Terror and Medicine - Medical Aspects of Biological, Chemical and Nuclear Terrorism

Contents

Preface

Introduction

Diabolical, Haunting Terror - Here and Now

Terror and Medicine -The Challenge

Epidemiology of Terror

Non-conventional warfare - unique epidemiology and medical management

Biological MDW management

Chemical MDW management

Radiation MDW

Conclusion

References

From Geneva to Afghanistan: The Ethical Implications of Terror and its Effect on the Physician

Ethics in a World of Terror

The role of the physician

Terror and civil liberties

The Model State Emergency Health Powers Act

The Revised Model Act

Terror and the allocation of resources

And what the future ...

References

National Preparedness for a Biological Mass Casualty Event: Between the Devil and the Deep Blue Sea

Policies and Doctrines of Non-Conventional Warfare

Non-Conventional Terrorism: Historical Aspects

Chemical Agents

Biological Agents

Conclusions

References

The Medical Management of Terrorist Attacks

Pre-event medical preparedness for the terrorist attack

Planning

Resources

Instruction and drills

Eventmanagement

Pre-hospital phase

At the hospital: immediate preparation phase

Treatment process

Post-event procedures

Conclusion

References

Hospital Management of a Bioterror Event

Pre-bioterror event preparations

Hospital management for bioterror event

Conclusion

References

Medical Guidelines for the Management of Mega-Terror

Pathophysiology of injuries related to mega-terror

Reaction of the national medical system to mega-terror

Pre-hospital setting

Guidelines for hospital management of mega-terror

Summary

References

Principles of Contingency Planning for an Unusual Biological Event

Objectives of a contingency and response plan

Basic assumptions

Main implications of the assumptions

Detection, identification and response phases

Stage I: Detection

Stage II: Identification

Response Phase

Conclusion

References

Chemical, Biological and Radiological Terror - General Overview

The Epidemiologic Pyramid of Bioterrorism

The classic epidemologic paradigm

Anthrax

Plague

Smallpox

The new epidemiologic paradigm

Communication

Civil liberties

Global reservoirs

Conclusion

References

Sydromic Surveillance for Early Detection and Monitoring of Infectious Disease Outbreaks Associated with Bioterrorism

Traditional surveillance system

Deficiencies of traditional surveillance systems

Syndromic surveillance for bioterrorist-initiated outbreaks

Syndromic surveillance systems in the U. S. A.

Statistical methods in syndromic surveillance

Examples of syndromic surveillance systems

Conclusions

References

Personal Protection against Chemical and Biological Warfare Agents

Exposure

Personal protection measures

Skin protection

Sealed rooms

Precaution measures and biosafety levels against biological warfare agents

Standard precautions

Transmission-based precautions

Extremely virulent microorganisms

Summary

References

Training Medical Personnel to Treat Casualties of Nuclear, Biological, or Chemical Warfare

Why should we improve a standardized approach for training?

What should we teach?

How should we teach?

Who should be taught

Who should teach?

Summary

References

Bioterrorism - The New Monster

The nature of terror

The arsenals

The healthcare response

Conclusion

References

Chemical, Biological and Radiological Terror - Chemical Agents

Preparedness of Local and National Health Systems for a Chemical Terrorist Attack

The detection phase

Pre-hospital medical management

Hospital preparedness

National preparedness

Summary

References

Organophosphates: Nerve Agents, Pesticides and their Use as Chemical Weapons

The cholinergic system

OP poisoning - pathophysiology

Pathophysiology of brain damage following OP poisoning

Other properties and characteristics of OP

Exposure thresholds

Clinical manifestations

Laboratory diagnosis of OP poisoning

Subacute and late clinical syndromes

Triage of OP casualties

Medical management

Pharmacologic pretreatment

Treatment after intoxication

Treatment of combined injury casualties

Organophosphales and terror

References

Cyanides

Military experience and terror with cyanide

Characteristics

Clinical presentation

Treatment

Conclusion

References

Acute Care and Management of Casualties with Combat Anticholinesterase Poisoning

References

The Tokyo Subway Sarin Attack

20 March 1995, Tokyo

Signs and symptoms (Table 1)

