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Bioterrorism for Nevada Nurses
This course has been awarded
four (4.0) contact hours.
This course expires on January 18, 2016.
All Rights Reserved. Reproduction and distribution of these materials are prohibited without the express written authorization of RN.com. Revised: January 3, 2007 Revised: January 3, 2009 Acknowledgements
RN.com acknowledges the valuable contributions of…
…The Centers for Disease Control (CDC) (www.cdc.gov), the key government agency responsible
for disseminating knowledge about various biological agents.

…U.S. Medical Research Institute of Infectious Diseases (USAMRRID).
USAMRRID spearheads
efforts to protect service members from biological threats. Its efforts are well known and utilized by
the civilian population. USAMRRID is located at Fort Detrick, Maryland.
….Nadine Salmon, MSN, BSN, IBCLC is the Clinical Content Manager for RN.com. She is a South
African trained Registered Nurse, Midwife and International Board Certified Lactation Consultant.
Nadine obtained an MSN at Grand Canyon University, with an emphasis on Nursing Leadership. Her
clinical background is in Labor & Delivery and Postpartum nursing, and she has also worked in
Medical Surgical Nursing and Home Health. Nadine worked for the international nurse division of
American Mobile Healthcare, prior to joining the Education Team at RN.com. Nadine is the Lead
Nurse Planner for RN.com and is responsible for all clinical aspects of course development. She
updates course content to current standards, and develops new course materials for RN.com.
…Karen Siroky, RN, MSN, original course coordinator of Bioterrorism for Nevada Nurses.
Purpose and Objectives
The purpose of this course is to provide the learner with information needed to prepare for and
respond to a bioterrorism attack in the state of Nevada.
After successful completion of this course, you will be able to:
1. Identify common acts of terrorism.
3. Identify the appropriate personal protective equipment required for exposure or potential exposure to a weapon of mass destruction due to an act of terrorism. 4. Identify common symptoms and methods of treatment associated with exposure to, or injuries caused by, chemical, biological, radioactive, and nuclear agents. 5. Define Syndromic Surveillance and reporting procedures for acts of terrorism that involve 6. Identify several types of information available on the Health Alert Network. RN.com strives to keep its content fair and unbiased. The author(s), planning committee, and reviewers have no conflicts of interest in relation to this course. Conflict of Interest is defined as circumstances a conflict of interest that an individual may have, which could possibly affect Education content about products or services of a commercial interest with which he/she has a financial relationship. There is no commercial support being used for this course. Participants are advised that the accredited status of RN.com does not imply endorsement by the provider or ANCC of any commercial products mentioned in this course. There is no "off label" usage of drugs or products discussed in this course. You may find that both generic and trade names are used in courses produced by RN.com. The use
of trade names does not indicate any preference of one trade named agent or company over another.
Trade names are provided to enhance recognition of agents described in the course.
Note: All dosages given are for adults unless otherwise stated. The information on medications
contained in this course is not meant to be prescriptive or all-encompassing. You are encouraged to
consult with physicians and pharmacists about all medication issues for your patients.
Introduction
Bioterrorism is a national security issue. Numerous state and federal agencies are dedicated to
prevention, reporting, and management of any potential terrorist act.
For the purposes of this course, bioterrorism will include more than just biological agents. Discussion
will include biological, chemical, radiological, and nuclear weapons.
Federal, state, and local agencies are working together to define plans and run mock drills that will
assist in a response to any biological terrorist attack.
Although this course is designed to meet the Nevada state requirements, healthcare workers outside
of Nevada may also find it useful.
Glossary
Biological agents: Are infectious microbes or toxins used to produce illness or death in people,
animals, or plants.
British Anti-Lewisite (BAL): Also known as dimercaprol. Is an ointment used to treat skin affected
by lewisite exposure.
BW: Biological Warfare
CG: Military term for Phosgene
EHRBCHET: The Environmental Health Readiness Branch Chemical Weapons Elimination Team
FEMA: Federal Emergency Management Agency
GB: Military term for Sarin, a human-made chemical warfare agent classified as a nerve agent.
HFRS: Hemorrhagic Fever with Renal Syndrome
L: Military designation for lewisite.
PPE: Personal Protective Equipment
Sulfur mustard: Also known as mustard gas or mustard agent, or by the military designations H, HD,
and HT.
USAMRIID: U.S Army Medical Research Institute of Infectious Diseases
VHF: Viral Hemorrhagic Fevers
WMD: Weapons of Mass Destruction

Terrorism

The Federal Emergency Management Agency (FEMA) defines terrorism as the use of force or
violence against persons or property in violation of the criminal laws of the United States for purposes
of intimidation, coercion, or ransom. Terrorists often use threats to create fear among the public, to try
to convince citizens that their government is powerless to prevent terrorism, and to obtain immediate
publicity for their causes.
Terrorists usually select targets that will produce large numbers of casualties, so most acts of
terrorism will also be Mass Casualty Incidents, also known as MCIs. This means that healthcare
providers and facilities will have to change the way they normally practice to appropriately respond to
an act of terrorism.
Weapons of Mass Destruction
Weapons of Mass Destruction (WMD) encompass a broad family of weapons, including:
• Other advanced weapons
These weapons are characterized by their broad-sweeping intended effects, such as inflicting mass
casualties and/or physical destruction (Virginia Tech office of the Vice President for Research, 2007).
Although this course is called “Bioterrorism,” the scope will include information about the major types
of weapons of mass destruction including: biological, chemical, radiologic, and nuclear.
Biological and Chemical Weapons
Biological agents are infectious microbes or toxins used to produce illness or death in people,
animals, or plants. Biological agents can be dispersed as aerosols or airborne particles. Terrorists
may use biological agents to contaminate food or water because they are extremely difficult to detect.
Chemical agents kill or incapacitate people, destroy livestock, or ravage crops. They can have an
immediate effect (a few seconds to a few minutes) or a delayed effect (several hours to several days).
Biological and chemical weapons have been used primarily to terrorize an unprotected civilian
population and not as weapons of war. This is because of fear of retaliation and the likelihood that the
agent would contaminate the battlefield for a long period of time. The Persian Gulf War in 1991 and
other confrontations in the Middle East caused concern in the United States regarding the possibility
of chemical or biological warfare. While no incidents occurred, there remains a concern that such
weapons could be involved in an accident or be used by terrorists.
Clues to a Biologic Warfare (BW) or Terrorist Attack
There can be epidemiologic clues to a bioterrorist attack. The U.S Army Medical Research Institute of
Infectious Diseases (USAMRIID) located at Fort Derick, Maryland lists the following as clues to a
possible biologic related terrorist attack:
• The presence of a large epidemic with a similar disease or syndrome, especially in a discrete • Many cases of unexplained diseases or deaths • More severe disease than is usually expected for a specific pathogen, or failure to respond to • Unusual routes of exposure for a pathogen, such as the inhalational route for diseases that • A disease that is unusual for a given geographic area or transmission season • Disease normally transmitted by a vector that is not present in the local area • Multiple simultaneous or serial epidemics of different diseases in the same population
Clues to a Biologic Warfare (BW) or Terrorist Attack
• A single case of disease by an uncommon agent (smallpox, some viral hemorrhagic fevers) • A disease that is unusual for an age group • Unusual strains or variants of organisms or antimicrobial resistance patterns different from • Similar genetic type among agents isolated from distinct sources at different times or locations • Higher disease rates in those exposed in certain areas, such as inside a building if released indoors, or lower rates in those inside a sealed building if released outside • Disease outbreaks of the same illness occurring in noncontiguous areas • A disease outbreak with zoonotic impact • Intelligence of a potential attack, claims by a terrorist or aggressor of a release, and discovery of munitions or tampering (USAMRIID, 2005)
Nuclear and Radiologic Weapons
Radiation is a form of energy that is present all around us. Different types of radiation exist, some of
which have more energy than others. Radiation released into the environment is measured in units
called curies. However, the dose of radiation that a person receives is measured in units called rem.
Possible terrorist events could involve introducing radioactive material into the food or water supply,
using explosives (like dynamite) to scatter radioactive materials (“dirty bomb”), bombing or destroying
a nuclear facility, or exploding a small nuclear device. Although introducing radioactive material into
the food or water supply could cause great concern or fear, it probably would not cause much
contamination or increase the danger of adverse health effects. A dirty bomb could cause serious
injuries from the explosion, it most likely would not have enough radioactive material in a form that
would cause serious radiation sickness among large numbers of people.
Nuclear and Radiologic Weapons
An explosion at a nuclear facility could cause a large amount of radioactive material to be released.
People at the facility would be contaminated with radioactive material and possibly be injured if there
was an explosion. Those people who received a large dose might develop acute radiation syndrome.
People in the surrounding area could be exposed or contaminated. After a nuclear explosion,
radioactive fallout would extend over a large region far from the point of impact, potentially increasing
people's risk of developing cancer over time.

