Bioterrorism. Ted Szymanski DO MFMER slide-1

Transcription

1 Bioterrorism Ted Szymanski DO 2015 MFMER slide-1

2 Biologic / Chemical Weapons 2015 MFMER slide-2

3 Most Likely Targets People Crops Livestock Bioterrorist attacks Relatively Easy to Obtain 1996 an Ohio man purchased bubonic plaque cultures through the mail In the US criminal investigations, the use of biological materials of mass destruction double just between 1997 & MFMER slide-3

4 Biologic / Chemical Weapons Biological or chemical agents used with the intent to kill, incapacitate, or cause fear Cheaper and easier to produce than nukes Mortality potential equal to that of nuclear weapons Easily dispersed and difficult to detect Aerosolization (stationary or mobile sprayers) Contamination of food and water Person-to-person 2015 MFMER slide-4

5 Biologic / Chemical Weapons Characteristics that make bio-agents good weapons Infectivity virulence toxicity incubation period transmission lethality stability 2015 MFMER slide-5

6 CBRNe The 20th CBRNE Command (Chemical, Biological, Radiological, Nuclear and high- yield Explosives or CBRNE) is the United States Army's Chemical, Biological, Nuclear, Radiological and high-yield explosives headquarters. CBRNe agents/weapons sometimes referred as WMD (destruction) Terrorist use of CBRNe agents, intended to cause terror instead of mass casualties, is therefore often referred to as weapons of mass disruption MFMER slide-6

7 Bacterial Agents Anthrax, Cholera, Plague, Tularemia, Q fever 2015 MFMER slide-7

8 Viral Agents Smallpox Venezuelan Viral hemorrhagic fevers hantavirus (cultivation is difficult and expensive) Encephalitis viruses equine 2015 MFMER slide-8

9 Biological Toxins Botulinum toxin, Ricin Staphlococcal Enterotoxin B (SEB) T-2 Mycotoxins 2015 MFMER slide-9

10 Anthrax Three forms: Inhalational Cutaneous GI 2015 MFMER slide-10

11 Anthrax Woolsorter s disease = Cutaneous form Inhalation of spores, incubation 1-6 days 2015 MFMER slide-11

12 Inhalational Anthrax Initially-Flu like but progress rapidly Fever, chills, drenching sweats, profound fatigue, minimally productive cough, nausea, vomiting, chest discomfort, respiratory distress sepsis and death (24 hours) Chest X-ray: Mediastinal widening, paratracheal & hilar fullness, pleural effusions, infiltrates Death typically occurs with hours after onset of severe symptoms Exposed / infected patients DO NOT require isolation 2015 MFMER slide-12

13 Inhalation Anthrax MFMER slide-13

14 Treatment Resp/GI Ciprofloxacin or doxycycline + one or two Rifampin, ampicillin, vancomycin, clindamycin, penicillin, imipenem Treatment up to 60 days 2015 MFMER slide-14

15 Cutaneous Anthrax Incubation 1-5 days Local edema followed by Macule-Pruritic papule resembling an insect bite vesicle (sometimes hemorrhagic) rupture and ulceration painless black eschar Eschar drying falling off within 1-2weeks 2015 MFMER slide-15

16 Cuntaneous Anthrax Patients with cutaneous anthrax may have fever, extensive edema and other systemic signs Antibiotics may not alter course however no antibiotic may result in mortality of 20% Ciprofloxacin, doxycycline or penicillin 8 weeks if exposure is confirmed 2015 MFMER slide-16

17 Cutaneous Anthrax MFMER slide-17

18 Gastrointestional Anthrax Incubation unknown but thought to be days Upper: Oral or esophageal ulcers leading to regional lymphadenopathy (compromising airway), edema and sepsis Lower: Massive ascites 2015 MFMER slide-18

19 Bubonic Pneumonic Septicemic Plague: Clinical Forms Yersinia pestis via a rodent zoonosis (transmitted by flea bites, contact and inhalation) 2015 MFMER slide-19

20 Bubonic Plague The most common form of plague Infected flea bites a person, or materials contaminated with Y. pestis enter through a break in the skin Swollen, tender lymph nodes (buboes), usually in the groin, axilla or cervical region Maybe so painful restricts patient from moving that affected area Rarely become suppurative or flunctuant Not spread from person to person 2015 MFMER slide-20

