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Report on the Toxic Chemical Syndrome Definitions and Nomenclature Workshop May 8-9 2012
Under contract to the U.S. Department of Homeland Security (DHS), American College of Medical Toxicology (ACMT) Subject Matter Experts (SMEs) reviewed this report and accompanying comments which were submitted by the 2012 Workshop participants provided in follow-up to the meeting. Following an iterative discussion of the nature, scope, and specific content of the participant stakeholder comments, the original 2012 DRAFT workshop document was edited to incorporate these subsequent comments and discussions. These edits were reviewed and approved by DHS Office of Health Affairs’ Chemical Defense Program, and have been incorporated into this updated workshop report. The 23 pages of this report represent updated Sections 1 and 2 of the 2012 Draft document. These edits involved:
1) Consolidating the initial 12 toxidromes from the Workshop’s breakout activities into a final total of 9; with the 3 routes of exposure (inhalation, ingestion, dermal) described within the single “Irritant/Corrosive” toxidrome; 2) Combining the “Cyanide-like” and “Knockdown Agents” into a single toxidrome: “Knockdown” and; 3) Expanded narrative to the toxidrome descriptions.
A detailed memo about specific changes is available from the CHEMM project team.
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Report of the Toxic Chemical Syndrome Definitions and Nomenclature Workshop, May 2012
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Report of the Toxic Chemical Syndrome Definitions and Nomenclature Workshop
May 8-9, 2012
Submitted to: National Library of Medicine and Department of Homeland Security
Submitted by: Toxicology Excellence for Risk Assessment
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FederalPointsofContactCAPTJoselitoIgnacio,MA,MPH,CIH,CSP,REHSActingDirector,ChemicalDefenseProgramDepartmentofHomelandSecurityOfficeofHealthAffairsJoselito.ignacio@hq.dhs.gov
Pertti(Bert)Hakkinen,PhDActingHead,OfficeofClinicalToxicologySpecializedInformationServicesNationalLibraryofMedicineNationalInstitutesofHealthPertti.hakkinen@nih.gov
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ContentsContents.........................................................................................................................................................3
ListofFiguresandTables ............................................................................................................................... 4
ListofAcronyms............................................................................................................................................. 5
1. Introduction ...............................................................................................................................................8
1.1 WorkshopOrganizingCommittee ...................................................................................................….8
1.2 Background.........................................................................................................................................9
1.3 IntendedUseoftheResultsoftheWorkshop..................................................................................10
1.4 OrganizationofthisReport ..............................................................................................................11
2. ToxicChemicalSyndromeDefinitionsandNomenclatureWorkshop ....................................................11
2.1 BreakoutGroups ..............................................................................................................................13
2.1.1 BreakoutGroupInstructions .....................................................................................................13
2.1.2 BreakoutGroupResults.............................................................................................................13
2.1.3 RecommendedToxidromes.......................................................................................................14
2.1.4 ToxidromeNaming ....................................................................................................................15
2.1.5 ParticipantBallots......................................................................................................................16
2.2 Discussion ........................................................................................................................................ .17
2.3 Conclusions.......................................................................................................................................19
2.4 ReferencesandSources ...................................................................................................................20
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ListofFiguresandTablesFigure1IntersectionofToxidromeUserGroups .......................................................................................10Table1BreakoutGroupAssignments ........................................................................................................13Table2.BreakoutGroupRecommendationsforToxidromeNamesandDescriptions ..............................14
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ListofAcronyms
AHLS–AdvancedHazmatLifeSupportprogram
ALS–Advancedlifesupport
BLS–BasiclifesupportCHEMM–ChemicalHazardsEmergencyMedicalManagement
CHEMM-IST–ChemicalHazardsEmergencyMedicalManagementIntelligentSyndromesTool
CNS–Centralnervoussystem
CSAC–ChemicalSecurityAnalysisCenter
CTRA–ChemicalTerrorismRiskAssessment
CWAs–Chemicalwarfareagents
DHS–DepartmentofHomelandSecurity
EMTs–Emergencymedicaltechnicians
F&ES–FireandEmergencyServices
GI–GastrointestinalHazmat–Hazardousmaterials
HHS–U.S.DepartmentofHumanandHealthServices
HPV–HighProductionVolume
HSDB–HazardousSubstancesDataBank
NICC–NationalInteragencyCoordinationCentersNIOSH–NationalInstituteforOccupationalSafetyandHealth
NLM–NationalLibraryofMedicine
NOC–NationalOperationsCenter
OHA–OfficeofHealthAffairs
PNS–Peripheralnervoussystem
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SAS–Solvents,Anesthetics,orSedatives
SLTT–State,Local,TribalandTerritorial
SME–Subjectmatterexpert
SOCs–SupportandOperationsCentersTERA–ToxicologyExcellenceforRiskAssessment
TICS–Toxicindustrialchemicals
TIMS–ToxicindustrialmaterialsWISER–WirelessInformationSystemforEmergencyResponders
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1. IntroductionTheDepartmentofHomelandSecurity(DHS)OfficeofHealthAffairs(OHA),withtheNationalLibraryofMedicine(NLM),sponsoredatechnicalworkshoponMay8-9,2012todiscussanddevelopaconsistent
lexicontodescribetoxicchemicalsyndromes,ortoxidromes1.Theworkshopgoalwastoreachconsensusonalistofsyndromes,theirdefinitions,anddesignatedsyndromenamestoestablishacommonlanguageforchemicaldefenseplanners,policymakers,firstresponders,firstreceivers,andhazardousmaterials(Hazmat)stakeholders.Thesyndromelistaimstoprovidethiscommonlexicontoassistkeystakeholdercommunitiesinquicklyandaccuratelyidentifyingthebroadchemicalagentcategory(ifnotthespecificchemicalagent)bywhichapatientwasexposedinordertorapidlydetermineappropriateemergencytreatment.Comprehensiveness,accuracy,andclearunderstandingofthelexiconservedastheprimarycriteriaindevelopingthislexicon.
