Toxic Industrial Chemicals Medical Response in SOF Operations. Outline

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1 Bundeswehr Medical Academy Dept F Medical CBRN Defence Toxic Industrial Chemicals Medical Response in SOF Operations Colonel Roman Wölfel, MD PhD DTMH Head, Bundeswehr CBRN Medical Task Force Outline History of TIC in War Spectrum of TIC TIC Threats in SOF Operations Medical Response 2 1

2 Use of Chemical Agents in World War I French gas attack 1915 German gas attack Use of Chemical Agents in World War I British soldiers releasing gas German soldiers releasing gas 4 2

3 Use of Chemical Agents in World War I 5 TIC Releases in Syria ❷ KAFR ZITA Chlorine gas release ❸ JOBAR Chlorine gas release ❹ KAFR ZITA Chlorine gas release ❺ KAFR ZITA Chlorine gas release ❼ MZEIREB Chlorine gas release ❽ SARMIN Barrel bombs with chlorine ❾ QMENAS Chlorine gas release ⓫ BINNISH Barrel bombs with chlorine ⓬ SARAQEB Barrel bomb with chlorine ⓭ SARAQEB Chlorine gas release ⓱ KANSAFRA Barrel bomb with chlorine ⓳ SARAQEB Chlorine gas release ⓴ ALEPPO Chlorine gas release 6 3

4 High Hazard Toxic Industrial Chemicals NATO International Task Force 25 (ITF-25) Ammonia Boron trichloride Fluoride Formaldehyde Phosphorus trichloride Phosgene Hydrogen bromide Hydrogen chloride Chlorine Nitric acid Sulfur dioxide Sulfuric acid Arsine Boron trifluoride Diborane Ethylene oxide Hydrogen fluoride Hydrogen sulfide Carbon disulfide Cyanide Tungsten hexafluoride 7 Bhopal Chemical Disaster 1984 Accidental release of 40 tons of methylisocyanate people exposed to cloud deaths caused by acute respiratory failure 4

5 TICs in Industrial Nations TICs in the Developing World 10 5

6 Clandestine Labs 11 Chemical Detection & Identification HazMatID LCD 3.3 FirstDefender Dräger Test Tubes HapSite ER Dräger Chip Measuring System 12 6

7 Intelligence & Reconnaissance Can Be Vital CAS No.: «Hydrofluoric acid» Acute toxicity, Oral (Cat 2) H300 Acute toxicity, Inhalation (Cat 2), H330 Acute toxicity, Dermal (Cat 1), H310 Skin corrosion (Category 1A), H314 Material can cause severe burns and blistering which may not be immediately painful or visible. The full extent of tissue damage may not exhibit itself for hours after exposure. Material is extremely destructive to tissue of the mucous membranes and upper respiratory tract, eyes, and skin 13 Industrial Chemicals in IEDs Chemical storage tanks 5000-gallon chlorine IED, Ramadi

8 Chlorine Gas Release (10 tons) 15 Kafr Zita, Syria 11 April

9 The Nose Knows Swimming pool = Chlorine Rotten eggs = Sulfur dioxide / Hydrogen sulfide Almonds = Cyanide 17 Tweety: I TOT I TAW A PUDDY TAT... I DID, I DID TEE A PUDDDD 9

10 Chlorine, Ammonia, SO2, Sulfuric Acid, Bleach Clinical sign: Noise Chlorine, Ammonia, SO2, Sulfuric Acid, Bleach Oxygen Bronchodilators, steroids Early intubation Assisted ventilation No antibiotics! (only after organism identification) Clinical sign: Noise 10

11 Chlorine, NO2, Phosgene, HC Smoke Clinical sign: Dyspnea Chlorine, NO2, Phosgene, HC Smoke T rust the patient! Early Dx depends upon symptoms R est the patient! Exertion worsens the prognosis O bserve the patient! Watch for clinical deterioration T ransport the patient ICU care may be life-saving Clinical sign: Dyspnea 11

12 Hydrogen cyanide & Cyanide salts Cyanide is a volatile, nonpersistent agent Widespread industrial use: electroplating, jewelry and metal cleaners photographic processing fumigant rodenticide Pits of peaches, cherries, apricots, apples, plums Many people cannot smell cyanide 23 Hydrogen cyanide & Cyanide salts Cyanide salts are well absorbed through the skin Onset time: Seconds with high inhaled concentrations Tissue hypoxia, especially of the heart and brain Absence of cyanosis (po2 ) Severe ingestion victims will off-gas cyanide from their breath 24 12

