Copyright © 2003 Robert C. Jones, M.D. GAS GAS GAS! Introduction to Weapons of Mass Destruction for Anesthesia Providers Robert C. Jones, M.D. LtCol, USAF,

Copyright © 2003 Robert C. Jones, M.D.

GAS GAS GAS!Introduction to Weapons of Mass

Destruction for Anesthesia Providers

Robert C. Jones, M.D.LtCol, USAF, MCStaff Anesthesiologist89th Medical WingAndrews AFB, MD

Version 1.0


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Part 1: Chemical Warfare

• Historical Perspective

• Classes of Chemical Warfare Agents

• Clinical Details of Chemical Agents

• Specific Anesthesia-related Issues

• References


Part 2: Biological Warfare


• Classes of Biological Warfare Agents


• References


Part 3: Nuclear/Radiological Warfare


• Types of Radiological Warfare Agents


• Future Issues: The Final Frontier?

• References





• Classes of Chemical Warfare Agents

• Clinical Details of Chemical Agents


• References



• 1000 BCE: Chinese used arsenical smoke as weapon• 600 BCE: Solon placed hellebore in water of Kirrha• 500 BCE: Sun Tzu writes of military uses of fire• 300 BCE: Indian Text Arthashastra, Chapter XIV,

describes recipes for chemical/biological warfare• 678 CE: Byzantines use “Greek Fire” to destroy fleet

References: http://news.bbc.co.uk/1/hi/world/south_asia/1986595.stm; http://www.postgradmed.com/issues/2002/10_02/devereaux.htm;

http://www.mssc.edu/projectsouthasia/history/primarydocs/Arthashastra/BookXIV.htm; http://stronghold.heavengames.com/sc/history/greekfire

Historical Perspective


• First Modern Use: WWI: Ypres, France, 22 April 1915• 5700 cylinders of chlorine gas released by Germans

• Phosgene, Mustard gas soon followed

Reference: http://www.worldwar1.com/sf2ypres.htm

Historical Perspective (cont'd)


Historical Perspective (cont’d)

• Nerve Agents first developed by German Chemist Gerhard Schrader prior to WWII:– Tabun (GA) [1936], Sarin (GB) [1938], Soman

(GD) [1944] (Note: “G” stands for “G”erman)• U.K. Developed VX in 1952– given to U.S.• Iraq known to possess Cyclosarin (GF), Dusty VX

References: http://www.bvb-consult.de/content/VX.pdf; http://www.verifin.helsinki.fi/cwc/cwa.asp


Historical Perspective (cont’d)

• Defoliants, incapacitant BZ used by U.S. in Vietnam• Iraq and Iran used chemical weapons extensively

during Iran-Iraq war 1980-88 (mustard, tabun, mycotoxins, etc.)

• Sarin deployed by Aum Shinri Kyo, Tokyo, 1995

References: http://www.cdc.gov/ncidod/EID/vol5no4/olson.htm; http://stacks.msnbc.com/news/826884.asp?cp1=1

From http://users.westnet.gr/~cgian/aum.jpg


Classes of CW Agents(with examples)

• Blister (mustard, Lewisite, phosgene oxime)

• Blood (HCN, cyanogen chloride, arsine)

• Choking (Chlorine, Phosgene)

• Nerve (tabun, soman, sarin, VX)

• Incapacitating (BZ, LSD, Agent 15)

• Vomiting (DA, DC, DM)

• Irritants (CS, CN, CR)

Used mainly for law enforcement/crowd control; not covered in this lecture


Modified from: http://www.vnh.org/EWSurg/ch06/06Classification.html#Table3

U.S. Military Chemical Warfare Agent Classification

Category US Code Common Name

Blister Agents HD Distilled Mustard

L Lewisite

CX Phosgene oxime

Blood Agents AC Hydrogen cyanide

CK Cyanogen chloride

Choking Agents CG Phosgene

CL Chlorine

Nerve Agents GA Tabun

GB Sarin

GD Soman

VX VX

Incapacitation Agents BZ, QNB Quinuclidinyl benzilate


Blister (Vesicant) Agents

• Mustard/Nitrogen Mustard: Attack DNA via alkylation; hydrolysis releases HCl (moist parts of body especially vulnerable– groin, axilla, eyes…)

• Phosgene oxime: not true vesicant; unbearable pain; penetrates chem gear and rubber easily

• Mustard heavier than air; persistent in cold temps

• < 5% fatality rate for mustard-- morbidity overwhelms care facilities, degrades readiness; psychological effect

Mustard Gas:

Sources: http://www.bt.cdc.gov/agent/blister/mustardgas/index.asp; http://www.emedicine.com/emerg/topic903.htm


Blister (Vesicant) Agents (Cont'd)

Sources: http://www.kirkwood.cc.ia.us/faculty/ryost/stereographs/WWI%20Illustrations/

; http://www.spartacus.schoolnet.co.uk/FWWmustard.htm

WW I British Soldiers blinded by Mustard (note bandages: not good idea…

keeps agent in contact with cornea longer)


Blood Agents

• "Blood Agent" antiquated term: actual site of toxicity inside cells (not bloodstream)

• Cyanide moiety binds to cytochrome a3 halts oxidative phosphorylation

• CNCl one of many cyanide-producing substances (including many seeds, cassava root, etc.)

