CBRNE represents the following agents: chemical, Biological, Radiological, Nuclear, and Explosive agents, which are dangerous substances that can be employed in terrorism or war. Based on the chemical option, chemical agents that kill humans or animals or threaten plant and animal life are known as chemical warfare agents (CWAs).
Chemical warfare agents are chemicals which if used as weapons of warfare will have intended toxic effects on large groups of people. The drugs are categorized depending on the impact they have on the physiology of human beings.
History:
First extensive utilization of CWAs occurred during First World War, in which Germans, British and French used chlorine, phosgene and mustard gas respectively. These attacks led to the loss of possibly several hundreds of thousands of people. Since then, CWAs have been utilized in several conflicts like in the Iran Iraq war and the Syrian civil war.
Types of Chemical Warfare Agents:
Nerve Agents: These are the most lethal CWAs, which inhibit the functions of the nervous system. Some of the well-known types are Sarin, VX, and Tabun.
Blister Agents: These agents damage the skin, eyes and respiratory system since they cause deep burning sensations. Some examples of these agents are Mustard gas and Lewisite.
Blood Agents: These agents blunt the transport of oxygen in the body resulting to asphyxia. Some of the examples are Cyanide and Hydrogen cyanide.
Choking Agents: These agents precipitate inflammation of the lungs, ooze and congest the lungs with fluid and hamper breathing. Some examples of these are chlorine and Phosgene respectively.
Effects of Exposure:
The consequences of exposure to a CWA depend on these factors as follows; The type of CWA and the amount the individual is exposed to, route of exposure also plays a significant role in the effects of exposure to a CWA. Signs and manifestations may be mild or severe and may occur on the initial day or as a late manifestation on several hours to days later.
Epidemiology
Incidence and Prevalence:
Roughly 1.3 million deaths in World War I were caused by CWAs.
Thus, the high incidence of CWA injuries mainly because chlorine, Phosgene, and mustard gas were liberally used during the war.
Mortality and Morbidity: The fatality rates of CWA exposure differ, while chlorine gas had fewer deaths in comparison to Phosgene and mustard gas. Morbidity was in the form of acute response which were respiratory problems, skin irritation and any other complication that may result from it and chronic conditions which were include respiratory diseases and skin cancer.
Chemical weapons, nevertheless, all over the pre-world War-II period, claimed about 1,176,500 non-fatal victims and 85,000 fatal ones. It is documented that the total weight of the agents used including the pulmonary, lachrymatory and vesicant agents for both the Allied and the Central Powers Totalling 50,965 tons were of chlorine, Phosgene and Mustard gas.
The only recorded instance of its (mustard gas) usage was probably in 1943, when Germany attacked several US ships. One of the US ships had been transporting 20000 mustard gas for counterattack in case of chemical attacks from the Germans. Since presence of the gas had been kept secret, people dealing with the injured on the coast had no indication that they were dealing with the effects of mustard gas. They administered the wrong treatments because of it. From records that were recently declassified, it was discovered that out of the hospitalized cases, 628 were because of mustard gas. At the same time, 69 deaths could be attributed to this agent, in part or total.
Anatomy
Pathophysiology
Etiology
Genetics
Prognostic Factors
Dose and Concentration
Exposure Dose: This suggests the quantity of agent that an individual is exposed to will determine the severity of the sign/symptoms and chance of survival.
Concentration: With higher concentrations it is proved that the effect is more severe, and the onset of this effect also occurs at a much faster rate.
Duration of Exposure
Thus, the overall dose is increased, which negatively affects the prognosis in cases of prolonged exposure.
The timeliness and type of medical intervention in this incidence are crucial in determining the outcomes.
Rapid Decontamination: In various cases, the agent’s removal from the body or environment as early as possible would go a long way in enhancing the results.
Availability of Antidotes: Some of them, for instance, the nerve agents have specific treatment (atropine, pralidoxime) that must be provided within the shortest possible time.
Advanced Sensors: Modern, sophisticated equipment for quick identification of CWAs should be employed. Though, some advanced technologies like gas chromatography-mass spectrometry (GC-MS), ion mobility spectrometry (IMS), and fourier transform infrared spectroscopy (FTIR) among others cannot be overlooked.
Portable Detection Devices: Provide the response teams with portable detecting apparatus which enable the recognition of CWAs within the incident location.
Decontamination
Decontaminants: Employ suitable cleaning agents like bleach solutions or specialized foams and a reactive sorbent to neutralize CWAs.
