Introduction to Medical Response to CBRNE Events Flashcards
What happened during the Tokyo Tube attack?
In 1995, Sarin gas was released in the subway via plastic bags
What is the mechanism of toxicity of nerve agents?
toxicity arises from inhibition of AChE at the NM junction
What are the clinical manifestations of muscarinic nerve agents?
Diarrhea Urination Miosis Bradycardia Bronchorrhea Bronchospasm Emesis Lacrimation Lethargy Salivation
What are the clinical manifestations of nicotinic nerve agents?
Mydriasis Tachycardia Weakness Hypertension Fasciculations
What nerve agent was previously used as a terrorist weapon by Aum Shinrikyo?
Sarin
What is the pharmacologic management/antidotes for nerve agents?
- atropine
- pralidoxime chloride (2-PAM)
- benzodiazepines
What is the odor of sulfur mustard?
garlic or horseradish-like odor, mustard, onion, or asphalt
What is the odor of nitrogen mustard?
fishy odor
What is the treatment for Lewisite?
British Anti-Lewisite (BAL) in peanut oil solution
What are examples of blood agents?
- hydrogen cyanide
- cyanogen chloride
What is the odor of hydrogen cyanide?
bitter almonds
What is the odor of cyanogen chloride?
pungent biting odor - like burnt fireworks
What is in the cyanide antidote kit?
- amyl nitrite
- sodium nitrite
- sodium thiosulfate
What does the hydroxycobalamin antidote react with?
cyanide ion to form cyanocobalamin and water
What is the mechanism of toxcity of cyanide?
Inactivates cytochrome oxidate which uncouples mitochrondiral oxidative phosphorylation
What is the odor of phosgene and di-phosgene?
newly mown or musty hay
What toxalbumin was used to kill Georgi Markov in London via subcutaneous injection?
ricin
What are the category A bioterrorism agents?
- anthrax
- botulium toxin
- smallpox
What is the name of the disease that anthrax causes?
Woolsorter’s disease
What are the methods of transmission for anthrax?
contact with broken skin, inhalation of spores, ingestion, and injection
What are the CXR findings of inhalation anthrax?
- widened mediastinum on CXR
- pleural effusion
What is the management of anthrax?
ciprofloxacin, meropenem, and linezolid
What is the most known toxic substance?
botulinum toxin
What are the clinical manifestations of botulinum toxin?
- End result = muscle paralysis
- Diplopia, dysarthria, dysphonia, dysphagia
What are the differences between smallpox and chickenpox?
- centrifugal distribution - important diagnostic feature
- synchronous changes in lesions
What are the category B bioterrorism agents?
ricin toxoalbumin from ricinus communis (castor beans)
What are the characteristics of alpha particles?
- massive, charged particles
- cannot travel far
- negligible external hazard
- damage: Internalized via lungs and GI, local cellular damage in immediate region
What are the characteristics of beta particles?
- very light, charged particles found primarily in fallout radiation
- can travel short distances in tissue
- damage: basal stratum of skin (“beta burns”) and lense of eyes
What are the characteristics of gamma particles?
- uncharged radiation similar to x-ray
- highly energetic
- pass through matter easily
- whole-body penetrating exposure
What are the characteristics of neutron particles?
- only released during nuclear detonation
- severely disrupt atomic structures
- 20x more damage than gamma rays
- not a concern in dirty bombs
What is found in food irradiation plants?
cobalt-60
What is used in x-rays and cancer treatments?
cesium-137
What is found in nuclear batteries?
strontium-90
What are the blistering agents?
- Nitrogen Mustard
- Sulfur mustards
- Lewisite
- Phosgene Oxime
What are the choking agents?
- Phosgene/Di-Phosgene
- Chlorine gases
What is the riot-control agent?
Oleoresin Capsicum (law enforcement pepper spray)
What are primary injuries from?
direct result of blast overpressure force
What is the most common fatal injury among initial blast survivors?
blast lung
What is the triad for blast lung?
- apnea
- bradycardia
- hypotension
What are secondary injuries from?
result from projectiles/debris/ fragments generated by an explosion’s overpressure and blast winds
What are tertiary injuries from?
result when the victim is accelerated by the explosion’ force and then knocked into hard surfaces or launched into the air
What does SALT stand for?
Sort
Assess
Lifesaving Interventions
Treatment/Transport
What are the life-saving interventions done in the red/hot zone?
- open the airway with the basic BLS maneuvers (may insert nasopharyngeal airway)
- if a child, give two rescue breaths if needed
- needle decompression
- tourniquet for major hemorrhage
- autoinjectors (nerve agent antidote, Epi-Pen)
What is categorized as immediate/red?
requires immediate care for a good probability of survival
What are examples of immediate/red injuries?
