AbbreviAtions a n d Acronyms - ckapfwstor001.blob.core ...

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Medical Aspects of Chemical Warfare Abbreviations and Acronyms

AbbreviAtions and Acronyms

AAA: arachidonic acid AC: hydrogen cyanideACGIH: American Conference of Governmental Industrial Hy-gienists Ach: acetylcholine AChE: acetylcholinesteraseADMS: assistant director of medical services AEF: American Expeditionary ForcesAEGL: acute exposure guidance levelAML: area medical laboratoryAMN: atropine methylnitrateAR: Army RegulationARC: American Red CrossARDS: acute respiratory distress syndrome ATCA: 2-aminothiazoline-4-carboxylic acidATNAA: antidote treatment nerve agent autoinjectorATP: adenosine triphosphateaTSP: active topical skin protectantA-V: atrial-ventricular

bBA: bromoacetone BAL: British anti-Lewisite (dimercaprol)BALF: bronchoalveolar lavage fluidBAS: battalion aid stationBBC: bromobenzyl cyanideBChE: butyrylcholinesteraseBEF: British Expeditionary ForcesBMZ: basement membrane zone BTX: batrachotoxinBZ: 3-quinuclidinyl benzilate

cCA: bromobenzyl cyanideCaE: carboxylesteraseCAI: chemical accident or incidentCAIRA: chemical accident or incident response and assistancecAMP: adenosine 3’,5’-cyclic monophosphate CANA: convulsive antidote, nerve agentCAS: Chemical Abstracts ServiceCB: chemical-biological CBIRF: Chemical/Biological Incident Response Force CBR: chemical, biological, and radiologicalCBRN: chemical, biological radiological, and nuclearCBRNE: chemical, biological, radiological, nuclear, explosiveCBRRT: chemical biological rapid response teamCDC: Centers for Disease Control and PreventionCEA: cultured epidermal autograftcGMP: current Good Manufacturing PracticeCHASE (Operation): Cut Holes and Sink ‘EmChE: cholinesteraseCK: cyanogen chlorideCN- : cyanide anionCN: chloroacetophenoneCNO- : cyanateCNS: central nervous system COLPRO: collective protectionCP EMEDS: collectively protected expeditionary medical support

CPRP: chemical personnel reliability programCR: dibenz(b,f)(1,4)oxazepine CS: o-chlorobenzylidene malononitrileCSA: The Covenant, the Sword, and the Arm of the LordCSEPP: Chemical Stockpile Emergency Preparedness ProgramCSF: colony-stimulating factorCSMSPD: chemical surety medical support program directorCt: concentration (C) of agent vapor or aerosol in air multiplied by time (t) of exposureCWA: chemical warfare agent CWC: Chemical Weapons Convention (1993)CWS: US Army Chemical Warfare Service

DDA PAM: Department of the Army pamphletDA: diphenylchloroarsineDC: diphenylcyanoarsineDCE: defense coordinating elementDEET: N,N-diethyl-meta-toluamideDEPMEDS: deployable medical system DFP: diisopropyl phosphorofluoridateDHHS: Department of Health and Human ServicesDHP: diisopropylfluorophosphateDHS: Department of Homeland SecurityDM: diphenylaminoarsine4-DMAP: 4-dimethylaminophenolDMS: director of medical servicesDNA: deoxyribonucleic acidDoD: Department of DefenseDOE: Department of EnergyDOJ: Department of JusticeDOT: Department of TransportationDVA: Department of Veterans Affairs

eECG: electrocardiogramEDTA: ethylenediaminetetraacetate EEG: electroencephalogramEKG: electrocardiogramEMEDS: expeditionary medical support EMS: emergency medical serviceEMT: emergency medical technicianEOC: emergency operations centerEPA: Environmental Protection AgencyEq: equine ER: endoplasmic reticulum Er: YAG: erbium: yttrium-aluminium-garnet ESF: emergency support function

FFBI: Federal Bureau of InvestigationFBS: fetal bovine serumFCC: federal coordinating centerFDA: Food and Drug AdministrationFEMA: Federal Emergency Management AgencyFHP: force health protectionFOC: full operational capabilityFRC: forward resuscitation care

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Medical Aspects of Chemical Warfare Abbreviations and AcronymsMedical Aspects of Chemical Warfare Abbreviations and Acronyms

GGA: tabunGABA(A): gamma-aminobutyric AGB: sarinGD: somanGF: cyclosarin GK-11: gacyclidineGM1: monosialotetrahexosylgangliosideGSA: General Services AdministrationGSH: glutathione

HH: mustardH2O2: hydrogen peroxideH2S: hydrogen sulfideHAZMAT: hazardous materials HAZWOPER: hazardous waste operations and emergency responseHC: hexachloroethane HCN: hydrogen cyanideHD: mustard (distilled)HE: high explosivesHHS: Department of Health and Human ServicesHN2: nitrogen mustardHSS: health service supportHu PON1: human paraoxonase 1HWA: Heereswaffenamt

iICAM: improved chemical agent monitorICG: indocyanine green ICS: incident command systemIDLH: immediately dangerous to life or health IgG: immunogammaglobulin IL: interleukinIM: intramuscularIMA: installation medical authorityIND: investigational new drugIOC: initial operational capabilityIOT&E: initial operational test and evaluationIP: intraperitoneal injection IPE: individual protective ensemble/equipmentIV: intravenous

JJFO: joint field officeJPEO: joint program executive office JPEO-CBD: Joint Program Executive Office for Chemical Biologi-cal DefenseJPMO: joint product management officeJSGPM: joint service general purpose maskJSLIST: joint service lightweight integrated suit technology JSMLT: joint service mask leakage tester JSPDS: joint service personnel skin decontamination systemJTF: joint task force

KKCN: potassium cyanide Km: a measure of the strength of binding of a substrate to an enzyme

LLCt50: the vapor or aerosol exposure that is lethal to 50% of the exposed populationLD50: median lethal doseLDPI: laser Doppler perfusion imaging LHON: Leber hereditary optic neuropathy LPS: lipopolysaccharideLSD: lysergic acid diethylamide

mMAC: multiagency coordinationMANAA: medical aerosolized nerve agent antidoteMCE: maximum credible eventMDMA: 3, 4-methylene-dioxymethylamphetamineMEDCOM: medical commandMEDEVAC: medical evacuation MITS: medical identification and treatment systemsMO: medical officerMOPP: mission-oriented protective posture MPE: most probable eventMRI: magnetic resonance imaging MRT: mean residence timeMRT: medical response teamMS C LRIP: milestone C low rate initial production MT: metric tonMTF: medical treatment facilityMULO: multipurpose overboot

nN2O: nitrogen oxide N2O4: nitrogen tetroxide NAAG: N-acetyl-aspartyl-glutamateNaCN: sodium cyanideNAD+ : nicotinamide adenine dinucleotideNaNO2: sodium nitrite NATO: North Atlantic Treaty OrganizationNBC: nuclear, biological, chemicalNCO: noncommissioned officerNCS: National Communications SystemNDA: new drug applicationNDMS: National Disaster Medical SystemNF: number facilityNIMS: National Incident Management SystemNIOSH: National Institute for Occupational Safety and Health NMDA: N-methyl d-aspartateNO: nitric oxideNO2: nitrogen dioxide NORTHCOM: Northern CommandNRP: National Response Plan NSAID: nonsteroidal antiinflammatory drug NSP: neurotoxic shellfish poisoning

oOC: oleoresin capsicum OH: hydroxyl radicalOP: organophosphorusOPCW: Organization for the Prohibition of Chemical WeaponsOPIDN: organophosphorus ester–induced delayed neurotoxicity Ops: operationsOSHA: Occupational Safety and Health Administration


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PPADPRP: poly(adenosine diphosphate-ribose) polymerasePAF: platelet-aggregating factor2-PAM Cl: 2-pralidoxime chloride2-PAM: 2-pralidoximePAPP: p-aminopropiophenone PARP: poly(ADP-ribose) polymerasePATS: protection assessment test system PB: pyridostigmine bromidePBN: alpha-phenyl-N-tert-butylnitronePBN: N-tert-butyl-alfa-phenylnitronePbTx: brevetoxinPCP: phencyclidinePFIB: perfluoroisobutylene pHu: plasma-derived humanPKC: protein kinase CPLA2: phospholypase A2pMo: plasma-derived mouse 2-PMPA: 2-pentanedioic acidPOM: program objective memorandumPPE: personal protective equipmentPR: protective ratioPS: chloropicrin PTSD: posttraumatic stress disorder PTX: palytoxin

rRADS: reactive airways dysfunction syndromeRBC-ChE: red blood cell cholinesteraseRCA: riot control agent RD50: dose required to cause a 50% decrease in respiration REM: rapid eye movementRH: relative humidityrHu BChE: recombinant human butyrylcholinesteraseRNA: ribonucleic acid RPM: respiratory rate, pulse, and motor functionRSDL: Reactive Skin Decontamination Lotion

sSCN- : thiocyanateSE: status epilepticusSERPACWA: skin exposure reduction paste against chemical warfare agents SMART: special medical augmentation response teamSNS: strategic national stockpileSRBD: seizure-related brain damageSS: SchutzstaffelSTART: simple triage and rapid treatment STEL: short-term exposure limit STM: Sacco triage methodSTX: saxitoxin

tTBSA: total body surface areaTEN: toxic epidermal necrosis TIC: toxic industrial chemicalTIM: toxic industrial materialTNF: tumor necrosis factorTRP: transient receptor potential TTX: tetrodotoxinTWA: time-weighted average

UUN: United NationsUSACHPPM: US Army Center for Health Promotion and Preven-tive MedicineUSAMRICD: US Army Medical Research Institute of Chemical DefenseUSAMRIID: US Army Medical Research Institute of Infectious DiseasesUSDA: US Department of AgricultureUSJCOM: US Joint Forces CommandUSMC: US Marine Corps

vV/Q: ventilation profusion ratioVAC: Vacuum-Assisted Closure Therapy VR1: vallinoid receptor subtype 1

WWBGT: wet-bulb globe temperature WMD: weapons of mass destruction

xxvii

Medical Aspects of Chemical Warfare Index

Index

A

Aberdeen Biological Chemical Agent Disposal Facilitymustard agent container drainage, 597

Abood, Leoanticholinergic deliriant research, 424

Abramson, Dr. Haroldlysergic acid diethylamide research, 413

Acetylcholinesteraseassays for measuring, 702description and mechanism of action, 158, 693nerve agent effect on, 158, 244, 316, 693–694

ACGIH. See American Conference of Governmental Industrial Hygienists

AChE. See AcetylcholinesteraseAcland, K.M.

uses of lasers in dermatological practice, 284Acticoat

mustard agent injury dressing, 280Activated charcoal

brevetoxin intoxication treatment, 630palytoxin intoxication treatment, 620saxitoxin treatment, 627tetrodotoxin treatment, 627

Active topical skin protectantcriteria for, 531–532development of, 531

Acute exposure guidance levelsfor chemical agents, 143

Acute respiratory distress syndromesulfur dioxide and, 345toxic industrial chemicals and, 354–355

Adams, Maj. Robertdiphenylaminearsine discovery, 464

AEF. See American Expeditionary ForcesAEGLs. See Acute exposure guidance levelsAfghanistan

September 11, 2001, terrorist attacks and, 65, 129Afghanistan War

chemical weapons and, 62AFS. See Alternative footwear systemAge factors

butyrylcholinesterase activity, 164erythrocyte cholinesterase, 164

Agency for Toxic Substances and Diseases RegistryHazardous Substance Emergency Events Surveillance System,

540Agent Orange

estimation of injuries from, 428Vietnam War and, 341

Aghajanian, GeorgeLSD research, 417

Aharoni, A.human paraoxonase 1 research, 251

Airplanessmoke tanks, 120used for chemical attacks, 26, 118–119

Aisne defensivechemical attacks, 29

Aisne-Marne offensivechemical attacks, 30–31division field hospitals, 95medical personnel as victims, 102US participation (figure), 31

Al Qaeda

chemical weapons and, 129, 145compared with Aum Shinrikyo, 129description, 129

Alexander, Lt. Col. StewartBari disaster and, 105

Alkyl methylphosphonic acidsnerve agents and, 694, 695, 696, 698

Alkyl MPAs. See Alkyl methylphosphonic acidsAlphabet Bomber

chemical attack description, 127Alprazolam

incapacitating effects, 420Alternative footwear system

description, 573Alzheimer’s disease

anticholinesterase drug treatment, 158, 704memantine treatment, 228physostigmine treatment, 704tetrahydroaminacridine treatment, 426

Ambros, Ottosarin research, 47, 156views on chemical warfare, 49

American Academy of Pediatricsforms of terrorism that require immediate attention, 656resources, 683–684

American Burn Associationcriteria for chemical burn injuries, 278

American Conference of Governmental Industrial Hygienists2-chlorobenzylidene malononitrile exposure guidelines, 447

American Expeditionary Forces. See also US Army Medical De-partment

Aisne-Marne Offensive and, 30–31Battle of Belleau Wood and, 28, 29–30Battle of Cambrai and, 24–25Battle of Cantigny and, 27, 29Battle of Chateau-Thierry and, 28, 29Battles of Sommervillier and Ansauville and, 25–26Champagne-Marne defensive and, 30chemical warfare casualties, 41–42earliest reported description involving chemical warfare on

(exhibit), 22first projector attack on (exhibit), 26Headquarters, First Army Corps, memorandum on the evacu-

ation of sick and wounded, 1918 (exhibit), 98Lys defensive and, 26–27major defensive campaigns, 1918 (table), 89major offensive campaigns of the AEF, 1918 (table), 101Meuse-Argonne campaign and, 33, 36Oise-Aisne offensive and, 321st Gas Regiment, 22, 37secret field order no. 41, annex no. 7, issued by the Fifth Divi-

sion, September 9, 1918 (exhibit), 100World War I AEF in offensive and defensive battles involving

chemical warfare (table), 23American Heart Association

Pediatric Advanced Life Support Course, 682recommended values for safe cardiovascular function (table),

542Aminophylline

incapacitating agent exposure treatment, 471phosgene inhalation treatment, 354

Amitai, Y.use of atropine in the pediatric population research, 663–664

AMLs. See Area medical laboratoriesAmmonia

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Medical Aspects of Chemical Warfare IndexMedical Aspects of Chemical Warfare Index

clinical presentation, 355–356corticosteroid treatment, 353gaseous ammonia effects at various concentrations (table), 355nonmilitary use, 341–342signs and symptoms of inhalation, 353

AMN. See Atropine methylnitrateAmyl nitrite

cyanide poisoning treatment, 383–384, 394–395, 397, 675–676Anders, M.W.

phosgene research, 736Anesthetics. See also specific agents

dissociative anesthetics, 419–420pediatric population and, 665, 667

Angolause of nerve agents against rebels, 63

Ansauville, Battle ofphosgene and chloropicrin attacks, 25–26

AnthraxCDC categorization as a category A threat agent, 616

Anthrax attacksdomestic preparedness and, 761Strategic National Stockpile and, 765

Antibiotics. See also Topical antibioticschlorine exposure treatment, 673mustard agent treatment, 672toxic industrial chemical exposure treatment, 363

Anticholinergic deliriants. See also specific agentsancillary supportive measures for the treatment of delirium

(exhibit), 430compound comparisons, 424–425diagnosis of syndromes caused by, 428incapacitating effects, 413, 421, 422–425mechanism of action, 422, 425safety of, 427summary of BZ and fentanyl derivatives (exhibit), 429testing on volunteers, 424–425treatment for intoxication, 425–426

Anticonvulsive therapy. See also specific agentsnerve agent exposure and, 189–190

Antidote treatment nerve agent autoinjectornerve agent exposure treatment, 182–186, 192, 193, 194, 518,

520–521, 651, 663replacement of Mark I kits and, 651, 652

Antioxidantstreatment of mustard agent exposure, 282

Antipsychotic drugs. See also specific agentsincapacitating effects, 420side effects, 420

Anxietydifferential diagnosis of incapacitating agent intoxication, 428

Arab-Israeli Six-Day Warbiological warfare and, 58nerve agent use, 58

Arab-Israeli Yom Kippur Warchemical weapons and, 61

ARDS. See Acute respiratory distress syndromeArea medical laboratories

domestic preparedness role, 763–764endemic diseases section, 764nuclear, biological, and chemical section, 764occupational and environmental health section, 763–764professional officer filler information system, 764structure of, 763

Armed Forces Institute of Pathology1-chloroacetophenone research, 463

Armed Forces Radiobiology Research InstituteCBRNE training program, 768

Arrhythmiasnerve agent exposure and, 179–180treatment for, 179, 190ventilatory support, 190

Arsenicals. See Lewisite; Phosgene oximeArthur, Vice Admiral Stanley

chemical warfare comments, 64AS. See Atropine sulfateAsahara, Shoko

Aum Shinrikyo and, 127Ashani, Y.

plasma-derived human butyrylcholinesterase research, 245Ashton, I.

dibenz[b,f]-1,4-oxazepine research, 467“Assay Techniques for Detection of Exposure to Sulfur Mustard,

Cholinesterase Inhibitors, Sarin, Soman, GF, and Cyanide” (Technical Bulletin Medical 296), 693

Assays of adducts to biomoleculesanalytical methods, 698–699analytical methods using adducts to biomolecules (table), 700application to human exposures, 699–701methods used to confirm human exposures to nerve agent ad-

ducts to biomolecules (table), 701ATCA. See 2-aminothiazoline-4-carboxylic acidAtkisson, Col. E.J.

AEF 1st Gas Regiment leadership, 22Atlanta Olympics bomb scare, 754ATNAA. See Antidote treatment nerve agent autoinjectorAtroPen

nerve agent exposure treatment, 182, 663pediatric population and, 663

Atropine. See also Atropine sulfate; Dry powder inhaler atropineantidote drug card for pediatric dosing of atropine (figure),

683brevetoxin intoxication treatment, 630incapacitating effects, 412, 413, 422, 425, 426pediatric population and, 663–664saxitoxin treatment, 627tetrodotoxin treatment, 627

Atropine methylnitratesoman-induced seizure-related brain damage treatment, 227,

228Atropine sulfate

adjuncts to, 182antidote treatment nerve agent autoinjector, 182–186arrhythmia treatment, 179, 190asymptomatic persons and, 185combined with oximes, 183, 188combined with 2-pyridine aldoxime methyl chloride, 183cyclosarin exposure and, 202dosage considerations, 182–186eye pain and, 192goal of therapy, 184–185inhalational exposure to vapor treatment, 185IV delivery of, 180Mark I kits, 182–186, 188, 190, 192, 194, 663mechanism of action, 182, 316medical aerosolized nerve agent antidote, 186, 192nerve agent exposure treatment, 175, 182–186, 244, 316organophosphorus compound exposure treatment, 184pediatric population and, 195routes of administration, 193–194side effects, 182–183topical application of, 190ventilatory support and, 181, 186, 193

aTSP. See Active topical skin protectantAtta, Gen. Qassim


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chlorine gas attack and, 66Aum Shinrikyo

chemical attacks against judges, 127–128, 695compared with Al Qaeda, 129sarin attack in the Tokyo subway, 4, 125, 128, 158, 178, 181–182,

193, 196–197, 223, 244, 316, 317, 321, 492, 518, 540, 657, 695–696, 699, 754

Austriacyanogen bromide introduction, 373

Aviado, D.incapacitating agent research, 442

Aviado, D.M.incapacitating agent research, 442

BBabad, H.

phosgene research, 345Baille, V.

soman-induced brain injury, 224–225Baker, Secretary of War Newton D.

Chemical Warfare Service and, 43BAL. See British antilewisiteBalali-Mood, M.

mustard exposure research, 313, 315BALF. See Bronchoalveolar lavage fluidBallantyne, B.

dibenz[b,f]-1,4-oxazepine research, 467, 468hydrogen cyanide research, 3541-chloroacetophenone research, 460, 4612-chlorobenzylidene malononitrile research, 451

Ballough, G.P.soman-induced brain injury, 225

Barbiturates. See also specific agentsdescription and incapacitating effects of, 418LSD intoxication treatment, 417safety margin, 418

Barlow, R.J.uses of lasers in dermatological practice, 284

Basic Personal Equipment, 561Baskin, S.I.

cyanide poisoning treatment, 396Bass, Col. Sampson

Program Manager for Demilitarization of Chemical Materiel and, 141

Basson, Dr. Wouteruse of 3-quinuclidinyl benzilate by Iraq, 413

Batrachotoxinchemical structure (figure), 632laboratory findings, 633lethality of, 633mechanism of action, 632monitoring, 633physical examination and, 632–633poison blow gun dart use, 632protection, 633sodium channel effects, 617sources, 632stability, 633surveillance, 633synthesis, 632toxicity, 632treatment, 633

Baud, F.J.cyanide poisoning research, 396

Baxter Healthcare Corporationplasma-derived human butyrylcholinesterase production, 653

BChE. See Butyrylcholinesterase

Behavioral and psychological changescategorization of, 176cyanide poisoning and, 393–394effects of nerve agent exposure, 175–176plasma-derived human butyrylcholinesterase and, 248–249

Belgian Consensus on SEstatus epilepticus treatment recommendations, 231

Belladonna alkaloids. See Anticholinergic deliriantsBelleau Wood, Battle of

chemical attacks, 29–30overview and detailed maps (exhibit), 28

Bellevue Hospital Centerpediatric nerve agent antidote dosing schedule, 684

Benzodiazepines. See also specific agentshypothermia and, 548–549incapacitating effects, 420LSD intoxication treatment, 417

Berber wardescription, 42–43

Berthollet, Comte Claude-Louissynthesis of cyanogen chloride, 116

Beswick, F.W.2-chlorobenzylidene malononitrile research, 450

Bhopal, Indiaaccidental release of methyl isocyanate, 131, 134, 326, 347

Biel, Johnanticholinergic deliriant research, 424

Bigeye bombsresearch on, 123, 125

bin Laden, Osamaformation of Al Qaeda and, 129September 11, 2001, terrorist attacks and, 65

Binary chemical weapons“Bigeye” bomb, 123, 125description, 3, 123development of, 122–124US Congress restrictions on, 124US Congress review of, 124

Bing, OscarLSD research, 417

Bio Shield towelettesincapacitating agents and, 470–471

Biobranemustard agent injury dressing, 280

Biological warfareArab-Israeli Six-Day War and, 58“Biotechnology: Impact on Biological Warfare and Biode-

fense,” 420–421chemical weapons comparison, 126Nixon’s ban on biological warfare agents, 138World War I and, 37

Biological Weapons Conventiondescription, 137–138Soviet Union and, 61–62

Bioregulatorsincapacitating effects, 420–422

Bioscavengersadvantages of enzymes, 245catalytic type, 250–251categories of, 245free radical scavengers, 232plasma-derived stoichiometric type, 245–249Project BioShield, 251recombinant stoichiometric type, 249–250

“Biotechnology: Impact on Biological Warfare and Biodefense,” 420–421

Bis-(2-chloroethyl)sulfide. See Mustard agent

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Biskup, R.C.dibenz[b,f]-1,4-oxazepine research, 468

Black, R.M.blood sample analysis for mustard agent, 723urine sample analysis for mustard agent, 711, 712, 716, 717

Black vinyl overbootsdescription and uses, 573

Blackford, Lt. Col. William W.chemical weapon use and, 12

Blair, Prime Minister Tony (Great Britain)warning to the UN on Iraq’s weapons of mass destruction

program, 66Blister agents. See VesicantsBlood cholinesterases

butyrylcholinesterase, 163–164erythrocyte cholinesterase, 164inhibition in, 164–166nerve agent scavenger activity, 164RBC-ChE monitoring, 161, 163relation of cholinesterase activity to vomiting after exposure to

VX (table), 166relation of effects of nerve agent exposure to erythrocyte cho-

linesterase activity (table), 166relation to signs and symptoms of nerve agent exposure,

