By Lance C. Peeples
The recent events in Syria underscore the need for firefighters to be prepared to respond to a chemical attack using nerve agents here in the United States. The Obama administration reports that the long standing dictator Bashar al-Assad used the nerve agent Sarin to attack civilian targets resulting in the deaths of approximately 1,400 people including children. Sarin is a semi-volatile chemical that presents both liquid and vapor hazards when disseminated.
Syria has the world’s third largest stockpile of chemical weapons after the United States and Russia. Assad is engaged in a three-way civil war with moderate rebels and radical Islamist fundamentalist who are waging jihad to remove Assad in hopes of establishing an Islamic caliphate and mandating Sharia law in Syria. As a result, there is a real possibility that chemical and possibly biological weapons may fall into the hands of radical Islamists if the Assad regime falls. If this occurs, it is entirely possible that these agents will be smuggled into the United States and firefighters will find themselves responding to an intentional nerve agent release.
The first problem early-arriving companies’ face is they may not even know they are responding to a chemical agent release. This may have been a problem for the first-arriving firefighters when the terrorist organization Aum Shinrikyo released Sarin gas in the Tokyo subway system in 1995. The initial reports may only indicate that a number of victims have suddenly fallen ill. For this reason, any incident involving multiple victims should be assumed to be a terror attack until proven otherwise. Company officers and firefighters must exercise caution when responding to reports of “multiple victims,” “an explosion,” any incidents in crowds or confined spaces such as malls or subways, and incidents at target hazards such as federal buildings.
(1) Firefighters responding to an incident where there has been an actual or suspected release of nerve agent must be protected with Level A personal protective equipment (PPE). Here, firefighters train on using this equipment. Structural firefighting PPE with SCBA will provide some minimal protection to allow for a retreat if firefighters themselves unexpectedly exposed. DO NOT INTENTIONALLY ENTER A SARIN GAS SCENE PROTECTED ONLY WITH STRUCTURAL FIREFIGHTING CLOTHING AND SCBA! (Photo by author.)
Although the nature and location of the reported emergency may provide some clues as to the possibility of a chemical attack, most first-due companies will not have available any type of detection equipment capable of identifying nerve agents. For this reason, you must observe the following precautions:
- Approach the scene from upwind.
- Be alert for secondary devices.
- Wear full self-contained breathing apparatus (SCBA) and turnout gear as you approach any scene that appears potentially suspicious. Obviously, this equipment will not provide full protection against a nerve agent. (For a fuller discussion of turnout gear in nerve agent attacks, click HERE.) I suggest wearing it only for an initial investigation where there is the “potential” for a nerve agent release. If the risk appears to be higher than “potential” the firefighters should retreat until hazmat crews can arrive. Any suspicion that there has been an actual release of a nerve agent should prompt a rapid retreat. You can’t help anyone if you’re dead!
- Be alert for multiple patients with respiratory symptoms, dead or dying birds or animals, and possibly discolored vegetation.
- Do not enter vapor clouds.
- Avoid contact with liquids.
- Resist the unbearable urge to rush in to help. If the patient has been immediately incapacitated by a nerve agent to the point where they are incapable of self-evacuation, it is highly likely that they will die despite any intervention you are able to provide.
- Direct patients capable of self-evacuation to a collection area for gross decon. Large numbers of patients can be deconned by separating the sexes and instructing them to strip to their underwear and then using a fog nozzle attached to an engine discharge to provide a gross decon shower.
- After gross decon, triage the victims to appropriate treatment areas.
The nerve agents that might be used in a terrorist attack include sarin (GB), tabun (GA), soman (GD), GE, VE, VG, VM, VR, VS, and VX.1 All of these agents work by interfering with the inhibition of the enzyme acetylcholinesterase (AChE).2 This results in overstimulation of the muscles by an excessive accumulation of the neurotransmitter acetylcholine (ACh).(2) Inhalation of these agents may result in the onset of symptoms within 30 seconds to two minutes, whereas transdermal absorption may result in symptom onset from 30 minutes to as long as 18 hours following exposure depending on concentration.(2)
Symptoms may be remembered using the acronym SLUDGEM:
S – Salivation
L – Lacrimation (tearing)
U – Urination
D – Defecation
G – Gastrointestional upset
E – Emesis
M – Miosis (pinpoint pupils)
Patients may appear to have tonic seizure activity; death occurs as a result of respiratory paralysis.
Treatment consists of removing the victim to a safe area; rapid gross decon; respiratory support (do not perform mouth to mouth; this may result in injury/death to the rescuer); and the administration of atropine, which works by antagonizing the effects of acetylcholine. Pralidoxime chloride (2PAM) reactivates AChE, thus reversing the effects of nerve agents. Atropine and 2PAM are often provided in an autoinjector that should be available to all firefighters serving in high-risk (at a minimum Urban Areas Security Initiative I) cities.
(Note: Unfortunately, quality control problems have caused the manufacturer to suspend production of these auto injectors. Evidently, a small percentage failed to fire when tested. For this reason, it may be necessary to administer a second dose from a different auto injector if symptoms do not resolve. There are no plans to recall the devices.)3
Having these autoinjectors stored in firehouses instead of on initial arriving companies will do little if any good. These reversal agents must be provided within minutes of exposure if they are to have any effect.
Given the recent events in the world, it is increasingly likely that firefighters will find themselves responding to an intentional release of a chemical weapon including the possibility of nerve agents. Firefighters arriving first-due at incidents involving such agents can minimize death and injury by maintaining high situational awareness. They should wear SCBA and turnout gear when investigating any incident with the potential for a possible nerve agent release and retreat immediately if any evidence suggests that there has been an actual release. Direct ambulatory victims to leave the danger area and undergo a gross decon. Victims who are too ill to self-evacuate will most likely die. Victims should be triaged and provided with supportive care. Atropine and 2PAM can be used to antagonize the effects of nerve agents, but it must be given as soon as possible for maximum effect. Ativan or valium may be used to control seizure activity.
REFERENCES
- Burke R. Counter-Terrorism for Emergency Responders. 2nd Ed. Taylor and Francis Group. Boca Raton. 2007. pp. 68-98.
- Geoghegan J, Tong JL. Chemical warfare agents. Continuing Education in Anaesthesia, Critical Care and Pain. December 1, 2006. 2006;6(6):230-234.
- www.ecbc.army.mil/downloads/cwirp/ECBC_ffpe_scba_rescue_ops.pdf.
Disclaimer: The opinions expressed herein are those of the author and do not reflect the position of St. Louis University or the Insitute of Biosecurity.
Lance C. Peeples is an adjunct faculty member in the Institute for Biosecurity and Disaster Preparedness at St. Louis University. He has more than three decades of fire/EMS experience. Peeples holds a MS degree from Oklahoma State University in Fire and Emergency Management Administration.