Syndromic Surveillance
Syndromic surveillance has been used for early detection of outbreaks to follow the size, spread, and
tempo of outbreaks, to monitor disease trends, and to provide reassurance that an outbreak has not
occurred. Syndromic surveillance systems seek to use existing health data in real time to provide
immediate analysis and feedback to those charged with investigation and follow-up of potential
outbreaks. Optimal syndrome definitions for continuous monitoring and specific data sources best
suited to outbreak surveillance for specific diseases have not been determined. Broadly applicable
signal-detection methodologies and response protocols that would maximize detection while
preserving scant resources are being sought.
There are advantages and disadvantages to syndromic surveillance systems. Syndromic surveillance
systems might enhance collaboration among public health agencies, healthcare providers,
information-system professionals, academic investigators, and industry. However, syndromic
surveillance does not replace traditional public health surveillance, nor does it substitute for direct
physician reporting of unusual or suspect cases of public health importance.
Categories of Biological Agents
Potential agents of bioterrorism are classified into 3 categories, depending on how easily they can be
spread and the severity of illness or death they cause:
Category A agents: Considered the highest risk and the highest priority.
Category B agents: Are the second highest priority.
Category C agents: Are the third highest priority and include emerging pathogens that could be
engineered for mass spread in the future.
Healthcare providers must be prepared to address various biological agents.
Category A Biological Agents
For each agent in Category A described in this course, we present an overview, symptoms,
treatments, vaccines, and decontamination issues. At the end of this section there is a discussion on
decontamination in general.
U.S Army Medical Research Institute of Infectious Diseases (USAMRIID)
(www.usamriid.army.mil/education/), located at Fort Derick, MD is the source of the critical
information on the various Category A potential agents of bioterrorism.
Category A agents include organisms and toxins that pose the highest risk to the public and national
security for the following reasons:
• They can be easily spread or transmitted from person to person
• They result in high death rates and have the potential for major public health impact • They could cause extreme concern and social disruption • They require special action for public health preparedness This course details those diseases in Category A and includes the following Category A bioterrorism agents: • Anthrax • Smallpox Material Protected by Copyright • Viral Hemorrhagic Fevers (VHF)
Bacterial Agents: Anthrax
Bacillus anthracis, the causative agent of Anthrax, is a gram-positive, sporulating rod. The spores are
the usual infective form. Anthrax is primarily a zoonotic disease of herbivores, with cattle, sheep,
goats, and horses being the usual domesticated animal hosts, but other animals may be infected.
Humans generally contract the disease when handling contaminated hair, wool, hides, flesh, blood,
and excreta of infected animals, and from manufactured products such as bone meal.
Infection is introduced through scratches or abrasions of the skin, wounds, inhalation of spores,
eating insufficiently cooked infected meat, or by being bitten by fleas.
The primary concern for intentional infection by this organism is through inhalation after aerosol
dissemination of spores. All human populations are susceptible. The spores are very stable and may
remain viable for many years in soil and water. They resist sunlight for varying periods.
Presentation of Anthrax
Signs and Symptoms
Incubation period is generally 1–6 days, although longer periods have been noted. Fever, malaise,
fatigue, cough, and mild chest discomfort progresses to severe respiratory distress with dyspnea,
diaphoresis, stridor, cyanosis, and shock. Death typically occurs within 24–36 hours after onset of
severe symptoms.

Diagnosis

Physical findings are non-specific. A widened mediastinum may be seen on CXR in later stages of
illness. The organism is detectable by Gram stain of the blood and by blood culture late in the course
of illness.
Treatment
Although effectiveness may be limited after symptoms are present, high dose antibiotic treatment with
penicillin, ciprofloxacin, or doxycycline should be undertaken. Supportive therapy may be necessary.
Decontamination of clothing with antimicrobial soap and water is also recommended.
Bacterial Agents: Anthrax
Prophylaxis
Oral ciprofloxacin (Cipro) or doxycycline (Vibramycin) for known or imminent exposure. An FDA-
licensed vaccine is available. Vaccine schedule is 0.5 ml SC at 0, 4 weeks, then 6, 12, and 18 months
(primary series), followed by annual boosters.
Isolation and Decontamination
Standard precautions for healthcare workers. After an invasive procedure or autopsy is performed,
the instruments and area used should be thoroughly disinfected with a sporicidal agent (hypochlorite).
Contagious?

Biological Toxins: Botulism

Botulinum
The botulinum toxins are a group of seven related neurotoxins produced by the spore-forming bacillus
Clostridium botulinum and two other Clostridia species. These toxins, types A through G, are the
most potent neurotoxins known; paradoxically, they have been used therapeutically to treat spastic
conditions (such as strabismus, torticollis & tetanus) and cosmetically to treat wrinkles.
The spores are ubiquitous; they germinate into vegetative bacteria that produce toxins during
anaerobic incubation. Industrial-scale fermentation can produce large quantities of toxin for use as a
BW agent. There are three epidemiologic forms of naturally occurring botulism—food borne, infantile,
and wound. Botulinum could be delivered by aerosol or used to contaminate food or water supplies.
When inhaled, these toxins produce a clinical picture very similar to food borne intoxication, although
the time to onset of paralytic symptoms after inhalation may actually be longer than for food borne
cases, and may vary by type and dose of toxin. The clinical syndrome produced by these toxins is
known as "botulism."
Biological Toxins: Botulism
Signs and Symptoms
Usually begins with cranial nerve palsies, including ptosis, blurred vision, diplopia, dry mouth and
throat, dysphagia, and dysphonia. This is followed by symmetrical descending flaccid paralysis, with
generalized weakness and progression to respiratory failure. Symptoms begin as early as 12–36
hours after inhalation, but may take several days after exposure to low doses of toxin.
Diagnosis
Diagnosis is primarily a clinical one. Biowarfare attack should be suspected if multiple casualties
simultaneously present with progressive descending flaccid paralysis. Lab confirmation can be
obtained by bioassay (mouse neutralization) of the patient’s serum. Other helpful labs include: ELISA
or ECL for antigen in environmental samples, PCR for bacterial DNA in environmental samples, or
nerve conduction studies and electromyography.
Treatment
Early administration of trivalent licensed antitoxin or heptavalent antitoxin (IND product) may prevent
or decrease progression to respiratory failure and hasten recovery. Intubation and ventilatory
assistance for respiratory failure. Tracheostomy may be required.
Prophylaxis
Pentavalent toxoid vaccine (types A, B, C, D, and E) is available for those at high risk of exposure.
Isolation and Decontamination
Standard Precautions for healthcare workers. Toxin is not dermally active and secondary aerosols
are not a hazard from patients. Decontaminate with soap and water. Botulinum toxin is inactivated by
sunlight within 1–3 hours. Heat (80OC for 30 min., 100OC for several minutes) and chlorine (>99.7%
inactivation by 3 mg/L FAC in 20 min.) also destroy the toxin.
Contagious?

Material Protected by Copyright

Bacterial Agents: Plague

Yersinia pestis is a rod-shaped, non-motile, non-sporulating, gram-negative bacterium of the family
Enterobacteraceae. It causes plague, a zoonotic disease of rodents. Fleas that live on the rodents
can transmit the bacteria to humans, who then suffer from the bubonic form of plague. The bubonic
form may progress to the septicemic and/or pneumonic forms. Pneumonic plague would be the
predominant form after a purposeful aerosol dissemination. All human populations are susceptible.
Recovery from the disease is followed by temporary immunity. The organism remains viable in water,
moist soil, and grains for several weeks. The bacterium can remain alive from months to years, but
are killed by 15 minutes of exposure to 55°C. It also remains viable for some time in dry sputum, flea
feces, and buried bodies but is killed within several hours of exposure to sunlight.
Signs and Symptoms
Pneumonic plague begins after an incubation period of 1–6 days, with high fever, chills, headache,
malaise, followed by cough (often with hemoptysis), progressing rapidly to dyspnea, stridor, cyanosis,
and death. Gastrointestinal symptoms are often present. Death results from respiratory failure,
circulatory collapse, and a bleeding diathesis. Bubonic plague, featuring high fever, malaise, and
painful lymph nodes (buboes) may progress spontaneously to the septicemic form (septic shock,
thrombosis, DIC) or to the pneumonic form.
Bacterial Agents
Plague
Diagnosis
Suspect plague if large numbers of previously healthy individuals develop fulminant Gram negative
pneumonia, especially if hemoptysis is present. Presumptive diagnosis can be made by Gram,
Wright, Giemsa, or Wayson stain of blood, sputum, CSF, or lymph node aspirates. Definitive
diagnosis requires culture of the organism from those sites. Immunodiagnosis is also helpful.
Treatment
Early administration of antibiotics is critical, as pneumonic plague is invariably fatal if antibiotic
therapy is delayed more than 1 day after the onset of symptoms. Choose one of the following:
streptomycin, gentamicin (Garamycin), ciprofloxacin (Cipro), or doxycycline (Vibramycin) for 10–14
days. Chloramphenicol (Chloromycetin) is the drug of choice for plague meningitis.
Prophylaxis
For asymptomatic persons exposed to a plague aerosol or to a patient with suspected pneumonic
plague, give doxycycline (Vibramycin) 100 mg orally twice daily for seven days or the duration of risk
of exposure plus one week. Alternative antibiotics include ciprofloxacin (Cipro), tetracycline, or
chloramphenicol (Chloromycetin). No vaccine is currently available for plague prophylaxis. The
previously available licensed, killed vaccine was effective against bubonic plague, but not against
aerosol exposure.
Isolation and Decontamination
Use Standard Precautions for bubonic plague and Respiratory Droplet Precautions for suspected
pneumonic plague. Y. pestis can survive in the environment for varying periods, but is susceptible to
heat, disinfectants, and exposure to sunlight. Soap and water are effective if decontamination is
needed. Take measures to prevent local disease cycles if vectors (fleas) and reservoirs (rodents) are
present.
Contagious?

