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Toxins of Terrorism and Mass Aggression

Toxins of Terrorism and Mass Aggression. Rama B. Rao, MD NYUMC/Bellevue Hospital Center. Non-Traditional Weapons. 5th Century B.C. use of pitch and sulfur in wars between Athens and Sparta. 19th Century Hong Kong.

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Toxins of Terrorism and Mass Aggression

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  1. Toxins of Terrorism and Mass Aggression Rama B. Rao, MD NYUMC/Bellevue Hospital Center

  2. Non-Traditional Weapons 5th Century B.C. use of pitch and sulfur in wars between Athens and Sparta

  3. 19th Century Hong Kong 1857 Arsenic laced bread sold to British patrons to induce terror at the E Sing Bakery

  4. Toxin Classes • Chemical Warfare • Biologicals • Nuclear Agent • Others

  5. Classification of Chemical Agents • Blistering agents or vesicants • Pulmonary or choking agents • Cellular asphyxiants or blood agents • Nerve Agents • Incapacitants

  6. Blistering Agents/ Vesicants • Lewisite • Phosgene oxime • Mustards of • Sulfur • Nitrogen

  7. Blistering Agents • Irritation to: • Mucus Membranes • Skin • Occasionally deeper tissues • Onset minutes to hours • Care supportive • Decontamination • BAL?

  8. Pulmonary/ Choking Agents • Phosgene • Chlorine • Oxides of Nitrogen • Impaired gas exchange

  9. Pulmonary/Choking Agents • Onset can be delayed • Pulmonary edema • Treatment supportive • Role of LT antagonists for phosgene uncertain

  10. Blood Agents: Arsine (AsH3) • Fishy/garlic odor • Onset 2-24 hours • Oxidant stressor • Topical: frostbite • Intravascular hemolysis and its complications • Limited decontamination • Treatment Supportive

  11. Cellular Asphyxiants • Cyanide • Cyanogen chloride • Mitochondrial toxins • Rapidly fatal • Antidote kit Zyklon B, WWII Auschwitz

  12. Cyanide Antidote Kit Hemoglobin Nitrites Methemoglobin Cyt a-a3 Mitochondria Cyanide Cyanomethemoglobin Sodium Thiosulfate Sodium Thiocyanate Rhodanese

  13. Nerve Agents • Sarin • Cyclohexy Sarin • Soman • Tabun • VX • Organophosphate insecticides

  14. Normal Cholinergic Function Neuron ACh ++++++++++ ------------------ +++++++ Target Organ Target Event

  15. Cholinesterase Function Choline ACh H3C H3C H3C H3C-N-CH2-CH2-OH + N-CH2-CH2-O-C-CH3 H3C O- H3C N+-HO _ + Cholinesterase O HO-C-CH3 Acetic Acid

  16. Normal Cholinesterase Function Neuron ACh Choline Acetic acid ++++++++++ ------------------ ----- Target Organ Termination of Event

  17. Cholinesterase Poisoning ACh H3C H3C O + N-CH2-CH2-O-C-CH3 H3C RO-P=OR’ O- O- N+-HO _ Poisoned Cholinesterase

  18. Cholinesterase Poisoning Neuron ACh ----+++------------- +++--------+++ Target Organ Repeated Stimulation

  19. Cholinergic Agents: Muscarinic Effects • Bradycardia • Bronchorrhea • Bronchospasm • Salivation • Small Pupils • Lacrimation • Urination • Defacation • GI • Emesis

  20. Atropine:Muscarinic Blocker Neuron ACh Atropine ----+++-------------------------+++ AChM Target Organ

  21. AUTONOMIC NERVOUS SYSTEM Excess AChN Parasympathetic Ganglia Sympathetic Excess AChM Catecholamines CNS Bradycardia Bronchospasm Bronchorrhea Tachycardia HTN Mydriasis Hypoxia

  22. NERVOUS SYSTEM AChN Parasympathetic Ganglia Sympathetic AChM Catecholamines CNS Bradycardia Bronchospasm Bronchorrhea Tachycardia HTN SOMATIC NERVOUS SYSTEM AChN Neuromuscular Junction

  23. Excess Acetylcholine: NMJ: Nicotinic Neuron ACh ----+++------------- +++--------+++ Skeletal Muscle:AChN Contraction Contraction Contraction FASCICULATIONS

  24. Excess Acetylcholine: NMJ: Nicotinic Neuron ACh ----+++++++++++++++++++++++ Skeletal Muscle:AChN FLACCID PARALYSIS

  25. Pralidoxime, 2-PAM O 2-PAM RO-P=OR’ O O- 2-PAM RO-P=OR’ O- _ _ Pralidoxime binds cholinesterase Reactivates cholinesterase

  26. Nerve Agents • Atropine for muscarinic toxicity • Oximes for nicotinic toxicity • Pralidoxime • Obidoxime • Aggressive decontamination

  27. Decontamination Shower Bed Fluid collection Gown Mask Full face PAPR SCBA GLOVES Rubber Nitrile rubber Neoprene rubber Butyl rubber Vitron Protective Equipment

  28. Crowd Control Agents • Lacrimators • Superfentanyl

  29. Toxins of Mass Aggression • Identify agent or classify clinical effects • Decontamination • Live saving maneuvers • Be prepared for the undiagnosed exposure • Personal protection • Handling secondary fears

  30. Resources • www.bt.cdc.gov/AgentlistChem.asp • chemdef.apgea.army.mil/textbook/contents.asp • www-cgsc.army.mil/carl/resources/csi/Heller/HELLER.asp

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