Weapons of Mass Destruction (WMD) Treatment Guidelines Richard C. Dart, MD, PhD Gregory M. Bogdan, PhD

1. Rocky Mountain Poison and Drug Center Weapons of Mass Destruction (WMD) Treatment GuidelinesRichard C. Dart, MD, PhDGregory M. Bogdan, PhD

2. Maui, HawaiiMay 2000 • 500 people gathered on the pier preparing for a 5K race • Suddenly a van parked near the starting line explodes injuring many of the racers

3. Maui, Hawaii • EMS, fire and police respond • Large number of people injured by explosion • Use of chemical agent suspected • Hazmat assistance is requested before anyone will be allowed to enter the area

4. Maui, Hawaii • HazMat responds and confirms that a chemical agent has been used • Decon is requested • 20 are dead, 250 injured • 1000 people evacuated • Sulfur mustard is the suspected agent

5. Maui, Hawaii • First victim decon’d and ready for triage • How will EMS triage & treat the victim prior to transport? • 3 area hospitals providing care for victims, first victim arrives in the ED • How will ED staff triage, evaluate & treat the victims?

6. History • 1915 - Germany uses chlorine 800 deaths • 1917 – Germany uses phosgene • Gas masks developed • French/British unsuccessfully use cyanide • 1917 - Germany uses mustard; 20K victims (5% die) • Protective clothing developed • 1925 - Geneva Protocol (US/Japan do not participate) • 1930 - First nerve agents synthesized (tabun & sarin) • WW II - No chemical weapons used

7. Vesicants • Introduced in WW I • Sulfur Mustard • Lewisite • Phosgene oxime (not a true vesicant) • Liquid and vapor threat • Affect skin and mucous membranes • Cause blistering of skin (vesicles)

8. Mustard • Sulfur mustard synthesized in 1800’s • First used in battle in 1917 by Germany • Used by Iraq in 1980’s against Kurds • US currently destroying its stockpile • Still considered a threat

9. UNMOVIC inspectors found artillery rounds filled with mustard gas at this facility on December 3, 2002. Iraqi official claimed these artillery rounds were previously declared. Still a Threat?

10. MustardProperties • Oily liquid • Yellow-brown color • Odor of garlic/onion/mustard • Odor fatigue • Evaporates slowly (persistent) • Except in temperatures > 100o F (vapor hazard) • Often mixed with other substances • Prevents solidifying

11. Mustard • Penetrates clothing easily • Not chemical PPE • Highly lipophilic • Absorbed quickly into skin (esp. warm, moist, thin) • Systemically absorbed • But rapidly binds tissues so systemic effects rare • Binds (alkylation) DNA, RNA, proteins, GSH • Cell death primarily in dividing cells

12. Mustard

13. MustardToxicity • Few deaths (3%) • Significant morbidity; lengthy hospitalizations (avg. = 42 days) • LD50 = 100 mg/kg = 1 teaspoon = 25% BSA

14. MustardEffects • Direct contact of liquid/vapor affects: • Skin • Eye • Respiratory • Delayed effects • Systemic effects (with significant absorption): • CNS • Bone marrow/lymphoid • GI

15. MustardEffects • Skin: • Delayed onset 2-48 hrs (usually 4-8) • Erythema, burning, pruritus • Followed by vesicles/blisters • Vesicle fluid does not contain mustard • Healing = weeks - months

16. MustardEffects • Eyes: • Quicker onset than skin (min - hrs) • Mild = conjunctivitis, blepharospasm • Moderate = corneal roughening, lid inflammation • Severe = corneal opacification/ulceration/perforation • Heal in wks–months; 1% permanent damage (scarring, glaucoma; blindness)

17. MustardEffects • Respiratory: • Most common cause of death • Burns, inflammation, pseudomembranes, laryngospasm, wheezing, airway obstruction • Hemorrhagic pulmonary edema (massive dose) • Symptoms = burning, watering, cough, hoarseness, dyspnea, chest pain, wheezing

18. MustardSystemic Effects • CNS • Usually mild and nonspecific • Apathy, somnolence, coma • Agitation, muscular activity; rarely sz’s • GI • Early = N/V common (hrs) • Late = N/V (days later) • Bone marrow/lymphoid • Leukopenia, anemia, thrombocytopenia (7 – 14 d) • Poor prognosis