Viral Agents: Smallpox
Smallpox is caused by the Orthopox virus, variola, which occurs in at least two strains, variola major
and the milder disease, variola minor. Despite the global eradication of smallpox and continued
availability of a vaccine, the potential weaponization of variola continues to pose a military threat. This
threat can be attributed to the aerosol infectivity of the virus, the relative ease of large-scale
production, and an increasingly Orthopoxvirus-naive populace. Although the fully developed
cutaneous eruption of smallpox is unique, earlier stages of the rash could be mistaken for varicella.
Secondary spread of infection constitutes a nosocomial hazard from the time of onset of a smallpox
patient's exanthem until scabs have separated. Quarantine with respiratory isolation should be
applied to secondary contacts for 17 days post-exposure. Vaccinia vaccination and vaccinia immune
globulin each possess some efficacy in post-exposure prophylaxis.

Signs and Symptoms

Clinical manifestations begin acutely with malaise, fever, rigors, vomiting, headache, and backache.
2–3 days later lesions appear which quickly progress from macules to papules, and eventually to
pustular vesicles. They are more abundant on the extremities and face, and develop synchronously.
Viral Agents: Smallpox
Diagnosis
Neither electron nor light microscopy are capable of discriminating variola from vaccinia, monkeypox,
or cowpox. The new PCR diagnostic techniques may be more accurate in discriminating between
variola and other Orthopoxviruses.

Treatment

At present there is no effective drug therapy, and treatment of a clinical case remains supportive.
Prophylaxis
Immediate vaccination or re-vaccination should be undertaken for all personnel exposed.
Isolation and Decontamination
Droplet and Airborne Precautions for a minimum of 17 days following exposure for all contacts.
Patients should be considered infectious until all scabs separate and quarantined during this period.
In the civilian setting strict quarantine of asymptomatic contacts may prove to be impractical and
impossible to enforce. A reasonable alternative would be to require contacts to check their
temperatures daily. Any fever above 38° C (101° F) during the 17 day period following exposure to a
confirmed case would suggest the development of smallpox. The contact should then be isolated
immediately, preferably at home, until smallpox is either confirmed or ruled out and remain in isolation
until all scabs separate. (Scabbing is complete and falls off; skin underneath is intact.)
Contagious?

Bacterial Agents: Tularemia

Francisella tularensis is a small, aerobic non-motile, gram-negative cocco-bacillus. Tularemia (also
known as rabbit fever and deer fly fever) is a zoonotic disease that humans typically acquire after skin
or mucous membrane contact with tissues or body fluids of infected animals, or from bites of infected
ticks, deerflies, or mosquitoes. Less commonly, inhalation of contaminated dusts or ingestion of
contaminated foods or water may produce clinical disease. Respiratory exposure by aerosol would
typically cause typhoidal or pneumonic tularemia. F. tularensis can remain viable for weeks in water,
soil, carcasses, hides, and for years in frozen rabbit meat. It is resistant for months to temperatures of
freezing and below. It is easily killed by heat and disinfectants.
Signs and Symptoms
Ulceroglandular tularemia presents with a local ulcer and regional lymphadenopathy, fever, chills,
headache, and malaise. Typhoidal tularemia presents with fever, headache, malaise, substernal
discomfort, prostration, weight loss, and a non-productive cough.
Bacterial Agents: Tularemia
Diagnosis
Clinical diagnosis. Physical findings are usually non-specific. Chest x-ray may reveal a pneumonic
process, mediastinal lymphadenopathy, or pleural effusion. Routine culture is possible but difficult.
The diagnosis can be established retrospectively by serology.
Treatment
Administration of antibiotics (streptomycin or gentamicin [Garamycin]) with early treatment is very
effective.

Prophylaxis

A live, attenuated vaccine is recommended for prophylaxis. It is administered once by scarification. A
two-week course of tetracycline is also effective as prophylaxis when given after exposure.

Isolation and Decontamination

Standard Precautions for healthcare workers. Organisms are relatively easy to render harmless by
mild heat (55 degrees Celsius for 10 minutes) and standard disinfectants.
Contagious?

Viral Agents: Hemorrhagic Fever
Viral hemorrhagic fevers (VHFs) refer to a diverse group of illnesses that are caused by distinct
families of RNA viruses from four viral families. In general, the term VHF is used to describe a severe
multI-system syndrome.
While some types of hemorrhagic fever viruses can cause relatively mild illnesses, many of these
viruses cause severe, life-threatening disease.
Examples of VHFs include ebola, dengue and yellow fever. These viruses are spread in a variety of
ways; some may be transmitted to humans through a respiratory portal of entry.
Although evidence for weaponization does not exist for many of these viruses, they are included in
this course because of their potential for aerosol dissemination or weaponization.

Signs and Symptoms

VHFs present as febrile illnesses which can feature flushing of the face and chest, petechiae,
bleeding, edema, hypotension, and shock. Malaise, myalgias, headache, vomiting, and diarrhea may
occur in any of the hemorrhagic fevers.
Characteristically, the overall vascular system is damaged, and the body's ability to regulate itself is
impaired. These symptoms are often accompanied by hemorrhage; however, the bleeding is itself
rarely life-threatening.
Viral Agents: Hemorrhagic Fevers
Diagnosis
Definitive diagnosis rests on specific virologic techniques. Significant numbers of military personnel
with a hemorrhagic fever syndrome should suggest the diagnosis of a viral hemorrhagic fever.
Treatment
Intensive supportive care may be required. Antiviral therapy with ribavirin (Virazole) may be useful in
several of these infections. Convalescent plasma may be effective in Argentine hemorrhagic fever.
Prophylaxis
The only licensed VHF vaccine is yellow fever vaccine. Prophylactic ribavirin (Virazole) may be
effective for Lassa fever, Rift Valley fever, and possibly HFRS (Hemorrhagic Fever with Renal
Syndrome).
Isolation and Decontamination
Contact isolation, with the addition of a surgical mask and eye protection for those coming within
three feet of the patient, is indicated for suspected or proven VHFs. Respiratory protection should be
upgraded to airborne isolation, including the use of a fit-tested HEPA filtered respirator, a battery
powered air purifying respirator, or a positive pressure supplied air respirator, if patients with the
above conditions have prominent cough, vomiting, diarrhea, or hemorrhage. Decontamination is
accomplished with hypochlorite or phenolic disinfectants.
Contagious?

