The topic of weapons of mass destruction (WMD) and related injuries is vast. The following article provides highlights of WMD and references the importance of personal protective equipment and decontamination. In your role as a pre-hospital care provider, it is unlikely that you will know the exact agent you will need to manage. It is important to recognize patterns of symptomatology to first, protect yourself and second stabilize your patients.
Weapons of mass destruction can be summarized by the acronym CBRNE, which stands for Chemical, Biological, Radiological, Nuclear and Explosive. We will highlight key features in each of the categories.In responding to a WMD incident, the responder must take into account not only the agent in question, but also the route of dispersal as this can modify operations including personal protective equipment (PPE), a method of decontamination, and expectation to the number of possible victims.Route of dispersal can be through aerosolization, thermal detonation, addition to water and food supply, and even human to human contact. The ideal transmission will be dependent on the individual properties of each agent.
Chemical agents are typically human-made and have been around for more than a century. These agents can be further broken down into the following.
Biological Biologic agents include bacteria, viruses, fungi and their byproducts. Their dispersal means are similar to chemical, and proper PPE is also critical. Initial symptoms may be non-specific and “flu-like” in nature. It may be difficult to even identify if an agent is even present let alone differentiate between different agents. The National Institute of Allergy and Infectious Disease have regularly updated sets of lists of the most dangerous biological agents. Category, A agents, are the most dangerous and are characterized by being easily disseminated or transmitted, have high mortality rates, may cause public panic or social disruption, and may require special action for public health preparedness. Category A Agents
Other Biological Weapons
Ricin is derived from the castor bean plant. This toxin in weaponized form would typically be inhaled or ingested leading to airway edema and necrosis or gastrointestinal hemorrhage followed by necrosis. Differentiation of ricin poisoning and sepsis can be very difficult as both may present similarly.Q Fever (Coxiella Burnetti) manifests after a 10 to 40 day incubation period with undifferentiated fever, headache, fatigue, and myalgias. What makes this agent so dangerous is that it can persist on inanimate objects for months and only requires a single organism to cause infection.Radiologic/Nuclear WeaponsRadiologic and nuclear weapons have been the subject of fear and controversy over the past decades. What is most important for the first responder is proper PPE, decontamination, and understanding the difference between exposure and contamination.
Prevention of contamination can be summed up by remembering the three tenets of time, distance, and shielding. Time refers to how long the victim was exposed to the source; distance is how far away the victim was from the source, and shielding is what PPE or other barriers were in place to lessen the radiation burden to the victim.Exposure refers to how close the victim was to the source of radiation, whereas contamination is when the victim comes in physical contact with the radiation source and subsequently continues to be exposed and may expose others. Contamination may be external or internal depending on the material being swallowed, absorbed or entering wounds in the skin. Decontamination will be discussed below.Explosive WeaponsExplosive weapons come in two general categories. High-order explosives undergo detonation and cause high pressure blast waves which cause the primary blast injuries. High order explosives include TNT, dynamite, and C4. Low-order explosives undergo degradation and lack the blast wave and include gunpowder, fireworks, and pyrotechnics. These low-order explosive while still potentially deadly lack the over pressurization and do not present with primary blast wave injuries. These devices may be augmented to include more destructive pieces such as ball bearings, using PVC piping due to its radiolucency, or even agents from other categories in order to further the destructiveness of the weapon. In general, these weapons are meant to cause as much fear and destruction as possible. This presents a dilemma for the healthcare provider as these patients can present with multisystem trauma necessitating stabilization of the ABCs and rapid transport to the closest appropriate trauma center.Blast injuries are divided into four categories:
Decontamination and PPE
Decontamination is the first, and one of the most important steps when evaluating and treating a victim of a WMD attack. Which type of decontamination you will choose will be dependent on your level of training, nature of the exposure, and the availability of resources.Emergency DecontaminationEmergency decontamination is the process of removing life-threatening agents as quickly as possible with or without the establishment of a decontamination corridor. This may be as simple as removing outer and all garments to washing with a safety shower or fire hose fog stream.Gross and Mass DecontaminationIn the prehospital world, patients will typically undergo multiple rounds of decontamination starting with gross mass decontamination with which ambulatory victims will walk through fog streams sprayed by fire engines. This is the quickest but least thorough of all types.Technical DecontaminationTechnical decontamination is a more thorough decontamination for providers and equipment. This is to ensure provider safety and to minimize further contamination.Definitive Decontamination Definitive decontamination is a more resource intense process in which both ambulatory and non-ambulatory victims are put through adecontamination corridor and thoroughly washed with soap and water. HAZMAT teams, Hospital Emergency Response Teams (HERT,) or other trained staff wearing PPE typically undertake these processes.