Global & Disaster Medicine

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CDC: After Hurricane Florence—Clinical Guidance for Carbon Monoxide Poisoning

CDC

CDC Health Alert Network (HAN) Health Advisory: Hurricane Florence—Clinical Guidance for Carbon Monoxide (CO) Poisoning

CDC issued the following Health Alert Network (HAN) Health Advisory on September 16, 2018. You are receiving this information because you subscribe to COCA email updates. If a colleague forwarded this email to you, yet you would like to receive future updates directly from COCA, click here.

If you have any questions about this or other clinical issues, please e-mail coca@cdc.gov

On behalf of the Clinician Outreach and Communication Activity (COCA)
Centers for Disease Control and Prevention (CDC)
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Distributed via the CDC Health Alert Network
September 16, 2018 1345 ET (1:45 PM ET)
CDC HAN-00415

Hurricane Florence—Clinical Guidance for Carbon Monoxide (CO) Poisoning

Summary
The Centers for Disease Control and Prevention (CDC) is reminding clinicians seeing patients from the areas affected by Hurricane Florence to maintain a high index of suspicion for CO poisoning. Other people who may be exposed to the same CO source may need to be identified and assessed.

The signs and symptoms of CO exposure are variable and nonspecific. A tension-type headache is the most common symptom of mild CO poisoning. Other symptoms may include dizziness, flu-like symptoms without a fever, drowsiness, chest pain, and altered mental status.

Clinical manifestations of severe CO poisoning include tachycardia, tachypnea, hypotension, metabolic acidosis, dysrhythmias, myocardial ischemia or infarction, noncardiogenic pulmonary edema, neurologic findings including irritability, impaired memory, cognitive and sensory disturbances, ataxia, altered or loss of consciousness, seizures, coma, and death, although any organ system might be involved.

Although CO poisoning can be fatal to anyone, children, pregnant women, the unborn, persons with sickle cell disease, older adults, and persons with chronic illness (e.g., heart or lung disease) are particularly vulnerable.

Background
High winds and heavy rain from Hurricane Florence began affecting the southeastern U.S. around September 12, 2018. Impact on the southeast coast and inland led to thousands of people without power.  Those without power may turn to alternate power sources such as gasoline generators and may use propane or charcoal grills for cooking. If used or placed improperly, these sources can lead to CO build up inside buildings, garages, or campers and poison the people and animals inside.

With a focused history of patient activities and health symptoms, exposure to a CO source may become apparent. Appropriate and prompt diagnostic testing and treatment are crucial to reduce morbidity and prevent mortality from CO poisoning. Identifying and mitigating the CO source is critical in preventing other poisoning cases.

Recommendations for Clinicians

  1. Consider CO poisoning in patients affected by Hurricane Florence, particularly those in areas currently without power. Assess symptoms and recent patient activities that point to likely CO exposure. Evaluation should also include examination for other conditions, including smoke inhalation, trauma, medical illness, or intoxication.
  2. Administer 100% oxygen until the patient is symptom-free or until a diagnosis of CO poisoning has been ruled out.
  3. Perform COHgb testing when CO poisoning is suspected. Venous or arterial blood may be used for testing. A fingertip pulse multiple wavelength spectrophotometer, or CO-oximeter, can be used to measure heart rate, oxygen saturation, and COHgb levels in the field, but any suspicion of CO poisoning should be confirmed with a COHgb level by multiple wavelength spectrophotometer (CO-oximeter). A conventional two-wavelength pulse oximeter is not accurate when COHgb is present. For more information, see https://www.cdc.gov/disasters/co_guidance.html.
  4. An elevated carboxyhemoglobin (COHgb) level of 2% or higher for non-smokers and 9% or higher COHgb level for smokers strongly supports a diagnosis of CO poisoning. The COHgb level must be interpreted in light of the patient’s exposure history and length of time away from CO exposure, as levels gradually fall once the patient is removed from the exposure. In addition, carbon monoxide can be produced endogenously as a by-product of heme metabolism. Patients with sickle cell disease can have an elevated COHgb level as a result of hemolytic anemia or hemolysis. For additional information about interpretation of COHgb levels, visit https://www.cdc.gov/disasters/co_guidance.html or call Poison Control at (800) 222-1222.
  5. Hyperbaric oxygen therapy (HBO) should be considered in consultation with a toxicologist, hyperbaric oxygen facility, or Poison Control Center (800) 222-1222. For additional management considerations, consult a toxicologist, Poison Control at (800) 222-1222, or a hyperbaric oxygen facility.
  6. Be aware that CO exposure may be ongoing for others spending time in or near the same environment as the patient. These individuals should be evaluated and tested as described in this advisory.
  7. Clinicians treating people for CO poisoning should notify emergency medical services (EMS), the fire department, or law enforcement to investigate and mitigate the source and advise people when it is safe to return.
  8. Advise patients about safe practices related to generators, grills, camp stoves, or other gasoline, propane, natural gas, or charcoal-burning devices. Stress that that these devices should never be used inside an enclosed space, home, basement, garage, or camper — or even outside near an open window or window air conditioner. Please see https://www.cdc.gov/co/pdfs/generators.pdf.