Category B and C Biological Agents
Category B Agents Bioterrorism
Alphaviruses: Venezuelen Equine (VEE), Eastern Equine (EEE), and Western Enchephalitis Equine Encephalomyelitis (WEE) Rickettsia prowazekii Toxins (e.g. Ricin, Staphylococcal enterotoxin B) Food safety threats (e.g. Salmonella spp., Escherichia coli 0157:H7) Water Safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

Category C Agents Bioterrorism

Emerging Threat Agents (Nipah virus, hantavirus)
More information on each of these agents can be found at the Centers for Disease Control website,
Chemical Agents
Chemical agents that might be used by terrorists range from warfare agents to toxic chemicals
commonly used in industry. Criteria for determining priority chemical agents include:
• Chemical agents already known to be used as weaponry.
• Availability of chemical agents to potential terrorists.
• Chemical agents likely to cause major morbidity or mortality.
• Potential of agents for causing public panic and social disruption.
• Agents that require special action for public health preparedness.
The CDC generally groups chemical agents into a number of categories. Not all categories or agents
can be discussed within the scope of this course. Five Specific agents/types of agents will be
discussed in detail later in this course.
Biotoxins
Blood Agents
Arsine (SA) Cyanide Cyanogen chloride (CK) Hydrogen cyanide (AC) Potassium cyanide (KCN) Sodium cyanide (NaCN) Choking/Lung/Pulmonary Agents Ammonia
Bromine (CA) Chlorine (CL) Hydrogen chloride Osmium Tetroxide Phosgene Diphosgene (DP) Phosgene (CG) Phosphine Phosphorus, elemental, white or yellow Long-Acting Anticoagulants
Nerve Agents
Blister Agents/Vesicants
Mustards Distilled mustard (HD) Mustard gas (H) (sulfur mustard) Mustard/lewisite (HL) Mustard/T Nitrogen mustard (HN-1, HN-2, HN-3) Sesqui mustard Sulfur mustard (H) (mustard gas) Lewisites/chloroarsine agents Lewisite (L, L-1, L-2, L-3) Mustard/lewisite (HL) Phosgene oxime (CX) Caustics (Acids)
Hydrofluoric acid (hydrogen fluoride) Hydrogen fluoride (hydrofluoric acid) Incapacitating Agents
Organic Solvents
Riot Control Agents/Tear Gas
Various agents and combinations of agents Bromobenzylcyanide (CA) Chloroacetophenone (CN) Chlorobenzylidenemalononitrile (CS) Chloropicrin (PS) Dibenzoxazepine (CR) Toxic Alcohols
Vomiting Agents

Emergency Room Procedures in Chemical Hazard Emergencies
The following information and information for medical management of other toxic chemical agents is
provided by The Agency for Toxic Substances and Disease Registry Division of Toxicology, part of
the CDC (http://www.atsdr.cdc.gov), and from the Environmental Public Health Readiness Branch,
Chemical Weapons Elimination team.
This course contains emergency guidelines from these agencies for 5 common agents: Nerve Agent,
Phosgene, Lewisite, Mustard, and Chlorine.
Agent identification is the #1 step in preparing to receive patients from a chemical emergency.

Emergency Room Procedures in Chemical Hazard Emergencies
Preparations
1. Try to determine agent identity. 2. Break out personal protection equipment, decontamination supplies, antidotes, etc. 3. Is chemical hazard certain or very likely? YES:
*
Don personal protective equipment.
* Set up hot line.
4. Clear and secure all areas that could become contaminated. 5. Prepare to or secure hospital entrances and grounds. 6. Notify local emergency management authorities if needed. 7. If chemical is a military agent and Army has not been informed, call them. 8. If an organophosphate is involved, notify hospital pharmacy that large amounts of atropine and 2- PAM may be needed.
When victim arrives
(Note: A contaminated patient may present at an emergency room without prior warning.)
9. Does chemical hazard exist?
* Known release/exposure (including late notification)
* Liquid on victim's skin or clothing
* Symptoms in victim, EMTs, others
* Odor (H, L, phosgene, chlorine)
* M-8 paper, if appropriate
YES: Go to 10.
NO: Handle victim routinely.
10. Hold victim outside until preparations are completed (don personal protective equipment to assist 11. If patient is grossly contaminated (liquid on skin, positive M-8 paper) OR if there is any suspicion of contamination, decontaminate patient before entry into building. M-8 paper tape provides a simple way to check exposed surfaces for the presence of chemical
agent contamination. The papers are treated with agent-sensitive dyes that change color in
the presence of liquid chemical agents. They can be placed on a person’s skin or clothing and
change color depending on the agent that the paper detects. M-8 will change to four possible
colors: red, yellow, green or blue. If the paper changes to red, it indicates possible blister
agent. A yellow, green or blue change indicates possible nerve agent.

Emergency Room Procedures in Chemical Hazard Emergencies
1. Establish airway if necessary.
2. Give artificial respiration if not breathing. 4. Symptoms of cholinesterase poisoning? * Pinpoint pupils
* Difficulty breathing (wheezing, gasping, etc)
* Local or generalized sweating
* Fasciculations (uncontrollable muscle twitching)
* Copious secretions
* Nausea, vomiting, diarrhea
* Convulsions
* Coma

YES:
Go to NERVE AGENT PROTOCOL (on the following pages)
YES: Go to CHLORINE PROTOCOL. (on the following pages)
6. Burns that began within minutes of poisoning? YES: Go to 7.
NO: Go to 8.
YES: Go to 9.
NO: Go to LEWISITE PROTOCOL (on the following pages)
8. Burns or eye irritation beginning 2-12 hours after exposure? YES: Go to MUSTARD PROTOCOL (on the following pages)
NO: Go to 9.
* Known exposure to phosgene
* Known exposure to hot chlorinated hydrocarbons
* Respiratory discomfort beginning a few hours after exposure
YES: Go to PHOSGENE PROTOCOL (on the following pages)
10. Check other possible chemical exposures: * Known exposure
* Decreased level of consciousness without head trauma.
* Odor on clothes or breath
* Specific signs or symptoms

Facts About Phosgene
What is phosgene?
• Phosgene is a major industrial chemical used to make plastics and pesticides. • At room temperature (70°F), phosgene is a poisonous gas. • With cooling and pressure, phosgene gas is converted into a liquid that can be shipped and stored. When liquid phosgene is released, it quickly turns into a gas that stays close to the ground and spreads rapidly. • Phosgene gas may appear colorless or a white to pale yellow cloud. At low concentrations, it has a pleasant odor of newly mown hay or green corn, but its odor may not be noticed by all people exposed. At high concentrations, the odor may be strong and unpleasant. • Phosgene itself is nonflammable but it can cause flammable substances around it to burn. • Phosgene is also known by its military designation, “CG.” Where phosgene is found and how it is used • Phosgene was used extensively during World War I as a choking (pulmonary) agent. • Phosgene is not found naturally in the environment; it is used in industry to produce many • Phosgene can be formed when certain compounds are exposed to heat, such as some types • Phosgene gas is heavier than air, so it would be more likely found in low-lying areas.
Exposure To Phosgene
The risk for exposure depends on how close an individual is to the place where the phosgene was
released. If phosgene gas is released into the air, people may be exposed through skin contact or
eye contact. They may also be exposed by breathing air that contains phosgene.
If phosgene liquid is released into water, people may be exposed by touching or drinking water that
contains phosgene.
If phosgene liquid comes into contact with food, people may be exposed by eating the contaminated
food.
Phosgene gas and liquid are irritants that can damage the skin, eyes, nose, throat, and lungs. The
extent of damage caused by phosgene poisoning depends on the amount of phosgene to which a
person is exposed, the route of exposure, and the length of time that a person is exposed.
Immediate Signs and Symptoms of Phosgene Exposure
During or immediately after exposure to dangerous concentrations of phosgene, the following signs
and symptoms may develop:
• Burning sensation in the throat and eyes • Watery eyes • Blurred vision • Difficulty breathing or shortness of breath • Nausea and vomiting • Skin contact can result in lesions similar to those from frostbite or burns • Following exposure to high concentrations of phosgene, a person may develop pulmonary edema
Later Signs and Symptoms of Phosgene Exposure
Exposure to phosgene may cause delayed effects that may not be apparent for up to 48 hours after
exposure, even if the person feels better or appears well following removal from exposure. Therefore,
people who have been exposed to phosgene should be monitored for 48 hours afterward. Delayed
effects that can appear for up to 48 hours include the following:
• Coughing up white to pink-tinged fluid
• Low blood pressure
• Heart failure
Management of Phosgene Exposure
Most people exposed to phosgene make a complete recovery. However, chronic bronchitis and
emphysema have been reported as a result of phosgene exposure.

