1. CBRNE Training Academy Understanding Nuclear, Biological and Chemical Events Risk Assessment Understanding Nuclear, Biological and Chemical Events Risk Assessment

2. Lecture Goals Understand the basics of: –Biological exposure –Chemical exposure –Nuclear/Radiological exposure –Transmission and contamination Develop personal risk assessment –Am I in danger? Understand the basics of: –Biological exposure –Chemical exposure –Nuclear/Radiological exposure –Transmission and contamination Develop personal risk assessment –Am I in danger?

3. Basic assumptions The hospital is not the scene EMS/Fire decontaminate patients 60-80% of people bypass EMS The hospital is not the scene EMS/Fire decontaminate patients 60-80% of people bypass EMS

4. Biological, Chemical and Nuclear General Concepts

5. Why are hazards hazardous? “Chemical” nature Host factors Environmental issues Exposure Dose “Chemical” nature Host factors Environmental issues Exposure Dose Philip Theophrastus Bombast von Hohenheim aka PARACELSUS (1493-1541) Philip Theophrastus Bombast von Hohenheim aka PARACELSUS (1493-1541)

6. What it is makes it bad Chemical nature and physical properties

7. Who you are makes it bad Age, health and disease

8. Where you are makes it bad Wind, water and weather

9. Exposure Route, duration and degree

10. The Specifics Biological agents

11. ready.gov If you see signs of a chemical attack, quickly try to define the impacted area or where the chemical is coming from, if possible.

12. Not ready.gov Hurricanes, animal corpses and the biohazard symbol have a lot in common. Think about it.

13. Biological basics Particles that cause disease –Bacteria –Viruses –Fungi Particles that cause disease –Bacteria –Viruses –Fungi

14. Awareness Unusual syndromes –Flu out of flu-season Unexpected geography or clusters –Plague in NYC –Pets and humans –Whole neighborhoods –Everyone from a Knicks game Unusual diseases –Hemorrhagic fevers Unusual syndromes –Flu out of flu-season Unexpected geography or clusters –Plague in NYC –Pets and humans –Whole neighborhoods –Everyone from a Knicks game Unusual diseases –Hemorrhagic fevers

15. Protection basics

16. Standard precautions

17. Examples of Personal Protective Equipment

18. Examples of biologic agents Bacteria Anthrax Tularemia Pneumonic Plague Viruses Smallpox Influenza Viral Hemorrhagic Fevers (VHFs); Lassa, Ebola, Marburg Biological Toxins Botulism Bacteria Anthrax Tularemia Pneumonic Plague Viruses Smallpox Influenza Viral Hemorrhagic Fevers (VHFs); Lassa, Ebola, Marburg Biological Toxins Botulism

19. How do they present? “Flu” like symptoms –Inhalational anthrax –Smallpox –Pneumonic plague –Viral Hemorrhagic fever –Tularemia –Pandemic influenza –Avian influenza –SARS Almost all of them “Flu” like symptoms –Inhalational anthrax –Smallpox –Pneumonic plague –Viral Hemorrhagic fever –Tularemia –Pandemic influenza –Avian influenza –SARS Almost all of them

20. Can I catch this? Anthrax Brucellosis Q fever Tularemia Equine encephalitis Toxins: Botulism, Staph enterotoxin B, Ricin NO Anthrax Brucellosis Q fever Tularemia Equine encephalitis Toxins: Botulism, Staph enterotoxin B, Ricin NO

21. Can I catch this? Pneumonic plague Smallpox Viral hemorrhagic fevers (VHF) –Lassa, Ebola, Marburg MAYBE Not contagious prior to symptoms Pneumonic plague Smallpox Viral hemorrhagic fevers (VHF) –Lassa, Ebola, Marburg MAYBE Not contagious prior to symptoms

22. Pneumonic Plague Naturally transmitted from person to person through large respiratory droplets Surgical mask is adequate for most people in most situations Droplet precautions Naturally transmitted from person to person through large respiratory droplets Surgical mask is adequate for most people in most situations Droplet precautions

23. Smallpox Naturally transmitted from person to person through large respiratory droplets & through direct contact with oral/pharyngeal secretions Less contagious than measles, chicken pox Naturally transmitted from person to person through large respiratory droplets & through direct contact with oral/pharyngeal secretions Less contagious than measles, chicken pox N100