Automated Systems: Implement automated decontamination systems for vehicles, equipment, and personnel.
Protective Equipment
Personal Protective Equipment (PPE): Make sure that those who would respond have the correct protective gear such as respirators and chemical suits and correct chemical-resistant gloves and boots.
Training: Holding periodic classes when the correct usage of PPE and the method of its decontamination is a must.
Role of anticholinergics in CBRNE-Nerve agent
Atropine
Atropine is one of the medicines used to treat cases of nerve agents through interfering with the effects of acetylcholine.
The crucial therapeutic endpoints in patients with atropine are the improvement in the lung clarity, relief of bronchoconstriction, and correction of bradycardia; tachycardia and pupillary response are not reliable indicators of sufficient atropinization.
Role of oximes in CBRNE-Nerve agent
Pralidoxime (2-PAM)
This medication also aims to restore the enzyme that nerve agents block known as acetylcholinesterase by reactivating it. This enzyme can be reactivated to normal function of the nerve.
Given for 30-40 min in the prescribed amount.
Side effects such as blurred vision, nausea, epigastric pain, and vomiting are associated.
Stimulatory effects by preventing cholinergic impulse transmission to the sphincter muscle of the iris and the ciliary muscle. When used in a form of weaker solution with a concentration of 0.5%, it produces mydriasis; mucous membranes’ stimulation in stronger solution with concentration of 1% leads to cycloplegia.
Effectiveness of cholinesterase inhibitors in CBRNE-Nerve agent
An orally taken cholinesterase inhibitor that can serve as a preventive measure where the patient is likely to encounter GF, GD and GA through the intake of chemoprophylactic agent before exposure. This suggestion is derived from animal research; a lack of data exists on the prevention’s effectiveness in people. Protective only against non-CNS, non-neuromuscular effects of nerve agents.
Use of Antidotes for Cyanide Poisoning
Hydroxocobalamin: The cyanocobalamin analog binds to cyanide to produce a compound, which is then excreted in the urine.
Sodium Thiosulfate: They work by reducing the lethal cyanide to the harmless thiocyanate, which is expelled through urine.
Sodium Nitrite: This antidote cause formation of methemoglobin which has an affinity for cyanide and thus competes with cytochrome oxidase to grab the toxin.
Prevention: Pertains more to protective steps that cover the release of CWAs into the environment or their misuse.
Protection: Ensuring the protection of people and assets through PPEs, decontamination, and secure zones and buildings.
Detection: Include systems of monitoring and identification of CWAs with the help of monitoring tools and detection apparatus.
Response: Active measures refer to the steps that must be taken because of a CWA incident and the substance includes evacuation of the area, medical treatment of the victims, and controlling the spread of the hazardous substance.
Recovery: Emphasis is on the process of bringing back the affected regions and people to their normal state by removing contaminants, rebuilding damaged structures and physically and psychologically integrating the victims into their communities.
Mitigation: Pertains to actions that are extended to prevent future occurrences, to increase the level of preparedness in the event of similar mishaps, and to teach the staff members.
CBRNE represents the following agents: chemical, Biological, Radiological, Nuclear, and Explosive agents, which are dangerous substances that can be employed in terrorism or war. Based on the chemical option, chemical agents that kill humans or animals or threaten plant and animal life are known as chemical warfare agents (CWAs).
Chemical warfare agents are chemicals which if used as weapons of warfare will have intended toxic effects on large groups of people. The drugs are categorized depending on the impact they have on the physiology of human beings.
History:
First extensive utilization of CWAs occurred during First World War, in which Germans, British and French used chlorine, phosgene and mustard gas respectively. These attacks led to the loss of possibly several hundreds of thousands of people. Since then, CWAs have been utilized in several conflicts like in the Iran Iraq war and the Syrian civil war.
Types of Chemical Warfare Agents:
Nerve Agents: These are the most lethal CWAs, which inhibit the functions of the nervous system. Some of the well-known types are Sarin, VX, and Tabun.
Blister Agents: These agents damage the skin, eyes and respiratory system since they cause deep burning sensations. Some examples of these agents are Mustard gas and Lewisite.
Blood Agents: These agents blunt the transport of oxygen in the body resulting to asphyxia. Some of the examples are Cyanide and Hydrogen cyanide.
Choking Agents: These agents precipitate inflammation of the lungs, ooze and congest the lungs with fluid and hamper breathing. Some examples of these are chlorine and Phosgene respectively.