Overfortypeopleparticipatedintheworkshop,includingfirstresponders,firstreceivers,medicaldirectors,trainers,andsubjectmatterexperts(SMEs)inemergencymedicine,emergencyresponse,andmedicaltoxicology.Participantswerefromcivilianandmilitaryagencies,universities,hospitals,and
emergencyresponseentities.
Aworkshoporganizingcommitteeconductedextensiveliteraturereviewsofcurrenttoxicsyndromesanddevelopedproposedcriteriaandsyndromestoserveasastartingpointfortheworkshop
discussionsandconsensusbuilding.Workshopparticipantsreviewedthesematerialsandprovidedwrittencommentspriortotheworkshop.TheWorkshopOrganizingCommitteesharedcommentswithparticipantsandusedthevaluableinputtostructuretheworkshopdiscussionsandprocess.
Theworkshopwashighlyinteractivetofullyutilizetheexperienceandknowledgeoftheparticipatingsubjectmatterexperts.Thefirstdayfocusedondiscussingandagreeinguponkeycomponentsand
issuesrelatedtotoxicsyndromedefinitionsandnomenclature.Theparticipantsthendividedintothreebreakoutgroupstodiscussandreachagreementonspecificsyndromedefinitionsandnomenclature.Thebreakoutgroupsreportedbacktothelargergrouponthesecondafternoonwithproposed
syndromesanddefinitions.ThisreportprovidesanaccuraterecordfortheworkshopparticipantsandwillserveasareferenceforthenextphasesofToxidromeLexicondevelopment.
1.1 WorkshopOrganizingCommitteeAcommitteecomprisedofDHS/OfficeofHealthAffairs(OHA),NLMandToxicologyExcellenceforRisk
Assessment(TERA)scientistsorganizedtheworkshop.Membersincluded:
· Dr.MarkKirk,DivisionofMedicalToxicology,DepartmentofEmergencyMedicine,UniversityofVirginia
· Capt.JoselitoIgnacio,DepartmentofHomelandSecurity
1Workshopattendeesagreedthatthetermstoxicsyndromeandtoxidromecanbeusedinterchangeablyastoxidromeisacontractionof“toxicsyndrome.”SeeDiscussionforfurtherexplanation.
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· JenPakiam,NationalInstitutesofHealth,NationalLibraryofMedicine
· HillarySadoff,BestValueTechnologyInc.,contractsupporttotheDepartmentofHomelandSecurity
· MichaelCarringer,BestValueTechnologyInc.,contractsupporttotheDepartmentofHomelandSecurity
· Dr.DavidSiegel,NationalInstitutesofHealth,NationalInstituteofChildHealth&Human
Development
· Dr.Pertti(Bert)Hakkinen,NationalInstitutesofHealth,NationalLibraryofMedicine · FlorenceChang,NationalInstitutesofHealth,NationalLibraryofMedicine
· StaceyArnesen,NationalInstitutesofHealth,NationalLibraryofMedicine
· Dr.AndrewMaier,ToxicologyExcellenceforRiskAssessment · JacquelinePatterson,ToxicologyExcellenceforRiskAssessment · Dr.SueRoss,ToxicologyExcellenceforRiskAssessment(Fellow)
· OliverKroner,ToxicologyExcellenceforRiskAssessment
1.2 BackgroundTensofthousandsofchemicalsareharmfultohumansandknowingthespecifictoxiceffectsofevenaportionofthepossiblechemicalagentswouldbeanimpossibletask.Toxicchemicalscanoftenbe
groupedintoclasses,wherebyallthechemicalsinagivenclasscausesimilartypesofadversehealtheffects.Theseconstellationsoftoxiceffectsorsyndromescompriseasetofclinical‘‘fingerprints’’forgroupsoftoxicants.Moreover,allthetoxicchemicalsassociatedwithagiventoxicsyndromeare
treatedsimilarly.Hence,duringtheearlyphasesofatoxicchemicalemergency,whentheexactchemicalisoftenunknown,identificationofthetoxicsyndromesthatarepresentcanbeausefuldecisionmakingtoolthatcanovercomemanyoftheproblemsassociatedwiththelackofinformation
onchemicalidentity.
