Section VII. HOMELAND SECURITY RESPONSE_Health Service Support in a Nuclear, Biological, and Chemical Environment Tactics, Techniques, and Procedures

5-28. Chemical, Biological, Radiological, Nuclear, and High-Yield

Explosive Response

Although, homeland security is not a specific military mission,

commanders must plan for and be prepared to support a lead federal

agency (such as the Federal Bureau of Investigation or Federal

Emergency Management Agency) in response to CBRNE event. When the

CBRNE event occurs on a military installation, the Weapons of Mass

Destruction--Incident Support Team (WMD-IST) is the lead federal

agency in charge of responding and establishes an incident command

center (ICC). The installation medical authority (IMA) provides

the HSS initial response to the event site. Request for assistance

from deployable HSS organizations and staffs are initiated by

the IMA through military channels. The incident commander will

submit a request for HSS assistance to a CBRNE event off the

military installation through the appropriate federal channels. The

President will direct any DOD response in support of a lead federal

agency to a CBRNE event. The Presidential direction to assist

will be passed down through military channels to the appropriate

HSS organization for response. The HSS response may be in the

form of special medical augmentation teams (SMART) support from

US Army Medical Command resources or HSS (table of organization

and equipment [TOE]) units may be directed to respond. Normally,

responding TOE units will provide HSS to nonmedical military

responders. However, the HSS mission may be to provide support to

the lead federal agency or civilian public health organizations,

emergency medical services (ambulance crews), or hospitals. The HSS

response will include, but not be limited to--

· Providing medical care to casualties at the incident

casualty decontamination site and supervising the casualty

decontamination process to ensure that no further injury is

caused to the casualty.

· Providing en route care for casualties from the incident site

to an MTF or designated location for further care. Normally,

TOE MEDEVAC assets are not used, but HSS personnel provide the

en route care on locally provided transport vehicles.

· Providing guidance to local responders in the management of

CBRNE casualties. The guidance may be on the correct use of

antidotes, chemoprophylaxis, prevention of contamination spread

in the MTF, patient decontamination at the MTF, and other

related medical management procedures.

· Identifying suspect chemical, biological, or radiological

materials used in the event.

· Providing guidance on application of standard precautions

for CBRNE, especially preventive measures to prevent spread of

contagious agents.

· Managing, triaging, and treating mass casualties.

5-29. Capabilities of Response Elements

For detailed Information on capabilities of SMARTs see FM 4-02 and

FM 8-42. For detailed information on capabilities and functions of

TOE HSS units see FM 4-02- and 8-series publications.

APPENDIX A

MEDICAL EFFECTS OF NUCLEAR, BIOLOGICAL, AND CHEMICAL WEAPONS AND

TOXIC INDUSTRIAL MATERIAL

A-1. General

Biological and chemical weapons/agents may be employed by

assassins, terrorists, rebels, and insurgents, as well as

well-formed battle organizations, across the continuum of

operations. In addition, nuclear weapons will remain a threat

on the future battlefield. Another weapon that may be used is

the RDD. The RDD can cause significant damage and present health

hazards to fighting forces by exposing them to radiation without

the thermal and full blast effects of nuclear weapons. The RDD can

disperse radioactive material over an area of the battlefield;

the area covered is dependent upon the amount of radioactive and

explosive material used. In order to detonate a nuclear weapon, an

adversary must first obtain access to the appropriate weapons-grade

material. However, an RDD can be produced and used by anyone with

access to industrial or medical radioisotopes and explosives.

Biological agents are easy to disperse on the battlefield without

immediate detection; however, their effects on exposed troops can

change the course of the battle. Some nations consider chemical

weapons as a component of their munitions for the battlefield.

As more nations enter the arena of developing biological and

chemical weapons, their potential effects on our troops will

increase. The enemy's use of TIMs as weapons or collateral damage

to TIM storage faculties can severely affect the unit personnel's

ability to continue the mission. The signs and symptoms of some

TIM exposure can be the same as those presented from exposure to

NBC weapons. Considerations of both the physical and biological

effects of these weapons are required for HSS operations. Field

Manual 4-02.283 provides additional information on nuclear and

radiological effects; FM 8-284 provides additional information on

biological agent effects; FM 8-285 provides additional information

on CW effects; FM 8-500 provides detailed information on hazardous

material (TIM) effects.

A-2. Physical Effects of Nuclear Weapons

_a._ The principal physical effects of nuclear weapons are blast,

thermal radiation (heat), and nuclear radiation. These effects

are dependent upon the yield (or size) of the weapon expressed

in kilotons (KT), the physical design of the weapon (such as

conventional and enhanced), and the method of employment. The

distribution of energy (Figure A-1) from the detonation of a

moderate-sized (3 to 10 KT) weapon is as follows:

(1) Fifty percent as blast.

(2) Thirty-five percent as thermal radiation; made up of a wide

spectrum of electromagnetic radiation, including infrared,

visible, and ultraviolet light and some soft x-ray radiation.

(3) Fourteen percent as nuclear radiation, 4 percent as initial

ionizing radiation composed of neutrons and gamma rays emitted

within the first minute after detonation, and 10 percent as

residual nuclear radiation (fallout).

(4) One percent as EMP.

_b._ Larger weapons are more destructive than smaller weapons,

but the destructive effect is not linear. Table A-1 presents a

comparison of three aspects of nuclear weapons effects with yield.

[Illustration: _Figure A-1. Distribution of energy._]

_c._ The altitude at which the weapon is detonated determines the

blast, thermal, and nuclear radiation effects. Nuclear blasts are

classified as air, surface, or subsurface bursts.

(1) An airburst is a detonation in air at an altitude below

30,000 meters, but high enough that the fireball does not touch

the land or water surface. The altitude is varied to obtain

the desired tactical effects. Initial radiation will be a

significant hazard, but there is essentially no local fallout.

However, the ground immediately below the airburst may have a

small area of neutron-induced radioactivity. This may pose a

hazard to troops passing through the area.

(2) A surface burst is a detonation in which the fireball

actually touches and vaporizes the land or water surface. In

this case, the area affected by blast, thermal radiation, and

initial nuclear radiation will be smaller than for an airburst

of comparable yield. However, in the region around ground

zero, the destruction will be much greater and a crater is

often produced. Additionally, all the material that was within

the fireball becomes fallout and will be a hazard downwind. A

surface burst is the most likely type of terrorist detonation.

(3) A subsurface burst is an explosion in which the detonation

is below the surface of land or water. Cratering usually

results. If the burst does not penetrate the surface, the

only hazard is from the ground or water shock. If the burst

penetrates the surface, blast, thermal, and initial nuclear

radiation will be present, though less than for a surface burst

of comparable yield. Local fallout will be heavy over a small

area.

(4) A high altitude burst occurs above 30,000 meters. Radiation

and physical effects do not reach the ground and there is no

local fallout. This is the only detonation where the effects

of the EMP are significant. Nonhardened electronic equipment

including many medical devices may become inoperative. The EMP

damage is a moot point with other types of detonations, as its

range is primarily limited to the area of intense physical

destruction.

_Table A-1. Comparison of Weapons Effects (Radii of Effects

in Kilometers--Airburst)_

==============================================================

1 KT 20 KT 100 KT 1 MT 10 MT

--------------------------------------------------------------

NUCLEAR

RADIATION 0.71 1.3 1.6 2.3 3.7

(1,000 cGy)

--------------------------------------------------------------

BLAST (50% INCIDENCE

OF TRANSLATION WITH

SUBSEQUENT IMPACT 0.28 1.0 1.4 3.8 11.7

WITH A NON-YIELDING

SURFACE)

--------------------------------------------------------------

THERMAL (50% INCIDENCE

OF 2ND-DEGREE BURNS TO 0.77 1.8 3.2 4.8 14.5

BARE SKIN, 10 KM

VISIBILITY)

==============================================================

A-3. Physiological Effects of Nuclear Weapons

The physiological effects of nuclear weapons are the result of

exposure to the blast; thermal radiation; ionizing radiation

(initial or residual) effects; or a combination of these. For

smaller weapons (less than 10 KT), ionizing radiation is the

primary creator of casualties requiring medical care, while for

larger weapons (greater than 10 KT), thermal radiation is the

primary creator of casualties.

_a._ The rapid compression and decompression of blast waves on the

human body results in transmission of pressure waves through the

tissues. Resulting damage is primarily at junctions between tissues

of different densities (bone and muscle), or at the interface

between tissue and airspace. Lung tissue and the gastrointestinal

system (both contain air) are particularly susceptible to injury.

The tissue disruptions can lead to severe hemorrhage or to an air

embolism; either can be rapidly fatal. Direct overpressure effects

do not extend out as far from the point of detonation as the drag

force and are often masked by the drag force effects. A typical

range of probability of lethality, with variations in overpressure

for a 1 KT weapon, is shown in Table A-2.

_Table A-2. Range of Lethality of Peak Overpressure_

==============================================================

LETHALITY PEAK OVERPRESSURE DISTANCE FROM

(APPROXIMATE %) (ATMOSPHERES) GROUND ZERO; METERS

--------------------------------------------------------------

1 2.3-2.9 150

50 2.9-4.1 123

100 4.1+ 110

==============================================================

(1) The significance of the data is that the human body is

relatively resistant to static overpressure compared to rigid

structures such as buildings. For example, an unreinforced

cinder block panel will shatter at 0.1 to 0.2 atmospheres.

(2) Overpressure lower than those in Table A-2 can cause

nonlethal injuries such as lung damage and eardrum rupture.

Lung damage is a relatively serious injury, usually requiring

hospitalization, even if not fatal; whereas eardrum rupture is

a minor injury, often requiring no treatment at all.

(_a_) The threshold level of overpressure for an unreinforced

unreflected blast wave that can cause lung-damage is about 1.0

atmosphere.

(_b_) The threshold level for eardrum rupture is around 0.2

atmospheres; the overpressure associated with a 50 percent

probability of eardrum rupture is about 1.1 atmospheres.

(3) Casualties requiring medical treatment from direct blast

effects are produced by overpressure between 1.0 and 3.5

atmospheres. However, other effects (such as indirect blast

injuries and thermal injuries) are so predominate that patients

with only direct blast injuries make up a small part of the

patient workload.

_b._ The drag forces (indirect blast) of the blast winds are

proportional to the velocities and duration of the winds. The

winds are relatively short in duration, but can reach velocities

of several hundred km per hour. Injury can result from missiles

impacting on the body or from the physical displacement of the body

against objects and structures.

(1) The distance from the point of detonation at which severe

indirect injury occurs is greater than that for equally serious

direct blast injuries. A high probability of serious indirect

injury can occur when the peak overpressure is about 0.2

atmospheres. This range will increase with the increased size

of the weapon; for a 1 KT weapon, the range is 0.22 km, whereas

for a 20 KT weapon, the range is 0.76 km. At greater ranges

injuries will occur and casualties will be generated, but not

consistently.

(2) The drag forces of the blast winds produced by a nuclear

detonation are so great that almost any form of vegetation or

structure will be broken up or fragmented into missiles. Thus,

multiple, varied missile injuries will be common, increasing

their overall severity and significance. Table A-3 lists ranges

at which significant missile injuries can be expected.

_Table A-3. Ranges for Probabilities of Serious Injury from Small

Missiles_

=================================================================

RANGES (km)

-----------------------------------------------------------------

YIELD 1% PROBABILITY OF 50% PROBABILITY OF 99% PROBABILITY OF

(KT) SERIOUS INJURY SERIOUS INJURY SERIOUS INJURY

-----------------------------------------------------------------

1 0.28 0.22 0.17

10 0.73 0.57 0.44

20 0.98 0.76 0.58

50 1.4 1.1 0.84

100 1.9 1.5 1.1

200 2.5 1.9 1.5

500 3.6 2.7 2.1

1,000 4.8 3.6 2.7

-----------------------------------------------------------------

1 INCIDENCE OF INJURY BASED ON SKIN AND TISSUE PERFORATION.

2 MISSILES USED WERE 10 GRAM (gm) IN WEIGHT.

=================================================================

(3) The velocity to which missiles are accelerated is the major

factor in causing injury. The probability of a penetration

injury increases with increasing velocity, particularly for

small, sharp missiles such as glass fragments. Small, light

objects are accelerated to speeds approaching the maximum

(wind) velocity. Table A-4 shows data for probability of

penetration related to size and velocity of glass fragments.

