Effective Management of Sarin Exposure

SECTION 1: DEMOGRAPHICS Case Title: Sarin Toxicity Patient name: George St. Pierre Scenario name: Sarin Toxicity Simulation developer(s): Neil Hanson, MD, Eugene Hobbs, CHT., Jeffrey M. Taekman, MD Date(s) of development: November 21, 2006 to December 1, 2006TableSECTION 2: CURRICULAR INFORMATION Educational Rationale In the current state of world politics, healthcare has become even more crucial for national security as the public health is in jeopardy from biologic and chemical warfare. More times than not, civilians are the targets of such attacks (in major urban centers) and the military personal who have trained diligently for such circumstances are not immediately available to lend their experience to such events. Thus, it falls to the nearest hospital to deal with such a crisis to save as many lives as possible while preventing further deaths. Biologic and chemical warfare training is often overlooked in residency programs, but is nonetheless an important part of the curriculum and should be implemented before allowing residents to graduate. The threat of terrorism is that an attack can happen at anytime and anywhere and thus all major centers should be prepared accordingly with staff who has experience in such calamities. Prior experience with the use of chemical warfare on civilian populations has demonstrated that casualties can rapidly escalate if healthcare professionals are not trained to protect themselves as well as treat those contaminated. The purpose of this case is 2-fold: (1) explore the diagnosis and treatment of Sarin exposure and (2) discuss the methods of protecting against contamination with toxic agents. Learning Objectives Accreditation Council for Graduate Medical Education General Competencies: Medical knowledge Patient care Practice-based learning and improvement Interpersonal and communication skills Professionalism Systems-based practice (1) State the molecular mechanisms behind Sarin toxicity (1) Generate a differential diagnosis for Sarin toxicity (2) Delineate how to effectively medically manage a patient with Sarin exposure (2) State the necessary healthcare Hazardous Materials (Hazmat) precautions when dealing with a patient who has been exposed (2) When in an area considered dangerous due to biologic, chemical, or nuclear contamination (“hot zone”), define who should receive immediate medical attention. Guided Study Questions What is Sarin and how does it work? What are some signs of Sarin exposure? How does one treat Sarin toxicity? What are some side-effects of this treatment? How is triaging of patients accomplished at the site of a “hot zone?” How should a healthcare provider properly protect him/herself when faced with patients who are suspected of chemical/biologic contamination? Should there be any specific precautions by healthcare providers when confronted with Sarin? What are the initial steps that should be taken at the site of contamination before transport of a critically ill patient to the hospital? References Used Centers for Disease Control and Prevention. 22 February 2006. The Department of Health and Human Services. 21 November 2006. Available at: http://www.bt.cdc.gov/agent/sarin/ Emergency preparedness for biologic and chemical incidents: a survey of anesthesiology residency programs in the United States. Anesth Analg. 2005;101:1135–1140. Effective countermeasure against poisoning by organophosphorus insecticides and nerve agents. Proc Natl Acad Sci USA. 2006;103:13220–13225. Sarin experiences in Japan: acute toxicity and long-term effects. J Neurol Sci. 2006;249:76–85. Prehospital management of Sarin nerve gas terrorism in urban settings: 10 years of progress after the Tokyo subway sarin attack. Resuscitation. 2006;68:193–202. Multiple casualty terror events: the anesthesiologist’s perspective. Anesth Analg. 2004;98:1746–1752. Intraosseous vascular access in the treatment of chemical warfare casualties assessed by advanced simulation: proposed alteration of treatment protocol. Anesth Analg. 2004;98:1753–1758. Miller RD. Anesthesia. 