HM Medical Clinic

 

Introduction

U.S. Army Medical Research Institute of
Chemical Defense (USAMRICD)
FIELD MANAGEMENT
OF CHEMICAL
CASUALTIES
Chemical Casualty Care Division
3100 Ricketts Point Rd
Aberdeen Proving Ground, MD 21010-5400
THIRD EDITION
February 2007
Emergency Response Numbers:
National Response Center (for chem/bio hazards and
terrorist events):
1-800-424-8802 or
1-202-267-2675

USAMRICD Emergency Response Line:
1-410-436-3276 or
CDC'S Emergency Response Line: HANDBOOK
REPRINTING
The US Army Medical Research Institute of Chemical Defense, Chemical Casualty Care Division, requests that users of this handbook, prior to distributing or reprinting parts of or this entire handbook, notify: Chemical Casualty Care Division US Army Medical Research Institute of Chemical Defense 3100 Ricketts Point Road Aberdeen Proving Ground, MD 21010-5400 USAMRICD
Chemical Casualty Care Division's
FIELD MANAEMENT OF CHEMICAL
CASUALTIES
HANDBOOK
Third Edition
COL (Ret) Gary Hurst, MC, USA LTC Shirley Tuorinsky, AN, USA COL James Madsen, MC, USA COL Jonathan Newmark, MC, USA LTC Benjamin Hill, MC, USA Lt Col Charles Boardman, USAF SFC Jeffrey Dawson, USA Ms. Patricia Hurst Mr. Laukton Rimpel Mr. Daniel Boehm Ms. Crystal Chadwick Disclaimer
The purpose of this Handbook is to provide concise, supplemental reading material for attendees of the Field Management of Chemical Casualties Course. Every effort has been made to make the information contained in this Handbook consistent with official policy and doctrine. This Handbook, however, is not an official Department of the Army publication, nor is it official doctrine. It should not be construed as such unless it is supported by other documents. TABLE OF CONTENTS
Nerve Agents
Vesicants
Lung-Damaging Agents and TICs
Riot Control Agents
Incapacitating
Biological Agents
Field Management of Casualties
Patient Decontamination
Chemical Defense Equipment
Appendices
With the end of the Soviet Union as a global superpower, the world as we knew it ended, and a turning point in world history began. We first witnessed this moment in 1990 with the formal reunion of East and West Germany, through Operations Desert Shield and Desert Storm, Operations Restore Hope in Somalia, and the United States' (U.S.) involvement in the Balkans Conflict, September 11, 2001, Afghanistan, and Operation Iraqi Freedom. This historic shift and the War on Terrorism will persist well into the next century. The ability and will to wage war on a large scale have not diminished, only shifted to new players. Former Soviet subjects have taken new and unpredictable directions. Strident nationalism and long suppressed ethnic rivalries have emerged with vicious, bloody warfare the end result. The disarray and economic upheaval inside Russia have allowed the sale of Russian weaponry and technology to perpetuate. The so-called third world nations and terrorists have also taken advantage of the new world order to challenge what was once thought unchallengeable. Economic investment and economic power have given military muscle to nations who, even 10 years ago, were struggling just to feed their people. In some cases, this newfound power has also taken on nationalistic fervor. As a consequence of the unprecedented world challenges, the threat spectrum faced by the U.S. into the next century has broadened. It now includes formerly democratic governments, members of regional cooperation alliances, and terrorists of all persuasions. Let's narrow our gaze somewhat and look at examples of threats within the chemical and biological (C/B) threat spectrum. THE C/B THREAT SPECTRUM
The threat of C/B weapons' use against coalition forces in Operation Desert Storm must be seen as the first of many C/B threats the U.S. military will face. Throughout the world, nations and terrorists are still attempting to, or have in fact, produced C/B agents and means to employ them. This handbook will provide some answers and suggestions, but you, the medical NCO, must read and research to ensure that the mission of providing health service support to chemical casualties will be successful. NERVE AGENTS
GA, GB, GD, GF, VX
Signs and Symptoms:
Small exposure—small pupils, runny nose, mild
difficulty breathing. Large exposure—sudden loss of
consciousness, convulsions, no breathing, flaccid paralysis, copious secretions from nose, mouth and lungs, small pupils. Liquid on skin:

Small to moderate amount—localized sweating,
nausea, vomiting, feeling of weakness. Large amount—sudden loss of consciousness,
convulsions, no breathing, flaccid paralysis, copious secretions from nose, mouth, and lungs. Detection: M256A1; Improved Chemical Agent
Monitor (IICAM); M8 paper; M9 paper; M22 (ACADA).
Decontamination: M291; large amounts of water and
soap; RSDL, 0.5% hypochlorite bleach, M295. [Note:
Never use full-strength or 5% bleach on skin!]
Immediate management: administration of MARK I
kits or ATNAA; diazepam (Convulsive Antidote Nerve
Agent-CANA). In addition, if casualty's symptoms are
severe, ventilation and suction of airways for
respiratory distress.
NERVE AGENTS
Nerve agents are considered the primary chemical agent threat to the U.S. military because of their high toxicity and effectiveness through multiple routes of entry. They are absorbed through the eyes, respiratory tract, and skin. TOXICITY
The classical nerve agents are Tabun (GA), Sarin (GB), Soman (GD), GF, and VX. Tables I and II show the toxicities of the nerve agents by inhalation and skin exposure. The Ct product, or C x t, is a marker of a dose of a vapor or aerosol to which someone
has been exposed. The units are usually mg/m3
for C and minutes for t. One can be exposed to
the same Ct of 100 mg-min/m3 by staying in a
concentration of 10 mg/m3 for 10 minutes
(10x10=100), 20 mg/m3 for 5 minutes
(20x5=100), or 5 mg/m3 for 20 minutes
(5x20=100). The Ct that will cause a biological
effect is constant over a range of C and t. Thus,
if a Ct of 100 mg-min/m3 of nerve agent causes
shortness of breath, it would be a result of any
combination of C and t that produces a product
of 100 mg-min/m3.
LCt50 is the Ct of agent vapor that will be lethal (L) to half of the population exposed to it. The ICt50 is the Ct that will incapacitate (I) half of those exposed to it. The word "incapacitate" must be defined when using this term. For example, dim vision might incapacitate a Soldier for some jobs, in which case the ICt50 will be the Ct needed to cause dim vision. On the other hand, incapacitation might be defined as loss of consciousness and twitching, in which case the ICt50 will be the Ct needed to produce these effects. The ICt50 shown in Table I causes severe effects, including convulsions. Table I shows the estimated LCt50, estimated ICt50, and Ct that will cause pinpoint pupils (miosis) in half of the exposed population (MCt50). Table II shows the estimated amounts that will cause lethality in half of the population when placed on the skin. The LD50 is the dose (D) of agent liquid or
solid that is lethal (L) to half of the population
exposed to it. The LD50 of VX, when placed on
human skin, is the size of a droplet that will
cover the width of two columns of the Lincoln
Memorial on a Lincoln penny.
TABLE I. Vapor Toxicity
Agent LCt50
TABLE II. LD50 on Skin
Agent Amount
MECHANISM OF ACTION
When a nerve agent poisons a Soldier, the action of the enzyme acetylcholinesterase
(AChE) is blocked. The normal function of
acetylcholinesterase is to break down
(hydrolyze) the chemical messenger, or
neurotransmitter, acetylcholine (ACh).
The nervous system is made up of electrically conducting cells called neurons. Neurons convey information by electrical signals, called action potentials. When an electrical signal reaches the end of the neuron, the information must be conveyed to the next cell by means of a chemical messenger or neurotransmitter. Cholinergic neurons are neurons, which use ACh as the neurotransmitter to communicate with other cells. When an electrical signal reaches the end of a cholinergic neuron, the neuron releases packets of ACh. These cross a space, called a synaptic cleft, to the next cell in the series, another neuron, gland cell, or muscle cell. There they interact with specialized proteins called synaptic receptors. The interaction of enough molecules of ACh with post-synaptic receptors, or receptors on the second cell, causes a new electrical signal to arise and continue the communication into the second cell. Acetylcholinesterase (AChE), an enzyme present on post-synaptic membranes, serves as the turn-off switch or governor of this process. AChE breaks down or hydrolyzes ACh, stopping the reaction from getting out of hand. Nerve agents act directly upon AChE. When a nerve agent inhibits AChE, it cannot
perform its normal function of hydrolyzing ACh.
ACh then accumulates, and the target cell's
action continues uncontrolled, producing a
clinical syndrome called cholinergic crisis.
The primary concern of the Soldier medic or combat lifesaver when treating the nerve agent poisoned Soldier is to provide correct, timely, and lifesaving care. The first step in providing this care is to understand the effects that vapor or liquid nerve agent exposure has on the Soldier. Nerve agent produces cholinergic crisis by inhibiting AChE and thus prolonging the action of ACh. The parts of the body that are affected by excessive acetylcholine accumulation are: • Nose (glands) • Mouth (glands) • Respiratory tract • Gastrointestinal tract • Cardiac muscle • Sweat glands • Skeletal muscle • Central nervous system (CNS) Eyes. Direct contact with a nerve agent
vapor or aerosol produces effects on the eyes. When the route of entry of the agent is through the skin or by ingestion, the effect on the eyes is delayed or may not occur. The main effect of the agent is to cause miosis, or pinpointing, of the pupils. One or both pupils may be pinpointed and unresponsive to light or darkness. Pinpoint pupils cause a complaint of dim vision that is more pronounced in low light conditions; Soldiers may complain that everything looks "black," even in the middle of the day. Frontal headache, mild aching around the eye, or severe eye pains are common complaints in a Soldier exposed to a moderate concentration of agent. About one patient in ten may complain of nausea. Twitching of the eyelids may be observed through the protective mask, and the eyes may be reddened. When a light source is used to test for pupillary response, the Soldier may complain of an ache behind the eyes due to light sensitivity. Nose and Mouth. The secretory glands of
the nose and mouth are as or more sensitive to nerve agent vapor or aerosol than the eyes. If the Soldier is poisoned by nerve agent liquid on the skin or by ingestion, the nose will become affected, but only in response to the whole body (systemic) involvement. But if exposed to a nerve agent vapor or aerosol, the nose will begin to run immediately. This effect has been described by patients recovering from accidental nerve agent vapor exposure as "worse than a cold or hay fever" and "like a leaking faucet." Even after low concentrations of agent, runny nose (rhinorrhea) may be severe. The mouth will secrete saliva so copious that watery secretions run out the corners of the mouth. Respiratory Tract. Inhalation of a small
amount of nerve agent vapor will cause the Soldier to complain of tightness in the chest or shortness of breath (dyspnea). This occurs because the excessive ACh stimulates the muscles in the airways to contract and constrict the airways (bronchoconstriction). As the concentration increases, breathing difficulty will become severe. One or two breaths of a high concentration of nerve agent vapor will cause gasping and irregular respirations within seconds to a minute or two. Cessation of breathing (apnea) can occur within minutes after exposure to a large amount of nerve agent, either by liquid on the skin or vapor. Excessive bronchial and upper airway secretions (bronchorrhea) caused by stimulation of the airway glands by the excessive ACh will compound breathing difficulty. These secretions can obstruct the airway and cause difficulty in moving air into and out of the lungs. Gastrointestinal (GI) Tract. After exposure
to a large but sublethal concentration of vapor, the Soldier will complain of nausea and may vomit. Nausea and vomiting may be the first effects from liquid nerve agent exposure on the skin. The Soldier may complain of nausea followed by vomiting, "heartburn," and pain in his abdomen. In addition, the Soldier may belch frequently and have diarrhea or involuntary defecation and urination. These effects usually occur within several minutes after vapor exposure. However, after liquid agent exposure on the skin, these effects may lag in onset for as long as 18 hours after exposure. Cardiac. The heart rate can either increase
or decrease after nerve agent exposure. Generally, blood pressure will increase, but the blood pressure can rarely be determined in a contaminated area because the casualty and the examiner are in protective gear. Although it is important in assessing the patient's cardiovascular status, the heart rate will not aid the Soldier medic/combat lifesaver in choosing the care needed to treat nerve agent poisoning. Sweat Glands. The skin is very permeable
to nerve agent. When penetration occurs after either liquid or vapor exposure, localized sweating occurs and progressively spreads over the surrounding skin area as nerve agent is absorbed. The likelihood that the Soldier medic/combat lifesaver will be able to observe this localized sweating is minimal. Skeletal Muscles. After exposure to a
moderate or large amount of nerve agent, the Soldier will complain of weakness and twitching of muscle groups. The twitching can first be noticed at the site of a liquid droplet on the skin. The muscles may show a rippling effect (fasciculation). As the nerve agent effect progresses, muscles can go into a prolonged contraction. However, instead of a prolonged contraction, the large muscle groups may begin unsynchronized contractions that cause the arms and legs to flail about. The hyperactivity of the muscles in these instances leads to muscle fatigue and flaccid paralysis (limp, unable to move). Unless the Soldier medic/combat lifesaver aggressively cares for this casualty, he/she will not survive. The twitching caused by the direct effect of nerve agents on skeletal muscle may be difficult to distinguish from the tonic-clonic movements of convulsive seizures, but they are not seizures. Seizures are caused by electrical discharges in the brain. A nerve agent poisoned patient who has been treated, has normal mental status, and is talking appropriately, but still has twitching, is most likely not seizing, but suffering the skeletal muscle effects only. Because certain muscles, especially the diaphragm, play a major role in breathing, the skeletal muscle effects of nerve agents can worsen the patient's respiratory status by weakening or paralyzing these muscles of respiration. Central Nervous System (CNS) (brain and
spinal cord). In the case of a large inhalation or
liquid dose, the effects are rapid and usually
fatal under battlefield conditions. The Soldier
almost immediately loses consciousness,
followed seconds later by seizure activity.
Several minutes later, respiration ceases.
Without immediate care, this Soldier will not
survive to reach Level 1 treatment. Seizures
may be present without motor activity, especially
in a patient who has been either twitching or
seizing for long enough that he/she has depleted
the muscles of energy in the form of adenosine
triphosphate (ATP).
When exposed systemically to low amounts of nerve agent, the Soldier may complain of generalized weakness. Some people who have survived low dose exposures have complained of nonspecific symptoms for weeks. These symptoms have included change in sleep pattern, mild memory losses, and new headaches. Some of these symptoms may reflect post-traumatic stress disorder. Understanding when these effects can most occur is critical for the Soldier medic/combat lifesaver. The length of time a casualty may be in your care is unknown. It is best to understand what may occur and when, because being surprised by and unprepared for the reactions of a nerve agent poisoned Soldier lessens his chances for survival. Tables III and IV show nerve agent effects, the onset time of these effects, and the required self- and buddy-aid. These tables show the typical time course for mild, moderate, and severe exposures to nerve agent. When a lethal or near lethal exposure occurs, the time to onset of symptoms and maximal severity of symptoms may be extremely brief. If aggressive care is not given to the Soldier exposed to a lethal concentration, death can result within five minutes after the appearance of symptoms. TABLE III. Nerve Agent Effects
Vapor Exposure
Small pupils (miosis) Runny nose (rhinorrhea) Mouth Salivation Tightness in the chest (dyspnea, bronchoconstriction) Time of onset: seconds to minutes after Self-aid: 1 MARK I Kit or ATNAA
Buddy-aid: stand by
All of the above, plus Severe breathing difficulty or cessation of Generalized muscular twitching, weakness, Loss of consciousness Loss of bladder, bowel control Time of onset: seconds to minutes after
Self-aid: none; Soldier will be unable to help
Buddy-aid: 3 MARK I Kits or 3 ATNAAs and
diazepam (CANA) immediately

Treat the casualty using his own MARK I
and diazepam to start. Do not use your own.