• Scent of "bitter almonds" genetically determined– 40-50% of population can't detect odor

Hydrogen Cyanide:

Sources: http://www.owlnet.rice.edu/~chem121/class/assignments/SBR_Homework/Homework6.htm

; http://www.atsdr.cdc.gov/mmg8.pdf; http://www.vnh.org/CHEMCASU/03Cyanide.html


Blood Agents

From: http://omega.dawsoncollege.qc.ca/ray/krebs/etc.htm

CN- Blocks electron transfer from cyt-a3 to oxygen


Blood Agents

Deadly via ingestion or inhalation, cyanide forces cells to resort to anaerobic metabolism death by cellular anoxia in minutes

Jonestown massacre, 1978: ingested in fruit drink

Gaseous HCN used during WWII at Nazi "Extermination Camps"


Blood Agent Treatment•100% oxygen– intubate as needed

• Cyanide Antidote Kit (often stocked in hospitals):

‾ Amyl nitrite via inhalation– 1 amp (0.2 cc) q 5 mins PRN

‾ Sodium nitrite: 300 mg iv over 5-10 mins

‾ Sodium thiosulfate: 12.5 grams iv

• Blood agents kill so quickly, many patients will die before treatment • Patients who are awake/alert >5 mins after exposure often need no significant treatment

http://www.emedicine.com/emerg/images/Large/867Chemical-generic.pdf


Choking Agents

• John Doughty, a New York City schoolteacher, first suggested use of chlorine gas as a CW agent during the American Civil War (not used)

• Chlorine: Reacts with water in lungs to form HCl, hypochlorous acid, free radicals

• Phosgene: HCl released in lungs; scent:new-mown hay • Heavier than air: collected in WWI trenches• Common pathophysiology: fulminant pulmonary

edema/ARDS; little long-term damage if survived

Phosgene:

Chlorine release on battlefield, WWIARDS/SIRS caused by phosgene

Sources: http://www.emedicine.com/emerg/topic905.htm; http://www.au.af.mil/au/awc/awcgate/gabrmetz/gabr001d.htm


Nerve Agents

VX nerve agent:

“Control Room!” he gasped then, and every speaker throughout the great cruiser of the void blared out the warning as he forced his already evacuated lungs to absolute emptiness. “Vee-Two Gas! Get tight!”

--First Officer Conway Costigan, Triplanetary, E.E. “Doc” Smith, © 1948

• Nerve Agents are among the most feared of all weapons of war

• Insidious, odorloss, colorless, extremely lethal

• All are anticholinesterases; antidotes/treatment available

Macromedia Shockwave graphic of neuronal transmission: http://camel2.conncoll.edu/academics/zoology/courses/zoo202/Nervous/synapse.html


Pathophysiology of Nerve Agents

http://www.zoology.ubc.ca/~auld/bio350/lectures/figures/nmj_cartoon.jpg; http://www.nature.com/nri/journal/v2/n10/slideshow/nri916_bx1.html

Nerve agents interfere with acetylcholinesterase; excessive ACh leads to depolarizing neuromuscular blockade downregulation of ACh receptors nondepolarizing blockade long-term effects


Nerve Agent Symptoms:

• Salivation

• Lacrimation

• Urination

• Defecation

• Gastrointestinal pain/gas

• Emesis

Early symptoms due to muscarinic effects (mnemonic: SLUDGE):

Note: also Early Signs: bronchospasm, bradycardia, miosis from cholinergic effects


Nerve Agent Symptoms (cont’d):

• Nicotinic Effects: – Impaired motor ability– Tachycardia (adrenal stimulation/hypercarbia)– Weakness– Flaccid paralysis– Apnea death

• GABA Antagonism: – tremors seizures/convulsions death

Late signs/symptoms due to nicotinic effecs and GABA antagonism:


Types of Nerve Agents

• Tabun (GA)– first developed• Sarin (GB)– used by Aum Shinri Kyo• Soman (GD)– receptor “aging” a factor • Cyclohexyl Sarin (GF)– sarin derivative• VX– persistent agent; 100X more deadly than