For More Information
Clinical Guidance for Carbon Monoxide (CO) Poisoning After a Disaster
https://www.cdc.gov/disasters/co_guidance.html

 


What antidotes should you have in your ER?

Antidotes-in-ER_AEM-2017


Victim dies from Novichok exposure


Shoko Asahara, the leader of the Japanese doomsday cult that carried out a deadly 1995 sarin gas attack on the Tokyo subway system, was executed by hanging Friday along with six of his followers.

NPR


Syrian atrocities in eastern Ghouta: UN draft documents use of chemical weapons against civilians

NY Times

“……In attacks on Jan. 13, Jan. 22 and Feb. 1, the draft said, government forces fired chemical agents, “most probably chlorine,” into a residential part of eastern Ghouta’s Douma neighborhood, near a sports stadium, roughly 800 yards from the front lines, between 5 a.m. and 6:30 a.m.

Some witnesses described a “slow-acting agent” that smelled like chlorine, the draft said, and they had sufficient time “to rouse the victims, obtain wet cloths to serve as makeshift face masks, and evacuate the affected areas.”……..Thirty-one people, including 11 children, were sickened in the first three attacks, but none died. Two other episodes of possible chlorine use, on Feb. 25 and March 7, caused more extensive casualties, killing two children, including an infant, and injuring 18 civilians...…..”


How did the Skripals survive Novichok?

BBC

“…..Dr Stephen Jukes, an intensive care consultant at the hospital, said: “When we first were aware this was a nerve agent, we were expecting them not to survive.

“We would try all our therapies. We would ensure the best clinical care. But all the evidence was there that they would not survive.”

Both Skripals were heavily sedated which allowed them to tolerate the intrusive medical equipment they were connected to, but also helped to protect them from brain damage, a possible consequence of nerve agent poisoning.

Over time, the sedation was reduced and the ventilation switched from the mouth to the trachea, as shown by the vivid scar seen on Yulia Skripal’s neck in the TV statement she gave after she was released.

Once the patients became more conscious, staff had to carefully consider what they could tell them without prejudicing the police investigation, and decide on the right moment to allow questioning by detectives.

Medical director Dr Christine Blanshard explained: “Those are very difficult decisions, because on the one hand you want to provide reassurance to the patients that they are safe and they are being looked after, and on the other hand you don’t want to give them information that might cause difficulties with subsequent police interviews.”

It was the doctors and nurses that, out of concern for their patients, insisted that international inspectors obtain a court order before they would be allowed to take blood samples from the Skripals.

Dr Jukes explained: “These are vulnerable patients, they needed some form of advocate and without a court order we could not allow things to happen to them without their consent.”

Once the Skripals were stable and able to speak, the key concern for medical staff was how their production of the key enzyme acetylcholinesterase – needed to re-establish their normal body functions – could be stimulated.

The body will do this naturally after nerve agent poisoning, but the process can take many months.

In trying combinations of drugs, Dr Murray says the hospital received input from “international experts”, some of them from Porton Down.

