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H A N D B O O K O F NUCLEAR, BIOLOGICAL, and CHEMICAL AGENT EXPOSURES H A N D B O O K O F NUCLE AR, BIOLOGIC AL, and CHEMICAL AGENT EXPOSURES Jerrold B. Leikin, M.D. Robin B. McFee, D.O. Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2007 by Lexi-Comp, Inc. All Rights Reserved. CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20130322 International Standard Book Number-13: 978-1-4200-4478-2 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibil- ity or liability for any errors or omissions that may be made. 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Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com TABLE OF CONTENTS SectionI-Antidotes PharmacyPreparednessforIncidentsInvolvingNuclear,Biological, orChemicalWeapons................................................................... 3 PoisonAntidotePreparednessinHospitals................................................ 21 Chempack................................................................................ 29 StrategicNationalStockpile............................................................... 35 Acetylcysteine............................................................................ 39 AmylNitrite............................................................................... 42 AnthraxVaccineAdsorbed................................................................ 43 AntitoxinBotulininTypesA,B,andE...................................................... 44 AsoximeChloride......................................................................... 45 Atropine.................................................................................. 46 BotulinumPentavalent(ABCDE)Toxoid................................................... 48 Budesonide............................................................................... 50 CalciumChloride ......................................................................... 53 CalciumGluconate........................................................................ 55 Charcoal.................................................................................. 57 CholestyramineResin..................................................................... 60 CyanideAntidoteKit...................................................................... 61 Deferiprone............................................................................... 61 Deferoxamine............................................................................. 62 Dextrose.................................................................................. 64 DiethyldithiocarbamateTrihydrate......................................................... 65 DiethyleneTriaminePenta-AceticAcid.................................................... 65 Dimercaprol............................................................................... 66 DOBUTamine............................................................................. 67 DOPamine................................................................................ 69 EdetateCalciumDisodium................................................................ 71 EdetateDisodium......................................................................... 73 Epinephrine............................................................................... 74 Filgrastim................................................................................. 77 Flumazenil................................................................................ 80 FolicAcid................................................................................. 82 Fomepizole............................................................................... 84 Glucagon................................................................................. 86 Glycopyrrolate............................................................................ 87 HI-6 ...................................................................................... 89 HLo-7 .................................................................................... 90 Hydroxocobalamin........................................................................ 91 InsectStingKit ........................................................................... 93 Isoproterenol.............................................................................. 93 K027 ..................................................................................... 94 Mafenide ................................................................................. 95 MethyleneBlue........................................................................... 96 Naloxone................................................................................. 97 Neostigmine.............................................................................. 99 NerveAgentAntidoteKit(NAAK) ........................................................ 100 Norepinephrine .......................................................................... 102 ObidoximeChloride...................................................................... 103 Oxygen(Hyperbaric)..................................................................... 104 Penicillamine ............................................................................ 105 Phentolamine............................................................................ 107 Physostigmine........................................................................... 109 PolyethyleneGlycol-HighMolecularWeight............................................. 111 PotassiumIodide ........................................................................ 112 Pralidoxime.............................................................................. 114 PrussianBlue............................................................................ 116 Pyridostigmine........................................................................... 117 Pyridoxine............................................................................... 118 Rifampin................................................................................. 120 TABLE OFCONTENTS Serpacwa................................................................................ 