Sarin via skin, 2 X deadlier via inhalation• Dusty VX– VX + carrier (talc, diatomaceous

earth): penetrates standard chem gear easilySee: http://www.bt.cdc.gov/agent/agentlistchem-category.asp#nerve for details of individual agents/treatment guidelines; see http://www.verifin.helsinki.fi/cwc/cwa.asp for chemical structures of agents; see http://www.nti.org/e_research/e3_20b.html for dusty agent info


Nerve Agent AntidotesUnlike many chem/bio weapons, specific antidotes

available for nerve agents

Excellent discussion of nerve agent treatment: http://www.emedicine.com/emerg/topic898.htm

• Atropine: anticholinergic; 2 mg q 2-5 mins titrated to antimuscarinic effect (reversal of bronchospasm, diminished airway secretions, improvement of bradycardia); NO effect on nicotinic sxs (weakness/paralysis); Mark 1 autoinjector: 2 mg IM dose

• Oximes (Pralidoxime [2-PAM Chloride, protopam], others): disrupts covalent bond between nerve agent and ACh; prevents “aging’ of receptors if given fast enough (2 minutes for soman); 1-2 grams IV/IM; Mark 1 autoinjector: 600 mg IM dose

• Benzodiazepines (midazolam, diazepam): for seizures; barbiturates CONTRAINDICATED (effects increased by anticholinesterases)

• Mydriatic cycloplegics (Tropicamide [Mydriacyl®, others]): for eye pain, miosis

• Experimental/Future Antidotes: H-series oximes, exogenous anticholinesterase, monoclonal antibodies against nerve agents


Pyridostigmine, Soman, and Aging• Soman causes rapid permanent inactivation

of ACh receptors (minutes), vs. hours for other nerve agents

• Pyridostigmine bromide (PB) protects subset of ACh receptors during soman exposure– improves outcome with immediate atropine/oxime treatment only

• PB has side-effects (controversial topic)• See references below for more info

Brief review: http://www.gulflink.osd.mil/library/randrep/pb_paper/mr1018.2.chap2.html; Extensive review: http://www.gulflink.osd.mil/library/randrep/pb_paper/


Persistence and Dissemination• Environmental stability of chemical agents

varies greatly• HCN gas dissipates rapidly (minutes) in

sunlight; mustard, VX persist for weeks/months in cold environment

• Expect waves of casualties based on secondary contamination

• Primary threat of chemical weapons is aerosol; contact threat from mustard/VX

See http://hld.sbccom.army.mil/ip/bca_qr_text_only.htm for detailed description of persistence/dissemination info on chem/bio agents


General Principles of Treatment for Chemical Casualties

• Force Protection: Don’t become a casualty yourself• Terminate Exposure: Remove from attack site• Triage: Immediate/Delayed/Minimal/Expectant• Decontaminate: full exposure/wash/rinse/repeat• Antidotes: based on clinical suspicion; won’t know agent early on• Atropine is your friend: may need 200+ mg for severe cases; dose to

effect (tachycardia is not endpoint)• Benzos for seizures: midazolam, diazepam• Intubation: consider non-depolarizing agent• Children/Elderly most susceptible to chemical agents

Modified from: http://ccc.apgea.army.mil/products/articles/Nerve_Agents_In_Children-cheat_sheet(revised).pdf


Decontamination of Chemical Warfare Casualties

Rule #1: Don’t become a casualty yourself!• Many physicians/healthcare providers became nerve gas casualties after Tokyo sarin attack…standard universal precautions USELESS• Expect at least a 5:1 ratio of unaffected to affected casualties• Decontaminate victims as soon as possible• Disrobing is decontamination; head to toe, more removal is better• Water flushing generally is the best mass decontamination method• After a known exposure to liquid chemical agent, emergency responders should be decontaminated as soon as possible to avoid serious effects.

From SBCCOM Online Homeland Defense site: http://hld.sbccom.army.mil/cwirp/cwirp_guidelines_mass_casualty_decon_download.htm; also see http://hld.sbccom.army.mil/ip/reports.htm


Decontamination of Chemical Warfare Casualties (cont’d)

Rule #2: Refer to Rule #1! Decontamination before Operation!

