DR.

ROMAN AL MAMUN
Lecturer and Autopsy Surgeon

Forensic Science and Toxicology

POTENTIAL TERRORISTAGENTS:
Chlorine (Cl2)
 First military poison in World War I
 Strong oxidizer that forms acids and is especially
damaging to respiratory tissue
 10-20 ppm: Acute respiratory tract discomfort
 1000 ppm: Rapidly fatal
Hydrogen cyanide (HCN)
 Highly toxic gaseous substance with potential for attack
through the atmosphere
 Cyanide binds with iron in the +3 oxidation state of
ferricytochrome oxidase enzyme preventing utilization of
O2 leading to rapid death.
Hydrogen sulfide (H2S)
Colorless gas with a foul, rotten-egg odor
 As toxic as hydrogen cyanide and may kill even more rapidly
 1000 ppm: Rapid death from respiratory system
 Paralysis
 Nonfatal doses can cause excitement due to damage the
central nervous system; headache and dizziness may be
symptoms of exposure.

Definition of Bioterrorism
"Bioterrorism” - The unlawful use, or threatened use, of
microorganisms or toxins derived from living organisms to produce
death or disease in humans, animals, or plants. The act is intended
to create fear and intimidate governments or societies in the
pursuit of political, religious, or ideological goals.

BIOWEAPON-RELATED DISEASES
•anthrax
•botulism
•brucellosis
•cholera
•food poisoning
•glanders
•hemorrhagic fever
•lassa fever
•melioidosis
•plague
•psittacosis
•Q-fever
•salmonellosis
•shigellosis
•smallpox
•tularemia
•typhoid fever
•typhus
•viral encephalitis

ADDITIONAL POTENTIAL BIOTERRORISM

AGENTS
•• Chlamydia psittaci

•• Cryptosporidium parvum

•• Escherichia coli O157:H7

•• hantavirus

•• Salmonella species

•• Shigella species

•• Vibrio cholerae

CLASSIFYING BIOTERROR AGENTS

CLASS A
•Contagious
•High death rates and high health impact on the public
•ANTHRAX, BOTULISM, SMALLPOX, TULAREMIA, PLAGUE
CLASS B
•Moderately easy to spread
•Some illness & death rates
•TYPHUS, WATER SAFETY THREATS, SALMONELLA

CLASS C
•Easily available
•Easily produced and spread
•Have potential for high death & illness rates
•NIPAH VIRUS

Biological Delivery Methods

•Food / Water

•Aircraft sprayers

•Vehicle sprayers

•Hand sprayers

•Mail

•Air handling systems

Human Vector

•Animal Vector
KEY INDICATORS OF A BIOLOGICAL TERROR
EVENT

•Occurrence of vector-borne disease where there is no vector

•Cluster of sick or dead animals

•Atypical seasonality

•Geographic Pattern of Illness

•More respiratory presentation of disease

Intrinsic Features
* Infectivity
* Virulence
* Lethality
* Pathogenicity
* Incubation period
* Contagiousness
* Stability

The Ideal Bioterror Weapon Would Be

1.contagious
2.virulent
3.robust
4.difficult to detect
5.drug-resistant
6.user-controllable
Advantages
1. A single microbial biological weapon can, because it reproduces
in the host, theoretically produce the desired detrimental outcome
in a target host. That is, a single smallpox virus or plague bacillus, if
deposited in the right place in the host, can grow and produce a
disease.
2. Biological toxins are among the most toxic agents known. For
example, the quantity of botox (Botulonium Toxin) in the dot of an
‘i’ is, when delivered properly, enough to kill about 10 people.
3. Most biological agents are relatively easy and inexpensive to
grow. Their cultivations do not require large factories and can
utilize common commercial equipment, such as that used in
making cheese. While viral agents are more difficult to cultivate
than bacterial agents, both can be cultivated by individuals with
limited scientific training.
4. Large quantities of biological weapons can, in most cases, be
produced in a short period (a few days to a few weeks) at small
facilities scattered over a large area.
5. Nondetection by routine scrutiny systems.
6. Destruction of enemy without any infrastructure damage.
7. Perpetrators can escape long before biological weapons cause
casualties.
8. Biological weapons are typically invisible in aerosol clouds and
not easy to detect until humans become ill.
Disadvantages
1. Difficulty of protecting the workers at all stages of production,
transportation, loading of delivery systems and final delivery:
Untrained and inexperienced personnel, ignorant of routine
precautions necessary to prevent contamination with the agents,
are accident prone. Immunization of these personnel will not be
effective in all cases.
2. Difficulty in maintaining quality control and sufficient
containment during growth and harvesting of agents: Primitive
conditions increase chances for the accidental release of the
biological weapons into the surrounding environment (as
happened in Russia with anthrax).
3. Effective delivery problems: Most biological materials, including
spores, are destroyed by exposure to UV light and drying. Agents
released in the air may disperse in unexpected ways due to the
vulgarities of wind patterns. Dispersal patterns may be ineffectual.
Rain may wash the agents out of the air before they reach their
target.
4. Poor storage survival: Many biological weapons must be stored
under special conditions to maintain efficacy. Further, they are
often difficult to maintain in a weapons delivery state (e.g. loaded
and ready to be fired in a rocket).
5. Difficult to control once released: One’s own troops may be
infected under the chaos of a war. In theory, it may be possible to
protect your own population against a BW you plan to use by
vaccination or the prophylactic administration of antibiotics, but
the chance that your enemy will discover what you are doing is
high.
Characteristics of Ideal Biological Weapon
1. Highly infectious; requiring only a few organisms to cause the
desired effect (e.g. smallpox) or highly effective; requiring a small
quantity of material to cause the desired effect (e.g. botox).
2. Efficiently dispersible, usually in the air; contagious or effective
on contact.
3. Readily grown and produced in large quantities.
4. Stable in storage; preferably in a ready-to-deliver state.
5. Resistant enough to environmental conditions so as to remain
infectious or operational long enough to affect the majority of the
target, but not so persistent as to affect the occupying army.
6. Resistant to treatment, e.g. antibiotics, antibodies,
pharmaceutical drugs, etc.
PREPARATION FOR BT ATTACK
•Familiarize medical staff with BT agents