TABLE IV. Liquid on Skin

Mild/Moderate

Muscle twitching at site of exposure Sweating at site of exposure Feeling of weakness Time of onset: 10 minutes to 18 hours
Self-aid: 1 to 2 MARK I Kits or ATNAAs,
depending on severity of symptoms Buddy-aid: stand-by
All of the above, plus Breathing difficulty or cessation of breathing Generalized muscular twitching, weakness, Loss of consciousness Loss of bladder and bowel control Convulsions Seizures Time of onset: minutes to an hour after
Self-aid: none; Soldier will be unable to
Buddy-aid: 3 MARK I Kits or ATNAAs and
diazepam (CANA) immediately
Treat the casualty using his own MARK I
and diazepam to start. Do not use your own.

TREATMENT
The most important care the casualty
receives is the care given within the first
several minutes after exposure (self-aid,
buddy-aid).

Immediate care, including administration of antidotes, can mean the difference between survival and death in a Soldier exposed to a nerve agent. It is imperative that every medic/combat lifesaver understands the effects of nerve agents, the time in which effects occur, and the correct steps to take to save the exposed Soldier. Every Soldier must know the signs and symptoms of mild and severe nerve agent poisoning and the correct first aid in order to evaluate and provide the appropriate self- and buddy-aid. SELF-AID AND BUDDY-AID
Timely and correct determination of the type of agent and route of entry causing the signs or symptoms is critical if the poisoned Soldier is to survive to reach definitive medical care. Nerve agents will, under most field conditions, be encountered in both the vapor and liquid forms. When nerve agents are encountered and Soldiers have donned protective equipment, a hasty self-evaluation for signs or symptoms of poisoning must be conducted. This self-evaluation implies that Soldiers know the signs and symptoms of mild and severe nerve agent poisoning, as well as the correct first aid. Tables III and IV show methods of exposure, resulting signs or symptoms, and self-aid or
buddy-aid to be rendered. Timely and correct
first-aid actions are critical to enhance the
casualty's chances for survival.

When the effects progress to more than one organ system, the situation has changed from a mild to a severe exposure. The buddy's aid in determining this change becomes critical. As the change occurs, the remaining MARK I Kits and one CANA autoinjector must be administered. Always follow self- or buddy-aid promptly with Level 1 medical care. SOLDIER MEDIC/COMBAT LIFESAVER
TREATMENT OF NERVE AGENT
POISONING
The Level 1 care provider (medic, combat lifesaver) must rapidly determine the following: • extent of the poisoning • what medications have been administered • complications induced by the poisoning and/or resulting from conventional wounds • if possible, route of exposure, liquid or vapor; liquid poisoning can delay onset of effects PROTECTIVE POSTURE
DURING TREATMENT
First, protect yourself by donning Mission- Oriented Protective Posture (MOPP) Level IV. CASUALTY DECONTAMINATION
Next, assist the casualty in performing decontamination of exposed skin in the following order: • arms and hands • other exposed skin areas Performing this decontamination eliminates nerve agents on the skin surface that could continue to absorb into the skin causing a "time release" effect of symptoms. TREATMENT GUIDELINES
The treatment guidelines provided below assume that the Soldier medic or combat lifesaver is certain that nerve agent poisoning has occurred. Use of atropine in the absence of nerve agent will cause the casualty to experience inhibition of sweating and heat storage problems in a warm climate. DRUG THERAPY
Atropine is the drug of choice for treating
nerve agent poisoning. It will dry secretions,
(including those in the airways), reduce
bronchoconstriction, and decrease
gastrointestinal motility.
Atropine
will not relieve miosis and will
not relieve muscle twitching or spasms or
increase diaphragm effort.

Mild and Improving Symptoms (Especially
Vapor-only Exposure).
Observation is all that is needed for the casualty with mild symptoms, such as rhinorrhea, slight or recovering breathing difficulty, or excessive salivation that is decreasing. In the casualty with mild symptoms that appear to be clearing, the one MARK I Kit administered during self-aid, followed by observation for several hours, will normally be all that is needed. In general, if there is suspicion that the patient may have had a liquid exposure, the patient should be observed for at least several hours and not returned to duty. Liquid exposures can cause symptoms with onset delayed by many hours. Pain in the eyes, twitching of the eyelids, redness, and miosis cannot be treated in the
field setting by the Soldier medic/combat
lifesaver. At the battalion aid station (BAS), eye
pain can be controlled with atropine eye drops.
These conditions, although annoying, are not
life-threatening.

Severe Symptoms.
If the casualty has severe symptoms involving two or more major organ systems (systemic) (gastrointestinal, skeletal muscle, respiratory, etc.), the first step is to administer all three MARK I Kits and diazepam. MARK I kits include autoinjectors of 2 mg atropine and 300 mg 2-PAM Cl. Giving one MARK I means injecting both into the patient. Diazepam (CANA) should always be
administered when the three MARK I Kits are
given together. Additionally, more atropine (2
mg) should be given every five minutes until the
patient breathes easily without excess
secretions complicating breathing. A total of 15
to 20 mg of atropine may be required in the first
3 hours after the onset of symptoms.
Atropine. If the casualty is unconscious
and in respiratory distress, three MARK I Kits
and diazepam should be given immediately,
followed by additional atropine as described
above. Over the next 5 to 15 minutes, 10 to 15
mg of atropine may be needed. Atropine
administered with the autoinjector will show
some effectiveness in three to five minutes.
During the time the atropine takes to reach
maximum effect, the constriction and secretions
in the airway and feeling of "tightness in the
chest" will begin to decrease. Atropine will have
a drying effect on salivation and rhinorrhea.
Atropine (2 mg) should be administered at 3 to
5-minute intervals until the casualty can tell the
Soldier medic/combat lifesaver that it is easier to breathe or manual ventilation becomes easier. Observe the casualty for indications that the atropine can be discontinued. At Level 2 and higher, IV access will allow more precise administration of additional doses of atropine through the IV route. There is no upper bound to atropine use.
• Secretions of the mouth, nose, and lungs • The casualty tells you that breathing is easier, or it is easier to administer assisted ventilation. Pralidoxime Chloride (2-PAM Cl) in the
autoinjector (600 mg, 2 ml) is the second drug
for use in nerve agent poisoning cases. The 2-
PAM Cl removes nerve agent (except Soman)
from the enzyme acetylcholinesterase. The 2-
PAM Cl (included in the MARK I Kit) must be
used as early as possible. If symptoms are
severe, involving two or more organ systems (for
example, the lungs and gastrointestinal tract), all
three MARK I Kits and diazepam (CANA)
should be given immediately. Additional
autoinjectors are not administered until an hour