6th ed. Orlando: Church Livingstone; 2005. Didactics None. Assessment Instruments None. SECTION 3: PREPARATION Monitors RequiredTableOther Equipment RequiredTableSupporting Files (cxr, ekg echo, Assessment, Handouts, etc) None Time DurationsTableCASE STEM The patient is a 31-year-old white man without significant medical history. He presents to the hospital with bradycardia, hypotension, and tachypnea after the onset of headache, blurred vision, and nausea. According to Emergency Medical Services (EMS), Mr. St. Pierre was informing medical personnel of his symptoms when he had an episode of emesis (nonbloody, nonbilious) onto the EMT before collapsing to the ground in an unresponsive state. Mr. St. Pierre was one among many subway riders who felt ill this morning, but one of the few who’s condition declined so rapidly. Other patients are being siphoned to other medical centers and thus Mr. St. Pierre is the only patient to come to your center. Metro Transit informed EMS that renovations were taking place in the subway tunnel and that they have now ceased all traffic through the area (Table 1).Table 1: Simulation GridBackground and Briefing Information for Facilitator/Coordinator’s Eyes Only George St. Pierre is a French-Canadian diplomat, stationed in Washington DC, who was on his way into work one morning when he and a number of other subway riders began to notice the onset of headache, blurred vision, and nausea. There are some minor renovations taking place at several of the subway stations. A few moments after the onset of symptoms, most people exited the car at the next stop and convened to call Emergency Services. Metro Transit was quick to respond and rushed the EMS onto the scene, whereupon they found a number of riders in cardiopulmonary arrest and some even seizing. EMS attempted to effectively triage patients, sending those with serious instability to the hospital immediately. Mr. St. Pierre and the other subway riders are victims of Sarin exposure perpetrated by a terrorist organization determined to cause strife and chaos. Mr. St. Pierre was one of the many victims in the car, which was poisoned. Luckily for him, he was the furthest away from ground-zero when the device was activated and one of the first individuals who exited the car at the next stop. Unfortunately, some of the passengers developed seizures almost instantaneously from their proximity to the gas and the inadequate ventilation of the Metro car. Mr. St. Pierre’s symptoms were initially mild in nature but with repeated contact of other exposed patients and remained proximity to the nerve agent, his status has escalated. On route to the hospital, his respiratory status has begun to decline and he has begun to experience bradycardia with poor distal perfusion. Should interventions not be immediately implemented, he will go into cardiopulmonary arrest and die. Mr. St. Pierre is a 31-year-old white man without significant medical history. He is on no medication (nor does he have any known allergies) and has received an excellent bill of health not >3 months ago on a routine physical. Of note, he has a family history of hypertension and diabetes, but is otherwise without any other pertinent medical history. The initial thought was the victims were all suffering from toxic fumes from construction taking place at the stations and therefore the EMS crew who is transporting him does not have protective clothing on. They will show signs of toxicity unless they are prophylactically treated when they arrive to the hospital. They have managed to secure an IV in place and are hanging a bag of NS when the ambulance arrives. Medical personnel should be cognizant of (1) ensuring isolation of the patient and EMS personnel, (2) protecting themselves against exposure with a Level C Hazmat suit equipped with a Positive Air Purifying Respirator (PAPR), (3) ensuring ABC’s, (4) administering treatment, and (5) decontamination of patients before movement from Isolation. PATIENT DATA BACKGROUND AND BASELINE STATE Patient History A 31-year-old white man without significant medical history presents to the ED after acute onset of syncope in the setting of vision changes and Review of Systems CNS: Unable to effectively assess; patient is obtunded and does not effectively follow commands Cardiovascular: N/A Pulmonary: N/A Renal/hepatic: N/A Endocrine: N/A Heme/coag: N/A Current Medications and Allergies NKDA Physical Examination General: Obtunded, responds to painful stimuli, diffuse muscular weakness, patient’s speech is incomprehensible Weight, height: 75 kg, 5′10″ Vital signs: Temperature 37.4°C, HR 42, BP 72/35, RR 38, oxygen saturation 85% (FM) Airway: Mallampatti Class II airway, normal anatomy, no limitation in cervical motion Lungs: Bilateral inspiratory and expiratory wheezing Heart: RRR, normal S1/S2, no S3/S4, no rubs/gallops/murmurs HEENT: meiosis, conjunctivitis, rhinorrhea, and excessive salivation Laboratory, Radiology, and Other Relevant Studies HCT: 0.38 CXR: No acute cardiopulmonary changes EKG: Sinus bradycardia

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