If exposed to phosgene:
• Leave the area where the phosgene was released and get to fresh air. If outdoors, go to the
highest ground possible, because phosgene is heavier than air and will sink to low-lying areas. • Remove all clothing, rapidly wash the entire body with large amounts of soap and water, and provide medical care as quickly as possible. Avoid pulling any contaminated clothing over the head. Seal all clothing in double plastic bags. • Inform the local or state health department or emergency personnel upon their arrival. Do not • If a person experiences burning eyes or blurred vision, rinse the eyes with plain water for 10 to 15 • If phosgene is ingested, do not induce vomiting or drink fluids. Treatment for phosgene exposure consists of removing phosgene from the body as soon as possible and providing supportive medical care in a hospital setting. No antidote exists for phosgene. Exposed people should be observed for up to 48 hours, because it may take that long for symptoms to develop or reoccur.
Phosgene Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post phosgene exposure:
If there is known phosphate poisoning, restrict fluids, perform chest x-ray and draw blood gases
ASAP. If results are consistent with phosgene poisoning, admit immediately and provide oxygen
under positive end-expiratory pressure and restrict fluids. Observe closely for at least 6 hours.
Facts About Sulfur Mustard
What is sulfur mustard?
• Sulfur mustard is a type of chemical warfare agent. These kinds of agents are called vesicants or blistering agents, because they cause blistering of the skin and mucous membranes on contact. • Sulfur mustard is also known as “mustard gas or mustard agent,” or by the military • Sulfur mustard sometimes smells like garlic, onions, or mustard and sometimes has no odor. It can be a vapor, an oily-textured liquid, or a solid. • Sulfur mustard can be clear to yellow or brown when it is in liquid or solid form. Where sulfur mustard is found and how it is used
• Sulfur mustard is not found naturally in the environment. • Sulfur mustard was introduced in World War I as a chemical warfare agent. Until recently, it was available for use in the treatment of a skin condition called psoriasis. Currently, it has no medical use.
Exposure To Sulfur Mustard
If sulfur mustard is released into the air as a vapor, people can be exposed through skin contact, eye
contact, or breathing. Sulfur mustard vapor can be carried long distances by wind.
If sulfur mustard is released into water, people can be exposed by drinking the contaminated water or
getting it on their skin.
People can be exposed by coming in contact with liquid sulfur mustard.
Sulfur mustard can last from 1 to 2 days in the environment under average weather conditions and
from weeks to months under very cold conditions.
Sulfur mustard breaks down slowly in the body, so repeated exposure may have a cumulative effect.

The adverse health effects caused by sulfur mustard depend on the amount people are exposed to,
the route of exposure, and the length of time that people are exposed.
Sulfur mustard is a powerful irritant and blistering agent that damages the skin, eyes, and respiratory
tract. It damages DNA, a vital component of cells in the body.
Sulfur mustard vapor is heavier than air, so it will settle in low-lying areas

Management of Sulfur Mustard Exposure
Exposure to sulfur mustard liquid is more likely to produce second- and third- degree burns and later
scarring than is exposure to sulfur mustard vapor.
Extensive breathing in of the vapors can cause chronic respiratory disease, repeated respiratory
infections, or death. Extensive eye exposure can cause permanent blindness.
Exposure to sulfur mustard may increase a person’s risk for lung and respiratory cancer.
If exposed to sulfur mustard:
• Immediately leave the area where the sulfur mustard was released. Try to find higher ground, because sulfur mustard is heavier than air and will settle in low-lying areas. • Rapidly remove the sulfur mustard from the body and any contaminated clothing as soon as possible after exposure, as this is the only effective way to prevent or decrease tissue damage to the body. Seal clothing in a plastic bag, and then seal that bag inside a second plastic bag. • Immediately wash any exposed part of the body (eyes, skin, etc.) thoroughly with plain, clean water. Eyes need to be flushed with water for 5 to 10 minutes. Do NOT cover eyes with bandages, but do protect them with dark glasses or goggles. The most important factor is removing sulfur mustard from the body. Exposure to sulfur mustard is treated by giving the victim supportive medical care to minimize the effects of the exposure. Though no antidote exists for sulfur mustard, exposure is usually not fatal. If someone has ingested sulfur mustard, do NOT induce vomiting. Give the person milk to

Mustard Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post sulfur mustard exposure:
If there is known sulfur mustard poisoning, check for airway obstruction. If present, a tracheostomy
may need to be performed ASAP.
Assess for skin burns. If large burns are present, establish IV lines, but do not push fluids as for
thermal burns. Drain vesicles by unroofing large blisters and irrigating the area with topical antibiotics.
Treat other symptoms appropriately. This may include the application of antibiotic eye ointment, the
use of sterile precautions prn and the administration of morphine prn for pain (generally not needed in
emergency treatment; might be appropriate for in-patient treatment).
Where lewisite is found and how it is used
Lewisite was produced in 1918 to be used in World War I, but its production was too late for it to be
used in the war. It has been used only as a chemical warfare agent. It has no medical or other
practical use. Lewisite is not found naturally in the environment.
Facts About Lewisite
What is lewisite?
Lewisite is a type of chemical warfare agent. This kind of agent is called a vesicant or blistering agent, because it causes blistering of the skin and mucous membranes on contact. Lewisite is an oily, colorless liquid in its pure form and can appear amber to black in its impure form. It has an odor like geraniums, and contains arsenic, a poisonous element. Lewisite is also known by its military designation, “L.” Exposure To Lewisite
Risk for exposure depends on how close an individual is to the site where the lewisite is released. If
lewisite gas is released into the air, people may be exposed through skin contact or eye contact.
Lewisite is a powerful irritant and blistering agent that immediately damages the skin, eyes, and
respiratory tract.
Exposure can also occur by inhaling air that contains lewisite.
If lewisite liquid is released into water, people may be exposed by drinking water that contains lewisite
or by getting the water on their bodies. If lewisite liquid comes into contact with food, people may be
exposed by eating the contaminated food.
Lewisite vapor is heavier than air, so it will settle in low-lying areas and will remain a liquid under a
wide range of environmental conditions. Thus, it can last for a long time in the environment.
Adverse health effects caused by lewisite depend on the amount people are exposed to, the route of
exposure, and the length of time that people are exposed.
Because it contains arsenic, lewisite has some effects that are similar to arsenic poisoning, including
stomach ailments and low blood pressure.
Signs & Symptoms of Lewisite Exposure
Most information on the health effects of lewisite is based on animal studies. Signs and symptoms
occur immediately following a lewisite exposure, and may include:
Skin changes: Pain and irritation within seconds to minutes, redness within 15 to 30 minutes
followed by blister formation within several hours. The blister begins as a small blister in the middle of the red areas and then expands to cover the entire reddened area of skin. The lesions (sores) from lewisite heal much faster than lesions caused by the other blistering agents, sulfur mustard and nitrogen mustards, and the discoloring of the skin that occurs later is much less noticeable. • Eye irritation: Pain, swelling, and tearing may occur on contact. Blindness may result.
Respiratory tract changes: Runny nose, sneezing, hoarseness, bloody nose, sinus pain,
Digestive tract: diarrhea, nausea, and vomiting.
Cardiovascular: “Lewisite shock” or low blood pressure may occur.
Showing these signs and symptoms does not necessarily mean that a person has been exposed to
lewisite. Lewisite does not suppress the immune system.
Management of Lewisite Exposure
If exposure to lewisite occurs, the area should be evacuated as quickly as possible. Moving quickly to
an area where fresh air is available is highly effective in reducing the possibility of death from
exposure to lewisite. People should move to the highest ground possible, because lewisite is heavier than air and will sink to low-lying areas. If the lewisite release is indoors, get out of the building. If you think you may have been exposed, remove your clothing as quickly as possible. Any clothing that has to be pulled over the head should be cut off the body and sealed in double plastic bags. This will help protect against further exposure to any chemicals remaining on the clothing. The entire body should be rapidly washed with soap and water, and medical attention sought as soon as possible. Treatment for lewisite exposure consists of removing lewisite from the body as soon as possible and
providing supportive medical care in a hospital setting.
An antidote for lewisite is available and is most useful if given as soon as possible after
exposure.

Lewisite Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post lewisite exposure:
• Survey the extent of injury, and treat affected skin with British Anti-Lewisite (BAL, also known as
• Treat affected eyes with BAL ophthalmic ointment (if available). • Treat pulmonary effects using BAL in oil, 0.5 ml/25 lbs body wt. deep IM to max of 4.0 ml. Repeat q 4 h x 3 (at 4, 8, and 12 hours). Morphine may be given prn for pain. • For severe pulmonary reactions to lewisite, shorten the time interval for BAL injections to q 2 h.
Facts about Chlorine
What Is Chlorine?
Chlorine is an element used in industry and in some household products, but can also be found in the form of a poisonous gas. It can be pressurized and cooled to change into a liquid for shipping and storage. When liquid chlorine is released, it turns into a gas that stays close to the ground and spreads rapidly. Chlorine gas can be recognized by its pungent, irritating odor, which is like the odor of bleach. The strong smell may provide a warning to people that they have been exposed. Chlorine gas appears to be yellow-green in color. Chlorine itself is not flammable, but it can react explosively or form explosive compounds with other chemicals such as turpentine and ammonia. Where chlorine is found and how it is used
Chlorine was used during World War I as a choking (pulmonary) agent, and is one of the most commonly manufactured chemicals in the United States. Its most important use is as a bleach in the manufacture of paper and cloth, but it is also used to make pesticides, rubber, and solvents. Chlorine is used in drinking water and swimming pool water to kill harmful bacteria. It is also as used as part of the sanitation process for industrial waste and sewage. Household chlorine bleach can release chlorine gas if it is mixed with other cleaning agents. Exposure To Chlorine
People’s risk for exposure depends on how close they are to the place where the chlorine was
released. If chlorine gas is released into the air, people may be exposed through skin contact or eye
contact. They may also be exposed by breathing air that contains chlorine.
If chlorine liquid is released into water, people may be exposed by touching or drinking water that
contains chlorine.
If chlorine liquid comes into contact with food, people may be exposed by eating the contaminated
food.
Chlorine gas is heavier than air, so it would settle in low-lying areas.
The extent of poisoning caused by chlorine depends on the amount of chlorine a person is exposed
to, how the person was exposed, and the length of time of the exposure.
When chlorine gas comes into contact with moist tissues such as the eyes, throat, and lungs, an acid
is produced that can damage these tissues.
Signs & Symptoms of Chlorine Exposure
During or immediately after exposure to dangerous concentrations of chlorine, the following signs and
symptoms may develop:
• Coughing
• Burning sensation in the nose, throat, and eyes • Burning pain, redness, and blisters on the skin if exposed to gas, skin injury similar to frostbite if • Difficulty breathing or shortness of breath (may appear immediately if high concentrations of chlorine gas are inhaled, or may be delayed if low concentrations of chlorine gas are inhaled) • Pulmonary edema within 2 to 4 hours Exhibition of these signs or symptoms does not necessarily mean that a person has been exposed to chlorine. Long-term complications from chlorine exposure are not found in people who survive a sudden exposure unless they suffer complications such as pneumonia during therapy. Chronic bronchitis may develop in people who develop pneumonia during therapy. Management of Chlorine Exposure
If exposure to chlorine occurs, the area should be vacated immediately. Quickly moving to an area
where fresh air is available is highly effective in reducing exposure to chlorine. If the chlorine release
was outdoors, move away from the area where the chlorine was released. Go to the highest ground
possible, because chlorine is heavier than air and will sink to low-lying areas.
If the chlorine release was indoors, get out of the building.