121 SilverSulfadiazine....................................................................... 122 SodiumBicarbonate ..................................................................... 123 SodiumNitrite ........................................................................... 125 SodiumPolystyreneSulfonate ........................................................... 126 SodiumThiosulfate ...................................................................... 127 Succimer................................................................................ 129 Thrombopoietin.......................................................................... 130 TrimedoximeBromide.................................................................... 131 Unithiol.................................................................................. 131 Vasopressin............................................................................. 132 SectionII-BiologicalAgents AvianInfluenza.......................................................................... 137 Botulism................................................................................. 147 Smallpox(Variola)andPoxviruses....................................................... 155 ManagementofHealthcareWorkerExposurestoHBV,HCV,andHIV.................... 170 Anthrax.................................................................................. 182 Arboviruses.............................................................................. 194 BrucellaSpecies......................................................................... 195 Burkholderiamallei...................................................................... 198 Clostridiumbotulinum.................................................................... 199 ClostridiumbotulinumFoodPoisoning ................................................... 202 Clostridiumperfringens.................................................................. 206 Coxiellaburnetii(QFever)............................................................... 208 Cryptosporidium......................................................................... 210 Encephalitis,Viral........................................................................ 212 Escherichiacoli,Enterohemorrhagic ..................................................... 213 Francisellatularensis.................................................................... 215 Hantavirus............................................................................... 220 JapaneseEncephalitisVirusVaccine(Inactivated)........................................ 222 JuninVirus .............................................................................. 223 Meningitis,Community-Acquired,Adult................................................... 225 Ricin..................................................................................... 226 SalmonellaSpecies...................................................................... 227 SevereAcuteRespiratorySyndrome(SARS)............................................. 230 ShigellaSpecies......................................................................... 233 Smallpox ................................................................................ 234 StaphylococcalEnterotoxinB............................................................ 237 T-2Mycotoxin ........................................................................... 239 Vibriocholerae.......................................................................... 239 ViralHemorrhagicFever(VHF) .......................................................... 241 WestNileVirus.......................................................................... 244 Yersiniapestis........................................................................... 245 SectionIII-ChemicalAgents BioterrorismandtheSkin................................................................ 253 DisasterandMassCasualtyIncidents.................................................... 259 ExamplesofMassExposuresInvolvingthePediatricPopulation.......................... 274 OrganophosphatePoisoning:CasePresentation ......................................... 282 ToxicologyBasicsofNonmedicinalAgentExposures..................................... 286 2,4,6-Trinitrotoluene...................................................................... 292 2,4-Dinitrotoluene........................................................................ 292 Adamsite................................................................................ 293 Ammonia................................................................................ 294 Arsenic.................................................................................. 295 Arsine................................................................................... 299 Benzene................................................................................. 300 Bromobenzylcyanide..................................................................... 303 CarbonMonoxide........................................................................ 303 CarfentanilCitrate ....................................................................... 309 ChemicalWarfareAgents................................................................ 309 Chlorine................................................................................. 311 TABLE OFCONTENTS Chloroacetophenone..................................................................... 313 Cyanide ................................................................................. 315 CyanogenBromide ...................................................................... 318 CyanogenChloride ...................................................................... 319 CyanogenIodide......................................................................... 320 CyclohexylSarin......................................................................... 320 Cyclotrimethylenetrinitramine............................................................. 322 Dinitrotoluene............................................................................ 