Global & Disaster Medicine

Archive for the ‘Hazardous Materials (HAZMAT)’ Category

October 26, 2002: The 57-hour hostage crisis ends when Russian special forces surrounded and raided the theater and with the help of a narcotic gas killed all the Chechan terrorists and 120 hostages

Cyanide Soup: A Gentlewoman’s Guide to Murder


“…….The police now say she is one of India’s most cunning serial killers, with cyanide her weapon of choice, served up in soups, snacks and ayurvedic beverages.

Her name is Jolly Joseph, and the authorities say she has confessed to killing six family members over the span of 14 years, including her husband, his parents and a 2-year-old niece. Officials, who say she will be charged with six counts of premeditated murder, accuse her of trying to inherit valuable property and other assets held by the family she married into……”

Tear gas for crowd control in Hong Kong


DOI:“…….Over 3000 rounds of tear gas have been deployed as crowd control agents by police since June.

The tear gas used by the police contains o-chlorobenzylidene malononitrile, an irritant that interacts with mucocutaneous sensory nerve receptors, including TRPA1 channels, and causes rapid clinical effects with a wide margin between the incapacitating dose and the lethal dose.

Although brief in duration, clinical manifestations include tearing and burning sensations in the eyes, cough, dyspnoea, skin rashes, blistering, hypertension, nausea, vomiting, and agitation…….”

FDA: Silverlon, is appropriate for use on first- and second-degree skin burns caused by exposure to sulfur mustard.


July 22, 2019
HHS Press Office: (202) 690-6343
Twitter: @HHSMedia

First medical product cleared in U.S. for use on certain injuries caused by sulfur mustard

The U.S. government reached a milestone in its long-standing efforts to defend the country against potential use of chemical weapons:  the first U.S. Food and Drug Administration (FDA) clearance of a product to manage certain blister injuries caused by sulfur mustard, commonly known as mustard gas.

“Our top priority is saving lives during national emergencies. To do so, we must make safe and effective medical products for all the illnesses and injuries stemming from the serious health security threats confronting our nation,” said Robert Kadlec, M.D., Assistant Secretary for Preparedness and Response (ASPR) at U.S. Department of Health and Human Services. “This product clearance is the latest step in delivering on that promise to the American people.”

The ASPR’s Biomedical Advanced Research and Development Authority (BARDA) provided technical expertise and funding to support the studies necessary to show that the product, Silverlon, is appropriate for use on first- and second-degree skin burns caused by exposure to sulfur mustard.

“Chemical weapons like sulfur mustard cause horrific, painful, and life-altering injuries, yet in the 100-year history of sulfur mustard use, no medical countermeasures existed – until now,” added BARDA Director Rick Bright, Ph.D. “At BARDA, we are excited to have supported the first cleared product for use on skin injuries caused by sulfur mustard. This clearance exemplifies BARDA’s ongoing commitment to our partners and the nation as we seek out promising technologies and products to improve our nation’s health security and protect Americans.”

Argentum Medical, LLC, has received FDA clearances for multiple indications for Silverlon since 2003 and in that time the wound dressing has been used extensively by the U.S. military to treat burn and blast wounds. Silverlon dressings also are used widely by the healthcare and first responder communities.

“The FDA plays an important role in preparing our nation for a range of threats, including chemical, biological, radiological, and nuclear threats, providing guidance and support for the development of medical countermeasures that can be used safely, effectively and reliably during public health emergencies,” said Acting FDA Commissioner Ned Sharpless, M.D. “The expanded indication for this first-of-its-kind wound contact dressing to include management of certain injuries caused by sulfur mustard vapor exposure demonstrates our commitment to working closely with our federal partners, including BARDA, to expedite the availability of medical countermeasures essential for managing responses to chemical weapons attacks in both civilian and battlefield settings.”

BARDA’s support for this additional indication began in 2013 as part of the federal government’s effort to repurpose approved drugs and medical products to save lives and reduce injury in an attack on the United States.

This multi-purpose approach has proven to be cost-effective in preparing mass casualty emergencies from chemical, biological, and radiological agents. Repurposing products in widespread use additionally ensures first responders have a familiar product to use in a time of crisis.