Treatment

Long-term follow-up

Conclusions

Summary

References

Mustard Gas - Clinical Implications and Management

Clinical effects of mustard

Acute effects of mustard

Long-term effects of mustard

Diagnosis

Patient management

Skin

Eyes

Airways

Gastrointestinal tract

Bone marrow

Summary

References

Simulation-Based Training of Medical Teams to Manage Chemical Warfare Casualties

Simulation in medicine

Training medical teams to treat chemical warfare casualties: current status

Treating the casualties

Organizing the scene

Simulation training to treat CWC: rationale

Pediatric chemical warfare casualties

Simulation training to treat CWC: implementation

The setting

The training concept

Adjusting the simulation setting

Simulators

Modifications of the simulators for the CWC

Research and development

Conclusion

References

Chemical, Biological and Radiological Terror - Biological Agents

Biological Warfare: Disease Prevention and Post-Exposure Medical Treatment

Treatment approaches to disease: biowarfare versus natural causes

Causative agents

Extent of exposure

Route of exposure

Timing of treatment

Clinical guidelines

Antiobiotics

Resistance

Broad-spectrum antibiotics

Intelligence

Administration

Vaccination

Antiviral drugs

Summary

References

Detection and Clinical Identification of a Biological Weapons Attack

Possible clues

Summary

References

The Spectrum of Clinical Presentations Associated with Biological Warfare

Respiratory syndromes (including pneumonia)

Hemorraghic fevers (HF)

Encephalities, meningitis, meningoencephalitis

Neurologic syndromes with flaccid paralysis

Fever syndromes with rash

Diarrheal syndromes

Summary

References

Biodefense Strategies against Superantigen Toxins

Methods

Results

Superantigen toxin antagonist

Protection and rescue of mice from lethal shock

Protected mice rapidly develop immunity to lethal shock

The antagonist targets a structurally conserved domain

Discussion

References

Tetracyclines and Ciprofloxacin as Treatment in Children and Pregnant or Lactating Women in the Era of Biologic Terror

Tetracyclines

Pregnant women

Lactating women

Children

Dosage and indications

Ciprofloxacin

Pregnant women

Lactating women

Children

Dosage and indications

Adverse effects

Conclusions

References

Anthrax - An Overview, 2003

Ecology and epidemiology

Pathophysiology

Clinical symptoms

Diagnosis

Post-exposure prophylactic treatment

Treatment of patients

Treating cutaneous anthrax

Treating inhalation and systemic anthrax

Treatment with antiserum

Steroid treatment

Experimental drugs

Vaccination

Summary

References

Smallpox: A Possible Comeback

References

Smallpox - Past, Present, and Future

The history and use of smallpox as a weapon of biological warfare

Epidemiology

The virus

Pathogenesis

Clinical aspects

Prognosis and Outcome

Diagnosis

Treatment

Prevention - immunization

Steps for disease prevention following exposure

Current status of the virus and the fear of renewed spread of the disease

The use of smallpox virus for biological warfare

Summary

References

Smallpox Preparedness in Israel: Recommendations and First Steps

The Disease

Vaccination

Vaccine production

Immunity of the Israeli population against smallpox, 2003

Smallpox containment

Resumption of routine smallpox vaccination

Summary

References

Analysis of the Israeli Smallpox Revaccination Program: Strengths, Weaknesses, Threats and Opportunities

Strengths

Weaknesses

Opportunities

Threats

Conclusion

References

Hemorraghic Fevers and Bioterror

Argentine hemorrhagic fever (1-6)

Bolivian hemorrhagic fever (7-11)

Brazilian hemorrhagic fever ("Sabia") (12-16)

Crimean Congo hemorrhagic fever (17-24)

Ebola (25-33)

Hantaviruses (34-39)

Lassa fever (40-48)

Marburg disease (49-53)

Omsk hemorrhagic fever (54-55)

Rift Valley fever (56-60)

Venezuelan hemorrhagic fever (61-64)

Yellow fever (65,66)

