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

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Incapacitating AgentsTABLE 12-1DIFFERENTIAL DIAGNOSIS FOR INCAPACITATING AGENTSSign or SymptomRestlessness, dizziness, giddiness, failure to obey orders, confusion, erratic behavior,stumbling or staggering, vomitingDryness of mouth, tachycardia at rest, elevated temperature, flushed face, blurredvision, pupillary dilation, slurred or nonsensical speech, hallucinatory behavior,disrobing, mumbling, picking behavior, stupor, comaInappropriate smiling or laughing; irrational fear; distractibility; difficulty expressingself; perceptual distortions; labile increases in pupil size, heart rate, and bloodpressure; stomach cramps and vomitingEuphoria, relaxation, day-dreaming, unconcerned attitude, easy laughter, hypotension,and dizziness on sudden standingTremor, clinging or pleading, crying, clear answers, decrease in disturbance withreassurance, history of nervousness or immaturity, phobias, bodily disturbancessuch as blindness and paralysisSleepiness, ataxia, rapid unconsciousness, miosis, reduced quality of respirationsdecrease with resulting respiratory depressionPossible EtiologyAnticholinergics, indoles,cannabinoids, anxiety reaction,other intoxications (such asalcohol, bromides, lead,barbiturates)AnticholinergicsIndoles (may mimic schizophrenicpsychosis in some respects)CannabinoidsAnxiety reactionFentanyl (carfentanyl)Data sources: (1) Departments of the Army, Navy, and Air Force, and Commandant, Marine Corps. Treatment of Chemical Agent Casualtiesand Conventional Military Chemical Injuries. Washington, DC: HQ: DA, DN, DAF, Commandant, MC1995: 3–1. Field Manual 8-285, NAVMEDP-5041, AFJMan 44-149, FMFM 11-11. (2) US Army Medical Research Institute of Chemical Defense. Medical Management of Chemical CasualtiesHandbook. 4th ed. Aberdeen Proving Ground, Md: USAMRICD; 2007.EXHIBIT 12-1SUMMARY OF BZ AND FENTANYL DERIVATIVES• Signs and symptoms¢ BZ and other glycolates: mydriasis; dry mouth; dry skin; increased deep tendon reflexes; decreased levelof consciousness; confusion; disorientation; disturbances in perception and interpretation (illusions and/or hallucinations); denial of illness; short attention span; impaired memory.¢ Fentanyl derivatives (carfentanil): dizziness, sleepiness, ataxia, miosis (if there is no hypoxia; with hypoxiathere is pupil dilation), rapid unconsciousness, vomiting, decreased respirations, central apnea, coma.• Field detection: No field detector is available for either BZ or fentanyl derivatives.• Decontamination¢ BZ: gentle but thorough flushing of skin and hair with water or soap and water is all that is required.Remove clothing.¢ Fentanyl derivatives (carfentanil): No decontamination required.• Management¢ BZ• Antidote: physostigmine.• Supportive: monitoring of vital signs, especially core temperature.¢ Fentanyl derivatives (carfentanil)• Antidote: opioid antagonist naloxone/naltrexone.• Supportive: monitoring of vital signs. Proper positioning of patient to maintain airway is critical untileffects of central respiratory depression diminish.Adapted from: US Army Medical Research Institute of Chemical Defense. Medical Management of Chemical Casualties Handbook. 4thed. Aberdeen Proving Ground, Md: USAMRICD; 2007.429
Medical Aspects of Chemical WarfareEXHIBIT 12-2ANCILLARY SUPPORTIVE MEASURES FOR THE TREATMENT OF DELIRIUM• Control and containment are of primary concern because delirium can easily lead to accidentsand inadvertent injury to others. Comatose or stuporous casualties may emerge from immobilityinto a stage of persistent crawling or attempted climbing (primitive behaviors sometimes called“progresso ostinato” [obstinate progression] in 19th-century descriptions of delirium). Tetheringor otherwise loosely restraining individuals who are disoriented is preferable to letting them moveabout freely without close supervision.• The danger of hyperthermia must be considered if the environment is warmer than 75°F. Deathfrom relatively low doses of anticholinergics has occurred due to impairment of sweating. Wetcloth is effective to reduce body temperature, and the casualty should be placed in the shade, ifavailable.• Dryness of the mouth and parching of the lips should be managed with moist swabs and smallamounts of vaseline or unguents. Fluids should be given sparingly and food withheld until theindividual is obviously capable of normal chewing and swallowing. If it is determined that thepatient is cognizant enough to manage foods and has oral motor skills, hard candy may be givento induce sufficient salivation to keep the tongue moist.• Significant skin abrasions can be caused by persistent repetitive movements, especially againstrough surfaces. The use of wrappings or gloves may be useful. A tendency to remove clothingis common, and reflects a general regression to simple habitual behaviors. If the environment isharsh, the casualty’s clothing may have to be secured so it cannot be removed.• Evacuation from the field to more adequate medical facilities is desirable in most cases. If evacuationis not possible, separation of the affected individuals into small groups (eg, in tents) is preferableto large aggregations, in which a few confused and hyperactive individuals can lead to anescalating problem of crowd control.Adapted from: Ketchum JS, Sidell, FR. Incapacitating agents. In: Sidell FR, Takafuji ET, Franz DR, eds. Medical Aspects of BiologicalWarfare. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. Washington, DC: Department of the Army, Office of The SurgeonGeneral, Borden Institute; 1997: 301.Medical ManagementThe standard measures for management of casualtiesapply to victims of incapacitating agents. Followingprovisional diagnosis, removal of the patientfrom the offending environment and decontaminationare required. If aggressive agitation or deliriumis present, segregation and even restraint measuresmay be needed, which should not be regarded aspunitive (a volunteer who was grossly incompetentduring an indoor simulation of a military outpostlater commented that in battle he should be tiedto a tree, since he would at least be protected fromdangerous acts and would not remember it lateranyway).During the Korean conflict, Colonel Albert Glassand colleagues concluded that treatment close to thefront lines produced a better psychiatric outcomethan evacuation to medical facilities further to therear. Heavy sedation was effective in dimming thememory of traumatic aspects of injury in patientswhose primary problem was emotional. More oftenthan not, a 3-day period of treatment with sedativesand supportive measures was sufficient to restorethe fighting capacity of the affected soldier. This approachto treatment applies to incapacitating agentsequally well when used with the appropriate antidotalregimen. Finally, as in any emergency, goodtraining and common sense are the most importantingredients of good care. Exhibit 12-2 lists ancillarysupportive measures for the treatment of casualtieswith delirium.430
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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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PROCESSMedical Aspects of Chemical
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Page 401 and 402: Medical Aspects of Chemical Warfare
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Triage of Chemical CasualtiesChapte
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Triage of Chemical Casualtiesreceiv
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Triage of Chemical Casualtiesentran
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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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