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Introduction |
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Threat of NBC Terrorism |
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Chemical Casualty Care |
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Biological Casualty Care |
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Radiological Casualty Care |
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Special Hospital Considerations in NBC Terrorist
Incidents |
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Additional Information for Independent Reading |
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Train healthcare providers to initiate the
correct medical response and treatment actions in a Nuclear, Biological, or
Chemical (NBC) terrorist incident, including: |
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Identifying various threat agents, and the signs
and symptoms of exposure to them |
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Selecting the proper treatment for resulting
conditions |
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Identifying special threats to healthcare
providers, such as secondary contamination |
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Nuclear Materials |
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Biological Agents |
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Chemical Agents |
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HMI NBCTI |
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Deliberate attack D |
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Greater agent toxicity D |
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Early hazard identification x |
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Potential for mass casualties D |
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Need for mass decontamination D |
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Unusual risk to D |
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healthcare providers |
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To familiarize you with |
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Recent NBC events |
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The potential for terrorist use of NBC agents |
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Sources and hazards of NBC agents |
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Targets and indicators of NBC attacks |
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Outcomes of NBC terrorist events |
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So that you can recognize an NBC attack and
understand the potential impacts |
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Lone individual |
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Identified local or non-aligned terrorist groups |
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Internationally sponsored |
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Doomsday cults |
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Insurgents |
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Agents are available & relatively easy to
manufacture |
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Large amount not needed in enclosed space |
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NBC incident difficult to recognize |
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Easily spread over large areas |
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Psychological impact |
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Can overwhelm existing resources |
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B’nai B’rith, Washington, D.C. |
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April 1997 |
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30 persons decontaminated |
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Effective dissemination difficult |
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Delayed effects can detract from impact |
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Counterproductive to terrorists’ support |
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Potentially hazardous to the terrorist |
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Development and use require skill |
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Home production |
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Laboratory / commercial production |
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Industrial facilities |
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Foreign military sources |
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Medical / university research facilities |
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Enclosed spaces |
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Large crowds (high profile events) |
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Critical facilities and infrastructure |
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Accessible facilities with significant hazard / damage
potential (materials in transit) |
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Facilities of interest to terrorists’ cause |
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It can’t happen to us |
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NBC agents are so deadly the victims will all
die anyway |
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There is nothing we can do |
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Use FBI video OR additional slides; not both |
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Update module with recent local incidents |
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Points to emphasize |
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Terrorist groups have means, motive, opportunity |
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NBC agents have far-reaching effects |
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Advantages and limitations of NBC agents |
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Identify potential targets in your community |
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Describe types of chemical warfare agents |
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Recognize signs and symptoms of exposure |
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Describe management of chemical agent attack
victims |
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Chemicals used in military operations to
kill, injure, or incapacitate |
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Battlefield use |
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World War I and Middle East conflicts |
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Terrorist use |
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Matsumoto and Tokyo, Japan |
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Matsumoto: |
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Approximately 280 injured |
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7 dead |
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Tokyo |
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12 dead |
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Approximately 1,000 hospitalized |
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5,500 sought medical care |
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10% of first responders
injured |
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Tabun, Sarin, Soman, VX |
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Mustard, Lewisite |
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Phosgene, Chlorine, Ammonia, Cyanide |
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Mace®, Pepper Spray |
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Nerve Agents |
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Vesicants |
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Industrial Chemicals |
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Riot Control Agents |
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Tabun (GA), Sarin (GB), Soman (GD), VX |
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Most toxic of the chemical agents |
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Penetrate skin, eyes, lungs |
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Loss of consciousness, seizures, apnea, death after large amount |
