth and stem cell recruitment to ischemic tissue. It should be considered prior<br />
to and after surgical interventions. Opioid analgesics may be necessary <strong>for</strong> prolonged<br />
periods as this chronic wound heals..<br />
The image depicts an individual with an estimated >20 Gy exposure from repeated<br />
fluoroscopy exposures to X-rays during a complicated series <strong>of</strong> angiography procedures<br />
on one day. Some erythema developed about 1 month later with desquamation the<br />
following week. About 4-5 months after exposure, the area began to ulcerate, with the<br />
extensive ulceration seen here at 1½ years after exposure. He eventually underwent<br />
skin grafting.<br />
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Slide 37<br />
Although the fetus receives a lower radiation dose than does the mother from external<br />
sources (because <strong>of</strong> the womb and other overlying maternal tissues, fetal health<br />
consequences can be severe, even at radiation doses too low to immediately affect the<br />
mother.<br />
The human embryo and fetus are particularly sensitive to ionizing radiation because <strong>of</strong><br />
their high rate <strong>of</strong> cell division (mitosis).<br />
Consequences can include growth retardation, mal<strong>for</strong>mations, impaired brain function,<br />
and cancer. Effects vary greatly based on gestational age and dose.<br />
Pregnant women should consult with their physicians if they have any concern about<br />
radiation exposure to their unborn baby. Physicians can find helpful in<strong>for</strong>mation at the<br />
CDC’s Bioterrorism website, and in consultation with radiation experts.<br />
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Slide 38<br />
Even during a radiological incident, medical triage is the highest priority. Radiation<br />
symptoms occurring in the first 24 hours after a total or partial body exposure are seldom<br />
life-threatening; there<strong>for</strong>e, all critical medical and traumatic issues should be addressed<br />
first. As long as it is safe and practical to do so, stabilization should take priority over<br />
decontamination.<br />
Examples <strong>of</strong> traumatic and medical issues include bleeding, injuries from shrapnel, blast<br />
effects, collapsed lung (pneumothorax), dirty wounds, or medical complaints <strong>of</strong> chest<br />
pain and difficulty breathing.<br />
Time, distance and shielding are the most important determinants <strong>of</strong> radiation exposure<br />
dose. These should be considerations during the initial triage, decontamination, and<br />
management <strong>of</strong> patients contaminated with radioactive material, but does not have any<br />
relevance <strong>for</strong> those who have been irradiated only.<br />
The photo depicts an assessment <strong>for</strong> potential extremity injuries as part <strong>of</strong> the initial<br />
patient evaluation/stabilization. Note that the provider is cutting the clothing in a direction<br />
away from the patient’s airway and is folding the potentially radioactive materialcontaminated<br />
portion outwards to keep any contamination <strong>of</strong>f the patient’s skin. As will<br />
be discussed later, another individual could be doing a radiation survey <strong>for</strong> potential<br />
radioactive contamination.<br />
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Slide 39<br />
As an example <strong>of</strong> the low likelihood <strong>of</strong> medical personnel being secondarily<br />
contaminated, the decontamination process <strong>for</strong> workers at Chernobyl who were in the<br />
reactor area at the time <strong>of</strong> the nuclear accident resulted in less than 10 mGy (1 rad) <strong>of</strong><br />
radiation exposure to the members <strong>of</strong> the medical team. This is equivalent to the<br />
radiation <strong>of</strong> one CT scan <strong>of</strong> the pelvis.<br />
In April, 1986 the Chernobyl nuclear power plant in the Ukraine had an event that<br />
contaminated a broad region and exposed thousands <strong>of</strong> people. By far, the most highly<br />
exposed and contaminated people were the fireman who first responded to the event<br />
and attempted to put out the fire. Many <strong>of</strong> these men suffered from Acute Radiation<br />
Syndrome and all were highly contaminated.<br />
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Slide 40<br />
Hospital staff are well versed in protecting themselves and their work areas from<br />
microbiological contamination through the use <strong>of</strong> standard precautions. The same<br />
techniques can be used effectively to protect personnel and the work area from<br />
contamination by radioactive materials. While fitted particulate respirators such as N95<br />
or higher will provide a higher level <strong>of</strong> protection against potential inhalation <strong>of</strong><br />
radioactive particulates, a surgical mask is usually adequate protection unless there is<br />
concern <strong>of</strong> alpha particle contamination.<br />
Frequent use <strong>of</strong> a radiation survey meter (Geiger counter) by a dedicated staff person<br />
(usually the Radiation Safety Officer or designee) can alert personnel to areas <strong>of</strong><br />
contamination, adequacy <strong>of</strong> decontamination, and the need to change their gloves or<br />
clothing when workers become contaminated, and to avoid spread <strong>of</strong> radioactive<br />
contamination in or outside the work area so that cleanup and extra precautions can be<br />
implemented. Such ease <strong>of</strong> detection and control is not possible with any other type <strong>of</strong><br />
hazardous material.<br />
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Slide 41<br />
A special treatment area layout should be established within existing emergency<br />
treatment areas to minimize the spread <strong>of</strong> any radioactive contamination. The major<br />
features <strong>of</strong> this layout are depicted in the slide and consist <strong>of</strong> a single point <strong>of</strong> egress (via<br />
the “step <strong>of</strong>f pad”) separate from the room entrance that allows monitoring <strong>of</strong> personnel<br />
or equipment <strong>for</strong> contamination by radiation survey personnel, and a separate individual<br />
in the treatment area to survey the patient, his/her wounds, and the patient<br />
decontamination process.<br />
The contaminated area (thought <strong>of</strong> as the “hot zone”) is separated from the remainder <strong>of</strong><br />
the department (the clean area or “cold zone”) by a buffer zone (warm zone). Exiting<br />
personnel are monitored <strong>for</strong> contamination (while still on the step <strong>of</strong>f pad) and<br />
contaminated gloves, shoes, coveralls, or other materials can be placed in receptacles<br />
set aside <strong>for</strong> them be<strong>for</strong>e stepping <strong>of</strong>f the pad. At that point, a whole body survey is<br />
conducted with a radiation meter, taking special note <strong>of</strong> hands, feet and face.<br />
Other modifications to “standard precautions” that are appropriate <strong>for</strong> the management<br />
<strong>of</strong> patients contaminated with radioactive material are reviewed in the next few slides.<br />
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Slide 42<br />
Carefully remove and bag patient’s clothing and personal belongings, which typically<br />
removes 80 - 90% <strong>of</strong> contamination. These should be put in a double bag, tied, sealed<br />
and labeled. Unfamiliar embedded objects in patient’s clothing or wounds may be<br />
radioactive sources. Handle these objects with long <strong>for</strong>ceps, handle only briefly, and<br />
keep distant from staff and patients until proven, with a survey meter, not to be<br />
radioactive. If radioactive objects are recovered, they should be placed in a container<br />
using tongs or <strong>for</strong>ceps.<br />
Survey the patient <strong>for</strong> contamination after clothing removal, using a consistent pattern to<br />
provide a complete survey.<br />
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Slide 43<br />
Decontaminate patients with several gentle ef<strong>for</strong>ts, rather than with a single aggressive<br />
ef<strong>for</strong>t. Soap and water are sufficient.<br />
Remove contaminated hair if necessary, using scissors or electric clippers. To avoid<br />
cutting the skin and providing an entry <strong>for</strong> internal contamination, do not shave.<br />
Use occlusive dressings to promote sweating and removal <strong>of</strong> persistent contamination<br />
from pores.<br />
Survey areas with a Geiger counter frequently until decontamination is complete.<br />
Once clothing is removed, decontamination should begin with any open wounds as there<br />
is greater chance <strong>of</strong> internal contamination from these. A face shield should be placed<br />
over the patient’s lower face to prevent splashing or movement <strong>of</strong> radioactive material<br />
towards the mouth and nose (to prevent ingestion/inhalation).<br />
If localized contamination persists after washing, cover the area with gauze and put a<br />
glove or tape plastic over the area to promote sweating as this may remove additional<br />
material from pores.<br />
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Slide 44<br />
In a radiation contamination event, any wound must be considered contaminated until<br />
proven otherwise and should be decontaminated prior to decontaminating intact skin.<br />
Protection <strong>of</strong> non-contaminated wounds with waterpro<strong>of</strong> dressings will minimize the<br />
potential <strong>for</strong> uptake <strong>of</strong> radioactive material. To decontaminate wounds, irrigate and<br />
gently scrub with a surgical sponge. Normal wound debridement should be per<strong>for</strong>med.<br />
Excision around wounds solely to remove contamination should only be per<strong>for</strong>med in<br />
extreme cases.<br />
Placement <strong>of</strong> gauze within a wound or over a denuded area will remove additional<br />
contamination.<br />
When wounds are contaminated, the physician must assume that incorporation (internal<br />
contamination) has occurred. Appropriate action is based on both radioactive and<br />
biologic half-life, radiotoxicity (type <strong>of</strong> radiation), and the amount <strong>of</strong> radioactive material.<br />
It is important to consult experts as soon as possible and to initiate measures that<br />
prevent or minimize uptake <strong>of</strong> the radioactive material into body cells or tissues.<br />
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Slide 45<br />
Radioactive material can sometimes enter the body through inhalation, ingestion, or a<br />
dermal wound. Deposition <strong>of</strong> radioactive materials in the body is a time-dependent<br />
physiological phenomenon related to both the physical and chemical natures <strong>of</strong> the<br />
contaminant.<br />
Internal contamination does not cause early signs or symptoms.<br />
While it remains inside the patient internal contamination will continue to irradiate the<br />
patient, though probably not harm others.<br />
Swabs <strong>of</strong> the nares should be assessed <strong>for</strong> radioactivity by the survey team. If internal<br />
contamination is suspected, arrange <strong>for</strong> additional bioassays <strong>of</strong> the patient. These could<br />
include analysis <strong>of</strong> blood, urine, feces, perspiration, nasal and saliva swabs, sputum,<br />
vomitus, and wound secretions, and will vary somewhat based on the particular<br />
radioactive isotopes.<br />