later. If severe signs or symptoms still persist
one hour after using the three MARK I Kits,
three additional 2-PAM Cl autoinjectors should
be administered. More than two sets of three 2-
PAM Cl (six total) must not be used.
Once the patient reaches Level 2 care, IV 2-
PAM Cl may be administered.
Excess 2-PAM Cl may harm the casualty by dangerously raising blood pressure and causing
laryngospasm. Never give more than 3
autoinjectors (or 2000 mg IV) of 2-PAM Cl per
hour.
Discontinue the use of 2-PAM Cl after symptoms of respiratory distress have eased. Diazepam (CANA) in the 10-mg autoinjector
is the drug adopted by the U.S. military for use
in controlling convulsing patients. The doctrine
for its use instructs the Soldier to administer one
diazepam autoinjector to his buddy immediately
after using the third MARK I Kit in severe
poisoning cases. Diazepam is not for self-use.
It should be given only to severe casualties by
the medic. The key to increasing the
effectiveness of the diazepam is administering it
before convulsions begin. Again, when two or
more organ systems become involved, one
diazepam autoinjector should be administered
along with the three MARK I Kits to lessen the convulsive activity the Soldier may experience. The Soldier medic or combat lifesaver may administer a second and third diazepam autoinjector using the guidelines below. After the first injection (buddy-aid): • Observe the casualty for about 10 minutes. • Ventilate if necessary. • Turn the casualty on his/her side to facilitate breathing. • Pad areas to prevent other injuries. • Restrain if necessary. • If still convulsing after 10 minutes, give the second diazepam autoinjector. Following the second injection (medical aid): • Observe the casualty for 5 to 10 minutes. • If still convulsing after 5 to 10 minutes, give a third diazepam autoinjector. Medical officers and PAs may choose to give more diazepam, either IM or IV, if they
deem it necessary.
ATNAA (Autoinjector Treatment, Nerve Agent
Antidote): This is a new autoinjector that will