See http://www.vnh.org/FieldManChemCasu/decon.htm and http://ndms.umbc.edu/conference2001/2001conH/Kniest.htm for Decon Station setup/management; pictures from http://www.nttc.edu/ertProgram/technology.asp?technology_id=109 and http://www.usuhs.mil/ccr/wmd_training_progams_homepage.htm

•First responders should assess ABCs/start Triage

•All care providers in MOPP 4 or civilian equivalent protective gear

•Ambulatory victims directed to marked safe area for decon

•All clothing/jewelry removed; clothing/belongings bagged/tagged

•Flush with water 2-5 mins (flush eyes 15 mins if exposed)

•Never transport patients to hospital before full decon

•Hospital should guard against contaminated “walk-ins”


Anesthesia Care for Chemical Warfare Casualties

• Airway Management– Assume full stomach/associated injuries/hypovolemia– Bronchospasm common effect of chlorine, phosgene, riot-

control agents (CS, CN), nerve agents treat with inhaled beta-agonists

– Secretions markedly increased treat with atropine for nerve agents (central effects) or glycopyrrolate for others (peripheral effects)

– Intubation facilitated with ketamine– safest induction agent– Patients intubatable without drugs due to coma/flaccid

paralysis: consider triage to expectant if limited resources


Anesthesia Care for Chemical Warfare Casualties (cont’d)

• Breathing– Oxygen therapy titrated to effect

– Assume massive requirement for nebulized bronchodilators; consider combined albuterol + ipratropium bromide treatment (DuoNeb®) for increased anticholinergic effect (nerve agents)

– Consider ventilator status: may need to draft hospital personnel to bag patients while awaiting transport to other facilities

– Pulmonary toilet key: frequent endotracheal suctioning may be required, especially with phosgene/chlorine (fulminant toxic [non-cardiac] pulmonary edema)




• Circulation:– Remember associated injuries from blast/trauma– Assume hypovolemia– Blister agent victims do not require massive resuscitation of

thermal injury patients – Tachycardia from antidote treatment (correctly or incorrectly

administered) may take away monitor for hypovolemia– watch urine output; may need invasive monitoring in severe cases

– Warm fluids– patients may be hypothermic from decontamination and environmental exposure



• Disability:– Treat seizures with benzos– Anticipate lots of unexposed anxious patients– may see hyperventilation

mimic toxic exposure– Central Anticholinergic Syndrome (CAS): from excess atropine effect;

Mnemonic: • Hot as a hare (Hyperthermia from impaired sweating) • Dry as a bone (Dry mouth from antisialogogue effect) • Red as a beet (Flushed skin) • Blind as bat (Mydriasis) • Mad as a hatter (Delirium from central anti-ACh effect of atropine)

– treat CAS with pysostigmine 1-2 mg iv gingerly; patient may need protection from self-injury (restraints)

See http://www.intox.org/pagesource/treatment/english/a-anticholinergic.htm



• Exposure:– Patient should have been stripped/decontaminated

before presenting to anesthesia (if not, refer to Rule #1: Don’t become a casualty yourself)

– At the first sign of toxicity in yourself, seek treatment for exposure: you are no good to your patients dead

– Treat hypothermia with forced air warming blankets, warmed fluids, increased ambient temperature




• Other:– Pyridostigmine pretreatment and anesthesia: See the

article by Keeler on CD: sidell_keeler_1990.pdf– Basic issues are resistance to succinylcholine and

sensitivity to non-depolarizers; risk of phase II block with succinylcholine drip; use nerve stimulator to assess status of NMJ to prevent prolonged blockade

– Atropine resistance due to AChE effects of PYR– Use nerve stimulator (DoRD guideline)



References: Chemical Warfare• http://www.usamriid.army.mil/education/instruct.html

(USAMRIID instructional materials)• http://www.bt.cdc.gov/ (CDC bioterrorism site)• http://www.fas.org/nuke/guide/usa/doctrine/dod/fm8-9/3

toc.htm (NATO handbook on NBC Defense)

• http://www.emedicine.com/emerg/WARFARE__CHEMICAL_BIOLOGICAL_RADIOLOGICAL_NUCLEAR_AND_EXPLOSIVES.htm (excellent site; CME available)

• http://hld.sbccom.army.mil/ (SBCCOM Homeland Defense site)

• http://www.vnh.org/Providers.html (amazing Virtual Naval Hospital site; See NBC links about half way down page; Go Navy!)



Part 2: Biological Warfare


• Classes of Biological Warfare Agents


• References


Biowar: Historical Perspective• Ancient use of cadavers to poison wells

• Neolithic use of frog poisons (curare) in South America

• 1347, Kaffa, Crimea: Tatar leader Kipchak khan Janibeg (supported by Venetians) catapulted bodies of bubonic plague victims into Genoese city

• 1763: British forces gave smallpox-infected blankets to immunolically-naïve Native Americans

Christopher, GW, et al, Biological warfare: a historical perspective, JAMA. 1997;278:412-417; http://www.brown.edu/Departments/Italian_Studies/dweb/plague/origins/spread.shtml


Biowar: Historical Perspective• WWI: Burkholderia (Pseudomonas) mallei and Bacillus

anthracis used by German agents to infect horses with glanders and anthrax

• WWII: Japanese biowarfare Unit 731 and others conducted experiments on prisoners; Chinese cities attacked with B anthracis, V cholerae, Shigella spp, Salmonella spp, and Y pestis.