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Slide 46<br />
There are certain specific medical therapies <strong>for</strong> the treatment <strong>of</strong> patients with internal<br />
contamination with radioisotopes. We will look at a couple <strong>of</strong> these in more detail.<br />
It is important to remember that removal <strong>of</strong> the element from the body also removes the<br />
radiation – and the biologic half-life <strong>of</strong> many elements is <strong>of</strong>ten shorter than the radiologic<br />
half-life <strong>of</strong> their radioactive <strong>for</strong>ms.<br />
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Slide 47<br />
Prussian Blue (Radiogardase) is an FDA-approved treatment <strong>for</strong> victims <strong>of</strong> a “dirty<br />
bomb” who are internally contaminated with radioactive Cesium or Thallium. This<br />
chelator <strong>for</strong>ms high affinity, nonabsorbable complexes with cesium and thallium.<br />
After oral administration, this compound decreases gastrointestinal absorption <strong>of</strong> Cs and<br />
Th. It also interrupts the recycling <strong>of</strong> these compounds from the systemic circulation<br />
through the bile and back into the gut. This increases the elimination <strong>of</strong> the radioactive<br />
elements from the body in the feces.<br />
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Slide 48<br />
Another chelating agent is DTPA, which is generally given IV. It is used to bind larger<br />
radioactive elements such as plutonium. There are two <strong>for</strong>ms <strong>of</strong> DTPA, one complexed<br />
with calcium, the other with zinc. Calcium DTPA is more effective in the first 24 hours<br />
after exposure, but Zn-DTPA is recommended <strong>for</strong> delayed or ongoing therapy. These<br />
agents exchange the calcium or zinc <strong>for</strong> the plutonium or other transuranic element<br />
(curium, americium) and the complex is excreted by the kidney in the urine.<br />
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Slide 49<br />
Going back to the initial management <strong>of</strong> an exposed patient:<br />
Triage should identify acute medical and surgical issues; these will take priority in patient<br />
care.<br />
The setting <strong>of</strong> exposure should be identified, as well as the nature and timing <strong>of</strong> any<br />
symptoms (primarily onset <strong>of</strong> nausea/vomiting) to assess <strong>for</strong> the likelihood and<br />
prognosis <strong>of</strong> acute radiation syndrome, localized radiation injury, or a combination <strong>of</strong><br />
effects.<br />
Early involvement <strong>of</strong> a radiation safety <strong>of</strong>ficer is important <strong>for</strong> dose assessment and to<br />
provide in<strong>for</strong>mation that will guide subsequent radiation-related therapy<br />
These patients will be scared, particularly since most will be relatively well on initial<br />
presentation, unless injured by shrapnel or other trauma.<br />
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Slide 50<br />
Given the infrequency <strong>of</strong> radiation exposure in modern healthcare, consultation with<br />
experts is very important. The radiation safety <strong>of</strong>ficer or health physicist can aid in<br />
identifying radioactivity and the extent <strong>of</strong> contamination, as well as in the safe disposal <strong>of</strong><br />
radioactive waste. These experts can also help guide the specimen collection and<br />
interpretation <strong>of</strong> symptoms and laboratory findings from irradiated or radioactivelycontaminated<br />
patients.<br />
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Slide 51<br />
On November 1, 2006, <strong>for</strong>mer Russian spy Alexander Litvinenko suddenly fell ill and<br />
was hospitalized. He died three weeks later, becoming the first known victim <strong>of</strong> lethal<br />
polonium-210-induced acute radiation syndrome. Traces <strong>of</strong> polonium were found in his<br />
urine, at his home, and at a London restaurant and hotel he visited the day he became<br />
ill, and traces were found elsewhere, suggesting involvement <strong>of</strong> Russian agents.<br />
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Slide 52<br />
Polonium-210 is an alpha-emitter, but its particle is <strong>of</strong> particularly high-energy. Polonium-<br />
210 gives <strong>of</strong>f 5,000 times more alpha particles than does the same amount <strong>of</strong> radium,<br />
another alpha-emitting radioisotope.<br />
Polonium’s high energy alpha particles can severely damage genetic material (DNA) if<br />
able to reach it. Since alpha particles only penetrate short distances, polonium is only<br />
harmful to humans through inhalation, ingestion, or contact with open wounds.<br />
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Litvinenko stated that he met with two <strong>for</strong>mer KGB agents (one <strong>of</strong> whom is an Italian<br />
security expert) early on the day he fell ill with abdominal pain, nausea, vomiting, and<br />
diarrhea; and was hospitalized. A British toxicologist suggests thallium poisoning, which<br />
is not an unreasonable thought early on. However the subsequent clinical course was<br />
not consistent with thallium.<br />
In addition to the claims and counter-claims made by many people, this murder has an<br />
important clue – the traceable alpha-emitter polonium-210, which has a radiologic halflife<br />
<strong>of</strong> 138 days. Thus the path <strong>of</strong> this radioisotope remains <strong>for</strong> many months.<br />
Alexander Litvinenko died November 23, 2006, just over 3 weeks post-exposure.<br />
Slide 54<br />
It is commonly said in medicine that the history makes the diagnosis. In these cases the<br />
key historic feature is identifying a possible radiation exposure. Some possible scenarios<br />
include:<br />
- Finding an unknown metallic object, as we saw in the Goiania Brazil event.<br />
- A history <strong>of</strong> working with radioactive chemicals, such as fluorescence spectroscopy,<br />
industrial radiography, etc; or working in a potential site <strong>for</strong> exposure, such as<br />
construction or a scrap metal yard.<br />
- Multiple people falling ill simultaneously with gastrointestinal effects, particularly with<br />
suggestive subsequent physical exam findings (such as skin lesions)<br />
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Slide 55<br />
To review, some clues identifiable during the physical examination or routine laboratory<br />
testing may also suggest radiation injury:<br />
- Skin ulceration, skin peeling (desquamation), skin redness (erythema), loss <strong>of</strong> hair or<br />
abnormal sweating <strong>of</strong> an area <strong>of</strong> skin which can be seen with exposure to beta-emitters<br />
or localized injury from gamma or X-rays (<strong>of</strong>ten in association with findings <strong>of</strong> acute<br />
radiation syndrome[ARS], such as):<br />
- Unexplained infections or bleeding, particularly in the gums or gastrointestinal tract<br />
usually seen a week or more into an episode <strong>of</strong> ARS.<br />
- Weight loss, diarrhea, fluid or electrolyte imbalance, kidney failure; all as a component<br />
<strong>of</strong> the multi-organ failure associated with severe ARS.<br />
- Shock, connfusion, disorientation, brain edema, loss <strong>of</strong> coordination (ataxia), seizures,<br />
or coma (1-2 days after a massive radiation exposure).<br />
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Slide 56<br />
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Slide 57<br />
The key points made in this presentation include:<br />
Stabilization is the highest priority. Patients die <strong>of</strong> their injuries much faster than they do<br />
from radiation poisoning.<br />
Radiation experts should be consulted liberally given the relatively uncommon<br />
opportunity <strong>for</strong> any individual clinician to care <strong>for</strong> an exposed patient.<br />
Training and drills should be <strong>of</strong>fered <strong>for</strong> all <strong>for</strong>ms <strong>of</strong> hazard response.<br />
Adequate supplies and survey instruments should be stocked, and they should be<br />
accessible and in working order.<br />
Standard precautions reduce contamination <strong>of</strong> the healthcare provider.<br />
Early symptoms and their intensity indicate the severity <strong>of</strong> the radiation injury. These<br />
should be inquired about, observed, and recorded.<br />
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Slide 58<br />
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Training Support Package<br />
Participant Guide<br />
Module Seven Summary<br />
Radiation is an especially powerful terrorism weapon because it instills considerable fear.<br />
Terrorist acts or threats involving radioactive materials are broadly categorized into radiologic<br />
events, which involve the non-nuclear release <strong>of</strong> radioactive materials, and nuclear events<br />
involving nuclear weapons. There are four major radiologic terrorist scenarios including, as<br />
examples, radiation sources intentionally hidden in public places or dispersed widely in<br />
communities; radiologic dispersion devices (RDDs or dirty bombs); attacks on nuclear facilities<br />
or radioactive materials in transit on trucks and trains that result in intentional release <strong>of</strong><br />
radioactive materials.<br />
RDD employs conventional explosives to disperse radioactive materials. RDD events may result<br />
in physical injuries, variable radiation contamination, and psychological trauma to a population.<br />
The severity <strong>of</strong> physical injuries depends on the nature <strong>of</strong> the explosives used, and the extent <strong>of</strong><br />
contamination depends on the degree to which the radioactive material is dispersed. Dispersal<br />
is dependent on the physical and chemical <strong>for</strong>m <strong>of</strong> the radioactive material, the explosives, and<br />
the atmospheric conditions.<br />
Certain radioisotopes used in industrial and medical devices could be positioned to cause<br />
serious exposure to an unsuspecting population. An estimated 2 million devices in the USA<br />
contain licensed radioactive sources, but there is no comprehensive national inventory tracking<br />
these industrial sources <strong>of</strong> radiation. Companies have reported losing track <strong>of</strong> almost 1700<br />
sources since 1998. More than half have yet to be found.<br />
Radiation injury occurs through ionization <strong>of</strong> water molecules leading to the production <strong>of</strong> free<br />
radicals, which directly cause organelle and cellular damage. Ionization can also break covalent<br />
bonds in macromolecules such as proteins and DNA and lead to changes in the biologic or<br />
chemical function, particularly when cellular repair mechanisms are ineffective. In acute injury,<br />
the risk <strong>of</strong> cellular damage is proportional to the total absorbed dose, becoming clinically<br />
apparent in organ malfunction or failure when significant numbers <strong>of</strong> cells have been damaged.<br />
Rapidly dividing cells, such as intestinal mucosal cells and blood-producing cells, are the most<br />
susceptible.<br />
Unlike thermal burns, where tissue injury is quickly apparent, cutaneous radiation injuries (CRI)<br />
findings are delayed. Early signs and symptoms (within hours) include itching, tingling, and<br />
transient skin reddening or swelling. This is followed by a symptom-free latent period <strong>of</strong> days to<br />
weeks, and then, depending on the dose, by intense skin reddening, blistering, peeling, and<br />
