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Case Studies of Medical Response to Mass Chemical Exposure

South Carolina train derailment (Chlorine) 1

  • At 2:40 AM on January 6, 2005, a Norfolk Southern freight train wrecked in Graniteville, South Carolina.
  • The train contained 42 cars including tankers filled with chlorine.
  • The chlorine escaped and created a large toxic cloud that covered a large populated area including a textile mill with 500 night shift workers inside.
  • The consequences of the event: 9 deaths, 529 sought medical care, 18 were treated at area physicians' offices, and 5400 were forced to evacuate in a 1-mile radius of the crash.
  • The Regional Poison Center was initially contacted by a person living near the crash site. She smelled a chemical odor and complained of burning eyes. The poison center promptly called the local ED and found on duty a single emergency physician, who was already overwhelmed with 1 critically ill patient, 6 patients who had pulmonary edema, and 100 patients in the waiting room. The public safety officer at the accident scene notified the ED and suggested that the accident involved a release of sodium nitrate. The poison center researched sodium nitrate's expected health effects from poisoning and found that patients did not exhibit those symptoms. Fifteen minutes later, the chemical was thought to be methanol.
  • Over 1 hour later, the chemical was confirmed to be chlorine. By then the poison center already gave the ED physician human health effects information and treatment recommendations based on the victims' reported clinical presentations.

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Tokyo sarin gas attack (Sarin) 1

  • On March 20, 1995, at 7:55 AM, terrorists released the nerve agent sarin into the Tokyo subway system.
  • People became immediately ill and many people rushed from the train cars and subway platforms to the streets.
  • Published accounts of this incident demonstrate a gap between clinicians rendering care and accurate information needed to guide their decisions.
  • On-scene emergency responders reported to hospitals that an explosion occurred in the subway and they should prepare for victims who have smoke inhalation and carbon monoxide poisoning.
  • The closest hospital, St. Luke's International Hospital, received 500 patients during the first hour of the event.
  • Only 23% of the patients arrived by ambulances while most arrived by walking, taxi, or private vehicle. The first patient arrived by foot and was the hospital's best information source at that time.
  • A delay in identifying the substance and lack of effective communication left hospital staff "blind" until 3 hours after the incident began. Health care providers treated patients without the benefit of knowing the causative agent. They relied on their clinical observations and the scanty and inaccurate information from the scene. Because sarin was not suspected, patients were brought into waiting rooms and other parts of the hospital for treatment without any attention to decontamination.
  • At 11:30AM, hospitals received word that the victims were exposed to the nerve agent, sarin, a military chemical weapon. They received the information by way of television news broadcast.
  • In the final analysis, approximately 1200 people had signs and symptoms suggestive of at least mild nerve agent poisoning, and 12 died. However, approximately 5500 people sought medical care. Also, reports suggest 135 (10%) prehospital providers and 110 (23%) hospital staff developed symptoms of nerve agent poisoning.

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Indianapolis, Indiana industrial accident (Cyanide) 1

  • In Indianapolis in 1995, the fire department evacuated nearby neighborhoods after realizing that a burning building contained cyanide.
  • Even though air monitoring found no evidence of cyanide, 80 employees at a distant warehouse began to complain of chest tightness, nausea, and dizziness.
  • Patients were transported to the hospital and two patients were treated using the cyanide antidote kit.
  • One patient required ICU admission, not from cyanide toxicity, but from the administered antidote's (sodium nitrite) resulting hypotension and ischemic electrocardiogram changes.

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Desert storm SCUD attacks 1

  • In 1991, during the United States-led Desert Storm operation, 39 Iraqi SCUD missiles landed in Israel.
  • These attacks caused over 1000 casualties. One half of the casualties were diagnosed with acute psychologic reactions or acute anxiety.
  • Because it was unknown if chemical weapons were part of the missilesÂ’ payload, it appeared that people anticipated toxic chemicals and without verification began to treat themselves.
  • One fourth of the casualties were due to inappropriate autoinjection of atropine because of fear that a chemical nerve agent attack had occurred. Another 40 patients were injured while rushing to a sealed room to avoid chemical exposure.
  • At least 11 deaths were attributed to the missile attacks, although only 2 were from missile trauma. Seven patients (including 1 child) reportedly suffocated from improper use of gas masks, and 4 died of myocardial infarctions.

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  1. Kirk MA, Deaton ML. Bringing order out of chaos: effective strategies for medical response to mass chemical exposure. Emerg Med Clin North Am. 2007 May;25(2):527-48. [PubMed Citation]