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Diagnosis made clinically; confirmed in
laboratory (cholinesterase) |
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Organs with cholinergic receptors |
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Muscarinic |
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Smooth
muscles |
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Glands |
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Nicotinic |
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Skeletal
muscles |
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Ganglia |
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Increased secretions |
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Saliva |
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Tears |
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Runny nose |
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Secretions in airways |
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Secretions in gastrointestinal tract |
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Sweating |
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Smooth muscle contraction |
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Eyes:
miosis |
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Airways:
bronchoconstriction (shortness of breath) |
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Gastrointestinal: hyperactivity (nausea, vomiting, and diarrhea) |
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Skeletal muscles |
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Fasciculations |
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Twitching |
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Weakness |
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Flaccid paralysis |
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Other (ganglionic) |
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Tachycardia |
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Hypertension |
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Cardiovascular |
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Tachycardia, bradycardia |
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Heart block, ventricular arrhythmias |
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Central Nervous System |
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Acute |
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Loss of consciousness |
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Seizures |
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Apnea |
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Prolonged (4-6 weeks) |
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Psychological effects |
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Mild exposure |
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Miosis (dim vision, eye pain), rhinorrhea,
dyspnea |
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Moderate exposure |
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Pronounced dyspnea, nausea, vomiting, diarrhea,
weakness |
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Severe exposure |
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Immediate loss of consciousness, seizures,
apnea, and flaccid paralysis |
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Vapor effects occur within seconds, peak within
minutes; no late onset |
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Mild exposure (to 18 hours) |
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Localized sweating |
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Fasciculations |
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No miosis |
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Moderate exposure (<LD50) (to 18
hours) |
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Gastrointestinal effects |
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Miosis uncommon |
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Severe exposure (LD50) (<30
minutes) |
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Sudden loss of consciousness |
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Seizures |
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Apnea |
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Flaccid paralysis |
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Death |
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Symptomatic |
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May be systemic or organ-specific |
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Combination of symptoms is more definitive |
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Situational |
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Multiple casualties with similar symptoms |
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Time or location factors in common |
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Airway/ventilation |
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High resistance |
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Antidotes |
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Atropine |
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2-PAMCl |
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Diazepam |
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Atropine |
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Antagonizes muscarinic effects |
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Dries secretions; relaxes smooth muscles |
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Given IV, IM, ET |
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No effect on pupils |
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No effect on skeletal muscles |
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IV in hypoxic patient Ů ventricular fibrillation |
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Starting dose - 2 mg |
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Maximum cumulative dose - 20 mg |
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Total dose calculated over time; but enough must
be administered to abate severe symptoms if casualty is to survive |
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Insecticide poisoning requires much more |
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Side effects in normal people |
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Mydriasis |
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Blurred vision |
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Tachycardia |
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Decreased secretions and sweating |
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Atropine - How much to give? |
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Until secretions are drying or dry |
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Until ventilation is “easy” |
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If conscious or casualty is comfortable |
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Do not rely on heart rate/pupil size |
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Pralidoxime Chloride (2PAM-Cl) |
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Remove nerve agent from AChE in absence of aging |
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1 gram slowly (20-30 minutes) in IV infusion |
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Hypertension with rapid
infusion |
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No effects at muscarinic
sites |
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Helps at nicotinic sites |
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Diazepam |
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Decreases seizure activity |
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Reduces seizure-induced brain injury |
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Give to severely-intoxicated casualties whether
convulsing or not |
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Treatment regimen |
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No signs/symptoms |
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Reassure |
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Observe |
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Vapor: 1
hour |
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Liquid:
Up to 18 hours |
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Mild vapor exposure |
