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Terror and Medicine - Medical Aspects of Biological, Chemical and Nuclear Terrorism
Contents
5
Preface
11
Introduction
13
Diabolical, Haunting Terror - Here and Now
15
Terror and Medicine -The Challenge
17
Epidemiology of Terror
18
Non-conventional warfare - unique epidemiology and medical management
19
Biological MDW management
20
Chemical MDW management
20
Radiation MDW
21
Conclusion
21
References
22
From Geneva to Afghanistan: The Ethical Implications of Terror and its Effect on the Physician
24
Ethics in a World of Terror
25
The role of the physician
26
Terror and civil liberties
28
The Model State Emergency Health Powers Act
29
The Revised Model Act
30
Terror and the allocation of resources
30
And what the future ...
31
References
31
National Preparedness for a Biological Mass Casualty Event: Between the Devil and the Deep Blue Sea
32
Policies and Doctrines of Non-Conventional Warfare
35
Non-Conventional Terrorism: Historical Aspects
37
Chemical Agents
37
Biological Agents
39
Conclusions
41
References
41
The Medical Management of Terrorist Attacks
43
Pre-event medical preparedness for the terrorist attack
43
Planning
44
Resources
45
Instruction and drills
45
Eventmanagement
45
Pre-hospital phase
46
At the hospital: immediate preparation phase
48
Treatment process
48
Post-event procedures
49
Conclusion
49
References
50
Hospital Management of a Bioterror Event
51
Pre-bioterror event preparations
52
Hospital management for bioterror event
53
Conclusion
54
References
54
Medical Guidelines for the Management of Mega-Terror
55
Pathophysiology of injuries related to mega-terror
56
Reaction of the national medical system to mega-terror
57
Pre-hospital setting
57
Guidelines for hospital management of mega-terror
58
Summary
59
References
60
Principles of Contingency Planning for an Unusual Biological Event
61
Objectives of a contingency and response plan
61
Basic assumptions
62
Main implications of the assumptions
62
Detection, identification and response phases
64
Stage I: Detection
64
Stage II: Identification
65
Response Phase
65
Conclusion
68
References
68
Chemical, Biological and Radiological Terror - General Overview
69
The Epidemiologic Pyramid of Bioterrorism
71
The classic epidemologic paradigm
72
Anthrax
73
Plague
74
Smallpox
75
The new epidemiologic paradigm
76
Communication
78
Civil liberties
78
Global reservoirs
79
Conclusion
79
References
79
Sydromic Surveillance for Early Detection and Monitoring of Infectious Disease Outbreaks Associated with Bioterrorism
81
Traditional surveillance system
82
Deficiencies of traditional surveillance systems
83
Syndromic surveillance for bioterrorist-initiated outbreaks
83
Syndromic surveillance systems in the U. S. A.
84
Statistical methods in syndromic surveillance
85
Examples of syndromic surveillance systems
86
Conclusions
94
References
94
Personal Protection against Chemical and Biological Warfare Agents
96
Exposure
96
Personal protection measures
98
Skin protection
100
Sealed rooms
102
Precaution measures and biosafety levels against biological warfare agents
103
Standard precautions
106
Transmission-based precautions
107
Extremely virulent microorganisms
108
Summary
109
References
109
Training Medical Personnel to Treat Casualties of Nuclear, Biological, or Chemical Warfare
111
Why should we improve a standardized approach for training?
112
What should we teach?
112
How should we teach?
113
Who should be taught
114
Who should teach?