If you think you may have been exposed, remove your clothing as quickly as possible. Any clothing
that has to be pulled over the head should be cut off the body and sealed in double plastic bags. This
will help protect against further exposure to any chemicals remaining on the clothing.
The entire body should be rapidly washed with soap and water, and medical attention sought as soon
as possible. Flush eyes with cold water and discard contact lenses with clothing. If chlorine is
ingested, do not induce vomiting or drink fluids. Inform either the local or state health department or
emergency personnel upon their arrival. Do not handle the plastic bags.
If you are helping other people remove their clothing, try to avoid touching any contaminated areas,
and remove the clothing as quickly as possible.
No antidote exists for chlorine exposure. Treatment consists of removing the chlorine from
the body as soon as possible and providing supportive medical care in a hospital setting.

Chlorine Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post chlorine exposure:
• If dyspnea is present, administer oxygen by mask as well as bronchodilators. Admit to hospital for
chest X-ray and further evaluation, as soon as possible. • Treat other problems and reevaluate.
• If the respiratory system is stable, provide supportive therapy; treat other problems or discharge.
Facts About Sarin (Nerve Agent)
What Is Sarin?
Sarin is a human-made chemical warfare agent classified as a nerve agent. Nerve agents are the
most toxic and rapidly acting of the known chemical warfare agents. They are similar to certain kinds
of pesticides called organophosphates in terms of how they work and what kind of harmful effects
they cause. However, nerve agents are much more potent than organophosphate pesticides.
Sarin originally was developed in 1938 in Germany as a pesticide, and is a clear, colorless, and
tasteless liquid that has no odor in its pure form. However, sarin can evaporate into a vapor and
spread into the environment. Sarin is also known as GB.
Where Sarin is Found and How It Is Used
Sarin is not found naturally in the environment. It is man-made and was used in chemical warfare
during the Iran-Iraq War in the 1980s, and in two terrorist attacks in Japan in 1994 and 1995. Sarin is
the most volatile of the nerve agents, which means that it can easily and quickly evaporate from a
liquid into a vapor and spread into the environment. People can be exposed to the vapor even if they
do not come in contact with the liquid form of sarin. Since sarin evaporates so quickly, it presents an
immediate but short-lived threat.
Material Protected by Copyright

Exposure To Sarin
Following the release of sarin into the air, people can be exposed through skin contact or eye contact.
They can also be exposed by breathing air that contains sarin. Sarin mixes easily with water, so it
could be used to poison water. Following release of sarin into water, people can be exposed by
touching or drinking water that contains sarin.
Following contamination of food with sarin, people can be exposed by eating the contaminated food.
A person’s clothing can release sarin for about 30 minutes after it has come in contact with sarin
vapor, which can lead to exposure of other people.
Because sarin breaks down slowly in the body, people who are repeatedly exposed to sarin may
suffer more harmful health effects. Sarin vapor is heavier than air and will sink to low-lying areas and
create a greater exposure hazard there.
Signs & Symptoms of Sarin Exposure
The extent of poisoning caused by sarin depends on the amount of which a person was exposed,
how the exposure occurred, and the length of time of the exposure.
People may not know that they were exposed because sarin has no odor. People exposed to a low or
moderate dose of sarin by breathing contaminated air, eating contaminated food, drinking
contaminated water, or touching contaminated surfaces may experience some or all of the following
symptoms within seconds to hours of exposure:
Exposure to large doses of sarin by any route may result in the following harmful health effects: • Respiratory failure possibly leading to death Note! Even a small drop of sarin on the skin can cause sweating and muscle twitching where sarin
touched the skin.
Nerve agents inhibit the function of chemical that acts as the body’s “off switch” for glands
and muscles. Without an “off switch,” the glands and muscles are constantly being
stimulated. They may tire and no longer be able to sustain breathing function.


Management of Sarin Exposure

Recovery from sarin exposure is possible with treatment, but the antidotes available must be used
quickly to be effective. Therefore, the best thing to do is avoid exposure.
Evacuate the area where the sarin was released and get to fresh air. Quickly moving to an area
where fresh air is available is highly effective in reducing the possibility of death from exposure to
sarin vapor. If the sarin release was outdoors, move away from the area where the sarin was
released. Go to the highest ground possible, because sarin is heavier than air and will sink to low-
lying areas.
If the sarin release was indoors, get out of the building.
If exposure occurs, remove all clothing, rapidly wash the entire body with soap and water, and get
medical care as quickly as possible. Any clothing that has to be pulled over the head should be cut off
the body and sealed in double plastic bags. This will help protect against further exposure to any
chemicals remaining on the clothing.
Flush eyes with cold water and discard contact lenses with clothing. If sarin is ingested, do not induce
vomiting or drink fluids. Inform either the local or state health department or emergency personnel
upon their arrival. Do not handle the plastic bags.
If you are helping other people remove their clothing, try to avoid touching any contaminated areas,
and remove the clothing as quickly as possible. Antidotes are available for sarin, and are most useful
if given as soon as possible after exposure.
Mild or moderate exposure usually results in a full recovery. Severe exposure results in death.
Unlike some organophosphate pesticides, nerve agents have not been associated with
neurological problems lasting more than 1 to 2 weeks after exposure.

Nerve Agent Protocol
The Environmental Health Readiness Branch Chemical Weapons Elimination Team (EHRBCHET)
recommends the following protocol post nerve agent exposure:
• If severe respiratory distress is present: * Intubate and ventilate
* Administer Atropine:
* Administer 2-PAM C1
• If major secondary symptoms are present: * Administer Atropine:
Inf/ped: 0.02 - 0.05 mg/kg IV *Administer 2-PAM C1: * OPEN IV LINE
• Repeat atropine as needed until secretions decrease and breathing easier Adults: 2 mg IV or IM Inf/ped: 0.02 - 0.05 mg/kg IV * Adults: 1.0 gm IV over 20-30 min and repeat q lh x 3 prn
* Inf/ped: 15 mg/kg slow IV
• If convulsions present, administer Diazepam 10 mg slow for Adults; IVInf/ped: 0.2 mg/kg IV.
• Reevaluate q 3-5 min. If signs worsen, repeat atropine as directed.
Note!
Warn the hospital pharmacy that unusual amounts of atropine and 2-PAM may be needed.

CDC Resources
It is more than possible that an unidentified chemical agent may bring patients to your facility. The
CDC has extensive guidelines for the treatment of patients with an unidentified chemical exposure.
These are too extensive to address in this course, but can be found at http://www.atsdr.cdc.gov/, the
website for the Agency For Toxic Substances and Disease Registry, which is part of the CDC.
This registry has a wealth of knowledge and management guidelines for a variety of toxic substances.