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Miosis, rhinorrhea - observation only |
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Increasing SOB - treat |
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Mild liquid exposure |
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Localized fasiculations & sweating - treat |
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One MARK I kit (2 mg atropine/ 600 mg 2 -PAMCl) |
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OR |
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1 gram 2-PAMCl IV |
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2 mg atropine, IM or IV |
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Parenteral atropine will not reverse miosis |
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Moderate vapor or liquid exposure |
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One or two MARK I kits |
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Or give IV: |
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2 to 4 mg atropine |
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1gm 2-PAMCl (infusion) |
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Severe - vapor or liquid |
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Give 3 MARK I kits or 6 mg atropine and 1 gram
of 2-PAMCl as soon as possible |
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Airway |
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Ventilation/O2 |
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Consider diazepam 10 mg IM (2 to 5 mg IV) |
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Repeat atropine every 5 to10 minutes as needed |
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Repeat 2-PAMCl in one hour |
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Atropine |
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Infant (0 to 2) 0.5 mg IM |
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IV for infants and children 0.02 mg/kg |
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Child (2 to 10) 1.0 mg IM |
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Adolescent (> 10) 2.0 mg |
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Elderly 1.0 mg IM |
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2-PAMCl |
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< 20 kg 15 mg/kg IV |
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> 20 kg 600-mg IM autoinjector |
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Elderly 1/2 adult dose (7.5 mg/kg IV) |
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2 PAMCl-induced hypertension |
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Phentolamine Adult 5 mg IV |
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Child 1 mg IV |
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Vapor exposure |
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Symptoms develop suddenly |
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Most ambulatory victims require minimal
intervention |
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Risk of secondary contamination, which is
minimized by removing the victim’s clothing |
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Requires immediate access to antidotes |
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Quickly cyclizes in tissue |
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Alkylates cell components, including DNA |
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DNA damage, cell death |
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Mild conjunctivitis |
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Moderate/severe conjunctivitis, lid inflammation
and edema, blepharospasm, and corneal roughening |
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Corneal opacification, ulceration, and/or
perforation |
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Well over 95% had only mild to moderate
conjunctivitis |
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Under 1% had permanent damage to cornea |
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Erythema |
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Small vesicles; later coalesce |
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Blisters/bulla |
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Possible coagulation necrosis with liquid |
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Upper:
nose sinuses, pharynx |
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(epistaxis, sore throat, hacking cough) |
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Mid:
Larynx (hoarseness) |
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Lower:
Bronchioles (dyspnea, productive cough) |
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Pulmonary edema is rare |
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Gastrointestinal |
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Within 24 hours |
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Nausea and vomiting |
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Cholinergic effects |
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After 3 to 5 days |
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Tissue destruction |
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Damages stem cells |
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Decreased WBC, RBC, platelets after 3 - 5 days |
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Survival rare if WBC < 200 |
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Decontamination must be done within minutes to
reduce damage |
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Delays in decontamination will not prevent
illness, but will prevent cross-contamination |
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Supportive care - soothing lotions, frequent
irrigation, topical antibiotics, pain medication |
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Do NOT overhydrate; not a thermal burn |
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Topical mydriatics |
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Topical antibiotics |
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Vaseline on lid edges |
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Topical steroids (only in the first 24 hrs) |
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Cool mist, cough suppressants for mild symptoms |
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Oxygen |
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Assisted ventilation |
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Early intubation |
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Bronchodilators (steroids) |
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Antibiotics AFTER organism identified |
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Causes severe irritation to eyes, skin, and
airways IMMEDIATELY on exposure (no delay) |
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Tissue necrosis,
pseudomembranes |
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Increased capillary
permeability |
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No bone marrow
effects |
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Immediate decontamination |
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British anti-Lewisite (BAL) for systemic effects |
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Supportive Care |
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Oxygen |
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Agents damage eyes, skin, respiratory system;
cause additional systemic effects |
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Mustard |
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Fast acting; symptoms delayed, no specific
antidote |
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Lewisite |
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Fast acting, symptoms immediate, BAL antidote
available |
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Decontamination is best initial treatment |
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At high concentrations: |
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Irritates eyes, nose, upper airways; possible
laryngospasm |
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Toxic to lungs by inhalation |
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Carbonyl group damages alveolar-capillary
