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| A) | the Civil War. | ||
| B) | World War I. | ||
| C) | World War II. | ||
| D) | the Vietnam War. |
Chemical warfare agents have the potential of being effective weapons for a terrorist attack. They are generally available or easy to manufacture, can be transported and delivered by many means, and their effects can be immediate or delayed. They are also well known, as they were first widely used in warfare during World War I[1].
| A) | Sarin | ||
| B) | Mace | ||
| C) | Lewisite | ||
| D) | Mustard gas |
Nerve agents are the most toxic weapons in the military chemical warfare arsenal. The most common are sarin (GB), tabun (GA), soman (GD), and VX liquid. The G-type agents are colorless, clear, tasteless liquids [2]. GB evaporates at roughly the same rate as water and has no odor. GA has a fruity odor, and GD smells slightly of camphor; both are less volatile than GB [2]. VX is the least volatile agent and is transparent, amber-colored, odorless, and slightly oily. Any of these compounds can cause seizures, apnea, loss of consciousness, and death [1]. They are all in the class of organophosphates and have physiologic effects similar to those seen when household insecticides are sprayed on an insect [1].
| A) | Sarin | ||
| B) | Tabun | ||
| C) | VX liquid | ||
| D) | Mustard gas |
Nerve agents are the most toxic weapons in the military chemical warfare arsenal. The most common are sarin (GB), tabun (GA), soman (GD), and VX liquid. The G-type agents are colorless, clear, tasteless liquids [2]. GB evaporates at roughly the same rate as water and has no odor. GA has a fruity odor, and GD smells slightly of camphor; both are less volatile than GB [2]. VX is the least volatile agent and is transparent, amber-colored, odorless, and slightly oily. Any of these compounds can cause seizures, apnea, loss of consciousness, and death [1]. They are all in the class of organophosphates and have physiologic effects similar to those seen when household insecticides are sprayed on an insect [1].
| A) | xerostomia. | ||
| B) | pupil dilation. | ||
| C) | bronchodilation. | ||
| D) | hyperactivity of the genitourinary and gastrointestinal tracts. |
Victims of a nerve agent attack may present with [1,2,3]:
Miosis (pinpoint pupils)
Hyperactivity of the genitourinary and gastrointestinal tracts, with involuntary urination, defecation, vomiting, and diarrhea
Bronchoconstriction and, in severe cases, respiratory arrest
Increased glandular secretions, such as thick bronchial mucus
Rhinorrhea
Lacrimation
Excessive salivation
Increased sweating
General weakness
Altered mental status
Autonomic instability
Paralysis
| A) | Type A. | ||
| B) | Level 1. | ||
| C) | Level 3. | ||
| D) | security notation X. |
Although the primary diagnosis of a nerve agent attack is made on clinical grounds, the Centers for Disease Control and Prevention (CDC) has established a laboratory network to analyze blood and urine samples to detect the presence of chemical warfare agents [9]. The CDC's Laboratory Response Network for Chemical Threats (LRN-C) designates three levels of laboratories. Level 1 labs are the most secure, have the most specific analytical equipment (apart from CDC labs), and test for exposures to high-threat chemical agents (e.g., mustard agents, nerve agents, toxic industrial chemicals). Level 2 labs maintain testing capabilities for exposures to chemical terrorism agents (e.g., cyanide, toxic metals, some toxic industrial chemicals); level 2 LRN-C methods are customizable and can be readily adapted to detect broad classifications of new and emerging threat agents. Level 3 labs are the most numerous and are able to perform basic tests in addition to providing support with sample logistics and training and research with local hospitals [4].
| A) | atropine. | ||
| B) | quinidine. | ||
| C) | VX liquid. | ||
| D) | chlorpromazine. |
Atropine, pralidoxime chloride, and diazepam (or other benzodiazepines) are the favored drugs for treatment of nerve agent victims [1]. Atropine blocks the effects of acetylcholine at the muscarinic sites. The drug pralidoxime chloride breaks the bond between the nerve agent and acetyl cholinesterase, allowing the enzyme to become available to break down acetylcholine; however, to be effective it must be administered within minutes to a few hours of exposure, depending on the agent [1,2]. Diazepam has been suggested as the best medication to use for seizures associated with nerve agent attacks. It has also been suggested that diazepam be used in all victims whether they are convulsing or not. These drugs are available in kits, many of which include "autoinject" syringes. The military has used a kit called the Mark 1, which includes atropine and pralidoxime chloride in autoinjectors; up to three Mark 1 kits may be administered as needed [1,10]. The injections must be given in a large muscle, preferably the outer thigh muscle or, alternately, the upper outer buttock in thinly built individuals [10].
| A) | involves the weaponization of a nuclear reactor. | ||
| B) | produces more physiologic than psychologic effects. | ||
| C) | disperses radioactive material without the use of explosives. | ||
| D) | would result in explosive injuries to those closest to the device and more widespread effects from exposure to released radiation. |
There are thought to be five primary ways in which nuclear materials might be used by terrorists. They include [1,5,6]:
Simple radiologic device (SRD): Radioactive material is spread around a public place without the use of explosives. This could be with sealed sources or loose material. The effects would be more psychologic than physiologic unless extremely high radiation doses could be produced.