How people can get more information about these agents

• Regional poison control center (1-800-222-1222)
• Centers for Disease Control and Prevention
• English (888) 246-2675 • Español (888) 246-2857 • TTY (866) 874-2646 • Emergency Preparedness and Response Web site (http://www.bt.cdc.gov/) • E-mail inquiries: cdcresponse@ashastd.org • Agency for Toxic Substances and Disease Registry (ATSDR) (1-770-488-7100; 24 hours a day)
Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and
Health (NIOSH), Pocket Guide to Chemical Hazards (www.cdc.gov/niosh/npg/npgd0504.html)
Radiation/Nuclear Agents
Radiation exposure is another possible terrorist threat. Radiation exposure could occur as the result
of a “dirty bomb.”
A dirty bomb is an explosive that contains radioactive material. Radiation exposure could also occur
due to a nuclear device being detonated. The possibility of large scale contamination is very real if
this occurs.
The CDC has outlined for physicians and other healthcare workers the following protocol to follow in
the event of radiation exposure.
Acute Radiation Syndrome
Acute Radiation Syndrome (ARS), also known as radiation toxicity or radiation sickness, is an acute
illness caused by irradiation of the body by a high dose of penetrating radiation in a very short period
of time (usually a matter of minutes).
The major cause of this syndrome is depletion of immature parenchymal stem cells in specific tissues. This can occur when the radiation exposure is greater than 0.7 Gray (Gy), or 70 rads. Mild symptoms may be observed as low as 0.3 Gy or 30 rads. The dose is usually external, and is penetrating (i.e., able to reach the internal organs). The entire body (or a significant portion of it) must have received the dose. Most radiation injuries are local, frequently involving the hands, and these local injuries seldom cause classical signs of ARS. The dose must have been delivered in a short time (usually a matter of minutes). Fractionated doses are often used in radiation therapy. These are large total doses delivered in small daily amounts over a period of time. Fractionated doses are less effective at inducing ARS than a single dose of the same magnitude. The Emergency Management Pocket Guide for Clinicians, a product of the CDC, offers a quick review of information related to radiation exposure: http://www.bt.cdc.gov/radiation/pdf/clinicianpocketguide.pdf
Classis Radiation Syndromes
There are three classic ARS Syndromes that occur:
Bone Marrow Syndrome (Hematopoietic Syndrome)
• The full syndrome will usually occur with a dose between 0.7 and 10 Gy (70 – 1000 rads) though mild symptoms may occur as low as 0.3 Gy or 30 rads. • The survival rate of patients with this syndrome decreases with increasing dose. • The primary cause of death is the destruction of the bone marrow, resulting in infection and Gastrointestinal (GI) syndrome
• The full syndrome will usually occur with a dose between 10 and 100 Gy (1000 – 10,000 rads) though some symptoms may occur as low as 6 Gy or 600 rads. • Survival is extremely unlikely with this syndrome. Destructive and irreparable changes in the GI tract and bone marrow usually cause infection, dehydration, and electrolyte imbalance. • Death usually occurs within 2 weeks. Cardiovascular (CV)/ Central Nervous System (CNS) Syndrome
• The full syndrome will usually occur with a dose greater than 50 Gy (5000 rads) though some symptoms may occur as low as 20 Gy or 2000 rads. • Death occurs within 3 days. Death is likely due to collapse of the circulatory system as well as increased pressure in the confining cranial vault as the result of increased fluid content caused by edema, vasiculitis, and meningitis.
Stages of Acute Radiation Syndrome
With any of the three above named syndromes, there are four stages of ARS that occur:
• Prodromal stage (N-V-D stage): The classic symptoms for this stage are nausea, vomiting, and possibly diarrhea (depending on dose) that occur from minutes to days following exposure. The symptoms may last (episodically) for minutes up to several days. • Latent stage: The patient looks and feels generally healthy for a few hours or even up to a few • Manifest illness stage: The symptoms depend on the specific syndrome (see Table 1) and last • Recovery or death: Most patients who do not recover will die within several months of exposure. The recovery process lasts from several weeks up to two years.
Cutaneous Radiation Syndrome (CRS)
The concept of cutaneous radiation syndrome (CRS) was introduced in recent years to describe the
complex pathological syndrome resulting from acute radiation exposure to the skin.
ARS will usually be accompanied by some skin damage. It is also possible to receive a damaging
dose to the skin without symptoms of ARS, especially with acute exposures to beta radiation or x-
rays. Sometimes this occurs when radioactive materials contaminate a patient’s skin or clothes.
When the basal cell layer of the skin is damaged by radiation, inflammation, erythema, and dry or
moist desquamation can occur. Also, hair follicles may be damaged causing epilation. Within a few
hours after irradiation a transient and inconsistent erythema (associated with itching) can occur.
Then, there may be a latent phase that lasts from a few days up to several weeks, when intense
reddening, blistering and ulceration of the irradiated site is visible.
Patient Management of Radiation Exposure
If radiation exposure is suspected:
• Secure ABCs (airway, breathing, circulation) and physiologic monitoring (blood pressure, blood gases, electrolyte and urine output) as appropriate. • Treat major trauma, burns and respiratory injury if evident. • In addition to the blood samples required to address the trauma, obtain blood samples for CBC, with attention to lymphocyte count, and HLA (human leukocyte antigen) typing prior to any initial transfusion and at periodic intervals following transfusion. • Treat contamination as needed. • If exposure occurred within 8 to 12 hours, repeat CBC, with attention to lymphocyte count, 2 or 3 more times (approximately every 2 to 3 hours) to assess lymphocyte depletion.
Diagnosis
The diagnosis of ARS can be difficult to make because it causes no unique disease. Also; depending
on dose, the prodromal stage may not occur for hours or days after exposure, or, the patient may
already be in the latent stage by the time they receive treatment, in which case the patient may
appear and feel well when first assessed.
If a patient received more than 0.05 Gy (5 rads) and 3 or 4 CBCs are taken within 8–12 hours of the
exposure, a quick estimate of the dose can be made. If these initial blood counts are not taken, the
dose can still be estimated using CBC results over the first few days. It would be best to have
radiation dosimetrists conduct the dose assessment, if possible.
If a patient is known or suspected of having been exposed to a large radiation dose draw blood for
CBC analysis with special attention to the lymphocyte count every 2–3 hours for the first 8 hours
following exposure (and every 4–6 hours for the following 2 days). Observe the patient during this
time for symptoms and consult with radiation experts before ruling out ARS.
If no radiation exposure is initially suspected you may consider ARS in the differential diagnosis if
there is a history of nausea and vomiting that is unexplained by other causes. Other indications are
bleeding or epilation or WBC (white blood count) and platelet counts abnormally low a few days or
weeks following unexplained nausea and vomiting. Again, consider CBC and chromosome analysis
and consultation with radiation experts to confirm diagnosis.
Initial Treatment and Diagnostic Evaluation
Treat vomiting, and repeat CBC analysis, with special attention to the lymphocyte count, every 2–3
hours for the first 8–12 hours following exposure (and every 4–6 hours for the following 2 or 3 days).
Precisely record all clinical symptoms, particularly nausea, vomiting, diarrhea, and itching, reddening
or blistering of the skin. (Be sure to include time of onset.)
Note and record areas of erythema. If possible, take color photographs of suspected radiation skin
damage. Consider tissue, blood typing, and initiating viral prophylaxis. Promptly consult with
radiation, hematology, and radiotherapy experts in regards to dosimetry, prognosis, and treatment
options.
Call the Radiation Emergency Assistance Center/Training Site (REAC/TS) at (865) 576-3131 (M-
F, 8 am to 4:30 am EST) or (865) 576-1005 (after hours) to record the incident in the Radiation
Accident Registry System.
For More Help
Note that the Radiation Emergency Assistance Center/Training Site (REAC/TS) can also be reached online at http://www.orau.gov/reacts/, and the Medical Radiobiology Advisory Team (MRAT) at (301) Also, more information can be obtained from the CDC Health Alert Network at http://www.bt.cdc.gov.
Initial Treatment and Diagnostic Evaluation
After consultation, begin the following (as indicated):
• Supportive care in a clean environment (if available, the use of a burn unit may be quite • Stimulation of hematopoiesis by use of growth factors. • Stem cell transfusions or platelet transfusions (if platelet count is too low). • Psychological • Careful observation for erythema (document locations), hair loss, skin injury, mucositis, • Confirmation of initial dose estimate using chromosome aberration cytogenetic bioassay when possible. Though resource intensive, this is the “gold standard” for dose assessment following acute exposures. • Consultation with experts in radiation accident management (Ricks, et al., 2002). Test Yourself:
If the platelet count is too low, ______ cell or platelet transfusions may be administered.
Answer: Stem

