Medical Aspects of Chemical Warfare (2008) - The Black Vault

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Toxic Inhalational Injury and Toxic Industrial Chemicalsmay cause hypotension that may be exacerbated bypositive airway pressure. Due to fluid shifts, urgentintravenous administration of either crystalloidor colloid solution (which in this situation appearequally effective) and the use of a pulmonary arterycatheter monitor (to avoid excessive fluid administration)may be required to maintain appropriatefluid balance while treating hypotension. The useof vasopressors is a temporary measure until fluidscan be replaced.Clinical CareAcute lung injury is one of the causes of noncardiogenicpulmonary edema, which causes an increase inlung vascular permeability, leading to accumulationof protein-rich edema in the interstitial and air spaces.Cardiogenic or high-pressure pulmonary edema iscaused by elevated pulmonary venous pressure fromleft ventricular dysfunction, valvular disease, or intravascularvolume overload. In addition to ARDS,noncardiogenic pulmonary edema is referred to as“clinical acute lung injury.” The care of these patientsrequires careful attention to the underlying causessuch as a treatable pulmonary infection. The modesof mechanical ventilation and hemodynamic managementin ARDS patients have been controversial foryears, although the National Institutes of Health andother institutions have established a protocol for ARDSpatients on mechanical ventilation. Discussion of thisprotocol and any other strategies is beyond the scopeof this chapter; however, one certainty is that ARDSmanagement demands quick recognition and intensivecare protocols. 100,101Patient TransportLung-damaging TIC casualties may need to beevacuated to a higher level of care if the receiving facilitydoes not have an intensive care setting. When acasualty is transferred to a higher level of care, supplementaloxygen and appropriate evaluation monitorsmust be provided.Long-Term EffectsThe replacement of damaged airway epitheliumwith granular tissue is one of the major etiologiesof chronic lung disease following centrally actingchemical agents such as ammonia. 91 See Chapter 9,Long-Term Health Effects of Chemical Threat Agents,for more detail.SUMMARYThe respiratory system, both the central and peripheralcompartments, can efficiently absorb inhaled lungdamagingagents, leading to airway and pulmonaryinjury. Few specific antidotes exist for treating inhaledtoxicants. Common pathophysiologic pathways linkthe syndrome of acute inhalation injury to preferentialmethods of clinical treatment. Understandingthe mechanisms of inhalation injury can simplify thedecision-making process for treating a casualty with apotential lung-damaging TIC inhalation exposure.AcknowledgmentThe authors wish to thank the following individuals for their efforts: Jennifer L Collins, biologist(USAMRICD), for reviewing the manuscript, and Peter Hurst, graphic designer (USAMRICD), forartwork.REFERENCES1. US Army Medical Research Institute of Chemical Defense. Medical Management of Chemical Casualties Handbook. 4thed. Aberdeen Proving Ground, Md: USAMRICD, Chemical Casualty Care Division; 2007.2. Beswick FW. Chemical agents used in riot control and warfare. Hum Toxicol. 1983;2:247–256.3. Stockholm International Peace Research Institute. Chemical/Biological Weapons and Biological Warfare. Vol 1 in: The Problemof Chemical and Biological Warfare. New York, NY: Humanities Press, 1971.365
Medical Aspects of Chemical Warfare4. Jackson KE. Phosgene. J Chem Educ. 1933;622–626.5. Elsayed NM, Salem H. Chemical warfare agents and nuclear weapons. In: Salem H, Katz SA, eds. Inhalation Toxicology.2nd ed. Boca Raton, Fla: CRC/Taylor & Francis; 2006: Chap 22.6. Gilchrist H. The residual effects of warfare gases: the use of phosgene gas, with report of cases. Med Bull Vet Admin.1933;10:1–36.7. Department of the Army. Employment of Riot Control Agent CS. San Francisco, Calif: HQ, 25th Infantry Division; 1970.DA Letter of Instructions 23–70.8. US Army Center for Health Promotion and Preventive Medicine. Industrial Chemical Prioritization and Determinationof Critical Hazards of Concern. Aberdeen Proving Ground, Md: USACHPPM; 2003: Appendix B. USACHPPM Report47-EM-6154-03.9. Walton M. Industrial ammonia gassing. Br J Ind Med. 1973;30:78–86.10. Das R, Blanc PD. Chlorine gas exposure and the lung: a review. Toxicol Ind Health. 1993;9:439–455.11. Baxter PJ, Davies PC, Murray V. Medical planning for toxic releases into the community: the example of chlorine gas.Br J Ind Med. 1989;46:277–285.12. Ballantyne B, Callaway S. Inhalation toxicology and pathology of animals exposed to o-chlorobenzylidene malononitrile(CS). Med Sci Law. 1972;12:43–65.13. Hu H, Christiani D. Reactive airways dysfunction after exposure to teargas. Lancet. 1992;339:1535.14. Olajos EJ, Salem H. Riot control agents: pharmacology, toxicology, biochemistry and chemistry. J Appl Toxicol.2001;21:355–391.15. Norris JC, Ballantyne B. Toxicology and implications of the products of combustion. In: Ballantyne B, Marrs TC, SyversenT, eds. General and Applied Toxicology. 2nd ed. London, England: Macmillan; 1999: 1915–1933.16. Isom GE, Way JL. Effects of oxygen on the antagonism of cyanide intoxication: cytochrome oxidase, in vitro. ToxicolAppl Pharmacol. 1984;74:57–62.17. Oehme FW, Rumbeiha WK. Veterinary toxicology. In: Ballantyne B, Marrs TC, Syversen T, eds. General and AppliedToxicology. 2nd ed. London, England: Macmillan; 1999: Chap 69.18. Burnett WW, King EG, Grace M, Hall WF. Hydrogen sulfide poisoning: review of 5 years’ experience. Can Med AssocJ. 1977;117:1277–1280.19. Haahtela T, Marttila O, Vilkka V, Jäppinen P, Jaakkola JJ. The South Karelia Air Pollution Study: acute health effectsof malodorous sulfur air pollutants released by a pulp mill. Am J Public Health. 1992;82:603–605.20. Reiffenstein RJ, Hulbert WC, Roth SH. Toxicology of hydrogen sulfide. Annu Rev Pharmacol Toxicol. 1992;32:109–134.21. Morgan WKC, Seaton A. Toxic gases and fumes. In: Morgan WKC, Seaton A, eds. Occupational Lung Diseases. 2nd ed.Philadelphia, Pa: WB Saunders Company; 1984: Chap 20.22. Karpov BD. Establishment of upper and lower toxicity parameters of perfluoroisobutylene toxicity. Tr Lenig Sanit-GigMed Inst. 1977;III:30–33.23. Oberdorster G, Gelein RM, Ferin J, Weiss B. Association of particulate air pollution and acute mortality: involvementof ultrafine particles? Inhal Toxicol. 1995;7:111–124.24. Chemical profile for phosgene. Chemical Market Reporter. June 21, 1999:1–4.366