Beginning in 2015, BARDA used Project BioShield authorities and the Project BioShield Special Reserve Fund to purchase Silverlon for the Strategy National Stockpile as part of BARDA’s burn countermeasure program. BARDA continues to work with Argentum on studies necessary for FDA clearance of Silverlon for use on radiation burns.

Silverlon is a silver-plated nylon dressing available commercially and used widely to aid in the management of acute skin wounds and first- and second-degree thermal burns. The silver plating helps kill bacteria within the dressing, and one dressing can be used for up to seven days. This allows for fewer dressing changes, which reduces the burden on caregivers and minimizes the pain and damage that would occur if the wound was disturbed.

Sulfur mustard was first used as a chemical weapon in World War I and can be released into the air, food or water. More recently the chemical was used in the Iran-Iraq war and in the Syrian Civil War.

Nigeria: CO kills 10 at a wedding and leaves ~30 on life support


“……Tragedy struck in Imo State on Monday after fumes from a generator left 10 guests who attended a traditional wedding dead…….[N]o fewer than 30 other guests were on life support in different hospitals in the Ikeduru and Mbaitoli Local Government Areas of the state as a result of the fumes they inhaled from the generator…..”


4/28/1995: A gas explosion beneath a busy city street in Taegu, South Korea, kills more than 100 people on this day in 1995.


“……an underground railroad was being constructed beneath the city streets. Metal sheets were put down in place of asphalt to cover holes in certain sections of downtown roads during the construction.

At about 7:30 a.m., during a busy rush hour, a large explosion rumbled beneath the streets, blasting the metal sheets high into the air. Flames shot out from underground, some 150 feet high, throughout a 300-yard area. Cars were transformed into fireballs and one was reported to have been thrown 30 feet into the air. Some pedestrians in the area were enveloped by fire; others further away were blown to the ground. Flaming debris hit people up to half of a mile away. The final death toll was 110, with hundreds injured……”


3/19/1937: Nearly 300 students in Texas are killed by an explosion of natural gas at their school


Nearly 300 students in Texas are killed by an explosion of natural gas at their school

3/2/1944: A train stops in a tunnel near Salerno, Italy, and more than 500 people on board suffocate and die.


“……either the train was unable to pull the overloaded freight cars up the slope or the train stopped to wait for a train descending in the opposite direction. In any case, the train sat idling in the tunnel for more than 30 minutes. While this might not have posed a severe danger in some circumstances, the train’s locomotives were burning low-grade coal substitutes because high-grade coal was hard to obtain during the war and the coal substitutes produced an excess of odorless and toxic carbon monoxide.

Approximately 520 of the train’s passengers were asphyxiated by the carbon monoxide as they sat in the train…..”

2/25/1984: A huge gas leak explosion destroys a shantytown in Brazil, killing at least 500 people, mostly young children.


“….When workers opened the wrong pipeline on February 24, highly combustible octane gas poured into the ditches of Vila Soco. Soon after midnight, an explosion was sparked, and a fireball ripped through the favela. Some homes were literally thrown hundreds of feet into the air; others were instantly incinerated. The temperature at the heart of the fireball was estimated at 1,800 degrees Fahrenheit…..”




**Meticulous attention to standard protocols for personal protection, recognizing toxidromes, and treating patients
continues to be the best way to prepare for and respond to chemical agent exposures**

This document provides a quick refresher on standard protocols for recognizing, treating, and protecting yourself from nerve agent exposures. Comprehensive follow-up guidance for Law Enforcement, Fire, EMS, HazMat, and Hospital-Based First Receivers incorporating lessons learned and best practices from the recent United Kingdom incidents will be forthcoming.

Nerve agents are extremely toxic chemical warfare agents. Several nerve agents exist and are generally categorized as either
“high volatility” or “low volatility” chemicals, a measure of how likely they are to disperse in air. A high volatility nerve agent (easily dispersed in air) means that the exposure is likely to occur from breathing in its vapors resulting in the rapid onset of symptoms.
A low volatility nerve agent (not easily dispersed in air) typically gets absorbed through the skin and has a delayed onset of signs
and symptoms. An example of a high volatility nerve agent is sarin, whereas VX is a low volatility agent. In the body, a nerve
agent exerts its effects by inhibiting an enzyme (acetylcholinesterase), resulting in acute illness – specifically, cholinergic crisis.
Organophosphorus or carbamate pesticides produce similar effects to nerve agents.