165–166time course of inhibition, 165vomiting and, 165–166

Blood sample analysisanalytical methods, 718–721application to human exposure, 721–726benefits of, 692collection issues, 692cyanide poisoning, 731, 733–734guidelines for collection, 739lewisite exposure, 728, 731mustard agent exposure and, 718–726published reports (1997-2006) of laboratory analysis of hu-

man blood samples following suspected exposure to sulfur mustard (table), 727

sample considerations, 739sample preparation methods for the gas chromatographic-

mass spectrometric analysis of sulfur mustard adducts to blood biomolecules (exhibit), 724–725

sample preparation procedure for sulfur mustard adducts to deoxyribonucleic acid in blood (exhibit), 722

Bolimov, Battle ofchlorine gas attacks, 17T-shells used at, 14

Bone marrowmustard agent exposure effects, 288–290, 669, 672

Boomfield, C.A.butyrylcholinesterase research, 245

Bootsalternative footwear system, 573black vinyl overboots, 573medical problems and, 573risk of falls and, 573

Borris, D.J.ketamine research, 230

Botulinum neurotoxinCDC categorization as a category A threat agent, 616

Bowers, M.B.nerve agent exposure research, 3202-chlorobenzylidene malononitrile research, 452

Boyer, A.E.urine sample analysis for mustard agent, 711

Boyton, Capt. E.C.

chemical weapon use and, 12Branch Davidian compound, Waco, TX

FBI attack on, 125Brandeis, R.

plasma-derived human butyrylcholinesterase research, 249Brevetoxin

chemical structure (figure), 629laboratory findings, 630mechanism of action, 629monitoring, 630physical examination and, 629–630protection, 631red tide blooms and, 628, 629–630, 631routes of exposure, 629–630signs and symptoms of intoxication, 630sodium channel effects, 617stability, 631surveillance, 631synthesis, 628–629toxicity, 629treatment, 630–631

Brisebois, R.J.mustard agent exposure treatment, 279

British antilewisitelewisite exposure treatment, 291, 293, 523, 667

Bronchoalveolar lavage fluidinhalational injury from toxic industrial chemicals and, 348

Broselow, Dr. JamesChemical Warfare Involving Kids Response Project and, 681

Broselow-Luten systemantidote drug card for pediatric dosing of atropine (figure),

683availability of, 681–682description, 681generic needs of children in a disaster situation and, 681–682logistical difficulties and, 681–683specific needs of children in a chemical disaster and, 682–683steps involved in administering a dose of medication (figure),

682Browder burn severity assessment, 282Brussels Convention

description, 136BTX. See BatrachotoxinBuChE. See ButyrylcholinesteraseBudesonide

chlorine inhalation treatment, 353Bulgaria

accidental release of chloropicrin in Sofia, 443, 455Bullard, Maj. Gen. Robert

comments on gas attacks, 26gas attack order, 22gas training for troops and, 22

Bullene, Maj. Gen. EgbertKorean War comments, 54

Buscher, H.long-term health effects of mustard, 312, 314

Bush, Pres. George H.W.chemical weapons destruction plan, 138

Bush, Pres. George W.National Incident Management System and, 492Project BioShield and, 251US Department of Homeland Security creation and, 755warning to the UN on Iraq’s weapons of mass destruction

program, 66Butyrylcholinesterase. See also Plasma-derived human butyryl-

cholinesterasebiomolecule assays and, 700–701


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bioscavenger use, 245, 706description, 158gender differences in activity of, 164physiological role, 163succinylcholine and, 164synthesis of, 163–164

BZ. See 3-quinuclidinyl benzilate

CCaE. See CarboxylesteraseCAIs. See Chemical accidents or incidentsCalabar bean

use as a nerve agent, 156Calamine lotion

mustard agent exposure treatment, 670California

accidental chloropicrin exposure in Kern, CA, 456, 457Calmatives. See BioregulatorsCambrai, Battle of

chemical warfare, 24–25trench conditions, 24

CANA. See Convulsive Antidote, Nerve Agent injectorCanada

Russia’s elimination of chemical weapons and, 145Canadian Department of National Defence

Reactive Skin Decontamination Lotion and, 652–653Cannabinoids

description and effects of, 418Cantigny, Battle of

chemical attacks, 27, 29Capacio, B.R.

blood sample analysis of mustard agent exposure (figure), 725Caplin ammonia inhalation classification, 355Capsaicin. See Oleoresin capsicumCarbamates

characteristics of, 198–199chemical structure (figure), 198compounds included, 158mechanism of action, 161, 198uses of, 158

Carbon monoxide gasGermany’s experimental testing on human subjects in concen-

tration camps, 105Carboxylesterase

bioscavenging use, 246Carcinoma

dibenz[b,f]-1,4-oxazepine exposure and, 468–469mustard agent exposure and, 312–314, 313–314, 315–3161-chloroacetophenone and, 461palytoxin and, 6192-chlorobenzylidene malononitrile and, 449

Cardiovascular systemAmerican Heart Association recommended values for safe

cardiovascular function (table), 542arrhythmias, 179–180batrachotoxin effects, 633brevetoxin effects, 630change in the electrocardiogram caused by the presence of

cyanide in the tissue (figure), 392cyanide poisoning effects, 391–393effects of nerve agent exposure, 179–180electrocardiogram from a cyanide-intoxicated individual

(figure), 392heart rate, 180incapacitating agent exposure effects, 472palytoxin effects, 619, 620paralytic shellfish poisoning effects, 626

saxitoxin effects, 623, 627tetrodotoxin effects, 623, 627

Carfentanildescription and incapacitating effects, 419

Cassava rootcyanide exposure and, 323, 374, 390, 731

Castro, J.A.1-chloroacetophenone research, 460

Catalytic bioscavengerschloroperoxidase, 250compared with stoichiometric scavengers, 250human paraoxonase 1, 250–251sources of, 250

CBRNE incidents. See Chemical, biological, radiological, nuclear or explosive incidents

CDC. See Center for Disease Control and PreventionCenter for Disease Control and Prevention. See also National Insti-

tute for Occupational Safety and Healthclassification of bioterrorism agents/diseases (table), 617demilitarization of chemical agents and, 142, 143Enhanced Surveillance Program, 622Laboratory Response Network and, 765–766list of toxic chemicals and chemical agents, chemical character-

istics, and medical first aid and antidote treatment, 761phosgene inhalation treatment guidelines, 354sample collection, shipping, and storage guidelines, 739–741Strategic National Stockpile and, 765threat agent categorization, 616–617

Center for Pediatric Emergency Medicinepediatric nerve agent antidote dosing schedule, 684

Central Intelligence Agencylysergic acid diethylamide and, 414saxitoxin capsules and, 628terrorist interest in food and water contamination, 672

Central nervous systembatrachotoxin effects, 633brain lesions, 178cyanide poisoning effects, 393–394electroencephalographic effects of nerve agent exposure,

176–177, 321–322hypoxia, 178–179, 180, 287long-term effects of nerve agent exposure, 177–179mustard agent effects, 276, 290, 315, 669nerve agent effects, 175–179, 317neuropsychiatric symptoms, 315organophosphate insecticide effects, 317palytoxin effects, 621pediatric exposure to toxic agents and, 659polyneuropathy, 317saxitoxin effects, 623, 625–626seizures, 178–179soman effects, 416tetrodotoxin effects, 623, 625–626

CG. See PhosgeneChad

Libya’s use of chemical weapons against, 63Champagne-Marne defensive

chemical attacks, 30US participation (figure), 31

Chapman, A.J.1-chloroacetophenone research, 462

Charles XII, King (Sweden)use of toxic smoke projectiles, 11

Chateau-Thierry, Battle ofchemical attacks, 29overview and detailed maps (exhibit), 28

ChE inhibitors. See Cholinesterase inhibitors

xxxii


Chemical, biological, radiological, nuclear or explosive incidentsdetection and response capabilities of DoD, 761–762effective information flow and, 754reach back capabilities of DoD, 763training and education issues, 767–770

Chemical Accident or Incident Response and Assistance Operationschemical surety resource, 594level 1 medical care, 609Medical Management of Chemical and Biological Casualties

Course, 594–595Toxic Chemical Training Course for Medical Personnel,

594–595Chemical accidents or incidents

Chemical Stockpile Emergency Preparedness Program, 609coordination required, 607–608decontamination procedure, 609emergency medical care, 608information needed, 608–609levels of medical care, 609medical aspects of response to, 607–609medical response teams and, 607planning phase, 607

Chemical agent detector kitsdescription and uses, 576–577

Chemical and biological protected shelterscomposition of, 585–586description, 585

Chemical Biological Medical Systems Joint Project Management Office

responsibilities, 4Chemical Corps

air and ground delivery systems for chemical weapons, 120cannabinoid research, 418changes of the 1970s, 60–61Chemical Warfare Service name changed to, 53incapacitant program, 55–56Korean War and, 54lysergic acid diethylamide testing, 416–417medical research on human volunteers during the 1950s, 55mission, 53–541950s changes in, 54–55planned changes of the 1970s, 60–61sarin production, 553-quinuclidinyl benzilate testing, 414training and education in CBRNE and, 767US Army reorganization and, 56–57Vietnam War and, 57

Chemical defense equipmentcollective protection, 584–587criteria for selection of, 560decontaminable litters, 588–589decontamination equipment, 581–584detection and warning systems, 575–579individual chemical patient resuscitation devices, 587–588individual protective equipment, 561–575integrated approach to protection, 560patient protective wraps, 587principles for optimal outcome, 560respirators, 560timely detection need, 560toxic industrial material protection, 580–581

Chemical personnel reliability programdescription, 605medical authority recommendations, 605medical support of, 605, 607potentially disqualifying factors, 605

Chemical protective glove set

decontamination of, 574description and composition of, 573

Chemical Security Analysis Centerdescription and role, 767

Chemical Stockpile Emergency Preparedness Programalternative year exercises, 766–767chemical accidents or incidents and, 609chemical depots, 766–767DoD role, 766federally managed exercises, 766FEMA role, 766

Chemical Surety (AR 50-6), 594Chemical terrorism. See Terrorist attacks“Chemical Warfare in Southeast Asia and Afghanistan” (Haig), 62Chemical Warfare Involving Kids Response Project

description, 681“Chemical Warfare Respiratory Protection: Where We Were and

Where We Are Going,” 561Chemical Warfare Service

airplane attack testing, 119chemical agent and weapon stockpiling, 119chemical weapon delivery system improvement, 118complaints about gas mask effectiveness, 83creation of, 22, 90, 117, 761divisions, 22Gas Service, 22, 89–90Italian-Ethiopian War and, 46low point in funding for, 44monitoring of Japan’s use of chemical weapons in China, 52name change to Chemical Corps, 53need for permanent status of, 43–44, 531920s and, 43–44organophosphorus compound designations, 47plans to use poison gas on Japan, 52–53staff statistics, 37standardization of chemical agents, 44training of troops during World War II, 53

Chemical weapons. See also Development of chemical weaponry; specific chemicals; specific conflicts

agent toxicity determination, 657capabilities of nations, 131–132categories of, 10“chemical threat” definition, 130comparative volatility of chemical warfare agents (table), 135compared with biological weapons, 126delivery systems, 80, 117–118, 119, 120–122, 123, 130, 132–133,

157demilitarization of, 609–611description, 2, 10desirable outcomes of the use of, 2direct injuries from, 10effectiveness as weapons, 79features of, 133future threats, 4general principles of chemical exposure, 657How to Tell the Gases poem by Maj. Fairfax Downey (exhibit),

41indirect injuries from, 10Joint Program Executive Office role, 4military advantages of, 2military chemical agents, 133–134modern chemical warfare agents (table), 134nonpersistent agents, 135persistent agents, 135–136, 244physical properties of chemical agents, 134–136political and legal ramifications of an attack, 692potential for use in the civilian sector, 692


xxxiii


psychological effect of, 2, 19–20stockpile management, 3–4tactical and strategic use of, 132terrorist threat, 4timeline of agents, 2–3toxin comparison, 616–617US stockpile agent destruction (table), 143volatility of, 134–135, 168wind and weather considerations, 80, 117, 131, 135–136

Chemical weapons agreementsBiological Weapons Convention, 137–138Chemical Weapons Convention, 138–145Geneva Protocol, 136–137UN Disarmament Committee, 137US-Soviet weapons destruction agreement, 138

Chemical Weapons Conventionbasic tenets, 139chemical demilitarization, 141–145, 766development of, 138disarmament provisions, 3fentanyl and, 419governmental proliferation threat, 145implementation issues, 140–141inspection and verification, 140noncompliance issues, 140, 141nongovernmental proliferation, 145prohibition on the use of tear gas in combat, 66, 431, 442ratification of, 138–139, 157schedule and category of chemicals and chemical weapons

(table), 139schedule of implementation plan (table), 140scheduling issues, 139–140, 157signing of, 65, 157“toxin” definition, 614

Chemically protected deployable medical systemcomposition of, 584–585description, 584M28 collective protection equipment, 585

Chen, K.K.cyanide poisoning research, 383, 384–385

Children. See Infants and childrenChina

ancient use of toxic smoke, 10, 12, 78chemical weapon production, 48incapacitating agent use, 443invasion by Japan in 1937, 46

Chlorineaccidental release of, 131, 134advantages of as a weapon, 126, 342Battle of Loos and, 18–19clinical presentation of exposure to, 672–673combined with phosgene, 341development of, 14discovery of, 116general mechanisms of toxic gas exposure (figure), 347nerve agents compared with, 181nonmilitary uses, 342pediatric population and, 673Second Battle of Ypres and, 14–18, 21, 80–82signs and symptoms of exposure, 359treatment for inhalation of, 353, 673US production of, 117“white star” mixture with phosgene, 19–20World War I use, 2, 14–19, 21, 80–82, 83

Chloroacetophenonenonmilitary uses, 342overall effects of, 342

Yemen Civil War and, 57, 58Chloroperoxidase

VX nerve agent and, 250Chloropicrin

accidental release of, 443, 455agricultural uses, 443, 455characteristics of PS, CN, DM, and CR (table), 458–459chemical structure (figure), 456chloropicrin syndrome, 456clinical effects, 456–457deployment methods, 456development and properties of (exhibit), 20earliest reported description involving chemical warfare on

the AEF (exhibit), 22introduction of, 20long-term effects, 457mechanism of action, 455physical characteristics, 456physiological effects, 456safes and vaults and, 455severe medical complications, 457synthesis of, 117, 443toxicity of, 443US production of, 117World War I use, 25–26, 455

Chlorovinylarsonous acidlewisite exposure and, 728published analytical approaches for the analysis of CVAA in

urine (figure), 729sample preparation methods for gas chromatographic/mass

spectrometric analysis of CVAA (exhibit), 730Chlorpromazine

LSD intoxication treatment, 417Cholinesterase analysis

colorimetric assays in the clinical laboratory, 702, 704electrometric ChE assay, 704Ellman assay, 702huperzine A, 704–706laboratory and field assays routinely used by the US Army

and their required processing (figure), 703mass spectrometry, 701–702organophosphorus compounds, 701–706pretreatment therapy for nerve agent poisoning, 704–706Test-Mate kit, 702, 704Walter Reed Institute of Research Whole Blood Assay, 702, 705

Cholinesterase inhibitors. See also Nerve agents; specific agentsblood cholinesterases, 161–166case report: accidental exposure of a man to liquid soman

(exhibit), 162–163, 312cholinesterase in tissue, 158compounds, 158–159development of, 46–47diagram of neuromuscular conduction (figure), 160mechanism of action, 159–161pharmacology of, 158–168reversible and irreversible types, 156

Cholinesterasesequine serum butyrylcholinesterase, 245fetal bovine serum AChE, 245plasma-derived human butyrylcholinesterase, 245–249

Cholinolytic 3-quinuclidinyl benzilateperfluoroisobutylene inhalation treatment, 354

Church, Maj. J.R.Chemical Warfare Service leadership, 90Churchill, Sir Winston

plans for gas warfare during World War II, 52City of New York Bureau of Emergency Medical Services

xxxiv


pediatric nerve agent antidote dosing schedule, 684City of New York Fire Department

pediatric nerve agent antidote dosing schedule, 684Civil War. See US Civil WarCK. See Cyanogen chlorideClark, M.G.

plasma-derived human butyrylcholinesterase research, 249Clean Air Act

destruction of chemical weapons stockpile and, 610Clermont

tetraethyl pyrophosphate testing, 46, 156Clinton, Pres. Bill

presidential decision directives outlining policy for deterring and responding to terrorism, 754

Clonidineincapacitating effects, 421

Cluster bombschemical weapon delivery, 120, 122

CN. See chloroacetophenone; 1-chloroacetophenoneCobalt EDTA

cyanide poisoning treatment, 385, 397Cobalt salts

cyanide poisoning treatment, 397Cochrane, Capt. Charles

batrachotoxin description, 632–633Cochrane, Rexmond

Battle of Cantigny and, 27Cohn Fraction IV-4 paste

plasma-derived human butyrylcholinesterase source, 247, 249, 251

Cole, T.J.2-chlorobenzylidene malononitrile research, 450

Colgrave, H.F.dibenz[b,f]-1,4-oxazepine research, 467, 469

Collective protectioncategories of, 584chemical and biological protected shelters, 585–586chemically protected deployable medical system, 584–585collectively protected expeditionary medical support, 585M20 simplified collective protection equipment, 586–587modular general purpose tent system chemical-biological

protective liner system, 587tactical application, 584

Collectively protected expeditionary medical supportdescription, 585

Colombian poison dart frogsbatrachotoxin source, 632

COLPRO. See Collective protectionComboPen

2-pyridine aldoxime methyl chloride administration, 187Cone, D.C.

summary of triage systems, 517Conner, M.W.

hexachloroethane smoke research, 327Convulsive Antidote, Nerve Agent injector

diazepam administration, 189–190nerve agent exposure treatment, 651

Cooper, G.J.wound decontamination research, 538–539

Cooper, W.C.organophosphate insecticide exposure research, 320

Corson, B.B.2-chlorobenzylidene malononitrile research, 444

Corticosteroids. See also specific agentsammonia inhalation treatment, 353brevetoxin intoxication treatment, 631chlorine exposure treatment, 673

incapacitating agent exposure treatment, 471mustard agent exposure treatment, 282phosgene inhalation treatment, 354, 363toxic industrial chemical exposure treatment, 363

The Covenant, the Sword, and the Arm of the Lordchemical attack plan, 127

CP EMEDS. See Collectively protected expeditionary medical support

CR. See Dibenz[b,f]-1,4-oxazepineCreasy, Maj. Gen. William

lysergic acid diethylamide research, 414Crone, H.D.

decontamination research, 529CS. See O-chlorobenzylidene malononitrile; 2-chlorobenzylidene

malonitrileCSA. See The Covenant, the Sword, and the Arm of the LordCSEPP. See Chemical Stockpile Emergency Preparedness ProgramCurran, D.

anticholinergic deliriant research, 422Currie, W.D.

phosgene research, 738Cushing, Dr. Harvey

account of Royal Army Medical Corps capabilities, Flanders, Belgium, May 5, 1917 (exhibit), 88

chemical attack observations, 101initial impressions of mustard agent, 88–89observations of the Second Battle of Ypres, 82

CVAA. See Chlorovinylarsonous acidCWC. See Chemical Weapons ConventionCWS. See Chemical Warfare ServiceCyanide. See also Cyanogen chloride; Hydrogen cyanide

accidental exposures, 374advantages and disadvantages of, 3, 126analytical methods for determining cyanide in biological

samples (table), 732–733chemical, physical, environmental, and biological properties

(table), 372conventional wounds contaminated with, 523description, 322, 731dietary issues, 323, 372–373, 374, 389endogenous cyanide concentrations for smokers and non-

smokers (table), 381executions and suicides and, 373–374“gas chambers” and, 373–374Germany’s experimental testing on human subjects in concen-

tration camps, 105goiter and, 324historical use, 372–373long-term exposure to, 323–324long-term health effects, 322–324mechanism of action, 343, 397, 731mechanism of toxicity, 673–674, 731military use, 372, 373pharmacokinetics and pharmacodynamics, 376physiology, 322quick-kill properties, 373reference range values, 734routes of exposure, 322sources, 372, 374, 731terrorist plots using, 4tobacco smoke and, 323, 324, 374toxicity, 377toxicodynamic effects (figure), 384Tylenol poisoned with, 373uses for, 673volatility of, 373World War I use, 372, 373


xxxv


Zyklon B development, 15Cyanide poisoning

analytical methods, 377, 731–734analytical methods to identify cyanide and its metabolites in

biological fluids (table), 378–379antidotal treatment, 383, 518–519, 675–676antidotes useful in acute cyanide poisoning (table), 395biochemical basis, 374–377blood sampling issues, 377, 379–381, 382, 387cardiac toxicity, 391–393case synopses, 388–389change in the electrocardiogram caused by the presence of

cyanide in the tissue (figure), 392clinical presentation and management of casualties, 381–386,

518–519, 674, 731computational models of cardiac tissue, 392–393Cyanokit treatment, 676decontamination, 386–387detection of cyanide and cyanide metabolites, 377–381effect of cyanide on a ventricular cell (figure), 392electrocardiogram from a cyanide-intoxicated individual

(figure), 392enzyme inhibition, 382–383fire victims and, 390–391, 731fundamentals of cyanide antidote therapy (figure), 385hemodialysis treatment, 383histopathologic changes in cardiac tissue, 391–392laboratory findings, 387, 674lethal dose, 383long-term effects, 387–389metabolic routes, 376, 731methemoglobin former treatment, 394–396mnemonic for recognition of cyanide toxicity (exhibit), 675mortality from, 322, 376, 381, 731mouth-to-mouth resuscitation and, 675multistage antidote kit treatment for managing unconscious,

cyanide-exposed patients (table), 675neurological/psychological responses to cyanide and its coun-

termeasures, 393–394oxygen therapy, 385patient transport/evacuation, 387pediatric considerations, 389–390, 674–676plot against the US Embassy in Italy, 128polyintoxications, 390–391procedures for collecting and storing blood samples for de-

layed cyanide analysis (exhibit), 382protection of rescuers, 382schematic diagram of possible detoxification reaction for cya-

nide in a theoretical cell (figure), 375specific antidotes, 394–397supportive treatment, 323, 383, 674, 675survivability of, 381–382, 388–389symptoms of severe ingestions, 323therapy principles, 381–386thiocyanate and, 380treatment, 674–676triage considerations, 386, 518–519, 521, 522, 5232-aminothiazoline-4-carboxylic acid and, 376US approach to cyanide antidotes (table), 386variation of sodium nitrite and sodium thiosulfate dose with

hemoglobin concentration (table), 676wound decontamination and, 538

Cyanogen bromideintroduction of, 373

Cyanogen chloridedelayed toxic effect, 373discovery of, 116

introduction of, 18synthesis of, 116US troop training and, 53World War I use, 373

Cyclohexylmethyl phosphonofluoridate. See CyclosarinCyclosarin

aging time, 202chemical structure (figure), 694hydrolysis pathway of sarin, soman, and cyclosarin (figure),

696Iraq’s production of, 202polyneuropathy and, 317synthesis of, 157toxicity and speed of action, 156, 168, 693treatment of exposure to, 202volatility of, 168

Cysteinephosgene exposure and, 736

Cytoxansimilarity of mustard agent to, 313

dDA PAM 40-8. See Occupational Health Guidelines for the Evaluation

and Control of Occupational Exposure to Nerve Agents GA, GB, GD, and VX

DA PAM 40-173. See Occupational Health Guidelines for the Evalu-ation and Control of Occupational Exposure to Mustard Agents H, HD, and HT

DA PAM 50-6. See Chemical Accident or Incident Response and As-sistance Operations

DA PAM 385-61. See Toxic Chemical Agent Safety StandardsDAET. See Diisopropyl aminoethanethiolDakin solution

treatment of mustard agent injuries, 280–281, 671Dantrolene

combined with diazepam, 228dosage considerations, 227soman-induced seizure-related brain damage treatment,

227–228Dark, Dr. Eric P.

personal account of a chemical attack (exhibit), 102Datura

use as an incapacitating agent, 413Davies, D.R.

nerve agent research, 317Davy, Sir Humphry

synthesis of phosgene, 116Debridement

enzymes and, 284–285lasers and, 284powered dermabrasion, 284treatment of mustard agent injuries, 280, 282, 283–285, 290,

