Detection
All four agents may be detected
by various mean. Paper three colors detectors can be used to test liquids.
(None available presently in North Iraqi Kurdistan)
Protection
Normal clothing is penetrated
by all these agents, as is the skin. This is true for liquid or vaporized
agent. Fortunately the absorption of vapors through the skin is slow, a
contaminated area can be passed by if respiratory and eye protection is
available. Otherwise one has to hold the breath and run away. In a car
close the window hold the breath and get as distant as possible before
reopening the windows and breathing. Only full gear total body suit with
hood and mask and overboots gives protection. For liquid form and contaminated
wet surface non touch technique, such as holding the contaminated item
by a plastic foil or bag while wearing surgical gloves, should be used,
remembering persistence can last for weeks. For vapor contamination, as
in case of Sarin, one has to wait for the agent to be dissipated by air
motion.
Prevention
Carbamate pyridostigmine,
if available, should be given at the dose of 30 mg every 8 hours. It would
start being effective some two hours after the first dose, but full benefit
is only after the third dose. The mechanism of action of pyridostigmine
is by reversible binding to acetylcholinesterase. The enzyme bound to pyridostigmineis
is therefore kept protected by the binding with the organophosphate (nerve
agent). For reason related to the strength of the binding the enzyme can
resume or keep its function after being bound with pyridostigmine, while
the binding with the nerve agent is much more damaging because is stronger
and longer lasting. Actually in the case of Soman the binding with acetylcholinesterase.
hardly breaks down at all, is irreversible. So the mechanism of action
of pyridostigmine is by competitive binding.
Pyridostigmine has been
used extensively during the Gul War of 1991, The tablets were taken for
a periods of 4 to 5 days by troops deemed at risk. Uncontrolled studies
on some 42,000 troops have shown that the tolerance, at the given dosage,
was good. About half of the soldiers had loose stools abdominal cramps
and nausea. Other effects were rhinorrhea, sweating, headache, urinary
urgency, tingling of the extremities. These symptoms were not requiring
suspension of treatment of from duties. Symptoms would ameliorate taking
the drug with food.
However other sources would
see in the use of pyridostigmine a potential cause of the so called Gulf
Syndrome, an ill defined series of disturbances common among Gulf War veterans.
Sings and symptoms
Sings and symptoms are basically
of three types and cause by
Treatment
The basic treatment will
be postural drainage of secretion and Atropine injection, 2 mg IM. If suction
available can be used for short times, two three seconds, then a long interval
so the patient can breath. Excessive prolonged suction will suck air and
oxygen out of the lung. Atropine to be repeated if necessary after half
an hour, up to three times. Diazepam (Valium) should be given 10 mg per
os. Diazepam IV slowly should be reserved for convulsion. Postural drainage
of bronchi combined with Atropine will help the respiration and counteract
all muscarinic symptoms and somewhat the CNS effects.
If possible -if available-
Atropine will be givencombined with pralidoxime I.M. such as in the MARK
I Kit –containig 600 mg of pralidoxime chloride-. This also can be repeated
after half an hour, up to a total of three times. I.V. pralidoxime is reserved,
if available, for hospital use (Adults 1-2 grams IV bolus over ten minutes
initially, children 20-50 mg/Kg IV over thirty minutes, to be repeated
after one to two hours, and then every twelve hours according to symptoms,
or as continuous infusion IV at the dose of 10-50 mg/Kg/hour up to 500
mg per hour, for 24 hours).
Decontamination
Since prolonged exposure
to small amount of agent on the skin will progress to cause severe symptoms,
decontamination is necessary. Localized sweating on the skin areas affected
is a sure sign of localization of here the agent has been in touch with
the skin.
Fortunately, for the chemical
nature of the agents the decontamination for the nerve agents is the same
than for Mustard agent. It will be based on the use of chlorinated water
and water and soap. Chlorination of water will be with 10 cc of bleach
(which is about 4,5% hypochlorite) added to one liter of water. This will
give a chlorination of water of about 0,05%, For eyes and mucosae and open
wound one cc. f bleach per liter (concentration 0,005%) should be used.
Procedure will be the same
as for mustard: use surgical gloves, undress the patients and place clothes
in a plastic bag. This bag will be placed in a second bag to be closed
by one other person. Bag will be given to relatives to bury it or wash
it with chlorinated water. Caution must be used with water employed for
it is to be assumed contaminated and potentially contaminating. Urines
and feces of patients are not contaminating. Remember the gloves employed
are themselves contaminated, fresh clothing should not be handle with gloves
wearing hands which have done the decontamination. If appropriate ad hoc
showers are available, one should add bleach to the water tank in the proportion
given, which is 10 cc of 5% bleach per liter of water. The shower area
should be decontaminated in between patients with higher concentration
of bleach chlorinated water with common household detergent added using
common floor cleaning swap.
Little protection if any
is given by surgical mask, one should remember it always. However the risk
of inhaling nerve agent while decontaminating is minimal if any at all.
(The NATO manual does
not recommend wet method, as in the case of blistering agents it recommends
use of "dry’ method with chlorinated cream and ointments, none of which
is available in North Iraqi Kurdistan presently. Moreover is likely that
new biological methods are presently available in NATO army, based on biological
DNA recombinant technology production of enzymes attacking the organophoisphate
molecules, such as Alteromonas Prolidase -Chem Biol Interact 1999 May 14;
119-120, 455-462).