24. Quarantine

25. I’m exposed, now what? Antibiotics (Doxycycline, Ciprofloxacin) –Anthrax, Plague Vaccine –Smallpox (within 4 days of exposure) Supportive care and experimental –Botulism –VHF –Equine encephalitis –Ricin exposure Antibiotics (Doxycycline, Ciprofloxacin) –Anthrax, Plague Vaccine –Smallpox (within 4 days of exposure) Supportive care and experimental –Botulism –VHF –Equine encephalitis –Ricin exposure

26. Biological summary Exposed Bag clothes Shower Universal precautions Quarantine Post-exposure prophylaxis (patient) Exposed Bag clothes Shower Universal precautions Quarantine Post-exposure prophylaxis (patient) Sick and contagious Isolate Universal precautions Respiratory precautions Post-exposure prophylaxis (patient and maybe staff)

27. Risk summary Not sick, unlikely to be contagious Decontaminate (maybe) Universal and respiratory precautions Isolation and hand washing Post exposure prophylaxis Not sick, unlikely to be contagious Decontaminate (maybe) Universal and respiratory precautions Isolation and hand washing Post exposure prophylaxis

28. The Specifics Chemical hazards

29. If you become aware of an unusual or suspicious release of an unknown substance nearby, it doesn't hurt to protect yourself. ready.gov

30. Not ready.gov If you are sprayed with an unknown substance, stand and think about it instead of seeing a doctor.

31. Awareness Five senses Toxidromes –Skin –Pupils –Bowels –Bladder –Mucous membranes –Mental status Five senses Toxidromes –Skin –Pupils –Bowels –Bladder –Mucous membranes –Mental status

32. Chemical basics What are its properties? –Solid, liquid, gas Any properties of concern? –Volatility –Flammability How was it released / distributed? How did it get here? What are its properties? –Solid, liquid, gas Any properties of concern? –Volatility –Flammability How was it released / distributed? How did it get here?

33. If you remember one thing... Decontamination

34. What do we worry about? Nerve Agents Blood Agents Choking Agents Blister (vesicant) Agents Riot Control Agents Nerve Agents Blood Agents Choking Agents Blister (vesicant) Agents Riot Control Agents

35. Nerve Agents Anti-human pesticide Absorbed through ALL routes, inhalation causes most rapid onset of symptoms Cholinergic toxidrome; SLUDGEM Primary effects observed in Tokyo were pinpoint pupils, dimmed vision, weakness Decontamination & PPE vital Anti-human pesticide Absorbed through ALL routes, inhalation causes most rapid onset of symptoms Cholinergic toxidrome; SLUDGEM Primary effects observed in Tokyo were pinpoint pupils, dimmed vision, weakness Decontamination & PPE vital

36. Nerve Agents March 1995 Sarin release 11 killed 5510 sought emergency medical care March 1995 Sarin release 11 killed 5510 sought emergency medical care

37. How do I treat this? Decontaminate ABC’s Antidotes –Mark I kit –Atropine –Oximes for aging Central Nervous System (CNS) depressants Decontaminate ABC’s Antidotes –Mark I kit –Atropine –Oximes for aging Central Nervous System (CNS) depressants

38. “Off-gassing” “Contagious” chemical –Georgia nurse –Tokyo doctors No decontamination performed No PPE used in any cases “Contagious” chemical –Georgia nurse –Tokyo doctors No decontamination performed No PPE used in any cases

39. “Blood” or metabolic agents Cyanide is primary example Common industrial agent Interrupts aerobic respiration (ability to use oxygen) Rapid, severe clinical deterioration Leads to collapse, apnea, seizures, severe metabolic acidosis & death Therapy Decontaminate Oxygen, bicarbonate, sodium thiosulfate Cyanide is primary example Common industrial agent Interrupts aerobic respiration (ability to use oxygen) Rapid, severe clinical deterioration Leads to collapse, apnea, seizures, severe metabolic acidosis & death Therapy Decontaminate Oxygen, bicarbonate, sodium thiosulfate

40. Blister (vesicant) agents Sulfur Mustard Environmental persistence Dermal effects in 1-2 minutes Systemic effects in 4-8 hours Decontamination and supportive care Sulfur Mustard Environmental persistence Dermal effects in 1-2 minutes Systemic effects in 4-8 hours Decontamination and supportive care