115
Summary
115
References
115
Bioterrorism - The New Monster
117
The nature of terror
117
The arsenals
118
The healthcare response
120
Conclusion
121
References
121
Chemical, Biological and Radiological Terror - Chemical Agents
123
Preparedness of Local and National Health Systems for a Chemical Terrorist Attack
125
The detection phase
126
Pre-hospital medical management
127
Hospital preparedness
128
National preparedness
131
Summary
132
References
133
Organophosphates: Nerve Agents, Pesticides and their Use as Chemical Weapons
135
The cholinergic system
136
OP poisoning - pathophysiology
137
Pathophysiology of brain damage following OP poisoning
139
Other properties and characteristics of OP
140
Exposure thresholds
141
Clinical manifestations
141
Laboratory diagnosis of OP poisoning
142
Subacute and late clinical syndromes
143
Triage of OP casualties
145
Medical management
145
Pharmacologic pretreatment
146
Treatment after intoxication
147
Treatment of combined injury casualties
150
Organophosphales and terror
150
References
151
Cyanides
154
Military experience and terror with cyanide
154
Characteristics
155
Clinical presentation
156
Treatment
158
Conclusion
160
References
160
Acute Care and Management of Casualties with Combat Anticholinesterase Poisoning
162
References
165
The Tokyo Subway Sarin Attack
167
20 March 1995, Tokyo
167
Signs and symptoms (Table 1)
168
Treatment
168
Long-term follow-up
169
Conclusions
170
Summary
170
References
171
Mustard Gas - Clinical Implications and Management
172
Clinical effects of mustard
173
Acute effects of mustard
173
Long-term effects of mustard
176
Diagnosis
177
Patient management
177
Skin
178
Eyes
179
Airways
180
Gastrointestinal tract
180
Bone marrow
181
Summary
181
References
181
Simulation-Based Training of Medical Teams to Manage Chemical Warfare Casualties
183
Simulation in medicine
184
Training medical teams to treat chemical warfare casualties: current status
184
Treating the casualties
185
Organizing the scene
186
Simulation training to treat CWC: rationale
186
Pediatric chemical warfare casualties
187
Simulation training to treat CWC: implementation
188
The setting
189
The training concept
190
Adjusting the simulation setting
191
Simulators
192
Modifications of the simulators for the CWC
192
Research and development
193
Conclusion
193
References
194
Chemical, Biological and Radiological Terror - Biological Agents
197
Biological Warfare: Disease Prevention and Post-Exposure Medical Treatment
199
Treatment approaches to disease: biowarfare versus natural causes
199
Causative agents
200
Extent of exposure
200
Route of exposure
200
Timing of treatment
201
Clinical guidelines
201
Antiobiotics
201
Resistance
201
Broad-spectrum antibiotics
203
Intelligence
203
Administration
203
Vaccination
204
Antiviral drugs
206
Summary
207
References
207
Detection and Clinical Identification of a Biological Weapons Attack
209
Possible clues
210
Summary
212
References
212
The Spectrum of Clinical Presentations Associated with Biological Warfare
213
Respiratory syndromes (including pneumonia)
215
Hemorraghic fevers (HF)
216
Encephalities, meningitis, meningoencephalitis
218
Neurologic syndromes with flaccid paralysis
220
Fever syndromes with rash
220
Diarrheal syndromes
221
Summary
223
References
224
Biodefense Strategies against Superantigen Toxins
228
Methods
230
Results
230
Superantigen toxin antagonist
230
Protection and rescue of mice from lethal shock
231
Protected mice rapidly develop immunity to lethal shock
232
The antagonist targets a structurally conserved domain
233
Discussion
234
References
238
Tetracyclines and Ciprofloxacin as Treatment in Children and Pregnant or Lactating Women in the Era of Biologic Terror
241
Tetracyclines
241
Pregnant women
242
Lactating women
242
Children
243
Dosage and indications
244
Ciprofloxacin
244
Pregnant women
245
Lactating women
245
Children
246
Dosage and indications
246
Adverse effects
246
Conclusions
248
References
248
Anthrax - An Overview, 2003
251
Ecology and epidemiology
252
Pathophysiology
253
Clinical symptoms
254
Diagnosis
257
Post-exposure prophylactic treatment
258
Treatment of patients
260
Treating cutaneous anthrax
261
Treating inhalation and systemic anthrax
261
Treatment with antiserum
263
Steroid treatment
264
Experimental drugs
264
Vaccination
265
Summary
266
References
266
Smallpox: A Possible Comeback
269
References
272
Smallpox - Past, Present, and Future
273
The history and use of smallpox as a weapon of biological warfare
273
Epidemiology
274
The virus
275
Pathogenesis
275
Clinical aspects
275
Prognosis and Outcome
277
Diagnosis
277
Treatment
278
Prevention - immunization
278
Steps for disease prevention following exposure
281
Current status of the virus and the fear of renewed spread of the disease
283
The use of smallpox virus for biological warfare
283
Summary
285
References
286
Smallpox Preparedness in Israel: Recommendations and First Steps
288
The Disease
289
Vaccination
290
Vaccine production
291
Immunity of the Israeli population against smallpox, 2003
292
Smallpox containment
293
Resumption of routine smallpox vaccination
297
Summary
298
References
298
Analysis of the Israeli Smallpox Revaccination Program: Strengths, Weaknesses, Threats and Opportunities
300
Strengths
301
Weaknesses
302
Opportunities
305
Threats
306
Conclusion
307
References
308
Hemorraghic Fevers and Bioterror
310
Argentine hemorrhagic fever (1-6)
311
Bolivian hemorrhagic fever (7-11)
311
Brazilian hemorrhagic fever ("Sabia") (12-16)
314