The laboratory, internationally known for its chemical weapons expertise, processed tests and offered advice on the best therapies.

New approaches to well-known treatments were tried. Dr Jukes said that the speed of the Skripals’ recovery came as a very pleasant surprise that he cannot entirely explain……”


Gaza: Baby dies from tear gas

Washington Post

“…..The dead included at least seven children under the age of 18, among them a 15-year-old girl, the ministry said. The baby was eight months old and died after inhaling tear gas at the main protest area east of Gaza City…..”

 


About 50 to 100 grams of liquid Novichok was used in the March 4 attack on the former Russian spy Sergei V. Skripal and his daughter,

NY Times

‘……….“One thing, perhaps, which is important to note is that the nerve agent seems to be very persistent,” he said. “It’s not affected by weather conditions. That explains, actually, that they were able to identify it after a considerable time lapse. We understand it was also of high purity.”

He said the agent could be applied with an aerosol spray or, “if you take the necessary measures, you could use it as a liquid.”
Health officials have begun a meticulous decontamination process, warning citizens of Salisbury that there might still be toxic “hot spots” in some areas, and that a thorough cleanup may take months.
Though citizens have been reassured that there is little threat to their health, the decontamination promises to be a vast undertaking, requiring backup from 190 army and air force specialists as well as input from the Defense Science and Technology Laboratory, the Home Office and the Ministry of Defense…..’

A giant explosion occurs during the loading of fertilizer onto the freighter Grandcamp at a pier in Texas City, Texas: 4/16/1947.

History Channel

 


French Republic Assessment of Chemical Attack in Douma, Syria April 2018.

NY Times

National assessment

Chemical attack of 7 April 2018 (Douma, Eastern Ghouta, Syria)

Syria’s clandestine chemical weapons programme

April 14, 2018

This document is based on technical analyses of open source information and declassified intelligence obtained by French services.
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I. SEVERAL LETHAL CHEMICAL ATTACKS TOOK PLACE IN THE TOWN OF DOUMA IN THE LATE AFTERNOON OF SATURDAY, 7 APRIL 2018, AND WE ASSESS WITH A HIGH DEGREE OF CONFIDENCE THAT THEY WERE CARRIED OUT BY THE SYRIAN REGIME.

Following the Syrian regime’s resumption of its military offensive, as well as high levels of air force activity over the town of Douma in Eastern Ghouta, two new cases of toxic agents employment were spontaneously reported by civil society and local and international media from the late afternoon of 7 April. Non-governmental medical organizations active in Ghouta (the Syrian American Medical Society and the Union of Medical Care and Relief Organizations), whose information is generally reliable, publicly stated that strikes had targeted in particular local medical infrastructure on 6 and 7 April.

A massive influx of patients in health centres in Eastern Ghouta (at the very least 100 people) presenting symptoms consistent with exposure to a chemical agent was observed and documented during the early evening. In total, several dozens of people, more than forty according to several sources, are thought to have died from exposure to a chemical substance.

The information collected by France forms a body of evidence that is sufficient to attribute responsibility for the chemical attacks of 7 April to the Syrian regime.

1. – Several chemical attacks took place at Douma on 7 April 2018.

The French services analysed the testimonies, photos and videos that spontaneously appeared on specialized websites, in the press and on social media in the hours and days following the attack. Testimonies obtained by the French services were also analysed. After examining the videos and images of victims published online, they were able to conclude with a high degree of confidence that the vast majority are recent and not fabricated. The spontaneous circulation of these images across all social networks confirms that they were not video montages or recycled images. Lastly, some of the entities that published this information are generally considered reliable.

French experts analysed the symptoms identifiable in the images and videos that were made public. These images and videos were taken either in enclosed areas in a building where around 15 people died, or in local hospitals that received contaminated patients. These symptoms can be described as follows (cf. annexed images):

– Suffocation, asphyxia or breathing difficulties, – Mentions of a strong chlorine odour and presence of green smoke in affected areas, – Hypersalivation and hypersecretions (particularly oral and nasal), – Cyanosis, – Skin burns and corneal burns.