670–671wound decontamination and, 539

Decontaminable littersdescription and uses, 588–589

Decontamination equipmentequipment decontamination, 582–583joint service personnel skin decontamination system, 582M291 skin decontamination kits, 533, 536, 581methods in development, 583–584patient thorough decontamination, 543–546pediatric population and, 661, 678personnel decontamination, 581–582

Decontamination of chemical casualtiesaction of chemical agents on the skin, 529–530air heaters and, 550

xxxvi


ambient temperature issues, 548–550appropriate uses for military decontaminants (table), 535barrier skin creams, 530–532casualty decontamination (figure), 502chlorine exposure and, 673civilian workers and, 528–529cold shock and, 548–549cold weather and, 548–550common problems with potential decontaminants, 533Contaminated Casualty Decontamination Course, 763cyanide poisoning and, 386–387, 675decontamination methods based on ambient temperature

(table), 550decontamination shelters, 544–546, 552description, 528, 551desirable traits of a skin decontaminant (exhibit), 534detection devices, 544dry decontaminants, 534, 536equipment for, 543–546, 581–584establishing a patient thorough decontamination area, 546–548field management of chemical casualties and, 497, 498–500,

501–504, 505, 506glove issues, 539hypothermia and, 548–549, 677immediate level, 500, 528incapacitating agents and, 469–471, 520individual protective ensemble and, 528methods of decontamination, 532–537military and civilian decontamination procedures, 528–529minimal decontamination procedures based on agent charac-

teristics (table), 498mustard agent and, 277, 312, 670nerve agent exposure and, 180–181objectives of, 532oxidation, 537packaged wet decontaminants, 536–537palytoxin and, 620, 621patents covering work on active topical skin protectant at the

US Army Medical Research Institute of Chemical Defense (table), 532

patient operational decontamination level, 500, 528, 529patient thorough decontamination level, 500, 539–548pediatric population, 670, 676–678placement of teams and areas, 514–516, 547purposes of, 528soap and water (hydrolysis), 533–534, 544, 551special populations and, 550–551time after exposure and, 528triage issues, 513–516, 677warming tents, 549waste water disposal, 546–547water concerns, 546–547wound decontamination, 538–539zones for, 677

Decontamination sheltersfixed facilities and, 545–546uses of, 544–545

Defense Medical Readiness Training InstituteCBRNE training program, 768

Defense Threat Reduction AgencyDefense Nuclear Weapons School, 769medical mission, 4responsibilities, 646

Deliriants. See Anticholinergic deliriantsDelivery systems

agent vaporization (figure), 134airplane smoke tanks, 120

base ejection, 132bulk release, 132chemical rockets, 120, 157cluster bombs, 120, 122, 157drones, 122explosive release, 132four modes of chemical agent release (figure), 133generator clusters, 122improvised explosive devices, 130, 145, 580land mines, 120–121, 157projectors, 26, 118, 119, 123, 157rocket program, 121–122, 157spray delivery, 132, 157spray tanks, 120toxic smokes, 10–11, 134trench mortars, 26, 118, 119typical German chemical cylinder set up and ready for dis-

charge (figure), 80vulnerability of battlefield areas, 132

Demilitarization of chemical agentsoccupational safety issues, 142Russian program, 144–145US program, 141–143, 766

Democratic National Convention of 2004CDC Enhanced Surveillance Program data, 622

Deoxyribonucleic acidmustard agent injury and, 264–265, 312, 315–316, 718–721sample preparation procedure for sulfur mustard adducts to

deoxyribonucleic acid in blood (exhibit), 722DEPMEDS. See Chemically protected deployable medical systemDermatological effects. See Skin effectsDespretz, Cesar-Mansuete

synthesis of mustard agent, 116–117, 260Detection and warning systems

point detectors, 575–577standoff detectors, 577–579toxic industrial material detection and identification, 580–581

Development of chemical weaponryearly chemical warfare agents (table), 116early history, 116–1171920s, 118–1191930s, 119–1201940s, 1201950s, 1201960s, 120–1221970s, 122–1241980s, 124–125World War I, 117–118World War II, 120

Dexanabinolmechanism of action, 229–230soman-induced seizure-related brain damage treatment,

229–230DFP. See Diisopropyl fluorophosphateDHS. See US Department of Homeland SecurityDiagnostics

archived human samples from past exposure incidents and, 692–693

biomonitoring, 692containers for shipping, 740cyanide poisoning, 731–734documentation for containers, 740far-forward field settings and, 693labeling specimens, 740lewisite exposure, 728–731method overview, 692–693nerve agents, 693–706


xxxvii


packaging specimens, 740phosgene exposure, 734–738preparing, shipping, and storing specimens, 740–741sample considerations, 739–741sulfur mustard exposure, 706–7283-quinuclidinyl benzilate, 738–739

Dianisidine chlorosulphonatedevelopment and use of, 13–14, 79

Diazepamanticonvulsive therapy, 189–190, 316arrhythmia treatment, 179brevetoxin intoxication treatment, 630Convulsive Antidote, Nerve Agent injector for, 189–190incapacitating effects, 420pediatric population and, 664severe nerve agent exposure and, 193, 194, 223, 244, 316, 520soman-induced seizure-related brain damage treatment,

227–228, 230, 231–232Dibenz[b,f]-1,4-oxazepine

acute effects, 467characteristics of PS, CN, DM, and CR (table), 458–459chemical structure (figure), 467clinical effects, 467–469deployment methods, 467initial deployment of, 442long-term effects, 468–469nonmilitary uses, 342physical characteristics, 467physiological effects, 467severe medical complications, 468–469

Dichlorethylsulphide. See Mustard agentDicobalt edetate. See Cobalt EDTADiglutathionyl dithiocarbonate. See also Glutathione

chemical structure (figure), 735phosgene exposure and, 735–736

Diisopropyl aminoethanethiolVX nerve agent assays and, 695

Diisopropyl fluorophosphatebioscavenger use on, 250British research on, 48electroencephalographic effects, 321toxicity of, 48

Diisopropyl phosphorofluoridate. See Sarinblood cholinesterase inhibition and, 164–165electroencephalographic effects, 176–177insecticide use, 158–159

Diller, W.F.phosgene research, 735

Dimercaprol. See British antilewisiteDiphenylaminearsine

acute effects, 465–466characteristics of PS, CN, DM, and CR (table), 458–459chemical structure (figure), 464clinical effects, 465–466deployment of, 464development of, 442, 464incapacitating dose, 465incapacitating effects, 416long-term effects, 466mortality from, 465physical characteristics, 464physiological effects, 464severe medical complications, 466

Diphosgene. See ChloropicrinDissociative anesthetics. See also specific agents

description and incapacitating effects, 419–420Ditran

incapacitating effects, 426Dizocilpine

soman-induced seizure-related brain damage treatment, 227–228

toxic effect of, 228DM. See DiphenylaminearsineDNA. See Deoxyribonucleic acidDoD. See US Department of DefenseDomankevitz, Y.

mustard agent injury treatment, 285Domestic preparedness

chemical preparedness programs and initiatives, 766–767Chemical Security Analysis Center, 767Chemical Stockpile Emergency Preparedness Program,

766–767DoD roles, 758–761DoD support to civil authorities, 761–764effective information flow and, 754emerging threats, 754exercises, 766–767, 769–770federal emergency response plan (figure), 762“incident command system” and, 754Laboratory Response Network, 765–766local responses, 754military healthcare role, 754, 764National Bio-Defense Analysis and Countermeasure Center,

767national civilian preparedness, 1990-2001, 754–755National Disaster Medical System, 765national preparedness programs and initiatives, 765–766“120 Cities Program,” 755organizational outline for incident management command

(figure), 757overview of the initial federal involvement under the Stafford

Act (figure), 760post-September 11, 2001, 755–758state and regional authorities and, 754Strategic National Stockpile, 765training and education, 767–770

DonepezilAlzheimer’s disease treatment, 158

Dorandeu, F.ketamine research, 230

Doughty, Johnchemical warfare proposals, 11–12

Downey, Maj. FairfaxHow to Tell the Gases poem, 41

DPIA. See Dry powder inhaler atropineDrager-Tubes industrial detectors, 580–581Drasch, G.

tissue sample analysis of mustard agent exposure, 726urine sample analysis for mustard agent exposure, 710,

715–716Drones

nerve agent delivery, 122Dry decontaminants

animal studies, 534, 536description, 534examples of, 536M291 skin decontamination kits, 533, 536, 581water issues, 546

Dry powder inhaler atropinedevelopment of, 652

Dugway Proving Ground, UTopen-air test of lethal chemical agents, 123sheep-kill incident, 59

Durham, D.

xxxviii


status epilepticus treatment, 231Durham, W.F.

organophosphate insecticide exposure research, 319Dynport Vaccine Company

plasma-derived human butyrylcholinesterase production, 653

eEaston, D.F.

mustard agent exposure research, 313Ecstasy. See 3,4-methylene-dioxymethylamphetamineEddleston, M.

atropine treatment research, 184Edgewood Arsenal, MD

Chemical Warfare Service and, 44, 117incapacitating agent research, 414, 422–424, 425–426, 463–464,

466, 467mustard agent production, 119phosgene production, 119post-World War I chemical training and research, 103shell-filling plants, 1173-quinuclidinyl benzilate research, 422–4242-chlorobenzylidene malononitrile research, 450

EEG effects. See Electroencephalographic effectsEgypt

ancient use of toxic smoke, 10Yemen Civil War and, 57–58, 341Yom Kippur War and, 61

Eisenhower, Pres. Dwight D.incapacitating agent research and, 414

Eldad, A.mustard agent injury treatment, 284

Electroencephalographic effectsnerve agent exposure, 176–177, 321–322organophosphate insecticide exposure, 321three-stage changes, 177

Electrometric ChE assaydescription and development of, 704

ELISA. See Enzyme-linked immunosorbent assayEllman assay

cholinesterase analysis, 702Elsayed, N.M.

mustard agent research, 265EMPA. See Ethyl methylphosphonic acidEmployment of Chemical Agents, Field Manual 3-10, 136Enzyme debridement

mustard agent injury treatment, 284–285Enzyme-linked immunosorbent assay

mustard agent exposure, 718, 721, 723phosgene exposure, 738

Enzymes. See BioscavengersEPA. See US Environmental Protection AgencyEq BChE. See equine serum butyrylcholinesteraseEquine serum butyrylcholinesterase

bioscavenging use, 245, 246Equipment decontamination

M295 equipment decontamination kits, 582M17 lightweight decontamination system, 583M100 sorbent decontamination system, 582–583

Erbium:yttrium-aluminum-garnet laser ablationmustard agent injury treatment, 284

Er:YAG. See Erbium:yttrium-aluminum-garnet laser ablationErythrocyte cholinesterase

gender differences in activity of, 164physiological role, 164relation of effects of nerve agent exposure to erythrocyte cho-

linesterase activity (table), 166Ethiopia. See Italian-Ethiopian War

Ethyl bromoacetate tear gasWorld War I and, 12–13

Ethyl iodoacetate tear gasWorld War I and, 13

Ethyl methylphosphonic acidVS nerve agent assays and, 695

Ethyl-S-diisopropylaminoethyl methylphosphonothiolate. See VX nerve agent

Explosive release of chemical weapons. See also specific systems, i.e., Cluster bombs

description, 132droplet release, 132–133vapor release, 132, 134

Exposure routes of nerve agents. See also specific agentsdefinitions of Ct, LCt50, and LD50 (exhibit), 168dermal exposure to liquid, 169–170, 185–186, 244effects of dermal exposure to liquid nerve agents (table), 169effects of exposure to nerve agent vapor (table), 169inhalational exposure to vapor, 168–169, 185, 244

Eyesatropine treatment and, 191–192chloropicrin effects, 457chronic eye disease, 314corneal damage, 274, 314dibenz[b,f]-1,4-oxazepine effects, 468dilute hypochlorite and, 537dim vision, 171–172diphenylaminearsine effects, 466eye pain, 172incapacitating agent effects, 442, 471irrigation of, 277, 287lewisite exposure effects, 293light reduction, 171–172mustard agent exposure effects, 274–275, 278, 290, 312, 667,

670, 672mustard agent injury treatment, 287, 288nerve agent exposure effects, 170–172oleoresin capsicum effects, 4551-chloroacetophenone effects, 461, 463palytoxin effects, 619, 621phosgene oxime exposure effects, 295recovery from injury to, 274, 278topical antibiotics for, 287, 288transient vision loss, 2872-chlorobenzylidene malononitrile effects, 448, 451–452visual acuity, 172

FFabrizi, L.

phosgene research, 737FBI. See Federal Bureau of InvestigationFBS AChE. See Fetal bovine serum AChEFDA. See US Food and Drug AdministrationFederal Bureau of Investigation

counterterrorism plans, 128homeland security role, 755oleoresin capsicum research, 443riot control agent use to attack the Branch Davidian com-

pound in Waco, TX, 125terrorist plot to release chlorine gas at Disneyland and, 657

Federal Emergency Management AgencyChemical Stockpile Emergency Preparedness Program role,

766–767counterterrorism plans, 128formation of, 755state and regional coordination and, 759

Federal Response Plan


xxxix


assignment of specific emergency support functions, 755FEMA. See Federal Emergency Management AgencyFentanyl

description and incapacitating effects, 419summary of BZ and fentanyl derivatives (exhibit), 429use by Russia in the Chechen hostage situation, 3, 65, 107, 413,

419Fetal bovine serum AChE

bioscavenging use, 245, 246Fidder, A.

blood sample analysis for mustard agent (figure), 723lewisite exposure research, 728organophosphorus compound research, 699urine sample analysis for mustard agent, 711, 713

Field management of chemical casualties. See also Treatment of incapacitating agent exposure; Treatment of mustard agent exposure; Treatment of nerve agent exposure; Treatment of toxic industrial chemical exposure

attack measures, 494–495“buddies” and, 486casualty decontamination (figure), 502casualty number and agent characteristics and, 496civilian perspective, 492–493cold zone, 500, 506comparison of military battlefield and civilian casualty care

and decontamination (table), 501comparison of taxonomy of care capabilities with levels (ech-

elons) of care particular to chemical casualty management (table), 488–489

core principles, 486decontamination area, 505decontamination equipment, 497decontamination levels, 500detailed example of the layout of a patient decontamination

site (figure), 504early control point and arrival area, 503–504evacuation corridor, 500force health protection description, 486hazardous materials (HAZMAT) response teams and, 492–493hazardous waste operations and emergency response training

and, 515HAZMAT incident medical treatment site setup (figure), 503health service support description, 486hot line, 505hot zone, 498–499, 501integration of military support into civilian homeland re-

sponse, 493–494key objectives, 495land-based forces, 487–491local responses, 492–493medical equipment and supplies needed, 497–498medical management process, 494–506military management concepts in the civilian setting, 500–502minimal decontamination procedures based on agent charac-

teristics (table), 498National Incident Management System, 492National Response Plan, 492national site setup and control zones for a hazardous materials

site (figure), 515patient processing, 502–506personnel requirements, 495–497pillars of force health protection (figure), 487postattack, or recovery, measures, 495preattack measures, 494rapid and effective response capability, 486sea-based forces, 491–492service-specific operations, 487–492

taxonomy of care capabilities (figure), 490terrorist attack capabilities, 493–494triage and treatment area (cold zone), 506triage area (warm side), 504–505vapor control line, 505warm zone, 499–500, 504–505wet-bulb globe temperature and, 495–496work-rest cycles and water consumption (without protective

ensemble) (table), 497work-rest cycles for workers, 495–496, 542worker fitness level and, 496–497zones of contamination, 498–500, 543

Field Management of Chemical Casualties Handbookmustard agent treatment, 670

Filbert, M.G.dexanabinol research, 229

Fisher, PFC David Allenexposure to mustard agent during the Persian Gulf War

(exhibit), 107Fiske, Maj. Norman E.

Italian-Ethiopian War observation report, 45520th Theater Army Medical Laboratory

field-forward assays for chemical agent exposure, 693Florida

paralytic shellfish poisoning and, 624Flumazenil

incapacitating effects, 420Fluoxetine

incapacitating effects, 421Foch, Marshal Ferdinand

Champagne-Marne defensive and, 30Meuse-Argonne campaign and, 33

Ford, Pres. Geraldincapacitating agent use and, 443

Foroutan, Syed Abbaschemical agent exposure in children and, 656nerve agent and mustard agent treatment research, 184,

195–196patient thorough decontamination research, 540, 547

Foulkes, Maj. Gen. Charles H.effectiveness of gas as a weapon, 79

4-dimethylaminophenolcyanide poisoning treatment, 395–396

4-DMAP. See 4-dimethylaminophenolFrance. See also specific battles and battle sites

Berber war, 42–43chemical warfare use during World War I, 12–21cyanide use during World War I, 373hydroxocobalamin treatment for cyanide poisoning, 396, 676incapacitating agent use, 443weaponizing of phosgene, 341

Franco-Prussian Warcyanide use, 373

Frandsen, A.dantrolene research, 228

Franzblau, A.2-chlorobenzylidene malononitrile research, 452

Free radical scavengersneuroprotectant use, 232

French, M.C.dibenz[b,f]-1,4-oxazepine research, 467

Fricke, cyanide poisoning treatment, 396

Fries, Maj. Gen. Amos A.chemical training for soldiers and, 104Chemical Warfare Service and, 43–44Gas Service command, 22, 89–90

xl


mustard agent and, 20Fujikawa, D.G.

ketamine research, 230Fuller, Maj. Gen. J.F.C.

Italian-Ethiopian War observation report, 46

GG8 Global Partnership against Proliferation of Weapons and Ma-

terials of Mass DestructionRussia’s elimination of chemical weapons and, 144

G-series nerve agents. See also specific agentscategorization of (exhibit), 47World War II use of, 3

GA. See TabunGacyclidine

soman-induced seizure-related brain damage treatment, 230Galanthamine

Alzheimer’s disease treatment, 158Gangliosides

mechanism of action, 227soman-induced seizure-related brain damage treatment, 227

Gas chromatographyblood sample analysis for mustard agent exposure, 721, 723,

725, 726combined with liquid chromatography for mustard agent as-

says, 711, 713lewisite exposure, 728nerve agent assays and, 695, 699sample preparation methods for the gas chromatographic-


sample preparation time, 693urine sample analysis for mustard agent, 710, 716–717, 718USAMRICD research, 693use with MS, 692, 693

“Gas fright” syndromedescription, 82

Gas masks. See also Respiratorsactivated charcoal use in, 561butyl rubber and, 562, 563canisters for, 561chemical destruction of the agent and, 561composition of, 562dead space and, 563development of, 18developmental objectives, 563early types, 80effectiveness against chlorine and phosgene, 19effectiveness against mustard agent, 21faceblanks for, 563“hypo helmets,” 561joint service general purpose masks, 563M17 series, 561modern design features, 561–562nose cups for, 563original design features, 561perfluorocarbon rubber and, 562silicone rubber and, 562, 563types of devices (figure), 84use of for children, 657voicemitters, 562

Gastrointestinal tractbrevetoxin effects, 630chloropicrin effects, 457dibenz[b,f]-1,4-oxazepine effects, 468diphenylaminearsine effects, 466mustard agent exposure effects, 275–276, 288, 290, 670, 672

oleoresin capsicum effects, 455palytoxin effects, 6192-chlorobenzylidene malononitrile effects, 452

Gay-Lussac, Joseph Louiscyanide research, 373

GB. See SarinGC. See Gas chromatographyGD. See SomanGender factors

butyrylcholinesterase activity, 164erythrocyte cholinesterase, 164

Geneva Protocolchemical weapons provisions, 57, 61, 136–137, 341, 413development of, 136–137United States ratification of, 60, 137weakness of, 137

Genovese, R.F.equine serum butyrylcholinesterase research, 249

Germany. See also specific battles and battle sitesairplane gas attacks during World War I (exhibit), 26chemical warfare use during World War I, 12–21, 79–82, 341,

413chlorine gas attacks, 12, 14–18experimental testing of chemical and biological warfare agents

in concentration camps, 105, 157failure to use chemical weapons in World War II, 48–50, 157,

262, 413mustard agent attacks, 2–3, 15, 18, 20–21, 25–26, 83, 261–262nerve agent production, 48, 156nerve agent use in World War II and, 3, 413phosgene attacks, 19–20phosgene oxime production, 294Russia’s elimination of chemical weapons and, 145secret development of nerve agents, 46trichloromethyl chloroformate attacks, 20Zyklon B use in Nazi concentration camps, 15, 51, 105, 373,

397, 656Gershon, S.

organophosphate insecticide exposure research, 319, 320GF. See CyclosarinGiesbrecht, G.G.

hypothermia research, 548Gilchrist, Col. Harry L.

chemical training for soldiers and, 103Chemical Warfare Service leadership, 90–91, 97plan of a division in action for chemical warfare training

purposes (figure), 86“Symptomology, Pathology and General Treatment of Gas

Cases,” 91GK-11. See GacyclidineGlass, Col. Albert

incapacitating agent treatment research, 430Glaucoma

carbamate treatment, 158Gloves

chemical protective glove set, 573–574decontamination of chemical casualties and, 539joint service lightweight integrated suit technology block 2

glove upgrade, 574Glutathione. See also Diglutathionyl dithiocarbonate

description, 735mechanism of lung injury, 352–353mustard agent reactions with, 265, 708, 711, 717–718phosgene exposure and, 735–736, 738reaction pathway of glutathione (figure), 712

Glycolates. See Anticholinergic deliriantsGM1 monosialoganglioside


xli


soman-induced seizure-related brain damage treatment, 227Goebbels, Paul Joseph

views on chemical warfare, 49Gongwer, L.E.

2-chlorobenzylidene malononitrile research, 449Goodman, Ephraim

incapacitating agent research, 412–413, 425, 427Graebe, Carl

1-chloroacetophenone invention, 442Graham, J.S.

mustard agent injury treatment, 284, 285, 671wound debridement of chemical casualties research, 539

Graniteville, South Carolinaaccidental release of chlorine, 131, 145, 548

Grant, Gen. Ulysses S.chemical weapon use and, 12

Gray, P.J.2-chlorobenzylidene malononitrile research, 451–452

Great Britain. See also specific battles and battle siteschemical warfare use during World War I, 12–21dibenz[b,f]-1,4-oxazepine use in prisons, 467excerpt from “Take Me Back to Dear Old Blighty!” (exhibit), 89nerve agent research, 48plans for gas warfare during World War II, 52Royal Army Medical Corps, 85–89Russia’s elimination of chemical weapons and, 145six chlorine-phosgene cloud attacks: British casualties Decem-

ber 1915-August 1916 (table), 83VX nerve agent synthesis, 157

Greeceancient use of incapacitating agents, 412ancient use of toxic smoke, 10, 78, 341cyanide use, 373Greek fire and flaming concoctions, 11, 78, 341

“Green cross.” See ChloropicrinGrignard, Francois Auguste Victor

chemical weapons developed by, 15Growth factors

mustard agent injury treatment, 285–286Gruenthal, M.

dantrolene research, 228GSCOSG. See Diglutathionyl dithiocarbonateGSH. See GlutathioneGuide for the Selection of Chemical Agent and Toxic Industrial Material

Detection Equipment for Emergency First Responders, 581“Gulf War” syndrome

description, 64Gutentag, P.J.

2-chlorobenzylidene malononitrile research, 449, 450Guthrie sulfur mustard synthesis, 260

HHaber, Fritz

comments on the importance of chemical warfare, 41development of chlorine gas as a weapon, 14, 15, 80Second Battle of Ypres and, 14, 15Zyklon B development, 15, 51

The Haguecourt of arbitration, 136

Haig, Gen. DouglasBattle of Loos and, 18

Haig, Secretary of State Alexander M., Jr.“Chemical Warfare in Southeast Asia and Afghanistan,” 62

Hair sample analysismustard agent, 726

Halothanepediatric population and, 667

HAPSITE Smart Chemical Identification Systemdescription, 544

Harel, M.human paraoxonase 1 research, 251

Harrigan, A.Armed Forces Chemical Journal article, 57

Hart, B.H. LiddellItalian-Ethiopian War observation, 46

Hassan, Capt. Kifah AliIraq’s attacks on the Kurds and, 126

Hay, AlistairRussia’s use of an incapacitating agent against Chechens, 413

HC smoke. See Hexachloroethane smokeHCN. See Hydrogen cyanideHD. See Mustard agentHealth Service Support in a Nuclear, Chemical and Biological Environ-

ment (FM 4-07.7), 609Health Service Support in a Theater of Operations, 512Heart rate

effects of nerve agent exposure, 180Heat injuries

acclimatization and, 604heat stress physiological monitoring for chemical agent work-

ers, 603–604individual protective ensemble and, 528, 541–543, 569moderating strategies, 603training and, 603

Heat strokedifferential diagnosis of incapacitating agent intoxication, 428

Hebb seizure-related brain damage research, 226Hefazi, M.

mustard exposure research, 313Heinrich, U.