• Vietnam: pungi sticks smeared with excrement• 1984: Salad bars in Oregon contaminated with

Salmonella Typhimurium to influence local election

Christopher, GW, et al, Biological warfare: a historical perspective, JAMA. 1997;278:412-417


Definition of Biowarfare Agent• The NATO definition of a biological agent is: a

microorganism (or a toxin derived from it) which causes disease in man, plants or animals or which causes the deterioration of material

• Toxin. A poisonous substance produced or derived from living plants, animals, or microorganisms… toxins have a relatively simple biochemical composition and are not able to reproduce themselves. In many aspects, they are comparable to chemical agents

Source: FM 8-9: NATO Handbook on the Medical Aspects of NBC Defensive Operations AMedP-6(B): Part II - Biological; http://www.vnh.org/MedAspNBCDef/2ch1.htm


Classes of Biowarfare Agents

• Bacteria (self-replicate; many communicable)

• Viruses (replicate via host; communicable)

• Toxins (most lethal substances; non-communicable)

• Future: Genetically Modified Organisms

• Future: Nanotech mechanical viruses


Bacillus Anthracis


Bacteria likely to be used in Biowarfare

• Bacillus anthracis (anthrax) : deadly attacks on Washington D.C., Florida, October 2001

• Francisella tularensis (tularemia)

• Yersinia pestis (plague)

• Coxiella burnetii (Q-Fever)

• Pseudomonas pseudomallei (Melioidosis)

• Vibrio cholerae (cholera)-- toxin

• Clostridium botulinum (botulism)-- toxin

•http://www.cdc.gov/ncidod/EID/vol8no10/02-0330.htm; http://www.emergency.com/2001/bio-treatment.htm


Ebola Virus


Viruses likely to be used in Biowarfare

http://www.emergency.com/2001/bio-treatment.htm;http://www.fas.org/nuke/intro/bw/agent.htm#b12

• Venezuelan Equine Encephalitis (VEE)

• Viral hemorrhagic fever agents (Marburg, Ebola, Congo-Crimean Hemorrhagic Fever, Rift Valley Fever, etc.)

• Variola (smallpox)

• Genetically-engineered superviruses


Ricin (from ricinus communis)http://www.ansci.cornell.edu/plants/toxicagents/ricin/ricin.html


Toxins likely to be used in Biowarfare

http://www.emergency.com/2001/bio-treatment.htm;http://www.fas.org/nuke/intro/bw/agent.htm#b12

• Saxitoxin-- neurotoxin from marine dinoflagellates• Botulinum-- C. botulinum• Ricin-- castor bean seeds• Staphylococcal Enterotoxin B (SEB)• Alpha toxin-- C. perfringens• Tetrodotoxin-- from blowfish• Tricothecene mycotoxins (>40)-- Yellow Rain;

significant as only dermally-active toxin


Toxin Case Study: Georgi Markov

• Bulgarian émigré writer and journalist

• Critical of communist regime

• Assassinated in London: microball laced with ricin injected via modified umbrella weapon 7 Sep 1978

• Died 4 days later-- No antidote


Picture: http://www.news.harvard.edu/gazette/2000/01.27/polio_story.html

Polio virus "To construct the virus, the researchers say they followed a recipe they downloaded from the internet and used gene sequences from a mail-order supplier"

http://news.bbc.co.uk/1/hi/sci/tech/2122619.stm


GMO Agents: Brave New World?

• 2002: Cello, et al.: Synthetic polio virus created from scratch

• Genetically Modified Organisms (GMO) increasingly common in food supply-- soon among biowarfare agents?

• Possible to create resistance to known treatments, increased virulence, altered disease pattern to disguise source, etc.

Cello J, Paul AV, Wimmer E, Chemical synthesis of poliovirus cDNA: Generation of infectious virus in the absence of natural template. Science 2002 July 11.


Nanobot injecting red cellshttp://www.foresight.org/Nanomedicine/Gallery/Images/inject.jpg


Nanotech Agents: Mors ex machina

• Nanotechnology: "Research and technology development at the atomic, molecular or macromolecular levels, in the length scale of approximately 1 - 100 nanometer range"

• Disruptive Technology-- could render current offensive/defensive/sensor systems obsolete

• U.S. Government National Nanotechnology Initiative site: http://www.nano.gov; area of intense research

• Micromechanical Doomsday Plague? (Crichton, M., Prey: A Novel, Harper-Collins, 2002)

http://www.janes.com/security/international_security/news/jcbw/jcbw030115_1_n.shtml

http://www.nano.gov/omb_nifty50.htm; http://www.wtec.org/loyola/nano/IWGN.Public.Brochure/IWGN.Nanotechnology.Brochure.pdf