membrane |
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Non-cardiac pulmonary edema: onset 2 to 12 hours |
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Dyspnea, cough with sputum |
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Management of non-cardiac pulmonary edema |
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Hypoxia, fluid loss; requires pulmonary care,
careful fluid replacement |
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ABSOLUTE REST POST-EXPOSURE |
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High concentration or prolonged exposure |
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Pulmonary edema, sudden death |
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Eye irritation, cough, dyspnea |
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More severe airway and lung |
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damage with high concentration |
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Management |
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Remove from exposure; manage airway |
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Oxygen, ventilation, PEEP |
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Intubation, bronchodilators |
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Anhydrous Ammonia |
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pH>12; (household ammonia pH < 12) |
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Wide industrial use |
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Plastics, fertilizer, explosives |
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Irritating, corrosive; causes necrosis, severe
pain |
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Serious injury to eyes, lungs, skin, GI tract |
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Management |
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Remove from exposure, decontaminate |
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Symptomatic; maintain airway |
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Irritating agents, lacrimators, “tear gas” |
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Cause reaction in |
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Eyes:
burning, tearing, eyelid spasm, redness |
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Airways:
burning, coughing, dyspnea |
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Skin:
burning, erythema |
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Eye irrigation and supportive care |
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Vapor exposure |
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Nerve agent symptoms develop suddenly, mustard
and phosgene symptoms are delayed |
|
Most ambulatory victims require minimal
intervention |
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Risk of secondary contamination |
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Requires airway management; antidotes for nerve
agents and Lewisite |
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Liquid exposure |
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Symptoms delayed minutes to hours |
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Greater
need for decontamination |
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Risk of secondary contamination, victims require
clothing removal & decontamination |
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Requires immediate access to antidotes |
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Be able to describe the various types of
biological warfare agents and recognize the signs and symptoms of
exposure. |
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Be able to describe how to properly manage and
treat infectious victims |
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Know which agents are a risk for secondary
transmission and how to protect against this spread using personal
protective equipment (PPE) and isolation measures. |
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Oldest of the NBC triad of agents |
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Used for > 2,000 years |
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Sieges of middle ages |
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Smallpox blankets given to Native Americans |
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Germany in World War I |
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Japan in World War II |
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Large epidemic with high illness and death rate |
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HIV(+) individuals may have first susceptibility |
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Respiratory symptoms predominate |
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Infection non-endemic for region |
|
Multiple, simultaneous outbreaks |
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Multi-drug-resistant pathogens |
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Sick or dead animals |
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Delivery vehicle or intelligence information |
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Travel history |
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Infectious contacts |
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Employment history |
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Activities over the preceding 3 to 5 days |
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Bacteria |
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Single celled microorganism |
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Invade tissue; cause inflammatory reaction or
produce toxins |
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May form spores |
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Anthrax |
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Plague |
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Tularemia |
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Q Fever |
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Bacillus anthracis - gram +, spore-forming
bacillus |
|
Endemic infection in animals |
|
Humans develop infection naturally from handling
contaminated fluids or hides (“Woolsorters Disease”) |
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Inoculation, ingestion, or inhalation of spores
which may travel to the regional lymph nodes |
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Vegetative bacteria produce edema factor and
lethal factor (toxins) |
|
Inhalation route has highest mortality and is
most likely route to be used by terrorists |
|
Inhaled anthrax causes a mediastinitis rather
than a pneumonia |
|
Untreated skin infection - 21% mortality if
septicemia develops (treated 1%) |
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2 to 6-day incubation period followed by fever,
myalgias, cough, and fatigue |
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Initial improvement followed by abrupt onset of
respiratory distress, shock, and death in 24 to 36 hours |
|
Physical findings are nonspecific, pneumonia is
rare |
|
Chest x-ray - may show widened mediastinum with
or without a bloody pleural effusion |
|
50 % of cases have associated hemorrhagic
meningitis |
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No documented cases of person-to-person
transmission of inhalational anthrax has ever occurred |
|
Cutaneous transmissions are possible |
|
Universal precautions required |
|
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|
An accident at a Soviet military compound in
Sverdlovsk (microbiology facility) in 1979 resulted in an estimated 66
deaths downwind. |
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Clinical picture of sudden onset of respiratory
distress with mediastinal widening on x-ray |
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A small number of patients may present with GI
or cutaneous anthrax |
|
Gram stain of blood and blood cultures - but
these may be late findings in the course of the illness |
|
ELISA and immunohistology testing may confirm
diagnosis but samples must go to reference laboratory |
|
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|
Acute Treatment |
|
Usually futile in severe mediastinitis patients
who inhaled or ingested spores |
|
Ciprofloxacin - 400 mg IV q 8 to 12 hr |
|
Doxycycline - 100 mg IV q 12 hr X 4 wks |