322 Diphenylchloroarsine..................................................................... 323 Diphenylcyanoarsine..................................................................... 324 Diphosgene.............................................................................. 324 Ethyldichloroarsine....................................................................... 325 EthyleneGlycolDinitrate................................................................. 325 Gasoline................................................................................. 326 HydrogenChloride....................................................................... 328 Kratom .................................................................................. 329 Lewisite ................................................................................. 329 Malathion................................................................................ 330 MethylIsocyanate ....................................................................... 333 Methyldichloroarsine..................................................................... 334 MustardGas............................................................................. 334 NapalmB................................................................................ 342 Nicotine ................................................................................. 343 NitrogenMustard(HN-1)................................................................. 347 NitrogenMustard(HN-2)................................................................. 348 NitrogenMustard(HN-3)................................................................. 350 Nitroglycerin............................................................................. 351 O-ChlorobenzylideneMalononitrile ....................................................... 352 OsmiumOxide........................................................................... 353 PentaerythritolTetranitrate............................................................... 354 PepperSpray............................................................................ 354 Perfluroisobutylene ...................................................................... 355 Phenibut................................................................................. 355 Phenyldichloroarsine..................................................................... 356 Phosgene ............................................................................... 357 PhosgeneOxime ........................................................................ 359 Phosphine............................................................................... 359 QuinuclidinylBenzilate................................................................... 361 Sarin .................................................................................... 362 SodiumAzide............................................................................ 365 SodiumMonofluoroacetate............................................................... 366 Soman .................................................................................. 368 SulfuricAcid............................................................................. 370 Tabun................................................................................... 371 Tetramethylenedisulfotetramine .......................................................... 373 ThalliumSulfate ......................................................................... 374 Thermite................................................................................. 376 Triethylamine............................................................................ 377 VR ...................................................................................... 377 VX....................................................................................... 378 WhitePhosphorus....................................................................... 380 SectionIV-LaboratoryAnalysis PublicHealthContactsforLaboratoryTestingtoConfirmExposure DuringaPotentialorKnownChemicalTerrorismEvent ................................ 385 SentinelLaboratoryGuidelinesforSuspectedAgentsofBioterrorismand EmergingInfectiousDiseases.......................................................... 399 SentinelLaboratoryGuidelinesforSuspectedAgentsofBioterrorism..................... 408 FieldIdentificationandDecontaminationofToxins........................................ 430 Acetylcholinesterase,RedCell,andSerum............................................... 439 AnionGap,Blood........................................................................ 440 AnthraxDetection........................................................................ 441 Arsenic,Blood........................................................................... 443 Arsenic,Hair,Nails ...................................................................... 444 TABLE OFCONTENTS Arsenic,Urine ........................................................................... 445 Autopsy ................................................................................. 445 BabesiosisSerology..................................................................... 463 BacterialCulture,Aerobes ............................................................... 463 BacterialCulture,Anaerobes............................................................. 465 BacterialCulture,Blood.................................................................. 466 BloodandFluidPrecautions,SpecimenCollection........................................ 469 BloodCollectionTubeInformation........................................................ 472 BloodGasesandpH,Arterial............................................................ 473 Botulism,DiagnosticProcedure.......................................................... 475 Carboxyhemoglobin,Blood............................................................... 476 Chain-of-CustodyProtocol ............................................................... 477 ChemicalTerrorismEvent................................................................ 478 CompleteBloodCount................................................................... 