Warning Signs of Biowar Attack

http://www.vnh.org/MedAspChemBioWar/chapters/chapter_20.htm#medical


Anesthesia Care for Victims of Biowarfare Attack

http://www.asahq.org/Newsletters/2002/3_02/katz.htmhttp://www.asahq.org/Newsletters/2002/3_02/uzzi.htm

• Refer to Rule #1 for Chemical Agents: Don’t become a casualty yourself

• Don’t assume that vaccination is 100% protective• Patients should be decontaminated before being

brought to hospital• Hospital should guard against contaminated

“walk-ins”– potential to shut down facility• Specific treatment based on agent– seek advice

from Infectious Disease consultants/CDC/internet resources


References: Biowar

• http://www.usamriid.army.mil/education/bluebook.html (Medical Management of Biological Casualties Handbook)

• http://www.vnh.org/DATW/toc.html (Defense against Toxin Weapons)

• http://www.vnh.org/MedAspNBCDef/2toc.htm (NATO Handbook on NBC Defense: Biological)

• http://www.bt.cdc.gov/Agent/agentlist.asp (includes CDC categories A, B, C with definitions)• http://www.bt.cdc.gov/agent/anthrax/index.asp (CDC

Anthrax home)• http://www.who.int/emc/diseases/smallpox/slideset/

(Smallpox slideset)



Part 3: Nuclear/Radiological Warfare


• Types of Radiological Warfare Agents


• Future Issues: The Final Frontier?

• References


Nuclear Warfare: Historical Perspective

• Ancient Atomic Warfare?: 5,000 year old Indian texts describe the military use and aftereffects of nuclear weapons

• Some geological formations (Saharan green glass, Scottish vitrified forts) have been interpreted as evidence of ancient atomic explosions

• Ancient flying machines (vimanas) are well-described in Indian literature used to deliver nuclear weapons?

http://www.nexusmagazine.com/articles/ancatomicwar1.html; http://www.atributetohinduism.com/Vimanas.htm


“Now I am become Death, the Destroyer of Worlds” – The Bhagavad Gita

Dr. Robert Oppenheimer, Father of the A-Bomb

When asked in an interview at Rochester University seven years after the Alamogordo nuclear test whether that was the first atomic bomb ever to be detonated, (Oppenheimer’s) reply was:

Well, yes, in modern history, of course.


Nuclear Warfare: Historical Perspective (Modern)

• Hiroshima, 6 August 1945: U-235; 13 kiloton yield; 75,000+ immediate fatalities; many more causalties

• Nagasaki, 9 August 1945: U-239; 20 kilton yield; 40,000+ immediate fatalities; many more casualties

Hiroshima, 1945

http://www.wikipedia.org/wiki/Little_Boy ;http://www.wikipedia.org/wiki/Fat_Man


Nuclear Warfare: Historical Perspective (Modern)

Seattle, WA, Feb 29, 2007

http://www.cdi.org/terrorism/dirty-bomb.cfm; http://news.bbc.co.uk/1/hi/health/2037769.stm; picture from:http://www.weertman.com/bruce/skybeam/orig/skybeam1_.jpg; scenario fictitious

;

• 5 KT “dirty bomb” laced with U-238 exploded atop Space Needle

• 207 initial deaths from blast; 2,109 radiation victims; entire city disrupted for 5 days following attack; fear >>> destruction


Types of Nuclear Weapons

• Fission: splitting of uranium isotope atoms; easier technically; less destructive than fusion

• Fusion: combination of hydrogen atoms helium; requires fission trigger; more complex

• “Dirty Bomb”: conventional bomb laced with radioactive material; far less destructive than nuclear explosion; “nuclear disruption” of populace vs. destruction


Medical Effects of Nuclear Blast

• Immediate Ionizing Radiation

• Infrared radiation (heat); Indirect effect (fires)

• Electromagnetic Pulse (EMP)

• Blast (overpressure)

• Fallout (delayed radiation)

• Psychological effects (panic)http://www.fas.org/nuke/guide/usa/doctrine/dod/fm8-9/1toc.htm


Effects of 1 Megaton Blast

http://www.pbs.org/wgbh/amex/bomb/sfeature/1mtblast.html; http://www.aussurvivalist.com/nuclear_war/nuclear_blast_effects.htm

Table 3 - Blast Effects of a 1-Mt Explosion 8,000 ft Above the Earth's Surface

Distance from ground zero

Peak overpressure

Peak wind velocity(mph)

Typical blast effects

(stat. Miles)

(Kilometers)

.8 1.3 20 psi 470 Reinforced concrete structures levelled.

3.0 4.8 10 psi 290 Most factories and commercial buildings are collapsed. Small wood-frame and brick residences destroyed and distributed as debris.

4.4 7.0 5 psi 160 Lightly constructed commercial buildings and typical residences are destroyed. Heavier construction is severely damaged.