EM IS a MUST
- Exsanguinating hemorrhage
- Mechanical airway obstruction
- Incomplete amputations
- Sucking chest wound
- Maxillofacial wounds with potential airway compromise
- Unstable chest and abdominal wounds
- Second-or 3rd burns involving 40-60% TBSA
- Tension pneumothorax
What is categorized as delayed/yellow?
can tolerate delay prior to surgical intervention without unduly compression likelihood of successful outcome
What are examples of delayed/yellow injuries?
S4, M3, T2
- Stable abdominal wounds with possible visceral injury
- Soft tissue wounds requiring debridement
- Second or 3rd degree burns involving 15-40% TBSA
- Smoke inhalation without airway or respiratory compromise
- Maxillofacial wounds without airway compromise
- Most orthopedic and vascular injuries requiring surgical intervention
- Most ocular and CNS (including C-spine) trauma
- Traumatic amputation with bleeding controlled
- Traumatic crush injuries without crush syndrome
What is categorized as minimal/green?
injuries requiring little more than first aid and should be rapidly directed away from the triage area
What are examples of minimal/green?
CAPS 1st
- Closed, uncomplicated fractures
- Auditory blast injuries (blast eardrum)
- Psychiatric and emotional distress
- Superficial wounds
- 1st/2nd-degree burns involving <15% TBSA
What is categorized as expectant/grey?
injuries requiring an unjustifiable expenditure of limited resources and should be triaged away, but not abandoned
What are examples of expectant/grey?
- Mutilating explosive wounds involving multiple anatomic areas/organs
- Agonal respirations
- Profound shock with multisystem injuries
- Second/3rd degree burns involving >60% TBSA
- Unresponsive individuals with penetrating head wounds
- Quadriplegic individuals with probably high spinal cord injuries
What is categorized as deceased/black?
injuries incompatible with life
What are exmaples of deceased/black?
- Decapitation
- Absence of vital signs with fixed and dilated pupils
- Traumatic head injury with gray matter evident
- Hemicorporectomy
- Burns expending over >60% body surface area
- Multiple penetrating wounds to the head, chest, abdomen, and/or pelvis
- Lethal radiation dose
What does MARCH-H stand for?
Massive hemorrhage Airway compromise Respirations Circulation Head Injuries Hypotherima
Who is it really good to use a SWAT-T tourniquet for?
for people with smaller extremities or children
What is the criteria for tension pneumothorax that needs a needle chest decompression?
- evidence of worsening respiratory distress or difficulty with BVM device
- decreased or absent breath sounds
- decopensated shock (SBP <90 mmHg - no radial pulse)
Where do you insert the needle for a tension pneumothorax?
2nd intercostal space
What is the modified HAINES?
High Arm IN Endangered Spine - lateral recovery position and head on outstretched arm
What is the Cushing’s triad?
- hypertension
- bradycardia
- respiratory changes
What is the scoring for eye opening response on the Glasgow coma scale?
4 Spontaneously
3 To speech
2 To pain
1 No response
What is the scoring for verbal response on the Glasgow coma scale?
5 Oriented to time, person, and place 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 1 No response
What is the scoring for motor response on the Glasgow coma scale?
6 Obeys command 5 Moves to localized pain 4 Flex to withdraw from pain 3 Abnormal flexion 2 Abnormal extension 1 No response
What is the neurogenic shock triad?
- hypotension
- bradycardia
- peripheral vasodilation
What is the lethal triad?
- hypothermia
- acidosis
- coagulopathy
What are the symptoms of mild hypothermia?
- shivering
- hypertension
- tachycardia
- tachypnea
- vasoconstriction
- poor judgment
- strange behaviors
What are the symptoms of moderate hypothermia?
- slow and labored breathing
- mild confusion (may appear alert)
- cyanotic lips, ears, fingers, and toes
- paradoxical undressing
- cardiac arrhythmias may begin
What are the symptoms of severe hypothermia?
- difficulty speaking
- amnesia
- inability to use hands
- incoherent or irrational behavior
- stupor
- loss of pain response
What is the most effective agent for decontamination?
copious use of soap and clean water
What is the inverse square law?
a law stating that the intensity of an effect such as illumination or gravitational force changes in inverse proportion to the square of the distance from the source
-further away = less exposure
What biological weapon/agent did Aum Shinrikyo cult use?
anthrax
What biological weapon/agents were used in World War Two?
plague, anthrax, dengue, tularemia
What biological weapon/agent was used on the city of Kaffa?
plague
What biological weapon/agent was used by the Bhagwan Shree Rajneesh cult?
salmonella enteritises serotype typhimurium
What biological weapon/agent was used during the French-Indian War?
smallpox
What are examples of nerve agents?
sarin and lethal agents
What is the mechanism of toxicity of blood agents?