_Table A-4. Probability of Glass Fragments Penetrating the

Abdominal Cavity_

=======================================================

MASS OF GLASS 1% 50% 99%

FRAGMENTS (gm) IMPACT VELOCITY (METERS PER SECOND)

-------------------------------------------------------

0.1 78 136 243

0.6 53 91 161

1.0 46 82 143

10.0 38 60 118

=======================================================

(4) Heavy, blunt missiles may not penetrate, but can result

in significant injury, particularly fractures. The threshold

velocity for skull fractures from a 4.5 milligram (mg) missile

is about 4.6 meters per second (m/sec).

(5) The drag forces of the blast winds are strong enough to

displace large objects (such as vehicles), or cause large

structures to collapse (such as buildings) resulting in serious

crushing injuries. Man himself can become a missile resulting

in injuries (called translational injuries). The velocity at

which the body is displaced will determine the probability and

the severity of injury. Assuming a displacement of 3.0 meters,

the impact velocity associated with various degrees of injury

is shown in Table A-5. The velocities in Table A-5 can be

correlated against yield. The ranges at which such velocities

can occur and the probability of injury are given in Table A-6.

_Table A-5. Translational Injuries_

================================================

A. BLUNT INJURIES AND FRACTURES

PROBABILITY OF INJURY VELOCITY (m/sec)

------------------------------------------------

1% 2.6

50% 6.6

99% 16.5

------------------------------------------------

B. FATAL INJURIES

PROBABILITY OF FATALITY VELOCITY (m/sec)

------------------------------------------------

1% 6.6

50% 17.0

99% 39.7

================================================

_Table A-6. Ranges for Selected Impact Velocities of a 70-Kilogram

Human Body Displaced by Blast Wind Drag Forces for Different Yield

Weapons_

==============================================

WEAPON YIELD VELOCITIES (m/sec)

(KT) 2.6 6.6 17.0

----------------------------------------------

RANGES (km)

----------------------------------------------

1 0.38 0.27 0.19

10 1.0 0.75 0.53

20 1.3 0.99 0.71

50 1.9 1.4 1.0

100 2.5 1.9 1.4

200 3.2 2.5 1.9

500 4.6 3.6 2.7

1,000 5.9 4.8 3.6

===============================================

A-4. Biological Effects of Thermal Radiation

The thermal radiation emitted by a nuclear detonation causes burns

in two ways--by direct absorption of the thermal energy through

exposed surfaces (flash burns); or by the indirect action of fires

in the environment (flame burns). Indirect flame burns can easily

outnumber all other types of injury.

_a._ Thermal radiation travels outward from the fireball in a

straight line; therefore, the amount of energy available to

cause flash burns decreases rapidly with distance. Close to the

fireball all objects will be incinerated. The range for 100

percent lethality will vary with yield, height of burst, weather,

environment, and immediacy of treatment. The critical factors

determining the degree of burn injury are the flux (calories per

square centimeter/second [cal/cm^2/sec]) and the duration of the

thermal pulse. The total amount of thermal radiation needed to

cause a flash partial thickness burn on exposed skin will vary with

the yield of the weapon and the nature of the pulse (Table A-7).

Most burn patients will come from the zones where partial thickness

burns occur. In areas where radiation, blast, and thermal intensity

are highest, burn victims surviving long enough to reach medical

care will be rare.

NOTE

The battle dress uniform (BDU), MOPP gear, or any other

clothing will provide additional protection against flash

burns. The airspace between the clothing significantly impedes

heat transfer and may prevent or reduce the severity of burns,

depending on the magnitude of the thermal flux.

_Table A-7. Factors for Determining the Probability of Partial

Thickness Burns_

==================================================================

YIELD OF WEAPON 1 KT 10 KT 100 KT 1 MT 10 MT

------------------------------------------------------------------

RANGE (km) FOR PRODUCTION

OF PARTIAL THICKNESS BURNS 0.78 2.1 4.8 9.1 14.5

ON EXPOSED SKIN

------------------------------------------------------------------

DURATION OF THERMAL

PULSE IN SECONDS 0.12 0.32 0.9 2.4 6.4

------------------------------------------------------------------

Cal/cm^2/sec REQUIRED TO

PRODUCE PARTIAL THICKNESS 4.0 4.5 5.3 6.3 7.0

BURNS ON EXPOSED SKIN

==================================================================

_b._ Indirect (flame) burns result from exposure to fires caused by

the thermal effects in the environment, particularly from ignition

of clothing. The larger-yield weapons are more likely to cause

firestorms over extensive areas. There are too many variables

in the environment to predict either incidence or severity of

casualties. Expect the burns to be far less uniform (in degree)

and not limited to exposed surfaces. For example, the respiratory

system may be exposed to the effects of hot gases produced by

extensive fires. Respiratory system burns cause high morbidity and

high mortality rates.

_c._ The initial pulse of radiation in the optical and thermal

bands can cause injuries in the forms of flash blindness and

retinal scarring. The initial brilliant flash of light produced

by the nuclear detonation causes flash blindness. This flash

swamps the retina, bleaching out the visual pigments and producing

temporary blindness. During daylight hours, this temporary effect

may last for about 2 minutes. At night, with the pupil dilated for

dark adaptation, flash blindness will affect personnel at greater

ranges and for greater durations. Partial recovery can be expected

in 3 to 10 minutes, though it may require 15 to 35 minutes for

full night adaptation recovery. Retinal scarring is the permanent

damage from a retinal burn. It will occur only when the fireball

is actually in the individual's field of view and should be a

relatively uncommon injury. The location of the scar will determine

the degree of interference with vision. Because night vision

apparatus electronically amplifies an image, it cannot transmit the

flash intensity and will not cause eye injury.

A-5. Physiological Effects of Ionizing Radiation

A nuclear burst results in four types of ionizing radiation:

neutrons, gamma rays, beta, and alpha radiation. The initial burst

is characterized by neutrons and gamma rays while the residual

radiation is primarily alpha, beta, and gamma rays. The effect

of radiation on a living organism varies greatly by the type of

radiation to which the organism is exposed. See Table A-8 for

characteristics of nuclear radiation.

_a._ Alpha particles are extremely massive, charged particles (four

times the mass of a neutron); they are a fallout hazard. Because of

their size, alpha particles cannot travel far and are fully stopped

by the dead layers of the skin or by the uniform. Alpha particles

are a negligible external hazard, but if inhaled or ingested, can

cause significant internal damage.

[Illustration: _Figure A-2. Threshold distance for minimal

chorioretinal burn and flash blindness versus yield (airburst) at

night._]

_Table A-8. Characteristics of Nuclear Radiation_

[Part 1]

+----------+-----------------+------------------+-------------------+

+----------+-----------------+------------------+-------------------+

| | | | |

+----------+-----------------+------------------+-------------------+

+----------+-----------------+------------------+-------------------+

| | | | |

+----------+-----------------+------------------+-------------------+

| | | | |

+----------+-----------------+------------------+-------------------+

[Part 2]

+----------+------------+--------------+---------------+-------------+

+----------+------------+--------------+---------------+-------------+

+----------+------------+--------------+---------------+-------------+

+----------+------------+--------------+---------------+-------------+

+----------+------------+--------------+---------------+-------------+

+----------+------------+--------------+---------------+-------------+

_b._ Beta particles are very light, charged particles that are

found primarily in fallout radiation. These particles can travel a

short distance in tissue; if large quantities are involved, they

can produce damage to the basal stratum of the skin. The lesion

produced is similar to a thermal burn (called a beta burn).

_c._ Gamma rays, emitted during the nuclear detonation and in

fallout, are uncharged radiation similar to X rays. They are highly

energetic and pass through matter easily. Because of its high

penetrability, radiation can be distributed throughout the body,

resulting in whole body exposure.

_d._ Neutrons, like gamma rays, are uncharged, are only emitted

during the nuclear detonation, and are not a fallout hazard.

However, neutrons have significant mass and interact with the

nuclei of atoms, severely disrupting atomic structures. Compared to

gamma rays, they can cause 20 times more damage to tissue.

_e._ When radiation interacts with atoms, energy is deposited

resulting in ionization (electron excitation). This ionization

may involve certain critical molecules or structures in a cell,

producing its characteristic damage. Two modes of action in the

cell are direct and indirect action. The radiation may directly

hit a particularly sensitive atom or molecule in the cell. The

damage from this is irreparable; the cell either dies or is caused

to malfunction. The radiation can also damage a cell indirectly by

interacting with water molecules in the body. The energy deposited

in the water leads to the creation of toxic molecules; the damage

is transferred to and affects sensitive molecules through this

toxicity.

_f._ The most radiosensitive organ systems in the body are the

male reproductive, the hematopoietic, and the gastrointestinal

systems. The relative sensitivity of an organ to direct radiation

injury depends upon its component tissue sensitivities. Cellular

effects of radiation, whether due to direct or indirect damage,

are basically the same for the different kinds and doses of

radiation. The simplest effect is cell death. With this effect,

the cell is no longer present to reproduce and perform its primary

function. Changes in cellular function can occur at lower radiation

doses than those that cause cell death. Changes can include

delays in phases of the mitotic cycle, disrupted cell growth,

permeability changes, and changes in motility. In general, actively

dividing cells are most sensitive to radiation. Additionally,

radiosensitivity tends to vary inversely with the degree of

differentiation of the cell.

_g._ Predicting radiation effects is difficult because often it

is unknown which organs were exposed. Thus, most predictions

are based on whole body irradiation. Partial body and specific

organ irradiation will occur due to shielding by equipment, from

fallout particles, or from internal deposition. Depending upon the

organ system, the irradiation can be severe. The severe radiation

sickness resulting from external, whole body irradiation and

its consequent organ effects is a primary medical concern. The

median lethal dose (LD) of radiation that will kill 50 percent

of the exposed persons within a period of 60 days (designated

as LD50/60) is estimated to be approximately 4.5 gray (Gy) if

appropriate medical care is not provided to the casualties.

Medical intervention should raise this figure to approximately 10

Gy. This larger figure includes most of the casualties who would

be actually capable of reaching medical care following a nuclear

detonation, and nearly all those who could be exposed to a RDD.

For acute effects of single high dose rate exposures of whole-body

irradiation to healthy adults see Table A-9.

_h._ Recovery of a particular cell system will occur if a

sufficient fraction of a given stem cell population remains after

radiation injury and appropriate stimulation and protection are

received. Complete recovery may appear to occur; however, the

immune system may repair incompletely with consequent greater

susceptibility to future insult from a variety of agents. It is

possible for late somatic effects to have a higher probability of

occurring because of the radiation damage. Efficacy of both prior

and future immunization in this group is not adequately understood.

_i._ Interactions between radiological injury and chemical or

biological agents appear to be synergistic. Insult by these

agents in radiologically injured personnel, even in individually

subclinical dosages, may result in significant clinical illness.

A-6. Handling and Managing Radiologically Contaminated Patients

_a._ _Radiologically Contaminated Patients._ Personnel from

contaminated areas may have fallout on their skin and clothing.

Although the individual will not be radioactive, he may

suffer radiation injury from the contamination. Removal of

the contamination should be accomplished as soon as possible;

definitely before admission into a clean treatment area. The

distinction must be made between a radiation-injured soldier and

one who is radiologically contaminated. Although personnel may

have received substantial radiation exposure, this exposure alone

does not result in the individual being contaminated. Contaminated

personnel do not pose a short-term hazard to the medical staff,

rather the contamination is a hazard to the individuals' health.

However, without patient decontamination, medical personnel may

receive sufficient exposure to create beta burns, especially with

extended exposure.

_b._ _Handling Radiologically Contaminated Patients._ To properly

handle radiologically contaminated personnel, medical personnel

must first detect the contamination. Detectors that may be used are

the AN/PDR27 and AN/VDR2 to monitor patients for contamination.

Generally, a reading on the meter twice the current background

reading indicates that the patient is contaminated. Monitoring

is conducted when potentially contaminated personnel arrive at

the MTF. This monitoring is conducted at the MTF's receiving

point before admitting the patient. Contaminated patients must

be decontaminated before admission. Removal of radiological

contamination is less important than immediate lifesaving treatment

and providing the best possible medical care. Lifesaving care

before decontamination is provided outside the MTF.

_c._ _Decontamination._ Removing all outer clothing and a brief

washing or brushing of exposed skin will reduce 95 percent of

contamination; vigorous bathing or showering is unnecessary. See

Appendix G for patient decontamination procedures.