2-chlorobenzylidene malononitrile research, 450Hellreich, A.

2-chlorobenzylidene malononitrile research, 450Hematologic effects

paralytic shellfish poisoning, 626Hemodialysis

saxitoxin treatment, 627tetrodotoxin treatment, 627

Henderson, Dr. Yandelltoxic gas research, 89

Henderson, NVaccidental release of chlorine, 131

Hesse, isolation of physostigmine, 46, 156Heston, W.E.

mustard exposure research, 313Hexachloroethane smoke

composition of, 358toxic effects of exposure, 324, 327, 358–359

Higginbottom, R.dibenz[b,f]-1,4-oxazepine research, 467, 468

Hill, A.R.2-chlorobenzylidene malononitrile research, 452

Himsworth, H.2-chlorobenzylidene malononitrile research, 452

Historical backgroundchemical attacks involving children, 656–657chemical terrorism, 125–130chemical warfare capabilities, 130–136chemical weapons agreements, 136–145cyanide use, 372–373development of chemical weaponry, 116–125early military uses of toxins, 10–11, 78–79incapacitating agents, 412–414, 443medical management of chemical casualties, 78–109

xlii


nerve agent use, 156–1581920s, 42–451930s, 45–471950s, 54–561960s, 56–601970s, 60–621980s, 62–631990s, 63–6521st century, 65–66US Civil War, 11–12World War I, 12–42World War II, 48–54

History of the Peloponnesian War (Thucydides), 10, 78Hitler, Adolf

chlorine gas attack and, 17, 49, 157Germany’s failure to use chemical weapons in World War II

and, 49, 157, 413HN-1. See Nitrogen mustardHoch, Dr. Paul

lysergic acid diethylamide research, 413Hoffmann, Albert

lysergic acid diethylamide research, 413Holland, P.

1-chloroacetophenone research, 463Holmes, J.H.

organophosphate insecticide exposure research, 319, 320Homatropine

eye pain and, 192topical application of, 190

“Honest John” rocketsnerve agent delivery, 122

Hospitalsdecontamination shelters, 545–546Hospital Management of CBRNE Incidents Course, 769M22 automatic chemical agent detector and alarm and, 577patient thorough decontamination areas, 529

How to Tell the Gases (Downey), 41HS. See Mustard agentH2S. See Hydrogen sulfideHu, H.

2-chlorobenzylidene malononitrile research, 452HU-211. See DexanabinolHu PON1. See Human paraoxonase 1Human paraoxonase 1

mutation designs, 250–251Hun stoffe. See Mustard agentHup A. See Huperzine AHuperzine A

compared with physostigmine, 704mechanism of action, 705–706pretreatment with, 704–706red blood cell and acetylcholinesterase protection studies us-

ing pyridostigmine bromide and huperzine A after ex-vivo exposure to soman (table), 705

Hurricane KatrinaNational Response Plan and, 492

Huxley, Aldous“psychedelic” definition and, 416

Hydrocyanic acidUS troop training and, 53

Hydrogen cyanide. See also Cyanide poisoningdiscovery of the properties and composition of, 116introduction of, 18nonmilitary uses, 342–343treatment for inhalation of, 353–354volatility of, 134, 136

Hydrogen sulfide

properties of, 343–344Hydrolysis compound assays

analytical methods, 695analytical methods for assay of nerve agent hydrolysis prod-

ucts (table), 697application to human exposure, 695–698hydrolysis pathway of sarin, soman, and cyclosarin (figure),

696methods used to confirm human exposures to nerve agents via

assay of hydrolysis products (table), 698Hydroxocobalamin

cyanide poisoning treatment, 385, 390, 393, 396–397, 651, 676properties, 396–397side effects, 396

Hypochloritedecontamination of chemical casualties and, 537pediatric casualties and, 677

Hypothermiadecontamination issues, 548–549, 677pediatric population and, 661stages and symptoms of (table), 548

IIbuprofen

phosgene inhalation treatment, 354ICAMs. See Improved chemical agent monitorsICG. See Indocyanine green fluorescence imagingIEDs. See Improvised explosive devicesImproved chemical agent detectors

false readings and, 576simplicity of operation, 576

Improved chemical agent monitorscold weather operation of, 550description, 544, 576effects on decontamination, 531

Improvised explosive devicesdevelopment and use of, 130, 145toxic industrial material used in, 580

Incapacitating agents. See also specific agentsanticholinergic deliriants, 422–425antipsychotic drugs, 420armed robots and, 415auditory method of incapacitation, 414cannabinoids, 418characteristics of PS, CN, DM, and CR (table), 458–459chemical methods of incapacitation, 415–425chloropicrin, 443, 455–457common features, 442controversy over using, 431–432conventional wounds contaminated with, 523decontamination, 469–471delivery systems, 122diagnosis of syndromes caused by, 428–430dibenz[b,f]-1,4-oxazepine, 442, 467–469differential diagnosis for (table), 429diphenylaminearsine, 443, 464–466dissociative anesthetics, 419–420factors in decisions to employ, 412, 415FBI’s use to attack the Branch Davidian compound in Waco,

TX, 125features of, 133–134goal of, 412higher integrative or cognitive functions and, 415history and modern development of, 412–414, 443indole-based psychedelics, 416–418irritants, nausea-producing agents, and toxins, 416Kratschmer reflex and, 442


xliii


legal barriers to acceptance as weapons, 431lethality of, 415medical care issues, 469–472medical management, 430methods of incapacitation, 414–425microwave effects, 414mortality from, 442nerve agents, 416neuropeptides and neuromodulators, 420–422new developments and future use, 472nonchemical methods of incapacitation, 414–415nonlethal land mines, 415nonmilitary uses, 342oleoresin capsicum, 443, 452–455olfactory devices, 414–4151-chloroacetophenone, 443, 460–464opioids, 418–419personal protection, 469phenethylamine-based psychedelics, 418physiological responses to, 348, 472–473police department use, 443policy perspective on, 431–432, 443production of, 59psychoactivity manifestations, 415purpose of, 442, 472research on, 55–56safety margin variations, 415safety of, 442safety of glycolates, 427sedative hypnotics, 418stimulants, 418summary of BZ and fentanyl derivatives (table), 429tranquilizers, 420treatment, 425–426, 471–472triage considerations, 520, 521, 522, 5232-chlorobenzylidene malononitrile, 416, 443, 444–452use of light, 414vesicants, 416

Indiaaccidental release of methyl isocyanate in Bhopal, 131, 134,

326, 347Individual chemical patient resuscitation devices

composition and uses of, 587–588description, 587

Individual protective ensemblebarrier creams and, 531cold weather and, 549heat injuries and, 528, 541–543M20 simplified collective protection equipment and, 586name and job markings for, 547removal of, 547

Individual protective equipmentdecontamination personnel requirements, 543–544protective clothing, 569–574psychological factors in the use of, 575respiratory protection, 561–569toxic industrial material and, 580training in the use of, 575vapor penetration of, 543–544

Individuals with physical or mental disabilitiesdecontamination issues, 551

Indocyanine green fluorescence imagingmustard agent injury assessment, 283

Indole-based psychedelics. See also specific agentsexperiments using, 3, 56“psychedelic” definition, 416

Industrial chemicals. See Inhalational injury from toxic industrial

chemicals; Toxic industrial chemicals; Toxic industrial materials; specific chemicals

Infants and children. See also Medical management of chemical toxicity in pediatrics

accidental exposures to mustard agent, 263cyanide poisoning and, 389–390, 394decontamination issues, 550–551treatment of nerve agent exposure, 1952-chlorobenzylidene malononitrile ingestion and, 452

Inhalational exposure to nerve agent vapor. See also Pulmonary system

atropine treatment, 185compared with dermal exposure, 169–170effects of, 168–169long-term health effects, 324–327severe exposures, 168–169

Inhalational injury from toxic industrial chemicalsairway compartments (figure), 355arterial blood gases and, 360biochemical responses, 351–353bronchoalveolar lavage and, 361carbon dioxide levels and, 361cell membrane destruction, 350centrally acting agents, 355–356, 359chemicals that act on both the central and peripheral airways,

359chest radiographs and, 360clinical presentation and diagnosis, 355–361decreased body weight and, 348determination of the damaged compartment, 340diagnostic tests, 360–361“dry land drowning,” 357gaseous ammonia effects at various concentrations (table), 355general mechanisms of toxic gas exposure (figure), 347general schema for the study of acute and chronic lung injury

(figure), 352glutathione and, 352–353inflammatory pathways, 350–351long-term health effects, 354–355, 365main inflammatory agents involved in acute lung injury, their

source and action (table), 351mechanism of injury, 340, 355, 356–357mechanism of lung injury and repair (figure), 349mechanisms of lung injury of gaseous respiratory irritants

(table), 346mechanistic effects, 346–353medical management, 361–365pathophysiological effects, 348–350patient transport and, 365peripherally acting agents, 356–360physiological responses, 347–348pulmonary capillary wedge pressure and, 361pulmonary function tests and, 360–361specific inhaled toxic-gas-induced effects and their treatments,

353–355ventilation/perfusion scans and, 361

Insecticides. See also Organophosphate insecticidesorganophosphorus compounds used as, 158–159, 316

Institute of Medicinestudy on the effects of mustard agent and lewisite exposure,

312–313, 314, 315, 316Interagency for Research on Cancer

classification of mustard as a human carcinogen, 315–316Intermediate syndrome

nerve agents and, 318–319organophosphate insecticides and, 318–319

International Classification of Epileptic Seizures

xliv


status epilepticus definition, 223International Red Cross

Yemen Civil War and, 58IPE. See Individual protective ensembleIpratropium

brevetoxin intoxication treatment, 631Iran

case history: nerve agent exposure in Nazhmar, Iran (exhibit), 662

Iran-Iraq Warassay techniques for mustard exposure, 692–693, 713, 715, 716,

721chemical weapons use, 3, 62–63, 106, 157–158, 195–196, 260,

312, 314, 373, 656mustard agent and, 262–263, 279, 288, 314, 315, 656, 667

Iraq. See also Iran-Iraq War; Persian Gulf Waraccidental exposure of two US soldiers to sarin in Baghdad,

157–158, 168, 195, 197case history: mustard gas exposure in 14 children and teenag-

ers from Halabja, Iraq (exhibit), 667chemical weapon stockpiles, 157, 312clinical cases of mustard exposure from Mofid Medical Center

following the Halabja, Iraq, attack on March 17, 1988 (ex-hibit), 668–669

clyclosarin synthesis, 157cyclosarin production, 202Operation Iraqi Freedom and, 65–66, 130stocks of sarin and VX, 202use of chemical weapons against the Kurds, 63, 65, 106, 126use of 3-quinuclidinyl benzilate during the Persian Gulf War,

413Irving, Capt. T.C.

report on field sanitation, 84–85Isoproterenol

phosgene inhalation treatment, 354Isosorbide dinitrate

palytoxin intoxication treatment, 622Israel

Arab-Israeli Six-Day War, 58deaths from improper use of gas masks, 657midazolam use for status epilepticus and, 664possible use of DM against Palestine, 443Yom Kippur War, 61

Italian-Ethiopian Warchemical weapons role, 45–46, 137, 262

ItalyCentro Chemico Militaire, 43cyanide plot against the US Embassy, 128early use of poison projectiles, 11Italian-Ethiopian War, 45–46mustard agent disaster at Bari, 21, 53, 105, 262Russia’s elimination of chemical weapons and, 145

JJaeger, Private August

warning of a German gas attack, 80Jakubowski, E.M.

nerve agent research, 699skin sample analysis for mustard agent exposure, 726urine sample analysis for mustard agent exposure, 716

Jane’s NBC Protection Equipment, 561Japan

accidental palytoxin poisoning, 620Aum Shinrikyo sarin attacks, 4, 125, 127–128, 158, 178,

181–182, 193, 196–197, 223, 244, 316, 317, 321, 492, 518, 540, 657, 695–696, 699, 754

chemical weapon production, 48

incapacitating agent use, 443invasion of China in 1937, 46, 262paralytic shellfish poisoning and, 624

Japanese puffer fish. See TetrodotoxinJobst

isolation of physostigmine, 46, 156Johnston Island

demilitarization of chemical agents, 142, 157Joint Combat Developer

role in chemical weapon management, 4Joint Commission on Accreditation of Healthcare Organizations

disaster and medical response to mass casualty events, 492, 493–494

training and education for domestic preparedness and, 767Joint Program Executive Office

role in chemical weapon management, 4Joint Program Executive Office for Chemical Biological Defense

medical identification and treatment systems joint product management office, 647–650

medical program management, 647responsibilities, 646–647

Joint Project Management Office for DecontaminationReactive Skin Decontamination Lotion and, 652–653

Joint Requirements Office for Chemical, Biological, Radiological, and Nuclear Defense

responsibilities, 646, 650role in chemical weapon management, 4

Joint Science and Technology Officeresponsibilities, 650role in chemical weapon management, 4

Joint service general purpose maskscomposition, 567description, 563M50 and M51 models, 567–568sizes, 568TIC filters, 568

Joint service lightweight integrated suit technologyblock 2 glove upgrade, 574description and composition of, 572design of, 572–573two versions of, 573

Joint service mask leakage testerdescription, 564fit and, 563, 564key features, 565

Joint service personnel skin decontamination systemdescription and uses, 582, 652

Joint services lightweight standoff chemical agent detectorsdescription and uses, 579

Joint Test and Evaluation Executive officerole in chemical weapon management, 4

Joint Vaccine Acquisition Programdescription, 4responsibilities, 647

Jones, Jimmass suicide of followers using cyanide, 374

Josse, D.human paraoxonase 1 research, 251

JPEO. See Joint Program Executive OfficeJPEO-CBD. See Joint Program Executive Office for Chemical

Biological DefenseJSGPMs. See Joint service general purpose masksJSLIST. See Joint service lightweight integrated suit technologyJSLSCADs. See Joint services lightweight standoff chemical agent

detectorsJSMLT. See Joint service mask leakage tester


xlv


KKargin, Col. V.A.

capture of soman research documents, 51Keeler, J.R.

interaction of pyridostigmine bromide with other commonly used battlefield medications, 201–202

Kemp, K.H.2-chlorobenzylidene malononitrile research, 452

Kennedy, Pres. John F.incapacitating agent research and, 414

Ketamineadverse effects, 231combined with diazepam, 230–231, 232description and incapacitating effects, 419–420dosage considerations, 230, 231–232mechanism of action, 230off-label use as a neuroprotectant, 231soman-induced seizure-related brain damage treatment,

230–232Kibler, A.L.

1-chloroacetophenone research, 462–463Kiese, M.

cyanide poisoning research, 394, 395–396“King of the war gases.” See Mustard agentKirwin, W.E.

1-chloroacetophenone research, 462Kishi, Y.

tetrodotoxin synthesis, 623Kjellstrom, B.T.

mustard agent injury treatment, 284Klasen, H.J.

enzyme debridement of mustard agent injuries, 284Kling, A.

phosgene research, 736Kluchinsky, T.A., Jr.

2-chlorobenzylidene malononitrile research, 447Koenig, K.L.

summary of triage systems, 517Kolokol-1. See FentanylKondritzer, Albert

3-quinuclidinyl benzilate research, 423Konzo

cyanide exposure and, 323Koplovitz, I.

memantine research, 228Korean War

chemical weapons and, 54, 105Korte, W.D.

skin sample analysis for mustard agent, 726Krar, William

terrorist attack plan, 128–129Krueger,

organophosphorus compound research, 156Krutzsch, Walter

criticism of the Chemical Weapons Convention, 140–141Kubic, V.L.

phosgene research, 736Kuhn, Richard

soman discovery and synthesis, 48, 51, 157Kukenthal, Hans

tabun research, 47Kumar, P.

1-chloroacetophenone research, 460–461Kurbegovic, Muharem. See Alphabet BomberKurds

Iraqi use of chemical weapons against, 63, 65, 106, 126, 373, 656–657

Kuschner, W.G.hexachloroethane smoke research, 327

KuwaitIraq’s invasion of, 63–64

LLaboratory Response Network

description and role, 765–766reference laboratories, 766sentinel laboratories, 766

Lacrimators. See Incapacitating agentsLam, D.G.

mustard agent injury treatment, 285Land mines

nonlethal types, 415used in conjunction with military barrier systems, 135VX nerve agent delivery, 120–121, 157

Lange, Willyorganophosphorus compound research, 47, 156

Larimer, E.cold-weather protection of decontamination personnel, 549

Laser Doppler perfusion imagingmustard agent injury assessment, 283

Lashleyseizure-related brain damage research, 226

LC. See Liquid chromatographyLDPI. See Laser Doppler perfusion imagingLeague of Nations

Conference for the Supervision of the International Trade in Arms and Ammunition, 136–137

Leber hereditary optic neuropathycyanide exposure and, 323–324

LeGrand, Waltergas chamber execution, 374

Lemercier, G.nerve-agent-induced brain damage research, 223

Levenphysostigmine isolation, 46

Levin, H.S.organophosphate insecticide exposure research, 320

Levine, R.A.1-chloroacetophenone research, 463

Lewis, Capt. W. Leelewisite named for, 117, 292

Lewisiteadditives for, 135analysis of urine and blood samples, 728antidote for, 291application to human exposure, 728–731biochemical mechanisms of injury, 292, 667biomarkers for, 728clinical effects, 292, 667cold weather and, 548compared with mustard agent, 261, 291description, 728diagnosis, 293early production of, 3Germany’s experimental testing on human subjects in concen-

tration camps, 105Institute of Medicine study on the effects of mustard agent

and lewisite exposure, 312–313, 314Japan’s use of against China, 46laboratory tests, 293“lewisite shock,” 293long-term effects, 294mechanism of action, 136, 728military use, 292

xlvi


properties of, 292published analytical approaches for the analysis of CVAA in

urine (figure), 729putative mechanism by which lewisite causes tissue damage

(figure), 292sample preparation methods for gas chromatographic/mass

spectrometric analysis of CVAA (exhibit), 730toxicity, 292treatment, 293, 667US production of, 117Veterans Administration study on the effects of mustard agent

and lewisite exposure, 312–313Ley, Robert

views on chemical warfare, 49LHON. See Leber hereditary optic neuropathyLibya

increase in chemical weapon development, 65use of chemical weapons against Chad, 63

Lidocainesaxitoxin treatment, 627tetrodotoxin treatment, 627

Limitation of Arms Conferencestockpiling of chemical weapons and, 44

Lindsay, C.D.mustard agent injury treatment, 285

Liquid chromatographyblood sample analysis for mustard agent, 723, 725, 726combined with gas chromatography for mustard agent assays,

711, 713combined with mass spectrometry for mustard agent assays,

692, 713, 720–721, 723nerve agent assays and, 695phosgene, 737urine sample analysis for mustard agent, 716–717, 718, 720–721

“Little John” rocketsnerve agent delivery, 122

Livens projectorsdescription, 118, 119

Long-term health effectschloropicrin exposure, 457cyanide poisoning, 387–389dibenz[b,f]-1,4-oxazepine exposure, 468–469lewisite exposure, 294mustard agent exposure, 291, 312–316nerve agent exposure, 177–179oleoresin capsicum exposure, 4551-chloroacetophenone exposure, 463–464retrospective studies and, 313toxic industrial chemical exposure, 354–355, 3652-chlorobenzylidene malononitrile exposure, 452

Loos, Battle ofchlorine gas attacks, 18–19

Lorazepambrevetoxin intoxication treatment, 630LSD intoxication treatment, 417nerve agent exposure treatment, 190, 223

Lott, Josephchemical warfare proposal, 12

LRN. See Laboratory Response NetworkLSD. See Lysergic acid diethylamideLudendorff, Gen. Erich

Lys Defensive and, 26Lund,

burn severity assessment, 282Lundy, P.M.

VX nerve agent research, 529Lung cancer

mustard agent exposure and, 313–314Lungs. See Pulmonary systemLuten, Dr. Robert

Broselow-Luten system and, 681–683Chemical Warfare Involving Kids Response Project and, 681

Lys defensivechemical attacks, 26–27

Lysergic acid diethylamideblood level assays, 417Chemical Corps testing of, 416–417historical background of research on, 413–414mode of action, 417physiological effects, 417, 428research on effects of, 56toxicity of, 417treatment for intoxication by, 417unique features of, 416unpredictability of effects, 417–418

MM22 automatic chemical agent detector and alarm

description, 544description and uses, 577

M272 chemical agent water testing kitsdescription and detection limits, 577

M45 chemical-biological masksdescription, 566Land Warrior program and, 567voicemitters, 566–567

M53 chemical-biological protective masksaudio frequency modifiers, 569protective hoods, 568–569sizes, 568US Special Operations Command requirements, 568

M8 chemical detector paperdescription and uses, 544, 575

M9 chemical detector paperdescription and uses, 544, 575–576

M28 collective protection equipmentdescription and uses, 585

M295 equipment decontamination kitsdescription and uses, 582

M17 lightweight decontamination systemdescription and uses, 583

M41 protection assessment test systemdescription, 564fit and, 563

M21 remote sensing chemical agent alarmsdescription, 578placement of, 579uses of, 579

M20 simplified collective protection equipmentdescription, 586IPE and, 586

M291 skin decontamination kitsAmbergard resin and, 652–653components, 536, 581description, 533, 581introduction of, 536Reactive Skin Decontamination Lotion and, 536, 653SERPACWA and, 652

M100 sorbent decontamination systemdescription and uses, 582–583

M256A1 chemical agent detector kitsdescription and uses, 576–577detection limits, 577

M42A2 chemical-biological combat vehicle masks


xlvii


description and uses, 566M40A1 chemical-biological field masks

components, 565–566composition of, 565sizes, 565–566voicemitters, 565

MacArthur, Gen. Douglascomments on US chemical warfare policy, 44–45

Madden, J.F.1-chloroacetophenone research, 463

Madderncyanide research, 373

Mafenide acetatepediatric population and, 672treatment of mustard agent injuries, 280, 281, 671–672

Malathionblood cholinesterase inhibition and, 165insecticide use, 158

MANAA. See Medical aerosolized nerve agent antidoteManning, K.P.

mustard agent exposure research, 313March, Chief of Staff Gen. Peyton C.

Chemical Warfare Service and, 43Mark I kits

buddy administration of, 190components, 651FDA approval for, 651nerve agent exposure treatment, 182–186, 188, 190, 192, 194,

518, 520–521, 523, 651–652pediatric population and, 663, 683treatment of children and, 195

Marrs, T.C.dibenz[b,f]-1,4-oxazepine research, 468hexachloroethane smoke research, 3272-chlorobenzylidene malononitrile research, 449

Martin, L.J.“apoptosis-necrosis continuum,” 224

Mass spectrometrybasis for, 692blood sample analysis for mustard agent exposure, 721, 725,

726cholinesterase analysis, 701–702combined with liquid chromatography for mustard agent as-

says, 713, 720–721lewisite exposure, 728mustard agent assays, 708, 716–717, 718, 720–721nerve agent assays and, 695, 699phosgene, 737sample preparation methods for the gas chromatographic-


sample preparation time, 693Maxwell, D.M.

fetal bovine serum AChE research, 245McBride, Capt. Lewis M.

rifling of the Stokes mortar barrel, 118McCombie, Hamilton

diisopropyl fluorophosphate research, 48McLean, M.J.

memantine research, 228McLeod, C.G., Jr.

nerve-agent-induced brain damage research, 223McNamara, B.P.