19. MustardManagement • Decontamination: • Ideally within 1 – 2 min • Little utility by the time symptoms develop • Dilute bleach (0.5%); water or soap/water acceptable • Water only for eyes • Symptomatic care (deaths rare): • Similar to burn patients • Fluid loss not severe (avoid overhydration) • > 25% BSA = risk of systemic toxicity • Secondary infections/sepsis

20. MustardSymptomatic Care • Skin • Burn care – Topical abx cream/oint; daily cleansing; dressings; systemic pain control • Eyes • Local care – daily irrigation; topical abx oint; topical mydriatic; keep eyes open; systemic analgesics • Ophtho consult; ?steroids • Respiratory • Humidified O2; antitussives/bronchodilators; ventilatory & airway support • ? Bronchoscopy to remove pseudomembranes

21. Project Goal • Consensus treatment guidelines for chemical agent exposures that provide health care professionals with appropriate treatment regimes. • Supported by Office of Public Health Emergency Preparedness (OPHEP) of the United States Department of Health & Human Services (HHS)

22. Atlanta Protocols Simple Algorithmic Real-Time Provider Specific Mass Casualties

23. Atlanta Protocols Simple Algorithmic Real-Time Provider Specific Mass Casualties

24. Current Response System

25. Committee Meeting Harry Wilson, 1937 How Do We Develop New Guidelines? • Evidence-Based Medicine • A philosophy involving inductive reasoning • which is based on a balanced and thorough • analysis of available evidence. • (Evidence-Based Medicine Working Group. Evidence-Based Medicine. JAMA 1992;268:2420-2425) • Individual expertise • Consensus Panel

26. Consensus Panel Members • Fred Henretig, MD • Steven Joyce, MD • Ed Kilbourne, MD • Mark Keim, MD • Mark Kirk, MD • James Madsen, MD • Dori Reisman, MD, MPH • Michael Shannon, MD • Frederick Sidell, MD • Chief Richard Stilp, RN • CDR Matthew Tarosky • Richard Thomas, PharmD • Richard Alcorta, MD • Eric Aufderheide, MD • Armando Bevelacqua • Alvin Bronstein, MD • Jeff Burgess, MD • Richard C. Dart, MD, PhD • Craig DeAtley, PA-C, MSHS • Philip Edelman, MD • Col. Edward Eitzen, MD, MPH • David Fenton • Robert Geller, MD • Lewis Goldfrank, MD • Robert Gum, DO, MPH

27. NBC Panel Profile

28. EBM + Consensus Process • Encourages use of appropriate data to develop consensus conclusions. • Potentially combines strengths of both procedures.

29. EBM + Consensus Process Creates framework based on evidence Fills in holes using medical expertise

30. Chemical Agents • Chlorine • Nerve Agents • Sulfur Mustard • Cyanogens • Isocyanates • Phosgene, Carbonyl Chloride

31. It Has Long Been Known... Interpreting the Medical Literature

32. It Has Long Been Known... I couldn’t find the reference

33. In My Experience... Once

34. In My Experience... Once In Case After Case... Twice

35. In My Experience... Once In Case After Case... Twice In A Series of Cases... Three times

36. Additional Work Is Needed...

37. Additional Work Is Needed... Maybe then our results will begin to make sense.

38. Thanks to my research team.

39. Thanks to my research team. They actually did the work

40. Guideline Assumptions • Rarely Utilized • Algorithm Design • Same format for all guidelines • Agent Identity May Be Unknown (or even wrong) • Most Patients Will Self-Report • Decontamination Procedures To Be Incorporated • Volume of patients may be within or greatly exceed the capacity of the EMS and ED

41. Maui, Hawaii • First victim decon’d and ready for triage • How will EMS triage & treat the victim prior to transport? • 3 area hospitals providing care for victims, first victim arrives in the ED • How will ED staff triage, evaluate & treat the victims?

42. NBC Guidelines Page 2 Page 1

43. OEP Guidelines “Atlanta Protocols”

44. History

45. Physical Examination

46. Additional Assessment

47. Treatment

48. Disposition

49. EMS Version of Guidelines • Same Ground Rules Simple Algorithmic Real-Time Provider Specific Mass Casualties

50. EMS – History