_d._ _Internal Contamination._ Internalization of radioactive

isotopes will primarily occur via inhalation, ingestion, and

contaminated wounds. Extensive internal decontamination should

only be undertaken when individual dose estimates indicate that

the individual will benefit from the procedures. Soldiers who

wear their protective mask will be adequately protected from

inhalation and ingestion of radioactive particulate matter.

Internal contamination is considered a delayed problem and does not

influence triage categories, as does irradiation injury.

_e._ _Treatment._ Treatment procedures for radiation injuries are

described in FM 4-02.283, FM 8-9, and the NATO Handbook, _Emergency

War Surgery_. Appropriate medical intervention and bone marrow

resuscitation will prevent most deaths secondary to irradiation and

infection.

_Table A-9. Acute Clinical Effects of Single High Dose Rate

Exposures of Whole-body Irradiation of Healthy Adults_

[Part 1]

-----------------------++-----------+------------+

|| 0-100 cGy |100-1000 cGy|

DOSE (RANGE) || (SUB- | (SUBLETHAL |

|| CLINICAL | RANGE) |

|| RANGE) |------------+

|| |100-200 cGy |

----------+------------++-----------+------------+

|INCIDENCE || | |

|OF NAUSEA || NONE | 5-50% |

|& VOMITING || | |

+------------++-----------+------------+

|TIME OF || ---- | APPROX |

INITIAL |ONSET || | 3-6 HRS |

PHASE +------------++-----------+------------+

|DURATION || ---- | LESS THAN |

| || | 24 HRS |

+------------++-----------+------------+

| || | |

|COMBAT || | |

|EFFECT- || 100% | 100% |

| IVENESS || | |

| || | |

----------+------------++-----------+------------+

LATENT |DURATION || ---- | MORE THAN |

PHASE | || | 2 WEEKS |

----------+------------++-----------+------------+

|SIGNS & || | MODERATE |

|SYMPTOMS || NONE |LEUKOPENIA |

+------------++-----------+------------+

|TIME OF || | |

|ONSET POST || ---- |2 WEEKS OR |

SECONDARY |EXPOSURE || | MORE |

PHASE +------------++-----------+------------+

|CRITICAL || | |

|PERIOD POST || ---- | NONE |

|EXPOSURE || | |

+------------++-----------+------------+

|ORGAN || | |

|SYSTEM || NONE | |

|RESPONSIBLE || | |

----------+------------++-----------+------------+

HOSPITAL- |PERCENTAGE || NONE |LESS THAN 5%|

IZATION +------------++-----------+------------+

|DURATION || ---- | 45-60 DAYS |

----------+------------++------------------------+

INCIDENCE OF DEATH || NONE | NONE |

-----------------------++-----------+------------+

AVERAGE TIME OF DEATH || ---- | ---- |

-----------------------++-----------+------------+

|| | REASSURANCE|

THERAPY || NONE | HEMATOLOGIC|

|| |SURVEILLANCE|

-----------------------++-----------+------------+

[Part 2]

-----------------------++--------------------+--------------------------+

|| 100-1000 cGy (SUBLETHAL RANGE) |

DOSE (RANGE) || |

||--------------------+--------------------------+

|| 200-600 cGy | 600-1000 cGy |

----------+------------++--------------------+--------------------------+

|INCIDENCE || | |

|OF NAUSEA || 50-100% | 75-100% |

|& VOMITING || | |

+------------++--------------------+--------------------------+

|TIME OF || APPROX 2-4 HRS | APPROX 1-2 HRS |

INITIAL |ONSET || | |

PHASE +------------++--------------------+--------------------------+

|DURATION || LESS THAN 24 HRS | LESS THAN 48 HRS |

| || | |

+------------++--------------------+--------------------------+

| ||CAN PERFORM ROUTINE |CAN PERFORM ONLY SIMPLE |

|COMBAT ||TASKS. SUSTAINED |ROUTINE TASKS. SIGNIFICANT|

|EFFECT- ||COMBAT OR COMPARABL |INCAPACITATION IN UPPER |

| IVENESS ||ACTIVITIES HAMPERED |PART OF RANGE. LASTS MORE |

| ||FOR 6-20 HRS. |THAN 24 HRS. |

----------+------------++--------------------+--------------------------+

LATENT |DURATION || APPROX 7-15 DAYS | NONE TO APPROX 7 DAYS |

PHASE | || | |

----------+------------++--------------------+--------------------------+

|SIGNS & || SEVERE LEUKOPENIA; PURPURA, HEMORRHAGE; |

|SYMPTOMS || INFECTION; EPILATION ABOUT 300 cGy. |

+------------++--------------------+--------------------------+

|TIME OF || |

|ONSET POST || SEVERAL DAYS TO 2 WEEKS |

SECONDARY |EXPOSURE || |

PHASE +------------++-----------------------------------------------+

|CRITICAL || |

|PERIOD POST || 4-6 WEEKS |

|EXPOSURE || |

+------------++-----------------------------------------------+

|ORGAN || |

|SYSTEM || HEMATOPOIETIC TISSUE |

|RESPONSIBLE || |

----------+------------++--------------------+--------------------------+

HOSPITAL- |PERCENTAGE || 90% | 100% |

IZATION +------------++--------------------+--------------------------+

|DURATION || 60-90 DAYS | 90-120 DAYS |

----------+------------++--------------------+--------------------------+

INCIDENCE OF DEATH || 0-80% | 90-100% |

-----------------------++--------------------+--------------------------+

AVERAGE TIME OF DEATH || 3 WEEKS TO 2 MONTHS |

-----------------------++-----------------------------------------------+

|| |

THERAPY || BLOOD TRANSFUSION, ANTIBIOTICS |

|| |

-----------------------++-----------------------------------------------+

[Part 3]

-----------------------++------------------------+----------------------+

|| OVER 1000 cGy (LETHAL RANGE) |

DOSE (RANGE) || |

||------------------------+----------------------+

|| 1000-3000 cGy | OVER 3000 cGy |

----------+------------++------------------------+----------------------+

|INCIDENCE || |

|OF NAUSEA || 100% |

|& VOMITING || |

+------------++-----------------------------------------------+

|TIME OF || LESS THAN 1 HR |

INITIAL |ONSET || |

PHASE +------------++------------------------+----------------------+

|DURATION || LESS THAN 48 HRS | APPROX 48 HRS |

| || | |

+------------++-----------------------------------------------+

| ||PROGRESSIVE INCAPACI- |PROGRESSIVE INCAPACI- |

|COMBAT ||TATION FOLLOWING AN |TATION FOLLOWING AN |

|EFFECT- ||EARLY CAPABILITY FOR |EARLY CAPABILITY FOR |

| IVENESS ||INTERMITTENT HEROIC |INTERMITTENT HEROIC |

| ||RESPONSE. |RESPONSE. |

----------+------------++------------------------+----------------------+

LATENT |DURATION || NONE TO APPROX 2 DAYS | NONE |

PHASE | || | |

----------+------------++------------------------+----------------------+

|SIGNS & ||DIARRHEA; FEVER; DISTUR-|CONVULSIONS; TREMOR |

|SYMPTOMS ||BANCE OF ELECTROLYTE |ATAXIA; LETHARGY. |

| ||BALANCE. | |

+------------++------------------------+----------------------+

|TIME OF || | |

|ONSET POST || 2-3 DAYS | |

SECONDARY |EXPOSURE || | |

PHASE +------------++------------------------+----------------------+

|CRITICAL || | |

|PERIOD POST || 5-14 DAYS | 1-48 HR |

|EXPOSURE || | |

+------------++------------------------+----------------------+

|ORGAN || | |

|SYSTEM || GASTROINTESTINAL TRACT |CENTRAL NERVOUS SYSTEM|

|RESPONSIBLE || | |

----------+------------++------------------------+----------------------+

HOSPITAL- |PERCENTAGE || 100% | 100% |

IZATION +------------++------------------------+----------------------+

|DURATION || 2 WEEKS | 2 DAYS |

----------+------------++------------------------+----------------------+

INCIDENCE OF DEATH || 90-100% |

-----------------------++------------------------+----------------------+

AVERAGE TIME OF DEATH || 1-2 WEEKS | 2 DAYS |

-----------------------++------------------------+----------------------+

|| MAINTENANCE OF | |

THERAPY || ELECTROLYTE BALANCE | SEDATIVES |

|| | |

-----------------------++------------------------+----------------------+

A-7. Radiological Patients in Stability Operations and Support

Operations

In stability operations and support operations, high levels

of environmental contamination and the use of RDD can cause

radiological injury to personnel at levels below that necessary

to produce performance decrement and traditional casualty status.

Treatment and evacuation guidelines will be in accordance with

command guidance. Individual physical dosimetry is the most

expedient measurement technique for this exposure (see Table A-10).

These radiation injuries and effects may also be seen in war;

especially, from hostile forces employment of RDDs.

_Table A-10. Stability Operations and Support Operations: Radiation

Injuries and Effects of Radiation Exposure of Personnel_

========================================================================

RADIATION TOTAL STOCHASTIC RISK

EXPOSURE CUMULATIVE LONG-TERM MEDICAL NOTE MEDICAL ACTIONS

STATUS DOSE HEALTH EFFECTS

------------------------------------------------------------------------

0 <0.05 cGy NORMAL RISK. US BASELINE 20% RECORD IN EXPOSURE

LIFETIME RISK OF RECORD IF NORMALLY

FATAL CANCER. MONITORED PERSONNEL.

------------------------------------------------------------------------

1A 0.05 TO UP TO 0.04% NONE (0.001 Sv US RECORD AS HISTORY IN

0.5 cGy INCREASED ANNUAL GEN. POP. MEDICAL RECORD--

RISK LIFETIME EXPOSURE LIMIT.) TACTICAL OPERATION

FATAL CANCER. EXPOSURE.

------------------------------------------------------------------------

1B 0.5 TO 5 cGy US RADIATION REASSURANCE RECORD IN MEDICAL

OCCUPATIONAL (0.05 Sv US RECORD--

RISK. ANNUAL TACTICAL OPERATION

0.04%-0.4% OCCUPATIONAL EXPOSURE.

INCREASED RISK LIMIT.)

LIFETIME CANCER.

------------------------------------------------------------------------

1C 5 TO 10 cGy 0.4%-0.8% COUNSEL REGARDING RECORD IN MEDICAL

INCREASED RISK INCREASED LONG- RECORD--

LIFETIME FATAL TERM RISK. TACTICAL OPERATION

CANCER. NO LIVE VIRUS EXPOSURE.

VACCINES X

3 MONTHS.

------------------------------------------------------------------------

1D 10 TO 25 cGy 0.8%-2% POTENTIAL FOR INC- RECORD IN MEDICAL

INCREASED RISK REASED MORBIDITY RECORD--

LIFETIME FATAL OF OTHER INJURIES TACTICAL OPERATION

CANCER. OR INCIDENTAL EXPOSURE. CONSIDER

DISEASE. <2% ROUTINE EVACUATION

INCREASED LIFETIME FROM THEATER IAW

RISK OF FATAL COMMANDER'S OPER-

CANCER. ATIONAL GUIDANCE.

------------------------------------------------------------------------

1E 25 TO 75 cGy 2%-5.6% INCREASED MORBIDITY RECORD IN MEDICAL

INCREASED RISK OF OTHER INJURIES RECORD--

LIFETIME FATAL OR INCIDENTAL TACTICAL OPERATION

CANCER. DISEASE. <6% EXPOSURE. CONSIDER

INCREASED LIFETIME EXPEDITED EVACU-

RISK OF FATAL ATION FROM THEATER

CANCER. IAW COMMANDER'S

OPERATIONAL

GUIDANCE.

========================================================================

A-8. Effects of Biological Weapons

Biological warfare is the intentional use, by an enemy, of live

agents or toxins to cause death and disease among personnel,

animals, and plants, or to deteriorate materiel.

_a._ _Live Agents._

(1) Live agents are living organisms like viruses, bacteria,

and fungi. They can be delivered directly (artillery or

aircraft spray), or through a vector such as a flea or tick.

Advances in modern weaponizing of biological agents have become

easier.

(2) For some agents, only a few organisms are needed to cause

infection. Live agents are small and light; they can be spread

great distances by the wind and contaminate unfiltered or

nonairtight places.

(3) Aerosolized particles of 1 to 5 micron (μ) size carrying

live agents are small and light. They require time after

they are ingested to multiply enough to overcome the body's

defenses. This incubation period may vary from hours to days or

weeks depending on the type of organism. Thus, to be effective,

a live agent attack would need to be launched well in advance

of a tactical assault.