|
Vaccination begins at the start of drug therapy |
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Prophylaxis |
|
Penicillin |
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Doxycycline |
|
IV Therapy |
|
Penicillin |
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Doxycycline |
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|
Yersinia pestis - gram(-), non-motile, non-spore
forming bacillus |
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|
Fleas living on infected rodents spread
infection to humans |
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|
Recovery offers temporary immunity |
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Produces disease by being consumed by
macrophages and transported to regional lymph nodes, causing regional
adenitis |
|
Bacteremia - spread to other organs (lungs,
spleen, liver, and brain) |
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Secondary transmission is possible and likely |
|
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|
2 to 3 day incubation period followed by high
fever, myalgias, chills, HA, and cough with bloody sputum |
|
In contrast to anthrax, pneumonia and sepsis
develop acutely and may be fulminant with patients developing dyspnea,
stridor, cyanosis, and circulatory collapse |
|
Patchy infiltrates or consolidation seen on
chest x-ray |
|
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|
|
Erythema, fever, rigors |
|
Bubo formation in regional lymph nodes |
|
Bubo aspiration and gram stain is diagnostic |
|
Differentiate from |
|
Tularemia |
|
Cat-scratch fever |
|
Staph-strep lymphadenitis |
|
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|
|
Gram stain and culture of lymph node aspirates,
sputum, or CSF samples |
|
Bipolar staining “Safety Pin” may be present |
|
Immunoassays are also available |
|
|
|
|
Care is otherwise supportive |
|
Vaccine effective only for bubonic plague |
|
Prophylaxis - tetracycline or doxycycline |
|
|
|
Antibiotics must be started within 24 hours of
symptoms to impact survival |
|
Streptomycin (30 mg/kg/day IM divided BID for 10
days) |
|
Doxycycline (100 mg IV BID for 10 days) |
|
Chloramphenicol for plague meningitis |
|
|
|
|
Prophylaxis |
|
Doxycycline |
|
Trimethoprim/Sulfamethoxazole |
|
IV Therapy |
|
Streptomycin (over 1 year of age) |
|
Gentamicin |
|
Chloramphenicol |
|
|
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|
|
|
Smallpox |
|
Viral Hemorrhagic Fevers (VHF) |
|
Venezuelan Equine Encephalitis (VEE) |
|
|
|
|
RNA or DNA within a protein coat |
|
Require a host to function and survive |
|
Many viruses attack a specific type of cell
causing disease or cancer |
|
|
|
|
May cause disease through direct cytopathic
effect, immune complex deposition and other effects |
|
May result in end-organ system failure, vascular
damage |
|
|
|
Few antiviral medications available |
|
|
|
Vaccination is the most effective means of
preventing infection |
|
|
|
|
Variola (Var-ď-óla) virus, an Orthopox virus,
both minor and major forms of smallpox exist |
|
Structure is a large DNA virus |
|
Declared eradicated in 1980 and the U.S. stopped
its civilian vaccination in 1981, U.S. military stopped in 1985 |
|
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|
In 1963, en route by air from Australia to
Sweden, a seaman stops in Djakarta, Singapore, Rangoon, Calcutta, Karachi,
Teheran, Damascus, and Zurich |
|
Fifteen days later he develops a fever and rash |
|
Diagnosed with smallpox; 19 cases identified |
|
More than 300,000 vaccinated worldwide |
|
|
|
|
DIAGNOSIS |
|
Clinical presentation |
|
Demonstrate virus from vesicular sampling via
electron microscopy |
|
Confirmation by tissue culture |
|
|
|
|
Contagious |
|
All contacts are quarantined for at least 17
days |
|
Infectious until all scabs are healed over |
|
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|
|
|
|
RNA viruses causing high fevers and generalized
vascular damage |
|
Human infections by insect bites or by contact
with blood and body fluids |
|
|
|
|
Fever, myalgias, prostration |
|
Cases evolve into shock and generalized
mucous membrane hemorrhage |
|
Conjunctival injection, petechial hemorrhage,
and hypotension |
|
Abnormal renal and LFT - poor prognosis |
|
Mortality varies; 50 - 80% Ebola Zaire |
|
Disease severity and survival depends on various
host factors; target organ is the vascular bed. |
|
|
|
|
|
Hemodynamic resuscitation and monitoring |
|
Invasive Swan Gantz catheter as feasible |
|
Careful fluid management |
|
use of colloid |
|
Vasopressors and cardiotonic drugs |
|
Cautious sedation and analgesia |
|
No anti-platelet drugs or IM injections |
|
Coagulation studies and replacement of clotting
factors / platelet transfusions |
|
|
|
|
|
No vaccine is available at this time |
|
Single room w/ adjoining anteroom as only
entrance |
|
handwashing facility with decontamination
solution |
|
Negative air pressure if possible |
|
Strict barrier precautions |
|
gloves, gown, mask. shoe covers, protective
eyeware/faceshield |
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consider HEPA respirator for prominent
hemorrhage, vomiting, diarrhea, cough |
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Chemical toilet |
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All body fluids disinfected |
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Disposable equipment/sharps into rigid
containers and autoclaved/incinerated |
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Double-bag refuse-outside bag disinfected |
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Electronic/mechanical equipment can be
paraformaldehyde disinfected |
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Wash / irrigate wound site immediately |
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Mucous membranes (eye, mouth, nose) |
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Continuous irrigation with rapidly flowing water
or sterile saline for >15 minutes |
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Skin |
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Scrub for >15 minutes while copiously soaking
the wound with detergent solution |
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Germicidal solution |
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(Dilute 1 part laundry bleach with 9 parts tap
water) |
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April 5, 1995 -
Zaire laboratory worker - fever and bloody diarrhea |
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May 17 - 93 cases - 92% fatality - most cases
were in health care providers |
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June 25 - 296 cases |
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Botulinum |
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Ricin |
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Staphylococcal Enterotoxin B (SEB) |
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|
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Naturally produced poisons |
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More toxic per weight than manmade chemical
agents |
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Non-volatile |
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Minimal absorption in intact skin |
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Not prone to person-to-person transmission |
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Neurotoxin produced by Clostridium botulinum -
Botulism |
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Most lethal compound per weight (15,000 times
more toxic than the nerve agent VX) |
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Different toxicity if inhaled or ingested |
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Blocks the release of ACh at 3 places in the
presynaptic terminal of the neuromuscular junction and autonomic nervous
system |
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Bulbar palsies and skeletal muscle weakness |
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Descending paralysis |
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Bulbar palsies |
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blurred vision |
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mydriasis |
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diplopia |
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ptosis |
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