What hospitals need in order to treat chemical attack victims
The threat of a chemical weapons attack is hanging over us. Chemical warfare has been around for centuries, beginning with the pouring of boiling crude oil on soldiers attempting to invade a fortress or castle. The opposing sides used mustard gas during World War I. The Iraqi government used chemical weapons in their war with Iran and against the Kurdish rebels.
Since we have enemies in our country who want to kill us in large numbers and since it is not difficult to obtain toxic chemicals, it is not a big stretch of the imagination to conclude that we can expect chemical attacks in cities across the country. Either we can live in denial until something happens (heaven forbid) or we can take measures that would save lives.
Noxious chemicals exist in virtually every household in America. If you have any doubts, look in the cabinet beneath your kitchen sink. If a terrorist drives a chemical tanker down "Broadway" or "Main Street" and blows it up (again, heaven forbid), he would be spraying several thousand gallons of lethal gases or liquids all over the town.
What is the emergency response plan for the hospital in your neighborhood?
The two basic components of an appropriate response plan to chemical attack are decontamination and treatment. Decontamination is the first priority because if the chemical agent is still on the skin or clothing, the damaging effects will continue. Additionally, the people providing care would be at risk. Therefore, removing the substance is the only way to stop further damage. Following that, the doctors and nurses can then focus on providing available treatment.
Accordingly, a plan for chemical decontamination should include the following procedures:
1. Set up portable male and female shower areas in the ambulance bay immediately upon activation of disaster protocol.
2. The person in charge of coordinating all services shall designate a decontamination team.
3. The decontamination team shall wear appropriate protective suits and report to the ambulance bay.
4. The triage nurses will screen patients as they arrive to determine priority while a clerk registers them.
5. Patients will disrobe and place their clothes in labeled plastic bags. The decontamination team will assist those who need help.
6. Patients must shower using soap and a soft brush, getting assistance as needed.
7. If the number of patients is too large to decontaminate every one of them in the showers, the fire department must be on hand to open fire hydrants and hose down groups of people using pressure-controlled hoses that would not cause injury.
8. After decontamination, hospital escort personnel will take patients to the designated treatment areas.
Regarding treatment, it would be most helpful to have an understanding of the different types of chemical weapons materials and their effects. Thus in case of exposure, you would be able to avoid panic and calmly make appropriate decisions. There are four different categories of chemical weapons: nerve agents, vesicants, industrial chemicals, and riot-control agents.
First, the commonly known nerve agents are tabun (GA), Sarin (GB), soman (GD), and VX. These compounds are pesticides. The Germans developed the G agents during the 1930s, and the British developed the V agents during the 1950s. These are the most toxic of all chemical weapon agents and can cause sudden loss of consciousness, seizures, respiratory failure, and death within minutes. Terrorists can store these neurotoxins in liquid form and transport them in canisters. The G and V agents have different properties. The former are volatile liquids and evaporate quickly while producing toxic vapors. The body absorbs the liquid through the skin and eyes, while the vapors enter through the lungs. VX has a consistency like motor oil and lingers indefinitely on the skin but does not produce a vapor hazard.
Since there would be no time for laboratory diagnosis in the event of chemical attack, doctors would have to diagnose the victims from clinical observation and event history. The nerve agents produce biological effects by inhibiting the producing of the ACNE enzyme (acetylcholinesterase). This enzyme controls the levels of acetylcholine, a neurotransmitter (allows impulses to travel between nerve cells). Without this enzyme control, the entire nervous system becomes overstimulated and hypersensitive. The resulting signs and symptoms are as follows:
- increased secretions as in drooling, tearing, runny nose, airway congestion, and profuse sweating
- smooth muscle contraction causing pinpoint pupils, asthmalike bronchospasms, nausea, vomiting, and diarrhea
- skeletal muscle disorder causing spasms, twitching, and weakness
- central nervous system irritability causing loss of consciousness, seizure, and respiratory failure
- cardiac disturbances causing rapid heart rate, high blood pressure, and heart block (electrical impulse failure)
Although the media often refers to nerve agents as "nerve gas," this is a misnomer. The "gas" spoken of is vapor. The severity of the exposure depends on the length of time that a person inhales the vapor with the liquid on the skin. A mild exposure will immediately cause eye pain, tearing, blurred vision, runny nose, and asthmatic response (shortness of breath and tightness in the chest). With a moderate dosage, the symptoms will progress to the intestinal tract with nausea, vomiting, and diarrhea. Once the contact becomes severe, the victim will lose consciousness and begin seizing within one to two minutes. After several minutes of nonstop seizure, there is total flaccid paralysis and death. Furthermore, if the amount of nerve agent is large enough in a given attack, the people closest to the source will die within one to two minutes of the strike. With regard to the nerve agents, the German compounds, like sarin, evaporate more quickly than VX. However, VX presents more of a contact hazard, with faster skin penetration.