Radiologic dispersal device (RDD): Explosives are utilized to spread contamination over a greater area. The bomb portion could injure, or possibly kill, those in the immediate vicinity, while the radioactive material affects those in the surrounding area. The high explosives rip the weapon apart and spread radioactive plutonium, an alpha emitter, around the accident site. This type of incident would occur if a nuclear weapon was intentionally destroyed. It is almost impossible for the weapon to "go nuclear" when dropped from a plane by mistake.
Nuclear reactor sabotage (NRS): This is an unlikely scenario in the United States and most parts of the world. Many fail-safe protections would need to be bypassed and high security areas breached by terrorists. The nuclear accident in Chernobyl, for example, required several safety systems to be bypassed and occurred in a building that did not have appropriate containment. All reactors in the United States, as in essentially all the world at this time, are in containment shells that are designed to prevent the escape of any significant amount of radioactivity from the facility. After 2001, researchers determined that a plane attack would be unlikely to penetrate the most common types of reactors in the country. Following the March 2011 tsunami in Japan (and associated radionuclide leakage from several breached containment shells), additional safety and security studies were undertaken in hopes of preventing a similar disaster.
Improvised nuclear device (IND): An IND is an operational nuclear device created with the intent of harm, built either from scratch or assembled from stolen or smuggled components. While obtaining fissile material is challenging, the level of sophistication required to produce such a device is relatively low. The IND would likely be a gun-type device, similar in construction to the Little Boy (Hiroshima bomb) design. The fuel (plutonium or weapons-grade uranium) would probably be purchased, gifted, or stolen. Confirmed cases of stolen fissile material are numerous in the former Soviet Union, and it is conceivable that some material has been successfully smuggled out.
Nuclear weapon: This scenario incites the most fear, especially if terrorists could obtain one or more of the ready-made devices. It is felt that the existing supplies of larger weapons, in the countries which possess them, are secure from theft. However, there have been many smaller, tactical nuclear weapons produced in the past that are not accounted for. This type of weapon could produce mass casualties, including killing those closest to the explosion, burning others, and causing radiation sickness in those within the immediate proximity who were not fatally injured by the blast.
| A) | Nausea | ||
| B) | Anorexia | ||
| C) | Vomiting | ||
| D) | Confusion |
In most cases, diagnosing injuries from ionizing radiation requires the history of radiation exposure. There can be instances when a victim is unaware of the cause and presents with a suggestive constellation of signs and symptoms of the prodromal stage of mild acute radiation syndrome (e.g., nausea, vomiting, anorexia) or a more severe syndrome (e.g., diarrhea, cramps, nervousness, confusion) [7]. In addition, there may be some signs that point to radiation injury, such as skin erythema or lesions without history of thermal burns. Unexplained epilation or a sudden drop in leukocytes or platelets could suggest radiation exposure as the etiology [1]. An examination of the blood, urine, or feces can be performed to determine the presence of any radionuclides that may have entered the body.
| A) | Decrease fluid intake | ||
| B) | Avoidance of decontamination | ||
| C) | Decorporation if radioactive materials are ingested | ||
| D) | None of the above |
The immediate treatment for victims of radiologic events includes prompt decontamination. This must be performed prior to the patient entering a care facility to prevent the facility from becoming contaminated. The procedure is similar to decontamination techniques used for chemical weapons, including the removal of clothing, copious washing of the body and wounds, and placing all contaminated items into a closed container.
During the first 8 to 12 hours postexposure, blood samples should be taken for complete blood count (CBC), with attention to lymphocyte count, every two to three hours [7]. In the following two days, repeat CBC every four to six hours. The Andrews Lymphocyte Nomogram is used to ascertain level of injury, with absolute lymphocytes in the 1,000–1,500 range indicating moderate injury, 500–1,000 indicating severe injury, 100–500 indicating very severe injury, and less than 100 indicating lethal injury.
| A) | one week. | ||
| B) | three weeks. | ||
| C) | one to two months. | ||
| D) | two to three months. |
Radiation injuries, traumatic injuries, and burns can occur simultaneously in a nuclear terrorist attack that includes the use of explosives. Because high doses of ionizing radiation can impair healing, a victim who receives high levels of whole-body radiation will usually have a greater degree of total injury, delayed recovery, and probability of death. A patient who has received more than 200 rems should have all major traumatic injuries treated within 48 hours. (Of note, a rem is equal to a rad for gamma rays.) This includes reducing fractures, suturing wounds, treating burns, and performing any required stabilizing surgery. If these interventions cannot be performed within the first two days, any major surgical procedures should be delayed an additional two to three months [1]. Use of burn units is recommended when indicated [7].