Nik Ahmad Shaiffudin Bin Nik Him MMC: 35241

MD, MMed (Emerg.Medicine, USM), AM(Mal)

nikshaiffudin@unisza.edu.my

WEAPON OF MASS WEAPON OF MASS DESTRUCTION (WMD)DESTRUCTION (WMD)

• Objectives : Develop the understanding of disaster medicine and mass casualty incident management

• Subject contents : Weapon of mass destruction (WMD)– Biological– Radiological– Chemical

• Performance criteria :– Discuss principles of decontamination– Perform on site decontamination procedure

ObjectiveObjective

1.1. Able to discuss Able to discuss the decontamination procedures in the decontamination procedures in WMDWMD

2.2. Perform the decontamination for suspected Perform the decontamination for suspected biological, chemical and radiological contamination.biological, chemical and radiological contamination.

Learning OutcomeLearning Outcome

Presentation OutlinesPresentation Outlines

1. Introduction2. Category of WMD3. Initial Management4. Summary

• Terrorism involving WMD is an ever-present threat in today’s world........

• As a health care provider, we may be called on to dealwith patients involved in an incident involving WMD's

IntroductionIntroduction

Terrorist ActTerrorist Act...??...??

– 2002 Homeland Security Act Public Law 107-2002 Homeland Security Act Public Law 107-295, 116 Statue 2135:295, 116 Statue 2135:• Activities that involve danger to human lifeActivities that involve danger to human life• Potential destruction of key infrastructure or key Potential destruction of key infrastructure or key

resourceresource• Influence governmentInfluence government• Intimidate or coerce civilian populationIntimidate or coerce civilian population

What Define’s a Terrorist Act?What Define’s a Terrorist Act?

• Weapons of Mass Destruction:– are chiefly designed to incite

terror, not to kill– consist of a variety of different

agents– can be delivered through a

variety of different means– can be extremely difficult to

control– are designed to cause

widespread and indiscriminate death and destruction

IntroductionIntroduction

Categorization ofCategorization ofWeapons of Mass DestructionWeapons of Mass Destruction

B NICE CBRNE

B Biological C Chemical

N Nuclear B Biological

I Incendiary R Radiological

C Chemical N Nuclear

E Explosive E Explosive

1. Chemical 1. Chemical Weapons....Weapons....

Classification of Chemical WeaponsClassification of Chemical Weapons

• Chemical agents are classified by the toxic effects they have on the body

• Chief Categories of Agents:– Nerve Agents– Vesicants or Blistering Agents– Choking or Pulmonary Agents– Blood Agents– Incapacitating or Riot-Control Agents

Why CW are attractive to terrorists ?

1. Difficult to detect

2. Highly efficient (little quantity is needed)

3. Inexpensive manufacturing to obtain

4. Simple technology is needed to produce them

Nerve Agents

• Action: Irreversibly bind to acetylcholinesterase (AChE), the enzyme that degrades acetylcholine (ACh)

• Leads to accumulation of acetylcholine, resulting in:– Muscarinic Effects: small pupils, dim vision, smooth muscle

contraction, copious hypersecretion (sweat, tears, runny nose)– Nicotinic Effects: skeletal muscle weakness, paralysis– CNS Effects: changes in mood, decreased mental status,

seizures, coma... respiratory failure and terminal arrhythmia

• Ex: Sarin (GB), Soman (GD), Tabun (GA), VX Gas

Muscarinic Effects of Nerve Agents

S.L.U.D.G.E.S.L.U.D.G.E.Salivation

Lacrimation

Urination

Diaphoresis

GI distress (diarrhea, vomiting)

Emesis

Nerve Agent Antidote:

• Self-injectable needle– Pralidoxime Chloride (600 mg)– Atropine (2 mg)

Vesicants / Blister Agents• Produce severe blisters and chemical burns, effecting

epithelium of the skin and respiratory tract• Slow acting: causes death in 48-72 hours• Fatality due to:

– Impaired gas exchange (hypoxia)– Loss of body fluids– Secondary infection

• Skin and eyes affected first, then lungs and bone marrow• Once symptoms have begun, decontamination is no longer

effective• Ex: Mustard Gas, Lewisite

2. Pulmonary Damaging Agents• Immediately irritating to the bronchial tree• Early effects:

– rhinitis/pharyngitis– tearing– eyelid spasm– upper respiratory tract irritation

• Later effects:– severe pulmonary toxicity– respiratory failure

• Ex: Phosgene, Chlorine

3. Blood Agents or Cyanides

• Combines with a cellular enzyme inhibiting the body’s ability to transport oxygen to vital organs

• Quick acting: causes death in minutes• Relatively large dose needed to be effective• Initial effects: rapid/deep breathing, anxiety,

agitation, dizziness, weakness, nausea, muscle trembling

• Later effects: loss of consciousness, decreased respirations, seizures, arrhythmias