21 Bubonic plague MFMER slide-21

22 Pneumonic plague: Incubation 2-3 days, inhalation of aerosolized bacteria (resp. isolation required) Highly contagious Fever, cough, bloody sputum, shock, DIC, LFTs; Gram s stain, culture, serology; 2015 MFMER slide-22

23 Pneumonic plague MFMER slide-23

24 Septicemic Plague May result from pneumonic or bubonic or by itself Fever Cough (bloody or watery sputum) Progressive Dyspnea Prominent GI Symptoms N/V, diarrhea, abd pain 2015 MFMER slide-24

25 Treatment Streptomycin, gentamycin or doxycycline Meningitis add choramphenicol days Aggressive supportive Therapy Never I&D buboes 2015 MFMER slide-25

26 Smallpox Smallpox (variola virus) Airborne transmission, highly infectious Even one case is a public health emergency Incubation 7-17 days, not contagious until rash All lesions progress at same time Present with High fever Up to 30% infected may die Overwhelming sepsis, dehydration 2015 MFMER slide-26

27 Smallpox MFMER slide-27

28 Vaccine Live virus (vaccinia). 1 protection fades after 5 years, revaccination lasts 30+ years Post-exposure vaccine is effective up to 3 days Adverse reactions: Accidental implantation, 2 infection, eczema vaccinatum, EM, generalized vaccinia, progressive vaccinia, keratitis 2015 MFMER slide-28

29 Smallpox (vaccinia) Vaccine Adverse Reaction Progressive vaccinia (vaccinia necrosum) MFMER slide-29

30 Smallpox (vaccinia) Vaccine Adverse Reaction Auto-inoculation of eyelid with vaccinia virus 2015 MFMER slide-30

31 Viral Hemorrhagic Fevers (VHF) Caused by 4 viral families Arenaviruses Argentine Hemorrhagic Fever Filoviruses Ebola Bunyaviruses Hantavirus Pulmonary Syndrome Flaviviruses Tick borne encephalitis 2015 MFMER slide-31

32 Transmission Contact with rodent urine, feces, saliva, blood From mosquito or tick bites Contact with vector-infected livestock 2015 MFMER slide-32

33 Symptoms Fever, fatigue, dizziness, myalgias Signs of bleeding range from conjunctival hemorrhage to multifactorial coagulopathy 2015 MFMER slide-33

34 Biologic Toxins Aerosolized botulism: Toxin can be absorbed through inhalation. It is relatively easy to produce, stable for aerosolization, and highly lethal Binds to the preganglionic membrane of cholinergic synapses and inhibits acetylcholine release Earliest complication involves the eyes (double vision). Progresses to descending paralysis and respiratory failure Unlike nerve agents, doesn t cause miosis or copious respiratory secretions HALLMARK: progressive descending flaccid paralysis 2015 MFMER slide-34

35 Botulism Risk Mortality for untreated cases around 60% Cases treated with supportive care, mortality <5% 2015 MFMER slide-35

36 Ricin Poison made from a castor bean extract Can be powder, mist or pellet Causes toxicity by inhibition of protein synthesis and leads to cell death 2015 MFMER slide-36

37 Ricin Inhalation airway necrosis, fever, cough, sweating, hemorrhagic pulmonary edema; treatment is appropriate respiratory support 2015 MFMER slide-37

38 Ricin Ingestion Necrosis of the GI epithelium Local hemmorhage Hepatic, splenic and renal necrosis Jaundice hematuria Treatment : replace GI fluid loss and gastric lavage if taken within one hour 2015 MFMER slide-38

39 Chemical Weapons Vesicants Nerve agents Cyanide Lung-damaging agents Riot control agents CN and CS (Tear gas) OC spray 2015 MFMER slide-39

40 Vesicants (Blister agents) Cause blisters on dermis Mustard Sulfur (HD) and nitrogen (HN) Lewisite (L) Phosgene oxime (CX) 2015 MFMER slide-40