482 Cyanide,Blood .......................................................................... 485 DisseminatedIntravascularCoagulationScreen.......................................... 486 Electrolytes,Blood....................................................................... 487 Electromyography........................................................................ 488 Fibrinogen............................................................................... 492 HantavirusSerology ..................................................................... 494 HeavyMetalScreen,Blood.............................................................. 495 HeavyMetalScreen,Urine............................................................... 495 IdentificationDNATesting................................................................ 496 LacticAcid,WholeBlood,orPlasma..................................................... 497 LiverDisease:LaboratoryAssessment,Overview ........................................ 498 Mercury,Blood .......................................................................... 501 Mercury,Urine........................................................................... 502 Methemoglobin,Blood................................................................... 503 Methemoglobin,WholeBlood............................................................ 504 MethyleneBlueStain,Stool.............................................................. 505 Nicotine,Serum,orPlasma.............................................................. 506 OrganophosphatePesticides,Urine,Blood,orSerum .................................... 507 Osmolality,Calculated,Serum,orPlasma................................................ 507 Osmolality,Serum....................................................................... 510 QFeverSerology........................................................................ 511 ShigaToxinTest,Direct ................................................................. 512 SmallpoxDiagnosticProcedures......................................................... 512 Thallium,Urine,orBlood................................................................. 513 Thiocyanate,Serum,Plasma,orUrine................................................... 514 TularemiaDiagnosticProcedures ........................................................ 514 UncrossmatchedBlood,Emergency...................................................... 515 VirusDetectionbyDFA.................................................................. 516 VolatileScreen,Blood,orUrine.......................................................... 517 Warming,Blood.......................................................................... 518 WestNileVirusDiagnosticProcedures................................................... 518 YersiniapestisDiagnosticProcedures ................................................... 519 SectionV-Radiation TheRealityofRadiationRisks:ARecentCaseofPolonium210as aWeaponofAssassinationandSubsequentPublicHealthThreat...................... 523 APrimerforNuclearTerrorismPreparedness............................................ 526 Americium............................................................................... 553 Cesium.................................................................................. 553 Cobalt................................................................................... 554 DepletedUranium ....................................................................... 556 Iodine ................................................................................... 557 Phosphorus.............................................................................. 557 Plutonium................................................................................ 558 Polonium................................................................................ 559 Radium.................................................................................. 560 Strontium................................................................................ 560 Tritium................................................................................... 561 Uranium................................................................................. 561 TABLE OFCONTENTS Appendix AlgorithmicApproachtoCaseClassification.............................................. 569 AssessmentofLiverFunction............................................................ 570 ClinicalSyndromesAssociatedwithFood-borneDiseases................................ 571 CreatinineClearanceEstimatingMethodsinPatientswithStableRenalFunction ......... 573 FluidandElectrolyteRequirementsinChildren........................................... 575 InitialIsolationandProtectiveActionDistancesTable .................................... 579 MedianHeightsandWeightsandRecommendedEnergyIntake.......................... 623 PoundstoKilogramsConversion......................................................... 624 ReferenceValuesforAdults ............................................................. 625 ReferenceValuesforChildren ........................................................... 630 RenalFunctionTests.................................................................... 633 StressReplacementofGlucocorticoids................................................... 636 WeaponsofMassDestructionPreparednessResources ................................. 638 PatientInformationSheets Ammonia-PatientInformationSheet .................................................... 649 Arsine-PatientInformationSheet........................................................ 651 Benzene-PatientInformationSheet..................................................... 653 Chlorine-PatientInformationSheet...................................................... 655 HydrogenCyanide-PatientInformationSheet ........................................... 657 LewisiteandMustard-LewisiteMixture-PatientInformationSheet........................ 659 NerveAgents-PatientInformationSheet................................................ 661 NitrogenMustard(HN-1,HN-2,andHN-3)-PatientInformationSheet.................... 