ulceration that may occur in several waves. In cases <strong>of</strong> high-dose exposures, irreversible tissue<br />
damage may occur and result in permanent hair loss, damaged sebaceous and sweat glands,<br />
tissue atrophy and fibrosis, alterations in skin pigmentation, and tissue necrosis.<br />
When acute whole-body exposure to high doses <strong>of</strong> penetrating radiation occurs, acute radiation<br />
syndrome (ARS) may result. ARS is the manifestation <strong>of</strong> radiation induced cellular death and<br />
deficiency in hematopoietic, gastrointestinal, and neurovascular tissue. Damage to these tissues<br />
results in clinical presentations termed the hematopoietic, gastrointestinal, and neurovascular<br />
(or central nervous system) syndrome, respectively.<br />
ARS occurs only above a threshold dose <strong>of</strong> about 0.7 Gy <strong>of</strong> penetrating radiation. With<br />
increasing doses, onset <strong>of</strong> the syndrome is more rapid, and the ARS is more severe and<br />
includes an increasing number <strong>of</strong> tissue types. ARS is described in 4 stages: the prodromal<br />
stage, the latent stage, the manifest illness stage, and recovery or death. The prodromal stage<br />
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Participant Guide<br />
occurs as early as minutes after exposure and lasts <strong>for</strong> up to several days. During this time,<br />
nausea, vomiting, anorexia, and, depending on dose, diarrhea occur. In the latent stage, the<br />
patient will feel generally well <strong>for</strong> hours to days. Timing and duration <strong>of</strong> the latent stage is also<br />
variable and dose dependent. The manifest illness stage occurs next, and the type <strong>of</strong> illness<br />
depends on the dose received and the type <strong>of</strong> syndrome, or syndromes, that occurs.<br />
At doses in the range <strong>of</strong> 0.7–10 Gy, the full hematopoietic syndrome occurs. Bone marrow<br />
depression leads to reduced white blood cell and platelet counts, with subsequent hemorrhage<br />
and infection. Patients exposed to lower doses recover over periods <strong>of</strong> weeks to a year.<br />
At doses above 1.2 Gy, the mortality rate <strong>for</strong> the hematopoietic syndrome increases, and the<br />
60-d median lethal dose (LD50) is 2.5–5 Gy. Death due to the hematopoietic syndrome occurs<br />
within a few months <strong>of</strong> exposure.<br />
At doses greater than 10 Gy (though known to occur at doses as low as 6 Gy), the<br />
gastrointestinal syndrome occurs as a result <strong>of</strong> intestinal mucosal stem cell death. This leads to<br />
fluid and electrolyte imbalance, dehydration, shock, and hemorrhage. In patients who develop<br />
the gastrointestinal syndrome death usually occurs within 2 weeks.<br />
At even higher doses (20 Gy), the neurovascular syndrome occurs. Damage to neurovascular<br />
tissue leads to hypotension, cerebral edema, seizures, and invariable death, <strong>of</strong>ten within 3 days<br />
<strong>of</strong> exposure.<br />
The management <strong>of</strong> patients with radiation exposure includes supportive care, care <strong>for</strong> other<br />
injuries, and assessment <strong>for</strong> signs <strong>of</strong> poor prognosis. The latter signs include rapid onset <strong>of</strong><br />
symptoms, gastrointestinal complaints, and a falling white blood cell count (lymphocyte number)<br />
measured by the Andrews nomogram.<br />
Decontamination is only relevant <strong>for</strong> patients who are contaminated, that is those with dermal or<br />
internal radioisotope deposition. Exposure to ionizing beams <strong>of</strong> radiation do not leave a patient<br />
radioactive or with the need <strong>for</strong> (or possibility <strong>of</strong>) decontamination.<br />
Expert consultation can be obtained locally through the radiation safety <strong>of</strong>ficer or medical<br />
physicist at most medical centers or through the Radiation Emergency Assistance<br />
Center/Training Site (REAC/TS) consulting service in Oak Ridge, TN.<br />
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Participant Guide<br />
Module Eight<br />
Observed Behaviors during Mass <strong>Chemical</strong> Exposures-<br />
Administration Page<br />
Mass chemical exposures, irrespective <strong>of</strong> their cause, have understandably resulted in<br />
considerable public anxiety. While public reaction to such events is not, per se, a toxicological<br />
issue, the burden placed on health care and triage systems by the “worried well” is an important<br />
concern <strong>for</strong> everyone involved in the management <strong>of</strong> such a crisis. Anticipating demand and<br />
encouraging communication are key elements in ensuring effective care and preventing public<br />
hysteria.<br />
Duration<br />
45 minutes<br />
Scope Statement<br />
Using illustrative examples, this module explores common stress reactions to mass chemical<br />
exposures with a view towards attenuating their potential impact.<br />
Terminal Learning Objective (TLO)<br />
• Understand how to anticipate and appropriately respond to<br />
psychological issues encountered in victims <strong>of</strong> real & perceived<br />
chemical exposures<br />
Enabling Learning Objectives (ELO)<br />
Resources<br />
• Describe expected behaviors <strong>of</strong> large groups <strong>of</strong> people after a<br />
perceived toxic chemical exposure<br />
• Recognize the signs and symptoms <strong>of</strong> acute psychological and<br />
emotional response to a traumatic event (e.g. disaster or fear <strong>of</strong> real<br />
or perceived toxic chemical exposure<br />
• Develop a strategy to aid victims with fear/strong emotions following a<br />
real or perceived toxic chemical exposure<br />
Each <strong>of</strong> the eight course modules is deployed as an interactive, instructor-lead, MS PowerPoint<br />
presentation containing didactic content, historical examples, and selected case studies. All<br />
presentations are included in a printed participant guide (PG) containing the modules’ overview,<br />
scope statement, terminal and enabling learning objectives, PowerPoint slide handouts, and a<br />
summary section.<br />
Instructor to Participant Ratio<br />
1:8 (minimum) to 1:25 (maximum)<br />
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Participant Guide<br />
Reference List<br />
1. Ali-Gombe A, Guthrie E, McDermott N. Mass hysteria: One syndrome<br />
or two British Journal <strong>of</strong> Psychiatry 1996;168(5):663-665.<br />
2. Auf der Heide E. Convergence behavior in disasters. Ann Emerg Med.<br />
2003;41(4):463-466.<br />
3. Bartholomew R. Mass hysteria.[comment]. British Journal <strong>of</strong><br />
Psychiatry 1997;170:387-388.<br />
4. Benedek D, Holloway H, Becker S. Emergency mental health<br />
management <strong>of</strong> bioterrorism events. Emerg Med Clin N Am.<br />
2002;20:1-15.<br />
5. Black D, Welch F, Murray V. Mass psychogenic illness attributed to<br />
toxic exposure at a high school [letter]. New England Journal <strong>of</strong><br />
Medicine 2000;342(22):1674.<br />
6. Bleich A, Dycian A, Koslowsky M, Solomon Z, Wiener M. Psychiatric<br />
implications <strong>of</strong> missile attacks on a civilian population: Israeli lessons<br />
from the Persian Gulf War. Journal <strong>of</strong> American Medical Association.<br />
1992;268(5):613-615.<br />
7. Boss LP. Epidemic hysteria: a review <strong>of</strong> the published literature.<br />
Epidemiologic Reviews 1997;19(2):233-243.<br />
8. Bowler R, Mergler D, Huel G, Cone J. Aftermath <strong>of</strong> a chemical spill:<br />
Psychological and physiological sequelae. Neurotoxicology. Fall<br />
1994;15(3):723-729.<br />
9. Boxer P. Occupational mass psychogenic illness: History, prevention<br />
and management. Journal <strong>of</strong> Occupational Medicine. Dec.<br />
1985;27(12):867-872.<br />
10. Clauw DJ, Engel CC, Jr., Aronowitz R, et al. Unexplained symptoms<br />
after terrorism and war: an expert consensus statement. Journal <strong>of</strong><br />
Occupational & Environmental Medicine. 2003;45(10):1040-1048.<br />
11. Clements CJ. Mass psychogenic illness after vaccination. Drug<br />
Safety. 2003;26(9):599-604.<br />
12. Cole LA. Bioterrorism threats: learning from inappropriate responses.<br />
J Public Health Manag Pract. 2000;6(4):8-18.<br />
13. Cole TB, Chorba TL, Horan JM. Patterns <strong>of</strong> transmission <strong>of</strong> epidemic<br />
hysteria in a school.[see comment]. Epidemiology. 1990;1(3):212-218.<br />
14. Colligan M. Mass psychogenic illness: Some clarification and<br />
perpectives. Journal <strong>of</strong> Occupational Medicine. Sept. 1981;23(9):635-<br />
638.<br />
15. Colligan M, Murphy L. Mass psychogenic illness in organizations: An<br />
overview. Journal <strong>of</strong> Occupational Psychology. 1979;52:77-90.<br />
16. Colligan M, Smith M. A methodological approach <strong>for</strong> evaluating<br />
outbreaks <strong>of</strong> mass psychogenic illness in industry. Journal <strong>of</strong><br />
Occupational Medicine. Jun. 1978;20(6):401-402.<br />
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Participant Guide<br />
17. Durodie B, Wessely S. Resilience or panic The public and terrorist<br />
attack. Lancet. 2002;360(9349):1901-1902.<br />
18. Engel CC, Jr. Outbreaks <strong>of</strong> medically unexplained physical symptoms<br />
after military action, terrorist threat, or technological disaster. Military<br />
Medicine. 2001;166(12 Suppl):47-48.<br />
19. Engel CC, Jr., Adkins JA, Cowan DN. Caring <strong>for</strong> medically<br />
unexplained physical symptoms after toxic environmental exposures:<br />
effects <strong>of</strong> contested causation. Environmental Health Perspectives.<br />
2002;110(Suppl 4):641-647.<br />
20. Faust H, Brilliant L. Is the diagnosis <strong>of</strong> "mass hysteria" an excuse <strong>for</strong><br />
incomplete investigation <strong>of</strong> low-level environmental contamination<br />
Journal <strong>of</strong> Occupational Medicine. 1981;23(1):22-26.<br />
21. Gallay A, Van Loock F, Demarest S, Van der Heyden J, Jans B, Van<br />
Oyen H. Belgian coca-cola-related outbreak: intoxication, mass<br />
sociogenic illness, or both American Journal <strong>of</strong> Epidemiology.<br />
2002;155(2):140-147.<br />
22. Joyce J, Hotopf M, Wessely S. The prognosis <strong>of</strong> chronic fatigue and<br />
chronic fatigue syndrome: a systematic review.1997;223-233.<br />
23. Chisholm D, Godfrey E, Ridsdale L, et al. Chronic fatigue in general<br />
practice: economic evaluation <strong>of</strong> counselling versus cognitive<br />
behaviour therapy Br J Gen Pract 2001;51(462):15-18.<br />
24. Holloway HC, Norwood AE, Fullerton CS, Engel CC, Jr., Ursano RJ.<br />
The threat <strong>of</strong> biological weapons. Prophylaxis and mitigation <strong>of</strong><br />
psychological and social consequences. JAMA 1997;278(5):425-427.<br />
25. Jones TF, Craig AS, Hoy D, et al. Mass psychogenic illness attributed<br />
to toxic exposure at a high school. New England Journal <strong>of</strong> Medicine.<br />
2000;342(2):96-100.<br />
26. Karsenty E, Shemer J, Alshech I, et al. Medical aspects <strong>of</strong> the Iraqi<br />
missile attacks on Israel. Isr J Med Sci. 1991;27:603-607.<br />
27. Kawana J, Ishimatsu S, Kanda K. Psycho-physiological effects <strong>of</strong> the<br />
terrorist sarin attack on the Tokyo subway system. Military Medicine.<br />
2001;166:23-26.<br />
28. Landauer MR. Physiological and Psychological Impact <strong>of</strong> Low-Level<br />
Radiation: An Overview. Military Medicine. 2002;167(Suppl. 1):141-<br />
142.<br />
29. Levine RJ. Is the presence <strong>of</strong> low-level environmental contamination a<br />