(4) These agents are sensitive to environmental conditions (for

example humidity and sunlight). Many bacterial agents will not

survive outside the host organism (human and animals).

(5) Live agents are not detectable by any of the five physical

senses; usually the first indication of a biological attack

is the ill personnel. The diseases caused by live agents may

be difficult to control when the aerosol attack is directed

against a large population. Some diseases may be transmitted

from person-to-person after the initial attack; examples

include plague, smallpox, and some viral hemorrhagic fevers.

(6) Because of their incubation period and life cycle, likely

areas for live agent use are in the combat service support

(CSS) area; but attacks in forward areas cannot be ruled out.

_b._ _Spore Forming Biological Agents._ Spore formers such as

anthrax can survive for an extended time, even under very adverse

environmental conditions (dry, extremes of temperatures, and

flooding). Once inhaled, ingested, or injected into the human body,

the spores germinate and produce the illness.

_c._ _Toxins._

(1) Toxins are by-products (poisons) produced by plants,

animals, or microorganisms. It is the poisons that harm man,

not the organisms that make the toxins. In the past, the

only way to deliver toxins on a large scale was by using the

organism. With today's technology large quantities of many

toxins can be produced; thus, they can be delivered without the

accompanying organism.

(2) Toxins have several desirable traits. They are poisonous

compounds that do not grow, reproduce, or die after they have

been dispersed; they are more easily controlled than live

organisms. Field monitors capable of providing prompt warning

of a toxin attack are not available; therefore, personnel must

learn to quickly recognize signs of attack, such as observing

unexplained symptoms of victims. Toxins produce effects similar

to those caused by chemical agents; however, the victims

will not respond to the first-aid measures that work against

chemical agents. Unlike live agents, mycotoxins (T2) can

penetrate intact skin; other toxins cannot. Because the effects

on the body are direct, the symptoms of an attack may appear

very rapidly. The potency of most toxins is such that very

small doses will cause injuries and/or death. Thus, their use

by an enemy may be an alternative to chemical agents because

it allows the use of fewer resources to cover the same or a

larger area. Slight exposure at the edges of an attack area

may produce severe symptoms or death from exposure to toxins

because of their extreme toxicity. Lethal or injury downwind

hazard zones for toxins may be far greater than those of CW

agents.

A-9. Behavior of Biological Weapons

Biological agents can be disseminated in a spectrum of physical

states. They may be living microorganisms or spore forms of the

organism. See Table A-11 for stability of various biological

agents. They may be spread by--

· Arthropods.

· Contact with infected animals.

· Contamination of food and water.

· Aerosol, liquid, or solid dispersion.

The only requirement is that they must be stable enough to survive

transport and dissemination. The toxicity of biological agents

is not the same for everyone; each individual does not react

exactly the same way to the same amount of an agent. Some are more

resistive than others because of race, sex, age, or other factors.

The dose is the quantity of a biological agent received by the

subject. The penetration of agents by various routes need not be

accompanied by irritation or damage to the absorbent surface. There

are often unique signs and identifying symptoms depending on entry

route (inhalation, ingestion, or dermal).

_a._ Biological agents dispersed by spray often enter the body

through the respiratory tract (inhalation injury). The agent may be

absorbed by any part of the respiratory tract from the mucosa of

the nose and mouth to the alveoli of the lungs.

_b._ Liquid droplets and (less commonly) solids may be absorbed

from the surface of the skin, digestive tract, and mucous

membranes. Agents penetrating the skin may form temporary

reservoirs under the skin.

_c._ Contaminated food and water can produce casualties when

ingested.

_Table A-11. Types and Characteristics of Some Biological Agents_

=========================================================================

ENTRANCE

TYPE OF AGENT STABILITY INCUBATION TIME AEROSOL NONAEROSOL

-------------------------------------------------------------------------

ANTHRAX HIGH HOURS TO 7 DAYS INHALATION SKIN, MOUTH

-------------------------------------------------------------------------

BOTULINUM TOXIN HIGH 24 TO 36 HOURS INHALATION MOUTH, WOUND

-------------------------------------------------------------------------

BRUCELLOSIS HIGH IN 1 TO 4 WEEKS INHALATION MOUTH, SKIN,

WET ENV- EYES

IRONMENT

-------------------------------------------------------------------------

CHOLERA MODERATE HOURS TO 5 DAYS MOUTH

-------------------------------------------------------------------------

PLAGUE(PNEUMONIC) LOW 2 TO 4 DAYS INHALATION

-------------------------------------------------------------------------

PLAGUE (BUBONIC) MODERATE 2 TO 10 DAYS BITE OF VECTOR

-------------------------------------------------------------------------

RICIN HIGH <36 HOURS INHALATION MOUTH

-------------------------------------------------------------------------

SMALLPOX HIGH 7 TO 17 DAYS INHALATION LESION CONTACT

-------------------------------------------------------------------------

STAPHYLOCOCCAL HIGH 1 TO 6 HOURS INHALATION MOUTH

ENTEROTOXIN B

-------------------------------------------------------------------------

TRICHOTHECENE HIGH MINUTES TO HOURS INHALATION MOUTH, SKIN

MYCOTOXIN

-------------------------------------------------------------------------

TULAREMIA LOW 2 TO 10 DAYS INHALATION MOUTH, SKIN,

BITE OF VECTOR

-------------------------------------------------------------------------

VENEZUELAN EQUINE MODERATE 1 TO 6 DAYS INHALATION BITE OF VECTORS

ENCEPHALITIS

-------------------------------------------------------------------------

VIRAL HEMORRHAGIC LOW DAYS TO MONTHS INHALATION BITE OF VECTORS

FEVERS

=========================================================================

A-10. Management of Biological Warfare Patients

_a._ _Management._ Management of patients suffering from the

effects of BW agents may include the need for isolation. Barrier

nursing for patients suspected of suffering from exposure to

BW agents will reduce the possibility of spreading the disease

to health care providers and other patients. Specimens must be

collected and submitted to the designated supporting laboratory for

identification. For details on hospital infection control aspects

of managing BW casualties, see FM 8-284.

_b._ _Mass Casualty._ A BW agent attack can produce a mass casualty

situation at all levels of HSS. A major problem with a BW mass

casualty situation is that HSS personnel are more susceptible to

becoming a casualty to BW agents. Also, the ill patient may be the

first indicator that a BW agent has been dispersed.

_c._ _Decontamination._ Decontamination is an individual and unit

responsibility. However, some individuals may arrive at the MTF

that have not been decontaminated or that become contaminated en

route to the MTF. These individuals must be decontaminated at the

MTF before they are admitted to prevent contamination of the MTF

and exposure of medical personnel to the biological agent. See

Appendix G for details on patient decontamination.

_d._ _Treatment._ Specific treatment is dependent upon the BW agent

used. Patients are treated for symptomatic presentation unless the

BW agent identity is known. Field Manuals 8-9 and 8-284 provide

detailed information on medical management and treatment.

A-11. Effects of Chemical Weapons

_a._ A chemical agent is a chemical that is used to kill, seriously

injure, or incapacitate man because of its physiological effects.

They can be disseminated by artillery, aircraft, rocket, or by

nonconventional means used by terrorists. When first employed in

combat during World War I, the chemical weapon (chlorine) was so

effective that the attacking Germans were not prepared to exploit

the success.

_b._ Chemical agents are very effective weapons against poorly

trained and equipped forces; however, they are less effective

against well-trained forces.

A-12. Behavior of Chemical Weapons

Chemical agents can be disseminated as a gas, vapor, or aerosol

under ambient conditions. They have a range of odors varying

from none to highly pungent characteristics. Their stability

is dependent upon the environmental conditions in the area of

employment. See Table A-11 for persistency of various chemical

agents.

_a._ The toxicity of a chemical agent is not the same for everyone;

each individual does not react exactly the same way to the same

amount of an agent. Some are more resistant than others because

of physiological factors. The dose is the quantity of a chemical

received by the individual for percutaneous or oral doses and

as a time-weighted concentration, milligrams-minute (m3), for

inhalation. It is usually expressed as milligrams of agent per

kilogram of subject body weight (mg/kg). The LD50 is the dose that

kills 50 percent of the exposed population. The incapacitation dose

50 (ID50) is the incapacitation dose for 50 percent of the exposed

subjects. The penetration of agents by various routes need not be

accompanied by irritation or delayed superficial damage to the

absorbent surface, but there are often unique signs and symptoms

identifiable by the route of entry.

(1) Gaseous, vapor, and aerosol chemical agents often enter the

body through the respiratory tract (inhalation injury). The

agent may be absorbed by any part of the respiratory tract from

the mucosa of the nose and mouth to the alveoli of the lungs.

Aerosol particles larger than 5 μ tend to be retained in the

upper respiratory tract; particles in the 1 to 5 μ range are

retained in the deep volume of the lungs; while those below

1 μ tend to be breathed in and out again; although a few are

retained in the deep volume of the lungs.

(2) Vapors and droplets of liquids can be absorbed from the

surface of the skin and mucous membranes. Toxic compounds that

are harmful to the skin can produce their effects in liquid or

solid state. Agents penetrating the skin may form temporary

reservoirs under the skin; the vapors of some volatile liquids

can penetrate the skin and cause intoxication. Additionally,

wounds and abrasions may present areas that are more permeable

than intact skin.

_b._ Chemical agents may be divided into two main categories

(persistent and nonpersistent) that describe how long they are

capable of producing casualties. Table A-12 lists the common

chemical agents, their effects and time of effectiveness. Table

A-13 lists the types and characteristics of common chemical agents.

(1) Persistent agents continue to present a hazard for

considerable periods (days) after delivery by remaining as a

contact hazard, or by slowly vaporizing to produce a hazard by

inhalation.

(2) Nonpersistent agents disperse rapidly after release and

present an immediate, short duration (hours) hazard. They are

released as airborne particles, aerosols, and gases.

_Table A-12. Common Chemical Warfare Agents_

=========================================================================

COMMON NAME EFFECT TIME TO EFFECT

-------------------------------------------------------------------------

TABUN (GA) INHALATION: SECONDS TO MINUTES

SARIN (GB) LETHAL NERVE AGENTS TOPICAL: MINUTES

SOMAN (GD) INGESTION: MINUTES TO HOURS

V-AGENTS

-------------------------------------------------------------------------

HYDROGEN CYANIDE LETHAL BLOOD AGENT MINUTES

-------------------------------------------------------------------------

MUSTARD BLISTER AGENTS 1 TO 12 MINUTES

LEWISITE MINUTES

-------------------------------------------------------------------------

LSD AND BZ INCAPACITATING AGENTS 15 TO 60 MINUTES

-------------------------------------------------------------------------

PHOSGENE LUNG-DAMAGING (CHOKING) MINUTES

CHLORINE SECONDS TO MINUTES

=========================================================================

_Table A-13. Types and Characteristics of Chemical Agents_

[Part 1]

================================================================

TYPE OF PERSISTENCE RATE OF

AGENT SYMBOL SUMMER WINTER ACTION

----------------------------------------------------------------

GA, GB, GD 10 MIN-24 HR 2 HR-3 DAYS VERY QUICK

=NERVE= -------------------------------------------------------

VX 2 DAYS-1 WK 2 DAYS-WEEKS QUICK

----------------------------------------------------------------

=CHOKING= CG, DP 1-10 MIN 10 MIN-1 HR IMMEDIATE

----------------------------------------------------------------

HD, HN 3 DAYS-1 WK WEEKS SLOW

------------------------------------------------------

=BLISTER= L, HL 1-3 DAYS WEEKS QUICK

------------------------------------------------------

CX DAYS DAYS VERY QUICK

----------------------------------------------------------------

=BLOOD= AC, CK 1-10 MIN 10 MIN-1 HR VERY QUICK

================================================================

[Part 2]

================================================================

TYPE OF ENTRANCE

AGENT SYMBOL VAPOR/AEROSOL LIQUID

----------------------------------------------------------------

GA, GB, GD EYES, LUNGS EYES, SKIN, MOUTH

=NERVE= -------------------------------------------------------

VX EYES, LUNGS EYES, SKIN, MOUTH

----------------------------------------------------------------

=CHOKING= CG, DP LUNGS EYES

----------------------------------------------------------------

HD, HN EYES, SKIN, LUNGS EYES, SKIN

------------------------------------------------------

=BLISTER= L, HL EYES, SKIN, LUNGS EYES, SKIN, MOUTH

------------------------------------------------------

CX EYES, LUNGS, SKIN EYES, SKIN, MOUTH

----------------------------------------------------------------

=BLOOD= AC, CK EYES, LUNGS EYES, MOUTH,

INJURED SKIN

================================================================

A-13. Characteristics of Chemical Agents

The effectiveness of a chemical agent is a measure of how much

agent is required to produce the desired effect. Thus, an agent

that is toxic at a lower dose than another similar agent is more

effective. Besides dose required for a given effect, persistency

may be used to measure effectiveness. Persistency depends on the

agent's physical characteristics, the amount of agent delivered,

its physical state, weapons system used, the terrain, and weather

in the target area. The desired effects will determine the

physical, chemical, and toxicological properties of the chemical

agent employed.