• Ex: Hydrogen cyanide

4. Riot Control Agents

• Potent lacrimators and irritants

• Effects are believed to be transient, not meant to be lethal (though some deaths in asthmatics and the elderly have been documented)

• Considered more humane than the alternative

• Ex: CN gas, CS gas

General General ManagementManagement Guidelines Guidelinesfor all classes of Chemical Weaponsfor all classes of Chemical Weapons

1. Move to fresh air2. Remove clothing3. Decontaminate 4. Supplemental oxygen5. Antidote6. Restrict physical activity7. Hospitalization/ medical attention

BiologicalWeapons of Mass Destruction

What is What is Bioterrorism?Bioterrorism?

“Intentional or threatened use of viruses, bacteria, fungi or toxins from living organisms to produce death or disease in humans, animals or plants”

1918 2004

Why Biologics are attractive to Why Biologics are attractive to terroriststerrorists ? ?

1. High morbidity and mortality2. Can be obtained from nature3. Creates panic and chaos4. Potential dissemination over large

geographic area5. Can overwhelm medical services6. Civilian populations may be highly

susceptible7. Difficult to diagnose and/or treat8. Some are transmitted person-to-

person via aerosol

Characteristics of Biological Attacks

• Incident may not be recognized for weeks• Responders and health workers are at risk of

becoming casualties themselves• Continuing effect with re-infection• Require special training and equipment to handle• Large numbers of “worried well” (30:1 ratio)• Fear of the unknown

Category A Bioterrorism Agents

• Variola major(Smallpox)

• Bacillus anthracis(Anthrax)

• Yersinia pestis(Plague)

• Clostridium botulinum(Botulism)

• Francisella tularensis(Tularemia)

• Ebola hemorrhagic fever • Marburg hemorrhagic

fever • Lassa fever• Argentine hemorrhagic

fever

Hart Senate Building/USPSHart Senate Building/USPS20012001

Anthrax: Cutaneous Vesicle

Development

Day 4

Day 6

Day 10

Day 2

Mediastinal wideningJAMA 1999;281:1735–1745

Anthrax: Inhalational

Category B Bioterrorism Agents

• Coxiella burnetti

(Q fever)• Brucella species

(brucellosis)• Burkholderia mallei

(glanders)• Venezuelan encephalomyelitis• Eastern and Western equine

encephalomyelitis • Ricin toxin from Ricinus

communis (castor beans)

• epsilon toxin of Clostridium perfringens

• Staphylococcus enterotoxin B

Food/Water Borne Agents• Salmonella species• Shigella dysenteriae• Escherichia coli O157:H7• Vibrio cholerae• Cryptosporidum parvum

Category C Bioterrorism Agents

• Nipah virus• Hantavirus• Tickborne hemorrhagic

fever viruses• Tickborne encephalitis

viruses• Yellow fever• Multi-drug resistant

tuberculosis (MDRTB)

Radioactive and NuclearWeapons of Mass Destruction

Radiation vs. Radioactive Material

• Radiation: energy transported in the form of particles or waves (alpha, beta, gamma)

• Radioactive Material: material that contains atoms that spontaneously emit radiation

• Light, radio waves and microwaves are types of radiation (Ionizing radiation is what we are concerned about)

• Radiation comes in the forms:– Alpha particles– Beta particles– Gamma rays

Penetration Abilities of Different Penetration Abilities of Different Types of RadiationTypes of Radiation

Alpha ParticlesStopped by a sheet of paper

Beta ParticlesStopped by a layer of clothingor less than an inch of a substance (e.g. plastic)

Gamma RaysStopped by inches to feet of concreteor less than an inch of lead

RadiationSource

Exposure vs. Contamination

Exposure: irradiation of the body

Contamination: radioactive material on patient (external) or within patient (internal)

Internal ContaminationThe biological pathways that can introduce radioactive

contamination internally include:

Injection

Inhalation

Ingestion

Absorption

Injuries Associated with Injuries Associated with Radiation Exposure Radiation Exposure

1.Acute Radiation Syndrome (ARS)

2.Cutaneous Radiation Syndrome

3.Chronic radiation exposure

4.Teratogenic effects

Radioactive/Nuclear WMDs:Possible Scenarios

1.Nuclear power plant incident

2.Nuclear weapon3. Improvised Nuclear

Device (IND)4. “Dirty bomb”

Acute Radiation Syndrome (A Spectrum of Disease)

Acute Radiation Syndrome (A Spectrum of Disease)

