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CBRNe  (abridged version)
Infection
by any of a variety of diseases is always a possibility in the urban
environment. This could be caused by biological warfare attack, natural
occurrence of the disease perhaps in a mutated form, or poor hygiene in
difficult conditions after some other major Event. Those most likely to be
encountered and their treatment are listed below.

(W) = Weaponised
od = once a day
bd = Twice a day
TDS = three times a day
QDS = four times
a day

Infectious Diseases and Biological & Nerve
Agent Warfare


Aflatoxin (W)
Not

contagious person to person but can cause poisoning if exposed to affected crops
through Inhalation, eye, skin or ingestion this toxin is produced by fungus from
the Aspergillus genus and can also be used in biological warfare. It causes
cancer that particularly affects the liver. Symptoms are Pain, vomiting, fever,
Jaundice which can be seen in the eyes or general complexion, swelling of limbs,
an enlarged liver may also be felt during palpation of the abdomen.
There is
no particular treatment other than supportive
measures.


Anthrax (W)
Anthrax is a bacterial
infection, which is rare and mainly occurs in Africa, Asia, China and Eastern
Europe. It has also been used as a bioterrorism weapon. Spread is by contact
with the infected carcasses of hoofed animals such as goats and sheep. Three
routes of infection;

• Through a cut or puncture in the skin.

Inhaled spores through the Lungs.
• Through eating poorly cooked infected
meat.

Black pustules form with swelling, fever, enlargement of liver and
spleen, if inhaled can cause pneumonia and shortness’ of breath, if swallowed
can cause internal bleeding.

Prophylactic treatment
Vaccination; give
0.5ml i/m at 0, 3, 6 weeks and 32
Oral Ciprofloxacin 500mg bd for 4 weeks +
vaccination or
Oral Doxycycline 100mg bd for 4 weeks +
vaccination

Exposure treatment
Ciprofloxacin 500mg BD for up to 60
days if Lungs or stomach are involved use Ciprofloxacin 400mg IV BD and
Clindamycin 900mg IV TDS + Rifampicin 300mg IV BD. Change to oral combination
when suitable.

Bio Weapon Exposure
Ciprofloxacin (iv) 400mg bd Or
Ciprofloxacin (po) 500mg bd or Doxycycline (po or iv) 200mg (Immediately) then
100mg bd

Brucellosis (W)
Brucellosis is an infectious

disease passed from animals to humans usually through contaminated food. Common
Symptoms include; Fever sometimes re-occurring, headache and back pain,
generalized weakness with joint and muscle pain. A general examination will show
enlarged Lymph nodes and an abdominal assessment may also reveal enlargement of
the liver and spleen. Can also cause localized infection in the testes, lungs
and heart leading to endocarditis.

Prophylactic treatment
Doxycycline
(po) 100mg bd for 21 days

Exposure treatment
Doxycycline (iv) 200 mg
(immediately) then 100mg bd and Rifampicin (iv) 300mg tds for 6
weeks

Cholera (W)
Cholera is caused by faecal-oral

contamination presents with copious watery stools, fever and vomiting, which
leads to profound dehydration. Incubation ranges from a few hours to 5 days.
Antibiotics are not usually effective, treat diarrhoea and rehydrate
patient.

Bio Weapon Exposure
Ciprofloxacin (iv) 400mg bd or
Ciprofloxacin (po) 500mg bd or Doxycycline (iv) 200mg (Immediately) then 100mg
(iv) bd

Clostridium botulinum (W)
This is a very potent form of food poisoning usually through the ingestion of contaminated water or food such as raw fish, poorly canned vegetables or syrups causing botulism in humans. It has many symptoms which include a sore dry mouth and throat causing difficulty in speaking and swallowing, Blurred vision, abdominal cramps and pain, nausea and/or vomiting, breathing problems, generalized weakness and can lead to paralysis. It is also used in biological warfare.

Treatment
Benzylpencillin 2.4g (iv) 4hrly and SNBTS G-BOT 003
antitoxin (iv) give 1 vial, repeat in 2hrs and at 12 – 24hrly intervals if
necessary

Diphtheria (W)
Prophylactic

treatment
Diphtheria immunization & Erythromycin (po) 1 g od to close
contacts of clinical disease

Exposure treatment
Booster immunization,
Diphtheria antitoxin & Erythromycin (po) 250 mg
qds

Escherichia coli (E coli) (W)
Exposure
treatment
Ciprofloxacin (iv) 400mg bd or Ciprofloxacin (po) 500mg
bd