Toxicsyndromesareeasilyidentifiedwithonlyafewobservations,suchas:
· Vitalsigns · Mentalstatus · Pupilsize
· Mucousmembraneirritation · Lungexamforwheezesorcrackles
· Skinforburns,moisture,andcolor
Toxicsyndromerecognitionisimportantbecauseitprovidesatoolforrapiddetectionofthesuspectedcauseandcanfocusthedifferentialdiagnosistoonlyafewchemicalswithsimilartoxiceffects.By
focusingoncertainchemicals,specificdiagnostictestingandtreatmentcanberenderedbasedonobjectiveclinicalevidence.Specifically,duringamassexposure,recognitioncanprovideatriagetoolforidentifyingtoxiceffectsandalsoprovideacommon‘‘language’’sothatallpersonnel,fromemergency
respondersonthescenetothehospitalemergencydepartment,canclearlycommunicateaclinicalmessage(Figure1).Withtheextraordinarynumberofchemicalsinuse,thistooldoesnotapplyto
Report of the Toxic Chemical Syndrome Definitions and Nomenclature Workshop, May 2012 Page 10
everychemicalbuttomostofthecommonlyencounteredchemicalsreportedinhazmatincidents,includingchemicalsthatarenotspecificallynamedbutthatmayconceivablybeusedinintentionalterroristreleases(i.e.,agentsofopportunityorchemicalwarfareagents).Theuseoftoxicsyndromesasadiagnostictoolisfundamentaltoaneffective,timelymedicalresponse.
Figure1IntersectionofToxidromeUserGroups.
Thescopeoftheworkshopwasprimarilyfocusedonon-sceneandhospitalresponsesintheearlyphasesofalarge-scalechemicalrelease.Theexposuresinthisscenarioarelikelytobeinhalationandpossiblydermal.Ingestionislesslikely.Thereforechemicalsthatwouldcausefood/waterborneoutbreaksorcovert/delayedpoisoningswerenotconsideredinthisworkshop.Thisworkshopfocused
ondevelopingadecision-makingtoolthatwillbeusedintheearlypartofaresponsewheninformationislimited.Delayedeffectswerelessemphasizedandtheclinicalcourseinitsentirety–hourstodayswasnotthefocus.Thisreportprovidesanaccuraterecordfortheworkshopparticipantsanda
referenceforthenextphasesofLexicondevelopment.
1.3 IntendedUseoftheResultsoftheWorkshopTheNLMandDHSareworkingtogetheronthisprojecttoimprovecommunicationthatassuresacoordinatedandeffectiveresponsetomassexposureincidentsinvolvingtoxicindustrialchemicals
(TICS),toxicindustrialmaterials(TIMS),orchemicalwarfareagents(CWAs).JointlywiththeU.S.DepartmentofHealthandHumanServices(HHS),DHS/OHAintendstopublishproductsfromthis
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workshoptolaythefoundationforaconsistentlexicondescribingtoxicsyndromesamongState,Local,Tribal,andTerritorial(SLTT),aswellasfederalfirstrespondersandfirstreceivers.Communicationinacrisisrequiresaccurateandsuccincttermswhichconveythehealthconditionsofpatients.Asdescribed,theDHSrecognizesthemyriadoftoxicsyndrometermsused,particularlybetweentheDepartmentof
Defenseandthecivilianmedicalandemergencyresponsecommunities.Bridgingthisgap,throughthisworkshopandtheproductsproducedthereafter,providesaframeworktobeginusingaconsistentsetoftermsanddefinitions.
TheNLMintendstousetheresultsofthisprojectinitsCHEMM(ChemicalHazardsEmergencyMedicalManagement)program.CHEMM(http://chemm.nlm.nih.gov/)enablesfirstresponders,firstreceivers,otherhealthcareproviders,andplannerstoplanfor,respondto,recoverfrom,andmitigatetheeffects
ofmass-casualtyincidentsinvolvingchemicals.CHEMMprovidesacomprehensive,user-friendly,web-basedresourcethatisalsodownloadableinadvance,sothatitwouldbeavailableduringaneventifthe
internetisnotaccessible.CHEMMwasproducedbytheHHS,OfficeoftheAssistantSecretaryforPreparednessandResponse,OfficeofPlanningandEmergencyOperations,incooperationwiththeNLM’sDivisionofSpecializedInformationServices,andmanymedical,emergencyresponse,toxicology,
andotherrelevantexperts.ResultsoftheworkshopmaybeusedtoexpandtheCHEMMIntelligentSyndromesTool(CHEMM-IST).CHEMM-ISTisaprototypedecisionsupporttooldevelopedbyexpertsinmedicineandemergencyresponseasanaidforidentifyingthechemicalsinamasscasualtyincidentand
providingguidelinesfortreatment.SinceCHEMM-ISTiscurrentlyintheprototypephaseofdevelopment,itshouldnotbeusedforpatientcare.Thistoolisintendedforusebybasiclifesupport(BLS)andadvancedlifesupport(ALS)providersaswellashospitalfirstreceivers.Moreinformation
aboutCHEMM-ISTisavailableathttp://chemm.nlm.nih.gov/chemmist.htm.
1.4 OrganizationofthisReportThepurposeofthisreportistocapturethekeyinformationfromtheworkshopandserveasreferencematerialforfurtherdevelopmentoftheToxidromeLexicon.
· Section1providesanintroductionandbackgroundontheneedfortoxicsyndromesanda
commonlexicon.
· Section2summarizestheworkshopandresults.