sufficient excuse <strong>for</strong> not diagnosing mass hysteria Journal <strong>of</strong><br />
Occupational Medicine. 1981;23(9):597-599.<br />
30. Moscrop A. Mass hysteria is seen as main threat from bioweapons.<br />
BMJ. 2001;323(7320):1023.<br />
31. Murakami H. Underground: The Tokyo gas attack and the Japanese<br />
psyche. New York: Random House; 2000.<br />
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Participant Guide<br />
Practical Exercise Statement<br />
32. Okumura T, Suzuki K, Fukuda A, et al. The Tokyo subway sarin<br />
attack: Disaster management, Part 2: Hospital response. Academic<br />
Emergency Medicine. 1998;5(6):618-624.<br />
33. Okumura T, Takasu N, Ishimatsu S, et al. Report on 640 Victims <strong>of</strong><br />
the Tokyo Subway Sarin Attack. Ann Em Med. 1996;28(2):129 - 224.<br />
34. Pastel RH. Collective behaviors: mass panic and outbreaks <strong>of</strong> multiple<br />
unexplained symptoms. Military Medicine. 2001;166(12 Suppl):44-46.<br />
35. Quigley C. Dual-edged sword: dealing with the media be<strong>for</strong>e, during,<br />
and after a weapon <strong>of</strong> mass destruction event. Military Medicine.<br />
2001;166(12 Suppl):56-58.<br />
36. Rifkin A. Mass psychogenic illness attributed to toxic exposure at a<br />
high school.[comment]. New England Journal <strong>of</strong> Medicine.<br />
2000;342(22):1674-1675.<br />
37. Romano J, King J. Psychologica and neuropsychological sequelae <strong>of</strong><br />
chemical terrorism. In: Flora S, Romano J, Baskin S, Sekhar K, eds.<br />
Pharmacological Perspectives <strong>of</strong> Toxic <strong>Chemical</strong>s and Their<br />
Antidotes. New Delhi: Narosa Publishing House; 2004:1-11.<br />
38. Taylor BW, Werbicki J. Pseudodisaster: A case <strong>of</strong> mass hysteria<br />
involving 19 school children. Pediatric Emergency Care. Aug.<br />
1993;9(4):216-217.<br />
39. Wessely S. Responding to mass psychogenic illness.[comment]. New<br />
England Journal <strong>of</strong> Medicine. 2000;342(2):129-130.<br />
40. Wessely S, Wardle C. Mass sociogenic illness by proxy: Parentally<br />
reported epidemic in an elementary school. British Journal <strong>of</strong><br />
Psychiatry. 1990;157:421-424.<br />
41. Nanagas KA, Kirk MA. Perceived poisons. Medical Clinics <strong>of</strong> North<br />
America. Nov 2005;89(6):1359.<br />
42. Martin-Gill C, Baer AB, Holstege CP, et al. Poison centers as<br />
in<strong>for</strong>mation resources <strong>for</strong> EMS in a suspected chemical exposure. J<br />
Emerg Med 2007;32(4):397-403.<br />
43. Sandman P. Crisis communication: Guidelines <strong>for</strong> action. Accessed<br />
January 16, 2005. http://www.psandman.com/handouts/AIHA-<br />
DVD.htm.<br />
44. US Department <strong>of</strong> Health and Human Services. Communicating in a<br />
Crisis: Risk Communication Guidelines <strong>for</strong> Public Health Officials;<br />
2002. http://www.riskcommunication.samhsa.gov.<br />
Each module presentation contains one or more interactive audience response questions<br />
designed to drive discussion, promote participant engagement, and test knowledge. Through<br />
the use <strong>of</strong> the Meridia® Audience Response system, participant responses can be collected,<br />
tabulated, and displayed within the presentation in real time. In order to use the interactive<br />
slides accompanying this presentation, the lecture hall must be equipped with the Meridia®<br />
Audience Response system and user keypads. In addition, a copy <strong>of</strong> the “Meridia® Q&A”<br />
s<strong>of</strong>tware component <strong>for</strong> MS PowerPoint must be installed on the presenter’s computer.<br />
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Participant Guide<br />
Assessment Strategy<br />
Participant progress toward course learning objectives is monitored through in<strong>for</strong>mal discussion<br />
and responses to each module’s practical exercise questions. Overall mastery <strong>of</strong> module<br />
content and concepts is documented by means <strong>of</strong> a comprehensive, end-<strong>of</strong>-day posttest<br />
touching on key learning objectives from each module. Each participant must obtain a score <strong>of</strong><br />
80% or better to successfully complete the training and obtain a course completion certificate.<br />
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Participant Guide<br />
Module Eight<br />
Icon Map<br />
Knowledge Check: Used when it is time to assess the learners’ understanding<br />
Example: Used when there is a descriptive illustration to show or explain<br />
Key Points: Used to convey essential learning concepts, discussions and introduction <strong>of</strong><br />
supplemental material<br />
Hint: Used to cover administrative items or instructional tips that aid in the flow <strong>of</strong> the<br />
instruction<br />
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Participant Guide<br />
Slide 1<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Module Eight<br />
Observed Behaviors during<br />
Mass <strong>Chemical</strong> Exposures<br />
Training Support Package<br />
1<br />
The psychological aspects <strong>of</strong> a mass exposure event are increasingly recognized as<br />
critically important issues <strong>for</strong> education and disaster planning. At first, this may NOT<br />
appear to be a toxicological problem. We cannot explain these symptoms through a<br />
simple receptor interaction. We do not have a specific toxic syndrome to identify this<br />
condition. We do not have an antidote to reverse this condition. However, applying the<br />
toxicologic principles <strong>of</strong> exposure pathway, dose-response, and clinical evaluation will<br />
allow emergency planners, emergency responders, and all health care providers to more<br />
effectively address commonly observed behaviors.<br />
Using illustrative examples, this module explores common stress reactions to mass<br />
chemical exposures with a view towards attenuating their potential impact.<br />
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Participant Guide<br />
Slide 2<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Learning Objectives<br />
By the end <strong>of</strong> this module participants will be able to:<br />
• Understand the psych impact <strong>of</strong> mass chemical exposures<br />
• Provide appropriate response to the mental health needs <strong>of</strong><br />
victims <strong>of</strong> real & perceived events<br />
• Describe expected behaviors <strong>of</strong> large groups <strong>of</strong> people after<br />
a perceived toxic chemical exposure<br />
• Recognize signs & symptoms <strong>of</strong> acute psychological /<br />
emotional response to a traumatic event<br />
• Develop a strategy to aid victims with fear/strong emotions<br />
following a real or perceived toxic chemical exposure<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
2<br />
This module provides a framework to understand what is <strong>of</strong>ten characterized as “mass<br />
hysteria”. This term – though in common use – fails to recognize the normal physiologic<br />
process that <strong>of</strong>ten leads to progressive symptoms and disability in the setting <strong>of</strong> a<br />
perceived toxic chemical exposure (or other fear-provoking event). There are several<br />
characteristic features <strong>of</strong> crowd response. However, sorting out physical responses to a<br />
toxic exposure from physiological and psychological responses to a stress stimulus can<br />
take time and may be challenging.<br />
Large numbers <strong>of</strong> people present after mass disasters with physiologic stress response.<br />
The term “physiologic” is used to describe normal or exaggerated body response – the<br />
so-called “fight or flight” response to a stress or fearful event. While the examples<br />
provided in this module highlight some <strong>of</strong> the classic stress symptoms, it should be<br />
emphasized that there is <strong>of</strong>ten a degree <strong>of</strong> diagnostic uncertainty inherent to these<br />
events.<br />
In the absence <strong>of</strong> a concerned and knowledgeable response, the fear reaction may<br />
escalate resulting in more symptomatic individuals and more lasting symptoms. People<br />
assessed as having stress reactions should be provided care. Proper planning is<br />
required so they do not overwhelm the acute care system.<br />
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Participant Guide<br />
Slide 4<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Audience Response Question<br />
Fifty people complain <strong>of</strong> nausea and several vomit<br />
after smelling a sulfur -like odor. Which <strong>of</strong> the<br />
following is the most likely explanation<br />
1. Hydrogen sulfide poisoning<br />
2. Food poisoning<br />
3. Mass psychogenic illness<br />
4. Panic<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
4<br />
Slide 5<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 1: “The Toxic Lady ”<br />
• A 31 year-old cancer patient is rushed by EMS to the nearest<br />
LA suburb ED on March 19th, 1994.<br />
– An “oily sheen ” is noted on her chest.<br />
• During the resuscitation, a nurse drawing her blood notices a<br />
peculiar acrid smell that seems to be coming from the patient<br />
and passes out.<br />
• The senior EM resident picks up the syringe used to draw the<br />
blood and notices yellow crystals, smells it, collapses.<br />
– Within minutes, 4 more care providers are “overcome. ”<br />
• During the ensuing evacuation the patient dies<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
5<br />
Let’s consider a few specific cases that highlight important aspects <strong>of</strong> psychological<br />
response to mass exposures. Several years ago, a very ill patient with metastatic<br />
cancer was brought by ambulance to a Los Angeles area hospital. During her initial<br />
evaluation, an unpleasant odor was noted, as well as an oily sheen to the skin. Health<br />
care providers participating in the resuscitation attempt passed out, causing others to<br />
evacuate the emergency department. The patient died and several providers were<br />
hospitalized.<br />
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Participant Guide<br />
Slide 6<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 1: Leading Theories<br />
• Patient drank pesticide in suicide attempt or used a<br />
solvent (DMSO) as a home cancer remedy<br />
• Hospital plumbing emitted a toxic gas<br />
• A secret methamphetamine lab operated in the<br />
hospital basement.<br />
• “Mass hysteria ”<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
6<br />
Several theories were proposed to explain this event. Given an odor and possible<br />
abnormal substance on the patient’s skin, an ingestion <strong>of</strong> undefined “pesticide” was<br />
proposed. Dimethyl sulfoxide (DMSO) is an industrial solvent used as an alternative<br />
cancer therapy. Other theories focused on a source within the hospital, including some<br />
outlandish suggestions, such as releases from a clandestine methamphetamine<br />
laboratory within the hospital.<br />
Despite the apparently genuine and severe illnesses <strong>of</strong> the ER staff, no satisfactory toxin<br />
that could have caused their illnesses has been identified. This has led to speculation as<br />
to whether so-called “mass hysteria” could have caused the symptoms experienced by<br />
the ER staff. Opinions are still divided as to the cause <strong>of</strong> the incident, without a clear-cut<br />
answer. Subsequent litigation has also not provided clarification.<br />
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Participant Guide<br />
Slide 7<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
• 37 exposed<br />
Case 1: “The Toxic Lady ”<br />
– 11 noticed unusual smell<br />