Plague (W)
Plague is caused by a bacteria that

infects wild rats, it is rare but can be found throughout the world. Incubation
period is 2 to 6 days. It comes in two forms, bubonic plague (spread by infected
fleas) and pneumonic plague (spread by droplets from coughing).
Prophylactic
treatment
Ciprofloxacin (po) 500mg bd for 14 days or Doxycycline (po) 100mg
bd for 14 days

Exposure treatment
Treat with Doxycycline 100mg
BD
Bio Weapon Exposure
Ciprofloxacin (iv) 400mg bd or Ciprofloxacin (po)
500mg bd or Doxycycline (iv) 200mg (Immediately) then 100mg (iv)
bd

Salmonella (W)
Transmitted through Fecal-Oral
contamination

Exposure Treatment
Ciprofloxacin (iv) 400mg bd or
Ciprofloxacin (po)500mg bd or Doxycycline (iv) 200mg (immediately) then 100mg
(iv) bd

Shigella sp (W)
Transmitted through

Fecal-Oral contamination, Highly Contagious

Exposure
Treatment
Ciprofloxacin (iv) 400mg bd or Ciprofloxacin (po)500mg bd or
Doxycycline (iv) 200mg (immediately) then 100mg (iv)
bd


Smallpox (W)
Caused by the orthopox virus It

is relatively easy to manufacture, infectious and can be administered by an
aerosol effect making it attractive to terrorist as a weapon.

There is no
effective drug treatment. After an incubation period of 7-19 days, casualty
become tired has a fever, rigors, vomiting, headache and backache. 2-3 days
later, a rash appear on the face, hands and arms; these get bigger as disease
progresses.

A vaccination is available, 30% of unvaccinated casualties
will die.
Diagnosis is clinical and treatment supportive. Smallpox can be
prevented by vaccination. Death rate for unvaccinated casualties is
30%.

Tetanus (W)
Tetanus is caused by the bacteria

Clostridium Tetani. It is transmitted through a puncture wound. Onset can take
up to two months, but usually takes around 7 days. Early sign is jaw stiffness
(hence the common name Lock Jaw), muscle stiffness, headache, fever and spasm.
It is fatal in 40% of cases, death occurring due to failure of respiratory
muscles.
Prophylactic treatment

Tetanus toxoid vaccine
Exposure
Treatment
Treatment is with anti-toxin and symptomatic relief, effects may
last several weeks. Tetanus immunisations last 10 years and cover for life is
received after 4 injections unless placed in a high risk
situation.

Tuberculosis (TB) (W)
Tuberculosis (TB) is
very infectious and transmitted by droplet infection. A primary pulmonary lesion

usually leads to lymph node involvement. There may be no initial symptoms but
the patient may be symptomatic from the lung lesion and have a cough, thick
sputum, haemoptysis, pneumonia, pleura effusion, fever, rigors, lethargy and
anorexia.
The disease may reactivate as post-primary TB, exhibiting the
initial symptoms or spreading to other organs and producing relative
symptoms.

Prophylactic treatment
BCG Vaccine

Exposure
treatment
If the patient shows no symptoms, treat with isoniazid and
rifampicin for 3 months. Symptomatic patients require complex treatments
involving multiple antibiotics over an extended period.
TB worldwide, is
becoming more virulent and resistant to antibiotics, immunisation is a far
better than treatment.

Tularaemia (W)
Prophylactic

treatment
Doxycycline (po) 100mg bd or Ciprofloxacin (po) 500mg bd both
14d
Exposure treatment
Gentamicin (iv) single daily 5mg/kg
od


Typhoid (W)
Typhoid is caused by a faeco-oral
contamination usually through consumption of poorly cooked food or dairy
products. Symptoms include headache, rigors, fever, decreased appetite,
constipation or diarrhoea, backache, nosebleed, tender abdomen.


Incubation can be anything between 3 days and 3 weeks. Fever rises daily
for 7-10 days, peaks for 7-20 days then drops over the next 7-10 days. In the
first stage of the disease, rose-coloured marks appear on the patient.
Treat
symptomatic diarrhoea, dehydration, pain and fever and give;


Prophylactic treatment
Vaccine typhoid Vi Single dose
0.5ml

Exposure treatment
Ciprofloxacin (iv) 400mg bd or Ciprofloxacin
(po) 500mg bd for 7-14 days

Q Fever
Rickettsia

Prophylactic treatment
Doxycycline (po) 100mg bd for
21 days

Exposure treatment
Doxycycline (iv) 100mg bd for 21
days

Other Diseases that can be weaponised are;
Jap B Encephalitis.
Pneumoniae, Polio, Ricin, Rotavirus, Smallpox, Staphylococcal enterotoxin B
(SEB), VEE, T2 Toxin, West Nile Fever


NERVE
AGENT TREATMENT
Effects of Nerve Agents

With all suspected
nerve agents examine patient’s pupils and note if normal, dilated or contracted
(Pin Point), note colour of skin and if sweating, check mouth for (mucosal)
secretions, record pulse and respiration rate.