13 Cyanide vs. Nerve Agent CYANIDE Rapid takedown Seizures Respiratory Arrest Incontinence = NERVE AGENTS Rapid takedown Seizures Respiratory Arrest Incontinence 25 Cyanide vs. Nerve Agent CYANIDE Rapid takedown Seizures Respiratory Arrest Incontinence Normal/large pupils Few secretions = NERVE AGENTS Rapid takedown Seizures Respiratory Arrest Incontinence Pinpoint pupils Severe secretions Twitching 26 13

14 Cyanide Antidotes 4-DMAP 100 % oxygen, aggressive airway management Inhale amyl nitrite perles for 30 sec every minute 10 ml (300mg) sodium nitrite 3% i.v. over >5 min 50 ml (12.5g) sodium thiosulfate 25% i.v. over 20 min 5 ml (250mg) 4-dimethylaminophenol (4-DMAP) i.v. 30 ml (7.5g) sodium thiosulfate 25% i.v. over 20 min Mild cases / smoke-inhalation: 5g Hydroxycobalamin (Cyanokit ) i.v. over 15 min Severe cases: 20 ml (300mg) dicobalt edetate i.v. 27 Cyanide Antidotes 100 % oxygen, aggressive airway management Inhale amyl nitrite perles for 30 sec every minute 10 ml (300mg) sodium nitrite 3% i.v. over >5 min 50 ml (12.5g) sodium thiosulfate 25% i.v. over 20 min 5 ml (250mg) 4-dimethylaminophenol (4-DMAP) i.v. 30 ml (7.5g) sodium thiosulfate 25% i.v. over 20 min Mild cases / smoke-inhalation: 5g Hydroxycobalamin (Cyanokit ) i.v. over 15 min Severe cases: 20 ml (300mg) dicobalt edetate i.v

15 Hydrogen Sulfide Crude aluminium sulfide? 29 Hydrogen Sulfide Poisoning Highly toxic, colorless gas Malodorous, intensely irritating More potent cytochrome oxidase inhibitor than cyanide Sources: Rotten eggs = Hydrogen sulfide decaying organic materials natural or volcanic gas petroleum sulfur deposits metal sulfides 15

16 Hydrogen Sulfide Poisoning Concentration Clinical effect 0.02 ppm odor threshold ppm nose/eye irritation, olfactory nerve paralysis ppm sore throat, keratoconjunctivits, chest tightness, pulmonary edema ppm headache, disorientation, loss of reasoning, coma, convulsions > 1000 ppm death Hydrogen Sulfide Poisoning Rotten eggs = Hydrogen sulfide rescuer protection basic life support 100 % oxygen, aggressive airway management Inhale amyl nitrite perles for 30 sec 10 ml (300mg) sodium nitrite 3% i.v. 5 ml (250mg) 4-DMAP i.v. Ø sodium thiosulfate 16

17 Hydrofluoric Acid (HF) Precursor to many compounds, incl. several nerve agents Highly corrosive liquid Powerful contact poison No irritating odor Delayed onset of symptoms (hours) for solutions of less than 7% 33 Hydrofluoric Acid Poisioning 17

18 Hydrofluoric Acid Poisioning Remove all soiled clothing Irrigation with plenty of water Apply calcium gluconate gel Hypocalcemia 10% calcium gluconate i.v. Tissue burns: Subcutaneous infiltration of calcium gluconate (0.5 ml of a 5% solution) Take Home Points There are plenty of TIC threats. Intelligence & Reconnaissance can be vital. Most TICs are difficult to detect for SOF medics. Chlorine, Cyanides, H2S and HF are highly relevant. Medical treatment is often symptomatic and supportive. There are antidote schemes for cyanide and H2S poisoning. Think cyanide poisoning in smoke inhalation. Never underestimate hydrofluoric acid. Say your prayers and get ready to work when the canary stops singing! 18

19 Further Reading NATO STANAG AMedP 7.x Series nso.nato.int/protected/ NIOSH Pocket Guide to Chemical Hazards Medical Management Guidelines (MMGs) Practical Guide for Medical Management of Chemical Warfare Casualties 37 Bundeswehr Medical Academy Task Force Med CBRN Defence