• Description varied: garlicky, ammonia like, gas -like, or chemical -<br />
like<br />
– 26 did not notice odor<br />
• Paramedics who transported patients and drew<br />
blood in the ambulance noticed no odor and<br />
developed no symptoms<br />
• 23/37 developed at least one symptom<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
7<br />
Of the 37 who were in close proximity to the event, only 11 reported noticing an unusual<br />
smell. The remaining 26 potentially-exposed individuals noticed no odor. While 23 <strong>of</strong> 37<br />
exposed eventually developed at least one symptom, the paramedics who transported<br />
the patient and drew blood in the ambulance – presumably with the closest contact and<br />
largest potential exposure - noticed no difference in odor and developed no symptoms.<br />
The lack <strong>of</strong> symptoms in those with a larger dose or longer time duration <strong>of</strong> exposure<br />
would argue against an inhaled toxic compound from the patient – this is in keeping with<br />
the concept <strong>of</strong> dose-response as described earlier in the course.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 8<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 1: Mass Psychogenic Illness or<br />
Toxic Exposure<br />
• 5 health care staff hospitalized<br />
– ED nurse hospitalized <strong>for</strong> 9 days developed chronic<br />
severe headaches, fatigue, dyspnea<br />
• A psychiatrist insisted it was an organic cause<br />
– ED physician hospitalized in ICU <strong>for</strong> 2 weeks requiring<br />
mechanical ventilation<br />
• 3 months in a wheelchair<br />
• Avascular necrosis <strong>of</strong> knees requiring 20 operations<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
8<br />
Two medical providers had significant hospitalizations, with ensuing chronic health<br />
issues - one with somewhat non-specific symptoms; the other with a more recognizable<br />
medical condition. These are serious health effects – but are they attributable to an<br />
original toxic exposure, consequences <strong>of</strong> medical interventions, or some combination<br />
there<strong>of</strong> If the <strong>for</strong>mer, this would be strong evidence <strong>for</strong> a toxic exposure. If these<br />
effects are “just” adverse events based on physiologic and psychological responses to a<br />
frightening event and/or iatrogenic complications <strong>of</strong> procedures or medications, it<br />
underlines the importance <strong>of</strong> intervening in this process early.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 9<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 1: Three Investigations<br />
• Coroner<br />
– Patient died from cervical cancer<br />
– Fumes that sickened hospital workers were just the “smell <strong>of</strong> death ”<br />
• Cal-OSHA<br />
– No safety violations<br />
– Three employees had “involuntary psychological reaction to some<br />
agents” while the rest suffered from mass hysteria<br />
• Cali<strong>for</strong>nia Dept <strong>of</strong> Health Services (CDC)<br />
– “An outbreak <strong>of</strong> mass sociogenic illness perhaps triggered by an o dor”<br />
– Also possible that a few staff members were exposed to unknown<br />
toxic chemical<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
9<br />
The coroner’s report determined the cause <strong>of</strong> death to be cervical cancer, but found no<br />
chemicals that might account <strong>for</strong> the event. That report speculated that others were<br />
overcome by “the smell <strong>of</strong> death”.<br />
The <strong>of</strong>ficial opinion <strong>of</strong> Cal-OSHA (state Occupational Safety and Health Administration)<br />
is that, while some <strong>of</strong> the staff may have been affected by hysteria, at least three people<br />
had a genuine reaction to some kind <strong>of</strong> toxin or agent. They also found no safety<br />
violations – meaning no methamphetamine laboratory in the hospital.<br />
The State Dept. <strong>of</strong> Health Services report said that most people (eventually over 30) who<br />
reported feeling ill were suffering from stress reactions, but that six staff who were felled<br />
may have been affected by either hysteria or a toxic agent.<br />
The Riverside Dept. <strong>of</strong> Health says that they now believe that the chief resident, a<br />
respiratory technician and a nurse with prolonged patient contact were not suffering from<br />
hysteria.<br />
Lawrence Livermore Lab released a report hypothesizing that dimethyl sulfate (an<br />
industrial gas with some irritant features and severe systemic effects) could have been<br />
produced from a dimethyl sulfoxide (DMSO) exposure or ingestion; and was the cause<br />
<strong>of</strong> toxic symptoms in some people.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 10<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
What is the correct terminology to identify<br />
“mass psychogenic illness ”<br />
More Common Terms<br />
• Mass Sociogenic Illness<br />
• Epidemic Hysteria<br />
• Mass Hysteria<br />
• Traumatic stress response<br />
Less Common Terms<br />
• Epidemic transient<br />
situational disturbance<br />
• Psychosocial casualties<br />
• Environmental somatization<br />
syndrome<br />
• Psychological sequelae<br />
• Psychic possession<br />
• Crowd poison<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
10<br />
A number <strong>of</strong> terms have been used to describe this type <strong>of</strong> response. Attempts to<br />
discuss and study this topic are problematic due to the highly variable terminology used<br />
to describe the underlying phenomenon. In a literature review Bartholomew reported the<br />
use <strong>of</strong> over 76 different terms referring to “mass psychogenic illness” like behavior. On<br />
the left <strong>of</strong> the slide are the terms that tend to be in current and common use, those on<br />
the right are less so. Psychic possession and Crowd Poison are particularly interesting<br />
terms.<br />
The existence <strong>of</strong> many terms and descriptive titles <strong>of</strong>ten indicates the difficulty in<br />
adequate definition or delineation <strong>of</strong> a disease or syndrome.<br />
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Participant Guide<br />
Slide 11<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Definitions<br />
• Diagnostic and Statistical Manual <strong>of</strong> Mental<br />
Disorders -IV-TR<br />
– Epidemic Hysteria<br />
• Shared symptoms develop in a circumscribed group <strong>of</strong> people<br />
following "exposure" to a common precipitant.<br />
• Medical literature<br />
– Multiple Unexplained Symptoms<br />
• Typically chronic and not triggered by a specific event<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
11<br />
A specific term is now used in the Diagnostic and Statistical Manual <strong>of</strong> Mental Disorders-<br />
IV-TR (DSM-IV) that describes the observed behaviors <strong>of</strong> groups exposed to an event.<br />
It is termed ‘epidemic hysteria.’ Although somewhat medicalized, this term carries a<br />
nonmedical meaning that may not be ideal (i.e., hysteria).<br />
A common term in the medical literature, but not in DSM, is Multiple Unexplained<br />
Symptoms (sometimes called Multiple Medical Unexplained Symptoms, MMUS; and<br />
other variants). This syndrome is very common, and while clinically similar in nature to<br />
epidemic hysteria, it is not generally triggered by a single event, is long standing, and is<br />
<strong>of</strong>ten pervasive in a patient’s life. Patients with this syndrome <strong>of</strong>ten come to attention in<br />
outpatient toxicology clinics with multiple previous physicians and diagnoses, and many<br />
tests showing normal or inconclusive results.<br />
The DSM is the standard manual <strong>for</strong> psychiatric diagnoses. It generally lists a number <strong>of</strong><br />
criteria (symptoms, exclusion criteria, and timeframes) required <strong>for</strong> a consensus<br />
diagnosis <strong>of</strong> psychiatric conditions. The DSM-IV-TR is the fourth update (text revision) <strong>of</strong><br />
this manual, published in 2000.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 12<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Be Careful What You Call It!<br />
• Condescending terms<br />
– Negative connotations<br />
– Hysteria implies individual is to blame <strong>for</strong> illness<br />
• Of course, physicians cannot have mass<br />
psychogenic illness<br />
– 1955 hospital epidemic with 300 affected<br />
• Once medical staff became affected, condition labeled as<br />
“epidemic benign myalgic encephalomyelitis ”<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
12<br />
Our mental health colleagues warn us that the use <strong>of</strong> the term ‘hysteria’ has negative<br />
connotations. It implies that the individual is purposely causing the problems. “So you<br />
think it is all in my head” Thus the use in DSM, while medically acceptable, may not be<br />
externally acceptable.<br />
In 1955 a hospital epidemic occurred with 300 individuals affected. Once the medical<br />
staff became affected, the condition was labeled as “epidemic benign myalgic<br />
encephalomyelitis.” Physicians may liberally use the term “mass (or epidemic) hysteria”<br />
but in this particular incident, they quickly renamed it to avoid being accused <strong>of</strong> being<br />
hysterical themselves.<br />
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Participant Guide<br />
Slide 13<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 2: Cyanide<br />
• 06:00 am<br />
– A pail caught fire at a plating company containing:<br />
• Sodium meta -nitrobenzene (85%)<br />
• Potassium cyanide (15%)<br />
• 15 workers <strong>of</strong> a downwind warehouse smelled<br />
smoke and noticed brief upper respiratory irritation<br />
• Evacuated to nearby (5 miles) airport facility but not<br />
in<strong>for</strong>med <strong>of</strong> potential cyanide exposure<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
13<br />
This next case highlights problems with communications and expectations in the setting<br />
<strong>of</strong> a possible mass exposure. On a cold January day in 1995 (Temperature 2 degrees<br />
F) a fire occurred in a plating company in Indianapolis, Indiana. Within an isolated room,<br />
a pail containing 85% sodium meta-nitrobenzene sulfonate and 15% potassium cyanide<br />
caught fire. Scrubbers filtered the escaping smoke from the room. 15 employees <strong>of</strong> a<br />
downwind warehouse noted the smell <strong>of</strong> smoke and brief irritant symptoms. The fire<br />
department evacuated nearby neighborhood including warehouse employees without<br />
in<strong>for</strong>ming them <strong>of</strong> potential cyanide exposure. The warehouse procedure was to<br />
evacuate to an airport facility (approx 5 miles away). The “All clear” was given at incident<br />
command because downwind air monitoring found no evidence <strong>of</strong> cyanide and<br />
calculations predicted no risk <strong>of</strong> cyanide release <strong>of</strong>f <strong>of</strong> property.<br />
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Participant Guide<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 2: Cyanide (Continued)<br />
• The original 15 evacuees and 85 contacts learned <strong>of</strong><br />
cyanide exposure and several began complaining <strong>of</strong><br />
chest tightness, nausea and dizziness<br />
• “Several are feeling ill and we ’ve got about 50<br />
people that were exposed over there, they ’re awake<br />
and oriented, they just wanted to be checked out. ”<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
14<br />
