The Pennsylvania Department of Health (PADOH) released the following information on November 6, 2003, regarding the recognition of selected clinical syndromes and potential chemical etiologies.
Since September 11, 2001, concern has increased about potential terrorist attacks involving the use of chemical agents. In addition, recent cases involving intentional or inadvertent contamination of food with chemicals have highlighted the need for health-care providers to be alert for patients in their communities who have signs and symptoms consistent with chemical exposures. To assist health-care providers with the recognition of chemical induced illness, the PADOH releases the following information summarizing epidemiologic clues and clinical signs or patterns of illness that might suggest covert release of a chemical agent and selected examples of chemical syndromes and potential chemical etiologies.
Epidemiologic clues that might suggest the covert release of a chemical agent include:
· An unusual increase in the number of patients seeking care for potential chemical-release--related illness;
· Unexplained deaths among young or healthy persons;
· Emission of unexplained odors by patients;
· Clusters of illness in persons who have common characteristics, such as drinking water from the same source;
· Rapid onset of symptoms after an exposure to a potentially contaminated medium (e.g., paresthesias and vomiting within minutes of eating a meal);
· Unexplained death of plants, fish, or animals (domestic or wild); and
· A syndrome (i.e., a constellation of clinical signs and symptoms in patients) suggesting a disease associated commonly with a known chemical exposure (e.g., neurologic signs or pinpoint pupils in eyes of patients with a gastroenteritis-like syndrome or acidosis in patients with altered mental status).
Various chemical agents could be used as covert weapons, and the actual clinical syndrome will vary depending on the type of agent, the amount and concentration of the chemical, and the route of the exposure.
TABLE. Selected* clinical syndromes and potential chemical etiologies
|
Category |
Clinical syndrome |
Potential chemical etiology |
|
Cholinergic crisis |
• Salivation, lacrimation, urination, defecation, GI cramping, emesis (SLUDGE), bronchorrhea, and/or diaphoresis • Miosis, fasciculations, weakness, bradycardia usually or tachycardia, hypotension or hypertension, altered mental status, and/or seizures |
• Nicotine† • Organophosphate insecticides†— less acetylcholinesterase activity • Carbamate insecticides • Medicinal carbamates (e.g., physostigmine) •Organochlorine insecticides |
|
Generalized muscle rigidity |
• Seizure-like, generalized muscle contractions or painful spasms (neck and limbs) and usually tachycardia and hypertension |
• Strychnine • intact sensorium |
|
Oropharyngeal pain and ulcerations |
• Lip, mouth, and pharyngeal ulcerations and burning pain |
• Paraquat† — dyspnea and hemoptysis secondary to edema or hemorrhage; can progress to pulmonary fibrosis over days to weeks • Diquat • Caustics (i.e., acids and alkalis) • Inorganic mercuric salts • Mustards (e.g., sulfur) |
|
Cellular hypoxia |
• Mild: nausea, vomiting, and headache • Severe: altered mental status, dyspnea, hypotension, seizures, and metabolic acidosis • Rapid collapse common |
• Cyanide† (e.g., hydrogen cyanide gas or sodium cyanide) — bitter almond odor§ — patient may note a musty or chlorine smell • Hydrogen sulfide • Carbon monoxide • Phosphine • Sodium monofluoroacetate (SMFA)† — hypocalcemia or hypokalemia • Sodium azide • Methemoglobin-causing agents |
|
Acute lung injury |
•Cough usually non-productive, shortness of breath, discomfort taking deep breaths, and wheezing • Symptom delays of hours up to two days • Hypoxia •Radiographic pneumonitis also delayed. |
• Chlorine • Phosgene+ • Nitrogen dioxide+ • Phosphine • Fumigants (methyl bromide, sulfuryl fluoride) • Anhydrous ammonia — corneal burns • Isocyanates — Skin, corneal burns |
|
Peripheral neuropathy and/or neurocognitive effects |
• Peripheral neuropathy signs and symptoms: muscle weakness and atrophy, “glove and stocking” sensory loss, and depressed or absent deep tendon reflexes • Neurocognitive effects: memory loss, delirium, ataxia, and/or encephalopathy |
• Mercury (organic)† — visual disturbances, paresthesias, and/or ataxia • Arsenic (inorganic)† — delirium and/or neuropathy • Thallium — delirium and/or neuropathy • Lead — encephalopathy • Acrylamide — encephalopathy and/or neuropathy • Methyl Bromide — delirium and/or neuropathy • Anticholinergics (plants or BZ, 3-Quinuclidinyl benzilate) — delirium |
|
Severe gastrointestinal illness, dehydration |
• Abdominal pain, vomiting, profuse diarrhea (possibly bloody), and hypotension, possibly followed by multisystem organ failure |
• Arsenic† • Ricin† — inhalation an additional route of exposure; severe respiratory illness possible • Abrin • Colchicine • Barium — hypokalemia common |
|
Hemolysis |
• Bloody urine, hemoglobinura followed by acute renal failure |
• Arsine • Stibine |
|
Hemorrhage |
• Unexplained bleeding one or multiple internal external sites, vitamin K dependent coagulation factors |
• Brodifacoum and other long-acting anticoagulants. |
* Not intended as a complete differential diagnosis for each syndrome or a list of all chemicals that might be used in a covert chemical release.
†Potential agents for a covert chemical release based on historic use (i.e., intentional or inadvertent use), high toxicity, and/or ease of availability.
§ Unreliable sign.
+Onset usually delayed 12-36 hours, but can be shorter in high concentration exposures.
A covert release of a chemical agent might not be identified easily for at least five reasons:
1. Symptoms of exposure to some chemical agents (i.e. ricin) might be similar to common diseases (e.g., gastroenteritis),
2. Immediate symptoms of certain chemical exposures might be nonexistent or mild despite the risk for long-term effects (e.g., neurocognitive impairment from dimethyl mercury, teratogencitiy from isotretinoin, or cancer from aflatoxin).
3. Exposure to contaminated food, water, or consumer products might result in reports of illness to health-care providers over a long period and in various locations,
4. Persons exposed to two or more agents might have symptoms not suggestive of any one chemical agent (i.e., mixed clinical presentation),
5. Health-care providers might be less familiar with clinical presentations suggesting exposure to chemical agents than they are with illnesses that are treated frequently.
More Information
To aid emergency department physicians and other emergency healthcare professionals who manage acute exposures resulting from chemical incidents, the Agency for Toxic Substances and Disease Registry (ATSDR) has developed Medical Management Guidelines (MMGs) for acute chemical exposures. MMGs are intended to aid healthcare professionals involved in emergency response to effectively decontaminate patients, protect themselves and others from contamination, communicate with other involved personnel, efficiently transport patients to a medical facility, and provide competent medical evaluation and treatment to exposed persons. MMGs are available at: http://www.atsdr.cdc.gov/mmg.html#bookmark03.
Additional information about responding to chemical attacks is available from the U.S. Army Medical Research and Material Command at http://www.biomedtraining.org/progmat.htm, the U.S. Army Medical Research Institute of Chemical Defense at http://ccc.apgea.army.mil, and the ATSDR at http://www.atsdr.cdc.gov/mhmi.html.
The PADOH provides Emergency Preparedness and Bioterrorism information at http://www.dsf.health.state.pa.us/health/site/. The Bureau of Epidemiology is the Department’s medical and epidemiological support entity during a terrorist attack or an environmental crisis.
For more information contact the PADOH at 1-877-PA-HEALTH or for emergency situations contact the Poison Control Center at 1-800-222-1222.
Reference
Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Vol. 52, No. 39, October 3, 2003.