•Incorporate into Disaster Planning

•Decontamination & Infection Control

•Communications with key agencies

•Laboratory, Respective health authorities of the Nation.

•Contacts to obtain stockpiled supplies: antibiotics, immune sera,
vaccines, etc.

•Security preparations

WHAT TO DO IF YOU SUSPECT A BIOTERRORIST

DISEASE
IMMEDIATELY NOTIFY:
•Hospital Infection Control
•Isolation: Smallpox, plague, hemorrhagic fevers
•Laboratory •Local Public Health Department

SPECIAL PROBLEMS WITH BT

•Identifying a covert attack

•Social disruption

•Prophylaxis for large populations

•Decontamination

•Secondary transmission

Investigation on three levels:

 Clinical
 Epidemiological
 Laboratory
Epidemiologic clues for Bioterrorism:
 Tight cluster of cases
 High infection rate
 Unusual or localized geography
 Unusual clinical presentation
 Unusual time of year
 Dead animals
RADIOLOGICAL WEAPON
A radiological weapon or radiological disper-sion device (RDD) is
any weapon that is designed to spread radioactive material with
the intent to kill and cause disruption.
One version, known as a dirty bomb, is not a true nuclear weapon
and does not yield the same explosive power.
It uses conventional explosives to spread radioactive material, most
commonly the spent fuels from nuclear power plants or radioactive
medical waste.
Another version is the salted bomb, a true nuclear weapon
designed to produce larger amounts of nuclear fallout than a
regular nuclear weapon.

Autopsy on a Radioactive Body

Before conducting the autopsy, the autopsy surgeon must enquire
about
1. The dose given to the patient.
2. Type and activity of radiation.
3. The interval since the last dose, and
4. Residual radioactivity in the body.
The following procedure should be followed when an autopsy is to
be performed on bodies containing high levels of liquid
radioactivity14,15
1. Supervision by an individual knowledge-able in radiation
(radiation safety officer from a local licensed facility).
2. External exposure monitoring of personnel (whole body and
hand).
3. Pre-selection of tools.
4. Anticipated supplies in room.
5. Secured area access.
6. Personnel time limits (rotation of personnel).
7. Bioassay of personnel at conclusion of procedure (to assure
radioactivity was not inhaled, absorbed or ingested).
8. Surveys of personnel with portable instrumentation upon exit
from procedure area.
9. Survey and decontamination of area and all equipments.
10. Disposal of contaminated waste items as radioactive.
11. Use of personal protective equipments:
i. Double gloves
ii. Face mask
iii. Eye (splash) protection
iv. Surgical hats
v. Plastic gowns
vi. Plastic shoe covers or rubber boots
vii. Lead aprons (where they might reasonably reduce exposure
levels).
Removal of highly radioactive organs is dependent upon
anticipated disposition of the body.
If a full autopsy will be performed, removal of the organs is
encouraged to limit pathological exposure.
If there will only be embalming, removal of organs could reduce
exposure.
Embalming should not be performed within 48 hours of the
administration of I131 for therapy, unless there are extenuating
circumstances.
Cremation of bodies containing radionuclides will contaminate the
crematorium and, in most cases, will leave contaminated ashes.
Removal and handling of the ashes must be performed with
appropriate personal protective equipments.
No radiation hazard would exist if a crematorium were to handle a
total of up to 200 mCi (miliicurie) 131I or 2000 mCi of all other
radionuclides annually.
Instruments and clothing that must be decontaminated (versus
becoming radioactive waste) can generally be cleaned by repeated
soaking in water with regular detergents.
Some items, as determined by the radiation safety professional,
may need to be held for decay of the radionuclide. Items to be
disposed as radioactive waste must be bagged and properly
marked with radionuclide, date and amount of radioactivity.
If the half-life is short, the material can be held for decay and
disposed as non-radioactive.
If the half-life is long, a radiation-safety professional should
determine the most appropriate way to dispose of the materials.