Once everyone arrived at the evacuation site, they were in<strong>for</strong>med <strong>of</strong> the chemicals<br />
involved in the fire. At that time – distant in time and varying greatly in their initial<br />
proximity to the event - several people began complaining <strong>of</strong> chest tightness, nausea<br />
and dizziness.<br />
Thirty minutes after the “All Clear” was given by the fire department, the county disaster plan<br />
was activated because these 100 individuals at the airport terminal were complaining or wanted<br />
to be checked to make sure they were OK.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 15<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 2: Cyanide (Continued)<br />
• 9:30 am Incident Command decides<br />
– No decontamination at scene necessary<br />
– Transport to area hospitals<br />
• Hospital 1: 36 patients<br />
• Hospital 2: 52 patients<br />
• Hospital 3: 12 patients<br />
• 9:50 am Treatment and Disposition<br />
– Hospital 1:<br />
• Gross decontamination in parking lot<br />
• Lilly Cyanide Antidote Kit (N=2)<br />
• Media interviews with cameras rolling<br />
– Hospitals 2 & 3: Quick check and release<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
15<br />
All patients were transported to three local hospitals.<br />
Hospital #1 received 36 patients. All were decontaminated outside the emergency<br />
department in the cold and two patients were administered Lilly cyanide antidote kit <strong>for</strong><br />
symptoms. The antidote was administered based on subjective symptoms. A resident<br />
interviewed on camera stated, “Apparently we have a cyanide antidote and we gave it to<br />
patients with low oxygen saturation.” One patient receiving the antidote became<br />
hypotensive after treatment, requiring overnight ICU admission.<br />
Hospitals #2 and #3 received 52 and 12 patients, respectively. Evaluation without<br />
decontamination was per<strong>for</strong>med at these sites.<br />
The media only filmed action at Hospital #1 where decontamination occurred - quite a<br />
spectacle in 2 degree weather.<br />
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Participant Guide<br />
Slide 16<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Medical Personnel Responses<br />
“Cyanide is deadly. Cyanide is bad stuff!<br />
If it were me, I ’d go get checked out. ”<br />
• EMTs wearing surgical masks to drive.<br />
– Upset that patients were not decontaminated.<br />
• Medics c/o lightheadedness and smelled ‘bitter<br />
almonds’<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
16<br />
It is clearly a popular and correct belief that cyanide is deadly. What these statements<br />
and actions disregard is the clinical pharmacokinetics <strong>of</strong> cyanide poisoning. The time <strong>of</strong><br />
onset (seconds to minutes with inhalation), clinical effects (multisystem collapse, not<br />
simply nausea and dizziness), and lack <strong>of</strong> utility <strong>of</strong> surgical masks to prevent cyanide<br />
exposure all went unrecognized or were ignored in the “heat <strong>of</strong> the moment”. Often in<br />
events like this, emergency response planners and health care providers, given their<br />
relatively prominent stature, can improve or worsen a situation by the messages they<br />
communicate and by the cues they provide by their actions. In this case it seems the<br />
“mass hysteria” was exacerbated, if not caused, by the medical community and<br />
emergency response crews.<br />
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Training Support Package<br />
Participant Guide<br />
Slide 17<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 2: Cyanide (Continued)<br />
• 12:30 pm media coverage<br />
– Footage and interviews from Hospital 1<br />
• Calls to Poison Center from:<br />
– Previously treated and released employees concerned<br />
they had not received “appropriate treatment ”<br />
– Hospitals 2 and 3 because several patients returned <strong>for</strong><br />
“appropriate treatment ”<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
17<br />
As soon as the noon news aired the story and showed the “appropriate treatment”, the<br />
regional poison center began to receive multiple calls from employees already released<br />
by the other hospitals.<br />
Because <strong>of</strong> the media coverage at Hospital #1, many who were treated at Hospitals #2<br />
and #3 returned <strong>for</strong> decontamination. Some patients returned to ED <strong>for</strong> additional care<br />
despite not having any symptoms.<br />
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Participant Guide<br />
Slide 18<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Lessons Learned<br />
• Patients remote to exposure may exhibit symptoms<br />
– May develop symptoms on learning <strong>of</strong> the exposure<br />
• Medical personnel can be affected<br />
– They can become victims<br />
– They may react inappropriately<br />
• e.g., use therapies with potential <strong>for</strong> adverse reactions<br />
• Treatment <strong>for</strong> presumed poisoning can be harmful<br />
– Decontamination in extremely cold weather<br />
– Adverse effects <strong>of</strong> antidotes<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
18<br />
We should recognize that patients who are remote to the exposure may complain <strong>of</strong><br />
symptoms that cannot plausibly be linked to the exposure itself.<br />
They may even develop symptoms only after hearing about the exposure. Hearing<br />
about an exposure is not a valid exposure pathway <strong>for</strong> transmitting a toxin, but is an<br />
excellent pathway <strong>for</strong> transmitting fear.<br />
Medical personnel are humans too. They can be affected by fear, particularly in the<br />
absence <strong>of</strong> relevant knowledge (thus becoming victims or reacting inappropriately)<br />
Treatment <strong>for</strong> ‘presumed poisoning’ can be harmful as was seen in this case<br />
(decontamination in extremely cold weather, adverse effects <strong>of</strong> antidotes)<br />
These observations are important to incorporate into emergency planning.<br />
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Slide 19<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Expect Large Numbers <strong>of</strong> Patients<br />
after Mass <strong>Chemical</strong> Exposure<br />
• Types <strong>of</strong> Patients<br />
• Obvious Medical Needs<br />
– Poisoned<br />
– Contaminated<br />
• Nonspecific symptoms<br />
– With no apparent exposure<br />
• Asymptomatic<br />
– “Just want to get checked out ”<br />
http://www.uli -atl.com/alerts_2007/alert_070118b.htm<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
19<br />
Three distinct types <strong>of</strong> patients <strong>of</strong>ten present in HazMat or mass chemical exposure<br />
situations. Each group has different needs. Ideally, they should be identified and<br />
separated in the triage process.<br />
Obviously ill or - at least - contaminated individuals require treatment. A contaminated<br />
person is potentially poisoned, and potentially a risk to others, so should be assessed <strong>for</strong><br />
symptoms related to exposure mechanism (e.g. inhalation) and agent, and assessed <strong>for</strong><br />
the need <strong>for</strong> decontamination..<br />
Others may have vague or non-specific symptoms. While it might be difficult to<br />
understand how victims in this group could have sustained a large enough exposure to<br />
become ill, they should be evaluated <strong>for</strong> any physiologic abnormalities (symptom nature<br />
and vital signs, screening physical exam – e.g. breath sounds, mucous membrane<br />
irritation) and reevaluated as adequate in<strong>for</strong>mation becomes available regarding the<br />
exposure or if they become more symptomatic.<br />
Generally, the largest group <strong>of</strong> people just ‘want to get checked out.’ They just need<br />
reassurance that everything is OK. These people are similar to car crash victims that<br />
are fine but come to ED to get checked out.<br />
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Participant Guide<br />
Slide 20<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Magnitude <strong>of</strong> Problem<br />
• Tokyo Sarin Incident 1995<br />
– 12 died<br />
– 1,200 required some care<br />
– 5,500 sought medical care but had no exposure<br />
• Bhopal Disaster 1984<br />
– >10,000 severe and 5000 died<br />
– 200,000 sought medical care<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
20<br />
We have talked about several to one hundred individuals with these last two case<br />
studies. Consider the difficulty in managing an event <strong>of</strong> the magnitude <strong>of</strong> the Tokyo<br />
Sarin nerve agent attack by the Aum Shinryko cult and the Bhopal methylisocyanate<br />
industrial disaster in India. .<br />
The numbers <strong>of</strong> affected individuals in these cases are so large that victims overwhelm<br />
surge capacity <strong>of</strong> any system, create triage problems, and deplete scarce resources.<br />
Responders and providers are unable to focus care on the most seriously ill. Even small<br />
HazMat spills can result in many hundreds being transported to hospitals. Protocols are<br />
misguided if large numbers <strong>of</strong> unexposed “victims” are directed to acute-care hospitals<br />
just “to get checked out”.<br />
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Slide 21<br />
During the 1991 United States–led Desert Storm operation, 39 Iraqi SCUD missiles<br />
landed in Israel. These attacks caused over 1000 casualties (including some traumatic<br />
injuries from explosives, shrapnel, and structural damage). However, one half <strong>of</strong> the<br />
casualties were diagnosed with acute psychologic reactions or acute anxiety.<br />
Also, because it was unknown if chemical weapons were part <strong>of</strong> the missiles’ payload, it<br />
appeared that people anticipated toxic chemicals and began to treat themselves without<br />
verification <strong>of</strong> chemical exposure or related symptoms. In one report, twenty-seven<br />
percent <strong>of</strong> the casualties were due to inappropriate autoinjection <strong>of</strong> atropine because <strong>of</strong><br />
fear that a chemical nerve agent attack had occurred.<br />
Another 40 patients were injured while rushing to a sealed room to avoid chemical<br />
exposure. Some deaths occurred from improper use <strong>of</strong> gas masks leading to suffocation<br />
(including at least one child), while others succumbed to myocardial infarctions. Only 2<br />
deaths were due to missile trauma.<br />
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Slide 22<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
What is Panic<br />
• Panic is:<br />
– A sudden fear which dominates or replaces thinking [ wikipedia.org ]<br />
– A sudden unreasoning terror <strong>of</strong>ten accompanied by mass flight<br />
[www.merriam -webster.com ]<br />
• Often used incorrectly to describe any type <strong>of</strong> fear, flight,<br />
evacuation, or lack <strong>of</strong> coordination<br />
– Flight is <strong>of</strong>ten appropriate<br />
• Panic flight is<br />
– Irrational, hysterical or groundless flight<br />
– Reckless disregard <strong>for</strong> others<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
22<br />
Panic is a term commonly applied to what is occurring in the minds <strong>of</strong> those exposed.<br />
Panic is different than the effects described so far (in which the threat is internalized and<br />
symptoms/signs develop.) In panic behavior, the person reacts irrationally to an event<br />
and runs or fights, etc. Sometimes flight is the appropriate thing to do (e.g., those<br />
individuals in the vicinity <strong>of</strong> the New York World Trade Center on the morning <strong>of</strong><br />