Comment

References

Ricin - A Potent Plant Toxin

History

The toxin

Structure

Mechanism and toxicity

Clinical features

Diagnosis

Treatment

Prognosis

Ricin in cancer therapy

References

Chemical, Biological and Radiological Terror - Radiological Terrorism

Radiation Terrorism - The Medical Challenge

Ionizing radiation

Biologic effects of ionizing radiation

Clinical radiation injury

Radiation incident scenarios

The response

Non-medical measures

Medical measures

The Goiania accident

Conclusion

References

Chemical, Biological and Radiological Terror - Trauma

Preparedness for Mass Casualty Situations - The Key to Success

Main guidelines

Standing orders

Step-by-step management

Problems

Conclusions

References

The Epidemiology of Terror - Data from the Israeli National Trauma Registry

Patients and Methods

Injury epidemiology

Treatment and outcome

Patient demographics

Discussion

Summary and conclusion

References

Limited Mass Casualties Due to Conventional Weapons - The Daily Level 1 Trauma Center

Field management

Field medical care for terrorist MCIs

Hospital triage

Special injury patterns of suicide bombings

Summary

References

Terror Attacks: The Role of Imaging

Blast injury

Managing the radiology department during a mass victim terrorist attack

Imaging of penetrating foreign objects - a multimodality approach

Plain film radiology

Real-time sonography in the ED

Computed tomography

Angiography

Disaster victim identification

Postmortem CT

Summary

References

Suicide Bombings: The General Surgeon's View

Mechanisms of injury

Specific considerations

Triage

Approach to management

Evaluation

Treatment

Conclusions

References

Acute Lung Injuries among Survivors of Suicide Bomb Attacks

Incidence/Prevalence

Clinical Examples

Pathogenesis

Diagnosis

Management and Treatment

Conclusions

References

Terror and War Burns in Israel

Burn treatment in Israel

War burns in Israel

Skin replacement in wartime

Homografts

Reconstituted skin

Homografts for partial-thickness burns

Unique war burns

Mustard gas burns

Expansion of hospitalization capacity

References

The Forensic Pathology of Terrorism in Israel - Two Years of Suicide Bombing

Identification techniques

Discussion

References

Penetrating Bone Fragments in Suicide Bombings: A Potential New Mode of Infection

History

Our experience

Modes of penetrating wounds during blast injury

Bone fragments

Metals

Glass

Unusual transmission of HBV

Epidemiology

Discussion

References

Otologic Manifestations of Blast Injury

The Blast Wave

Mechanism of blast injury

Factors affecting blast injury of the ear

Effect of the blast wave on the auditory system

Patients' complaints and symptoms

External ear damage

Middle ear damage

Inner ear damage

The vestibular system

Recovery of the damage to the ear after blast injury

Summary

References

Chemical, Biological and Radiological Terror - Rehabilitation of Victims of Terror

Unique Aspects of Rehabilitation of Spinal Cord Injuries in Victims of Terror

Case Report

Spinal cord injuries

Discussion

References

Chemical, Biological and Radiological Terror - Psychological Aspects

Conventional, Chemical and Biological Terror of Mass Destruction: Psychological Aspects and Psychiatric Guidelines

Clinical syndromes following conventional and non-conventional terror attacks

Presumes scenarios of terror attacks

Conventional mega-terror attacks

Terror attacks with non-conventinal devices

Considerations for community deployment during a non-conventional terror attack

References

Prevention Program against Biological Warfare: The Public must be an Informed and Active Participant

The threat

Preventive program against biological warfare

Expected natural behavior in time of disaster

The natural process of coping with an external threat

The need to process new information

The need for trust in the leadership

What deters the leadership from relaying information?

How to conduct a dialogue with the public

Essence of the communication to the public

Conclusions

References

Clinical Pictures Expected at the Stage of Impact in a Situation of Biological Warfare

Reactions to the threat

Reactions to trauma among civilians

Conclusion

Refernces

War Stress in a Primatry Care Clinic in Gilo, a Neighborhood of Jerusalem

Exposure of the Israeli population to war stressors

Measurement of demoralization

Gilo under fire

Discussion

Implementation of community programs to face terrorist attacks

References

Chemical, Biological and Radiological Terror -- Veterinary Medicine

Animal health

Public health

Agricultural biological warfare/terrorism

Conclusion

References

List of Contributors

About the Editors