663 Phosgene-PatientInformationSheet.................................................... 665 Phosphine-PatientInformationSheet ................................................... 667 SulfurMustard-PatientInformationSheet ............................................... 669 Index ................................................................................... 671 PREFACE In virtually any field in medicine, each disease process is approached by the clinician one patientatatime.Diagnosisandtherapeuticapproacharethusindividualizedasismonitoring ofthepatient’sstatus.Protocolsserveasaninexactguidetoaidinthisprocess. However,theapproachtonuclear,biological,orchemicalagentexposurespresentsdifferent and unique challenges to the clinician. In these scenarios, the clinicians are usually encountering multiple exposures (sometimes even mass exposures) from a single, often poorly defined, event. Early presenting symptoms are not distinct and can often be quite variable. Laboratory analysis may be required from environmental (often nonbiologic) specimens.Sceneevaluationandprehospitaldecontaminationmayturnouttobethemost important intervention. Hospital resource utilization must be a consideration. Even the pathologistperformingautopsiesrequiresadequatepreparation. Itiswiththeseconsiderationsthatthisbookwascreated.Whilethebookisdividedintoagent monographs, the clinician is advised that oftentimes multiple agents or even classifications may be responsible for a certain exposure. Toxidrome (or symptom complex) recognition providesthemostimportantclinicalcluesastotheetiologicagentwhenmultipleexposures are analyzed as a group. We have made every attempt to update this data regularly and welcomethereader’scomments. JerroldB.Leikin,MD RobinB.McFee,DO EDITORS Jerrold Blair Leikin, MD, FACP, FACEP, FACMT, FAACT, FACOEM Dr. Leikin is director of medical toxicology at Evanston Northwestern Healthcare-OMEGA, Glenbrook Hospital, located in Glenview, Illinois. He is associate director of the Toxikon ConsortiumbasedatCookCountyHospitalinChicago.Heisalsoprofessorofmedicineat RushMedicalCollegeandprofessorofemergencymedicineatFeinbergSchoolofMedicine atNorthwesternUniversityinChicago,Illinois. Dr. Leikin received his medical doctorate degree from the Chicago Medical School in 1980 and completed a combined residency in internal medicine and emergency medicine at EvanstonHospitalandNorthwesternMemorialHospitalin1984.Hecompletedafellowshipin medical toxicology at Cook County Hospital in Chicago in 1987. He is also board certified intheabovespecialties. Dr.Leikinwastheassociatedirectoroftheemergencydepartmentfrom1988(cid:2)2001atRush- Presbyterian(cid:2)St Luke’s Medical Center in Chicago. Dr. Leikin was medical director of the Rush Poison Control Center for eleven years. He was also medical director of the United States Drug Testing Laboratory for five years. He is currently a consultant with the Illinois PoisonCenter,WisconsinPoisonCenter,andPROSARProductandDrugSafetyCallCenter locatedinSt.Paul,Minnesota. Dr. Leikin has presented over 100 abstracts at national meetings and has published about 200 articles in peer-reviewed medical journals. He is coeditor of the American Medical Association Handbook of First Aid and Emergency Care, and the American Medical Association Complete Medical Encyclopedia, both published by Random House. Dr. Leikin isalsoeditor-in-chiefofthejournalDisease-A-Month.Hehaswrittenseveralchaptersonthe subjects of toxicology, emergency medicine, critical care medicine, internal medicine, and observationalmedicinetextbooks.Dr.LeikinisanactivememberoftheAmericanAcademy of Clinical Toxicology, American College of Medical Toxicology, the American College of EmergencyPhysicians,theAmericanCollegeofOccupationalandEnvironmentalMedicine, andtheAmericanMedicalAssociation.Heismarriedandhastwochildren. Robin B. McFee, DO, MPH, FACPM Dr.RobinMcFeeisanationallyrecognizedexpertinmedicaltoxicology,adolescenthealth, substance abuse, bioterrorism, and weapons of mass destruction. In addition to extensive expertiseinemerginginfectiousdiseases,shehasexperienceinhazmat,searchandrescue, as well as search and recovery. Dr. McFee has given approximately 300 invited lectures sinceSeptember11,2001,regionally,nationally,andinternationally.Sheconductsresearch in preparedness including the development of new interventions against WMD and has presented research at numerous scientific conferences. In 1997, she co-founded Seabury Adolescent Health; in 2001, she co-founded the Center for Bioterrorism and Weapons of MassDestructionPreparedness(CB-PREP)inFt.Lauderdale,andin2004,ThreatScienceTM. Dr.McFeereceivedhermedicaldegreefromtheNewYorkCollegeofOsteopathicMedicine and a master’s degree in public health (MPH) from The Mailman School of Public Health, ColumbiaUniversity.Sheisboardcertifiedandcompletedapreventivemedicineandpublic healthresidencyatthe StateUniversityofNew YorkatStonyBrook. Sheisafellowofthe AmericanCollegeofPreventiveMedicine.Inaddition,Dr.McFeecompletedpost-residency training in medical toxicology at Winthrop University Hospital and has received extensive advancedtraininginWMD,publicpreparedness,andemergingglobalthreats.Sheisawell- respected medical educator, having received numerous teaching awards including Innova- tions to Curriculum Award from the American Medical Association (AMA), an Excellence in

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Treating nuclear, biological, and chemical agent exposures presents a unique set of challenges. These scenarios usually involve multiple exposures, sometimes even mass exposures, from a single, often poorly-defined, event. Early symptoms are not distinct and can often be variable. Laboratory analyse
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Handbook of Nuclear, Biological, and Chemical Agent Exposures PDF

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Treating nuclear, biological, and chemical agent exposures presents a unique set of challenges. These scenarios usually involve multiple exposures, sometimes even mass exposures, from a single, often poorly-defined, event. Early symptoms are not distinct and can often be variable. Laboratory analyse

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