In view of the foregoing, the planners must bear in mind that the reversibility of nerve agent damages depends on lapsed time from initial exposure to decontamination and treatment. Hospital personnel must go through a series of drills with mock disasters using these new disaster-plan protocols. Everyone has to know exactly where he or she belongs and what his or her job is. Otherwise, the staff would be fumbling around in chaos, with lives being lost as the cost of management failure.
With respect to treatment, three medications are available to treat the signs and symptoms of nerve agent intoxication: atropine, pralidoxime chloride, and diazepam (Valium). The atropine will reverse the symptoms of mild to moderate exposure. Pralidoxime chloride will reverse the chemical processes of sarin and VX. However, this antidote will only work within four to five hours of exposure for sarin and sixty hours of exposure for VX. The Valium will stop the seizure activity but will not change the nature of the nerve agent within the body. The doctors will determine the various dosages.
To continue, the vesicants are sulfur mustard and lewisite. Mustard is both a vapor inhalation and a liquid contact hazard. Regarding mustard, the main problem with this substance is that symptoms usually do not appear until after irreversible damage has occurred. The body absorbs mustard through inhalation or skin contact within one to two minutes, while the lapse of clinical symptoms from exposure to onset is commonly four to eight hours but can happen from two to forty-eight hours. The injurious effects of mustard liquid and vapor are as follows:
- inflammation, swelling, and corneal ulceration of the eyes resulting in blindness
- burning, itching, redness, and blisters of the skin
- nosebleed, sore throat, and hacking cough
- hoarseness of the voice
- shortness of breath and productive cough
- nausea and vomiting
- bone marrow damage resulting in hemophilia and immune deficiency
The amount of permanent harm depends on the dosage or concentration released in a particular attack.
The treatment can only be supportive since there is no known antidote to sulfur mustard exposure. The disaster plan should include protocols for immediate decontamination and certain treatments for the skin, eyes, and airway.
The emergency responders have to decontaminate as quickly as possible by wetting the victim down with a shower or hose. If the mustard is not washed off within thirty minutes of exposure, it will be too late to lessen the effects because the chemical will have been absorbed and the cellular destruction will have already taken place.
For skin that is irritated and itching, any washing and application of any type of soothing lotion would be helpful. Where there are blisters, the required treatment is application of antibiotic ointment and sterile dressings. Additionally, the dressings need changing several times per day with generous rinsing of the wounds.
For the eyes, gentle irrigation would be helpful only within the first few minutes of exposure. Sometimes the eyelids clamp down spastically in response to the chemical assault. When this happens, attempting to force the eyes open would do more harm than good because by this time the damage has already happened. Follow-up treatment usually includes prescribed eyedrops to prevent scarring, antibiotic eye solutions or ointments and petroleum jelly applied to the eyelids to prevent them from being stuck in a closed or open position.
Treatment of the upper airway involves the use of cool mist and cough syrup. Victims with deeper airway effects such as shortness of breath need to be in intensive care with mechanical ventilation support. If there is an asthmatic response, the standard treatment for asthma applies.
Lewisite, although less infamous than sulfur mustard, is a major concern because there are military stockpiles throughout the world. While it produces most of the same effects as mustard, the symptoms appear more quickly before permanent damage occurs. Lewisite also causes more skin injury. Since it causes immediate irritation-to the nose and throat, any attempt to run from the exposure would result in deeper lung damage because the breathing would become deeper and more rapid. Additionally, lewisite causes loss of blood volume with injury to the liver and kidneys with no effect on the bone marrow.
Washing the victim with soap and water as quickly as possible will remove most of the chemical and reduce the potential damage. There is an antidote, anti-lewisite, that prevents the shock response with liver and kidney damage.