2. ToxicChemicalSyndromeDefinitionsandNomenclatureWorkshopTheworkshopagendawasdesignedtobehighlyinteractivetotakeadvantageoftheexperienceandknowledgeoftheparticipants.Theworkshoporganizingcommitteemetbyteleconferencenumerous
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timespriortotheworkshopandhadextensivediscussionstodefinethescopeoftheprojectandidentifykeyindividualsandorganizationstoinviteandinvolveintheproject.Researchwasconductedtoidentifyotherorganization’slexiconsanddefinitions,andthesewereevaluatedforapplicabilitytothisproject.Acrosswalkcomparingandcontrastingtoxicsyndromesystemsfromover20organizations
wasdeveloped,alongwithaproposedlistofsyndromesanddefinitionsfortheworkshop’sinitialconsideration.Thecommitteesentapackagewiththesematerialstotheinviteespriortotheworkshopandsolicitedinputonkeyquestionsfromtheinvitees.Inviteesprovidedtheirinitialthoughtsand
commentsregardingthekeyquestionstothecommitteepriortotheworkshop.Thecommitteereviewedtheresponsesandmodifiedtheworkshopsessionstomakebestuseoftheworkshoptimeandreachtheobjectiveofdevelopingaconsensuslistoftoxicsyndromes,definitions,and
nomenclature.
OpeningremarkswereprovidedbyDr.JamesPolkandCapt.JoselitoIgnaciooftheDHS.Theydescribed
theneedtopreparecommunitieswhoarepotentiallyinharm’swayfromindustrialchemicalexposuresaswellaspotentialterroristattack.TheDHShaspartneredwiththeNLMtodevelopacommonvocabularyforchemicalsyndromesthatwillbereadilyunderstoodbybothcivilianandmilitaryfirst
responderandfirstreceivercommunities,therebyimprovingcommunicationandultimatelythepublichealthresponse.Dr.PerttiHakkinenwelcomedparticipantsonbehalfoftheNLMandbrieflydescribedhowtheworkshopresultsareintendedtobeincorporatedintotheNLM’ssuiteofdecisionsupporttools
(e.g.,CHEMM).
Thefirstday’sagendafocusedonsharinginformationonkeycomponentsandissuesrelatedtotoxicsyndromedefinitionsandnomenclature.Twoplenaryspeakersprovidedbackgroundonissuesand
currentefforts.Dr.MarkKirk,currentlyattheUniversityofVirginia,andpreviouslytheDirectoroftheChemicalDefenseProgramattheDHS,explainedwhytoxicsyndromerecognitionandtrainingisvitalandproposedatieredapproachtosyndromerecognitionandresponse.Ms.JessicaCoxoftheDHS
ChemicalSecurityAnalysisCenterdescribedworkonChemicalTerrorismRiskAssessment(CTRA).Shepresentedinformationontoxidromesthatweredevelopedforthatprogram.
Followingtheplenaryspeakers,Dr.AndyMaierofTERAledthegroupthroughdiscussionsanddecisions
onkeyaspectsfortheworkshop,includingtheidealnumberofsyndromes,guidanceforsyndromenames,andelementsofsyndromedefinitions.Thegroupthendividedintothreebreakoutgroupstodiscussandreachagreementonspecificsyndromedefinitionsandnomenclature.Thebreakoutgroups
reportedbacktothelargergrouponthesecondafternoonwithalistofsyndromesandtheirdefinitions.Thelargergroupdiscussedthebreakoutgrouprecommendationsandkeyissues,andidentifiedresearchneeds.
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2.1 BreakoutGroups2.1.1 BreakoutGroupInstructionsTheworkshopattendeesdividedintothreebreakoutgroupstodiscussandreachagreementonalistofsyndromesanddefinitions.
Table1BreakoutGroupAssignments
Group TypesofChemicalsandEndpoints
Group1 UpperandLowerPulmonary,Vesicants,Irritants,Corrosives
Group2 BloodAgents,Hemolytic,Metabolic,Anticoagulants,Asphyxiants
Group3 Convulsants,CholinergicCWA,Cholinergicpesticide,Opioids,Anxiety
Thebreakoutgroupswerechargedwithdiscussingandreportingontwelveelementsforeach
recommendedsyndrome.
1. Clinicallyrelevantroutesofexposureandtypesofsources2. Organsystemsgenerallyaffected
3. Initialsignsandsymptoms4. Progressionofsignsandsymptoms5. Underlyingpathology,biologicalprocesses,ormodesofaction
6. Industrialchemicalusesandchemicalwarfare/terrorismexamples7. Commontreatmentprotocols,specificantidotes,andkeysupportivemeasures8. Recommendationforasyndromenamethatwouldmeettheagreeduponcriteria
9. Aclearandconcisesyndromedefinitionthatwillbereadilyunderstoodbythetargetaudiences
10. Anyissuesorconcernsaboutthesyndrome11. Identifydatagapsorresearchthatcouldbedonetosignificantlyaidintherapididentificationof
atoxicsyndromebyfirstrespondersandreceivers12. Rationaleorreasoningfortoxidromegroupingandnamingdecisions
Rapporteursfromeachbreakoutgroupreportedbacktotheworkshopontheirgroup’sdiscussionsand
recommendations.
2.1.2 BreakoutGroupResultsThethreebreakoutgroupsdiscussedpossibletoxidromes.Eachgroupdevelopedanumberofsyndromes,definitions,andrationales.Section2.1.3containsasummaryofthenineindividualtoxidromesthatthebreakoutgroupsrecommended,withconsolidationof“Cyanide-like”and“Knockdown/Asphyxiants”agentsintoone“Knockdown”toxidromeandgroupingof
“irritants/corrosives”intoasingletoxidromeirrespectiveofrouteofexposure.