Nerve Agents
(Organophosphates, Sarin etc)
Symptoms
Pin Point Pupils, Sweaty, Increased
Secretions and Respiration Rate, Decreased Pulse Rate

Field
Treatment
Atropine 2-6mg. Titrate to effect to raise Pulse >90

Pralidoxime Mesylate (P2S) 500mg Slow Injection
Diazepam

Hospital
Treatment
Atropine 2-6mg. Titrate to effect to raise Pulse >90
P2S
500mg – 4g
Diazepam
Obidoxime should be used for Tabun
(GA)


Cyanide & Hydrogen
Sulphide
Symptoms

Normal or Dilated Pupils, Pink or Cyanosed
Skin, Normal Secretions, Decreased Respiration Rate, feels unwell

Field
Treatment
2 Amps Amyl Nitrate via respirator if unconscious

Hospital
Treatment
Sodium 300mg over 3 min
Nitrate 12.5g over 10 min
Sodium
Chloride (Na) (50ml of 25% sol) Rpt
Thiosulphate 300mg (20ml amp) over 1
min
Dicobalt edentate


Atropine
Symptoms

Dilated Pupils, Hot and Dry Skin, Dry Mouth,
Anxiety

Field Treatment
None

Hospital
Treatment
Physostigmine 2mg and repeat after 5
mins

Methaemaglobin-aemia
Symptoms

Pupils Normal,
Cyanosed Skin, Normal secretions, Decreased Respiration Rate.

Field
Treatment
None

Hospital Treatment
Methylene blue 70mg slowly wait
30 - 60mins repeat once

Vesicants
Symptoms
Airway,
Eye and Skin damage and systemic effects

Field
Treatment
None

Hospital Treatment
Three day course of Antibiotics


Lewisite
Symptoms

Stinging for 10-20 seconds,
Deep Pain and Toxic Blisters

Field Treatment
Immediate
Decontamination

Hospital Treatment
Dimercaprol Systemic 150mg QDS for
4 days then 150mg BD
To treat eyes use 5%-10% in base oil and ointment on
skin
Treat Blisters with Providone iodine or silver
sulfadiazine


Pulmonary
Oedamogen
Symptoms

Pupils normal, secretions normal or frothy,
Skin Normal, Pale or Cyanosed, Increased Respiration Rate.

Field
Treatment
Rest movement may kill

Hospital Treatment
Hydrocortisone
400mg IV

BZ
Symptoms
Confused,
Hallucinations

Field Treatment
Diazepam

Hospital
Treatment
Physostigmine 45mcg/kg im

Radiation
Incidents


There have been around 100 civilian nuclear accidents in
the last 15 years, fortunately only a few have resulted in a direct loss of
life. Well known ones include the Chernobyl Disaster in 1986 where over 50
people died at the time off the disaster but several thousand are believed to
have since died of cancer. This year (March 2011) in Japans Fukushima Daiichi
nuclear disaster several explosions caused by an earthquake released radiation
into the air creating a 20km exclusion zone around the nuclear plant. Two months
later surveys recorded hazardous levels of radiation outside the exclusion
zone.

The likelihood of being exposed to a nuclear explosion is extremely
slim but I will detail the basic facts for completeness with more emphasis on
the possibility of radioactive contamination from a civilian
accident.

The effects and intensity of nuclear weapons vary considerably
depending of the yield and the height at which it is detonated. This can be at
ground level, in the air, underwater or in the up atmosphere. There is an
optimum height at which a weapon is detonated for maximum blast damage. If the
explosion occurs on or too near the ground, a large part of the force is
reflects back up into the air, with less effects on ground targets.

The
harmful effects of a nuclear explosion can be divided into the following
categories;

Blast Wave
The blast wave will cause

total destruction of people and property close to the explosion, with decreasing
effect as it moves away from ground zero. As with a conventional blast serious
injuries can occur at a distance away from ground zero.
Typical distances for
blast waves are below;
• 0.7 km for 1 kiloton (kt)
• 3.2 km for 100
kt;
• 15.0 km for 10 megatons (Mt)

Primary
injuries
Primary injuries are caused by shock waves, ear drums can

burst, brain hemorrhages can occur, damage to lungs and other hollow organs such
as the intestines, not all injuries may be immediately apparent. Injuries can
result in shock and respiratory failure. Blast waves can exceed 1000 km/hr and
can cause loss of memory, confusion, headache and disorientation.
As the
blast wave will flatten and damage most building injuries and fatalities are
commonly caused through structural collapse as much as primary blast damage.