NUCLEAR WEAPON
A nuclear weapon is an explosive device that derives its destructive
force from nuclear reactions, either fission or a combination of
fission and fusion.
Both reactions release vast quantities of energy from relatively
small amounts of matter.
Only two nuclear weapons have been used in the course of
warfare, both by the US near the end of World War II. On 6 August,
1945, a Uranium gun type fission bomb, code named “Little Boy”,
was detonated over the Japanese city of Hiroshima.
Three days later, on 9 August, a Plutonium implosion type fission
bomb, code-named “Fat Man”, was exploded over Nagasaki,Japan.
These two bombings resulted in the deaths of approximately
200,000 people, mostly civilians, from acute injuries sustained from
the explosions.
The role of the bombings in Japan’s surrender, and their ethical
status, remain the subject of scholarly and popular debate.

MASS DISASTER MANAGEMENT (FOCUS ON ROLE OF MEDICO-

LEGAL EXPERT)
Disaster strikes without warning is indiscriminate in its choice of
victims and has the potential of overcoming even the most
prepared of systems.
So, we need to plan to effectively manage such incidents.
All the planning in the world will not prevent tragedy from
occurring, whether it is by natural causes or manmade, still the
only way to prepare for rare, uncommon and unrepetitive events is
to think about them, to attempt to generalize the problems they
cause and to try to develop a system that can respond to the
known but can improvise and also respond to the unknown and
not previously experienced as well.
The management of dead bodies involves a series of activities that
begins with the search for corpses, in situ identification of the
body, transfer to the facility that serves as a morgue, delivery of
the body to family members and assistance from the State for final
disposal of the body in accordance with the wishes of the family
and the religious and cultural norms of the community.

In medicolegal work, the objectives are to:

1. Legally determine or pronounce death.
2. Recover the remains of the dead.
3. Establish identity of the dead.
4. Estimate the time of death.
5. Determine the cause of death.
6. Explain the possible circumstances of death.
7. Prepare the remains for final disposal, and
8. Study the event to assist in prevention in the future.

Keeping in mind the objectives of medico-legal work and as integral

part of mass disaster management team member, the medicologist
should either set a temporary morgue at the site of disaster or
should choose a permanent morgue.
These are mass fatality incident morgue, which means the facility
where the confirmed identification of the remains is established,
where a medicolegal autopsy is performed, where detailed death
incident reports are filled out and where all elements of aftercare
are completed.

Tear gases and other disabling chemicals:

10-chloro-5,10-dihydrophenarsazine (adamsite, or DM)
1-chloroacetophenone (CN)
a-bromophenylacetonitrile (larmine, BBC or CA)
2-chlorobenzalmalononitrile (CS)
dibenzoxazepine (CR)
oleoresin capsicum (OC)
3-quinuclidinyl benzilate (BZ)
Choking agents (lung irritants):
phosgene
chloropicrin
Blood gases:
hydrogen cyanide
Vesicants (blister gases):
bis(2-chloroethyl) sulphide (mustard gas)
2-chlorovinyldichloroarsine (lewisite)
bis(2-chloroethylthioethyl) ether (agent T)
tris(2-chloroethyl)amine (a nitrogen mustard)
Nerve gases:
ethyl NN-dimethylphosphoramidocyanidate (tabun, or GA)
O-isopropyl methylphosphonofluoridate (sarin, or GB)
O-1,2,2-trimethylpropyl methylphosphonofluoridate (soman, or
GD)
O-cyclohexyl methylphosphonofluoridate (cyclosarin, or GF)
O-ethyl S-2-diisopropylaminoethyl methylphosphonothiolate (VX)
O-ethyl S-2-dimethylaminoethyl methylphosphonothiolate
(medemo)
O-isobutyl S-2-diethylaminoethyl methylphosphonothiolate (VR)
Further toxins
Ricin
Saxitoxin
Clostridium botulinum toxin
Staphylococcal enterotoxin
Aflatoxin
Bacteria and rickettsiae
Bacillus anthracis
Francisella tularensis
Brucella suis
Burkholderia mallei
Burkholderia pseudomallei
Yersinia pestis
Rickettsia prowazeki
Coxiella burnetii

Viruses
Venezuelan Equine Encephalitis virus

WEAPON OF MASS DESTRUCTION

A weapon of mass destruction (WMD) is a weapon that can kill
and bring significant harm to a large number of humans and/or
cause great damage to man-made structures, natural structures or
the biosphere in general.