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2.1.3 RecommendedToxidromesTable2.ToxidromeNamesandDescriptions:ConsolidatedBreakoutGroupRecommendations
AnticholinergicToxidrome
Understimulationofcholinergicreceptorsleadingtodilatedpupils(mydriasis),decreasedsweating,elevatedtemperature,andmentalstatuschanges,includingcharacteristichallucinations.
AnticoagulantsToxidromeAlterationofbloodcoagulationthatresultsinabnormalbleedingindicatedbyexcessivebruising,andbleedingfrommucousmembranes,thestomach,intestines,urinarybladder,andwounds,aswellasotherinternal(e.g.intracranial,retroperitoneal)bleeding.
Acuteexposuretosolvents,anesthetics,orsedatives(SAS)ToxidromeCentralnervoussystemdepressionleadingtoadecreasedlevelofconsciousness(progressingtocomainsomecases),depressedrespirations,andinsomecasesataxia(difficultybalancingandwalking).
CholinergicToxidromeOverstimulationofcholinergicreceptorsleadingtofirstactivation,andthenfatigueoftargetorgans,leadingtopinpointpupils(miosis),seizing,wheezing,twitching,andexcessiveoutputfromallsecretorycells/organs(“leakingallover”–bronchialsecretions,sweat,tears,saliva,vomiting,incontinence).
ConvulsantToxidromeCentralnervoussystemexcitation(GABAantagonismand/orglutamateagonismand/orglycineantagonism)leadingtogeneralizedconvulsions.
Irritant/CorrosiveImmediateeffectsrangefromminorirritationofexposedskin,mucousmembranes,pulmonary,andgastrointestinal(GI)tracttocoughing,wheezing,respiratorydistressandmoresevereGIsymptomsthatmayprogressrapidlytosystemictoxicity.
KnockdownToxidromeDisruptedcellularoxygendeliverytotissuesmaybecausedbysimpleasphyxiaduetooxygendisplacementbyinertgases,hemoglobinopathies(e.g.carbonmonoxide,methemoglobininducers)impairingoxygentransportbytheredbloodcell,and/orimpairmentofthecell’sabilitytouseoxygen(e.g.mitochondrialinhibitorssuchascyanide).Allofthesesituationsleadtoalteredstatesofconsciousness,progressingfromfatigueandlightheadednesstoseizuresand/orcoma,withcardiacsignsandsymptoms,includingthepossibilityofcardiacarrest.
OpioidToxidromeOpioidagonismleadingtopinpointpupils(miosis),andcentralnervoussystemandrespiratorydepression.
Stress-Response/SympathomimeticStress-ortoxicant-inducedcatecholamineexcessorcentralnervoussystemexcitationleadingtoconfusion,panic,andincreasedpulse,respiration,andbloodpressure.
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2.1.4 ToxidromeNamingThebreakoutgroupsdiscussedtheirreasoningbehindgroupingchemicalsintothetoxidromesandthenamingofthetoxidromes.Notethattheinitialtwelvebreakoutgrouptoxidromeslistedbelowhavebeenreducedtonine(Table2).Theroutesofexposurefor“Irritant/Corrosive”wereconsolidatedinto
asingletoxidrome,andthe“Knockdown/Asphyxiants”and“Cellularasphyxia(cyanide-like)”toxidromeswerecombined,inordertosimplifytrainingandrecall.
Acuteexposuretosolvents,anesthetics,orsedatives(SAS)Toxidrome
Thebasisforcreatingandnamingthistoxidromeistheexistenceofasimilarclinicalpresentationin
casualtiesexposedtoanyofthemembersofthesegroups(solvents,inhalationalanesthetics,andsedative-hypnoticcompounds)followingacuteexposure.Thedelayedeffectsofsolventexposuredo
notformpartofthistoxidrome.
AnticholinergicToxidrome
Exposuretoananticholinergicchemicalmayresultinunderstimulationofcholinergicreceptorsleadingtosymptomsandsignssuchasdilatedpupils(mydriasis),decreasedsweating,elevatedtemperature,rapidheartrate,andmentalstatuschanges,andcharacteristichallucinations.
AnticoagulantsToxidromeThistoxidromeisbasedontheclearlydefinedunderlyingtoxicmodeofactionofalterationofbloodcoagulation.
CholinergicToxidrome
Thistoxidromenamewaschosenbaseduponclinicalrelevanceandaccuracyaswellaseaseofrecall.Examplesofnamesinitiallyconsideredincluded:SLUDGE,DUMBBEL[L]S,BBB,MTWHF,CCC,
organophosphate-like,acetylcholinesterase,pinpointpupils,wetallover,twitching,andseizing*(*threeseizingtoxidromes).
ConvulsantToxidrome
Thistoxidromenamewaschosenbaseduponclinicalrelevanceandaccuracyaswellaseaseofrecall.Examplesofnamesinitiallyconsideredincluded:Generalconvulsanttoxidrome,Convulsants,convulsions,andseizuresnothingelse*(threeseizingtoxidromes).
Knockdown/AsphyxiantsToxidromeThereisaunifyingpathophysiologicalbasis(i.e.,disruptedcellularoxygendeliveryand/oruse)forall
agentsinthistoxidromefortheinitialpresentation;however,someagentshavespecifictreatmentsorantidotesthatareaccommodatedinthesecondtierofthistoxidrome.