1-chloroacetophenone research, 4602-chlorobenzylidene malononitrile research, 446–447, 449, 450

McNamara, Secretary of Defense Robert S.Project 112 and Project 80 and, 56

MCU-2/P chemical-biological masksdescription and uses, 566

MDMA. See 3,4-methylene-dioxymethylamphetamineMeade, Capt. John

Italian-Ethiopian War observation report, 45–46MEDCOM. See US Army Medical CommandMedical aerosolized nerve agent antidote

description, 651nerve agent exposure treatment, 186, 192, 651–652purpose of, 651–652shelf life issues, 652

Medical chemical defense acquisition programsacquisition manufacturing strategy, 649acquisition process, 646business and contracting strategy, 650challenges, 650–651compound purity and, 651concept development (pre-milestone A activities), 647–648current good manufacturing processes and, 649intellectual property rights and, 649joint vaccine acquisition program, 647lifecycle management products, 651–652manufacturing challenges, 651medical chemical acquisition organizations, 646–647medical chemical acquisition processes and concerns, 647–651model for integrating pharmaceutical development, FDA

regulatory, and the Department of Defense acquisition pro-cesses (figure), 648

operations and support phase, 649production and deployment, 649products in advanced development, 652–654specific concerns, 650–651status of, 651–654sustainment programs, 652system development and demonstration, 649technology development and, 648–649test and evaluation strategy, 649–650transformational medical technologies initiative, 647US Food and Drug Administration and, 646, 647, 648–653

Medical Defense Against Mustard Gas: Toxic Mechanisms and Pharma-cological Implications, 265

Medical Identification and Treatment Systemsdescription, 4

Medical identification and treatment systems joint product man-agement office

acquisition business and contracting strategy and, 650advanced development of drugs and, 650“animal rule” for drug product approval and, 647, 651coordination with the technology base, 648lifecycle management, 649mission of, 647production and deployment plans and, 649responsibilities, 647streamlining of acquisition, 650technology development and, 648–649

Medical Management of Chemical Agent Casualties Handbook, 184Medical management of chemical casualties. See also Medical

management of chemical toxicity in pediatricsMedical Management of Chemical and Biological Casualties

Course, 763, 768post-World War I, 103–107pre-World War I, 78–79projections for the future, 108World War I, 79–102

Medical management of chemical toxicity in pediatricsBroselow-Luten system: a systematic approach with color

coding, 681–683

xlviii


case history: mustard gas exposure in 14 children and teenag-ers from Halabja, Iraq (exhibit), 667

case history: nerve agent exposure in Nazhmar, Iran (exhibit), 662

challenges to, 657–661Chemical Warfare Involving Kids Response Project, 681clinical cases of mustard exposure from Mofid Medical Center


color coding system, 681–683decontamination equipment and treatment supplies, 661dermatologic vulnerability, 659developing a family emergency plan (exhibit), 680effects of specific agents, 661–676example of a pediatric-specific hospital emergency drug cache

(table), 679family emergency plan, 678, 680general principles of chemical exposure, 657history of chemical attacks involving children, 656–657logistical time increase, 681–682management of mild to moderate nerve agent exposures

(table), 665management of severe nerve agent exposure (table), 667management of vesicant exposures (table), 671managing pulmonary agent exposures (table), 674metabolic vulnerability, 660National Center for Disaster Preparedness, 683neurobehavioral vulnerability, 660neurological vulnerability, 659organ maturity and, 660pediatric signs of mustard exposure (table), 670pediatric vulnerabilities and implications for clinical manage-

ment (table), 658plasma protein binding and, 659preoperative care of children with nerve agent intoxication,

665, 667preparing for a chemical event, 678–680psychological impact, 678, 680psychological vulnerability, 660resources, 681–684respiratory vulnerability, 659steps involved in administering a dose of medication (figure),

682strategies to help children cope with terrorist events (exhibit),

680traumatic injury vulnerability, 660uncooperative or nonverbal children, 678unique vulnerabilities, 656volume of distribution and, 659–660volume status and, 659

Medical surveillance for chemical agent workersdiagram (figure), 598factors determining the type and frequency of surveillance,

599heat stress physiologic monitoring, 603–604medical surveillance compared with personnel reliability, 599periodic medical examinations, 600–601potential exposure evaluations, 602preplacement examinations, 599–600, 603–604respirator clearances, 602screening, 599substance abuse and dependency screening, 602–603termination examinations, 601–602

Meier, H.L.PARP inhibitor treatment, 227

MemantineAlzheimer’s disease treatment, 228

pharmacokinetics of, 228soman-induced seizure-related brain damage treatment,

228–229Memorandum on Gas Poisoning in Warfare with Notes on its Pathology

and Treatment, 90Mendelson, J.A.

treatment of mustard agent injuries, 281Mescaline

clinical effect research, 56Metabolic system

cyanide poisoning and, 376pediatric vulnerability to toxic agents and, 660

Metal fume feverhexachloroethane smoke and, 327, 358

Metcalf, D.R.organophosphate insecticide exposure research, 319, 320

Methemoglobin formers. See also specific agentscyanide poisoning treatment, 383–384, 386, 390, 394–396

Methotrexatesimilarity of mustard agent to, 313

Methyl isocyanateaccidental release of in Bhopal, India, 131, 134, 326, 347

Methylprednisolonetoxic industrial chemical exposure treatment, 363

Meuse-Argonne offensivearmy-level gas hospitals, 97chemical attacks, 33, 36overview of (figure), 35Spanish influenza and, 101

Meyer, Victormustard agent research, 117, 260

Michel, H.O.electrometric ChE assay research, 704

Midazolambrevetoxin intoxication treatment, 630developmental concerns, 653FDA approval issues, 653nerve agent exposure treatment, 190, 223, 664

Military medicine. See also Medical management of chemical casualties

chemical accident and incident preparedness, 142–143chemical weapon implications, 145–146preparation for chemical attacks, 132

Minami, M.sarin research, 695, 696

Mion, G.ketamine research, 230

Mirzayanov, Vladimirnerve agent development by Russia and, 3

Mission-oriented protective posturebarrier creams and, 531gear for levels 1-4 (figure), 570levels of (exhibit), 570–571levels of protection, 569patient thorough decontamination and, 543soap and water decontamination and, 534triage of chemical casualties and, 513, 514water issues, 546

Mitochondrial permeability transition inhibitorsneuroprotectant use, 232

MITS JPMO. See Medical identification and treatment systems joint product management office

MK-801. See DizocilpineMMB4 dimethanesulfonate

development of, 653stability concerns, 653

Modular general purpose tent system chemical-biological protec-


xlix


tive liner systemdescription and uses, 587

Montreal Protocolmedical aerosolized nerve agent antidote and, 652

MOPP. See Mission-oriented protective postureMorgenstern, P.

long-term health effects of mustard, 312, 314Morphine

description and incapacitating effects, 418MS. See Mass spectrometryMSMTESE. See 1-methylsulfinyl-2-[2-(methylthio)ethylsulfonyl]

ethaneMultiservice Tactics, and Procedures for NBC Protection (Field

Manual 3-11.4), 569Murray, V.

2-chlorobenzylidene malononitrile research, 451–452Mustard agent. See also Nitrogen mustard

accidental exposures, 263, 717–718, 723, 725additives for, 135alkylation of deoxyribonucleic acid and, 264–265, 312, 718analysis of specimens, 706–708analytical methods used to verify exposure to sulfur mustard

in biomedical samples (table), 714–715barrier skin creams for, 530, 531biochemical mechanisms of injury, 263–265, 708blister fluid analysis, 726blood sample analysis, 718–726carcinogenesis, 290, 312–314, 315–316case history: mustard gas exposure in 14 children and teenag-

ers from Halabja, Iraq (exhibit), 667casualties caused by, 20, 261, 262–263, 266, 667central nervous system effects, 276, 290, 315chronic eye disease and, 314chronic pulmonary disease and, 314clinical cases of mustard exposure from Mofid Medical Center


clinical effects, 266–276, 312, 356, 519, 656, 667, 669compared with phosgene oxime and lewisite, 261, 291Cushing’s impressions, 88–89day of death after exposure in World War I fatal mustard

casualties (table), 266decontamination issues, 277, 312description (exhibit), 21development and properties of, 15, 20, 83diagnosis, 276–277, 692–693disaster at Bari, 21, 53, 105, 262Edgewood Arsenal, MD, production, 119gas mask effectiveness and, 21German production statistics, 48Germany’s experimental testing on human subjects in concen-

tration camps, 105hair sample analysis, 726hospitalization and, 262, 277, 281, 670hydrolysis of sulfur mustard to produce thiodiglycol, followed

by oxidation reactions (figure), 708initial clinical effects from mustard exposure (table), 266Institute of Medicine study on the effects of mustard agent

and lewisite exposure, 312–313, 314introduction of, 18, 261Italian-Ethiopian War use, 45–46Japan’s use of against China, 46laboratory findings, 669laboratory tests for, 277long-term health effects, 291, 312–316mechanism of action, 136, 312, 656median lethal dose, 519

medical management, 83, 135metabolism, 265military use, 262–263mortality rates, 266, 276, 277, 278mutagenesis, 315–316name derivation, 261–262nerve agents compared with, 181neuropsychiatric symptoms and, 315neutralization of, 533partial-thickness injury treatment, 283pattern of injury, 3pediatric population and, 669–670pediatric signs of mustard exposure (table), 670PFC David Allen Fisher’s exposure to mustard agent during

the Persian Gulf War, 106–107properties, 263published reports (1997-2006) of laboratory analysis of hu-

man blood samples following suspected exposure to sulfur mustard (table), 727

published reports (1995-2006) of laboratory analysis of human urine samples for glutathione reaction products following a suspected exposure to sulfur mustard (table), 720

published reports (1995-2006) of laboratory analysis of hu-man urine samples for hydrolysis metabolites following suspected exposure to sulfur mustard (table), 719

putative mechanisms by which sulfur mustard causes tissue damage (figure), 264

rapidity of reaction to, 265, 514, 656reaction pathway of glutathione (figure), 712reactions with glutathione, 265recovery time after exposure to, 262, 278, 519reports published prior to 1995 showing laboratory analysis of

human biomedical samples following suspected exposure to sulfur mustard (table), 709

reproductive toxicity, 315–316respirator effectiveness, 25–26, 83sample preparation methods for the gas chromatographic-


sample preparation methods for the gas chromatographic/mass spectrometric/mass spectrometric analysis of the sul-fur mustard urinary β-lyase metabolites (exhibit), 713

sample preparation procedure for sulfur mustard adducts to deoxyribonucleic acid in blood (exhibit), 722

scarring of epithelial surfaces and, 315skin effects, 267–274skin sample analysis, 726soap and water decontamination, 533, 534synthesis of, 116–117, 312teratogenesis, 315–316tissue sample analysis, 726toxicity, 667treatment of exposure to, 277–291, 670–672triage issues, 519urine sample analysis, 708–718US production of, 117US troop training and, 53Veterans Administration study on the effects of mustard agent

and lewisite exposure, 312–313Vietnam War and, 57volatility of, 135weather considerations, 135–136, 263, 266World War I use, 2–3, 15, 18, 20–21, 25–26, 27, 260, 261wound decontamination and, 538Yemen Civil War and, 57, 58

Mutagenic effects2-chlorobenzylidene malononitrile, 448

l


Myasthenia gravistreatment of, 156, 198

nN-acetylcysteine

phosgene inhalation treatment, 354N-methyl-d-aspartate receptor antagonists

dexanabinol, 229–230dizocilpine, 228gacyclidine, 230ketamine, 230–232memantine, 228–229

Nagao, M.sarin research, 699

Nakajima, T.sarin research, 695, 696

Naloxoneopioid overdose treatment, 418

Namba, T.organophosphate insecticide exposure research, 320

NAPP. See Nerve agent pyridostigmine pretreatmentNasal effects

nerve agent exposure, 172–173Nasser, Pres. Gamal Abdul (Egypt)

Yemen Civil War and, 57–58National Academy of Sciences

anticholinergic deliriant research and, 424causal relationship between lewisite exposure and chronic

respiratory disease, 294National Bio-Defense Analysis and Countermeasure Center

description and role, 767National Center for Disaster Preparedness

Mark I kit recommendations, 663Program for Pediatric Preparedness, 683

National Defence Research Institute of Swedenhair specimen analysis for mustard agent, 726

National Defense Authorization Act“Defense against Weapons of Mass Destruction,” 128, 754

National Defense Strategy of the United States of America, 758National Disaster Medical System

description, 765National Fire Protection Agency

levels of protection, 580National Guard

domestic preparedness role, 763National Incident Management System

command and management component, 756description, 492, 755–756incident-specific resources, 756organizational outline for incident management command

and coordinating centers (figure), 759National Institute for Occupational Safety and Health

levels of protection, 580permissible chlorine exposure level, 359phosgene limits, 734powered-air purifying respirators and, 5442-chlorobenzylidene malononitrile exposure guidelines, 447,

450Working in Hot Environments, 541

National Institute of JusticeGuide for the Selection of Chemical Agent and Toxic Industrial Ma-

terial Detection Equipment for Emergency First Responders, 581National Institute of Standards and Technology

3-quinuclidinyl benzilate monitoring, 739National Institutes of Health

carcinogen bioassays on chemical agents, 1341-chloroacetophenone research, 461

Project BioShield and, 251National Medical Chemical and Biological Advisory Team

description and role, 764National Research Council

acute exposure guidance levels for chemical agents, 143dibenz[b,f]-1,4-oxazepine and, 4671-chloroacetophenone and, 4632-chlorobenzylidene malononitrile gene mutation and, 448

National Response Frameworkcoordination guidelines for DHHS, 761description and role, 758

National Response Plandescription, 492, 755–756federal department or agency support to state and local gov-

ernments, 758–759integration of the federal government’s domestic prevention,

preparedness, response, and recovery plans, 756National Security Strategy of the United States of America, 758National Strategy for Homeland Security, 755, 758National Toxicology Program

2-chlorobenzylidene malononitrile carcinogenicity and, 449NATO Handbook on the Medical Aspects of NBC Defensive Operations

mustard agent treatment, 670NDMS. See National Disaster Medical SystemNeostigmine

description, 158tetrodotoxin treatment, 628

Nernst, Walther Hermannaccomplishments, 15dianisidine chlorosulphonate development, 13–14, 15, 79, 80

Nernst Ni-Shrapnel. See Dianisidine chlorosulphonateNerve agent pyridostigmine pretreatment

description, 158dosage considerations, 202

Nerve agents. See also Incapacitating agents; Neuroprotection as a treatment for nerve agent survivors; Organophosphorus compounds; Pyridostigmine bromide; Treatment of nerve agent exposure; specific agents and types of agents

accessibility of and ease of manufacturing, 244, 251adducts to biomolecules, 698–701advantages of as a weapon, 126agents included, 661aging half-time of nerve agents (table), 198analytical methods for assay of nerve agent hydrolysis prod-

ucts (table), 697Arab-Israeli Six-Day War and, 58behavioral effects, 175–179bioscavengers, 232, 244–253cardiovascular system effects, 179–180case history: nerve agent exposure in Nazhmar, Iran (exhibit),

662case report: accidental exposure of a man to liquid soman

(exhibit), 162–163central nervous system effects, 175–179chemical, physical, and environmental properties (table), 167chemical structure (figure), 694cholinesterase analysis, 701–706clinical presentation, 662compared with chlorine, phosgene, and mustard agent, 181compared with commonly used ChE inhibitors, 166–168compared with insecticides, 316–317conventional wounds contaminated with, 522–523definitions of Ct, LCt50, and LD50 (exhibit), 168dermal exposure to liquid, 169–170, 185–186, 244description, 204, 316diagnostics, 693–706effects of dermal exposure to liquid nerve agents (table), 169


li


effects of exposure to nerve agent vapor (table), 169effects of nerve agents in humans (table), 170effects on organs and organ systems, 170–180exposure routes, 168–170eye effects, 170–172fluoride regeneration and, 699general clinical tests, 694general treatment principles, 180–190, 205, 316German production of, 48Germany’s development of, 46–47Germany’s experimental testing on human subjects in concen-

tration camps, 105historical background of the use of, 156–158hydrolysis compound assay, 695–698inhalational exposure to vapor, 168–169, 185, 244intermediate syndrome and, 318–319laboratory findings, 662lessons learned from Iran, Japan, and Iraq, 195–197, 223lethality of, 244, 661long-term health effects, 316–322mechanism of action, 156, 159, 204–205, 662median lethal dose, 244methods used to confirm human exposures to nerve agent ad-

ducts to biomolecules (table), 701methods used to confirm human exposures to nerve agents via

assay of hydrolysis products (table), 698mnemonic for cholinergic crisis (exhibit), 662molecular models (figure), 166muscle necrosis and, 318nasal effects, 172–173nerve agent antidote kits and pretreatments, 64neuropsychiatric symptoms and, 320–321parent compound assay, 694–695pediatric population effects, 661–667pediatric treatment, 195persistent nature of, 244pharmacology of, 166–168physical properties, 167–168polyneuropathy, 317production during the 1950s, 55pulmonary system effects, 173–174return to duty considerations, 194–195rocket program, 121–122secondary contact and, 244signs and symptoms of mild to severe exposure, 191–194skeletal muscle effects, 174–175, 188skin effects, 169–170, 185–186, 244, 529, 661specific treatment by exposure category, 190–194toxicity of, 661toxicological studies, 322triage considerations, 518, 520–521, 522–523use in combination with other weapons, 244volatility of, 134–135, 168World War II use, 3, 48wound decontamination and, 538Yemen Civil War and, 57

Neuroleptics. See Antipsychotic drugsNeuropathology of nerve-agent-induced brain damage

seizure-related brain damage, 224–225seizures and status epilepticus, 223–224, 664

Neuropeptides and neuromodulators. See also specific agentsincapacitating effects, 420–422

Neuroprotectantsclasses of drugs, 226–227gangliosides, 227N-methyl-d-aspartate receptor antagonists, 228–232poly(ADP-ribose) polymerase inhibitors, 227

ryanodine receptor antagonists, 227–228Neuroprotection as a treatment for nerve agent survivors

free radical scavengers, 232mitochondrial permeability transition inhibitors, 232neuropathology and the mechanism of nerve-agent-induced

damage, 223–225neuroprotectants, 226–232“neuroprotection” definitions, 225–226neuroprotective hypothermia, 232relevance of neuroprotection to nerve agent survivors, 225–226

Neuroprotective hypothermianerve agent exposure treatment, 232

Neuropsychiatric symptomsmustard agent exposure and, 315nerve agent exposure and, 320–321organophosphate insecticide exposure and, 319–320

Neurotoxic shellfish poisoningbrevetoxin and, 631treatment, 631

Neuve-Chapelle, Battle ofdianisidine chlorosulphonate use, 14

Newmark, J.treatment guidelines for children, 195

Ni-shells. See Dianisidine chlorosulphonateNicoloau, K.

brevetoxin research, 628Nicotera, P.

mustard agent research, 265Niebauer, M.

dantrolene research, 228Niemann,

sulfur mustard synthesis, 260NIMS. See National Incident Management System1920s

airplane use for chemical attacks, 26, 118–119Berber war with France and Spain, 42–43Chemical Warfare Service and, 43–44improvements in chemical weapon delivery systems, 118new US policy on chemical warfare, 44–45

1930sItalian-Ethiopian War, 45–46Japanese invasion of China, 46new chemical agent development, 119new chemical weapon development, 119–120organophosphorus compound development, 46–47

1940schemical weapon delivery system improvements, 120

1950sChemical Corps changes, 54–55chemical weapon delivery system improvements, 120incapacitant program, 55–56Korean War, 54medical research on human volunteers, 55nerve agent production and development, 55Soviet threat, 56

1960sArab-Israeli Six-Day War, 58Army reorganization, 56–57chemical warfare program changes, 59–60chemical weapon delivery system improvements, 120–122Dugway Proving Ground incident, 59incapacitating chemical agent development, 59Operation CHASE, 59, 60psychedelic agent experiments, 3public hostility toward chemical weapons, 59sarin accident in Okinawa, 59Vietnam War, 57

lii


Yemen Civil War, 57–581970s

binary weapon development, 122–124plans to abolish the Chemical Corps, 60–61restoring the Chemical Corps, 61restrictions on sea dumping of chemical weapons, 60Soviet Union’s use of chemical warfare agents, 61–62Yom Kippur War, 61

1980sAfghanistan War, 62chemical training, 63Haig Report, 62Iran-Iraq War, 62–63Soviet-US Memorandum of Understanding, 63

1990schemical attacks, 125chemical weapon development in Libya, 65Persian Gulf War, 63–65

Nishioka, N.S.mustard agent injury treatment, 285

Nitritescyanide poisoning treatment, 383–384, 386, 390, 394–395, 397

Nitrogentoxic effects of exposure, 326–327

Nitrogen dioxidepathophysiological effects, 350

Nitrogen mustard. See also Mustard agentbiochemical mechanisms of injury, 263–265description, 119gastrointestinal tract effects, 276potential terrorist use and, 667synthesis of, 260three forms of, 262use of in chemotherapy, 260–261

Nixon, Pres. Richard M.ban on biological warfare agents, 138destruction of chemical weapons and, 61, 122United States ratification of the Geneva Protocol and, 60, 137

Nonivamide. See Pelargonyl vanillylamideNonlethal weapons. See Incapacitating agentsNonsteroidal antiinflammatory drugs

treatment of mustard agent exposure, 282Noort, D.

phosgene research, 737sarin research, 696

North Koreachemical weapons capability, 145

Notes on Gas as a Weapon in Modern War, 90Nozaki, H.

patient thorough decontamination research, 540NRF. See National Response FrameworkNRP. See National Response PlanNSAIDs. See Nonsteroidal antiinflammatory drugsNSP. See Neurotoxic shellfish poisoningNunn, Sen. Sam

chemical warfare comments, 125Nunn-Lugar Cooperative Threat Reduction Program

Russia’s elimination of chemical weapons and, 144Nunn-Lugar-Domenici Act

domestic preparedness program provision, 128, 754–755

OO-chlorobenzylidene malononitrile

acute effects, 447–448acute inhalation toxicity of CS in animals (table), 448animal studies of effects, 448–449carcinogenicity studies, 449

characteristics of (table), 445chemical structure (figure), 446chronic toxicology, 449clinical effects, 447–452deployment of, 444exposure guidelines, 447human studies, 449–452incapacitating effects, 416, 444inhalation toxicology studies, 448introduction of, 342, 443long-term effects, 452personal defense spray use, 443physical characteristics, 444repeat exposures, 448–449safety of, 472severe medical complications, 452subclinical toxicology studies, 449symptoms of exposure to, 444thermal degradation products, 444, 446–447Vietnam War use, 444

O-ethyl N,N-dimethyl phosphoramidocyanidate. See TabunO-ethyl-S-[2(diisopropylamino)ethyl]. See VX nerve agentOC. See Oleoresin capsicumOccupational health and the chemical surety mission

administrative documentation to support a chemical surety inspection (exhibit), 606–607

advising agencies for the treatment of chemical agent injury (exhibit), 595

categorization of workers based on their likelihood of expo-sure to chemical agents (exhibit), 601

chemical agent definition, 594chemical agent workplace, 596–597Chemical Surety (AR 50-6), 594chemical surety definition, 594demilitarization of chemical warfare agents, 609–611information sources for chemical surety, 594inspection of chemical storage containers, 596installation medical authority responsibilities, 594, 599–604,

608medical aspects of a chemical accident or incident response

and assistance, 607–609Medical Management of Chemical and Biological Casualties

Course, 594–595, 608medical response team and, 607–609medical support of the chemical personnel reliability program,

599, 605–607medical surveillance for chemical agent workers, 597–604personal protective equipment needs, 596–597, 599refresher training programs, 605safe treatment and disposal of chemical agents and weapons,

596–597Toxic Chemical Training Course for Medical Personnel,

594–595, 608training and education for chemical agent workers, 604–605understanding patients’ occupational healthcare needs and,

595Occupational Health Guidelines for the Evaluation and Control of Oc-

cupational Exposure to Mustard Agents H, HD, and HTchemical surety resource, 594potential exposure evaluations, 602RBC-ChE monitoring, 601