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The Coat of Arms1818Medical Departm
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Textbooks of Military MedicinePubli
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MEDICAL ASPECTS o fCHEMICAL WARFARE
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ContentsContributorsForeword by The
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ContributorsMICHAEL ADLER, PhDResea
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DONALD M. MAXWELL, MSResearch Chemi
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ForewordThe US military has been co
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PrefaceA significant concern for th
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PrologueThe original edition of Med
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xxii
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Medical Aspects of Chemical Warfare
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Nerve AgentsChapter 5NERVE AGENTSFR
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Nerve AgentsAbout 10,000 to 30,000
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Nerve Agentsphorofluoridate (DFP) w
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Nerve AgentsFig. 5-2. This schemati
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Nerve AgentsExhibit 5-1 continuedis
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Nerve Agentsactivity but only 15% t
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Nerve AgentsTABLE 5-3CHEMICAL, PHYS
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Nerve AgentsTABLE 5-4EFFECTS OF EXP
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Nerve Agentsaffecting the other eye
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Nerve Agentsmay cause severe rhinor
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Nerve Agentsof jerks and tremor.Cen
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Nerve Agentsand they were decreased
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Nerve Agentsnerve agent toxicity on
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Nerve Agentspatient. Decontaminatio
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Nerve AgentsFig. 5-5. The Mark I ki
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Nerve Agentsadministered intramuscu
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Nerve Agentsthat hydroxamine reacti
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Nerve AgentsOral administration may
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Nerve AgentsTABLE 5-7RECOMMENDED TH
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Nerve Agentsimpairment such as whee
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Nerve Agentssuboptimal, manner. The
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Nerve Agentsthan those who did not.
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Nerve Agentssible for binding nerve
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Nerve Agentsfor comparison was not
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Nerve AgentsTABLE 5-11EFFECTS OF PY
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Nerve Agentstivity of smooth muscle
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Nerve Agents38. Grob D, Lilienthal
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Nerve Agents77. McDonough JH, Shih
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Nerve Agents117. McLeod CG Jr, Sing
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Nerve Agents154. Tryphonas l, Veino
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Nerve Agents193. Funckes AJ. Treatm
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Nerve Agents235. Suzuki T, Morita H
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Nerve Agents274. Pellegrini JE, Bak
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Page 375 and 376: PROCESSMedical Aspects of Chemical
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Triage of Chemical CasualtiesChapte
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Triage of Chemical Casualtiesreceiv
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Triage of Chemical Casualtiescatego
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Triage of Chemical CasualtiesIn a f
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Triage of Chemical Casualtiesnose)
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Triage of Chemical CasualtiesWith n
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Triage of Chemical Casualties14. Sa
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Decontamination of Chemical Casualt
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• Analyze using GC-MS with methan
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Abbreviations and AcronymsAbBreviat
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Abbreviations and AcronymsPADPRP: p
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