Effects of Exposure:
The consequences of exposure to a CWA depend on these factors as follows; The type of CWA and the amount the individual is exposed to, route of exposure also plays a significant role in the effects of exposure to a CWA. Signs and manifestations may be mild or severe and may occur on the initial day or as a late manifestation on several hours to days later.
Incidence and Prevalence:
Roughly 1.3 million deaths in World War I were caused by CWAs.
Thus, the high incidence of CWA injuries mainly because chlorine, Phosgene, and mustard gas were liberally used during the war.
Mortality and Morbidity: The fatality rates of CWA exposure differ, while chlorine gas had fewer deaths in comparison to Phosgene and mustard gas. Morbidity was in the form of acute response which were respiratory problems, skin irritation and any other complication that may result from it and chronic conditions which were include respiratory diseases and skin cancer.
Chemical weapons, nevertheless, all over the pre-world War-II period, claimed about 1,176,500 non-fatal victims and 85,000 fatal ones. It is documented that the total weight of the agents used including the pulmonary, lachrymatory and vesicant agents for both the Allied and the Central Powers Totalling 50,965 tons were of chlorine, Phosgene and Mustard gas.
The only recorded instance of its (mustard gas) usage was probably in 1943, when Germany attacked several US ships. One of the US ships had been transporting 20000 mustard gas for counterattack in case of chemical attacks from the Germans. Since presence of the gas had been kept secret, people dealing with the injured on the coast had no indication that they were dealing with the effects of mustard gas. They administered the wrong treatments because of it. From records that were recently declassified, it was discovered that out of the hospitalized cases, 628 were because of mustard gas. At the same time, 69 deaths could be attributed to this agent, in part or total.
Dose and Concentration
Exposure Dose: This suggests the quantity of agent that an individual is exposed to will determine the severity of the sign/symptoms and chance of survival.
Concentration: With higher concentrations it is proved that the effect is more severe, and the onset of this effect also occurs at a much faster rate.
Duration of Exposure
Thus, the overall dose is increased, which negatively affects the prognosis in cases of prolonged exposure.
The timeliness and type of medical intervention in this incidence are crucial in determining the outcomes.
Rapid Decontamination: In various cases, the agent’s removal from the body or environment as early as possible would go a long way in enhancing the results.
Availability of Antidotes: Some of them, for instance, the nerve agents have specific treatment (atropine, pralidoxime) that must be provided within the shortest possible time.
Emergency Medicine
Detection and Identification
Advanced Sensors: Modern, sophisticated equipment for quick identification of CWAs should be employed. Though, some advanced technologies like gas chromatography-mass spectrometry (GC-MS), ion mobility spectrometry (IMS), and fourier transform infrared spectroscopy (FTIR) among others cannot be overlooked.
Portable Detection Devices: Provide the response teams with portable detecting apparatus which enable the recognition of CWAs within the incident location.
Decontamination
Decontaminants: Employ suitable cleaning agents like bleach solutions or specialized foams and a reactive sorbent to neutralize CWAs.
Automated Systems: Implement automated decontamination systems for vehicles, equipment, and personnel.
Protective Equipment
Personal Protective Equipment (PPE): Make sure that those who would respond have the correct protective gear such as respirators and chemical suits and correct chemical-resistant gloves and boots.
Training: Holding periodic classes when the correct usage of PPE and the method of its decontamination is a must.
Emergency Medicine
Atropine
Atropine is one of the medicines used to treat cases of nerve agents through interfering with the effects of acetylcholine.
The crucial therapeutic endpoints in patients with atropine are the improvement in the lung clarity, relief of bronchoconstriction, and correction of bradycardia; tachycardia and pupillary response are not reliable indicators of sufficient atropinization.
Emergency Medicine
Pralidoxime (2-PAM)
This medication also aims to restore the enzyme that nerve agents block known as acetylcholinesterase by reactivating it. This enzyme can be reactivated to normal function of the nerve.
Given for 30-40 min in the prescribed amount.
Side effects such as blurred vision, nausea, epigastric pain, and vomiting are associated.
Stimulatory effects by preventing cholinergic impulse transmission to the sphincter muscle of the iris and the ciliary muscle. When used in a form of weaker solution with a concentration of 0.5%, it produces mydriasis; mucous membranes’ stimulation in stronger solution with concentration of 1% leads to cycloplegia.