_a._ Nerve agents are primarily organophosphorus esters similar to

insecticides. Those of military importance are combined under this

term. Although some have been given names, they are usually known

by their code letters: GA; GB; GD; and VX. They are all liquids,

varying in volatility that is in a range between gasoline and heavy

lubricating oil. Their freezing points are -40 degrees Celsius or

lower.

(1) Liquid nerve agents are pale yellow to colorless and are

almost odorless. They are moderately soluble in water and

highly soluble in lipids (oil). They are rapidly destroyed by

strong alkalies and chlorinating compounds. Normal clothing

is readily penetrated by liquid or vapor agents. Butyl rubber

and synthetic material are more resistant than natural fibers.

Agents can penetrate into nonabsorbent material such as web

belts and can continue to present a hazard by desorption

(off-gassing) of the vapor. Although local sweating and

twitching may occur, usually there is no local irritant change

after cutaneous exposure. Toxicity depends upon the route of

entry and physical characteristics.

(2) Nerve agents strongly inhibit the cholinesterase enzymes.

When acetylcholine is released by the nerve junction, it

is hydrolyzed by the enzyme. Acetylcholine is the chemical

mediator for transmission of the nerve impulses in numerous

synapses of the central nervous system (CNS) and the autonomic

nervous system and at the endings of the cholinergic nerves

(for example: affecting the smooth muscles of the iris,

ciliary, bronchial tree, and gastrointestinal tract). The

inhibition of cholinesterase by nerve agents is almost

irreversible, so the effects are prolonged. Until the

cholinesterase level is restored to normal, there is an

increased susceptibility to nerve agent exposure. During this

time, the effects of repeated exposure are cumulative and the

patient may feel "subpar" (for example: tired, fatigue easily,

poor appetite, impaired concentration) until recovery is

complete.

(3) Nerve agent poisoning is easily identified by the

characteristic signs and symptoms as follows:

(_a_) =MILD= symptoms (self-aid). Casualties with MILD symptoms may

experience most or all of the following:

· Unexplained runny nose.

· Unexplained sudden headache.

· Sudden drooling.

· Difficulty in seeing (dimness of vision) (miosis).

· Tightness in the chest or difficulty in breathing.

· Localized sweating and muscular twitching in the contaminated

area.

· Stomach cramps.

· Nausea.

(_b_) Casualties with =MODERATE= symptoms (buddy aid) will

experience an increase in the severity of most or all of the MILD

symptoms. Especially prominent will be an increase in fatigue,

weakness, and muscle fasciculations. The progress of symptoms from

MILD to MODERATE indicates either inadequate atropine treatment or

continuing exposure to agent.

(_c_) =SEVERE= symptoms (buddy aid). Casualties with SEVERE

symptoms may experience most or all of the MILD symptoms, plus most

or all of the following:

· Strange or confused behavior.

· Wheezing, dyspnea (severe difficulty in breathing), and

coughing.

· Severely pinpointed pupils.

· Red eyes with tearing.

· Vomiting.

· Severe muscular twitching and general weakness.

· Involuntary urination and defecation.

· Convulsions.

· Unconsciousness.

· Respiratory failure.

_b._ There are three major families of blister agents (vesicants);

HD and HN, L, and CX. Most vesicants (except CX) are relatively

persistent. Mustards can modify the structure of nucleic acids,

cellular membranes, and proteins by combining with certain

functional groups (particularly the sulfhydryl-containing enzymes)

for which they have an affinity.

(1) The cutaneous syndrome is divided into four phases: latent,

erythema, vesication, and necrosis. Vesicants can penetrate the

skin by contact with either liquid or vapor. The latent period

is characteristic of the agent. For mustards it is usually

several hours, for L it is short, and for CX it is negligible.

The latent period is also affected by the dose, temperature,

and humidity. The symptoms of the erythema phase are red,

painful itching followed by painful necrosis that heals slowly.

(2) In the eyes, vesicants produce intense pain and

photophobia. Blistering of the eyelids and mucous membranes can

result in temporary blindness. Even after recovery, scars on

the cornea can reduce visual acuity.

(3) In the respiratory tract, these agents attack the mucous

membranes irritating them. They can paralyze vocal chords and

can lead to chemical pneumonitis, or possibly death.

(4) Although blister agents can affect other organs and produce

deleterious effects, the skin, eyes, and respiratory tract are

the principle organs effected.

_c._ Chemical agents that attack lung tissue (choking agents) and

cause pulmonary edema are classed as lung damaging agents. Choking

agents consist of CG and DP, CL, and PS. Phosgene is typical of the

lung-damaging agents; it is used as the example here.

(1) Phosgene is a colorless gas that has an odor resembling new

mown hay. Although effects are primarily confined to the lungs,

phosgene may also cause mild irritation of the eyes and upper

respiratory tract. Phosgene causes a shift in the membrane

potential of the alveoli allowing the passage of fluid into

the alveoli, resulting in massive pulmonary edema and severely

impairing the exchange of oxygen (O_{2}) and carbon dioxide

(CO_{2}) between the capillary blood and the alveolar air.

(2) Initially hypoxemia occurs and is followed shortly by

hyperventilation when the frothy edema fluid fills the

bronchioli and CO_{2} expiration stops.

(3) Signs and symptoms during and immediately following

exposure are coughing, tightness of chest, nausea, occasionally

vomiting, headache, and lacrimation (tearing).

_d._ Blood agents consist of AC and CK; both are readily absorbed

by the mucous membranes and the intact skin. The odor of AC

resembles bitter almonds, but many people cannot detect it.

Detecting the odor of CK is difficult because of its irritating

and lacrimatory effects. It is also poorly absorbed by the metallic

salt-impregnated charcoal filters in the protective mask. These

agents inhibit certain enzymes (particularly cytochrome oxidase)

that are important for oxidation-reduction in the cells; therefore,

cell respiration is inhibited and oxygen carried by the hemoglobin

is not consumed causing the venous blood to remain bright red.

Initial symptoms are characterized by violent convulsions,

increased deep respiratory movements, followed by cessation of

respiration within one minute, slowing of heart rate to death. High

concentrations exert their effects rapidly; however, if the patient

is still alive after the cloud has passed, he will probably recover

spontaneously.

_e._ Incapacitating agents are chemicals that produce a temporary

disabling condition that persists for hours to days after exposure

to the agent has ceased (unlike that produced by riot control

agents). While not required, medical treatment produces a more

rapid recovery. Characteristics of these agents are that they--

· Are highly potent and logistically feasible.

· Produce their effects mainly by altering or disrupting the

higher regulatory activity of the CNS.

· Produce effects that last for hours or days rather than

momentary or fleeting.

· Do not seriously endanger life, except in exceedingly high

doses.

· Produce no permanent injury.

The two types likely to be encountered are CNS depressants and CNS

stimulants.

(1) Central nervous system depressants are compounds that have

a predominant effect of depressing or blocking the activity

of the CNS; often by interfering with the transmission of

information across synapses. An example of this type of agent

is BZ. The action of acetylcholine, both peripherally and

centrally, appears to be blocked by BZ. Low doses disrupt

higher integrative functions of memory, problem solving,

attention, and comprehension. High doses produce toxic delirium

that destroys the ability to perform any military task. Within

the CNS, BZ seems to produce its effects in the same way as

atropine. Small doses cause sleepiness and decreased alertness

with elevated heart rate, dry skin and eyelids, drowsiness,

increased pupil size, and elevated skin temperatures.

Progressive intoxication is marked by an inability to respond

effectively to the environment (4 to 12 hours), followed by

increasing activity and random/unpredictable behavior (12 to 96

hours). Because the patient cannot sweat, heat stress becomes a

problem.

(2) Central nervous system stimulants are agents that cause

excessive nervous activity, often by boosting or facilitating

transmission of impulses across synapses. The effect is

to "flood" the cortex and other higher regulatory centers

with too much information, making concentration difficult

and causing indecisiveness and an inability to act. These

include LSD, psilocybin, and mescaline. Intoxication shows

sympathetic stimulation (rapid heart rate, sweaty palms,

pupillar enlargement, and cold extremities) and mental

excitation (nervousness, trembling, anxiety, and inability to

relax or sleep); feelings of tension, exhilaration, heightened

awareness, paranoid ideas, and profound states of terror may

also occur.

A-14. Management of Chemical Agent Patients

_a._ _Management._ Movement of chemical agent casualties can spread

the contamination to clean areas. All casualties are decontaminated

as far forward as the situation permits. All patients must be

decontaminated before they are admitted into a clean MTF. The

admission of one contaminated patient into an MTF will contaminate

the facility; thereby reducing its treatment capabilities.

_b._ _Mass Casualty._ A mass casualty situation is presented

when chemical agents are employed. Additional HSS personnel and

equipment must be provided in a short period of time if the level

of care is to be maintained. Treatment at far forward MTFs is

limited to life- or limb-saving care. Patients that can survive

evacuation to the next level of care are not treated at the forward

facility. This provides time for treating those patients that

cannot survive the evacuation time.

_c._ _Decontamination._ Decontamination is an individual and unit

responsibility. However, some individuals may arrive at the MTF

that have not been decontaminated or that become contaminated en

route to the MTF. These individuals must be decontaminated at the

MTF before they are admitted to prevent contamination of the MTF

and exposure of medical personnel to the chemical. See Appendix G

for detailed information on patient decontamination procedures.

_d._ _Treatment._ Field Manuals 8-9 and 8-285 provide treatment

procedures for chemical agent patients.

A-15. Management of Toxic Industrial Material Patients

_a._ _Management._ Movement of TIM casualties can spread the

contamination to clean areas. All casualties are decontaminated

as close to the incident site as possible. All patients must be

decontaminated before they are admitted into a clean MTF. The

admission of one contaminated patient into an MTF may contaminate

the facility; thereby reducing its treatment capabilities.

_b._ _Mass Casualty._ A mass casualty situation is presented when

the number of casualties exceeds the capabilities of medical

personnel at the location to provide needed care at the incident

site. Treatment at the incident site is limited to life- or

limb-saving care. Patients that can survive are evacuated to the

nearest MTF with a patient decontamination capability.

_c._ _Decontamination._ Decontamination is an individual and

first responder responsibility. However, some individuals that

self evacuated or were evacuated due to the mass casualty

situation arrive at the MTF that have not been decontaminated.

These individuals must be decontaminated at the MTF before they

are admitted to prevent contamination of the MTF and exposure of

unprotected medical personnel and other patients to the TIM. See FM

8-500 for detailed information on decontamination procedures for

TIM contaminated casualties.

_d._ _Treatment._ Field Manual 8-500 provides treatment procedures

for some TIM casualties. Treatment for many TIM casualties is agent

specific and receiving MTFs must be prepared for these events.

EXAMPLE: Treatment for a casualty exposed to toxic levels of an

inorganic phosphate pesticide would be treated in the same manner

as a nerve agent casualty except the amount of antidote for the

pesticide poisoned casualty will be many times greater than for the

nerve agent casualty.

APPENDIX B

SAMPLE/SPECIMEN COLLECTION AND MANAGEMENT

Section I. INTRODUCTION

B-1. General

_a._ Critical elements for accuracy in analysis of NBC samples

and physiological specimens are correct collecting, packaging,

handling, and transporting techniques. The quality of any

analytical evaluation is directly related to the quality of the

sample/specimen and the degree of postcollection degradation that

occurs prior to testing. Health service support personnel collect

and submit specimens for suspect NBC hazards/agents involving

humans and animals. Chemical corps and other nonmedical units

collect and submit environmental (air, plant, and soil) samples for

suspect NBC hazards/agents. Preventive medicine personnel collect

and submit water and ice samples for suspect NBC hazards/agents.