Cellularasphyxia(cyanide-like)ToxidromeThistoxidromenamewaschosenbaseduponclinicalrelevanceandaccuracyaswellaseaseofrecall.Examplesofnamesinitiallyconsideredincludethefollowing:Cellularasphyxiatoxidrome,Cellularasphyxiants,Cyanide,Cyanide-like,cherry-red,notwetallover,severearrhythmiaearly,dilatedpupils,
andseizing*(threeseizingtoxidromes).
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OpioidToxidromeThistoxidromenamewaschosenbaseduponclinicalrelevanceandaccuracyaswellaseaseofrecall.
Examplesofnamesinitiallyconsideredincludethefollowing:Opioids,Sedative,Solvent,andchanged
mentalstatusunresponsivewithorwithoutseizures.
Stress-response/sympathomimeticToxidrome
Thistoxidromenamewaschosenbaseduponclinicalrelevanceandaccuracyaswellaseaseofrecall.
Examplesofnamesinitiallyconsideredincludethefollowing:Anxiety,psychological/stressresponse,fight-flight-or-freezeresponse,andsympathomimetic.
Irritant/CorrosiveToxidromesSubstanceswithsignificantirritantandcorrosivepropertiesweredividedintothreetoxidromesbasedontherouteofexposureasitcorrespondstotheorgansystemand/ortissuedamaged.
Irritant/CorrosiveInhalationToxidrome
Fortheinhalationtoxidrome,thespectrumofinjurypresentationsuggeststhatacombinationofupperandlowerpulmonaryinjuriesintoonetoxidromeisappropriateforusebyfirstresponders.
Theinitialassessmentwillfocusongeneralrespiratorycomplaints,whichwillnotdifferentiatebetweenupperandlowerpulmonaryinjuryandtheinitialtreatmentswillbesimilarforbothupperandlowerpulmonary.
Irritant/CorrosiveIngestionToxidrome
Theeffectsofthistoxidromeareimmediate,withinitialtreatmentbeingsimilar(i.e.,
supportivecare).Additionalinformation(e.g.,epidemiologicalreview)willberequiredgiventhetargetednatureofaningestionpoisoning.
Irritant/CorrosiveTopicalToxidrome
Chemicalburns,vesicants,andotherskinirritants/corrosivesarelumpedtogetherunderthis
syndromeforthefollowingreasons:treatment(initialemergencymedicalresponse)issimilar,regardlessofthedegreeofskinoreyeeffects;differentiationbetweencorrosivesandchemical
burnscouldnotbedistinguishedsignificantlyfromadiagnosticandemergencymedicaltreatmentperspective;and,irritantsandcorrosivespresentinaprogressivespectrumofinjurytotheskinandeyes.
2.1.5 ParticipantBallotsWithineachbreakoutgroup,theparticipantswereaskedtocompleteballotsindicatingtheiragreement/disagreementwiththeirbreakoutgroup’stoxidromesandanyadditionalcomments.
Seventeenworkshopparticipantscompletedandreturnedballotstorecordtheir“votes”andcommentsonthebreakoutgrouprecommendations(Group1:n=4;Group2:n=7;Group3:n=6).
Areviewoftheballotsdeterminedthatallbreakoutgroupparticipantsagreedwiththeirgroup’s
recommendationsaspresentedtothelargerworkshop,withoneexception.OneparticipantinGroup3questionedtheinclusionoftheAnticholinergicToxidrome“becausethereisalowlikelihoodthatanyofthesechemicalswouldbeencounteredbyfirstresponders.”
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2.2 DiscussionAnumberofgeneralandspecificissueswerediscussedbytheworkshopparticipantsduringtheplenarysessions.Thesearebrieflydescribedbelow.
Useofterm“Toxidrome”versus“ToxicSyndrome.”Thegroupnotedthatthesetermscanappropriatelybeusedinterchangeably.ManySMEsfavored“toxidrome”–primarilyforeaseofuseinthefieldand
training.Thereisvalueindocumentingtheconnectionbetweentheterm“toxidrome”anditslongerform“ToxicSyndrome.”Toxidrome,asusedforthecurrentapplication,alsoavoidsconfusionwithothertermsandvariantsinthemedicalliteraturesuchas“ToxicChemicalSyndrome”or“ToxicShock
Syndrome”whichwouldnotbeequivalenttoa“toxidrome.”
Toxidromenameandshortdefinition.TheSMEsagreedonguidingprinciplesfortoxidromenamingandtheneedforandkeycomponentsofaconcisename.Atoxidromenamemustbememorable(appliedin
thefield)andmeaningful(toguideatreatmentaction).Theconcisedefinitionshouldbeonetotwosentences,capturingaconstellationofthekeyobservableelementsoftheclinicalpresentationaswellaskeytreatmentsoractions.Formatissufficientlyflexibletoincludeotherinformationthatfacilitates
recognition.TheSMEsindicatedthattheuseofthetoxidromeconceptwouldnecessarilyentailsomemisclassificationofpatientsasthereisatrade-offbetweenusabilityinthefieldanddiagnosticaccuracy.Theallowanceformisdiagnosisshouldtypicallyerronthesideofover-treatment,basedonthenature
oftheconsequencesoftreatment.