Secondary injuries
Secondary injuries are caused by

casualties being hit by debris, which is thrown by the explosion, some can cause
blunt trauma whilst others will cause penetrating
injuries.

Tertiary injuries
Tertiary injuries are
caused by impact injuries from the casualty being thrown in the air and landing
on or against a hard surface. Fractures and head injuries are common tertiary
injuries

Quaternary injuries
Are other miscellaneous
effects such as burns, contamination, retinal damage etc


Radiation effects on skin
Following exposure to
radiation itchy, reddened areas of skin occur within a few hours. This can last
for several weeks during which time the skin will blister and become ulcerated.
Healing occurs as with any burn although areas may remain damaged with loss of
colour and hair growth

Thermal Radiation (Heat)
At
the centre of a nuclear explosion the temperature briefly reaches tens of
millions of degrees. Close to the explosion the heat will vapourise everything,
as it expands it causes fires, severe burns and eye injuries. If the blast is
close to the ground it forms a fireball and a mushroom cloud.
As radiation
covers the visible, infrared, and ultraviolet light burns can extend further
than the blast radius. Two types of eye injuries occur the first is flash
blindness this is usually temporary lasting 30-60 minutes.
Retinal burns can
also occur and permanent damage can occur if the retina is scared and the
casualty had looked directly at a fireball, else damage is likely to be minor at
worst.

Electromagnetic pulse (EMP)
EMP causes cables

and metal posts to generate high voltage electricity causing damage to
unshielded electronics, changes in the ionosphere also cause disruption in radio
traffic. Despite popular belief it is very difficult to protect electronic
circuitry form EMP attack.

Ionizing Radiation
A

relatively small amount of the blasts energy takes the form of ionizing
radiation as neutrons, alpha particles, gamma rays and electrons, the greater
the distance from the point of explosion the less the initial radiation effects.
Dust and particles released during the initial blast are irradiated and become
fallout, this can be distributed away from the original site of the explosion by
weather patterns.

Radiation Poisoning
Rad =
Radiation absorbed dose. Normal background radiation is 0.1 Rad / year. Maximum
recommended dose for a nuclear worker is 5 Rads / year.
Radiation poisoning
can be external through direct irradiation or internal through ingestion of
contaminated foods or animal products. Symptoms vary in onset and intensity
dependant on the total dose of radiation exposure the higher the dose the
quicker and more intense the symptoms show. Relatively small doses induce loss
of appetite, nausea, diarrhoea, abdominal pain, vomiting, headache, anaemia,
infections and increased risk of haemorrhage where as larger doses see below are
invariably fatal. Long term exposure at low doses can increase the risk of
developing cataracts, cancers and birth defects in future
generations.

Mortality Rates
<100 Rads No long
term effects
150 Rads 10% have mild radiation poisoning
250 Rads 50% have
radiation poisoning
400 Rads 25% Mortality
600 Rads 50% Mortality
800
Rads 75% Mortality
1000 Rads 100%
Mortality

Sterility
A dose of 100-200 rads in women

will suppress menstruation for up to 3 years; only 10 rads will lower sperm
counts in men and a dose of 400 rads will cause sterility in either
gender.

Treatment of Radiation Poisoning
Treatment is

supportive give antiemetic, Antipyretics, Antibiotics (Ciprofloxacin, Ceftazidme
and gentamicin) and blood transfusions. Potassium iodide offers some protection
against Thyroid Cancer if radioactive iodine is
ingested.

Protection and detection
A number of
devices are available for the detection of radiation the two most common are
dosimeters and Geiger counters, both are available from ex military sources.
Nuclear, Biological and Chemical (NBC) Suits and Respirators are also available
these offer protection from airborne contamination and inhalation or accidental
ingestion of fallout.

The military have detection devices for identifying
chemical and nerve agents, but these are unavailable to civilians. However
detection papers (M8) for the identification of liquid nerve and blister agents
are available, which change colour according to the agent as well those for
identifying chemicals in aerosol form (M9).

Initial radiation decrease in
strength using the inverse square law, If it was 900 rads at 1km from blast, it
would be 225 rads at 2km and 100 rads at 3km. It also decreases in time by a
using the seven, tenths rule. After 7 hours it will be at 10th of original
strength, after 49 hours at 100th and after 343 hours at 1000th of original
strength.

To protect against fallout make your refuse in the centre of a
building away from walls and roofs where fallout may settle. A 5 cm course of
brick will reduce radiation by 50%.