The term chemical,biological,radiological,and nuclear (CBRN) is a

replacement for the cold-war term nuclear,biological and chemical
(NBC), which had replaced the term atomic, biological and
chemical (ABC) that was used in the 50s.
The addition of the R (for radiological) is a consequence of the
“new” threat of a radiological weapon (also known as “dirty
bombs”).
In the new millennium, the term CBRNe has been introduced as an
extension of CBRN — the e in this term representing the enhanced
(improvised) explosives threat.
The first recorded use of the term “weapon of mass destruction”
was by Cosmo Gordon Lang, Archbishop of Canterbury, in 1937 in
reference to the aerial bombardment of Guernica, Spain.
Chemical Warfare (CW) involves using toxic properties of chemical
substances as weapons. These do not fall under the term
conventional weapons, which are primarily effective due to their
destructive potential.
Nerve Agent
Agents
The common nerve agents are: Tabun (GA), Sarin (GB), Soman (GD),
Cycloserine (GF) and VX gas.
Schrader synthesized the first nerve agent Tabun (GA), in late 1936;
Sarin was introduced in 1937 and Soman in 1944.
Mode of Action
They inactivate enzyme acetylcholinesterase, preventing the breakdown
of the neurotransmitter acetylcholine in the victim’s synapses and
causing both muscarinic and nicotinic effects.
Clinical Features
Miosis (pinpoint pupils), blurred or dim vision, headache, nausea,
vomiting, diarrhea, copious secretions/sweating, muscle twitching or
fasciculation, dyspnea, seizures, loss of consciousness.
Rate of Action
Vapors: seconds to minutes; Skin: 2–18 hours.
Persistency
VX is persistent and a contact hazard; other agents are non-persistent
and present mostly inhalation hazard.
Asphyxiant/Blood Agent
Agents
Most common agents are— arsines, cyanogens chloride, hydrogen
cyanide, etc.
Mode of Action
Arsine: Causes intravascular hemolysis that may lead to renal failure.
Cyanogen chloride/hydrogen cyanide: Cyanide directly prevents cells
from using oxygen. The cells then use anaerobic respiration, creating
excess lactic acid and metabolic acidosis.
Clinical Features
Possible cherry-red skin, cyanosis, confusion, nausea, patients may gasp
for air, seizures prior to death, metabolic acidosis.
Rate of Action
Onset is sudden, non-persistent, and it has an inhalation hazard.
Vesicant/Blistering Agent
Agents
Sulfur mustard, nitrogen mustard, lewisite (L) and phosgene oxime (CX).
Mode of Action
Agents are acid-forming compounds that damages skin and respiratory
system, resulting burns and respiratory problems.
Clinical Features
Severe skin, eye and mucosal pain and irritation, skin erythema with
large fluid blisters that heal slowly and may become infected, tearing,
conjunctivitis, corneal damage, mild respiratory distress to marked
airway damage.
Rate of Action
Mustards: Vapors: 4–6 hours, eyes and lungs affected more rapidly;
Skin: 2–48 hours.
Lewisite: Immediate.

Persistency
Persistent and a contact hazard.
Chocking/Pulmonary Agent
Agents
The common agents are chlorine, hydrogen chloride, nitrogen oxides,
phosgene, etc.
Mode of Action
The mode of action is same to blister agents in that the compounds are
acids or acid-forming, but action is more pronounced in respiratory
system, flooding it and resulting in suffocation; survivors often suffer
chronic breathing problems.
Clinical Features
There is airway irritation, eye and skin irritation, dyspnea, cough, sore
throat, chest tightness, wheezing, bronchospasm.
Rate of Action
It acts immediately and may extends up to 3 hours. Its action is non-
persistent and has an inhalation hazard.
Lesser CW Agents
i. Lacrimators/tear gases.
ii. Sternutators or nasal irritants.
Tear Gases
Tear gas, formally known as a lachrymatory agent or lachrymator (from
lacrima meaning “tear” in Latin), is a possibly lethal chemical weapon
that stimulates the corneal nerves in the eyes to cause tears, pain and
even leads to blindness.
Definition and origins.
Tear gas is a term used to refer to a group of toxic chemical agents that
disable people exposed to them by irritating the lungs, skin, or eyes.
These agents are also called lachrymatory agents, peripheral
chemosensory irritants (PCSI), riot control agents and harassing agents,
and qualify as “less-lethal” weapons.
Toxic lachrymatory chemical agents are among the most commonly
used types of riot control agents.
At least 15 chemicals have been used worldwide as harassing
agents,with CS gas being the most commonly used by law enforcement
for crowd control.
PHR uses the term “toxic chemical agents”instead of tear gas in this
report to underscore the toxicity of these chemicals.
“Tear gas,” implying that these chemical agents merely cause tearing, is
a misnomer.
Precursors to today’s lachrymatory riot control agents may have been
used against civilian populations as early as 1912,and militaries
employed toxic lachrymatory agents as weapons for the first time in
1914.
Some of the chemicals used in today’s riot control agents, however,
evolved from chemical weapons developed as early as the 1800s.
CS gas was identified as a lachrymatory agent in 1928 and was
weaponized in the mid-1950s.
The letters “CS” stand for the initials of B.B. Corson and R.W. Stoughton,
American chemists who discovered the
properties of the chemical in 1928.
Toxic lachrymatory agents and other chemical warfare agents
(CWAs) were used extensively throughout both World Wars I and II.
The United States used CS gas on the battlefield for the first time during
the 1960s Vietnam War.
Responding to widespread use of chemical weapons on the battlefield
during WWI, over 30 countries signed a UN protocol in 1925 that
prohibited the use of poisonous gases in war.