5.9 9.5 3 psi 95 Walls of typical steel-frame buildings are blown away; severe damage to residences. Winds sufficient to kill people in the open.

11.6 18.6 1 psi 35 Damage to structures, people endangered by flying glass and debris.


Radiation Units• Roentgen: amount of x-ray or gamma ray radiation (electromagnetic radiation) that

produces 1/3 x 10-9 coulomb of electric charge in one cubic centimeter of dry air at standard conditions.

• RAD: The rad is a unit used to measure a quantity called absorbed dose. This relates to the amount of energy actually absorbed in some material, and is used for any type of radiation and any material. One rad is defined as the absorption of 100 ergs per gram of material. The unit rad can be used for any type of radiation, but it does not describe the biological effects of the different radiations.

• REM: The rem is a unit used to derive a quantity called equivalent dose. This relates the absorbed dose in human tissue to the effective biological damage of the radiation. Not all radiation has the same biological effect, even for the same amount of absorbed dose. Equivalent dose is often expressed in terms of thousandths of a rem, or mrem. To determine equivalent dose (rem), you multiply absorbed dose (rad) by a quality factor (Q) that is unique to the type of incident radiation.

• Gray: The gray is a unit used to measure a quantity called absorbed dose. The unit gray can be used for any type of radiation, but it does not describe the biological effects of the different radiations. Absorbed dose is often expressed in terms of hundredths of a gray, or centi-grays. One gray is equivalent to 100 rads.

• Sievert: The sievert is a unit used to derive a quantity called equivalent dose. This relates the absorbed dose in human tissue to the effective biological damage of the radiation. Not all radiation has the same biological effect, even for the same amount of absorbed dose. Equivalent dose is often expressed in terms of millionths of a sievert, or micro-sievert. To determine equivalent dose (Sv), you multiply absorbed dose (Gy) by a quality factor (Q) that is unique to the type of incident radiation. One sievert is equivalent to 100 rem.

http://www.bartleby.com/64/C004/037.html; http://www.physics.isu.edu/radinf/terms.htm

(boring stuff you thought you’d never have to see again after USU)


Radiological Weapons (Dirty Bombs)

• Non-nuclear spread of radioactive materials via conventional explosion

• Most likely isotope: Cesium-137 (gamma ray hazard; 30 year half-life; very common [byproduct of nuclear reactors; used in radiation therapy])

• Increased risk of cancer long-term (but not severe)

http://www.time.com/time/nation/article/0,8599,182637,00.html; http://www.terrorismanswers.com/weapons/dirtybomb2.html


Medical Effects of “Dirty Bomb”

• Blast (1000s of times less than nuclear)• Radiation (1000s of times less than nuclear)• Psychological Effect (panic, possibly severe)• Terror, not absolute destruction, goal of “dirty bomb”

http://www.cnn.com/2002/HEALTH/06/10/cohen.dirty.bomb.otsc/

“So clothes off, wash up, use an N-95 mask.”

-- Elizabeth Cohen, CNN News, minimizing radiological effects


Anesthesia Implications of Nuclear/Radiological Weapons

http://www.conelrad.com/conelrad100/c100.php?id_num=33

“Duck and Cover”


10 Basics of Response to Nuclear/Radiological Attack1. Assure medical staff that when an incident combines radiation exposurewith physical injury, initial actions must focus on treating the injuriesand stabilizing the patient.2. You or your hospital must be prepared to manage large numbers offrightened, concerned people who may overwhelm your treatmentfacility. 3. You or your hospital must have a plan for distinguishing betweenpatients needing hospital care and those who can go to an off-site facility.4. You or your hospital must know how to set up an area for treatingradiation incident victims in an emergency room. 5. You or your hospital should be aware that a good way to approachdecontaminating a radioactively contaminated individual is to act asif he or she had been contaminated with raw sewage. 6. You or your hospital must know how to avoid spreading radioactivecontamination by using a double sheet and stretcher method for transportingcontaminated patients from the ambulance to the emergencytreatment area. 7. You must know how to recognize and treat a patient who has beenexposed to significant levels of radiation. 8. You should recognize the radiological findings of illness/injury causedby biological or chemical terrorist agents. 9. You should know what agencies or organizations to contact in the eventof a radiation emergency and how to reach them. 10. You or your hospital must have a plan to evaluate and counsel noninjuredpatients exposed to radiation at a location outside of the hospital.

http://www.acr.org/cgi-bin/fr?mast:masthead-about,text:/departments/educ/disaster_prep/dp_primer.html


Triage of Radiation Casualties

From: http://www.fas.org/nuke/guide/usa/doctrine/dod/fm8-9/1ch6.htm#s4p2


Anesthesia Implications

• Rule #1: Don’t become a casualty yourself! Ensure appropriate patient decon before admission to hospital