41. Choking (pulmonary) agents Phosgene and Chlorine –Common industrial agents Cause delayed lung injury Chlorine + water = HCL Airway management Decontamination (maybe) Supportive care Phosgene and Chlorine –Common industrial agents Cause delayed lung injury Chlorine + water = HCL Airway management Decontamination (maybe) Supportive care

42. “Riot control” agents Many compounds –Solids within liquids Primarily irritants –High pressure particulate –Burns (eyes, skin) –Coughing, asthma-like symptoms Decontamination is key Many compounds –Solids within liquids Primarily irritants –High pressure particulate –Burns (eyes, skin) –Coughing, asthma-like symptoms Decontamination is key

43. Chemical summary Decontamination Protect yourself Identify the toxidrome Many agents have specific therapies Aggressive supportive care Monitor for delayed toxicity Decontamination Protect yourself Identify the toxidrome Many agents have specific therapies Aggressive supportive care Monitor for delayed toxicity Decontamination

44. Risk summary Whatever patient had, staff has less Protect yourself –Decontamination... –Personal protective equipment Low risk once clean Whatever patient had, staff has less Protect yourself –Decontamination... –Personal protective equipment Low risk once clean

45. The Specifics Nuclear/Radiological hazards

46. ready.gov Or if it would be better to go inside a building and follow your plan to shelter-in-place.

47. Not ready.gov After exposure to radiation it is important to consider that you may have mutated to gigantic dimensions: watch your head.

48. Basics of radiation ContaminationIncorporationIrradiation Risk No Risk Maybe Risk

49. Awareness and protection Detection Decontamination Distance Deflection Detection Decontamination Distance Deflection

50. Radiologic principles Alpha, Beta, Gamma, Neutron RAD’s and REM’s Alpha, Beta, Gamma, Neutron RAD’s and REM’s 0.003 REM 0.005 REM 6 REM/yr 45 REM ??? REM 200 REM > 400 REM

51. What do we worry about? Simple radiological device Radiological dispersal device Reactor Improvised nuclear device Nuclear weapon Simple radiological device Radiological dispersal device Reactor Improvised nuclear device Nuclear weapon

52. Acute Radiation Syndrome Associated effects –Rapidly dividing cell populations –GI distress, altered mental status, shock –Therapy is primarily supportive Trauma and radiation –Treatment within 48 hours –Or delay 2 to 3 months Associated effects –Rapidly dividing cell populations –GI distress, altered mental status, shock –Therapy is primarily supportive Trauma and radiation –Treatment within 48 hours –Or delay 2 to 3 months

53. Radiation summary You must think about it Detection, decontamination, distance Treatment is primarily supportive Trauma and radiation within 48 hours –Stabilize first, decontaminate second You must think about it Detection, decontamination, distance Treatment is primarily supportive Trauma and radiation within 48 hours –Stabilize first, decontaminate second

54. Risk summary Stay away from source (distance) Whatever patient had, staff has less Decontaminate contaminated patients –Irradiated patients pose no risk –Incorporated depends on source Very low risk to staff Stay away from source (distance) Whatever patient had, staff has less Decontaminate contaminated patients –Irradiated patients pose no risk –Incorporated depends on source Very low risk to staff

55. Am I safe? Risk Assessment

56. General Rule #1 Unless patient is sick with a contagious illness, they pose no threat to staff. Corollary Treat all patients as contagious. Decontaminate everyone. Protect yourself. Unless patient is sick with a contagious illness, they pose no threat to staff. Corollary Treat all patients as contagious. Decontaminate everyone. Protect yourself.

57. General Rule #2 Whatever the patient was exposed to, the staff will be exposed to far less. Corollary Decontamination reduces risk even more. Decontaminate everyone. Protect yourself. Whatever the patient was exposed to, the staff will be exposed to far less. Corollary Decontamination reduces risk even more. Decontaminate everyone. Protect yourself.

58. General rule #3 You can only detect radiation if you think about radiation. Corollary Screen everyone with a Geiger counter. Decontaminate everyone. Protect yourself. You can only detect radiation if you think about radiation. Corollary Screen everyone with a Geiger counter. Decontaminate everyone. Protect yourself.

59. Questions?