In 1997, the Chemical Weapons Convention (CWC) effectively

prohibited the use of chemical and biological weapons in warfare, and
promoted disarmament.
The CWC, however, allows law enforcement officials to use some
chemical agents during periods of peacetime or civil unrest.
The convention calls permissible chemicals “riot control agents” and
stipulates that these agents must have effects which disappear shortly
after exposure.
Common lachrymators include CS (Ortho-chlorobenzylidene
malononitrile), CR (dibenzoxazepine), CN (phenacyl chloride),
nonivamide, bromoacetone, xylyl bromide and syn propanethial-S-oxide
(from onions).
First used in 1914, xylyl bromide was a popular tearing agent since it
was easily brewed.

The chemical agents 2-chloroacetophenone (CN; Mace), o

chlorobenzylidene malonitrile (CS) and oleoresin capsicum (OC; pepper
spray) are highly potent irritant incapacitating agents commonly used
by law enforcement agencies as a non-lethal option for subduing
combative and violent suspects,for crowd control purposes in times of
civil disorder and for alleviating siege and hostage situations.
1–3 Military organisations have also used these agents for similar
purposes, for training and as chemical warfare agents.
The US military used CS during the Vietnam War for tunnel denial
and crowd control.
Since the Entry Into Force of the Chemical Weapons Convention in
1997,7 these agents have been banned as a method of warfare.
However, under a 1975 presidential order,the US military can still use
these agents in war zones under limited defensive circumstances with
the approval of top military commanders, for example, for controlling
rioting prisoners.
CN, also known as Mace, was initially the most widely used agent by
law enforcement agencies; however, in more recent years, CS has
largely replaced CN.
Products containing CN and CS are also available as a handheld spray for
personal selfdefence and protection.
OC pepper spray has over recent years become increasingly popular
with law enforcement agencies, having replaced both CN and CS for
civilian use.
These agents are commonly referred to as tear gases, riot control
agents, harassing agents, incapacitating agents and lacrimators.
They are typically dispersed via aerosol, and following exposure they
cause immediate and intense eye, nose, mouth, skin and respiratory
tract irritation that can lead to temporary incapacitation of exposed
individuals.
While serious systemic effects are uncommon, exposure to high
concentrations may lead to more serious complications and even
death.
The three most commonly used chemical riot control agents—CN, CS
and OC—and presents an up-to-date overview of the mechanism of
action, symptoms expected and medical management required
following exposure.
Tear gas works by irritating mucous membranes in the eyes, nose,
mouth and lungs, and causes crying, sneezing, coughing, difficulty in
breathing, pain in the eyes, temporary blindness, etc.
Lachrymators are thought to act by attacking sulfhydryl functional
groups in enzymes.

CHEMICAL PROPERTIES
CN (CAS 532-27-4) has a molecular formula of C8H7ClO and a molecular
weight of 154.59.
It has a melting point of about 58–59°C, a boiling point of 244–245°C,
and at 20°C it has a low vapour pressure of 5.4×10–3 mm Hg.
CN is practically insoluble in water, though it is freely soluble in ethanol,
ether and benzene.
CN was developed at the end of the First World War, although it was
not used during combat.
Following the First World War, it was widely used both by the military
and various law enforcement agencies until the development of the
more potent and less toxic incapacitant, CS, which became available in
1959.
CS (CAS 2698-41-1) has a molecular formula of C10H5ClN2 and a
molecular weight of 188.6; it was discovered in 1928 by the British
chemists Ben Corson and Roger Stoughton, the common name CS being
derived from the first letter of their two surnames.
It has a cyanocarbon structure.
It is a white crystalline solid with pepper-like odour with a melting point
of about 93°C and a boiling point of 310°C.
It has a low vapour pressure, is sparingly soluble in water while being
Lachrymatory agents are commonly used as riot control and CW agents.
During World War I, more toxic lachrymatory agents were used.
Certain lachrymatory agents are often used by police to force
compliance, most notably tear gas,soluble in acetone, methylene
chloride, ethyl acetate and benzene.
It hydrolyses somewhat slowly in water, producing o
chlorobenzaldehyde and malononitrile.
OC, capsaicin (N-(4-hydroxy-3-methoxybenzyl)-8-methylnontrans-
6-enamide, CAS 8023-77-6), present naturally in the capsicum group of
herbs and shrubs, has a molecular formula of C18H27NO3 and a
molecular weight of 305.
It is an odourless, pungent tasting off-white solid with a melting point
of about 65°C and a boiling point of 210–220°C.
It has a low vapour pressure, is practically insoluble in water while being
freely soluble in alcohol, ether, chloroform and benzene.