Occupational Health Guidelines for the Evaluation and Control of Oc-cupational Exposure to Nerve Agents GA, GB, GD, and VX

categories of personnel required to have RBC-ChE measured, 601

chemical surety resource, 594potential exposure evaluations, 602


liii


Occupational Safety and Health Administrationdisaster and medical response to mass casualty events, 492fixed decontamination shelter recommendations, 545–546hazardous waste operations and emergency response training,

515levels of personal protective equipment (exhibit), 542, 580monitoring of decontamination personnel guidelines, 542OSHA Best Practices for Hospital-Based First Receivers of Victims

from Mass Casualty Incidents Involving the Release of Hazardous Substances, 493

permissible chlorine exposure level, 359personal protective equipment guidelines, 515powered-air purifying respirators and, 544work-rest cycle recommendations, 495–496

Ochsner, Gen. Hermannnonlethal gas attacks on Soviet troops, 52views on chemical warfare, 49

Office of the Surgeon GeneralCBRNE programs and, 768

Oise-Aisne offensivechemical attacks, 32US participation (figure), 33

Okinawaaccidental release of sarin, 59, 60

Oklahoma Citybombing of the Murrah Federal Building, 754

Okumura, T.Aum Shinrikyo sarin attack on the Tokyo subway, 493patient thorough decontamination research, 540

Olajos, E.J.oleoresin capsicum research, 455tear gas research, 342

Oleoresin capsicumacute effects, 454characteristics of (table), 445chemical structure (figure), 453clinical effects, 454–455deployment methods, 453description, 452–453FBI research on, 443historic use of, 453long-term effects, 455medical complications, 455medicinal use of, 453personal protection use, 443physical characteristics, 453physiological effects, 453, 454safety of, 472US Postal Service use, 4421-chloroacetophenoneanimal studies, 460–461carcinogenicity, 461characteristics of PS, CN, DM, and CR (table), 458–459chemical structure (figure), 460deployment methods, 460description, 457harrassing dose, 461human studies, 461–464incapacitating effects, 416invention of, 442long-term effects, 463–464personal defense spray use, 443physical characteristics, 457, 460physiological effects, 460severe medical complications, 464sublethal effects, 461toxicology, 460–461

volunteer acute exposure studies, 461“120 Cities Program”

description and focus of, 7551-methylsulfinyl-2-[2-(methylthio)ethylsulfonyl]ethane

urine sample analysis for mustard agent and, 711, 716–7171,1’-sulfonylbis[2-(methylsulfinyl)ethane]

urine sample analysis for mustard agent and, 711, 717, 718OPCW. See Organization for the Prohibition of Chemical WeaponsOperation CHASE

chemical weapon dumping and, 59, 60Operation Desert Shield, 64Operation Desert Storm. See also Persian Gulf War

accidental battlefield exposure to chemical agents, 129–130description, 64–65pyridostigmine bromide therapy and, 202–204

Operation Enduring FreedomSeptember 11, 2001, attacks and, 65

Operation Iraqi Freedomimprovised explosive devices and, 130Iraq’s failure to report its chemical warfare research and weap-

ons production and, 65–66Operation Solid Shield, 87

field training for chemical attacks, 106OPIDN. See Organophosphorus ester-induced delayed neurotox-

icityOpioids. See also specific agents

cyanide poisoning treatment, 523description and incapacitating effects of, 418–419, 421nerve agent exposure treatment, 523overdose treatment, 418pediatric population and, 667popularity as illicit drugs, 419side effects, 667

OPs. See Organophosphorus compoundsOral effects

2-chlorobenzylidene malononitrile, 448Organization for the Prohibition of Chemical Weapons

Chemical Weapons Convention and, 138, 140–141Organophosphate insecticides. See also specific agents

compared with nerve agents, 316–317electroencephalographic effects, 321intermediate syndrome and, 318muscle necrosis and, 317–318neuropsychiatric symptoms and, 319–320polyneuropathy, 317

Organophosphorus compounds. See also Insecticides; Nerve agents; specific agents

anticholinesterase use, 251–252atropine treatment, 184brain injury and, 223cardiac arrhythmias and, 190categorization of (exhibit), 47compounds included, 158earliest reported incident of toxicity from, 47German development of, 46–47incapacitating effects, 416mechanism of action, 161, 244, 701original use for, 244pediatric effects, 658, 661physostigmine development, 46Test-Mate OP Kit field-forward assay, 693tetraethyl pyrophosphate development, 46–47toxicity of, 661–662, 701

Organophosphorus ester-induced delayed neurotoxicitydescription, 317

Orrenius, S.mustard agent research, 265

liv


OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances, 493

Osmond, Humphry“psychedelic” definition and, 416

OTZ. See 2-oxothiazolidine-4-carboxylic acidOwens, E.J.

dibenz[b,f]-1,4-oxazepine research, 468Oxides of nitrogen

air pollution and, 344–345diagnosis of exposure to, 358forms of, 344sources of, 358toxic effects of, 326–327, 358

Oximes. See also Mark I kits; specific agentsadministration considerations, 188–189, 702antidote treatment nerve agent autoinjector and, 188, 189combined with atropine, 183, 188, 223cyclosarin exposure and, 202description, 186differences among agents, 187dosage considerations, 187–188mechanism of action, 186–187nerve agent exposure treatment, 186–189, 197–198, 663, 702pediatric population and, 663

PP-aminopropiophenone

cyanide poisoning treatment, 394, 396Palestine

Israel’s possible use of DM against, 443Palmer, Col. John M.

military training program comments, 56Palytoxin

accidental exposure, 620adverse effects of human palytoxin intoxication (exhibit), 621bioterrorism threat from, 622chemical structure (figure), 618clinical signs and symptoms of intoxication, 619health effects, 619laboratory findings, 619–620lethality of, 622mechanism of action, 617–618median lethal dose, 618–619physical examination results, 619primary source, 617protection against, 622public health surveillance programs, 622routes of exposure, 619, 620, 622sodium channel effects, 617–618stability of, 622synthesis, 617toxicity, 618–619, 620treatment, 620–622

Papaverinepalytoxin intoxication treatment, 622

Papirmeister, B.mustard agent research, 278

PAPP. See P-aminopropiophenoneParalytic shellfish poisoning

clinical signs and symptoms, 625–626food sources, 624–625physical examination and, 626red tide blooms and, 622saxitoxin and, 622, 624–625, 625–626tetrodotoxin and, 624–625

Parathion

blood cholinesterase inhibition and, 165eye effects of exposure to, 170insecticide use, 158muscle necrosis and, 318

Paris Convention. See Chemical Weapons ConventionPARP inhibitors. See Poly(ADP-ribose) polymerase inhibitorsPatel, Marilyn Hall

gas chamber executions with cyanide and, 374Patient protective wraps

description and uses, 587Patient thorough decontamination

benefits of, 540civilian sector and, 540–541decontamination shelters, 544–546, 552decontamination worker protection, 541–543description, 500, 528detection devices, 544handling patients, 547hospital areas for, 529individual protective equipment, 543–544medical monitoring, 541musculoskeletal injury to decontamination workers, 541need for, 539–540night operations and, 547–548personnel needs, 540–541transport equipment, 544water concerns, 546–547work-rest cycles for workers, 542, 543worker safety and, 541–543wound contamination and, 538

PATS. See M41 protection assessment test systemPattle, R.E.

dibenz[b,f]-1,4-oxazepine research, 467Paulet, G.

cyanide poisoning research, 394, 396PAVA. See Pelargonyl vanillylamidePB. See Pyridostigmine bromidePbTx. See BrevetoxinPCP

description and incapacitating effects, 419treatment for intoxication by, 420

Pediatrics. See Infants and children; Medical management of chemical toxicity in pediatrics

Pelargonyl vanillylamidechemical structure (figure), 453police department use, 443synthesis of, 453

Pentazocinedescription and incapacitating effects, 418–419

Pereira, M.A.phosgene research, 737

Perfluoroisobutylenenonmilitary uses, 357physiological effects, 354supportive care for exposure to, 358toxic effects of, 324, 326, 345toxic fumes from, 357–358treatment for inhalation of, 354

Periodic medical examinations for chemical workerscomparing data from preplacement examinations, 600frequency and extent of, 600–601interval medical history and physical, 601

Pershing, Gen. John J.AEF leadership, 22, 24, 25, 27, 33, 36, 89comments on the importance of chemical warfare, 41

Pershing missilesnerve agent delivery, 122


lv


Persian Gulf War. See also Operation Desert Stormchemical weapons and, 63–65, 106–107“Gulf War” syndrome, 64nerve agent antidote kits and pretreatments, 64, 704PFC David Allen Fisher’s exposure to mustard agent, 106–107pyridostigmine bromide therapy and, 202–204use of 3-quinuclidinyl benzilate by Iraq, 413

Pert, Candacemorphine research, 418

Pesticides. See Organophosphate insecticidesPetras, J.M.

nerve-agent-induced brain damage research, 223PFIB. See PerfluoroisobutylenePharmacology of cholinesterase inhibitors

blood cholinesterases, 161–166cholinesterase in tissue, 158cholinesterase-inhibiting compounds, 158–159inhibition of blood cholinesterases, 164–166mechanism of action, 159–161nerve agents, 166–168

Phenethylamine-based psychedelicsdescription and effects of, 418

PhenothiazinesLSD intoxication treatment, 417

Philippe, HenriChampagne-Marne Defensive and, 30

Phosgeneaccidental release of, 134animal studies, 735chemical reactivity, 354combined with chlorine or diphosgene, 341compared with phosgene oxime, 294cysteine adducts, 736development of, 15, 734earliest reported description involving chemical warfare on

the AEF (exhibit), 22Edgewood Arsenal, MD, production, 119France’s weaponizing of, 341Germany’s experimental testing on human subjects in concen-

tration camps, 105glutathione and glutathione adducts and, 735–736inflammatory pathways, 350–351inhalation of, 734–735interleukin-6 levels and, 737–738latent period for symptoms, 324–325lethal dose, 735long-term health effects of exposure, 324–326, 354macromolecule adducts, 737mechanism of action, 136, 734metabolism and markers for exposure, 735–737nerve agents compared with, 181nonmilitary uses, 345odor of, 734, 735pathophysiological effects, 348, 349, 734pediatric effects of exposure to, 673physiological responses, 348, 354, 734properties and attributes of (exhibit), 19regulatory threshold limit value, 734replacement of chlorine with, 18small molecule adducts, 736–737synthesis of, 116toxicity of, 734treatment for inhalation of, 354–355, 363triage issues, 521, 522US production of, 117vapor pressure, 734“white star” mixture with chlorine, 19–20

World War I use, 2, 19–20, 25–26, 83, 341Yemen Civil War and, 57

Phosgene oximebiochemical mechanisms of injury, 294clinical effects, 295compared with mustard agent and lewisite, 261compared with phosgene, 294eye effects of exposure, 295military use, 294patient management, 295properties, 294pulmonary effects of exposure, 295putative mechanisms by which phosgene oxime causes tissue

damage (figure), 294skin effects of exposure, 295

pHuBChE. See Plasma-derived human butyrylcholinesterasePhysostigmine

adverse effects, 426, 704chemical structure (figure), 198compared with huperzine A, 704deliriant intoxication treatment, 425–426, 523description, 158development and isolation of, 46mechanism of action, 425, 426PCP intoxication treatment, 4203-quinuclidinyl benzilate intoxication treatment, 426

Pinacoloxymethyl-fluorophosphonate. See SomanPlasma-derived human butyrylcholinesterase

administration of, 247advantages for human use, 246–247, 252, 253availability of, 249, 653behavioral safety of, 248–249Cohn Fraction IV-4 paste source, 247, 249, 251compared with fetal bovine serum AChE, 245efficacy of, 247–248, 252immunological safety of, 248, 252pharmacokinetics, 247, 252–253, 702prophylactic dose, 247protection by human butyrylcholinesterase against nerve

agent poisoning (table), 252purification from human plasma, 247pyridostigmine bromide and, 251recombinant type, 249–250safety of, 247, 252–253sarin and, 698–699stability of, 247, 252

Plasma-derived stoichiometric bioscavengerscholinesterases, 245–247compared with catalytic bioscavengers, 250plasma-derived human butyrylcholinesterase, 245–247

Playfair, Lyoncacodyl cyanide artillery shell proposal, 11

Point detectorschemical agent detector kits, 576–577improved chemical agent detectors, 576M22 automatic chemical agent detector and alarm, 577M8 chemical agent detection paper, 575M9 chemical agent detection paper, 575–576M272 chemical agent water testing kits, 577

Polhuijs, M.sarin research, 696, 698–699

Poly(ADP-ribose) polymerase inhibitorssoman-induced seizure-related brain damage treatment, 227

Polymer fume feverperfluoroisobutylene and, 358polytetrafluoroethylene and, 345

Polyneuropathy

lvi


nerve agents and, 317organophosphate insecticides and, 317

Polytetrafluoroethyleneformation of toxic gases, 345pathophysiological effects, 349–350polymer fume fever and, 345

Porcine heterograftmustard agent injury dressing, 280

Porter, E.2-chlorobenzylidene malononitrile research, 446

Porter, Maj. Gen. William N.chemical weapon warnings, 48

Posttraumatic stress disordercomorbidity with other mental illness, 321nerve agent exposure and, 175, 319, 321pediatric population and, 660, 680

Powered dermabrasionmustard agent injuries and, 284

Powers, Francis Garysaxitoxin capsules and, 628

Pregnant womencyanide poisoning treatment, 385pyridostigmine bromide pretreatment safety, 201sarin exposure and treatment, 196

Preplacement examinations for chemical workersbaseline data, 600factors restricting the wearing of protective clothing and, 600functions of, 600heat stress monitoring and, 603–604job description and, 599medical history questionnaire, 600

Pretreatment therapy for nerve agent poisoninghuperzine A, 704–706pyridostigmine bromide, 158, 197–204, 244, 252, 651, 704

Professional officer filler information systemarea medical laboratories’ endemic diseases section and, 764MEDCOM personnel and, 764

PROFIS. See Professional officer filler information systemProgram for Pediatric Preparedness

goals of, 683Web site, 683

Project 80description, 56

Project 112description, 56

Project BioShieldinteragency partnership on, 251

Projectorsattacks on the AEF (exhibit), 26binary weapons and, 123CWS standardization of, 120, 121–122description, 26Livens projectors, 118, 119rockets, 120, 121–122VX nerve agent delivery, 121–122

Protective clothingboots, 573fabrics for, 569factors in the decision to wear, 569gloves, 573–574heat and, 569joint service lightweight integrated suit technology, 572–573MOPP levels and, 569protective ensembles, 572–573

Protective equipment. See Gas masks; Respirators; Individual protective equipment

PS. See Chloropicrin

PSP. See Paralytic shellfish poisoningPsychedelic agents. See Indole-based psychedelicsPsychochemicals. See Incapacitating agentsPsychological effects

chemical weapons, 2, 19–20cyanide poisoning, 393–394pediatric population and, 660

PTSD. See Posttraumatic stress disorderPTX. See PalytoxinPulmonary system. See also Inhalational exposure to nerve agent

vapor; Inhalational injury from toxic industrial chemicals; spe-cific agents and disorders

batrachotoxin effects, 633brevetoxin effects, 630chlorine effects, 673chloropicrin effects, 456–457chronic pulmonary disease, 314dibenz[b,f]-1,4-oxazepine effects, 467–468diphenylaminearsine effects, 466incapacitating agent effects, 442, 471–472intubation, 288lewisite exposure effects, 293, 294mustard agent exposure and, 275, 287, 288–290, 290–291, 312,

313–314, 670, 672nerve agent exposure effects, 173–174oleoresin capsicum effects, 4541-chloroacetophenone effects, 461–462onset of symptoms, 275paralytic shellfish poisoning effects, 626pediatric exposure to toxic agents and, 659phosgene exposure effects, 295, 325–326pulmonary cancer relationship to mustard agent exposure,

313–314respiratory failure, 1742-chlorobenzylidene malononitrile effects, 447–449, 449–450ventilation considerations, 173

Pulsed CO2 laser ablationmustard agent injury treatment, 284

Pumiliotoxinsodium channel effects, 617

Punte, C.L.1-chloroacetophenone research, 4612-chlorobenzylidene malononitrile research, 449, 450, 451

Pyridostigminechemical structure (figure), 198myasthenia gravis treatment, 156, 198nerve agent exposure treatment, 174, 244soman exposure and, 179

Pyridostigmine bromideadverse effects, 201, 202–203compared with atropine and oxime therapy, 199–200dosage considerations, 202, 704effect of therapy on median lethal dose in monkeys exposed to

soman (table), 199effect of therapy with and without pyridostigmine pretreat-

ment on protective ratios in animals exposed to nerve agents (table), 200

effects of pyridostigmine pretreatment on US soldiers in the Persian Gulf War (table), 203

efficacy of for pretreatment, 158, 199–201, 202, 704FDA post-marketing studies, 652informed consent issues, 204, 650–651interaction with other commonly used battlefield medications,

201–202myasthenia gravis treatment, 158“off-label” use of, 650pretreatment for nerve agent poisoning, 197–204, 244, 252, 651,


lvii


704red blood cell and acetylcholinesterase protection studies us-


regulatory status, 204safety of administration, 201–202surgery and, 204unexplained medical symptoms and, 203–204wartime use, 202–204

QQuayle, Vice Pres. Dan

chemical weapon comments, 64Queen, F.B.

1-chloroacetophenone research, 463

RRADS. See Reactive airways dysfunctionRapsahl, Julius

warning of a German gas attack, 80Raveh, L.

fetal bovine serum AChE research, 245plasma-derived human butyrylcholinesterase research,

245–246, 249RBC-ChE. See Red blood cell cholinesteraseReactive airways disease syndrome

2-chlorobenzylidene malononitrile exposure and, 452Reactive airways dysfunction

sulfur dioxide and, 3452-chlorobenzylidene malononitrile and, 342

Reactive Skin Decontamination Lotiondescription, 533, 536–537, 652–653, 653development of, 652–653M291 SDK and, 536, 653safety of, 653

Read, R.W.urine sample analysis for mustard agent, 711, 716, 717

Reagan, Pres. Ronaldbinary chemical weapons and, 3, 124–125

Recombinant human butyrylcholinesteraseclinical trials, 653–654sources of, 249–250

Recombinant stoichiometric bioscavengersrecombinant human butyrylcholinesterase, 249–250

Red blood cell cholinesterasedescription, 158monitoring, 161, 163periodic medical examinations for chemical workers and, 600preplacement examinations for chemical workers and, 600temperature effect on inhibition, 165

Regional Emergency Medical Advisory Committee of New York City

pediatric nerve agent antidote dosing schedule, 684Remifentanyl

description and use of, 667Rengstorff, R.H.

dibenz[b,f]-1,4-oxazepine research, 4681-chloroacetophenone research, 4632-chlorobenzylidene malononitrile research, 450–451

Renshaw, B.long-term health effects of mustard agent, 315

Republican National Convention of 2004CDC Enhanced Surveillance Program data, 622

Respirators. See also Gas masksclearances for chemical workers, 602effectiveness against mustard agent, 25–26, 83

fit issues, 560, 563powered-air purifying type, 544training in use of, 560use of for children, 657

Respiratory protectiongeneral principles, 561joint service general purpose masks, 567–568joint service mask leakage tester, 563, 564–565M45 chemical-biological masks, 566–567M53 chemical-biological protective masks, 568–569M41 protection assessment test system, 563, 564M42A2 chemical-biological combat vehicle masks, 566M40A1 chemical-biological field masks, 565–566masks, 561–569MCU-2/P chemical-biological masks, 566small box respirators, 561

Return to dutymustard agent exposure and, 290–291nerve agent exposure and, 194–195

Rhoads, Dr. Cornelius P.Bari disaster and, 105

Rhodanesehydrogen cyanide inhalation treatment, 353–354

rHu BChE. See Recombinant human butyrylcholinesteraseRice, P.

mustard agent injury treatment, 285Riche, Alfred

synthesis of mustard agent, 117, 260Ricin

CDC categorization as a category B threat agent, 616Rinkel, Max

lysergic acid diethylamide research, 413Riot control agents. See Incapacitating agentsRitter, Franz

sarin research, 47Rivastigmine

Alzheimer’s disease treatment, 158Rockets

“Honest John” rocket, 122“Little John” rocket, 122nerve agent delivery, 120, 121–122, 157

Roman empireancient use of toxic smoke, 10–11, 78cyanide use, 372–373incapacitating agent use, 443

Roosevelt, Pres. Franklin D.no-first-use policy for chemical weapons, 52, 137

Rosenstock, L.organophosphate insecticide exposure research, 320

Rotenberg, J.S.cyanide poisoning research, 674treatment guidelines for children, 195

Roth, V.S.2-chlorobenzylidene malononitrile research, 452

Rowntree, D.W.organophosphate insecticide exposure research, 320

Royal Army Medical Corpsadvanced dressing stations, 87base hospitals, 87casualty clearing stations, 87collecting, evacuating, and distribution zones, 85Dr. Harvey Cushing’s account of Royal Army Medical Corps

capabilities, Flanders, Belgium, May 5, 1917 (exhibit), 88evacuation modes, 87main dressing stations, 87regimental aid posts, 86–87responsibilities, 85

lviii


Royall, Under Secretary of War Kenneth C.chemical warfare comments, 53

RSDL. See Reactive Skin Decontamination LotionRüdiger, Col.,

sarin research, 47, 156Russia

Chemical Weapons Convention and, 3, 65, 157demilitarization of chemical agents and, 144–145stockpile destruction (table), 144use of fentanyl in the Chechen hostage situation, 3, 65, 107,

413, 419Russian VX. See also VX nerve agent

chemical structure (figure), 694Ryanodine receptor antagonists

soman-induced seizure-related brain damage treatment, 227–228

SSacco triage method

description, 517Saddam Hussein

bombing of Sardasht using mustard agent, 656Iraq’s chemical weapon capabilities and, 64Iraq’s invasion of Kuwait and, 63–64

Saint Mihiel offensivechemical attacks, 32–33division field hospitals, 95–96medical support for the treatment of chemical casualties, 99overview and detailed map of US participation (figure), 34

Salem, H.hydrogen cyanide research, 354incapacitating agent research, 442oleoresin capsicum research, 455tear gas research, 342

Salt Lake City, UTaccidental release of ammonia, 145

Sandberg, C.G.cyanide poisoning research, 393

Sarinaccidental exposure of two US soldiers to in Baghdad,

157–158, 168, 195, 197advantages of as a weapon, 126animal testing of, 47atropine treatment, 179Aum Shinrikyo cult attack with sarin in the Tokyo subway, 4,

125, 127–128, 158, 178, 181–182, 193, 196–197, 223, 244, 316, 317, 321, 492, 518, 540, 657, 695–696, 699, 754

behavioral effects of exposure, 175, 176carboxylesterase and, 246case report: exposure of three men to sarin (exhibit), 172chemical structure (figure), 694clinical effects, 316codenames for, 47electroencephalographic effects of exposure, 177, 321–322German production of, 48, 119, 156hydrolysis pathway of sarin, soman, and cyclosarin (figure),

696intermediate syndrome and, 318–319Iran-Iraq War and, 157, 195–196molecular model (figure), 166muscle necrosis and, 318plasma-derived human butyrylcholinesterase and, 245polyneuropathy and, 317production during the 1950s, 55projectile delivery, 121–122properties of, 3pulmonary system effects, 173–174

signs and symptoms reported by Tokyo hospital workers treating victims of sarin subway attacks (table), 541

Soviet Union production of, 156synthesis of, 693toxicity and lethality of, 47, 693toxicological studies, 3222-pyridine aldoxime methyl chloride treatment, 187US production of, 120volatility of, 134, 168

Saudi Arabia. See Arab-Israeli Six-Day WarSaunders, Bernard Charles

diisopropyl fluorophosphate research, 48Saxitoxin

chemical structure (figure), 623clinical signs and symptoms of poisoning, 624–626laboratory findings, 626–627lethal dose, 623–624mechanism of action, 623monitoring, 627protection issues, 628sodium channel effects, 617, 623sources of, 622stability, 627, 628synthesis, 622–623toxicity, 623–624treatment, 627, 628

SBME. See 1,1’-sulfonylbis[2-(methylsulfinyl)ethane]Scheele, Carl Wilhelm

cyanide research, 116, 373discovery of chlorine, 116

Schouosboe, A.dantrolene research, 228

Schrader, Gerhardorganophosphorus compound research, 47sarin research, 156tabun research, 47, 156, 693

