With all biological threats, it is important to determine the agent that has been released. The healthcare provider may be one of the first to detect that there may have been an attack through a victim or victims presenting in clinics or emergency departments. The sudden influx of patients with the same symptoms may be the first indication that an attack has occurred. It is necessary to promptly and efficiently identify the agents and appropriate treatment to decrease morbidity and mortality.
Evidence-Based Practice: With bacterial attacks, whether by bombs, aerosols, or ingestion through food or water, it is important to do the following: ● Identify the bacteria by laboratory tests. ● Treat with appropriate antibiotics. ● Take appropriate actions for confinement and containment with isolation when necessary. ● Use aggressive hand-washing techniques. ● Prevent cross contamination and spread. ● Treat symptoms.
● Provide emotional support. (CDC, 2012, 2015a, 2015b, 201b)
Chemical terrorism Chemical terrorist attacks or disasters can pose a serious threat to communities. Depending on the agent and the mode of transmission, attacks can be life-threatening to the public, first responders, and subsequent medical providers who are in contact with the agents and the patients being treated. A chemical terrorist attack or disaster calls for an immediate response from forensic toxicologists, law enforcement, and public health officials to identify the agent that was used (Nwanegbo, 2013). Organophosphates (OP) that are found in Class 1 pesticides have been banned by 192 nations (Worek et al., 2016). Some of these agents, which may still be used in other countries, include malathion and diazinon. The Chemical Weapon Convention, which banned chemical weapons production, development, and storage, was entered into in April 1997 (United Nations Treaty Collection, 2021). Despite this ban, these agents are being used by terrorists and there is the possibility of an accidental spill of OP agents (Worek et al., 2016). OP agents such as sarin are used in chemical attacks by terrorists. These agents are nerve gasses and can be dispensed by a bomb, sprayed into the air, or may come in the form of a powder or liquid. The liquid form can seep into the skin and react slower than other forms. Contact agents may sit on a surface then transfer to the skin. This can happen quickly or slowly depending on the strength of the agent and how long it has been exposed to the elements or the number of times it has been transferred from surface to surface (Worek et al., 2016). Many agents are inexpensive to make and disseminate. How- to information is readily available on the Internet. Agents can be disseminated through water, air, and the food supply. The seriousness of a chemical terrorist attack or disaster depends on the type of agent used, how it is disseminated, and weather conditions. Agents such as sarin disseminated in a closed building will have high fatality rates. The same agent disseminated in open air will quickly lose its potency when there is high humidity, increased temperatures, and strong winds (Nwanegbo, 2013). It takes large quantities of a chemical to disperse in a water source, so this is used less frequently for terrorist purposes but can certainly happen by accident. The nerve agent used against Sergei Skripal in Britain on March 4, 2018, was in the form of a powder called Novichok that Russia developed. This new agent is classified as a Category C agent. This same agent also poisoned a couple 4 months later in the same area of Britain. The female died and her male partner survived after spending 20 days in the hospital. Initially, it was unknown if the second poisoning was deliberate or residual from the first poisoning. It was determined that the victims were poisoned after finding what looked like a perfume bottle. The female victim sprayed the liquid in it on her wrists and the male broke the bottle in his hands (Sawyer, 2018).
No matter what the chemical agent is, public health officials, investigators, and toxicologists must work quickly to identify the agent. Then, they must contain the chemical agent and determine a plan to decontaminate the site. Identifying the agent will help healthcare providers devise a treatment plan. Classes of chemical agents There are three classes of agents that must be identified for proper treatment. Table 2 depicts these agents. Table 2. List of the Different Types of Chemical Agents Nerve Agents Blister Agents Choking Agents GA – Tabun HD - Sulfur
CG – Phosgene
mustard (Yperite)
GB – Sarin
HN - Nitrogen mustard
DP – Diphosgene
VX - Methylphosphonothioic Acid
Note: From “Types of chemical weapons,” by Federation of American Scientists. Copyright 2013 by Federation of American Scientists. Reprinted with permission. Nerve agents The most serious chemical agents are the nerve agents that can result in death if immediate treatment is not initiated. The nerve agents can inhibit or bind acetylcholinesterase and make it inactive in the body. These agents are related to organophosphates. Nerve agents will affect the iris, ciliary body, bladder, gastrointestinal tract, cardiac muscle, and respiratory tract. Widespread symptoms may appear in less than 1 minute because the lungs will carry the toxin to the circulatory system and systematically affect the entire body (Federation of American Scientists, 2013). Less toxic effects may result in miosis or constriction of the pupils. The constriction may be unequal and result in redness of the eyes. Mild lung exposure may result in watery nasal discharge or prolonged wheezing (Federation of American Scientists, 2013).
Evidence-Based Practice: The transmission mode of nerve agents through either inhalation, skin exposure, or ingestion, may dictate the sequence of symptoms. Inhalation exposure usually results in respiratory symptoms, whereas ingestion the first symptoms may be gastrointestinal (Federation of Medical Scientists, 2013).
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