ToxidromePackaging,OutreachandCommunication:TheSMEsdiscussedtheneedforpackagingofthetoxidromestofacilitatefielduse.Thegoalofidentifyingandactingonaconstellationof
undifferentiatedfindingswasnotedasaneedinpackagingthetoxidromes(andsymptomconstellations)inameaningfulwaytousers.Suggestionsfordoingthisincludedasimplifiedsignsandsymptomsassessmentapproach(e.g.,speech,sight,skin,seizures)andamatrixconceptthatallowsa
processforlinkingtoxidromesandmakingadjustmentintreatment.Othergroupingstrategieswerementioned.
Learning,Heuristics,CognitiveBiases,andLevelsofExpertise:Asystemthatrecognizesthedifferentusersofthetoxidromesandtheirvaryingmethodsforidentifyingtoxidromes,aswellasdifferinglevelsofexpertise,willbeneeded.Thelevelofunderstandingofthetoxidromesusedbyfirstresponders,fire
andemergencyservices,lawenforcement,emergencymedicaltechnicians,willbedifferentandwillincorporatecognitivebiasesthatmustbeunderstood.Thisinformationmightbeincludedaspartofthelearningpackagedevelopedforthetoxidromes.Firstreceiversattheemergencydepartment,primary
carephysicians,andmedicalschools/studentsneedadeeperunderstandingofthetoxidromesandabilitytoconsiderbroaderdifferentialdiagnoses.PoisonControlCentersneedamoredetailedlevelofguidanceplusdirectreachbacktoMedicalToxicologists.MedicalToxicologistsmustserveasthefinal
backstopfordefinitivediagnosis,aswellashavetheabilitytoprovidespecificfollow-uporcriticalinformationrequestsandrecommendationsforrefiningtreatmentandresponse.
Report of the Toxic Chemical Syndrome Definitions and Nomenclature Workshop, May 2012 Page 18
CommunicationsandKnowledgeManagement:Thecompletepackageshoulddrawupontheknowledgemanagement/communicationsystemsavailable.Knowledgemanagementmustincludetwo-waycommunications,leveragecurrentsystems(e.g.,StateFusionCenters,PoisonControlCenters,NLM
toolssuchasCHEMM-IST,Federalreachbackcenters/SupportandOperationsCenters[SOCs])andintegratewithlocalemergencyoperationscenters.Participantssuggestedresourcessuchas“PowertotheEdge”byDavidAlbertsandconceptssuchasprinciplesof“NetcentricOperations”and“postand
smartpull”(whereallinformationispostedtothenetworkwhichallowsforpullingorpushingofrelevantinformationtopeoplewhoneedit).Inaddition,Dr.Canevadescribedaconcept,the“TrinityofKnowledge,”whichencompassesthreedimensionsofhowpeopleacquireanddevelopknowledge:
learning,knowledgemanagement,andsense-making.Understandingtheseconceptscanaidindevelopingthetoxidromesandfortrainingusers.
ResearchNeeds:Avarietyofideasforresearchneedswerehighlightedasstartingpointsforfutureefforts.Researchaimedatevaluatingtheeffectivenessoftoxidromesinthefieldasatoolforguiding
treatmentwasviewedasaresearchneed.NoneoftheSMEswereawareofsignificantresearchinthisarea.Suggestionsformovingforwardincludeddevelopingaclinicaltrial-likeapproachorevaluatingdatafrompastincidentswithdataanalytics.Researchthatprovidesinformationoftherelationship
betweenfieldapplicabilityanddiagnosticaccuracywasalsonotedasausefuloutcomeoffutureanalyses.Participantsnotedthatsomedata(andexperience)oneffectivenessoftrainingonfieldretentionoftoxidromeshasbeendone.
Thecurrenteffortfocusesonmasscasualty(exposure)incidentsfollowingprincipallyacuteexposurestochemicalagents(withfocusonCWA,TICs,andTIMs).Addingscenariosformass-scaleexposurestocommercialpharmaceuticalsviaingestionmayaddadditionalcomplicationsthatwillneedtobe
exploredasthismightbroadenthearrayofspecifictoxidromesneeded(e.g.,theideaofcardiotoxicants).
Severaladditionaltopicswereraisedbutnotdiscussedin-depth.Thesetopicsincludeduseof
“informationmining”strategiesortoolsandhowtoadapttofutureandchangingneedstoensuretheproductofthisworkshopisanevergreenresource(i.e.,updatedandimprovedtoreflectnewinformationandknowledge).
Aftertheworkshop,severalattendeesprovidedadditionalmaterialsandsuggestionsforconsideration.AnarticlebyPaulWaxandcolleagues(Wax,BeckerandCurry,2003)reviewswhatisknownabout
incapacitatingagentssuchasfentanylderivatives,theiraerosolization,andtherationalefortheiruse
asincapacitatingagents.ApaperbyBurklow,Yu,andMadsen(2003)reviewsindustrialchemicalsand
theiruseaschemicalweaponsorforterroristattacks,focusingonchlorineandphosgene.Thepaperdiscusseslarge-airways(TypeI)damage,damagetosmallairwaysandalveolarsepta(TypeIIdamage),
andboth.Italsoaddressesriskstochildrenfromthesetypesofchemicals.Athirdsuggestedpaperwas
onthetopicofacuteorganophosphatepoisoningandmedicalmanagement(Eddlestonetal.,2008).