replace the MARK I in the military inventory. It
contains dual chambers, which administer 2.1
mg atropine and 600 mg 2-PAM Cl sequentially
through one needle. When it is fielded, it will
require only half the time to treat a casualty as
does the present MARK I. Doctrine for its use
will be identical to the present MARK I.
SERPACWA (Skin Exposure Reduction Paste
Against Chemical Weapon Agents): This lotion
is applied to the skin prior to possible chemical
situations, to prevent direct contact with the
agent. It is applied like a lotion/cream, and
replenished as needed. It is not intended for use
on broken skin. It protects against nerve agent
liquid.
VENTILATION
Although the use of pyridostigmine pretreatment will decrease the need for assisted ventilation in nerve agent casualties, the need will arise, on occasion, for assisted ventilation in some severe nerve agent casualties. Aggressive airway maintenance and the use of assisted ventilation will greatly increase the casualty's chances for survival. Providing assisted ventilation in a potentially contaminated environment is possible using the
Resuscitation Device, Individual, Chemical
(RDIC) (see chapter on equipment). By using
this device, the Soldier can survive to reach the Level 1 care facility where mechanical ventilation can take over. Without this aggressive, far-forward resuscitation, the Soldier will not survive. The U.S. military has adopted the policy of pretreating Soldiers against the nerve agent's
effect on AChE with pyridostigmine. Each
Soldier in the combat theater of operations is
issued one package of pyridostigmine tablets.
Each blister pack contains 21 tablets, and each
tablet contains 30 mg of pyridostigmine. The
Soldier takes the pretreatment only on order
from the unit commander. When ordered, one
tablet is taken orally every eight hours. If a
scheduled dose is missed, it will not be made
up; the Soldier will take one tablet at the earliest
opportunity to begin the next eight-hour interval.
The Soldier will discontinue taking the tablets on
order from the unit commander. The
pretreatment is dispensed in a 14-day blister
pack. Doctrine allows commanders to renew the
order once, for a total of 28 days.
Pyridostigmine bromide shields the AChE enzyme from the full effects of GD. It prevents GD from permanently and irreversibly binding the enzyme, which it would otherwise do in two minutes. Pyridostigmine enhances the efficacy
of 2-PAM Cl in GD casualties. The pretreatment
does not increase the effectiveness of treatment
for GB, GF, or VX. These nerve agents also
become irreversibly bound to AChE but require
many hours to do so, and the binding does not
affect therapy. The effect of pyridostigmine
bromide is to convert what would have been
a lethal dose of GD into a dose that is
survivable, but only if antidotes are promptly
and correctly given. Instead of a dead Soldier,
we have a sick one who requires treatment.
Pretreatment is not an antidote. Pretreatment alone will not protect the Soldier
and does not reduce the effects from the nerve
agent. When used in conjunction with the MARK
I Kit, pyridostigmine enhances the effectiveness
of the MARK I Kit against GD only. It is critical
that the Soldier medic understand that the effect
of the pretreatment will have no effect on the
severity of nerve agent poisoning symptoms.
Therefore, an aggressive approach to care with
antidotes is still warranted.
The Food and Drug Administration (FDA) approved the use of pyridostigmine bromide as pretreatment against GD in early 2003. This use of pyridostigmine bromide is therefore not experimental, and commanders are legally permitted to order it. Soldiers should be told that common side- effects of pyridostigmine bromide are increased bowel movements and abdominal cramping. In most cases these side effects decrease or go away completely after a few days. If these or other symptoms persist, Soldiers should see their combat medic or medical officers before going off the medication if command has ordered that it be taken. H, HD, L, HL
Signs and Symptoms: asymptomatic
latent period (hours). Erythema and blisters on the skin; irritation, conjunctivitis and
corneal opacity and damage in the eyes;
mild upper respiratory signs to marked
airway damage; also gastrointestinal
effects and bone marrow stem cell
suppression. Fever is not typically
associated with the agents.
Detection: M256A1; ICAM; M8 paper; M9
paper.
Decontamination: M291; water/soap in
large amounts. M295 for equipment.
Management: Decontamination
immediately after exposure is the only way
to prevent damage. Symptomatic
management of lesions.
VESICANTS
The blister agents are second only to nerve agents as a concern to the U.S. military. The primary threat blister agents are sulfur mustard (H/HD), Lewisite (L), and a mixture of mustard and Lewisite (HL). Mustard is a concern because there are large stockpiles of it, it is easily manufactured, and because it is both incapacitating and lethal. Mustard was the largest cause of chemical casualties in World War I. It was also used extensively by Iraq in the war with Iran. Although there were many casualties from mustard in World War I, only about 3% of the casualties died as a result. This low death rate occurred despite the relatively poor protection and level of medical care available at that time (e.g., no antibiotics). Mustard rapidly penetrates the skin, causing both localized cellular damage and systemic damage. The true deadly nature of the agent's effect is that the Soldier exposed to a large amount of liquid or vapor mustard faces total systemic assault. The reasons for this are (1) failure of the body's immune system, with sepsis and infection as the major contributing causes of death, and (2) pulmonary damage, which is also a major contributory factor in death. PHYSICAL CHARACTERISTICS
The severity of blister agent effects will, in part, be affected by the environmental conditions at the time of exposure. Warm, humid conditions increase the severity of blister agent damage and shorten the time of symptom onset. Cold weather retards the time of symptom onset, and providing the exposed skin remains cold, lessens the severity of blister agent damage. Mustard (H/HD) has a fairly high freezing point of 58oF agent, while the mixture HL, containing 37% HD to 63% Lewisite, has a freezing point of -3oF. The lower freezing point of the mixture will cause the agents to have a significant impact on combat operations in a cold northern environment, as well as in a warm desert environment. Blister agents also have a relatively high vapor density when compared to air. Mustard has a vapor density 5.4 times greater than air, Lewisite a density 7.1 times greater, and HL is 6.5 times heavier than air. The more dense a vapor is, the more likely it is to flow to low spots such as valleys, closed spaces, or the floor. The Soldier medic/combat lifesaver can use the current intelligence on threat chemical capabilities and the physical characteristics of blister agents to determine likely exposure mechanisms (liquid and/or vapor) based on temperature. Utilizing all of these data elements, the combat lifesaver and combat medic can then be proactive to the predicted chemical threat; that is, take active steps to prevent or lessen the impact of chemical agent employment on individuals. This information, coupled with understanding the medical implications of an exposure, will allow the combat lifesaver/Soldier medic to "war game" scenarios and anticipate, ahead of time, the required, correct response needed to optimize casualty care. When operating in cold northern climates or desert regions, particularly at night, care must be exercised to prevent getting contamination into warm-up tents, operations areas, or sleeping areas. An agent at its freezing temperature brought in on clothing or skin will liquefy as it warms and slowly produce vapors. Unless this situation is detected early, Soldiers will be exposed within these confined spaces. In the temperature ranges mentioned earlier, provisions must be made for monitoring personnel and their equipment in a warm-up tent before the individuals occupy work or rest areas. All personnel in the monitoring tent must wear protective masks during monitoring. If the unit fails to conduct monitoring of personnel and equipment before entering sleep or work areas, the potential exists for intoxication by multiple routes of exposure. Soldiers could absorb agent through the skin by handling equipment contaminated with a liquid agent, or vapors desorbing from equipment contaminated by liquid agent could affect the eyes and respiratory tract. DETECTION
Mustard received its name because of its garlic, horseradish, or mustard odor and can be detected by smell, visual observation (oily), M8 and M9 Chemical Detection Papers, the M256A1 Chemical Detection Kit, and the IICAM. The human nose can detect mustard (H/HD) in concentrations of 0.6 to 1.0 mg/m3. While this seems an undesirable way to detect blister agent, it must be understood that the U.S. military has no automatic vapor/liquid detection capability. Alert Soldiers will most likely smell the agent vapor before encountering the liquid. After release, H/HD appears as a thick, colorless or pale yellow liquid, and HL appears as a dark oily liquid. The M8 Chemical Detection Paper will turn red in the presence of liquid mustard. The
detector ticket from the M256A1 will detect
mustard vapor in concentrations of 2 mg/m3 to
12 mg/m3 within 10 minutes. The IICAM will detect mustard in concentrations of 0.03 mg/m3 to 30 mg/m3. H/HD. Clinical signs and symptoms from
mustard exposure are not apparent until hours later (see Table); however, tissue damage occurs within two minutes. If decontamination is not done within the first two minutes after exposure, nothing can be done to prevent a mustard injury. Clinical effects occur on the skin, in the eyes, and in the airways. In the event of severe exposure, effects occur days later in the bone marrow and gastrointestinal tract. The effects on the skin are redness (erythema) that resembles sunburn, and later, blisters. The eyes initially are irritated and later may become swollen shut. The first effects in the airways are the upper airways, with a hacking cough, hoarseness, and throat and nasal irritation. If the exposure is severe, the agent later damages the lower airways. The major effects and the times at which the first effects begin are shown in the table. HL. The effect of HL liquid on the eyes and
skin, or vapor in the eyes or respiratory tract, is immediate. HL causes intense pain and lid twitching in the eyes. Within an hour, edema of the conjunctivae and lids begins and rapidly results in eye closure. The casualty feels stinging pain within seconds after contact with liquid HL. The pain
causes the casualty to decontaminate rapidly.
Rapid decontamination is the only way to
avoid severe burns. After five minutes of
contact with HL, the upper layer of skin
(epithelium) will die and appear gray. Painful
erythema will begin shortly afterwards, and
painful blisters may appear within 12 hours.
The immediate irritation from HL vapor is so intense that an individual will immediately mask or exit the area. Respiratory casualties will be unable to do either. Pulmonary effects are similar to those caused by mustard alone, except that pulmonary edema (fluid in the lungs) is more likely after Lewisite. SELF-AID AND BUDDY-AID
The actions needed for self-aid or buddy-aid are essentially non-medical in nature. Reacting as quickly as possible to warnings of an attack by donning the protective mask and going to MOPP IV, detecting the agent as early as possible, and removing any suspect liquid (decontaminating) using the M291 Skin Decontaminating Kit (SDK) are the easiest ways to prevent a blister agent casualty. Reacting quickly to attack indicators will prevent most, if not all, casualty-causing exposures. Some indicators that an attack is in progress or you have come in contact with agent from a previously unknown attack are as follows: • The out of place smell of mustard, garlic, • Color change in M9 detector tape. • Color change in M8 detector card. • Overt indications such as enemy helicopters spraying liquid, indirect artillery fire that detonates with dull or muffled explosions. • An oily feeling of "rain" as it impacts on • Liquids that appear too thick or oily and appear out of place on equipment, plants, or terrain. Self-aid or buddy-aid for exposure to blister agents includes decontamination of the eyes. When exposure is suspected, time is critical. Unless the individual was wearing a protective mask at the time of the suspected exposure, the assumption must be that the eyes were exposed. Following the task in STP 21-1-SMCT, Soldier's Manual of Common Tasks, the individual must decontaminate the eyes and,
although this is not a buddy-aid task, having
assistance will increase the effectiveness of the
procedure. Remember that time is critical for
effective mustard decontamination as blister
agents become "fixed" to tissue components
within two minutes after deposition. Using the
M291 SDK as soon as possible to remove agent
and flushing the eyes with water will do much to
prevent or lessen the physical damage from
blister agent exposure.
TABLE. Effects of Mustard Vapor
ORGAN SEVERITY
Burning Gritty feeling Swelling of lids Moderate pain Marked swelling of Possible cornea damage Severe pain Nosebleed Hoarseness Hacking cough Severe productive cough Shortness of breath (mild to severe) COMBAT LIFESAVER/MEDIC ACTIONS
The initial medical treatment actions required by the combat lifesaver/Soldier medic at the time of exposure are little more than what the individual himself can do. Self-aid decontamination must be done at the time of exposure. Because of the long time delay until the onset of symptoms under combat conditions, the wounded, exposed individual will have been returned to duty or evacuated by the time symptoms appear. CASUALTY DECONTAMINATION
The casualty should have performed skin and equipment decontamination with the M291 and the M295, respectively, before being seen by the combat lifesaver/Soldier medic. Because of the persistent nature of blister agents, the decontamination of the patient must be as thorough as possible. As with nerve agent exposure, you must protect yourself by masking and donning MOPP gear. When beginning treatment, attempt to determine what type of decontamination has been done and when. Understanding the potential contamination threat posed by the casualty will allow the combat lifesaver/Soldier medic to avoid cross contamination. Decontamination performed within two minutes reduces the toxic effects by greater than 50%. FIELD TREATMENT
The actions required at the unit level for blister agent casualties are two-fold. First is triage for evacuation or return to duty, and second is the actual treatment of the casualty. Triaging the Soldier is based on several factors--the severity of observable effects, the opinion of the triaging combat lifesaver/Soldier medic as to whether or not the effects will progress further, and the impairment of normal duty requirements the symptoms cause in the individual. Casualties with signs or symptoms that appear at the earliest onset time possible (see Table) generally require evacuation with little chance for quick return to duty from the Medical Treatment Facility (MTF) because the initial effects will progress. Faster onset of symptoms can indicate exposure to higher concentrations of agent with more severe lesions, for which the care available at a MTF is required. Eyes. Individuals with mustard conjunctivitis
will require application of a steroid antibiotic eye ointment. FM 8-285, Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries, recommends dexamethasone sodium phosphate-neomycin ophthalmic ointment for application. This drug decreases the inflammation and has antibacterial effects. Systemic narcotic analgesics are recommended for eye pain. Under no circumstances should the eyes be bandaged as this will allow the eyelids to stick together, and the secretions will not have a means to drain. The resulting accumulation in the conjunctival sac can lead to infection and corneal ulcerations. Individuals presenting with blister agent conjunctivitis will require evacuation to a MTF for treatment by an ophthalmologist as soon as possible. Petroleum jelly or antibiotic ointments should be placed on the eyelashes to prevent abscess formation. Skin. Individuals presenting with erythema
(reddening of the skin), which limits motion in a limb will need to be evacuated. Erythema covering greater than 5% of the body in noncritical areas, using the Rule of 9s to determine the coverage, will require evacuation. Individuals with erythema involving less than 5% of the body may need evacuation, but this usually is determined by the location of the erythema and the duty impairment caused. The treatment for erythema is that needed for the itching and burning sensations that accompany it. Application of a topical steroidal cream or calamine lotion will provide temporary relief. Normally erythema progresses to vesication (blister formation) with the size and number of blisters forming being dependent on the severity of exposure, skin condition (sweaty and moist or dry) at the time of exposure, and location of the exposure on the individual. Blisters the size of a quarter or smaller should be left intact, if possible. The blister, which is filled with a sterile fluid, will act as a protective cover over the wound providing good protection from infection. These small, unbroken blisters should be covered with a petrolatum gauze bandage. The dressing should be changed every three to four days. The blister fluid does not contain live agent. Large blisters should be unroofed, and blisters that have broken should have the ragged roof of the blister removed. The area of the open blister should be cleaned with tap water or saline and a petrolatum gauze bandage applied. The primary concern when treating blisters of any size is prevention of infection. The decision to evacuate or return to duty must not be made only on the basis of blister formation. Initial blister formation may be slight, but over time could progress to large blisters unmanageable in the field. If a casualty is not evacuated, the combat lifesaver or Soldier medic must instruct the individual on self-aid care for the blister. The individual should be given a topical antibacterial cream, such as 10% mafenide acetate or silver sulfadiazine burn cream, and instructed to apply a 1/8 inch layer to the blister four times a day. A petrolatum gauze bandage should then cover the area. Lungs. The Soldier who presents with any
sign or symptom of respiratory exposure should be evacuated promptly. The combat lifesaver/Soldier medic cannot determine damage to the larynx or trachea. Any unnecessary delay in diagnosis and required treatment at the MTF must be avoided. If the airway is obstructed by blisters, they may be unroofed.
Estimation of body surface area by the use
of the Rule of 9s. (Copied from FM 8-230)
Signs and Symptoms: few. After
exposure to high Ct, seizures, respiratory and cardiac arrest. Detection: M256A1 Kit Detector
Sampler; NOT the M8A1 alarm and
Decontamination: Skin decontamination
is usually not necessary because the agents evaporate rapidly. Wet, contaminated clothing should be removed and the underlying skin decontaminated with water or other standard Management: Antidote: intravenous
Soduim Nitrite and Sodium
Thiosulfate. Supportive: oxygen;
correct acidosis. (CYANOGENS; BLOOD AGENTS)
s of most concern in t category commonly known as blood agents are hydrogen cyanide (AC) and cyanogen chloride (CK). The basic physical action of these agents is to disrupt oxygen utilization at the cellular lev l. nts have a very high vapo pressure, which causes rapid evaporation of the liquid immediately after release. The rapid vaporization significantly reduces the likelihood of a liquid exposure. The AC or CK vapo on the ground will quickly expand outward and up. The high volatility will, within a very shor time, cause the vapor to near the poi t of delivery. Within a short period of time, it will pose little threat downwind from the release point. It is beca se of dissipation <24 hrs that these age called non-persistent. DETECTION
only detection available to the Soldier is
the M256A1 Chemical Detection Kit Detector Sampler. The first indica on of c agent AC might be the sme or in the case of agent CK, the sud o the nose and throat. Do not rely on smell to ct the agent since the majority of the population is not able to detect it, and the effective concentration is too low to be noted. Cyanide causes very few signs and symptoms in man. Death occurs within after inhalation of a large amount. Inhalat lower concentration will produce a slower onset of effects. The major signs and symptoms are shown in the table below. TABLE. Cyanide (AC and CK)
Effects from Vapor Exposure
Moderate, from low concentration
• Transient increase in rate and depth of • Nausea, vomiting • Eye irritation These may progress to severe effects if exposure continues. The time of onset of these
effects depends on the concentration, but is
often within minutes after exposure.
Severe, from high concentration
• Transient increase in rate and depth of breathing--15 seconds • Convulsions--30 se • Cessation of respiration--2 to 4 minutes • Cessation of heartbeat--4 to 8 minutes In addition to the above, CK causes intense irritation of the eyes, nose, and airways. The effects may be similar to those of lung-damagin agents because of the chlorine. SELF-AID AND BUDDY-AID
The only self-aid for AC and CK is to mask. The only buddy-aid for AC or CK exposure may involve helping a Soldier mask followed by removal from the co COMBAT LIFESAVER/MEDIC ACT
set of symptoms may precl the combat lifesaver rendering aid.
ms shown in the table nts and lead rapidly to Rapid evacuation to Level 1 medical care and administration of the cyanide treatment set will improve the casualty's If the casualty can still talk and walk wit difficulty after exposur an d presents at the battalion aid station (BAS), c han e of survival is LUNG-DAMAGING AGENTS AND
TOXIC INDUSTRIAL CHEMICALS
Ammonia, CG, Cl, HC Smoke, NOx
Signs and Symptoms: sudden laryngospasm
and collapse. Central airway: breathing
difficulty, wheezing; sneezing, coughing,
hoarseness when talking. Peripheral airway:
breathing difficulty, chest tightness.
Detection: Odor of newly mown hay or freshly
cut grass or green corn. There are no specific
military field detection devices for these
compounds; however, the ACADA can detect
battlefield agent vapors when deployed as an
area surveillance tool.