9/11/2001).<br />
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Slide 23<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Can People Panic during a Disaster<br />
http://scifipedia.scifi.com /<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
23<br />
In July 1938 in a CBS Mercury Theater radio program that terrified the nation, Orson<br />
Wells broadcast a live presentation <strong>of</strong> H.G.Wells' science-fiction novel, War <strong>of</strong> the<br />
Worlds. Only later did much <strong>of</strong> the eastern seaboard realize that it was science fiction,<br />
not an actual extraterrestrial invasion. The following day, the New York Times front page<br />
announced: "Many flee homes to Escape Gas Raid from Mars...“<br />
Slide 24<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Cycle <strong>of</strong> Fear and Perceived Poisoning<br />
• Perceived high risk <strong>of</strong> uncontrolled<br />
release <strong>of</strong> dreaded toxin<br />
• Input<br />
– Mucous membrane irritation<br />
– Lightheadedness<br />
– Noticing a bad odor<br />
– Observing friends become ill<br />
• Natural response is fear<br />
• Fear leads to autonomic arousal<br />
– Palpitation<br />
– Sweating<br />
• Autonomic arousal misinterpreted as<br />
a symptom <strong>of</strong> poisoning<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
24<br />
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Like it or not, we now live in a world <strong>of</strong> heightened awareness that a dreaded event is<br />
going to occur. If we have an unexpected input (irritation, funny odor, see a friend faint)<br />
then we may manifest a natural response - fear. Fear and anxiety lead to autonomic<br />
arousal (tachycardia – rapid heart beat, <strong>for</strong>ceful heart beat – “pounding in the chest” –<br />
perhaps with increased blood pressure, sweating, tremor, lightheadedness, rapid<br />
breathing). Autonomic arousal occurs from release <strong>of</strong> epinephrine and norepinephrine<br />
from our adrenal glands. These symptoms may feel like a chemical exposure to the<br />
person and he/she becomes even more fearful. These symptoms are REAL, and<br />
rein<strong>for</strong>ce the victim’s perception <strong>of</strong> being poisoned. In the absence <strong>of</strong> reassurance,<br />
evaluation, or recognition <strong>of</strong> this fear-arousal cycle, unexposed or non-poisoned people<br />
may panic, and one person panicking may lead to mass panic.<br />
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Slide 25<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Panic is Rare During a Disaster<br />
• Observed groups <strong>of</strong> patients in period <strong>of</strong> impact<br />
– “Cool and Collected ” (75%)<br />
– Stunned and bewildered (>20%)<br />
– Confused, anxious, hysterical crying (
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong><br />
Training Support Package<br />
Participant Guide<br />
Slide 26<br />
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Slide 27<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Case 3: A Gas Smell<br />
• A gas odor is noted in a school classroom<br />
• The teacher complains <strong>of</strong> headache, nausea, shortness <strong>of</strong><br />
breath and dizziness<br />
• 80 students, 19 staff, 1 family member go to the ED<br />
– 38 hospitalized <strong>for</strong> unclear reasons<br />
• Scene investigation: no environmental cause<br />
– 5 days later school reopened<br />
• 71 people return to the ED <strong>for</strong> similar symptoms<br />
• Exhaustive investigation: no environmental cause<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
27<br />
The last case we will discuss highlights some <strong>of</strong> the difficulties in ruling-out a toxic<br />
exposure and the resulting problems that situation creates. In November 1998, a teacher<br />
at the Warren County High School in McMinnville, Tennessee noticed a "gasoline-like"<br />
smell in her classroom, and soon thereafter she had a headache, nausea, shortness <strong>of</strong><br />
breath, and dizziness. The school was evacuated, and 80 students and 19 staff<br />
members went to the emergency room at the local hospital; 38 persons were<br />
hospitalized overnight. An investigation did not identify any problems with spills, gas<br />
leaks or the like; and the school was reopened. However, symptoms reoccurred.<br />
Despite several intensive investigations, no contamination or toxin was identified.<br />
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<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Features Suggestive <strong>of</strong><br />
“Mass Psychogenic Illness ”<br />
• Rapid onset and recovery<br />
• Contagious, spreads via:<br />
– Sight (particularly “line <strong>of</strong> sight ”)<br />
– Smell<br />
• Diversity <strong>of</strong> symptoms w/o physical signs or abnormal labs<br />
• Benign morbidity with no sequelae<br />
– Though remember the “Toxic Lady ”<br />
• Often recurs when returning to environment<br />
• No reasonable organic basis<br />
– Environmental investigation is negative<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
28<br />
When we evaluate cases <strong>of</strong> potential toxic mass exposure, there are certain features<br />
suggestive <strong>of</strong> mass psychogenic illness that we should recognize:<br />
Onset is generally immediate or rapid, <strong>of</strong>ten precipitated by sensing an odor or viewing<br />
another person getting “sick”.<br />
The clinical complaints are <strong>of</strong>ten variable between patients, and clinical evaluation<br />
proves negative.<br />
Most people recover quickly and have no long term morbidity, though patients can suffer<br />
self-harm unintentionally.<br />
Symptoms may recur due to lingering anxiety on re-entry, while concentrations <strong>of</strong> any<br />
noxious (unpleasant) agent or toxic compound is generally less due to ventilation and<br />
the passage <strong>of</strong> time.<br />
No toxic exposure is identified, or a potential exposure inconsistent with the toxidrome, is<br />
found.<br />
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Slide 29<br />
In the high school case just described, these are the varied symptoms identified among<br />
the 91 people initially evaluated at the hospital. All are protean or nonspecific symptoms,<br />
and the findings varied among the patients, suggesting it is not due to an exposure to<br />
any given toxic substance.<br />
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Slide 30<br />
.<br />
There are several features from this high school event that argue <strong>for</strong> Mass Psychogenic<br />
Illness. Perhaps the most important piece <strong>of</strong> evidence is the development <strong>of</strong> symptoms<br />
in a number <strong>of</strong> people not in the classroom where the odor was first noticed. When an<br />
investigation was conducted, no compounds were found beyond what would be<br />
expected in an occupied building. Of course, there are always criticisms as it is <strong>of</strong>ten<br />
difficult to “prove a negative”.<br />
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Slide 31<br />
Of course, we do not want to miss actual poisoning events. In this sense, psychogenic<br />
illness is a diagnosis <strong>of</strong> exclusion. Note the similarity between many <strong>of</strong> the symptoms<br />
seen in minor nerve agent poisoning and stress-induced symptoms. Obviously as more<br />
severe effects develop, the syndromes become easier to differentiate.<br />
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Slide 32<br />
Similar to minor nerve agent poisoning, low dose cyanide exposure can cause<br />
symptoms very similar to that <strong>of</strong> mass psychogenic illness. As cyanide poisoning<br />
progresses, the diagnosis becomes more obvious.<br />
Again, it is important to remember that psychological effects should be diagnosed with caution.<br />
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Slide 33<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Is there a solution<br />
www.bu.edu<br />
commons.wikimedia.org<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
33<br />
It requires some aspects <strong>of</strong> psychiatry and detective work to work through some <strong>of</strong> these<br />
cases – both the nature <strong>of</strong> the potential exposures and the likelihood <strong>of</strong> toxic vs.<br />
psychological symptoms (or a mixture).<br />
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Slide 34<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Is it Real<br />
• Emergency Response<br />
– Don’t get caught up on figuring out if it exists or not<br />
– “Psychogenic illness ” is a diagnosis <strong>of</strong> exclusion<br />
– Create a “holding environment ”<br />
• Location away from high -tempo triage activities<br />
• Symptoms monitored and re -evaluated<br />
• Research<br />
– Need <strong>for</strong> good epidemiological data that clarifies<br />
characteristics <strong>of</strong> each group (defines needs)<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
34<br />
Don’t ask this question. Assume it is real, until and unless you have very good evidence<br />
<strong>of</strong> psychogenic/stress-response symptoms only.<br />
People should be placed in as “low stress” an environment as possible and re-evaluated<br />
<strong>for</strong> under-triage based on a developing case definition as more in<strong>for</strong>mation becomes<br />
available. Characterizing the response <strong>of</strong> various groups (e.g. vulnerable populations) is<br />
still an area that needs more research.<br />
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Slide 35<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Planning Suggestions<br />
• Expect the problem – Plan <strong>for</strong> it<br />
• “Base disaster plans on what people are likely to do rather<br />
than what they should do ”<br />
Auf der Heide : Disaster Response: Principles <strong>of</strong> Preparation and Response<br />
• Don’t ignore these patients<br />
– And take them seriously<br />
• Early diagnostic & management decisions are critical to the<br />
success <strong>of</strong> the emergency response<br />
– EDs have little surge capacity<br />
– Decontamination and PPE burden the health care system<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
35<br />
The problem <strong>of</strong> stress-response symptoms and their effect on both the number <strong>of</strong> people<br />
presenting <strong>for</strong> evaluation and the interpretation <strong>of</strong> clinical presentations is very real and<br />
should be incorporated into disaster planning.<br />
As one <strong>of</strong> the CDC–based emergency physicians has written, disaster plans should be<br />
based on what people are LIKELY to do, rather than what they SHOULD do.<br />
Since you can be sure that people will seek care if concerned or scared – and will not<br />
wait <strong>for</strong> an orderly triage or decontamination process in the field – we should plan to<br />
direct people arriving to our hospitals to an area that allows <strong>for</strong> secondary triage, to<br />
avoid overwhelming the acute care areas. Expert assistance should be sought to<br />
determine the actual need <strong>for</strong> decontamination, and the need <strong>for</strong> or level <strong>of</strong> personal<br />
protective equipment (PPE).<br />
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Slide 36<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Training Suggestions<br />
• Teach emergency responders basic toxicology<br />
principles<br />
– e.g. Dose -Response (“dose makes the poison ”)<br />
• Look <strong>for</strong> objective signs <strong>of</strong> toxicity<br />