Veterinary personnel collect and submit food samples, such as

fruits and vegetables, and specimens from animals for suspect

NBC hazards/agents. Specimens collected from patients that are

suspect of being exposed to a biological agent are forwarded to the

supporting medical laboratory (such as the TAML, AML or US Navy

Forward Deployed PVNTMED Unit) for analysis.

_b._ Essentially all military operations from war to stability

operations and support operations may generate medical laboratory

testing requirements. Each scenario, geographical region,

population base, and suspect agent will impact on the type

and amount of samples/specimens required and the collection

process. During all operations, express permission is required

before collecting specimens from civilians because of religious

or sociological beliefs in many cultures. To obtain such

specimens without permission could result in unnecessary mission

complications.

NOTES

1. The term "sample" refers to nonhuman and nonanimal origin.

The term "specimen" refers to human and animal origin.

2. Always consider that chemical agents may have been employed.

Check for chemical agents before collecting a biological

sample/specimen. Chemical agents can damage or destroy

biological agents. Also, chemical agents not identified in

the sample/specimen can pose a hazard to receiving laboratory

personnel. Mark all samples that are potentially contaminated

with chemical agents as such.

3. Precautions should be taken to protect the sample/specimen

collector from potential BW agents; at a minimum, respiratory

protection and rubber gloves must be worn. Additional care

must be taken when collecting samples/specimens to prevent

cross-contamination. Gloves must be changed or decontaminated

between sample/specimen collections.

4. Samples will not be delivered to the clinical laboratory of

an MTF for analysis. They must be delivered to the designated

supporting medical laboratory for processing. This will prevent

accidentally spreading a biological agent in the MTF.

_c._ Coordination for follow-on testing is absolutely critical to

the sample/specimen collection process.

_d._ Coordination with the receiving laboratory should be made to

establish sample requirements, preferred collection techniques,

methods of preservation, and transportation conditions, when the

tactical situation and/or mission permits.

_e._ The number of medical specimens that need to be collected

varies with the type of analysis performed and the impact

of the values determined. The number and types of "control"

samples/specimens required to validate test information is

determined by the supporting medical laboratory personnel. Random

sampling, matched with control populations, or other techniques

will be employed as the requirements are identified.

B-2. Sample/Specimen Background Information

_a._ A complete history of the circumstances about each

sample's/specimen's acquisition must be provided to the agency

conducting the analysis.

_b._ Critical information includes, but is not limited to--

· Meteorological conditions. Describe what the meteorological

conditions were at the time of the alleged attack and at the

time of the sampling.

· Attack to collection time. State the length of time after

alleged attack when sample/specimen was taken.

· Circumstances of acquisition. Describe how the

sample/specimen was obtained and the source of the

sample/specimen.

· Physical description. Describe the physical state of the

sample/specimen (solid, liquid, powder, apparent viscosity),

color, approximate size, identity of the sample/specimen

(that is, dirt, leaves, blood, tissue), and dose rate (if

radiologically contaminated).

· Circumstances of the agent deposition. Describe the

type of delivery system, a description of how the weapon

functioned, how the agent acted on release, sounds heard during

dissemination, a description of any craters or shrapnel found

associated with the burst, and colors of smoke, flames, or

mists that may be associated with the attack.

· Agent effects on vegetation. Describe the general area

(jungle, mountain, grassland) and changes in the vegetation

after the agent deposition (that is, color change, wilting,

drying, dead) in the main attack and fringe areas.

· Agent effects on humans. How the agent affected personnel

in the main attack area versus fringe areas; the duration of

agent effects; peculiar odors that may have been noticed in the

area before, during, or after an attack; measures taken that

alleviated or worsened the effects; and the approximate number

of victims and survivors (include age and gender).

· Agent effects on animals. Describe how they are affected.

· Grid coordinates or other descriptive information on sample

collection location.

B-3. Sample/Specimen Collection and Preservation

_a._ _Ante mortem Specimens._ Physiological specimens from living

human or animal patients can include just about any conceivable

body source or excreted by-product. It must be noted that specimen

types are seldom interchangeable; the exact type and amount of

specimen required for a specific assay must be known before a

collection procedure is initiated (see Table B-1).

· Patients seen in an MTF may be the first and in some cases

the only source for sampling for suspect biological agent

release. The primary medical care provider will determine

the level of treatment for these patients and the specimens

required for laboratory diagnosis. The MTF laboratory is

not equipped to handle biological agents and, therefore,

specimens generated will be forwarded to the supporting medical

laboratory for analysis. Patient disposition will be based

on evacuation policies, exposure, suspect agent, clinical

symptoms, and required treatment/isolation.

· Blood specimens represent the most common analytical sample.

Certain techniques and special care must be exercised to ensure

an acceptable specimen is collected and to minimize an adverse

affect to the patient or specimen collector. In general,

phlebotomy requires the use of a 20 to 22-gauge needle to

minimize mechanical hemolysis during aspiration using a syringe

or Vacutainer^{TM} tube collection system. Blood collected with

a syringe and needle should be transferred to an appropriate

Vacutainer^{TM} tube immediately after collection. The type

of tube, type of anticoagulant or preservative, and amount of

blood collected will vary with the specific assay requested.

Unless some special sample preparation step is required, the

blood is best left in the original rubber-stopper tube for

transport.

· Urine specimens are best collected using a clean-catch

(midstream, if possible) technique in a sterile urine cup. The

volume of sample required will vary depending on the specific

assay requested; however, 25 to 50 ml is sufficient for most

tests.

· Tissue specimens can originate from any body source

accessible by scraping, swabbing, or minor excision. Tissue

specimens are collected only by medical trained personnel.

Specific techniques for collecting these specimens are not

provided in this appendix.

· Sputum specimens are best collected using a sterile cup. The

volume of specimen will normally be very small. However, a

sufficient quantity must be collected to provide for in-theater

testing and to provide for CONUS laboratory testing.

· Nasal swabs should be collected using sterile cotton-tipped

swabs. The swabs with specimen from each person should

be placed in a separate sterile container to prevent

cross-contamination.

NOTE

In cases where the supporting laboratory cannot be contacted,

as a minimum the following specimens should be collected:

Urine--25 to 50 ml in a sterile container. Blood--two

7 to 10 ml tubes without anticoagulant (red-stopper

Vacutainer^{TM}); two 7 to 10 ml tubes with potassium or

sodium ethylenediaminetetraacetate (EDTA) (lavender-stopper

Vacutainer^{TM}).

· All specimens (regardless of physiological source) must be

labeled to positively identify the individual or animal from

whom it was collected; at a minimum, the individual's full

name, unique personal identification number (social security

number, when possible), military unit and location, and date

and time of collection should be written on the label of the

specimen container.

· All specimens are collected using aseptic techniques. All

specimens are packaged, handled, and transported in a manner

that ensures they arrive at the final destination laboratory

in a testable condition. Personal protection guidelines must

be adhered to when collecting or processing specimens; at a

minimum, this includes gloves and a mask. In the laboratory,

a gown or other protective items may also need to be used. In

the field, under suspect NBC conditions, collectors should be

in MOPP Level 4 or inside NBC-protected vehicles. Common sense

and the clinical and/or tactical situation will determine the

extent of personal protection necessary.

· Preservation of specimens, either chemically or mechanically

(cooling), will be necessary to minimize the amount of analyte

degradation that occurs after removing the specimen from its

physiological microenvironment. The optimal preservation

technique will vary with different laboratory tests and must

be confirmed for each requested assay. While freezing may

preserve some serum constituents, freeze-thawing cycles may

denature others. Freezing may also completely destroy certain

microorganisms. This caution also applies to tissue specimens

since "fixing" tissue with a standard 10 percent formalin

solution will preserve tissue for special staining techniques;

however, it renders the specimens completely useless for

microbiological culture. Always verify specimen preservation

requirements for storage and transport with the supporting

medical laboratory before processing the specimen. Ideally,

confirmation of the correct handling conditions should be

coordinated before collection.

· The importance of coordinating sample/specimen collection

with the supporting laboratory facility cannot be overstated.

Contact the receiving laboratory for instructions when

doubt exists about the appropriate source, collection

technique, storage and preservation conditions (such as,

aerobic or anaerobic environment), and transportation

requirements for samples/specimens. Extremely small volumes of

samples/specimens, properly collected and handled, can yield a

tremendous amount of information to assist in making medical,

tactical, and strategic decisions. Conversely, very large

quantities of poorly collected and insufficiently preserved

samples/specimens are essentially worthless for most analytical

techniques.

· Analysis beyond intratheater capabilities will be coordinated

by the supporting laboratory, when deployed, or through medical

channels in the absence of an in-theater supporting laboratory.

_b._ _Post mortem and Forensic Specimens._ The analysis

of specimens from deceased humans and animals can provide

valuable information about the disease, organisms, injuries, or

environmental conditions at the time of death. This information

can greatly enhance the treatment of others affected by the same,

or physiologically similar, process. Specimen collection for post

mortem or forensic examination is very important; the techniques

involved reflect a significant degree of training, experience, and

skill. Most specimens will be of the same type and size as for

ante mortem specimens, but types and amounts of specimens will be

determined by the collector.

(1) The collection of specimens from remains should be

conducted exclusively by a pathologist, or other personnel

specifically trained in forensic collection techniques. An

exception is when Special Operations Forces (SOF) personnel are

operating under radio silence conditions; the most qualified

medical person with the operation collects, preserves,

and transports or coordinates transport of specimens for

evaluation. The same chain of custody requirements applies

to specimens collected by SOF personnel, as with all other

specimens.

(2) A large amount of support information can be gained by

analyzing the site of injury and subsequent death. This "site

scene" investigation requires a tremendous attention to detail

and a trained observer. If forensic personnel cannot be

contacted, or will be unduly delayed in arriving at the scene,

then photographs of the victim and the immediate surroundings

should be made. The scope and extent of the photographs should

be composed to reflect as much detail as possible to assist

forensic personnel in reviewing the scene retrospectively.

In the event that photography is not feasible, detailed

sketches of the scene should be made to assist the forensic

investigation.

(3) Techniques such as cardiac or bladder puncture, needle

biopsy of organs, spinal tap, or exploratory laparotomy will

not be performed by untrained personnel unless specifically

requested and directed by forensic investigators.

_Table B-1. Specimen Collection for Suspect Biological Warfare

Agents_

========================================================================

EARLY POSTEXPOSURE CLINICAL

CONVALESCENT/TERMINAL/POSTMORTEM

------------------------------------------------------------------------

=ANTHRAX=

_0 TO 24 HOURS._ _24 TO 72 HOURS._

NASAL AND THROAT SWABS, AND SERUM (TT OR RT) FOR TOXIN ASSAYS.

INDUCED RESPIRATORY SECRETIONS BLOOD (E, C, H) FOR PCR.

FOR CULTURE, FA, AND PCR. BLOOD (BC OR C) FOR CULTURES.

_3 TO 10 DAYS._

SERUM (TT OR RT) FOR TOXIN ASSAYS.

BLOOD (BC OR C) FOR CULTURE.

PATHOLOGY SPECIMENS.

------------------------------------------------------------------------

=PLAGUE=

_0 TO 24 HOURS._ _24 TO 72 HOURS._

NASAL SWABS, SPUTUM, AND BLOOD (BC AND C) FOR CULTURE AND

INDUCED RESPIRATORY SECRETIONS BLOODY SPUTUM (C) FOR FA. SERUM

FOR CULTURE, FA, (TT OR RT) FOR F-1 ANTIGEN ASSAYS.

AND PCR. BLOOD (E, C, OR H) FOR PCR.

_>6 DAYS._

SERUM (TT OR RT) FOR IgM,

LATER FOR IgG.

PATHOLOGY SPECIMENS.

------------------------------------------------------------------------

=TULAREMIA=

_0 TO 24 HOURS._ _24 TO 72 HOURS._

NASAL SWABS, SPUTUM, AND BLOOD (BC OR C) FOR CULTURE.

INDUCED RESPIRATORY BLOOD (E, C, OR H) FOR PCR.

SECRETIONS FOR CULTURE, FA, SPUTUM FOR FA AND PCR.

AND PCR. _>6 DAYS._

SERUM (TT OR RT) FOR IgM AND

LATER IgG, AGGLUTINATION TITERS.

PATHOLOGY SPECIMENS.

------------------------------------------------------------------------

=MELIOIDOSIS/GLANDERS=

_0 TO 24 HOURS._ _24 TO 72 HOURS._

NASAL SWABS, SPUTUM, AND BLOOD (BC OR C) FOR CULTURE.

