Respiratory problems in

mass casualties - what

do we need to know?
None of us is as smart as all of us.
Leroy Robert "Satchel" Paige (July 7,
1906June 8, 1982)

RESPIRATORY GATE
GATE

Chlorine
smallpox

H1N1

Chlorine

Inhaled drugs

Suspect and protect

PRINCIPLES

Remove and decon

Treat and or transport

Suspect chemical exposure if :

the patient change significantly after exposure
there are symptoms which BEGAN (first
symptom, even if mild) within 48 hours of a
chemical exposure
the first exposure symptom/(s) get better away
from exposure
the type of symptom consistent with the chemical

Suspect Biological Agents if :

Severe disease manifestations in previously
healthy people
Higher than normal number of patients with
fever and respiratory/G.I. Complaints
Multiple people with similar complaints from
a common location

An endemic disease appearing during

an unusual time of year
Greater numbers of patients with:

Severe pneumonia

Sepsis or Sepsis with coagulopathy

Fever with rash

Diplopia with progressive weakness

PROTEC
T

Protect your personnel and the patient

from further exposure. Appropriate
and available and use of PPE

REMOVE
DECONTAMINATE
Remove and Decontaminate
at the field, or
at the ED facilities.
Victims are contaminated, but usually
they dont contaminate if the
therapist not come in direct contact
with the agent.
agent.

TREAT/TRANSPORT
Treat according the diagnoses, and
the physical condition of the person,
even guided by suspicion and clinical
diagnoses as laboratory investigation
is not always available.
Transport to an appropriate facility if
available

Chemicals agents

Chemicals agents
Latent period
 Depending chemical attributes, weather, ecc

Symptoms not different from the usual

come across on ED

Chemical agents
the patient change significantly after
exposure
there are symptoms which BEGAN
(first symptom, even if mild) within 48
hours of a chemical exposure
the first exposure symptom(s) get
better away from exposure
the type of symptom consistent with
the chemical

First symptoms
Lung agents

Cough , dizziness nose/lung irritation

blister

Cough, hoarseness, and wheezing

Nerve

Bronchoconstriction ,

Blood

Tachypnea , hypertension respiratory

depression , bradycardia

Biological agents

Why to choose
 Easy to obtain - Inexpensive to produce
 Potential dissemination over large geographic
area
 Creates panic - Can overwhelm medical services
 High morbidity and mortality
 Difficult to diagnose and/or treat
 Some are transmitted person-to-person via
aerosol

Category A

Greatest potential for widespread panic and social disruption

Variola major
(Smallpox)
Bacillus anthracis
(Anthrax)
Yersinia pestis
(Plague)
Clostridium botulinum (Botulism)
Francisella tularensis
(Tularemia)
Ebola hemorrhagic fever
Marburg hemorrhagic fever
Lassa fever
Argentine hemorrhagic fever

Category B

Coxiella burnetti
(Q fever)
Brucella species
(brucellosis)
Burkholderia mallei
(glanders)
Venezuelan encephalomyelitis
Eastern and Western equine
encephalomyelitis
Ricin toxin from Ricinus communis (castor
beans)
epsilon toxin of Clostridium perfringens
Staphylococcus enterotoxin B

Category C

Nipah virus
Hantavirus
Tickborne hemorrhagic fever viruses
Tickborne encephalitis viruses
Yellow fever
Multi-drug resistant tuberculosis (MDRTB)

Protect
Wash hands and Wear gloves
Use appropriate PPE
Process contaminated material
Clean and disinfect

Insist to occupational health prevention

Accommodate patients at risk in private
or isolated location

Prevention
Pre-exposure
active immunization
prophylaxis
identification of threat/use

Incubation period
detection and diagnosis
active and passive immunization
antimicrobial or supportive therapy

Prevention
Obvious disease
diagnosis
treatment
may not be available
may overwhelm system
may be less effective

direct patient care will predominate

Common initial
symptoms

Incubation
Period

Anthrax

Cough Chest Pain

Dyspnea

1-6d

Pneumonic
Plague
(Yersinia
pestis)
pestis)

Stridor
Cough
Dyspnea

1-6 days

Smallpox
(Variola virus)

Headache
Cough
Rash (2-3 days later)

Botulinum
Toxin
(Clostridium
botulinum)
botulinum)

Primary
neurological, delayd
respiratory
(Respiratory Failure
Cyanosis)

1-5 days or
within 24-36
hours if
ingested

Gradual to
progressiv
e

High (60%)
without rapid
treatment or
ventilatory
support

No person-toperson
transmission

Typhoidal
Tularemia

Cough chest pain,

syndrome influenza
pulmonary 30%-80%

2 to 21 days

acute

Moderate if
untreated (2030%), Low if
treated (5%)

No person-toperson
transmission

Viral
Hemorrhagic
Fever

Fever, Malaise,
Prostration,
Syndromes
INFLUENZA
PULMONARY

4 to 21 d

acute

Moderate to high,
depending from
the specie

Moderate P to P

17d

Onset:

rapid

Rapid

sudden

Lethality:

Transmission

High (80-90%)

Not
transmissible
person to
person

High (90-100%)
without treatment
within 24 hours of
symptoms

High (person
to person)

Moderate
(20-40% in unvac;
3% in rec vacc )

High (person
to person)

Conclusions

Remember

Suspect and protect

Remove and decon

Treat and or transport