MODE OF APPLICATION:

Due to these chemical properties, these agents are typically dispersed

as fine powdered particles, for example, as a smoke by means of
pyrotechnic mixture, via fogging machines or as vapour generated from
pressurised liquid systems (aerosolisation).
In the training scenario, pyrotechnic pellets produce a fine particulate
aerosol.
In the medical literature, the terms spray and aerosol tend to be used
interchangeably.
However, there are distinctions between the different forms of
lacrimators.
Aerosol typically refers to products that are airborne dispersions used
to affect many people in an area such as crowd control, whereas
sprays are typically handheld canisters containing the active agent in
solution; this is sprayed directly at a single person to incapacitate them.
Occasionally liquid products may be dispersed directly at a larger
number of people by being added to water and dispersed by water
cannon or similar larger-scale devices.14–16 The devices typically used
to disperse these agents include bombs, large spray tanks, grenades or
canisters that can either be thrown or shot as projectiles, or smaller,
handheld spray devices.

MECHANISMS OF TOXICITY:
The mechanism of action of these agents in humans is not
fully understood.
Both CS and CN are thought to act as SN2-alkylating agents, reacting
readily with nucleophilic sites.

Important targets include thiol and sulfhydryl groups of

enzymes, including lactic dehydrogenase, glutamic dehydrogenase
and pyruvic decarboxylase.
Inactivation of these metabolic enzyme systems may be related to
tissue injury that occurs following exposure.
Transient receptor potential (TRP) channels are present in airway
sensory fibres, with TRPV1 (vanilloid) receptors found to be sensitive to
OC.
The result is a sensation of pain, but also an inflammatory response,
due to the process of neurogenic inflammation.
This involves release of neuropeptides (including importantly substance
P) at the terminals of the C (and special A) fibres, both peripherally and
at their junction in the dorsal horn of the spinal cord.
These neuropeptides in turn provoke inflammation.
Another subtype, TRPA1, was subsequently shown to be the sensory
neuronal receptor for mustard oil (allyl isothiocyanate) and widely
sensitive to other reactive irritants, including CS.
Both TRPA1 and V1 receptors are thought to be the final common
pathway for inflammatory signalling pathways.
An additional mechanism of action for the irritant and painful
effects may be due to bradykinin release.
CS also contains two cyanogenic groups,and while they may contribute
to the local irritant effects of the compound, under normal
circumstances it is not thought that enough cyanide would be liberated
to cause systemic effects.
However, experimentally minimal amounts of cyanide and thiocyanate
can appear in the urine following intravenous or oral administration of
CS.

CLINICAL FEATURES:

The effects of these agents are related to the concentration of

the compound and duration of exposure.
High concentrations over short periods may be more hazardous than
the same dose delivered as low concentrations over longer time
periods.
Evidence for toxicity, as measured by the threshold for irritation, is
greatest for CN (1.0 mg m3), followed by CS (0.004 mg m3) and OC
(0.002 mg m3).
In contrast, OC and CS are less lethally toxic than CN. Nevertheless,
deaths have been reported following exposure to CN, typically at high
concentrations in an enclosed space for an extended period of time.
While some concerns have been raised about the safety of CS and
OC,25 they are regarded as generally safe when used appropriately.
The eyes and respiratory systems are the primary target organs, with
onset of ocular and respiratory tract irritation occurring within 20–60 s.
The ocular symptoms include pain,blepharospasm, photophobia,
conjunctivitis, diffuse conjunctival and scleral injection, periorbital
oedema, eyelid erythema and lacrimation.
They do not typically cause irreversible eye effects, but more severe
ocular injuries have been reported,including hyphema, uveitis,
necrotising keratitis, coagulative necrosis, symblepharon, secondary
glaucoma, cataracts and traumatic optic neuropathy and loss of sight.
However, these injuries were noted following exposure to explosive
devices discharged near the face and eyes.
Additionally, some reports suggest that the carrier solvent used with
some sprays may contribute to corneal abrasions.
This makes it difficult to determine if the ocular damage was due to the
tear gas itself,the carrier solvent or as a result of the explosive discharge
of the product.
Following inhalation, effects can include a stinging or burning sensation
in the nose, tightness and pain in the chest, sore throat, sporadic breath
holding, dyspnoea, coughing, sneezing and difficulty breathing.
Copious rhinorrhoea may occur along with salivation and burning
sensation in the mouth and tongue.
Contaminated saliva that is swallowed may lead to epigastric discomfort
and may contribute to nausea and vomiting and/or diarrhoea.
Persistent coughing may also contribute to retching.
Panic and agitation are common, especially on a first exposure.
Other less specific symptoms may include headache, fever,syncope,
dizziness and tachycardia.
Further systemic effects are unlikely to occur from typical exposures;
however, if used in very high concentrations or within confined non-
ventilated areas, more severe effects are possible, including
bronchospasm, laryngospasm, haemoptysis, reactive airways
dysfunction,chemical pneumonitis, pulmonary oedema, asphyxia,
heart failure, hepatocellular damage and death.
Some subjects may develop hypersensitivity reactions with fever and
pulmonary involvement.
Dermal contact to CS typically causes a tingling or burning sensation,but
prolonged exposure can lead to a range of other adverse effects,
including erythema, oedema, blistering and superficial burns.
The latter more severe dermal symptoms are more commonly
encountered with exposure to CN, which tends to cause more severe
dermal injuries than CS.
Aerosol and liquid contact with CN typically leads to pruritis, localised
pain, erythema,rash, purpura, desquamation, vesicles, blistering,
second-degree burns, bulla, scaling and subcutaneous oedema.
Topical OC products used as pain treatments can also cause burning,
stinging and erythema,and have also caused contact dermatitis
following exposure during food preparation.
Severe dermal manifestations appear more common where handheld
spray products are used.
The solvents in these products may contribute to the cutaneous
complications.
Additionally, adverse skin effects may be accentuated by moisture
such as from perspiration, lacrimation, rhinorrhoea or high humidity.
Further dermal effects, including irritant or allergic contact dermatitis
and acute generalised exanthematous pustulosis, may be delayed in
onset, not presenting until 12–24 h or longer post-exposure.
Additional risks in riot control situations where tear gases are used
include burns from direct contact with the hot metal canister used to
disperse these agents or burns caused by the flame generated by the
pyrotechnic mixture used.
The unpleasant effects produced tend to force those exposed to seek
fresh air,and the majority of irritant effects typically resolve within 10–
30 min if patients are quickly removed from the source.
However, some effects, especially respiratory effects such as cough and
impaired respiratory function,may persist for longer periods in some
situations.
Visual acuity typically returns to normal rapidly while erythema of the
lid margins and photophobia may persist longer.
Rhinorrhoea and salivation may persist for 12 h, and headaches can be
prolonged for up to 24 h.
Dermal erythema generally subsides within 45–60 min while effects
such as blistering and irritant contact dermatitis typically heal with
drying of the blistered area within 4 days and minimal scarring after 4
weeks.
Long-term sequelae following exposure to these agents are rare.