INDUCED RESPIRATORY BLOOD (E, C, OR H) FOR PCR.

SECRETIONS FOR CULTURE AND SPUTUM AND DRAINAGE FROM SKIN

PCR. LESIONS FOR PCR AND CULTURE.

_>6 DAYS._

BLOOD (BC OR C) AND TISSUE FOR

CULTURE.

SERUM (TT OR RT) FOR

IMMUNOASSAYS.

PATHOLOGY SPECIMENS.

------------------------------------------------------------------------

=BRUCELLOSIS=

_0 TO 24 HOURS._ _24 TO 72 HOURS._

NASAL SWABS, SPUTUM, AND BLOOD (BC OR C) FOR CULTURE.

INDUCED RESPIRATORY BLOOD (E, C, AND H) FOR PCR.

SECRETIONS FOR CULTURE AND _>6 DAYS._

PCR. BLOOD (BC OR C) AND TISSUE FOR

CULTURE.

SERUM (TT OR RT) FOR

IMMUNOASSAYS.

PATHOLOGY SPECIMENS.

------------------------------------------------------------------------

=Q FEVER=

_0 TO 24 HOURS._ _2 TO 5 DAYS._

NASAL SWABS, SPUTUM, AND BLOOD (BC OR C) FOR CULTURE IN EGGS

INDUCED RESPIRATORY OR MOUSE INOCULATION.

SECRETIONS FOR CULTURE AND BLOOD (E, C, AND H) FOR PCR.

PCR. _>6 DAYS._

BLOOD (BC OR C) FOR CULTURE IN

EGGS OR MOUSE INOCULATION.

PATHOLOGY SPECIMENS.

------------------------------------------------------------------------

=BOTULISM=

_0 TO 24 HOURS._ _24 TO 72 HOURS._

NASAL SWABS AND INDUCED NASAL SWABS AND RESPIRATORY

RESPIRATORY SECRETIONS FOR SECRETIONS FOR PCR (CONTAMINATING

PCR (CONTAMINATING BACTERIAL DNA) AND TOXIN ASSAYS.

BACTERIAL DNA) AND TOXIN _>6 DAYS._

ASSAYS. USUALLY NO IgM OR IgG.

SERUM (TT OR RT) FOR TOXIN PATHOLOGY SPECIMENS (LIVER AND

ASSAYS. SPLEEN FOR TOXIN DETECTION).

------------------------------------------------------------------------

=RICIN INTOXICATION=

_0 TO 24 HOURS._ _36 TO 48 HOURS._

NASAL SWABS AND INDUCED SERUM (TT OR RT) FOR TOXIN

RESPIRATORY SECRETIONS FOR ASSAY.

PCR (CONTAMINATING CASTOR TISSUE FOR IMMUNOHISTOLOGICAL

BEAN DNA) AND TOXIN ASSAYS. STAINING.

SERUM (TT OR RT) FOR TOXIN PATHOLOGY SPECIMENS.

ASSAYS. _>6 DAYS._

SERUM (TT OR RT) FOR IgM AND IgG

IN SURVIVORS.

------------------------------------------------------------------------

=STAPH ENTEROTOXICOSIS=

_0 TO 3 HOURS._ _2 TO 6 HOURS._

NASAL SWABS AND INDUCED URINE FOR IMMUNOASSAYS.

RESPIRATORY SECRETIONS FOR NASAL SWABS AND INDUCED

PCR (CONTAMINATING BACTERIAL RESPIRATORY SECRETIONS FOR

DNA) AND TOXIN ASSAYS. PCR (CONTAMINATING BACTERIAL

SERUM (TT OR RT) FOR TOXIN DNA) AND TOXIN ASSAYS.

ASSAYS. SERUM (TT OR RT) FOR TOXIN

ASSAYS.

_>6 DAYS._

SERUM FOR IgM AND IgG.

------------------------------------------------------------------------

=T-2 TOXICOSIS=

_0 TO 24 HOURS POSTEXPOSURE_ _1 TO 5 DAYS._

NASAL AND THROAT SWABS AND SERUM (TT OR RT) AND TISSUE FOR

INDUCED RESPIRATORY TOXIN DETECTION.

SECRETIONS FOR IMMUNOASSAYS, _>6 DAYS POSTEXPOSURE._

HPLC/MASS SPECTROMETRY. URINE FOR DETECTION OF TOXIN

METABOLITES.

------------------------------------------------------------------------

=EQUINE ENCEPHALOMYELITIS=

(VEE, EEE, AND WEE VIRUSES) _24 TO 72 HOURS._

_0 TO 24 HOURS._ SERUM (TT OR RT) AND THROAT FOR

NASAL SWABS AND INDUCED CULTURE.

RESPIRATORY SECRETIONS FOR SERUM (E, C, H, TT, OR RT) FOR

RT-PCR AND VIRAL CULTURE. RT-PCR. THROAT SWABS UP TO 5 DAYS

FOR CULTURE THEN CSF.

SERUM (TT OR RT) FOR ANTIGEN

ELISA.

_>6 DAYS._

SERUM (TT OR RT) FOR IgM.

PATHOLOGY SPECIMENS PLUS BRAIN.

------------------------------------------------------------------------

=POX=

(SMALLPOX AND MONKEYPOX) _2 TO 5 DAYS._

_0 TO 24 HOURS._ SERUM (TT OR RT) FOR VIRAL

NASAL SWABS AND INDUCED CULTURE

RESPIRATORY SECRETIONS FOR _>6 DAYS._

PCR AND VIRAL CULTURE. SERUM (TT OR RT) FOR VIRAL CULTURE

DRAINAGE FROM SKIN LESIONS/

SCRAPINGS FOR MICROSCOPY, EM,

VIRAL CULTURE, AND PCR.

PATHOLOGY SPECIMENS.

------------------------------------------------------------------------

=EBOLA=

_0 TO 24 HOURS._ _2 TO 5 DAYS._

NASAL SWABS AND INDUCED SERUM (TT OR RT) FOR VIRAL

RESPIRATORY SECRETIONS FOR CULTURE.

RT-PCR AND VIRAL CULTURE. _>6 DAYS._

SERUM (TT OR RT) FOR VIRAL CULTURE

PATHOLOGY SPECIMENS PLUS ADRENAL

GLAND.

------------------------------------------------------------------------

=LEGEND:=

BC Blood culture

C Citrated blood

CSF cerebrospinal fluid

DNA deoxyribonucleic acid

E EDTA

EEE eastern equine encephalitis

ELISA enzyme-linked immunosorbent assay

EM electron microscopy

F-1 fraction-1

FA fluorescent antibody

H Heparin

HPLC high-pressure liquid chromatography

IgG immunoglobulin class G

IgM immunoglobulin class M

PCR polymerase chain reaction

RT Red Top, if TT is not available

RT-PCR reverse transcriptase/polymerase chain reaction

TT Tiger top

VEE Venezuelan equine encephalitis

WEE western equine encephalitis

=========================================================================

_c._ _Water Sample Collection._

(1) Water samples for identification or verification of

biological agent contamination are collected by PVNTMED

personnel. The supporting laboratory should provide guidance on

sampling procedures and collecting kits for use in collecting

the samples. In the absence of guidance, a technique for use of

the Sep-Pak^{TM} is described in FM 3-19.

(2) When sampling kits are not available, samples may be

collected in other available sterile containers. The best

containers for use are the 100-ml glass bottles used for

collecting routine water samples. All water samples must be

collected and placed in a cooler or refrigerator until the

sample is transported to its destination. During transportation

the samples must be maintained at a temperature between 1°C and

4°C.

_d._ _Food Samples._ Veterinary personnel must collect suspect

biologically contaminated food samples for submission to the

supporting laboratory for in-theater verification of contamination.

All food samples must be collected and placed in sterile

containers. Place the samples in a cooler or refrigerator until the

sample is transported to its destination. During transportation the

samples must be maintained at a temperature between 1°C and 4°C.

_e._ _Animal Specimens._ Veterinary personnel collect specimens

from suspect biologically contaminated/diseased animals. The same

types and amounts of specimens are prepared and shipped in the same

manner as are human specimens.

_f._ _Environmental Samples._ Environmental samples are collected

as directed in the operators' manual or other publications for

operating collection systems. Example: The Biological Integrated

Detection System (BIDS) collects an environmental sample using a

single liquid sample collector. The collector is a high-volume

aerosol sampling and collection device. On demand it samples

ambient air through a two-stage virtual impactor that concentrates

aerosol particles in the 2 to 10 micrometer diameter-size range.

The concentrate particle stream is directed through a wet collector

containing a buffer solution and, over a 45-minute period, a 40 to

50 ml sample is collected. On order or when test results indicate

a suspected agent, the sample and associated documentation are

packaged and transported IAW FM 3-101-4.

B-4. Chain of Custody

_a._ A strict chain of custody must be maintained for every

sample/specimen collected. Use DD Form 1911 (Material

Courier Receipt), or other document (such as DA Form 4137

[Evidence/Property Custody Document]) as directed for each

sample/specimen collected. The chain of custody document must

accompany the sample/specimen during transport from the point

of collection to the final receiving laboratory. Each time the

sample/specimen is transferred to another individual, the receiving

person must sign the document to show that they received the

sample/specimen and state what happened to the sample/specimen

while in their custody. The document will provide the answer to the

following questions:

· When was the sample/specimen collected?

· Who has maintained custody of the sample/specimen?

· What has been done with the sample/specimen at each change of

custody?

_b._ The samples/specimens must be appropriately packaged, labeled,

and evacuated to the designated medical laboratory for confirmation

of a biological attack. The standard chain of custody for the

evacuation would be as follows:

· Sampling unit.

· Unit S2/security office or medical operations officer.

· Technical escort unit or other command-designated escort

personnel.

· In-theater supporting medical laboratory.

· Designated CONUS laboratory.

Section II. SAMPLING TECHNIQUES AND PROCEDURES

B-5. General

The collection of environmental, and background (control)

samples/medical specimens is an integral part of investigating

allegations pertaining to the first use of chemical or biological

agents. The types of samples/specimens taken and the collection

methods primarily depend upon the circumstances encountered by the

collector. During all chemical and biological sampling operations,

the commander establishes the required protective equipment to

fit the situation. This appendix includes a recommended list

of equipment for use during chemical and biological sampling

operations (Table B-2).

_Table B-2. Example NBC Collection and Shipping Equipment List_

======================================================================

AMOUNT DESCRIPTION STOCK NUMBER

----------------------------------------------------------------------

20 LABELS, PAPER, PRESSURE SENSITIVE 7530-00-577-4376

2 GLOVES, 8-8½, EDMONT WILSON^{TM} 8415-00-JO2-2902

2 GLOVES, 9-9½, EDMONT WILSON^{TM} 8415-00-634-4639

1 TAPE, ADHESIVE, PRESSURE SENSITIVE, 2 INCH 7510-00-159-4450

1 PLIERS, #47, 5 INCHES 6520-00-543-5330

1 SCREWDRIVER, FLAT TIP, ¼ INCH 5120-00-596-865

1 TONGS, TEFLON^{TM} TIPS AF 15-202-5

2 MICROSPATULA, WITH TEFLON^{TM} ENDS AF 21-401-50A

1 SCISSORS, UNIVERSAL TYPE AF 08-951-30

1 SCOOP, POLYPROPYLENE, 5X2X2 ASP S1021-5

2 SPOON/SPATULA WITH TEFLON^{TM} AF 14-356-10

1 KNIFE, POCKET 5110-00-526-8740

5 BOTTLES, SAMPLE, POLYETHYLENE, 6 OUNCE CP J-6103-50

1 PIPET, JUMBO, TRANSFER TYPE (500/PKG) AF 13-711-7

10 PIPET, GRADUAL, TRANSFER TYPE (500/PKG) AF 13-711-9A

10 BAG, INSULATED, TYPE I AF 01-814-8

10 BAG, INSULATED, TYPE 2[*] AF 01-814-10

1 BAG, WHIRL/PAK, 6 OUNCE (500/PKG) AF 01-812-6B

1 STRIP, pH TESTING, NONBLEEDING, PLASTIC SW S-65271

1 SEP-PAK^{TM} C18 W51910 (50/BOX)

2 SYRINGE, HYPODERMIC, 50 OR 60 ml 6515-00-168-6913

2 STOPCOCK, THREE-WAY ASP S8965-2

1 TUBING, LABORATORY, R3602 CLEAR AF 14-169-3B

1 PEN, MARKING, WATERPROOF AF13-381 (12/PKG)

2 TUBES, TENAX^{TM} EC ST-023

1 BLADE, SURGICAL, CS2L 150S 6515-01-009-5297

2 PACK, ICE CP TR-6345-20

6 PAD, NONADHESIVE, 3X4, 100s 6510-00-111-0708

4 PAD, COOLING, CHEMICAL, 4S 6530-00-133-4299

2 PIGLETTES SPECIAL ORDER

1 TAPE, ANTISEIZE 8030-00-889-3535

1 AIR SAMPLER, PERSONAL LSS G4980

1 KIT, METRIC, POCKET BUBBLE GL4981

2 METHANOL

1 WATER, DISTILLED (5 BOTTLE/PKG)

1 MATCHES, WATERPROOF

20 RAZOR, SURGICAL PREP 6515-00-926-2089

10 WATCH, WRIST 6645-00-066-4279

2 PARAFILM WITH DISPENSER 6640-01-185-3289

2 FLOOR SWEEP (VERMICULITE) 8720-01-026-9419

100 SEALS, TAMPER-RESISTANT

1 A GAS METER CAPABLE OF PROVIDING

ON-STATION ANALYSIS/DETECTION CAPABILITY

FOR MULTIPLE GASES TO INCLUDE INDUSTRIAL

GASES.