Decontamination: Vapor - fresh air; liquid -
copious water irrigation.

Management: termination of exposure, ABCs
of resuscitation, enforced rest and observation,
oxygen with or without positive airway pressure
for signs of respiratory distress, other supportive
therapy as needed.
LUNG-DAMAGING AGENTS AND
TOXIC INDUSTRIAL CHEMICALS
Over 1,800 toxic industrial chemicals (TICs) are used in industry, stored at industrial sites, and transported on the world's road and rail systems. Some of these chemicals were deployed as chemical warfare agents during the First World War, killing and injuring thousands, and can have the same deadly consequences today if released during an accident or th terrorist sabotage. Death from exposure to TICs is more frequent when they are inhaled. Inhaling a TIC in the form of a gas, vapor (gas coming from a liquid), or aerosol (liquid or solid particles suspended in a gas) can cause a sudden closure of the larynx (laryngospasm) causing the victim to become and collapse. TICs can also cause damage to the tissues of the upper airways, resulting in swelling, scarring, and airway narrowing, which can restrict breathing. TICs can damage lung tissues, allowing body plasma and other fluids to leak into the lung air sacs (alveoli), causing pulmonary ed h from asphyxiation. The military medic/combat lifesaver should know about TIC lung-damaging agents because Soldiers might become exposed to them. Knowing how to identify the signs and symptoms and provide appropriate support the individual exposed to these agents will save lives. Understanding the Respiratory System.
The respiratory system can be divided into two
parts. Understanding these parts can greatly
simplify the treatment problem solving process.
Central
Airway. This includes the
nasopharynx (nose), oropharynx (mouth), larynx (vocal cords), trachea and bronchi (airway from the throat into the lungs). Tissues in this area are very moist and thin and can be damaged by TICs. Peripheral Airway. This includes the lung
sacs (alveoli) distributed throughout the lung tissue. During normal respiration, inhaled gasses fill the alveoli and then move slowly through their walls. The gasses then move through the thin walls of the blood vessels (capillaries) surrounding the alveoli and into the blood. TICs can damage the walls of alveoli and the capillaries surrounding them; allowing blood plasma and cells to leak into the air space of the alveoli. TICs are numerous. Those that pose a frequent threat to the Soldier in the field are listed here. Though the list is not complete, casualties from other lung-damaging agents are managed the same way as these examples. In low doses, highly reactive TICs have a greater effect on the central airway; other TICs and still others that are not as re ctive in the central airway, travel deeper in the respiratory tract and destroy the tissues of the alveoli in the peripheral airways. Any TIC inhaled in large doses will cause damage to both eripheral airways.
CENTRALLY ACTING TICs:

Ammonia: This highly caustic and reactive
gas is used for industrial refrigeration, for
cleaning, the processing of some illicit drugs,
merous legitimate industrial p cesses. It is a good exa mple of a TIC that, in low doses, is primarily cent rally acting. It rapid forms a strong base (alkali) when it contacts the moist tissues of the central airway.The alkali burns and destroys the tissues it contacts victim may suddenly go in to laryngospas and collapse. The tissues of the airway will also become swollen. Scar tissue may form along the airway. Frequently, damaged tissue in the airway will die, slough off, and obstruct it. Sulfur Mustard (HD) is an example of a
chemical agent produced solely for warfare that acts on the central airway if inhaled. HD will cause tissue to slough off in large sheets, known as pseudomembranes, which block the airway. The various degrees of airway restriction cause casualties with central airway restriction/obstruction to be unabl to sneeze and cough, have hoarseness when
they talk, and make wheezing noises when they
breathe.
PERIPHERALLY ACTING TICs:

Phosgene. Today phosgene is a major
industrial chemical used in many manufacturing processes. More importantly, it is released from heating or burning many common chemicals or solvents. Carbon tetrachloride, perchloroethylene (a degreasing compound), methylene chloride (used in paint removal), and many other compounds break down to phosgene with flame or heat. Also, common substances, such as foam plastics, release phosgene when they burn. A Soldier pres with shortness of breath in the absence of a chemical attack or other obvious cause should be questioned very carefully about whether he has been near any burning substances or chemical vapors that were near flame or other hot materials (e.g., a heater with open coils). Perfluoroisobutylene (PFIB ). PFIB is
given off when Teflon® burns at high temperatures, such as in a vehicle fire. Teflon® is used to line the interior of many military vehicles, particularly armored vehicles and aircraft. Closed-space fires in these vehicles release PFIB. Survivors of short of breath should be questioned carefully regarding their exposure to the smoke. Oxides of Nitrogen. Oxides of nitrogen, or
NOx, are components of photochemical smog that can be produced by the burni or the burning of industrial waste. These substances can build up to high concent where artillery is fired and there is inadequate ventilation. Soldiers who become short of breath after heavy firing should be suspected of exposure to this lung-dam HC Smoke. HC smoke is a mixture of equal
amounts of hexachloroethane, zinc oxide, and
approximately 7% grained aluminum or
aluminum powder used in the military for
obscuration. The zinc oxide can cause lung
damage if inhaled in toxic amounts. Appropriate
precautions, such as the wear of protective
masks, must be taken when HC smoke is used.