Signs and Symptoms of Nerve Agent Poisoning
Caveat: Poisoned patients may not demonstrate all of these symptoms
• Mouth/Skin: Drooling (Salivation), foaming at the mouth, and excessive sweating
• Nose/Eyes: Runny nose and watery eyes (Lacrimation) with small (often pinpoint) pupils (Miosis)
• Chest: Cough, chest tightness, difficulty in breathing, wheezing, respiratory failure, “wet” fluid filled lungs
• Abdominal: Urination, Diarrhea, abdominal (Gastrointestinal) cramps, belching, nausea, and/or vomiting (Emesis)
• Mental Status: Confusion, drowsiness, slurred speech, ataxia, unconsciousness, coma
• Muscle/Neurological: Fatigue, weakness, twitching, tremors, cramps, absent reflexes, seizures
Underlined findings = “SLUDGE”- Salivation, Lacrimation, Urination, Diarrhea, Gastrointestinal cramps, Emesis
Other mnemonic used = “DUMBBELS” – Diarrhea, Urination, Miosis/Muscle weakness, Bronchospasm/Bronchorrhea,
Bradycardia, Emesis, Lacrimation, Salivation/Sweating

Clinical Effects of Nerve Agents versus Opioids
Nerve Agent                                                                                                   Opioid
Nose: Runny                                                                                              nose Normal
Airway Secretions/drooling/foaming at the mouth                              Normal
Breathing /Respiratory status:  Increased work of breathing/chest tightness/wheezing/difficulty in breathing/cough/“wet”
fluid filled lungs– more prominent with inhaled exposure; dermal exposure may not cause bronchoconstriction or bronchorrhea
Decreased respiratory rate
Heart rate: Slowed                                                                                         Normal
Mental Status /Neurological: Slow/unconscious/seizures/confusion/slurred speech/ataxia/coma/absent reflexes/ tremors

Slow or unconscious/coma/seizures
Eyes:  Tearing/small pupils-pinpoint                                                   Small pupils-pinpoint
Skin: Wet/sweaty/cyanosis                                                                   Normal/cyanosis
Gastrointestinal: Belching/cramps/vomiting/diarrhea                      Normal
GU: Urination                                                                                                Normal
Muscles: Fatigue/weakness/twitching/ cramps                                    Normal


Detection (If you strongly suspect a nerve agent)
•Contact HazMat or special operations teams
•Notify the local FBI Field Office WMD coordinator

Personal Protective Equipment (PPE)
•Emergency responders should have the proper training and education to work with hazardous materials.
•Those providing or assisting with patient care including decontamination should follow institutional policy for a chemical incident, wearing a recommended chemical protective suit, gloves, boots, and respiratory protection to prevent any secondary exposure from patients or objects.
•After patient decontamination is complete, providers should wear a gown and a double layer of nitrile gloves during
patient contact.

Patient Decontamination
•A person potentially exposed to a nerve agent should be decontaminated whether they develop signs of acute illness or not.
•Removal of clothing is a vital step to reduce ongoing and secondary exposure. Responders should pay particular attention to the risk of secondary exposure during clothing removal. Double bagging removed clothing is ideal.
•Wiping skin with a paper towel, dry wipe, or other cloth will also contribute to effective decontamination. This dry decontamination step can be performed by patients themselves and, along with clothing removal, should be done as early as possible.
•If contamination with liquid agent is suspected, patients should be decontaminated with water, ideally with a high-volume, low-pressure shower, including soap if available, gentle rubbing with a soft cloth or sponge, and active drying with a clean towel after the shower.
•If Reactive Skin Decontamination Lotion (RSDL) is available, it is recommended for spot decontamination.