41 Vesicants Central Symptoms : Sneezing, coughing, wheezing, irritation (low to moderate dose) Mustard: Dangerous as a liquid or gas After entering the body through dermis or via respiration, it reacts with water. The resulting chemical causes large necrotic blisters on the dermis and mucus Late onset of SOB progressing to pulmonary edema (Higher dose exposure) 2015 MFMER slide-41

42 Vesicants Phosgene: Pulmonary edema, not a true vesicant Skin blanch and wheal usually without blisters Lewisite: Dangerous as a liquid or gas Unlike mustard, causes immediate pain Results in increased capillary permeability which leads to respiratory failure, edema severe shock and end-organ damage 2015 MFMER slide-42

43 Chemical Weapons Nerve Agents Developed in WW II Tabun (GA), Sarin (GB), Soman (GD), GF, VX VX is the most potent, sarin the most volatile Powerful inhibitors of acetylcholinesterase (SLUDGE, killer B s, paralysis, death) High risk of secondary contamination Self-protection, decontamination 2015 MFMER slide-43

44 Cholinergic Overdose Diarrhea Urination Miosis/muscle weakness Bronchorrhea Bradycardia Emesis Lacrimation Salivation/sweating 2015 MFMER slide-44

45 Treatment Oxygen, atropine, 2-PAM Military Mark 1 auto injector kit (2 mg atropine and 600 mg 2-PAM) 2015 MFMER slide-45

46 Sarin March 1995 Tokyo, Japan Dead 12 Critical 17 Severe 37 Moderate 984 Outpatient 4073 Unknown 387 Total MFMER slide-46

47 Cyanide Rapidly transported through the body Prevents cells from using oxygen Subsequently cells die Most sensitive brain and heart Two compounds Hydrogen cyanide (1782) used in WWI Cyanogen chloride (1916) forms a layer close to the ground and evaporates at a slow rate of speed 2015 MFMER slide-47

48 Symptom Development Inhalation: Within 60 seconds go from gasping, loss of consciousness to convulsions 3-5 minutes apnea 5-8 minutes asystole Ingestion : 7 min tachypnea, dizziness 10 min anxiety, cramping, vomiting 20 min lossof consciousness 25 min apnea/asystole 2015 MFMER slide-48

49 Treatment: Rapid diagnosis Cyanide Antidote kits (CAK) Hydroxocobalamin kit (Cyanokit) Not 100% successful 2015 MFMER slide-49

50 Radiation Exposure Types of exposure External (e.g. radiation therapy) Internal (inhalation, ingestion) Contact with skin and clothes requires decontamination Median lethal dose: 4.5 Gy Doses over 1 Gy produce GI symptoms (N/V/D) Survival probable <2 Gy N/V for hours, then home Survival unlikely >8 Gy Fulminant N/V/D, desquamation Earlier symptoms indicate a higher dose and worse prognosis 2015 MFMER slide-50

51 Radiation Exposure Rad = Radiation absorbed dose Energy imparted to matter 100 rads = 1 Gray (Gy) Nonionizing visible light } microwave Heat radar Ionizing - least penetrating - 8 mm penetration (burns) - deep penetration, acute radiation sickness Neutrons: Fallout Radon gas: Decay of uranium 238 ( ) 2015 MFMER slide-51

52 Radiation Exposure Tissues with high cell division are most affected GI & heme systems are the most vulnerable Suspect radiation illness Unexplained burns, GI sx & pancytopenia Skin dosimetry and lab dosimetry (more accurate) Epilation ~ 3 Gy Erythema ~ 6 Gy Dry desquamation ~ 10 Gy 48 hour absolute lymphocyte count (cells most affected) > 1200 (very good) (possibly lethal) < 300 (lethal) 2015 MFMER slide-52

53 Radiation Decon Internal decontamination GI decontamination Activated charcoal and whole bowel irrigation Potassium iodide for I-131 ingestion Chelating agents for radioactive heavy metals Supportive care 2015 MFMER slide-53

54 MCI Alert Plan: Evacuation (prevent new victims) Determine exposure type Early hospital notification Number of victims Decontaminate on scene if possible Separate hospital entrance Closed system drainage and ventilation Wash with soap and water (including hair) Trim nails, cut hair 2015 MFMER slide-54

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58 Questions? 2015 MFMER slide-58