Personal Protective Equipment (PPE)
The development and use of proven PPE is essential to the health and safety of workers. PPE
(equipment designed to protect persons from the risk of injury by creating a barrier against workplace
hazards) is of particular importance to terrorism preparedness and response to ensure worker health
and safety. PPE has always played an important role in public health and must continue to be
customized to mitigate the risks associated with chemical, biological, radiological/ nuclear and mass
trauma hazards.
Of equal importance is training to ensure workers can properly assess an environment’s hazards and
select the appropriate PPE.
The type of PPE used varies with each situation. The following discussion of types of PPE is general
in nature. If an act of terrorism occurs the type of PPE needed will be determined and action should
be taken to follow guidelines that are issued.
Levels of Personal Protective Equipment (PPE)
There are basically four levels of personal protective equipment:
Level A protection is required when the greatest potential for exposure to hazards exists, and
when the greatest level of skin, respiratory, and eye protection is required. Examples of Level A clothing and equipment include positive-pressure, full face-piece self contained breathing apparatus (SCBA) or positive pressure supplied air respirator with escape SCBA, totally encapsulated chemical- and vapor-protective suit, inner and outer chemical-resistant gloves, and disposable protective suit, gloves, and boots. • Level B protection is required under circumstances requiring the highest level of respiratory
protection, with lesser level of skin protection. Examples of Level B protection include positive-pressure, full face-piece self contained breathing apparatus (SCBA) or positive pressure supplied air respirator with escape SCBA, inner and outer chemical-resistant gloves, face shield, hooded chemical resistant clothing, coveralls, and outer chemical-resistant boots. • Level C protection is required when the concentration and type of airborne substances is
known and the criterion for using air purifying respirators is met. Typical Level C equipment includes full-face air purifying respirators, inner and outer chemical-resistant gloves, hard hat, escape mask, and disposable chemical-resistant outer boots. The difference between Level C and Level B protection is the type of equipment used to protect the respiratory system, assuming the same type of chemical-resistant clothing is used. The main criterion for Level C is that atmospheric concentrations and other selection criteria permit wearing an air-purifying respirator. • Level D protection is the minimum protection required. Level D protection may be sufficient
when no contaminants are present or work operations preclude splashes, immersion, or the potential for unexpected inhalation or contact with hazardous levels of chemicals. Appropriate Level D protective equipment may include gloves, coveralls, safety glasses, face shield, and chemical-resistant, steel-toe boots or shoes. While these are general guidelines for typical equipment to be used in certain circumstances, other combinations of protective equipment may be more appropriate, depending upon specific site characteristics.
Health Alert Network
The Health Alert Network (HAN) is a nationwide communications system that was established by the
Centers for Disease Control and Prevention, and is implemented by each state.
It is designed to enable a two-way, 24/7 flow of critical health information among the Nevada State
Health Division and local and rural health care professionals throughout the state, including
physicians, nurses, hospitals, laboratories, clinicians, public health workers, emergency management
and others.
The Nevada Health Alert Network has the ability to:
• Provide ongoing surveillance activities to quickly identify potential health threats • Offer laboratory capabilities to perform testing to determine the threat agent • Conduct disease investigations • Effectively report incidents and share information • Efficiently transmit emergency communications among all involved parties
Contact Information For HAN
The Nevada Health Alert Network (HAN) contains up to date information and links to “Hot Topics” in
Disaster Preparedness. Since these are constantly changing, the reader can obtain current
information on key health topics through one resource. Relief agencies are outlined and links
provided, so that in the case of an emergency, they can be easily accessed. Additionally the HAN
contains links to county specific emergency management and public health departments and Federal
contacts.
The CDC Bioterrorism Hotline Phone Number is the best contact to use when concerned about any
types of suspected terrorism activities that could affect the public health. By using this number, you
will be connected with one of the key government agencies with information about bioterrorism, and
they can provide you with appropriate information and direction.
24 Hour CDC Bioterrorism Hotline – 770.488.7100

Federal Links
Ready.gov
(www.ready.gov)
This website provides information for individuals, families and businesses, to take action to prepare
themselves for all types of emergencies, including chemical and bioterrorism.
U.S. Department of Health and Human Services (www.dhhs.gov)
HHS is the U.S. government's principal agency for protecting the health of all Americans and
providing essential human services, especially for those who are least able to help themselves.



Centers for Disease Control

(www.cdc.gov)
The CDC is the principal agency in the United States government for protecting the health and safety
of all Americans and for providing essential human services, especially for those people who are least
able to help themselves.
CDC and American Red Cross: Readiness Today
(http://www.redcross.org/preparedness/cdc_english/CDC.asp)
The CDC and the American Red Cross have combined to create this informative website with
information about what types of emergency supplies, including food and water, you should maintain,
information about quarantine and isolation, and tools for coping.

Health Resources and Services Administration

(www.hrsa.gov)
The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of
Health and Human Services, is the primary Federal agency for improving access to health care
services for people who are uninsured, isolated or medically vulnerable.

Department of Homeland Security

(www.dhs.gov)
The National Strategy for Homeland Security and the Homeland Security Act of 2002 served to
mobilize and organize our nation to secure the homeland from terrorist attacks.

Federal Emergency Management Agency

(www.fema.gov)
The Federal Emergency Management Agency (FEMA) describes its role as follows: FEMA's role in
managing terrorism includes both antiterrorism and counterterrorism activities (FEMA, 2006).
Nevada is part of Region IX of FEMA, with its regional office located in Oakland, CA.
Federal Bureau of Investigation
(www.fbi.gov)
The Federal Bureau of Investigation (FBI) is part of the U.S. Department of Justice. FBI priorities
outlined in 2003 include protecting the United States from terrorist attack (FBI, n.d.).
State Links
There are three key links in the State Section: Nevada Office of Homeland Security
(http://www.dhs.gov/), Nevada Division of Emergency Management (http://www.nemaweb.org/), and
Nevada Department of Agriculture (http://agri.nv.gov/). The Nevada Office of Homeland Security is
the state section of the national department. The Nevada Division of Emergency Management is part
of the Nevada Department of Public Safety. It contains information and communication about issues
that affect the public safety of the citizens of Nevada. The Nevada Department of Agriculture is also
included due to threats to water and wildlife.
County Links
There are a number of helpful links to differing health services agencies in Nevada. Many of the links
include information specific to individuals and families as they make their plans for disaster
management. (http://dem.nv.gov/links/)

Conclusion

Nevada, like other states, has a well defined response plan to possible bioterrorist attacks.
The information offered in this course is designed to familiarize the nurse with the general processes
and also to offer the website locations of key organizations and documents to become familiar with
and to use in the event of a bioterrorism attack.
Resources
Knowing what resources to use is critical in the event of a biological attack. The following list of
resources is one that provides both federal and state specific information on bioterrorism, response,
and treatment issues.
Centers for Disease Control (www.cdc.gov). The central federal government agency with information
about infectious diseases
Department of Homeland Security (www.dhs.gov). The federal agency tasked with making sure the
nation is secure.
Federal Emergency Management Agency (www.fema.gov). The federal agency within DHS whose
responsibility is emergency response at the federal level to all types of emergencies, including
bioterrorist attacks.
U.S Army Medical Research Institute of Infectious Diseases (USAMRIID)
(www.usamriid.army.mil/education). A key source of critical information on various potential biological
weapons.
References
Agency for Toxic Substances and Disease Registry Division (2012). Retrieved from
www.atsdr.cdc.gov
Virginia Tech Office of the Vice President for Research. (2005). Opportunity Update. Retrieved from
www.research.vt.edu/funding/ou/prev/ou041505.html .
Centers for Disease Control and Prevention (CDC). (n.d.). Bioterrorism Agents/Disease. Retrieved
from http://www.bt.cdc.gov/agent/agentlist-category.asp#b
Texas Department of State Health Services (2012). Public Health Response and Recovery Diagnosis
and Event Management Tools. Retrieved from
http://www.dshs.state.tx.us/Layouts/ContentPage.aspx?PageID=34568&id
=49440&terms=Public+Health+Response+and+Recovery+Diagnosis+and+Event+Management+Tool
s.#tools
National Institute For Occupational Safety & Health [NIOSH] (2012). Respirators. Workplace Safety &
Health Topic. Retrieved from: http://www.cdc.gov/niosh/topics/respirators/
Nevada State Health Division. (2012). Nevada Health Alert Network. Retrieved December 18, 2012
from http://health.nv.gov/PHP_HealthAlertNetwork.htm .
Material Protected by Copyright
Ricks, R.C., et al., Eds., (2002). The Medical Basis for Radiation Accident Preparedness: The Clinical Care of Victims, Parthenon Publishing, New York. U.S Army Medical Research Institute of Infectious Diseases (USAMRIID) (2005). USAMRIID’s medical management of biological casualties handbook. At the time this course was constructed all URL's in the reference list were current and accessible. rn.com. is committed to providing healthcare professionals with the most up to date information available. Copyright 2005, AMN Healthcare, Inc. Please Read: This publication is intended solely for the use of healthcare professionals taking this course, for credit, from RN.com. It is designed to assist healthcare professionals, including nurses, in addressing many issues associated with healthcare. The guidance provided in this publication is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from RN.com.

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