- can combine with ferric ion (Fe3+) in cytochrome-oxidase complex in mitochondria, thus preventing use of oxygen
- cell switches to anaerobic metabolism, creating lactic acid and high anion gap metabolic acidosis
- leads to progressive tissue hypoxia with potential cellular death
What organs are most sensitive to blood agents?
heart and CNS
What makes biological agents so appealing?
- Relatively inexpensive to produce and distribute
- Require the least amount of scientific sophistication
- Allows for evasion before detection
- Early symptoms of most biological agents are nonspecific
What is the pathophysiology of Anthrax?
spores are highly resistant to drying, heat, gamma radiation, UV light, and many disinfectants
What are the clinical manifestations of Anthrax?
cutaneous, inhalation, gastrointestinal, injection
What are the effects of radiation on hematopoietic?
- on the neutrophils (fighting infections)
- bone marrow stem cells die, drops in all cell lines, infection, bleeding
What are the effects of radiation on gastrointestinal tissues?
- villi shrinkage and changes in mucosal cell morphology occurs as new cells fail to replace those lost (GI stem cells die)
- copious diarrhea and vomiting, anorexia, cramps, infection
What is spinal shock?
- occurs after an acute spinal cord injury
- fall, MVA, assault, or driving injury
What are the decontamination priorities?
- Objective #1 : prevent further harm and optimize survival/recovery
- Objective #2: prevent further dissemination outside containment
What are the types of decontamination?
- personal
- casualty
- personnel
- mechanical
What is personal decontamination?
self- or buddy- contamination
What is casualty decontamination?
decontamination of those injured/incapacitated
What is personnel decontamination?
decontamination of non-casualties
What is mechanical decontamination?
removal of contamination from surfaces
What are moderate manifestations of hydrogen cyanide toxicity?
- HA
- Nausea
- Vertigo
- Weakness in legs
- Convulsions
- Coma
(CNS damage)
What are severe manifestations of hydrogen cyanide toxicity?
- Rapid and deep breathing
- Violent convulsions
- Cessation or respirations
- Cardiac arrest and death
(Lung and heart damage)
What are manifestations of cyanogen chloride?
- Irritation to eyes and lungs
- Respiratory tract damage
What stops alpha rays?
- Paper
- Clothing
- Skin
What stops beta rays?
Thin plates made of wood, aluminum, etc
What stops gamma rays?
- Lead
- Ion
- Other thick metal plates
What stops neutron rays?
- Water
- Concrete
What injuries are caused by primary explosions?
- Blast lung
- Injury to TM
- Shearing of aorta causing aortic rupture
- Spalling dense pressure displaces fragments into a less dense medium, affects the lungs
- Imploding: overexposure of compressed gas within tissue and expands out.
What injuries are caused by tertiary explosions?
- Coup-contrecoup brain injuries
- Crush injuries - extensive MSK injuries
What injuries are caused by quaternary explosions?
- Chemical, thermal, and chemical burns.
- Facial burns and carbonaceous debris around the nose
- Difficulty speaking
When do you use a tourniquet?
Control life-threatening external hemorrhage (areas amenable to tourniquets use or for any traumatic amputations
Where do you place a tourniquet?
- Place 1st tourniquet 2-3 inches above bleeding site
- Place the second tourniquet proximally but side-by-side if bleeding not controlled w/ first device
What are all the types of tourniquets?
- Combat Application Tourniquet “CAT”: most recommended tourniquet
- SOFT-T
- SWAT-T
How would the Glasgow soma scale be written if pt was intubated?
T10 - T2 since there is no verbal response being tested.
What does neurogenic shock cause?
- Decrease in sympathetic nervous system outflow below the level of injury
- Spinal cord injury above T6
- Hypothermia, warm red skin below the level of injury (vasodilation)
- Loss of bladder and bowel
What does spinal shock cause?
Absence of all voluntary and reflexes neurologic activity below the injury:
- Flaccid paralysis
- Loss of sensation
- Decreased deep tendon reflex
What is time in reference to radiation?
less time spent near the source less radiation received
What is distance in reference to radiation?
greater the distance from source less radiation received (1/X^2)
- 1/2^2 = 1/4 decreased exposure by 1/4 the original distance
What is shielding in reference to radiation?
Behind shielding from source = less radiation received.
What agents were used in World War I?
- Chlorine
- Phosgene