Report of the Toxic Chemical Syndrome Definitions and Nomenclature Workshop, May 2012 Page 19
2.3 ConclusionsAcommonlanguagetodescribeandrecognizetoxicchemicalexposuresisessentialforemergencyrespondersandfirstreceiverstobepreparedtoproviderapidandappropriateresponsestoindustrialchemicalmassexposures,aswellaspotentialterroristattacks.Thecurrenteffortandthisworkshop
focusedonmassexposureincidentsfollowingacuteexposurestochemicalagents(withafocusonCWA,TICs,andTIMs).Thescopeoftheworkshopwasprimarilyfocusedonthesceneandhospitalresponseintheearlyphasesofalarge-scalechemicalrelease,withexposureslikelytobeinhalationandpossibly
dermal.Thisworkshopfocusedondevelopingadecision-makingtoolthatwillbeusedintheearlypartofaresponsewheninformationislimited.Delayedeffectswerelessemphasizedandtheclinicalcourseinitsentirety–hourstodayswasnotthefocus.
TheToxicChemicalSyndromeDefinitionsandNomenclatureWorkshopwasheldonMay8-9,2012attheDepartmentofHomelandSecurityofficesinWashington,DC.Morethanfortyparticipants
discussedtheessentialelementsoftoxicchemicalsyndromesortoxidromesthatwouldbeusefultotrainfirstreceiversandrespondersincasesofterroristattackorindustrialaccidents.Theworkshopattendeeswereadiversegroupandincludedfirstresponders,firstreceivers,medicaldirectorsof
poisoncontrolcenters,andsubjectmatterexperts(SMEs)inemergencymedicine,emergencyresponse,medicaltoxicology,andtrainers.Theycamefromcivilianandmilitaryagencies,universities,hospitals,andemergencyresponseentities.Thediversityoftheparticipantsprovidedtheneeded
breadthofexpertiseandbackgroundstodevelopaconsensuslexiconthatwillbeofmostvaluetotheintendedusers.
Workshopparticipantsagreedthattheterms“toxidrome”and“toxicsyndrome”canbeused
interchangeably,andthat“toxidrome”hasanumberofadvantagesthatmakeiteasiertouseinthefield.Theyagreeduponguidingprinciplesforthenamingoftoxidromesandforatoxidromedescription(i.e.,aconcisedefinitionofonetotwosentencesthatcapturesaconstellationofthekeyobservable
elementsoftheclinicalpresentationaswellaskeytreatmentsoractions).Theexpertsrecognizedthattheuseofthetoxidromeconceptwouldnecessarilyentailsomemisclassificationofpatientsasthereisatrade-offbetweenusabilityinthefieldanddiagnosticaccuracy.Theallowanceformisdiagnosisshould
typicallyerronthesideofover-treatment,basedonthenatureoftheconsequencesoftreatment.
Theexpertworkshopinitiallyrecommendedtwelvetoxidromestoestablishacommonlanguageforchemicaldefenseplanners,policymakers,firstresponders,firstreceivers,andhazardousmaterials
(hazmat)stakeholders.Thesetwelvetoxidromesweresubsequentlyconsolidatedtotheninelisted
inTable2inordertoprovideacommonlexicontoassistkeystakeholdercommunitiestoquickly
andaccuratelyidentifythebroadchemicalagentcategory(ifnotthespecificchemicalagent)towhichapatientwasexposedandtotherebyrapidlydetermineappropriateemergencytreatment.
Theninetoxidromeswerebuiltaroundclinicalpresentations,ratherthanchemicalgroupingor
treatmentoptions.Theexpertsfocusedondescribingtoxidromeswithsignsandsymptomsthatfirst
respondersandfirstreceiverswouldbeabletoobserveinthepatients.Thefocuswasonacute
exposures.Theworkshopexpertssoughttodevelopnamesforthetoxidromesthatwerebasedonclinicalrelevanceandaccuracy,aswellaseaseofrecall.
Report of the Toxic Chemical Syndrome Definitions and Nomenclature Workshop, May 2012 Page 20
Workshopparticipantsbrieflydiscussedhowtheinformationontoxidromescouldbepackagedfor
trainingandcommunicationtotheintendedusersandfielduseandofferedseveralsuggestionsincludinggroupingstrategiesoralgorithmsforeaseofremembrance.Inaddition,theydiscussedthatdifferenttypesofuserswillhavedifferingrequirementsforlevelsandtypesofinformationthatwill
needtobeaccommodated.Thecompletetoxidromepackageshouldincorporateavailableknowledgemanagementandcommunicationsystemsandincludeprovisionsforfeedbackandrevision.
Theworkshopexpertsidentifiedavarietyofideasforresearchneedsandfuturework.Theseincludeddevelopingaclinicaltrial-likeapproachorevaluatingdatafrompastincidentswithdataanalyticsand
exploringadditionalscenarios(andrelevanttoxidromes)formass-scaleexposurestocommercial
pharmaceuticalsviaingestion.
Thisreportisintendedtoprovideanaccuraterecordofworkshoppreparations,discussions,and
conclusionstoserveasaresourceforparticipantsandothersinthenextphasesofLexicondevelopment.
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DepartmentofHomelandSecurity(DHS).ChemicalSecurityAnalysisCenter(CSAC).2011.ChemicalSegregationbyToxidromeforChemicalTerrorismRiskAssessment.PowerPoint
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