Schwarzkopf, Gen. H. Normanchemical warfare comments, 64

Sciuto, A.M.phosgene research, 348, 736, 737–738

Scopolaminedescription and incapacitating effects, 421, 422

SE. See Status epilepticusSeizure-related brain damage

description, 223mechanisms contributing to nerve-agent-induced SRBD

(figure), 225neuropathology of, 224–225secondary stroke injury and, 226

Seizuresbrain damage cause, 223central nervous system effect of nerve agent exposure,

178–179, 244neuropathology of, 223–224seizure-related brain damage, 223status epilepticus and, 223therapeutic window, 223

September 11, 2001, terrorist attacksdomestic preparedness issues, 755–758, 765, 767–768, 769Operation Enduring Freedom and, 65Strategic National Stockpile and, 765

Serotonin 5-HTincapacitating effects, 421

SERPACWA. See Skin exposure reduction paste against chemical warfare agents

Settle, J.A.D.mustard agent exposure treatment, 279


lix


Shaw, F.H.organophosphate insecticide exposure research, 319, 320

Shellfish poisoning. See Brevetoxin; Saxitoxin; TetrodotoxinShih, T.M.

dizocilpine research, 228memantine research, 228

Shryock, RichardVedder’s comments on, 108

Sibert, Maj. Gen. William L.Chemical Warfare Service leadership, 22, 90

Silver nitrate solutiontreatment of mustard agent injuries, 280

Silver sulfadiazine creamtreatment of mustard agent injuries, 281, 670, 671

Silverlonmustard agent injury dressing, 280

Simple triage and rapid treatment systemdescription, 517

Six-Day War. See Arab-Israeli Six-Day WarSkeletal muscle system

brevetoxin effects, 630effects of nerve agent exposure, 174–175, 188, 318effects of organophosphate insecticide exposure, 317–318muscle necrosis and, 317–318paralytic shellfish poisoning effects, 626saxitoxin effects, 627tetrodotoxin effects, 627

Skin cancermustard exposure and, 313

Skin effects of chemical agents. See also specific agentsactive barrier creams, 531–532active topical skin protectant and, 531–532barrier skin creams and, 530–532classes of barrier creams, 531factors affecting the absorption of agent, 529–530patents covering work on active topical skin protectant at the

US Army Medical Research Institute of Chemical Defense (table), 532

pediatric population and, 659skin “compartments,” 529skin exposure reduction paste against chemical warfare

agents, 530–531Skin effects of incapacitating agents

chloropicrin, 457dibenz[b,f]-1,4-oxazepine, 468diphenylaminearsine, 466oleoresin capsicum, 454–4551-chloroacetophenone, 461, 462–463treatment, 4712-chlorobenzylidene malononitrile, 448, 450–451

Skin effects of lewisite exposureblistering, 292–293erythema, 292

Skin effects of mustard agent exposurebulla description, 267, 671compared with toxic epidermal necrosis, 278, 279cosmetic and/or functional deficits, 278current treatments, 278–281cutaneous sensitivity, 315cytopathology, 269–270erythema, 267, 268, 279, 667healing time for skin lesions, 268, 270, 278hyperpigmentation, 268–269, 315, 672immediate treatment improvements, 281–282improved therapies, 281–287injury assessment, 282–283models and histopathology, 270–271

onset of symptoms, 267, 312penetration of the skin, 529return to duty considerations, 291scarring of epithelial surfaces, 315skin cancer, 313, 315skin proteins and immunohistopathology, 272–274thermal burns compared with, 278–279, 290threshold amount needed to produce skin lesions, 267, 312treatments, 278–287, 290ultrastructural pathology, 271–272vesication, 267, 270–274, 279–281

Skin effects of toxin intoxicationbrevetoxin, 630palytoxin, 620, 621tetrodotoxin, 627

Skin exposure reduction paste against chemical warfare agentsapplication of, 531barrier properties, 530–531components, 530, 532development of, 530effectiveness, 531effects on decontamination, 531function, 531M291 skin decontamination kits and, 652

Skin exposure to liquid nerve agentsatropine treatment, 185–186compared with inhalational exposure, 169–170effects of dermal exposure to liquid nerve agents (table), 169factors in effects of, 169

Skin substitutesadvantages of, 286mustard agent injury treatment, 286–287selection of, 286

Sleep-Ezedescription and uses, 421

Small Business Innovative Research Programfunding for seizure detectors, 223

Smokingcyanide levels and, 323, 324, 374, 731endogenous cyanide concentrations for smokers and non-

smokers (table), 381SNS. See Strategic National StockpileSnyder, Solomon

morphine research, 418Soap and water (hydrolysis)

infants and children and, 551, 677mechanism of action, 533–534patient thorough decontamination and, 534, 544skin decontamination method, 533–534water concerns, 546

Sodium channel toxins. See also Batrachotoxin; Brevetoxin; Pumil-iotoxin; Saxitoxin; Tetrodotoxin

three-dimensional representation of a voltage-gated sodium channel sitting in a phospholipid bilayer membrane (figure), 624

Sodium nitritecyanide poisoning treatment, 383–384, 394–395, 675–676hydrogen cyanide inhalation treatment, 353limitations of, 396side effects, 394use in children, 390

Sodium thiosulfatecombined with hydroxocobalamin, 396, 676cyanide poisoning treatment, 383, 386, 390, 391, 396, 397,

675–676dosage considerations, 396hydrogen cyanide inhalation treatment, 353

lx


Solomon, I.2-chlorobenzylidene malononitrile research, 452

Somanadditives for, 135aging half-time, 316assays for, 699atropine treatment, 179barrier creams and, 531behavioral effects of exposure, 176capture of research documents, 51carboxylesterase and, 246case report: accidental exposure of a man to liquid soman

(exhibit), 162–163, 312central nervous system effects, 416chemical structure (figure), 694diazepam treatment, 179effect of therapy on median lethal dose in monkeys exposed to

soman (table), 199effects of soman on acetylcholinesterase activity in whole

blood from human volunteers who had taken pyridostig-mine bromide (figure), 706

effects of soman on acetylcholinesterase activity in whole blood from human volunteers who were given an increasing dose of huperzine A (figure), 707

fetal bovine serum AChE and, 245hydrolysis pathway of sarin, soman, and cyclosarin (figure),

696incapacitating effects, 416median lethal dose, 694–695molecular model (figure), 166muscle necrosis and, 318neuropsychiatric effects, 320oxime treatment and, 189plasma-derived human butyrylcholinesterase and, 245–249pulmonary system effects, 174pyridostigmine bromide pretreatment, 179, 199, 201, 704red blood cell and acetylcholinesterase protection studies us-


seizure-related brain damage, 224–225, 226–232, 244severe exposure to, 161synthesis of, 48, 157, 693toxicity and lethality of, 47, 693toxicological studies, 322volatility of, 168

Somme, Battle of the“white star” mixture of phosgene and chlorine and, 19

Sommervell, Maj. William V.symptomology of gas poisoning, 91

Sommervillier, Battle ofphosgene and chloropicrin attacks, 25–26

Soviet Union. See also RussiaAfghanistan War and, 62Biological Weapons Convention and, 61–62capture of soman research documents, 51chemical weapons threat, 56“Foliant” chemical agent program, 3Memorandum of Understanding with the United States on

prohibiting chemical weapons, 63nerve agent weaponization, 3no-first-use policy on chemical weapons during World War II,

51–52sarin and tabun production, 156US-Soviet weapons destruction agreement, 138use of chemical warfare agents in the 1970s, 61–62

SpainBerber war, 42–43

Spanish influenzaeffects of, 101

Speer, Albertviews on chemical warfare, 49–50

Spray deliverydescription, 132nerve agents, 120, 157

SRBD. See Seizure-related brain damageSS John Harvey

mustard agent disaster at Bari, Italy and, 21, 53, 262Stafford Act

federal department or agency support to state and local gov-ernments and, 758–759

overview of the initial federal involvement under the Stafford Act (figure), 760

Stahl, C.J.1-chloroacetophenone research, 463

Stalin, Josefno-first-use policy on chemical weapons during World War II,

51–52Stander, T.

1-chloroacetophenone research, 463Standoff detectors

early warning for line-of-sight distances, 577joint services lightweight standoff chemical agent detectors,

579M21 remote sensing chemical agent alarms, 578–579

Stanton, Secretary of War Edwin M.Doughty’s chemical warfare proposal and, 12

Staphylococcal enterotoxin BCDC categorization as a category B threat agent, 616

Stark, Col. A.N.emergency gas teams and, 97

START triage systemdescription, 517

Status epilepticusbrain damage cause, 223definition of, 223nonconvulsive type, 223pediatric population and, 664therapeutic window, 223

Steenland, K.organophosphate insecticide exposure research, 319

Stein, A.A.1-chloroacetophenone research, 462

Stenhouse, Johnsynthesis of chloropicrin, 117

Steroids. See also Corticosteroidspalytoxin intoxication treatment, 621

Stimson, Secretary of State Henry L.letter from Gen. MacArthur, 44–45

Stimulantsdescription and effects of, 418

STM. See Sacco triage methodStokes mortars

description, 118, 119Stoughton, R.W.

2-chlorobenzylidene malononitrile research, 444Strasbourg Agreement of 1675

description, 136Strategic National Stockpile

description and role, 765pediatric-ready medications and, 678“push packages” of pharmaceutical and supplies, 765

Strategy for Homeland Defense and Civil Supportobjectives, 758

Stroke


lxi


seizure-related brain damage and, 226Stubbs, Maj. Gen. Marshall

Soviet chemical weapons threat comments, 56STX. See SaxitoxinSubstance abuse and dependency

screening of chemical agent workers, 602–603US Army policies, 602–603

Succinylcholinebutyrylcholinesterase and, 164pediatric population and, 666

Sudecon Decontamination Wipesincapacitating agents and, 470

Sulfur dioxidecommon sources of, 345

Sulfur mustard. See Mustard agentSuper Bowl of 2001

CDC Enhanced Surveillance Program data, 622Suschitzkey, H.

dibenz[b,f]-1,4-oxazepine research, 467, 468Swanston, D.W.

dibenz[b,f]-1,4-oxazepine research, 4681-chloroacetophenone research, 460

SwitzerlandRussia’s elimination of chemical weapons and, 145

“Symptomology, Pathology and General Treatment of Gas Cases” (Gilchrist), 91

SyriaYom Kippur War and, 61

Systoxblood cholinesterase inhibition and, 165

TT-2 mycotoxin

CDC categorization as a category B threat agent, 616T-shells. See Xylyl bromideTabershaw, I.R.

organophosphate insecticide exposure research, 320Tabun

advantages of as a chemical weapon, 47assays for, 699behavioral effects of exposure, 175capture of German facility for manufacturing, 50–51, 157chemical structure (figure), 694development of, 693German production of, 48, 119, 156, 693Iran-Iraq War and, 157, 195–196molecular model (figure), 166muscle necrosis and, 318properties of, 3pulmonary system effects, 174pyridostigmine bromide pretreatment, 199, 201Soviet Union production of, 156synthesis of, 156testing of, 47toxicity and lethality of, 47, 693toxicological studies, 322volatility of, 168

Taniyama, S.palytoxin research, 620

TDG. See ThiodiglycolTDG-sulfoxide. See Thiodiglycol sulfoxideTear gas. See Incapacitating agentsTeflon. See PolytetrafluoroethyleneTEN. See Toxic epidermal necrosisTerbutaline

chlorine inhalation treatment, 353Termination examinations for chemical workers

changes in duties and, 601–602timing of, 601

Terrorist attacksadvantages of chemical agents for, 126–127Al Qaeda, 129“Alphabet Bomber,” 127Aum Shinrikyo, 4, 125, 127–128, 129, 158, 178, 181–182, 193,

196–197, 223, 244, 316, 317, 321, 492, 518, 540, 657, 695–696, 699, 754

chemical terrorism incidents, 126–129The Covenant, the Sword, and the Arm of the Lord, 127cyanide plot against the US Embassy, Italy, 128“domestic terrorism” definition, 126fear of future chemical attacks, 560military installation protection, 126September 11, 2001, attacks, 65, 560“terrorism” definitions, 125–126“terrorist” definition, 125William Krar, 128–129

Test-Mate kitfield-forward assay for organophosphorus exposure, 693, 702,

704Tetraethyl pyrophosphate

development of, 46–47synthesis of, 46, 156

TetrahydroaminacridineAlzheimer’s disease treatment, 4263-quinuclidinyl benzilate intoxication treatment, 426

Tetrodotoxinchemical structure (figure), 623clinical signs and symptoms of poisoning, 624–626laboratory findings, 626–627lethal dose, 623–624mechanism of action, 623monitoring, 627physical examination and, 626protection issues, 628signs and symptoms of intoxication, 628sodium channel effects, 617, 623sources of, 622stability, 627, 628surveillance, 628synthesis, 622–623toxicity, 623–624treatment, 627, 628

Thiodiglycolanalysis methods for urine samples to measure thiodiglycol or

thiodiglycol and thiodiglycol-sulfide (table), 710mustard agent exposure and, 707, 708–711, 713–718target analytes for analysis methods outlined in Table 22-7

(table), 711Thiodiglycol sulfide

analysis methods for urine samples to measure thiodiglycol or thiodiglycol and thiodiglycol-sulfide (table), 710

target analytes for analysis methods outlined in Table 22-7 (table), 711

Thiodiglycol sulfoxidemustard agent exposure and, 708, 710–711, 716–718

Thiosulfate. See Sodium thiosulfateThirty Years War

use of toxic smoke projectiles, 11Thomas, S.J.

mustard agent exposure treatment, 2793,4-methylene-dioxymethylamphetamine

description and effects of, 4183-quinuclidinyl benzilate

analytical methods for exposure to, 739

lxii


Chemical Corps research, 414, 422–424chemical structure (figure), 739clinical pharmacology, 422–423delirium features, 423–424description and incapacitating effects, 422, 427, 738development of, 3, 59duration of action, 738inhalation studies, 422–423, 427lethal dose, 738mechanism of action, 738–739molecular weight, 738parameter definitions, 423physostigmine treatment for intoxication by, 426, 523placidity and, 425routes of administration, 422safety of, 427stockpiles of, 739summary of BZ and fentanyl derivatives (table), 429tetrahydroaminacridine treatment for intoxication by, 426therapeutic ratio, 427use of by Iraq during the Persian Gulf War, 413weaponization of, 738

ThucydidesHistory of the Peloponnesian War, 10, 78

TICs. See Toxic industrial chemicalsTIM. See Toxic industrial materialTissue sample analysis

mustard agent, 726Tobacco use. See SmokingTobramycin

mustard agent treatment, 672Tooele Army Depot, UT

demilitarization of chemical agents, 141–142, 143, 157Topical antibiotics. See also Antibiotics

treatment of mustard agent exposure, 280, 672Torngren, S.

individual protective equipment research, 543–544Torsade de pointes

nerve agent exposure and, 179Total-body cooling

neuroprotectant use, 232Toxic Chemical Agent Safety Standards

protection levels for workers, 596Toxic epidermal necrosis

compared with skin injuries from mustard agent, 278, 279Toxic industrial chemicals. See also Toxic industrial material;

specific agentscommon sources, 340definitions of airborne toxic material (table), 340description, 340forms of, 340history and use, 341–345inhalational injury from, 340–365mechanism of injury, 340, 355, 356–357mechanisms of toxicity, 345–353military uses, 341nonmilitary uses, 341–345potential for accidental or deliberate exposure, 341respiratory protection equipment, 563triage considerations, 519–520, 522, 523US Army Center for Health Promotion and Prevention Medi-

cine toxic industrial chemicals (table), 343–344Toxic industrial material. See also Toxic industrial chemicalsdetection and identification, 580–581

individual protection, 580respiratory protection equipment, 563use in improvised explosive devices, 580

Toxic smokescommon sources, 345early military use, 10–11, 78, 341pathophysiological effects, 350uses for, 134

Toxicological studiesnerve agents, 322

Toxins. See also specific agentsaccidental exposure, 616biotoxin threat, 616categories of, 614chemical warfare agent comparison, 616–617Chemical Weapons Convention definition, 614delivery methods and use of, 614, 616emergent threats, 617established threats, 616–617food and water supplies and, 616list of known toxins and their sources (table), 615–616nature of the threat from, 614storage capability and use of, 614terrorism and use of, 614, 633

Transformational medical technologies initiativedescription, 647

Treatment of Chemical Agent Casualties, 184Treatment of incapacitating agent exposure. See also Field manage-

ment of chemical casualties; specific agents and drugscardiovascular system, 472eyes, 471laboratory findings, 472respiratory tract, 471–472skin, 471

Treatment of mustard agent exposure. See also Field management of chemical casualties; specific agents and drugs

airway injuries, 287–290antimicrobials, 280–281antioxidants, 282biologic dressings, 280bone marrow issues, 288–290, 672burn centers and, 278categories of casualties, 277changing of dressings, 280debridement, 280, 282, 283–285, 290, 670decontamination, 277, 312, 670deep injury treatment, 281, 283depth of injury assessment, 282–283dressings, 280, 282, 285eye injuries, 287fluid and electrolyte monitoring, 278, 279gastrointestinal tract issues, 288, 290goal of blister management, 670growth factors, 285–286hospitalization issues, 262, 277, 281indocyanine green fluorescence imaging, 283Laser Doppler perfusion imaging, 283long-term effects, 291nonsteroidal antiinflammatory drugs, 282off-gassing and, 282, 671pain control, 278, 279pediatric population and, 670–672return to duty guidelines, 290–291secondary infection risk, 281, 288–289skin injuries, 278–287, 670–672skin substitutes, 286–287supportive care, 278topical antibiotics, 280unroofing and cleansing of blisters, 279–280vacuum-assisted closure therapy, 287


lxiii


Treatment of nerve agent exposure. See also Field management of chemical casualties; Neuroprotection as a treatment for nerve agent survivors; specific nerve agents and drugs

anticonvulsive therapy, 189–190antidote treatment nerve agent autoinjector, 182–186, 192, 193,

194atropine therapy, 182–186, 244cardiac arrhythmia treatment, 190challenges of administration, 244, 253decontamination of the patient, 180–181effect of therapy on median lethal dose in monkeys exposed to

soman (table), 199general principles, 180–190, 244, 316mild exposure, 192minimal exposure, 191–192moderate exposure, 192moderately severe exposure, 192–193oxime therapy, 186–189, 197–198pediatric population and, 663–665pretreatment considerations, 197–204, 244protection of the rescuer, 180, 193psychogenic casualties and, 196recommended therapy for casualties of nerve agents (table),

191regimen of antidotal therapy, 223, 244severe exposure, 193–194suspected exposure, 191terminating the exposure, 180–181timing of administration, 244, 252treatment by exposure category, 190–194value of aggressive treatment, 197ventilatory support, 181–182, 186

“Treatment of Status Epilepticus in Adults: Columbia University Protocol,” 231

Treatment of toxic industrial chemical exposure. See also Field management of chemical casualties; specific agents and drugs

acute medical management, 362–365airway secretion management, 363–364clinical care, 365establishing an airway, 362–363history assessment for casualties exposed to lung-damaging

agents (exhibit), 362hypotension treatment and prevention, 364–365hypoxia prevention and treatment, 364patient history, 361patient transport, 365physical assessment for casualties of lung-damaging chemical

agents (exhibit), 363physical examination, 361–362pulmonary edema treatment, 364rest from physical exertion, 363termination of exposure, 362triage for casualties of lung-damaging toxic industrial chemi-

cals (exhibit), 364Treaty of Versailles

description, 136Trench mortars

attacks on the AEF (exhibit), 26CWS standardization of, 119–120description, 26Stokes mortars, 118, 119

Triage of chemical casualtiesalternative areas for, 678benefit of assistance issues, 512–513challenges unique to, 516combined injuries and, 522–523conventional wounds contaminated with chemical agents,

522–523cyanide and, 518–519, 521, 522, 523cyanide poisoning, 386decontamination, 513–514delayed treatment category, 516, 521, 577development of a pharmaceutical cache of medications, 678division triage stations, 94dynamic nature of, 513, 524emergent category, 516essential information for, 512evacuation issues, 516–517expectant treatment category, 516, 522, 577immediate treatment category, 516, 520–521, 577incapacitating agents and, 520, 521, 522, 523levels of care, 513lung-damaging agents and, 519–520, 522, 523medical management issues, 517–520minimal treatment category, 516, 521–522, 577national site setup and control zones for a hazardous materials

site (figure), 515natural course of disease and, 512–513nerve agents and, 518, 520–521, 522–523nonemergent category, 516pediatric population and, 677placement of teams, 514–516, 547principles and processes, 512–516, 524Sacco triage method, 517START system, 517treatment, decontamination, and transport linkage, 514–516triage and treatment area (cold zone), 506triage area (warm side), 504–505triage by category and agent, 520–522“triage” definition, 512triage for casualties of lung-damaging toxic industrial chemi-

cals (exhibit), 364US military triage categories, 516–517vesicants and, 519, 521–522, 523

Triazolamincapacitating effects, 420

Trichloromethyl chloroformate. See ChloropicrinTrilon group of nerve agents. See Sarin; Soman; TabunTropical ataxic neuropathy

cyanide exposure and, 323Truman, Pres. Harry S

United States ratification of the Geneva Protocol and, 60, 137Tsuchihashi, H.