•Nerve agent toxicity is the result of excessive acetylcholine, causing cholinergic crisis. Therapy focuses on treating the excessive secretions and bronchospasm with anticholinergic medications such as atropine with dosing titrated to respiratory secretions and airway resistance. Pralidoxime chloride (2-PAM Cl), a specific nerve agent antidote, augments the primary therapy of atropine; continuous infusions may be beneficial.
•Seizures should be managed with escalating doses of benzodiazepines (midazolam, lorazepam, or diazepam).
All patients, even without convulsions, who meet the severe criteria should be treated with midazolam, lorazepam,
or diazepam 10 mg IV/IM/IO. A pediatric patient in this setting is defined as an individual less than 18 years old
AND with an ideal body weight (IBW) of ≤ 40 kg. If IBW is > 40 kg, adult medication and dosing are more appropriate. For patients under 40 kg, use midazolam only: 0-13 kg –70 mcg/kg, >13-40 kg – 5 mg.
•Autoinjectors (AI) are a convenient means of rapidly administering drugs to treat nerve agent exposure, which may be especially useful pre-hospital or at a hospital managing a large number of patients. However, only certain drugs in specific doses are available in autoinjectors: DuoDote or Antidote Treatment Nerve Agent Autoinjector (ATNAA) or Mark 1 kit (atropine 2 mg/2-PAM Cl 600 mg); atropine 2 mg, 1 mg, or 0.5 mg; 2-PAM Cl 600 mg; diazepam 10 mg.

*National Model EMS Clinical Guidelines are also acceptable:


Mild/Moderate symptoms include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea.

Severe symptoms include unconsciousness, convulsions, apnea, flaccid paralysis.

Mild / Moderate Symptoms                                         Severe Symptoms
Infant (0-2 yrs)       Atropine: 0.05 mg/kg IV/IM/IO                                    Atropine: 0.1 mg/kg IV/IM/IO
2-PAM Cl: 15 mg/kg IV/IM/IO                                      2-PAM Cl: 25 mg/kg IV/IM/IO


Child (2-10 yrs)        Atropine: 1 mg IV/IM/IO                                                Atropine: 2 mg IV/IM/IO
2-PAM Cl: 15 mg/kg IV/IM/IO                                       2-PAM Cl: 25 mg/kg IV/IM/IO

Adolescent (>10 yrs)  Atropine: 2 mg IV/IM/IO/AI;                                   Atropine: 4 mg IV/IM/IO/AI;
2-PAM Cl: 15 mg/kg IV/IM/IO                                 2-PAM Cl: 25 mg/kg IV/IM/IO

Adult                              Atropine: 2 to 4 mg IV/IM/IO/AI;                           Atropine: 6 mg IV/IM/IO/AI;
2-PAM Cl: 600 mg IV/IM/IO/AI                             2-PAM Cl: 1800 mg IV/IM/IO/AI

Elderly, Frail                Atropine: 1 mg IV/IM/IO                                            Atropine: 2 to 4 mg IV/IM/IO
2-PAM Cl: 10 mg/kg IV/IM/IO                                   2-PAM Cl: 25 mg/kg IV/IM/IO

Repeat atropine (2 mg IV/IM) at 5- 10 minute intervals until secretions have diminished and breathing is comfortable or airway resistance has returned to near normal.

Specific Pediatric Considerations
For pediatric patients, existing autoinjectors may provide more than the recommended doses of atropine and
pralidoxime. The reference below provides a strategy to mitigate this issue if time and resources allow. This method allows you to discharge the contents of autoinjectors and dilute the drug to prepare the proper dose. Expert opinion would still recommend that, given the benefit compared to the possible harm in delaying treatment, severe patients should be treated with autoinjectors even if they provide doses above recommendations.
Corvino TF, Nahata MC, Angelos MG, Tschampel MM, Morosco RS, Zerkle J, Nelson RN. Availability, stability, and sterility of pralidoxime for mass casualty use. Ann Emerg Med. 2006 Mar; 47(3):272-7.

Additional Considerations
•If faced with a mass casualty incident and if pharmaceutical therapies become exhausted, consider contingency medical countermeasures at your discretion.
•Poison Control Centers provide 24-hour-a-day patient care support at 1-800-222-1222.
•The Secretary of Health and Human Services issued a declaration, effective April 11, 2017, under the Public Readiness and Emergency Preparedness Act (PREP Act) to provide liability immunity to certain individuals and entities against any claim of loss relating to the use of medical countermeasures against nerve agents, given certain conditions are met:
Other Resources
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention /
Agency for Toxic Substances and Disease Registry
Office of the Assistant Secretary for Preparedness and Response
Personal Protective Equipment
U.S. Department of Labor
Occupational Safety and Health Administration
Patient Decontamination
U.S. Departments of Health and Human Services and Homeland Security
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Preparedness and Response
National Fire Protection Association




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