An orally taken cholinesterase inhibitor that can serve as a preventive measure where the patient is likely to encounter GF, GD and GA through the intake of chemoprophylactic agent before exposure. This suggestion is derived from animal research; a lack of data exists on the prevention’s effectiveness in people. Protective only against non-CNS, non-neuromuscular effects of nerve agents.
Emergency Medicine
Hydroxocobalamin: The cyanocobalamin analog binds to cyanide to produce a compound, which is then excreted in the urine.
Sodium Thiosulfate: They work by reducing the lethal cyanide to the harmless thiocyanate, which is expelled through urine.
Sodium Nitrite: This antidote cause formation of methemoglobin which has an affinity for cyanide and thus competes with cytochrome oxidase to grab the toxin.
Emergency Medicine
Prevention: Pertains more to protective steps that cover the release of CWAs into the environment or their misuse.
Protection: Ensuring the protection of people and assets through PPEs, decontamination, and secure zones and buildings.
Detection: Include systems of monitoring and identification of CWAs with the help of monitoring tools and detection apparatus.
Response: Active measures refer to the steps that must be taken because of a CWA incident and the substance includes evacuation of the area, medical treatment of the victims, and controlling the spread of the hazardous substance.
Recovery: Emphasis is on the process of bringing back the affected regions and people to their normal state by removing contaminants, rebuilding damaged structures and physically and psychologically integrating the victims into their communities.
Mitigation: Pertains to actions that are extended to prevent future occurrences, to increase the level of preparedness in the event of similar mishaps, and to teach the staff members.
CBRNE represents the following agents: chemical, Biological, Radiological, Nuclear, and Explosive agents, which are dangerous substances that can be employed in terrorism or war. Based on the chemical option, chemical agents that kill humans or animals or threaten plant and animal life are known as chemical warfare agents (CWAs).
Chemical warfare agents are chemicals which if used as weapons of warfare will have intended toxic effects on large groups of people. The drugs are categorized depending on the impact they have on the physiology of human beings.
History:
First extensive utilization of CWAs occurred during First World War, in which Germans, British and French used chlorine, phosgene and mustard gas respectively. These attacks led to the loss of possibly several hundreds of thousands of people. Since then, CWAs have been utilized in several conflicts like in the Iran Iraq war and the Syrian civil war.
Types of Chemical Warfare Agents:
Nerve Agents: These are the most lethal CWAs, which inhibit the functions of the nervous system. Some of the well-known types are Sarin, VX, and Tabun.
Blister Agents: These agents damage the skin, eyes and respiratory system since they cause deep burning sensations. Some examples of these agents are Mustard gas and Lewisite.
Blood Agents: These agents blunt the transport of oxygen in the body resulting to asphyxia. Some of the examples are Cyanide and Hydrogen cyanide.
Choking Agents: These agents precipitate inflammation of the lungs, ooze and congest the lungs with fluid and hamper breathing. Some examples of these are chlorine and Phosgene respectively.
Effects of Exposure:
The consequences of exposure to a CWA depend on these factors as follows; The type of CWA and the amount the individual is exposed to, route of exposure also plays a significant role in the effects of exposure to a CWA. Signs and manifestations may be mild or severe and may occur on the initial day or as a late manifestation on several hours to days later.
Incidence and Prevalence:
Roughly 1.3 million deaths in World War I were caused by CWAs.
Thus, the high incidence of CWA injuries mainly because chlorine, Phosgene, and mustard gas were liberally used during the war.
Mortality and Morbidity: The fatality rates of CWA exposure differ, while chlorine gas had fewer deaths in comparison to Phosgene and mustard gas. Morbidity was in the form of acute response which were respiratory problems, skin irritation and any other complication that may result from it and chronic conditions which were include respiratory diseases and skin cancer.
Chemical weapons, nevertheless, all over the pre-world War-II period, claimed about 1,176,500 non-fatal victims and 85,000 fatal ones. It is documented that the total weight of the agents used including the pulmonary, lachrymatory and vesicant agents for both the Allied and the Central Powers Totalling 50,965 tons were of chlorine, Phosgene and Mustard gas.
The only recorded instance of its (mustard gas) usage was probably in 1943, when Germany attacked several US ships. One of the US ships had been transporting 20000 mustard gas for counterattack in case of chemical attacks from the Germans. Since presence of the gas had been kept secret, people dealing with the injured on the coast had no indication that they were dealing with the effects of mustard gas. They administered the wrong treatments because of it. From records that were recently declassified, it was discovered that out of the hospitalized cases, 628 were because of mustard gas. At the same time, 69 deaths could be attributed to this agent, in part or total.