Crimean Congo hemorrhagic fever (17-24)
314
Ebola (25-33)
315
Hantaviruses (34-39)
316
Lassa fever (40-48)
317
Marburg disease (49-53)
318
Omsk hemorrhagic fever (54-55)
318
Rift Valley fever (56-60)
319
Venezuelan hemorrhagic fever (61-64)
320
Yellow fever (65,66)
320
Comment
322
References
322
Ricin - A Potent Plant Toxin
326
History
326
The toxin
327
Structure
328
Mechanism and toxicity
328
Clinical features
329
Diagnosis
330
Treatment
331
Prognosis
332
Ricin in cancer therapy
332
References
332
Chemical, Biological and Radiological Terror - Radiological Terrorism
335
Radiation Terrorism - The Medical Challenge
337
Ionizing radiation
338
Biologic effects of ionizing radiation
338
Clinical radiation injury
339
Radiation incident scenarios
341
The response
342
Non-medical measures
342
Medical measures
343
The Goiania accident
345
Conclusion
347
References
347
Chemical, Biological and Radiological Terror - Trauma
349
Preparedness for Mass Casualty Situations - The Key to Success
351
Main guidelines
351
Standing orders
353
Step-by-step management
354
Problems
357
Conclusions
357
References
358
The Epidemiology of Terror - Data from the Israeli National Trauma Registry
360
Patients and Methods
361
Injury epidemiology
361
Treatment and outcome
364
Patient demographics
366
Discussion
367
Summary and conclusion
368
References
369
Limited Mass Casualties Due to Conventional Weapons - The Daily Level 1 Trauma Center
370
Field management
373
Field medical care for terrorist MCIs
375
Hospital triage
377
Special injury patterns of suicide bombings
380
Summary
384
References
385
Terror Attacks: The Role of Imaging
386
Blast injury
387
Managing the radiology department during a mass victim terrorist attack
389
Imaging of penetrating foreign objects - a multimodality approach
392
Plain film radiology
392
Real-time sonography in the ED
393
Computed tomography
394
Angiography
395
Disaster victim identification
397
Postmortem CT
398
Summary
399
References
399
Suicide Bombings: The General Surgeon's View
401
Mechanisms of injury
401
Specific considerations
402
Triage
404
Approach to management
405
Evaluation
405
Treatment
408
Conclusions
409
References
410
Acute Lung Injuries among Survivors of Suicide Bomb Attacks
412
Incidence/Prevalence
412
Clinical Examples
413
Pathogenesis
417
Diagnosis
419
Management and Treatment
419
Conclusions
423
References
423
Terror and War Burns in Israel
425
Burn treatment in Israel
427
War burns in Israel
428
Skin replacement in wartime
432
Homografts
432
Reconstituted skin
433
Homografts for partial-thickness burns
433
Unique war burns
434
Mustard gas burns
435
Expansion of hospitalization capacity
436
References
436
The Forensic Pathology of Terrorism in Israel - Two Years of Suicide Bombing
438
Identification techniques
442
Discussion
444
References
446
Penetrating Bone Fragments in Suicide Bombings: A Potential New Mode of Infection
448
History
449
Our experience
451
Modes of penetrating wounds during blast injury
451
Bone fragments
451
Metals
454
Glass
455
Unusual transmission of HBV
455
Epidemiology
455
Discussion
458
References
459
Otologic Manifestations of Blast Injury
461
The Blast Wave
461
Mechanism of blast injury
462
Factors affecting blast injury of the ear
462
Effect of the blast wave on the auditory system
463
Patients' complaints and symptoms
463
External ear damage
463
Middle ear damage
463
Inner ear damage
465
The vestibular system
466
Recovery of the damage to the ear after blast injury
467
Summary
468
References
468
Chemical, Biological and Radiological Terror - Rehabilitation of Victims of Terror
471
Unique Aspects of Rehabilitation of Spinal Cord Injuries in Victims of Terror
473
Case Report
473
Spinal cord injuries
475
Discussion
480
References
481
Chemical, Biological and Radiological Terror - Psychological Aspects
483
Conventional, Chemical and Biological Terror of Mass Destruction: Psychological Aspects and Psychiatric Guidelines
485
Clinical syndromes following conventional and non-conventional terror attacks
486
Presumes scenarios of terror attacks
488
Conventional mega-terror attacks
493
Terror attacks with non-conventinal devices
495
Considerations for community deployment during a non-conventional terror attack
500
References
502
Prevention Program against Biological Warfare: The Public must be an Informed and Active Participant
505
The threat
506
Preventive program against biological warfare
507
Expected natural behavior in time of disaster
508
The natural process of coping with an external threat
509
The need to process new information
510
The need for trust in the leadership
511
What deters the leadership from relaying information?
512
How to conduct a dialogue with the public
513
Essence of the communication to the public
513
Conclusions
514
References
515
Clinical Pictures Expected at the Stage of Impact in a Situation of Biological Warfare
516
Reactions to the threat
517
Reactions to trauma among civilians
520
Conclusion
521
Refernces
522
War Stress in a Primatry Care Clinic in Gilo, a Neighborhood of Jerusalem
525
Exposure of the Israeli population to war stressors
526
Measurement of demoralization
527
Gilo under fire
527
Discussion
533
Implementation of community programs to face terrorist attacks
535
References
536
Chemical, Biological and Radiological Terror -- Veterinary Medicine
539
Animal health
542
Public health
543
Agricultural biological warfare/terrorism
545
Conclusion
546
References
546
List of Contributors
548
About the Editors
562
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