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No deaths from mechanical injuries were visible. All of these symptoms are characteristic of a chemical weapons attack, particularly choking agents and organophosphorus agents or hydrocyanic acid. Furthermore, the apparent use of bronchodilators by the medical services observed in videos reinforces the hypothesis of intoxication by choking agents.

2. – Given in particular ongoing military operations in Eastern Ghouta around 7 April, we assess with a high degree of confidence that the Syrian regime holds responsibility.

Reliable intelligence indicates that Syrian military officials have coordinated what appears to be the use of chemical weapons containing chlorine on Douma, on April 7.

The attack of 7 April 2018 took place as part of a wider military offensive carried out by the regime on the Eastern Ghouta region. Launched in February 2018, this offensive has now enabled Damascus to regain control of the entire enclave.

As a reminder, the Russian military forces active in Syria enable the regime to enjoy unquestionable air superiority, giving it the total military freedom of action it needs for its indiscriminate offensives on urban areas.

The tactic adopted by pro-regime forces involved separating the various groups (Ahrar al-Sham, Faylaq al-Rahman, and Jaysh al-Islam) in order to focus their efforts and obtain negotiated surrender agreements. The three main armed groups therefore began separate negotiations with the regime and Russia. The first two groups (Ahrar al-Sham and Faylaq al-Rahman) concluded agreements that resulted in the evacuation of nearly 15,000 fighters and their families. During this first phase, the Syrian regime’s political and military strategy consisted in alternating indiscriminate military offensives against local populations, which sometimes included the use of chlorine, and pauses in operations for negotiations.

Negotiations with Jaysh al-Islam began in March but were not fully conclusive. On 4 April, part of the Jaysh al-Islam group (around one quarter of the group according to estimates) accepted the surrender agreement and fighters and their families were sent to Idlib (approximately 4,000 people, with families). However, between 4,500 and 5,500 Jaysh al-Islam fighters, mostly located in Douma, refused the terms of negotiation. As a result, from 6 April onwards, the Syrian regime, with support from Russian forces, resumed its intensive bombing of the area, ending a pause in ground and aerial operations that had been observed since negotiations began in mid-March. This was the context for the chemical strikes analysed in this document.

Given this context, the Syrian regime’s use of chemical weapons makes sense from both the military and strategic points of view:

 Tactically speaking, this type of ammunition is used to flush out enemy fighters sheltering in homes and engage in urban combat in conditions that are more
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favourable to the regime. It accelerates victory and has a multiplier effect that helps speed up the capitulation of the last bastion of armed groups.

 Strategically speaking, chemical weapons and particularly chlorine, documented in Eastern Ghouta since early 2018, are especially used to punish civilian populations present in zones held by fighters opposed to the Syrian regime and to create a climate of terror and panic that encourages them to surrender. As the war is not over for the regime, it uses these indiscriminate strikes to show that resistance is futile and pave the way for capturing these last pockets of armed resistance.

 Since 2012, the Syrian forces have repeatedly used the same pattern of military tactics: toxic chemicals are mainly used during wider urban offensives, as was the case in late 2016 during the recapture of Aleppo, where chlorine weapons were regularly used in conjunction with traditional weapons. The zones targeted, such as Eastern Ghouta, are all major military objectives for Damascus.

3. – The French services have no information to support the theory whereby the armed groups in Ghouta would have sought to acquire or have possessed chemical weapons.

The French services also assess that a manipulation of the images circulated massively from Saturday, 7 April is not credible, in part because the groups present in Ghouta do not have the resources to carry out a communications operation on such a scale.

II. SINCE APRIL 2017, THE SYRIAN REGIME HAS USED CHEMICAL WEAPONS AND TOXIC AGENTS IN ITS MILITARY OPERATIONS INCREASINGLY OFTEN.

4. – The Syrian regime has conserved a clandestine chemical weapons programme since 2013.

The French services assess that Syria did not declare all of its stockpiles and capacities to the Organisation for the Prohibition of Chemical Weapons (OPCW) during its late, half-hearted accession to the Chemical Weapons Convention (CWC) in October 2013.