Dose and Concentration
Exposure Dose: This suggests the quantity of agent that an individual is exposed to will determine the severity of the sign/symptoms and chance of survival.
Concentration: With higher concentrations it is proved that the effect is more severe, and the onset of this effect also occurs at a much faster rate.
Duration of Exposure
Thus, the overall dose is increased, which negatively affects the prognosis in cases of prolonged exposure.
The timeliness and type of medical intervention in this incidence are crucial in determining the outcomes.
Rapid Decontamination: In various cases, the agent’s removal from the body or environment as early as possible would go a long way in enhancing the results.
Availability of Antidotes: Some of them, for instance, the nerve agents have specific treatment (atropine, pralidoxime) that must be provided within the shortest possible time.
Emergency Medicine
Detection and Identification
Advanced Sensors: Modern, sophisticated equipment for quick identification of CWAs should be employed. Though, some advanced technologies like gas chromatography-mass spectrometry (GC-MS), ion mobility spectrometry (IMS), and fourier transform infrared spectroscopy (FTIR) among others cannot be overlooked.
Portable Detection Devices: Provide the response teams with portable detecting apparatus which enable the recognition of CWAs within the incident location.
Decontamination
Decontaminants: Employ suitable cleaning agents like bleach solutions or specialized foams and a reactive sorbent to neutralize CWAs.
Automated Systems: Implement automated decontamination systems for vehicles, equipment, and personnel.
Protective Equipment
Personal Protective Equipment (PPE): Make sure that those who would respond have the correct protective gear such as respirators and chemical suits and correct chemical-resistant gloves and boots.
Training: Holding periodic classes when the correct usage of PPE and the method of its decontamination is a must.
Emergency Medicine
Atropine
Atropine is one of the medicines used to treat cases of nerve agents through interfering with the effects of acetylcholine.
The crucial therapeutic endpoints in patients with atropine are the improvement in the lung clarity, relief of bronchoconstriction, and correction of bradycardia; tachycardia and pupillary response are not reliable indicators of sufficient atropinization.
Emergency Medicine
Pralidoxime (2-PAM)
This medication also aims to restore the enzyme that nerve agents block known as acetylcholinesterase by reactivating it. This enzyme can be reactivated to normal function of the nerve.
Given for 30-40 min in the prescribed amount.
Side effects such as blurred vision, nausea, epigastric pain, and vomiting are associated.
Stimulatory effects by preventing cholinergic impulse transmission to the sphincter muscle of the iris and the ciliary muscle. When used in a form of weaker solution with a concentration of 0.5%, it produces mydriasis; mucous membranes’ stimulation in stronger solution with concentration of 1% leads to cycloplegia.
An orally taken cholinesterase inhibitor that can serve as a preventive measure where the patient is likely to encounter GF, GD and GA through the intake of chemoprophylactic agent before exposure. This suggestion is derived from animal research; a lack of data exists on the prevention’s effectiveness in people. Protective only against non-CNS, non-neuromuscular effects of nerve agents.
Emergency Medicine
Hydroxocobalamin: The cyanocobalamin analog binds to cyanide to produce a compound, which is then excreted in the urine.
Sodium Thiosulfate: They work by reducing the lethal cyanide to the harmless thiocyanate, which is expelled through urine.
Sodium Nitrite: This antidote cause formation of methemoglobin which has an affinity for cyanide and thus competes with cytochrome oxidase to grab the toxin.
Emergency Medicine
Prevention: Pertains more to protective steps that cover the release of CWAs into the environment or their misuse.
Protection: Ensuring the protection of people and assets through PPEs, decontamination, and secure zones and buildings.
Detection: Include systems of monitoring and identification of CWAs with the help of monitoring tools and detection apparatus.
Response: Active measures refer to the steps that must be taken because of a CWA incident and the substance includes evacuation of the area, medical treatment of the victims, and controlling the spread of the hazardous substance.
Recovery: Emphasis is on the process of bringing back the affected regions and people to their normal state by removing contaminants, rebuilding damaged structures and physically and psychologically integrating the victims into their communities.
Mitigation: Pertains to actions that are extended to prevent future occurrences, to increase the level of preparedness in the event of similar mishaps, and to teach the staff members.
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