MANAGEMENT:
The optimum treatment for individuals affected by OC, CS or CN is
currently based on results from case reports or case series as high-level
evidence for the best treatment is not available.
There is no antidote for these agents with treatment mainly consisting
of thorough decontamination and symptom-directed supportive care.
Removal of those exposed from the contaminated area and into fresh
air is the most important initial undertaking.
Aerosolised tear gases are heavier than air, and any exposed patient
who has lost consciousness or is lying should be lifted off the ground;
emergency response vehicles should also try and park in higher areas.
Transport to a medical facility is recommended for symptomatic
exposures.
A concern with the medical management of those affected by CN or CS
is secondary contamination of first responders such as police or
ambulance, or the medical staff at the hospital.
While it is uncommon for there to be heavy contamination of people
following exposure to these products, there is a risk of secondary
exposure occurring.
For example, among attending physicians treating exposed patients,
minor effects such as facial pruritis and respiratory and eye irritation
may develop.
Removal of contaminated clothing, prompt decontamination, the use of
gloves, goggles,gowns and surgical masks by medical personnel, and, if
possible, treatment in a well-ventilated room are recommended to
minimize secondary contamination.
Removed contaminated clothing should be sealed in a double plastic
bag.
Treatment for ocular exposures initially requires thorough eye
decontamination.
Flushing the eyes with water or saline for 10–20 min is the most often
recommended initial treatment for decontamination of the eyes.
Some have recommended using air flow over the eyes, such as that
directed from fans or the use of a cold hairdryer to decontaminate the
eyes following exposure to aerosolised smoke products.
This is purported to help the gas vaporise and therefore relieve
irritation.
However, it seems improbable that a powder that dissolves into
solution on the surface of the eye would readily be converted into a gas
at normal temperature and pressure even with air flow over the eyes.
This technique is also unlikely to be effective for liquid solvent spray
products.
Additionally, some studies have noted that cold air blowing over the
face and eyes did not produce any clinical improvement and only served
to increase contamination of the treatment facility,whereas flushing
with normal saline resulted in considerable improvement in symptoms.
Based on this review of the literature, flushing with saline or water for
15–20 min would appear to be the most sensible initial procedure for
any exposure to CN or CS.
Patents may require a topical anaesthetic to enable them to open their
eyelids sufficiently for effective irrigation.
Contact lenses should be removed before flushing.
If following irrigation more than mild, resolving symptoms are present,
a full ophthalmological examination should be undertaken, including
fluorescein staining and slit-lamp examination.
For persistent symptoms or if there is injury noted, then specialist
ophthalmological assessment is recommended.
Further treatment may need to include oral analgesics, topical
antibiotics and a cycloplegic or mydriatic.
In some situations, for example, when a tear gas grenade explodes in
close proximity to the face, there may be particles embedded in the
cornea or conjuctiva.
Following flushing, removal of these particles is necessary; use of a
cotton wool swab or a needle tip at a slit lamp is recommended.
Skin:
Skin exposures should be thoroughly decontaminated with copious
flowing water and soap to remove the contaminate and settle the
burning sensation.
The face should be wiped to remove any particles before being washed.
Saline irrigation should be used for vesiculated skin.
Other decontamination methods have been investigated; a mild alkaline
solution (sodium carbonate or sodium bicarbonate) or a sodium
metabisulfite solution has been recommended, although these
may not always be available and are unlikely to provide much benefit
over water,thus they are probably unnecessary.
Baby shampoo was found to be no better than water alone in one
randomized trial.
Diphoterine, a commercial decontamination solution purportedly
containing chelating and amphoteric properties,has been investigated
with some positive findings,as has the use of vegetable oil though
further evidence is required before advocating their use.
It is rare that severe contact dermatitis occurs,in which case it is
generally treated with topical corticosteroids and/or antihistamines
such as diphenhydramine; systemic steroids may be required if
symptoms are severe.
Significant chemical burns should be treated in the same way as
thermal burns.
Respiratory
While the majority of respiratory symptoms are mild and should
improve with cessation of exposure and removal to fresh air,high
concentrations (such as exposure in a confined space) or prolonged
exposure periods may cause significant respiratory symptoms.
Monitoring and support of respiratory function is important in any
symptomatic patient.
Pulse oximetry and arterial blood gases should be monitored.
If significant respiratory distress develops, initial supportive treatment
includes oxygen administration.
Chest radiographs can assist in identifying any pulmonary
complications.
Suctioning may be required for those with copious respiratory
secretions.
Along with continued oxygen therapy, inhaled bronchodilators such as
β-2-agonists (ie, salbutamol) may assist those with bronchospasm
and/or obstructive changes on lung function tests.
Inhaled steroids may also assist in patients with bronchospasm (or non-
productive cough).
Respiratory failure may rarely occur secondary to laryngospasm; airway
protection and assisted ventilation may be required.
Exacerbation of asthma, emphysema or bronchitis may occur in those
with a pre-existing respiratory condition, or uncommonly,asthma may
develop due to an allergic respiratory response to the agent.
Standard asthma treatment protocols should be followed.
Reactive airways dysfunction or pulmonary oedema has only rarely
been reported and may be delayed or exercise induced.
Pulmonary oedema is managed primarily by non-pharmacological
treatments, including resting from activity and oxygen therapy.
Standard face mask supply of 50–60% oxygen may maintain adequate
oxygenation.
However, mechanical ventilation with continuous positive airway
pressure or positive-end-expiratory pressure ventilation may be
required if PaO2 cannot be maintained above 50–55 mm Hg.