VX nerve agent research, 695TTX. See TetrodotoxinTurpin, Eugene

secret weapon developed by, 8022nd Chemical Battalion

mission of, 59721st century

Operation Enduring Freedom, 65Operation Iraqi Freedom, 65–66Russia’s use of fentanyl in the Chechen hostage situation, 3,

65, 41320th Support Command

domestic preparedness role, 7632-aminothiazoline-4-carboxylic acid

cyanide poisoning and, 3762-chlorobenzylidene malonitrile

nonmilitary uses, 342overall effects of, 342Yemen Civil War and, 341

2-oxothiazolidine-4-carboxylic acidchemical structure (figure), 736

lxiv


phosgene and, 7362-PAM Cl. See 2-pyridine aldoxime methyl chloride2-pralidoxime chloride. See 2-pyridine aldoxime methyl chloride2-pyridine aldoxime methyl chloride

administration considerations, 187, 188–189, 652, 682–683combined with atropine, 183, 223, 651dosage considerations, 187, 189, 194intermediate syndrome treatment, 318limitations of, 653nerve agent exposure treatment, 174, 183, 197–198, 244, 316,

651pediatric population and, 663, 664, 682–683side effects, 187, 188soman-induced seizure-related brain damage treatment, 227treatment of children and, 195

UUniformed Services University of the Health Sciences

CBRNE training programs, 768United Kingdom. See Great BritainUnited Nations

Bush’s and Blair’s warning on Iraq’s weapons of mass destruc-tion program, 66

Disarmament Committee, 137Iran-Iraq War and, 63report condemning the production and stockpiling of chemical

weapons, 60Yemen Civil War and, 58

United States. See also specific conflicts, leaders, cities, states, military installations, agencies, and departments

chemical demilitarization program, 141–143, 609–611, 766Chemical Weapons Convention and, 65, 157chlorine production, 672chloropicrin production, 455diphenylaminearsine production, 464gas chamber executions with cyanide, 374Geneva Protocol ratification, 60, 137, 443Memorandum of Understanding with the Soviet Union on

prohibiting chemical weapons, 63nerve agent weaponization, 3phosgene production, 345, 672plans for gas warfare during World War II, 52–53post-World War I chemical warfare policy, 44–45Russia’s elimination of chemical weapons and, 144sarin production, 157stockpile agent destruction (table), 143US-Soviet weapons destruction agreement, 138VX nerve agent development and production, 157World War I experience of chemical warfare, 21–42, 117

University of Maryland Medical Centercoordination with local resources, 678triage for chemical agent casualties, 677

University of Pennsylvanianeuropeptide research, 420

Upshall, D.G.dibenz[b,f]-1,4-oxazepine research, 467, 469

Urine sample analysisanalysis methods for urine samples to measure thiodiglycol or

thiodiglycol and thiodiglycol-sulfide (table), 710analytical methods, 708–713application to human exposure, 713, 715–718collection issues, 692cyanide poisoning, 734guidelines for collection, 739lewisite exposure, 728, 729mustard agent exposure, 708–718noninvasive, 692

published reports (1995-2006) of laboratory analysis of human urine samples for glutathione reaction products following a suspected exposure to sulfur mustard (table), 720

published reports (1995-2006) of laboratory analysis of hu-man urine samples for hydrolysis metabolites following suspected exposure to sulfur mustard (table), 719

sample considerations, 739sample preparation methods for the gas chromatographic/

mass spectrometric/mass spectrometric analysis of the sul-fur mustard urinary β-lyase metabolites (exhibit), 713

US Air Forcecollectively protected expeditionary medical support and, 585field management of chemical casualties, 490–491

US Army. See also Chemical Corps; Chemical Warfare Service; US Department of Defense; specific divisions and installations

area medical laboratories, 763–764binary weapon research, 122–123Chemical Materials Agency, 142, 143Chemical Stockpile Emergency Preparedness Program,

142–143chemical training improvements during the 1980s, 63Defense Medical Readiness Training Institute, 768demilitarization of chemical agents, 141–143destruction of chemical weapons stockpile and, 610–611Employment of Chemical Agents, 136field management of chemical casualties, 481, 487, 489520th Theater Army Medical Laboratory, 693M20 simplified collective protection equipment and, 587Medical Department, 79Medical Management of Chemical Agent Casualties Handbook, 184reorganization of, 56–57substance abuse and dependency policies, 602–603Toxic and Hazardous Materials Agency, 141Treatment of Chemical Agent Casualties, 18420th Support Command, 763

US Army Center for Environmental Health Researchbiomonitoring device, 631

US Army Center for Health Promotion and Prevention Medicinedomestic preparedness role, 763, 764

US Army Chemical Corps. See Chemical CorpsUS Army Chemical Materials Agency

chemical accidents or incidents and, 607missions of, 596–597

US Army Chemical SchoolCBRNE courses, 769

US Army Materiel Commandchemical accidents or incidents and, 607

US Army Medical Commanddomestic preparedness role, 761, 763, 764resources of, 764

US Army Medical Departmentambulance company dressing stations, 93–94army-level gas hospitals, 97base and gas hospitals, 95bathing of chemical casualties, 92, 93, 95battalion aid stations, 92–93bulletins aimed at keeping personnel current on chemical

warfare developments, 91casualty cards, 97classification of chemical casualties, 94–95classification of wounded soldiers, 97company aid posts, 92defensive gas training, 89difficulty of carrying “anti-gas” medical equipment, 96division field hospitals, 95–96division gas medical officers, 92division triage stations, 94


lxv


evacuation hospitals, 94–95evacuation in trench versus open warfare, 99–101evacuation methods, 97–99gas-proofing of dugouts, 93Headquarters, First Army Corps, memorandum on the evacu-

ation of sick and wounded, 1918 (exhibit), 98increase in the number of gas casualties and, 91organization of, 89–101origination of, 89Royal Army Medical Corps as basis for, 89Sanitary Corps staffing, 90secret field order no. 41, annex no. 7, issued by the Fifth Divi-

sion, September 9, 1918 (exhibit), 100separation of chemical casualties from other wounded sol-

diers, 97special wards for chemical casualties, 94specialized hospital gas teams, 92techniques to detect malingerers, 92training and education in CBRNE and, 767, 768uniform procedure for handling chemical casualties, 91

US Army Medical Institute of Infectious DiseaseCBRNE training program, 768Contaminated Casualty Decontamination Course, 763Hospital Management of CBRNE Incidents Course, 769Medical Management of Chemical and Biological Casualties

Course, 763, 768US Army Medical Research and Materiel Command

drug acquisition responsibilities, 650US Army Medical Research Institute of Chemical Defense

“Assay Techniques for Detection of Exposure to Sulfur Mustard, Cholinesterase Inhibitors, Sarin, Soman, GF, and Cyanide,” 693

barrier skin creams, 530–532CBRNE training, 768chemical casualty site teams, 607chemical warfare exposure assay development, 693Contaminated Casualty Decontamination Course, 763Field Management of Chemical and Biological Casualties

Course, 768–769glove issues in decontamination, 539Hospital Management of CBRNE Incidents Course, 769Medical Management of Chemical and Biological Casualties

Course, 594–595, 608, 763, 768role and responsibilities, 5sample collection, shipping, and storage guidelines, 739–741Toxic Chemical Training Course for Medical Personnel,

594–595, 608working conditions, 597

US Army Northern Commanddomestic preparedness role, 761, 763, 764

US Army Ordinance Corpstraining and education in CBRNE and, 767

US Army Research and Development laboratory3-quinuclidinyl benzilate monitoring, 739

US Army Soldier and Biological Chemical Commandglove issues in decontamination, 539

US Bureau of Minestoxic gas research, 89

US Civil Warchemical warfare proposals, 11–12

US Coast Guardfield management of chemical casualties, 491, 492

US Code“terrorism” definition, 126

US Congress. See also specific legislationantiterrorism training bill, 125binary chemical weapon development restrictions, 124

demilitarization of chemical agents and, 142law controlling storage, testing, and disposal of agents outside

the United States, 60review of binary weapons, 124–125subcommittee on noxious gases, 21–22

US Defense Intelligence Agency“Biotechnology: Impact on Biological Warfare and Biode-

fense,” 420–421US Department of Agriculture

domestic preparedness role, 761Laboratory Response Network and, 765–766

US Department of Defense. See also US War Departmentanalysis of possible accidental battlefield exposure to chemical

agents during Operation Desert Storm, 129–130Army reorganization, 56–57Assembled Chemical Weapons Alternatives Program, 142chemical agent medical countermeasure requirements, 646Chemical Stockpile Emergency Preparedness Program role,

766–767defense acquisition executive responsibilities, 646domestic preparedness roles, 755, 758–764, 767–7705000 series documents, 647–648incapacitating agents characteristics, 412investigational new drugs and, 650military installation protection from terrorist attacks, 126National Medical Chemical and Biological Advisory Team, 764Project BioShield and, 251pyridostigmine bromide informed consent issues, 204, 650–651Quadrennial Defense Review Report of 2006, 758, 770requests for assistance in chemical casualty management, 494support for civilian chemical casualty management, 493support to civil authorities, 761–764“terrorism” definition, 12522nd Chemical Battalion support operations, 5972-chlorobenzylidene malononitrile variation creation, 444

US Department of Energydomestic preparedness role, 755

US Department of Health and Human ServicesChemical Stockpile Emergency Preparedness Program role,

766disaster and medical response to mass casualty events, 492drug acquisition responsibilities, 650first responder policy recommendations, 493homeland security role, 755Laboratory Response Network and, 765–766National Response Framework coordination guidelines for,

761Project BioShield and, 251Strategic National Stockpile and, 765

US Department of Homeland Securitycolor-coded threat condition chart, 755creation of, 755homeland security councils and, 755Laboratory Response Network and, 765–766lead federal agency for domestic incident management, 755National Incident Management System, 492, 755–756National Response Framework, 758National Response Plan, 755–756Office for Domestic Preparedness, 770organizational outline for incident management command

(figure), 757Project BioShield and, 251state and regional coordination and, 759Strategic National Stockpile and, 765

US Department of State“terrorism” definition, 125

US Environmental Protection Agency

lxvi


Chemical Stockpile Emergency Preparedness Program role, 766

demilitarization of chemical agents and, 142, 143levels of protection, 580waste water disposal issues, 546

US Food and Drug Administration“animal rule” for drug product approval, 647, 651anticholinesterase treatment for Alzheimer’s disease, 158clinical trial phases, 647investigational new drug submissions, 649, 650Laboratory Response Network and, 765–766medical chemical defense acquisition programs and, 646, 647,

648–653“off-label” uses for drugs, 650phosgene inhalation treatment guidelines, 354Project BioShield and, 251pyridostigmine bromide approval, 204Reactive Skin Decontamination Lotion approval, 536

US General Accounting OfficeCBRNE training programs and, 768

US Joint Forces Commanddomestic preparedness role, 764

US Marine Corpschemical/biological incident response force, 762–763field management of chemical casualties, 489–490Joint Non-lethal Weapons Directorate, 431M20 simplified collective protection equipment and, 587

US Navybinary weapon research, 123field management of chemical casualties, 489, 491–492hospital ships, 491–492

US Office of Management and BudgetProject BioShield funding, 251

US Postal Serviceoleoresin capsicum use, 443

US War Department. See also US Department of Defensechemical warfare plan, 22chemical weapon stockpiles and, 44gas warfare function centralization, 22Memorandum on Gas Poisoning in Warfare with Notes on its

Pathology and Treatment, 90Notes on Gas as a Weapon in Modern War, 90

USACHPPM. See US Army Center for Health Promotion and Prevention Medicine

USAMRICD. See US Army Medical Research Institute of Chemical Defense

USAMRIID. See US Army Medical Institute of Infectious DiseaseUSNS Comfort

hospital ship capability, 491USNS Mercy

hospital ship capability, 491USS Bon Homme Richard

hospital ship capability, 491USS Kearsage

hospital ship capability, 491

VV-series nerve agents. See also specific agents

categorization of (exhibit), 47production during the 1950s, 55weaponization of, 3

VAC. See Vacuum-assisted closure therapyVacuum-assisted closure therapy

contraindications to, 287mustard agent injuries, 287

van Galen, Christoph Bernharduse of toxic smoke projectiles, 11

Van Hooidonk, C.decontamination research, 534, 536

Vanderbelt, J.M.cyanide poisoning research, 396

Vedder, Lt. Col. Edwardcareer of (exhibit), 103chemical training for soldiers and, 103comments on Shryock, 108Medical Aspects of Chemical Warfare, 1041-chloroacetophenone research, 462

Veephysostigmine isolation, 46

Ventilatory supportarrhythmias and, 190atropine and, 181, 186, 193hydrogen cyanide inhalation, 354incapacitating agent exposure and, 471–472intermediate syndrome, 318mass casualty incidents, 181, 519–520mechanical devices for, 181mouth-to-mouth ventilation, 181, 675mustard agent injuries, 288–289, 672nerve agent exposure treatment, 181–182, 520triage issues, 519–520

Vesicants. See also Incapacitating agents; Lewisite; Mustard agent; Phosgene oxime

chemical, physical, environmental, and biological properties of vesicating agents (table), 260–261

conventional wounds contaminated with, 523description, 260, 667management of vesicant exposures (table), 671pediatric population and, 667–673prolonged morbidity from, 667triage considerations, 519, 521–522, 523types of, 260–261

Veterans Administrationphosgene exposure research, 325–326study on the effects of mustard agent and lewisite exposure,

312–313Viala, B.

2-chlorobenzylidene malononitrile research, 471Vietnam War

Agent Orange use, 341defoliant use, 105mustard agent use, 57tear gas use for clearing tunnels, 1052-chlorobenzylidene malononitrile use, 444

Vinci, Leonardo dapoison projectile proposal, 11

Vision. See EyesVolunteers

anticholinergic deliriant testing on, 424–425effects of soman on acetylcholinesterase activity in whole

blood from human volunteers who had taken pyridostig-mine bromide (figure), 706

effects of soman on acetylcholinesterase activity in whole blood from human volunteers who were given an increasing dose of huperzine A (figure), 707

medical research on human volunteers during the 1950s, 551-chloroacetophenone testing on, 461

von Deimling, Gen.chemical warfare comments, 15–16

von der Linde, Hans-Jürgensarin research, 47, 156

von Krueger, Gerdeorganophosphorus compound research, 47

von Tappen, Hans


lxvii


T-shell development, 14VR nerve agent

description, 156toxicity of, 168vapor hazard, 168volatility of, 168

VS nerve agentweather conditions and, 135

VX nerve agentadditives for, 135assays for, 699barrier creams and, 531behavioral effects of exposure, 175–176carboxylesterase and, 246chemical structure (figure), 694chloroperoxidase and, 250clinical effects, 316eye effects of exposure to, 170incapacitating effects, 416inhibition of blood ChE activity, 165land mine delivery, 120–121molecular model (figure), 166mortality from, 316neuropsychiatric effects, 320plasma-derived human butyrylcholinesterase and, 245–246,

247, 249projectile delivery, 121pulmonary system effects, 174RBC-ChE inhibition, 165relation of cholinesterase activity to vomiting after exposure to

(table), 166routes of exposure, 695skin effects, 529soap and water decontamination, 533, 534synthesis and production of, 157toxicity of, 693, 695vapor hazard, 168volatility of, 135, 168, 316

Vycudilik, W.urine sample analysis for mustard agent, 708, 713

WWada, S.

mustard agent exposure research, 314Waitt, Maj. Gen. Alden H.

assessment of the future of chemical warfare in 1946, 54chemical training for soldiers and, 103–104post-World War II discovery of German gas reserves, 104–105summary of CWS’s planning for the next war, 119

Walker, M.C.ketamine research, 231

Wallace rule of nines, 282Walter Reed Institute of Research Whole Blood Assay

cholinesterase analysis, 702, 705–706Ward, Kyle, Jr.

description of nitrogen mustard, 119Water testing kits. See M272 chemical agent water testing kitsWatson, Maj. Gen. Gerald G.

chemical training and, 63Weather. See Wind and weather considerationsWeger, N.

cyanide poisoning research, 394, 395–396Weigand, D.A.

2-chlorobenzylidene malononitrile research, 451Weimar, J.T.

2-chlorobenzylidene malononitrile research, 451Wepfer

cyanide poisoning description, 373Wet decontaminants

Reactive Skin Decontamination Lotion, 533, 536–537water issues, 546

White, C.1-chloroacetophenone research, 462

White, R.G.1-chloroacetophenone research, 463

White House Office of Homeland Securitycreation of, 755National Strategy for Homeland Security, 755

WILD20soman-induced seizure-related brain damage treatment, 227

Willder, W.B.2-chlorobenzylidene malononitrile research, 452

Willems, Jan L.Iranian mustard casualties, 263, 266, 268, 715

Wils, E.R.J.skin sample analysis for mustard agent, 726urine sample analysis for mustard agent, 708–709, 716

Wilson, I.B.oxime research, 186–187

Wilson, President WoodrowWorld War I and, 12, 21

Wind and weather considerationschemical attacks, 80, 117, 121, 135–136cold shock, 548–549decontamination in cold weather, 548–550hypothermia, 548–549stages and symptoms of hypothermia (table), 548

Winternitz, M.C.phosgene exposure research, 325

Wolfe, A.D.fetal bovine serum AChE research, 245, 246

Wolff, H.C.anticholinergic deliriant research, 422

Wooten, J.V.lewisite exposure research, 728

World Health Organizationdiphenylaminearsine exposure research, 466

World Trade Centerbombing in 1993, 754

World Trade OrganizationCDC Enhanced Surveillance Program data, 622

World War I. See also American Expeditionary Forces; specific battles, battle sites, and countries

aftermath, 36–37, 41Allied retaliation against chemical warfare, 18an attack on a platoon of the 28th Division (exhibit), 27armistice ending, 36casualties attributed to gas, 36–37, 41–42, 82, 83, 341chemical agent production, 117chemical agents used (in chronological order) (table), 342chemical attacks involving children and civilians, 656chemical casualties (table), 79chemical warfare use by France, Great Britain, and Germany,

12–21, 79–82, 312, 341, 373, 397chemical weapons, 117–118chlorine gas use, 2detailed map of Ypres (figure), 17Dr. Harvey Cushing’s account of Royal Army Medical Corps

capabilities, Flanders, Belgium, May 5, 1917 (exhibit), 88earliest reported description involving chemical warfare on

the AEF (exhibit), 22early Allied chemical warfare plans, 12–13evacuation in trench versus open warfare, 99–101excerpt from “Take Me Back to Dear Old Blighty!” (exhibit), 89

lxviii


field sanitation and, 83–85first airplane gas attacks on American forces (exhibit), 26first projector attack on the AEF (exhibit), 26“gas fright” syndrome, 82gas mask development, 18, 19, 80, 561–562historical summary of chemical warfare agents used in (table),

38–41hospitalized casualties, in percentages by causative weapon

(figure), 85incapacitating agent use, 443, 455initial responses to gas attacks, 82–85map of Belgian-French border (figure), 16map of western Europe (figure), 13medical personnel as victims, 101–102mustard agent use, 2–3, 15, 18, 20–21, 25–26, 27, 260, 261–262,

530phosgene use, 2, 734prewar intelligence and the Second Battle of Ypres, 79–82profiles of chemists (exhibit), 15Royal Army Medical Corps role, 85–89six chlorine-phosgene cloud attacks: British casualties Decem-

ber 1915-August 1916 (table), 83Spanish influenza and, 101trichloromethyl chloroformate use, 20US experience with chemical warfare, 21–42

World War IIcapture and detainment of German military scientists in Op-

eration Dustbin, 51capture of soman research documents, 51chemical weapon delivery system improvements, 120demilitarization of captured weapons, 54German gas reserves, 104–105Germany’s experimental testing of chemical and biological

warfare agents in concentration camps, 105, 157nerve agents and, 3, 48no-first-use policy on chemical weapons, 51–52sea dumping of captured chemical weapons, 54smoke and flames agents and, 104Zyklon B use in Nazi concentration camps, 15, 51, 105, 373,

397, 656Worldwide NBC Mask Handbook, 561Wound decontamination

general considerations, 538initial decontamination, 538off-gassing and, 282, 538–539thickened agents and, 538wound exploration and debridement, 539

Wurtz, Charles A.discovery of cyanogen chloride, 116synthesis of tetraethyl pyrophosphate, 156tetraethyl pyrophosphate synthesis, 46

xXylyl bromide

development and use of, 14, 17, 79

Y“Yellow cross.” See Mustard agentYemen Civil War

chemical weapons use, 57–58, 262, 341Compromise of 1970, 58

Yen, D.cyanide poisoning research, 385

Yeung, D.T.human paraoxonase 1 research, 251

Yih, J.P.

2-chlorobenzylidene malononitrile research, 451–452, 471Yom Kippur War. See Arab-Israeli Yom Kippur WarYperite. See Mustard agentYpres, First Battle of

stalemate result of, 14Ypres, Second Battle of

casualties, 82chlorine gas attacks, 14–18, 21, 79–82detailed map of Ypres (figure), 17prewar intelligence and, 79–82

ZZante, R.

phosgene research, 735Zeiler, A.G.

phosgene research, 345Zhukov, Soviet Defense Minister

chemical weapons threat, 56Zinc oxide

physiological effects, 358–359toxic effects of exposure, 327

Zyklon Bdevelopment of, 15use in Nazi concentration camps, 15, 51, 373, 397, 656

lxix

Medical Aspects of Chemical Warfare

Dedicated to the Memory of

Brennie E. Hackley, Jr, and Frederick R. Sidell

DR BRENNIE E. HACKLEY, JR

Chemist, Teacher, Scientific Advisor

July 29, 1924 – November 5, 2006

Dr Hackley received a BS in chemistry from Wil-berforce University in 1946. Following graduation, he enlisted in the US Army and was later commissioned as an officer. After more than 30 years’ service, he retired from the US Army Reserve Corps in 1981 at the rank of colonel. Dr Hackley began his civilian career in 1952 as an organic research chemist in the Medicinal Chemistry Branch of the Army Chemical Center and went on to earn advanced degrees in chemistry from the Univer-sity of Delaware, including a PhD in 1957. During his career, Dr Hackley studied the relationship between chemical structures and chemotherapeutic activity in reference to efficacy against toxic agents. He contrib-

uted to the elucidation of mechanisms of reactions of nucleophiles with organophosphorus compounds and synthesized a number of oximes, for which he held 18 patents. One oxime synthesized by Dr Hackley, tox-ogonin, was adopted as an antidote against chemical nerve agents by the US Air Force.

In 1984 Dr Hackley was designated Chief Scientist and Scientific Advisor to the Commander of the US Army Medical Research Institute of Chemical Defense (USAMRICD). During Operation Desert Storm, Dr Hackley responded to emergency calls by combat divisions for predeployment briefings on medical management of chemical casualties, initiating a traveling training program that prepared deploying medical personnel to treat soldiers on the battlefield if chemical weapons were employed. As an instruc-tor and course director for USAMRICD’s Medical Management of Chemical and Biological Casualties course, Dr Hackley delivered lectures in Saudi Ara-bia; Johnston Island, Hawaii; Okinawa, Japan; and Germany on pulmonary agents, cyanide, vesicants, and nerve agent threats.

While serving as chairman of the Scientific Steering Committee on Nerve Agent Antidotes, he advised the Command that one of the precursors for the then cur-rent synthesis of the oxime HI-6, under consideration as a replacement for the fielded 2-PAM chloride, was carcinogenic and would not pass scrutiny by the Food and Drug Administration. Additionally, Dr Hackley convinced the Command that HI-6 wasn’t cost effec-tive, and that its effectiveness compared to 2-PAM chlo-ride was not great enough to justify its replacement.

Dr Hackley represented the US Army Medical re-search program competently and effectively for almost 6 decades. His efforts significantly improved commu-nication and relationships between the Chemical and Medical Corps and strengthened USAMRICD’s image as the lead laboratory for the development of medical countermeasures for chemical threat agents.

lxx

Medical Aspects of Chemical Warfare

DR FREDERICK R. SIDELL

Physician, Teacher, Scientist

July 27, 1934 – February 14, 2006

No physician has contributed more to the US Army Medical Department’s chemical defense training and education programs than Dr Frederick Sidell. Dr Sidell graduated from Marietta College in Marietta, Ohio, in 1956, and also later from the New York University School of Medicine. He completed his internship and residency in internal medicine at Cleveland Metropoli-tan General Hospital. Dr Sidell initially served 2 years on active duty with the Army Medical Corps in the rank of captain. He was stationed at Edgewood Arsenal in Maryland, an assignment that would determine his future in medicine and lead to his subsequent employ-ment with the Department of Defense. While with the Department of Defense Dr Sidell became one of the world’s leading experts and educators in the field of medical effects of chemical warfare agents. He retired in 1995 after 30 years in government service.

In the late 1960s, when training in medical chemical defense was very limited, Dr Sidell and some of his col-leagues recognized the need for specialty training and developed a course for military medical personnel on the medical management of chemical agent casualties. Dr Sidell guided the development of this new training

program and served as the course director for many years. Eventually, such training was expanded to ad-ditional courses for nonmedical personnel and military leaders. Dr Sidell also prepared and updated detailed educational materials addressing nerve agents, vesi-cants, cyanide, and pulmonary agents, and provided education and training for the Chemical Stockpile Emergency Preparedness Program and the Domestic Preparedness Program.

Dr Sidell’s expertise was nationally and interna-tionally recognized, and he was often called upon for highly sensitive assignments that required technical expertise. These included a trip to southeast Asia in 1979 to investigate the alleged use of “yellow rain” against the Hmong in Laos. In 1988, he examined Kurdish civilian casualties who were victims of chemi-cal warfare in their homeland. He traveled to Japan in 1995 to assist and advise Japanese physicians on the care of causalities from a terrorist-led sarin nerve agent incident in the Tokyo subway system.

Dr Sidell was the lead editor of the first edition of Medical Aspects of Chemical and Biological Warfare, pub-lished in 1997, contributing to many of the chapters on chemical warfare agents. His research and studies have been published in over 100 reports and articles, and he also wrote several handbooks on the treatment of chemical casualties. Following his official retirement, Dr Sidell continued providing education and training in the management of chemical agents and casualty treatment to civilian first responders, including many emergency medical treatment units throughout the United States.

In addition to the many achievement awards and commander’s medals received by Dr Sidell, a new building at the Edgewood area of the Aberdeen Proving Ground was named the Sidell Learning Center in 2002 in recognition of his great contribu-tion to medical education and training. In 2003 Dr Sidell was inducted into the Marietta College Hall of Honor, becoming one of only 24 people to be so recognized at that time. Dr Sidell’s knowledge, ex-perience, and dedication contributed greatly to the development of the outstanding medical training programs throughout the Department of Defense today. His insight and pragmatic views have guided the development of medical policy against weapons of mass destruction and medical research on safe and effective medical countermeasures against cur-rent and future chemical threats facing the military.

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