Methods of protection

• Time

• Distance

• Shielding

Explosive

1.1. Pipe BombsPipe Bombs

2.2. IED’sIED’s

3.3. C4, TNTC4, TNT

Atlanta Olympic GamesAtlanta Olympic Games19961996

World Trade CenterWorld Trade Center19931993

Oklahoma CityOklahoma City19951995

MEDICAL MANAGEMENT OF CBRNE

The Principles Of Management - The Principles Of Management - RAINRAIN

1.1. RecognizeRecognize the hazard or threat the hazard or threat– Rapid interpretationRapid interpretation

2.2. AvoidAvoid the hazard, contaminant or injury potential the hazard, contaminant or injury potential– Liquids, powders, vapor clouds, Liquids, powders, vapor clouds,

3.3. IsolateIsolate the hazard area the hazard area– Time, distance & shielding from you and othersTime, distance & shielding from you and others

4.4. NotifyNotify the appropriate support agencies the appropriate support agencies– Notify command authority (law enforcement, fire, etc.)Notify command authority (law enforcement, fire, etc.)

Initial On-site Activities

• Manage the Scene

• Manage the Victims: Triage, Treat, Transport

Manage the Scene• Notify appropriate authorities • Control incident perimeter • Establish Incident Command • Identify radiation types and isotopes • Measure levels of radiation continuously • Ensure responder safety

– Wear personal protective equipment (PPE) – Use personal dosimeters – Consult radiation worker exposure guides

• Establish "zones of response" – Radiological incident zones of response – IND incident zones of response

• Establish patient handling flows – In the field

• Establish locations for field activities (IAEA) • Patient handling flows in the field for a radiological event (IAEA) • RTR system (Triage, treatment and transport after an IND detonation)

– In a medical facility • Control zone in the emergency department

Recommendation for Generic Areas to be Established by First Responders

SALT Mass Casualty Triage Algorithm (Sort, Assess, Lifesaving Interventions, Treatment/Transport) — Adapted for a Very Large Radiation Emergency

Perform Lifesaving Tasks Before Managing Radiation Problems

Managing victims with contamination General guidance

• Rescuing victims with contamination should occur only after On-scene management activities have been taken to ensure responder and public safety • Minimally contaminated victims do not pose a health risk to rescuers or healthcare providers. • Perform life and limb-saving tasks before managing external or internal radiation contamination. • Do not delay life-saving rescue or transport of a seriously injured or contaminated person.

Transport Victims of Radiation Emergencies

• Perform life-saving tasks before managing radiation problems or assessing contamination and decontamination status.

• Victims of exposure and contamination should be transported to medical facilities (to Appropriate

Facilities ) with the expertise to manage these problems.

DecontaminationDecontamination

A chemical and/or physical process to remove and prevent the spread of a contaminant from an emergency scene because of the contaminant’s ability to cause harm to living beings and/or the environment

Can First Responders Do Decon!

• If it can be done safely!

• Contaminated live victims should receive immediate emergency decon.

Live Patients Can’t Wait for Technical Decon to Arrive!

Types of DecontaminationTypes of Decontamination

1.Emergency

2.Gross

3.Technical

Emergency DecontaminationEmergency Decontamination

• Fire Hose near point of Entry• Decontamination Foam

Distributor• Design system per the mission

WET

STRIPFLUSHCOVER

Mengasingkan Mangsa di Bilik Dekontaminasi

Pengurusan Dekontaminasi Mangsa –mangsa di

“Hot Zone”

Pengurusan Mangsa di “Warm Zone”

Kemasukan Pesakit ke WadMelalui “Speed Path”

“Cold Zone” Keluar

Dekontaminasi Petugas-petugas

Petugas-petugas memakai PPE

Gross DecontaminationGross Decontamination

• Remove clothing – Cut victim clothing off if needed– Better to remove clothing dry if possible– Remove respiratory protection last

• Remove contaminates– Water– Brushes and/or wipes

Gross Decontamination

Technical DeconTechnical Decon

Four Step process– Gross Wash– Wash & Rinse– Doffing or removal of

Equipments/ attire– Personal Shower

Emergency vs. Mass DeconEmergency vs. Mass Decon

Mass Decon is Emergency Decon for More People!

Main Purposes of Mass Decontamination

• Protect response and medical personnel

• Remove chemical agent from Contaminated victims

• Limit spread of contamination

Summary

1.1. Ensure safetyEnsure safety2.2. Know the HazardsKnow the Hazards3.3. Develop Rapid ThinkingDevelop Rapid Thinking...... WMD??...... WMD??4.4. Understand the Terrorism IssuesUnderstand the Terrorism Issues5.5. Incident Command System.....Coordination!!!Incident Command System.....Coordination!!!6.6. Decontamination ProceduresDecontamination Procedures7.7. Don’t Become Part of the ProblemDon’t Become Part of the Problem

THANK THANK YOUYOU