Gastrointestinal
While gastrointestinal symptoms are not common, retching,nausea and
vomiting can occur due to the irritant effects.
Some people appear to be especially sensitive to the effects and may
vomit more readily, while vomiting also appears more common when
high concentrations are attained,such as when exposure occurs in a
confined space or when a long duration of exposure occurs.
Ingestion of contaminated saliva may also contribute to vomiting and
diarrhoea.
Very rarely actual ingestion has occurred and led to gastrointestinal
disturbances.
There are limited data on the benefit or otherwise of gastrointestinal
decontamination procedures following ingestion.
Due to the relatively minor effects expected following ingestion, the risk
of adverse effects from decontamination likely outweighs any potential
benefit.
Gastrointestinal decontamination with gastric lavage or activated
charcoal is therefore not recommended.
Overall gastrointestinal symptoms typically resolve spontaneously, and
further specific treatment is not required.
However, if vomiting or diarrhoea is persistent or severe, this may
contribute to fluid and electrolyte imbalances, acidosis, shock, seizures,
obtundation and hypokalaemia.
In this situation, patients may require symptomatic care with
intravenous rehydration, antiemetic agents and adequate electrolyte
replacement.

Sternutators
These are organic compounds of arsenic dispersed by heat or
detonation in the form of very fine, particulate clouds or smokes.
In Latin “sternuto” means sneezing.
Commonly used compounds are: diphenylchlorarsine (DA),
chlorodihydrophenarsazine (DM), diphenyl cyanarsine (DC).
Examples of CW
Use of CW began with the First World War (1914–1918), during which
more than one lac people died and about 1.2 million seriously affected
due to the use of phosgene, chlorine and nitrogen mustard.
During the Second World War (1939–1945), the Germans used a
number of nerve agents like tabun (GA), sarine (GB) and soman (GD),
together referred as “G” military agents causing organophosphorus
poisoning.
Agent Orange
US Military force used Agent Orange, a combination of Herbicide
Orange (HO) and Agent LNX as a part of its CW program in Operation
Ranch Hand during the Vietnam War (1961–1971) killing 4 lacs people
and creating birth defects in 5 lacs children.
Pepper Spray
Recently, much has been talked about the use of less toxic agents like
Pepper Spray (derived from red chili or capsicum which contains active
principle capsaicin) over lacrimators or tear gases for controlling riots.
It can also be used as a self-protecting agent especially by women for
protecting themselves from unwanted situations.

Thank You…….