Syria omitted, notably, to declare many of the activities of its Scientific Studies and Research Centre (SSRC). Only recently has it accepted to declare certain SSRC activities under the Chemical Weapons Convention (CWC), but not, however, all of them. Initially, it also failed to declare the sites at Barzeh and Jemraya, eventually doing so in 2018.

The French services assess that four questions asked of the Syrian regime by the OPCW and which have remained unanswered require particular attention, particularly in the context of these latest cases of the use of chemical weapons in Syria: – possible remaining stocks of yperite (mustard gas) and DF (a sarin precursor); – undeclared chemical weapons of small calibre which may have been used on several occasions, including during the attack on Khan Sheikhoun in April 2017;
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– signs of the presence of VX and sarin on production and loading sites; – signs of the presence of chemical agents that have never been declared, including nitrogen mustard, lewisite, soman and VX.

Since 2014, the OPCW Fact-Finding Mission (FFM) has published several reports confirming the use of chemical weapons against civilians in Syria. The UN-OPCW Joint Investigation Mechanism (JIM) on chemical weapons attacks has investigated nine occasions when they have allegedly been used. In its August and October 2016 reports, the JIM attributed three cases of the use of chlorine to the Damascus regime and one case of the use of yperite to Daesh, but none to any Syrian armed group.

5. – A series of chemical attacks has taken place in Syria since 4 April 2017

A French national assessment published on 26 April 2017 following the Khan Sheikhoun attack listed all the chemical attacks in Syria since 2012, along with the assessment of their probability according to French services. This attack, carried out in two phases, at Latamneh on 30 March, and then at Khan Sheikhoun with sarin gas on 4 April, led to the death of more than 80 civilians. The French authorities considered at the time that it was very likely that the Syrian armed and security forces held responsibility for the attack.

The French services have identified 44 allegations of the use of chemical weapons and toxic agents since 4 April 2017, the date of the sarin attack on Khan Sheikhoun. Of these 44 allegations, the French services consider that the evidence collected around 11 of the attacks gave reason to assess they were of a chemical nature. Chlorine is believed to have been used in most cases, while the services also believe a neurotoxic agent was used at Harasta on 18 November 2017.

In this context, a considerable rise in cases of use can be noted since the non-renewal of the mechanism of the UN-OPCW Joint Investigation Mechanism (JIM) in November 2017 because of Russia’s veto at the UN Security Council. A considerable increase in chlorine attacks since the beginning of the offensive on Eastern Ghouta has also been clearly observed and proven. A series of attacks preceded the major attack of 7 April 2018, as part of a wider offensive (at least 8 chlorine attacks in Douma, Shayfounia and Hamouria).

*

These facts need to be considered in the light of a chemical warfare modus operandi of the Syrian regime that has been well documented since the attacks on Eastern Ghouta on 21 August 2013 and on Khan Sheikhoun on 4 April 2017. As part of a continuous increase in violence employed against civilians in enclaves refusing the regime’s authority, and in violation of its international obligations despite clear warnings from UN Security Council and OPCW members, Damascus seeks to seize a tactical military advantage locally, and above all to terrorize populations in order to break down all remaining resistance. It can be noted that, since the attacks of
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7 April 2018, the group Jaysh al-Islam has negotiated its departure from Douma with the regime and Russia, demonstrating the success of this tactic.

On the basis of this overall assessment and on the intelligence collected by our services, and in the absence to date of chemical samples analysed by our own laboratories, France therefore considers (i) that, beyond possible doubt, a chemical attack was carried out against civilians at Douma on 7 April 2018; and (ii) that there is no plausible scenario other than that of an attack by Syrian armed forces as part of a wider offensive in the Eastern Ghouta enclave. The Syrian armed and security forces are also considered to be responsible for other actions in the region as part of this same offensive in 2017 and 2018. Russia has undeniably provided active military support to the operations to seize back Ghouta. It has, moreover, provided constant political cover to the Syrian regime over the employment of chemical weapons, both at the UN Security Council and at the OPCW, despite conclusions to the contrary by the JIM.

This assessment will be updated as we collect new information.
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