• Hospital should have system to guard against contaminated “walk-ins”; Geiger counters at entrances

• Primary surgical issues will be conventional traumatic injuries (possible pneumothorax/barotrauma from overpressure; most injuries caused by flying debris); initial ATLS approach appropriate after decon

• Supportive care; careful attention to sterile technique in patients with crashing immune systems/incipient neutropenia

• Brain irradiation may cause unpredictable CNS dysfunction • Radiation victims far less threat to health care providers than

chem-bio warfare victims (radiation decreases as square of distance from source); most damaging radiation to tissues (alpha) also short-range (millimeters)


Future Issues


Future Issues: Directed Energy Weapons

• Frying Purple People Heater: U.S. military has deployed directed V-MADS directed energy weapon crowd control purposes; uses 95 GHz millimeter waves to heat skin; range 700 meters

• U.S. Army Field Manual 71-2, Appendix D: “The battlefield of the next war will include directed-energy weapons (DEWs). Several threat weapons have already been tested in combat; improved versions of these weapons may be fielded soon. For the task force commander, the DEW battlefield is here now.”

• Potential terrorist weapon: Insidious, painful, difficult to counteract

Vehicle-Mounted Active Denial System (V-MADS)

http://www.globalsecurity.org/military/systems/ground/v-mads.htm; http://www.de.afrl.af.mil/factsheets/activedenial.html; http://usasma.bliss.army.mil/pubs/FM_71-2/PDF/appd.pdf


Future Issues: The Final Frontier?

From http://www.indianest.com/hinduism/024.htm

“Lord Sri Krsna drove the chariot between the two armies on the Battlefield of Kuruksetra, and while there He shortened the life spans of the opposite party by His merciful glance.”

http://www.webcom.com/ara/col/art/bhisma.html

• Revolutions in military affairs: Saltatory evolution (stone stick sword bow and arrow gun directed energy ? psychic weapons )

• Air University Study Air Force 2025 explicitly mentions psychotronic weapons as a “wild card” of future warfare that may vitiate U.S. conventional military advantage (along with nanotechnology, genetic engineering…)

• U.S. Army Command and General Staff College’s Military Review, December 1980, “The New Mental Battlefield: Beam Me Up, Spock”: Psychotronics, mind control, and remote viewing as elements of 21st century warfare https://calldbp.leavenworth.army.mil/eng_mr/txts/VOL60/00000012/art5.pdf#xml=/scripts/cqcgi.exe/

@ss_prod.env?CQ_SESSION_KEY=HIJULEYVRIOP&CQ_QH=124183&CQDC=12&CQ_PDF_HIGHLIGHT=YES&CQ_CUR_DOCUMENT=1; http://www.au.af.mil/au/2025/monographs/A-F/a-f-a.htm


References: Treating Radiation Casualties• http://www.vnh.org/MedManRadCasu/index.html• http://www.vnh.org/BUMEDINST6470.10A/6470-

10A.pdf• http://www.acr.org/cgi-bin/fr?mast:masthead-about,text:/

departments/educ/disaster_prep/dp_primer.html• http://www.nbc-med.org/• http://books.nap.edu/books/0309036925/html/

205.html#pagetop (Health Consequences of Nuclear War)• http://nuketesting.enviroweb.org/hew/ (Nuclear War

Resources)• http://www.fas.org/nuke/guide/usa/doctrine/dod/fm8-

9/1toc.htm (NATO Handbook on Medical Aspects of Nuclear Warfare)


Questions?

This is my PowerPoint. There are many like it but mine is 2000. My PowerPoint is my best friend. It is my life. I must master it as I master my life. My PowerPoint without me is useless. Without my PowerPoint, I am useless. I must format my slides true. I must brief them better than the other staff sections who are trying to out brief me. I must brief the impact on the CINC before he asks me. I will. My PowerPoint and myself know that what counts in this war is not the information. We know that it is the number of slides, the colors of the highlights, and the format of the bullets that counts. My PowerPoint is human, even as I, because it is my life. Thus I will learn it as a brother. I will learn its weaknesses, itsstrengths, its fonts, its accessories, its formats, and its colors. I will keep my PowerPoint slides current and ready to brief. We will become part of each other. We will… Before The Goddess I swear this creed. My PowerPoint and myself are defenders of my country. We are the masters of our subject. We are the saviors of my career. So be it, until victory is America's and there is no enemy, but peace (and the next exercise)!

--The Powerpoint Ranger’s Creed

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Copyright © 2003 Robert C. Jones, M.D. GAS GAS GAS! Introduction to Weapons of Mass Destruction for Anesthesia Providers Robert C. Jones, M.D. LtCol, USAF,