– Toxidrome recognition<br />
• Irritant Gas Syndrome<br />
• “Knock-down” or metabolic poisoning<br />
• Opioid intoxication<br />
• Cholinergic/Cholinesterase inhibitor<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
36<br />
Emergency responders have an important role in evaluating patients and the scene <strong>of</strong><br />
an event. Developing an appreciation <strong>for</strong> possible exposure pathways (e.g. inhaling a<br />
vapor or gas) and the effects <strong>of</strong> dose (identification <strong>of</strong> possible point source release and<br />
severity <strong>of</strong> symptoms based on proximity to same) are important pieces <strong>of</strong> in<strong>for</strong>mation as<br />
we attempt to identify a toxic exposure or psychogenic symptom source.<br />
In a mass casualty event, approach patients looking <strong>for</strong> common elements that define a<br />
cluster <strong>of</strong> symptoms and signs (a toxidrome). We have not covered all <strong>of</strong> the possible<br />
syndromes in this course, but have provided a framework to apply to any situation.<br />
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Slide 37<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Improve Communications<br />
• In<strong>for</strong>mation is the ANTIDOTE <strong>for</strong> fear<br />
• Make substance identification a priority and report to health<br />
care providers as soon as possible<br />
• Make inter-agency coordination a priority in planning<br />
– Strive <strong>for</strong> “single voice ” communications with the media and the<br />
public. When you speak, you speak <strong>for</strong> all <strong>of</strong> us!<br />
• Teach risk communication skills to ALL responders<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
37<br />
Accurate in<strong>for</strong>mation is the “antidote” <strong>for</strong> fear; but inaccurate or wrong in<strong>for</strong>mation can<br />
be “poisonous”, resulting in frustration, mistrust and bad patient care. Previous disaster<br />
events illustrate the problem <strong>of</strong> communications during a crisis. Communications at all<br />
levels is crucial to emergency response planning.<br />
Accurate in<strong>for</strong>mation and flow <strong>of</strong> in<strong>for</strong>mation is critical to a successful emergency<br />
response.<br />
Plans should include contingencies <strong>for</strong> communication breakdown and problems with<br />
inaccurate and changing in<strong>for</strong>mation. If the described symptoms do not fit the<br />
“identified” compound, seek verification. All early messages should stress the dynamic<br />
or uncertain nature <strong>of</strong> such in<strong>for</strong>mation. Emphasize some <strong>of</strong> the common mistakes made<br />
with substance identification (e.g. hydrochloric acid <strong>for</strong> hydr<strong>of</strong>luoric acid) and the need to<br />
compare toxidromes with stated agents.<br />
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Slide 38<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Unconventional Partnerships<br />
• Behavioral care experts<br />
• Epidemiologists<br />
– Develop tools to evaluate behaviors during catastrophic events<br />
– Evidence based planning based on Social -behavioral observations<br />
• Medical Toxicologists<br />
– Medical Toxicologists are clinical experts in the human health e ffects<br />
<strong>of</strong> poisoning<br />
– Accessed through ACMT, poison centers, or direct contact<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
38<br />
Emergency response planning should utilize experts from a number <strong>of</strong> different areas,<br />
including behavioral health, epidemiology, toxicologists. The goal is to have a<br />
coordinated flow <strong>of</strong> in<strong>for</strong>mation and resources to provide the most appropriate care to<br />
those who need it. Medical Toxicologists are experts in the area <strong>of</strong> human health effects<br />
from poisoning. We need to work closely with other experts to most effectively respond<br />
to mass chemical exposures.<br />
Uncertainty creates anxiety. The sooner the identification <strong>of</strong> the causative agent(s) is<br />
confirmed, the more reliable health risk in<strong>for</strong>mation and treatment recommendations can<br />
be provided.<br />
Most importantly, ALL experts should work together within the National Incident<br />
Management System (NIMS) unified command structure so that a “single message” is<br />
given to the community. Conflicting in<strong>for</strong>mation from “experts” will raise the anxiety <strong>of</strong><br />
the community and may increase the number <strong>of</strong> victims seeking aid <strong>for</strong> reassurance or<br />
anxiety-induced physical symptoms.<br />
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Slide 39<br />
There are many excellent sources <strong>of</strong> in<strong>for</strong>mation to assist in planning including the CDC<br />
website and ATSDR Planning Guide depicted here. It is anticipated that the extent <strong>of</strong><br />
future disasters can be minimized, particularly in terms <strong>of</strong> psychological casualties and<br />
inappropriate testing and treatment, by using expertise available to emergency<br />
responders and planners.<br />
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Slide 40<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>:<br />
<strong>TICs</strong> & <strong>TIMs</strong><br />
Summary<br />
• Expect large numbers <strong>of</strong> patients after mass chemical exposure<br />
– Often difficult to identify those needing immediate medical care<br />
• Avoid labels without objective diagnostic criteria<br />
– “Worried well ”, “Mass hysteria ” less helpful than “I know you are worried;<br />
things check out OK now. I will check on you again …”<br />
• Use historic lessons, expected behaviors to guide planning<br />
• Communication is Key<br />
– Interagency coordination may avoid needless fear<br />
• Know your resources and partner with them<br />
– Including ACMT/Medical Toxicologists<br />
Module One – Observed Behaviors during Mass <strong>Chemical</strong> Exposures<br />
40<br />
In summary, we should expect large numbers <strong>of</strong> patients after a potential mass chemical<br />
exposure; some will be in need <strong>of</strong> urgent treatment, some will have a variety <strong>of</strong> nonspecific<br />
stress-induced symptoms, and others will just be concerned.<br />
Rather than labeling these people, we should strive to acknowledge their concerns,<br />
assess their physical status and re-evaluate their condition.<br />
Planning <strong>for</strong> large numbers <strong>of</strong> patients with various needs should be a routine part <strong>of</strong> our<br />
disaster planning. Improving communication and utilizing the expertise available<br />
regionally and nationally are important steps in preparing <strong>for</strong> chemical terrorism and<br />
HazMat events.<br />
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Slide 41<br />
<strong>Chemical</strong> <strong>Agents</strong> <strong>of</strong> <strong>Opportunity</strong> <strong>for</strong> <strong>Terrorism</strong>: <strong>TICs</strong> & <strong>TIMs</strong><br />
Questions<br />
Training Support Package<br />
41<br />
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Module Eight Summary<br />
The initial stages <strong>of</strong> a mass chemical exposure, particularly one <strong>of</strong> unknown origin or malicious<br />
intent, engender fear and anxiety in the general population and have the potential overwhelm<br />
clinical centers. After a mass chemical exposure the vast majority <strong>of</strong> individuals presenting <strong>for</strong><br />
treatment or screening will be the worried well. Adding to the burden <strong>of</strong> identifying those who<br />
need immediate care and reassuring those who do not, stress reactions among patients (and<br />
medical personnel) may closely mimic the symptoms <strong>of</strong> certain chemical exposures.<br />
As was seen with past chemical exposure crises (1991 Gulf War concerns, 1995 Tokyo sarin<br />
attack, 1984 Union Carbide Bhopal disaster) patients remote from the event may exhibit<br />
symptoms. Given the added triage burden, medical personnel may be inclined to err on the side<br />
<strong>of</strong> caution when dealing with potentially exposed patients. However, injudicious or over-liberal<br />
application <strong>of</strong> decontamination procedures and aggressive antidotal therapies (e.g. atropine,<br />
cyanide antidote kit) can itself pose a risk to health.<br />
In order to minimize the added burden on the system and preempt unnecessary clinical visits it<br />
is critical that in<strong>for</strong>mation regarding the event be rapidly and widely disseminated. In past<br />
crises, lack <strong>of</strong> communication between agencies and the absence <strong>of</strong> central guidance has been<br />
a major contributory factor. In order to effectively manage the public reaction to a crisis, the<br />
media’s message must be an integral part <strong>of</strong> the risk communication plan.<br />
Stress reactions to chemical release follow a somewhat predictable progression. This process<br />
begins when a subject becomes aware <strong>of</strong> the release or potential release <strong>of</strong> a dangerous toxin.<br />
Past studies have shown that the initial fear response is augmented or mitigated by the novelty<br />
<strong>of</strong> the agent at hand, the subject’s knowledge regarding the agent, whether or not antidotes or<br />
therapies exist <strong>for</strong> the treatment <strong>of</strong> this exposure, and whether or not the agent itself can be<br />
detected and/or identified.<br />
A natural fear that one has been exposed engenders a heightened awareness <strong>of</strong> body<br />
sensations. Minor symptoms or observations may become magnified thereby exacerbating the<br />
initial reaction and potentially leading to autonomic arousal. The outward signs <strong>of</strong> this autonomic<br />
arousal may be misinterpreted as symptoms <strong>of</strong> exposure.<br />
Further complicating matters, many <strong>of</strong> the non-specific symptoms relating to stress reactions<br />
may themselves closely mimic signs <strong>of</strong> chemical exposure (headache, dizziness, nausea,<br />
mucous membrane irritation, numbness, weakness, drowsiness).<br />
Disaster management and appropriate planning <strong>for</strong> a mass chemical exposure should focus on<br />
what people are likely to actually do during an emergency. While overt labeling <strong>of</strong> subjects as<br />
“hysterical” or “worried-well” can be stigmatizing, any response plan must consider the burden<br />
from both psychological and physical casualties.<br />
It is critical that triage staff not become preoccupied attempting to determine if a given exposure<br />
is “real”. As psychogenic illness is generally a diagnosis <strong>of</strong> exclusion, triage strategies should<br />
focus on identifying toxic syndromes and addressing objective signs <strong>of</strong> exposure. While caution<br />
is warranted, one should presume symptomatic patients are poisoned unless other evidence<br />
exists.<br />
Risk communication should be tightly coordinated to ensure all groups speak with the same<br />
voice. Careful interagency planning and coordination supported by risk communication training<br />
<strong>for</strong> staff is key. A comprehensive approach should focus on building partnerships between first<br />
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responders, clinical staff, health departments, emergency services personnel, behavioral<br />
experts, and medical toxicologists.<br />
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