1 A COMBUSTIBLE GAS INDICATOR THAT INDICATES

PERCENTAGE OF OXYGEN AND EXPLOSIVITY.

1 A GAS METER THAT DETECTS VAPOR IN PARTS

PER MILLION (PPM) AND INDICATES PRESENCE

OF VAPOR AND ITS STRENGTH.

1 SWABS, THROAT

2 CAN, 6 POUND, METAL

10 BAG, MYLAR

1 CONTAINER, LEAD SHIELDING (FOR RADIATION

SAMPLES)

1 CONTAINER, SHIPPING, IATA

1 CHEST, ICE

10 BAG, PLASTIC, RECLOSABLE

[*] WILL BE REPLACED BY MYLAR BAGS

======================================================================

B-6. Expended Material

The NBC recon units collect samples under various circumstances.

For example, a recon unit may collect samples in an area free of

hostile forces. The Special Forces NBC Reconnaissance team may

collect samples within the enemy area of operations or deep into

the enemy's rear area. Samples include toxic agent munitions,

chemical products, air, water, soil, and vegetation. In addition,

all expended material used to collect the samples should be turned

in to the laboratory with the samples. This material includes items

such as expended M256A1 kits, M8 and M9 paper. These items should

be recovered, packaged, and shipped with the suspected samples for

analysis. Different information may be derived from each type of

sample; Table B-3 compares different types of samples.

B-7. Environmental Samples

Control or background samples that are collected from clean samples

must be identical to the samples collected from the areas near the

attack areas as baseline data. The contaminated samples must be

compared to the baseline data (control samples). This is especially

true if unknown or nonstandard chemical and/or suspected biological

agents were employed. The analysis center uses the control samples

to compare with a contaminated one. The recon unit collects control

samples of soil, water, and vegetation from areas about 500 meters

upwind of an alleged attack area. Control samples generically are

the same as those collected in an alleged attack area. For example,

if leaves from an apple tree in an attack area were collected as

a suspected contaminated sample, the recon team should collect

leaves (as a control sample) from an apple tree outside of the

contaminated area. If water from a pond in the attack area is

collected, the recon unit should collect control samples of water

from a pond (not a moving stream) in a nearby clean area. The size

of an environmental control sample should be about the same as the

suspected contaminated sample collected from the attack area (see

Table B-4, page B-20).

_Table B-3. Comparison of Sample Types_

======================================================================

SAMPLE STABILITY ANALYSIS

SAMPLE TYPE INFO VALUE TO COLLECT TIME REQUIRED RELIABILITY

----------------------------------------------------------------------

AIR GOOD GOOD 20 MIN HIGH

WATER GOOD GOOD 5 MIN HIGH

SOIL FAIR FAIR 5 MIN MODERATE

VEGETATION FAIR POOR 10 MIN LOW

TISSUE EXCELLENT FAIR 30 MIN HIGH

BLOOD GOOD FAIR 10 MIN HIGH

URINE GOOD FAIR 10 MIN HIGH

MUNITION FRAGMENTS FAIR FAIR 10 MIN FAIR

PACKING MATERIALS FAIR FAIR 10 MIN FAIR

======================================================================

B-8. Collection of Air and Vapor Samples

_a._ Air is a good sample matrix since it is a well-mixed medium.

Air from a sample site contains a static concentration of

contaminants. The concentration of contaminants depends upon the

flow rate of the contaminant into the environment, the wind speed,

and the physical state of the contaminant, the terrain contours,

and temperature as a variable. The sample should be taken within

102 meters of a contaminated surface and at the downwind edge of

a contaminated area. The method should consist of pumping a given

volume of air, by hand or electric pump, through sample tubes.

_b._ To avoid contamination, persons conducting air sampling should

not use cologne, perfume, insect repellent, medical creams, or

strong soaps before taking a sample. The fragrances from these

products are volatile organic compounds that may be absorbed on the

filter and skew analytical results. Smoke also severely interferes

with air sampling, therefore, avoid tobacco and vehicle exhaust

smoke.

_c._ The primary method for collecting air samples is with the PAS

1000 automatic air sampler in conjunction with a Tenax^{TM} tube

for a total of three to four minutes when possible. Upon completion

of sampling, place the Tenax^{TM} tube in a 2¼-inch piglette.

Seal the piglette around the cap with either pressure-sensitive

or Teflon^{TM} tape. Once sealed, place the piglette into a Mylar

or reclosable bag. Fold the bag around the piglette in a circular

motion, then apply another bag and fold again. Once the bag is

folded around the piglette, use any type tape to secure the bag

around the piglette. Place the piglette into a refrigerator or

cooler until the sample is transported to its destination.

_d._ When chemicals are permitted into the atmosphere from a

facility, the best places to obtain samples are close to the

emission source where the concentration of the chemical is not

diluted. The further from the original point of release, the

more diluted the sample becomes from mixing with air, water, or

environmental pollutants.

_e._ Natural and man-made terrain features such as hills, valleys,

and rows of buildings, sometimes aid the collector by channeling

emissions. When these features are associated with a particular

facility, their downwind side is a suitable place to collect a

sample because the emission remains more concentrated further from

the release point.

_f._ For collection in a possibly contaminated location, and if

the situation permits, initially use a detection kit such as

the M18A2/M256AI to determine if a possible vapor hazard exists

from known chemical agents. Also, use the kit when personnel

are required to examine possible toxic agent munitions. In any

case, collect air samples with the white-band tubes and save for

identification and analysis.

_g._ Small air samplers also enable the collector to obtain vapor

samples from alleged toxic agent munitions at a safe distance while

explosive ordnance disposal (EOD) operations are performed. If EOD

personnel are not on the scene, the air sampler can be activated,

and the collector can stand at a safe distance while the sampler is

operating.

_h._ Perform sampling operations as soon as possible when directed

by a higher headquarters or after suspected chemical or biological

contamination is encountered.

B-9. Collection of Water Samples

_a._ Water sampling is a matter of collecting enough water to get

acceptable information about the contaminants. The collector should

provide the analysis center with one C18 and one silica cartridge

when using the Sep-Pak^{TM} technique or 100 ml in a sterile bottle

when Sep-Pak^{TM} is not available.

_b._ General guidelines: If it is believed that the threat has used

standard chemical agents during an attack, use the M272 chemical

agent water test kit for initial screening and sampling.

_c._ When collecting water samples using the Sep-Pak^{TM} C18

cartridge, the following items are required:

· One 60 cc syringe without needle.

· One 3-way sterile, plastic, stopcock with protective covers.

· One piece of plastic tubing (3/16" inner diameter × 6" long

minimum).

· Sterile water or methanol.

· One clean container, such as a Teflon^{TM} cup or glass jar.

_d._ Prior to collecting each sample, prime the Sep-Pak^{TM} system

in the following manner:

· =Step 1.= Attach Sep-Pak^{TM} directly to 60 cc syringe.

· =Step 2.= Pour small amount of sterile water or methanol into

container.

· =Step 3.= Insert tip of Sep-Pak^{TM} into container.

· =Step 4.= Withdraw at least 40 cc of solution.

· =Step 5.= Detach Sep-Pak^{TM} from syringe and discard

solution from syringe.

· =Step 6.= Repeat steps 3 through 5 using the same syringe.

_e._ After priming the Sep-Pak^{TM}, assemble the components in the

following configuration:

· Attach the 3-way stopcock to a 60 cc syringe.

· Attach the Sep-Pak^{TM} to the opposite end of stopcock.

· Attach the plastic tubing to the open end of the Sep-Pak^{TM}.

_f._ Use the following procedures to collect samples with

Sep-Pak^{TM}:

· =Step 1.= Ensure that the lever on the stopcock is turned

sideways with the off arrow pointed toward the large outlet

port.

· =Step 2.= Place the open end of the plastic tubing into the

water near the bottom, without touching the bottom or sides of

the body of water.

· =Step 3.= Draw 60 cc of water into the syringe.

· =Step 4.= Turn the stopcock lever to the off position by

positioning the lever to point toward the stopcock.

· =Step 5.= Push the plunger all the way in, discharging the

water from the syringe through the outlet port.

· =Step 6.= Repeat steps 1 through 5.

· =Step 7.= Detach a plastic tubing from the Sep-Pak^{TM}, and

discard it as contaminated waste.

· =Step 8.= Detach Sep-Pak^{TM} from 3-way stopcock; place into

sample container; seal with pressure-sensitive tape; and mark

for Identification.

NOTE

You should take a minimum of four samples: three samples of the

suspected contamination and one control sample from a nearby

unaffected (none contaminated) area for reference.

· =Step 9.= Dispose of the syringe and stopcock as contaminated

waste.

· =Step 10.= Insert the sample container in a cooler or

refrigerator until the sample is transported to its destination.

_g._ For samples to be representative of the overall contaminated

area, the collection point should be carefully selected. Collect

samples from--

· Drains and slow-moving streams, since contamination and

dilution from other sources are minimized.

· Stagnant pools of water if the pools of water are part of

chemical waste areas, such as a landfill or chemical disposal

area. Chemicals may percolate into stagnant pools or sumps

close to the site.

NOTE

If an oil film, globules of organic materials, or an unnatural

appearing powder-like material is visible on the water's

surface, collect a surface sample of the material. If not,

collect the sample from near the bottom of the water source

(stream, lake, pond, water container). The upper layers of

water may have lesser amounts of contaminants, due to higher

temperatures that promote decomposition. Since most chemicals

of interest are more dense than water, contaminants usually

sink to the bottom of the water source.

_h._ Collect the sample without the Sep-Pak^{TM} by immersing

a capped or stoppered container to the desired depth, removing

the cap or stopper, letting the container fill, and then capping

the container. An alternate method for deeper water is to use a

plastic, pump-operated siphon to pump water from a specific depth.

_i._ The best time to collect a sample of water from a location

is when intelligence or local reports indicate that a process of

possible interest is ongoing. In the absence of reliable reporting,

this may be indicated by increased activity, higher than normal

amounts of security, or increased flow from facility chimneys or

water discharge pipes. In field areas where a toxic agent has been

sprayed or disseminated over a land area, the best time to collect

water samples is just after the start of a rainstorm when runoff is

beginning. Natural surface drainage will concentrate any remnants

of toxic compounds in depressions, streams, or ditches.

B-10. Collection of Soil Samples

Soil is a suitable medium to collect as samples for toxic organic

compounds. A critical point, however, is that the precise site

of the agent deposition must be sampled for best results.

Contamination may be recognized by discoloration or apparent

deposition of material on the soil's surface. If discoloration or

deposits of material are evident, only collect the discolored soil

or deposited materials, if possible. Dead, malformed, and wilted

foliage is an indicator of contamination. Soil samples should be

collected from open areas, along the drip line tents, stationary

equipment, bottom of ditches and terrain depressions.

_a._ Collect the soil samples by using a knife, spoon, spatula,

or similar item to scrape a square of topsoil (2×5×1 centimeters)

from areas that appear to have been contaminated in to a collection

container. If chunks or clods of earth are collected, select those

that are no larger than 10×5×1 centimeters (see Table B-4). Also,

collect a control sample of soil of the same type and texture from

a nearby uncontaminated area.

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