TICs THAT ACT BOTH CENTRALLY AND
PERIPHERALLY:
Chlorine: This is a good example of a
combination agent, one that acts on both airway
compartments in low doses. It is widely used in
industry for the manufacture of plastics,
lubricants, and to purify water. It was the first
chemical agent used effectively on the First
World War battlefield against unprotected military troops. Its effectiveness as a weapon was greatly reduced once protec were widely available for wear on the battlefield. Chlorine turns to hydrochloric acid when it contacts the moisture of the airway; it then causes chemical burns to the tissue. It produces signs and symptoms seen with exposure to both central and peripherally acting agents. Its action is a reminder that even though central damage may seem like the primary concern in some patients (e.g., they are coughing and wh the medic must always treat the casualty as if they could develop peripheral symptoms and take seriously any patient complaints about feeling chest tightness or having breathing difficulty. PROTECTION
The military mask, if fitted wi
filter canister, will protect against chlorine,
ne, PFIB, NOx, and HC smoke in the
open battlefield. Specific filters, or the
thing apparatus with its
own air supply, are mandated for other TICs,
such as ammonia. Masks will not be
in environments where the TIC displaces
oxygen, such as occurs with carbon
DETECTION
Chlorine and ammonia have their own distinctive odors. Phosgene smells like newly cut grass, newly mown hay, or green co important to remember that odor is not a detection method, and this does not protect against tonic inhalation effects. There are no specific field detection devices for these compounds; however, the ACADA can detect battlefield agent vapors when deployed area surveillance tool. PHYSICAL PROPERTIES
Lung-damaging TICs are ty ang close to the ground when released. They tend to evaporate and disperse very quickly depending on temperature and wind conditions. If the TIC is in liquid form at room temperature, then it will tend to give off a Vapors can become trapped in clothing fibers and "off-gas" to affect those who are ne have no respiratory protection. Although skin decontamination after vapor exposure is not a high priority, clothing should be removed and the underlying skin decontaminated with soap and water. MECHANISM OF ACTION
Airway. Centrally-acting TI
as ammonia and HD, will form strong acids or bases (alkali) with the water in the tissue central airway and then destroy these tissues. Damaged tissues will swell and can slough into the airway, restricting breathing. Peripheral Airway. Phosgene is the most
studied peripheral agent. It causes pulmona edema, which is life threatening. Less is known about the other compounds; however, it is believed that they are very similar. Phosgene causes effects in the lung by inhalation only. It does not cause lung effects when absorbed through the skin, injected, or orally ingested. When inhaled, phosgene travels to the very end of the smallest airways, the bronchioles, and causes damage to these airways. Additionally, it causes damage to the thin membrane that separates the smallest blood vessels (the capillaries) and the air sacs (the alveoli). Phosgene reacts with the proteins and enzymes in these alveolar-capillary membranes to cause damage to the membranes. These membranes usually function to separate the blood in the capillaries from the air in the alveoli, but when the membranes are damaged, they cannot do this. Blood, or at of the blood, the plasma, can leak through the damaged membrane into the alveoli. When the plasma leaks into the alveoli, the air sacs become full of fluid, and air cannot enter them. Therefore, exchange of oxygen from the air into the blood is hindered, and the casualty suffers oxygen deprivation. The extent of the lack of ends on the extent of the phosgene exposure and the number of alveoli filled with plasma. This is similar to what happens with drowning, in that the alveoli fill up with fluid. However, in this instance, it is blood, not from an external source. For this reason, phosgene poisoning is sometimes referred to as "dry land drowning." CLINICAL EFFECTS
Centrally-acting agents. Immediately or
shortly after exposure to these gases or vapors, the individual can develop laryngospasm, though this is not true in all exposures. As the airways are irritated and damaged, the in ividual will sneeze and have pain in the nose (nasopharynx inflammation); can develo swallowing (oropharynx inflammation); hoarseness, a feeling of choking and noise with exhalation (larynx inflammation); pain in the chest, coughing, and wheezing during (trachea and bronchi inflammation). This can progress to peripheral effects if the exposur great enough where the TIC has reached the peripheral airway. Scarring of the central airway can create permanent airway narrowing depending on the agent involved and the dose received. Peripherally-acting agents. Very shortly
after exposure to phosgene or other agents
affecting the peripheral airway, the casualty may
typically have an asymptomatic period of 30
minutes to 72 hours, but most significant
exposures have a latent period less than 24
hours. The duration and concentration of the
exposure will determine the time to symptom
onset. The casualty may notice irritation of the
eyes, nose, and throat, but more commonly,
there may be no effects during or immediately
after exposure. The major effects
phosgene exposure (and the other compounds),
like the effects from mustard, do not oc
hours later.
The casualty will notic e shortness of breath between 2 and 24 hours after exposure. Initially, this may be mild, and the eventual severity of the shortness of breath (dyspnea) will depend on the amount of exposure.
progresses, the dyspnea will become more severe, and soon a cough will develop. If the damage is severe, the casualty will start coughing up clear, foamy sputum, the plasma from his blood that has leaked into his alveoli. A casualty with a very mild exposure to phosgene (or another of these compoun develop dyspnea 6 to 24 hours after exposure. He will notice it first after heavy exertion; owever, later he will be come short of breath after any activity. With proper care, he will do well and recover completely. A casualty with a severe exposure to phosgene (or another of these compounds) will
notice shortness of breath within four to six
hours after exposure. Increased difficulty to
breathe, even at rest, will occur, and despite
intensive pulmonary care, the casualty may not
survive.
The average casualty from a lung-damaging agent will be in between these two extreme cases. When the onset of dyspnea is greater than six hou after expo sure, there may be ression to dyspnea at rest. However, with good pulmonary care beginning early after the onset of effects, the casualty should recover completely. FIELD CARE
The medic/combat lifesaver should be al rt to the possibility that patients can be exposed to lung-damaging agents even when battlefield agents are not being used. Exposure to ous, lung- damaging TICs is a likely possibility from industrial sabotage, from exposure to the smokes from burning vehicles, and during common military operations. A casualty who complains of shortness of breath should be questione d extensively about exposure to smoke from bu owder, or industrial chemicals. The most important things to do for such a casualty are to ensure he/she is free from
contamination (he/she is out of the smoke or
wearing a mask) and is kept completely
(preferably placed on a litter so they do not
walk).
en a little exertion can g reatly intensify e effects of these a gents and speed the progress of pulmonary edema. A casualty who is short of breath requires assisted ventilation with oxygen, or oxygen alone. Those suspected of exposure to lung- damaging TIC should be observed for 24 to 36 hours, even if they are not immediately ha thing. Those with a com chest tightness should be rested immediately. A
dyspneic casualty must be ev
quickly s possible
to a medical facility that can provide intensive pulmonary care, as the patient's condition can rapidly deteriorate once the lungs begin to fill with fl uid. Survival is less likely for a casualty who becomes dyspneic within the first four hours after exposure, as pulmonary edema is already rapidly occu The casualty will certainly not survive without proper pulmonary care. A casualty who first experiences breathing difficulty more than four hours after exposure has a good chance of survival if appropriate medical care is RIOT CONTROL AGENTS
CN, CS, CR, OC, and DM
Signs and Symptoms: CN, CS, CR, and OC:
tingling and pain on exposed skin and mucous
membranes, burning in the nostrils and tearing
of the eyes. With severe exposure:
laryngospasm. CN, CS, CR: with severe
exposure: respiratory discomfort and skin
burning, blistering. DM: delayed skin irritation,
vomiting, and malaise.
Detection: no detector.
Decontamination: CN, CS, CR, and DM:
eyes: thoroughly flush with water, saline, or
similar substance. Skin: flush with copious
amounts of water, soap is beneficial. Generally,
decontamination is not needed if the wind is
brisk. OC: Pain may increase if water used for
decontamination of OC. This is best
decontaminated using baby shampoo, milk, or
vegetable oil.
Management: Usually none is needed; effects
are self-limiting.
RIOT CONTROL AGENTS
These agents irritate the skin, mucous membranes, and airways, causing the individual to be unable to perform their normal duties due to discomfort. Riot cont called irritants or tearing agents. The riot control agents frequently used are CS, CR, CN, and OC because of their high safety ratio (the lethal dose far exceed needed to cause irritating effects). OC is very popular for police use on individuals and small crowds and CS for dispersal of large crowds. he military uses CS for training. Exposur ng the excav tion of buried containers of the agent on military reservations and when individuals entered areas where large amounts of the agent were previously rel and the residue remained. Table: Riot Control Agent
Physical
Properties at
Standard
CN Mace® Aerosolized explosive dispersal or in a smoke generating mixture that produces a white smoke cloud. Odor like apple blossoms. explosive dispersal or in a smoke generating mixture that produces a white smoke cloud. Pungent pepper odor. aerosolized powder from grenades or put in solution. White cloud and powder producePepper like odor. DM Adamsite Yello - a particulate smoke from a heat generating device that produces a canary yellow cloud which becomes colorless as it dissipates. No odor but irritating to airways. OC Pepper Sticky resin Liquid or foam spray. Colorless resin suspended in solvent. Odorless unless combined with a scent (e.g., citrus). PHYSICAL CHARACTERISTICS
As a group, the riot control agents CN, CR, and DM are solid crystalline powders that can be suspended in a liquid and aerosolized. Oleoresin capsicum (OC), from cayenne peppers, is not a solid, but a resin that can be mixed in a liquid solution. DETECTION
There are no detectors for these agents. The agents CN, CS, and CR immediately irritate tissues and prod discomfort causing pain in he eyes tearing, the eyelids to sp asm shut sneezing and a heavy nasal discha causes coughing and shortness of breath. Exposure to significant amounts of CN, CS, and CR can cause skin redness and skin blis rin DM is unique in that its effects are delayed for several minutes and exposure will cause skin discomfort, vomiting and mental malais n. OC is also unique in its mechanism f action. In large concentrations, as in the riot control agent OC, capsaicin causes the mass release of the neurotransmitter substance P. This causes an overwhelming sensation of pain until the body's store of substance P is depleted. SELF-AID AND BUDDY AID
The first action to take for those expose CN, CS, CR, and DM is to remove the individual from the aerosolized cloud. A wet cloth o er the nose and mouth can help reduce the nu aerosolized particles inha d. If a protective able then it should be donned. Special protective clothing g that covers the arms and legs will help to protect the skin from contact with the agent. If a person's expo ure o ccurs in a well- ventilated area, the irritation s unlikely. High do se exp sure, for example when an individual is in the ag for prolonged periods in a confined space, can cause skin blistering, upper airway difficu and laryngospasm if protective garments and respirators are not worn. In large doses, DM will cause vomiting and mental depression can last for several hours after exposure. OC is dispensed as a liquid or foam spray containing resins that stick to the skin. Dabbing the agent with a cloth may help to reduce the amount of OC resin on the skin. The pain from OC will recede over time without decontamination. COMBAT LIFESAVER/MEDIC ACT
The medical treatment actions provided by the combat lifesaver/medic are little more than provided through self-aid. Normally the eyes will become bloodshot and red. f es of a crystallized agent get into the eye, the eye should be irrigated with copious amounts of clean water and treated with antibiotic eye ointments. Pieces of exploding canister have been known to damage the eye. Impaction cases should be treated according to eye injury protocols and follow-up consultation provided by an ophthalmologist. Open b on the skin can be irrigated with sterile saline and covered with antibioti c ointment. Inhalers and supplemental oxygen should be administered to those with breathing difficulties, such as asthmatic conditions, which may become exacerbated. Irritated skin can be washed with a mild baking soda solution to normalize skin pH. Washing the eyes with baby shampoo and rinsing with copious amounts of water can help reduce the eye pain from exposure to OC and other riot control agents. CASUALTY DECONTAMINATION
No decontamination is required with most exposures to CN, CS, CR, and DM. Indi can move briskly in a well-ventilated area eyes and mouth closed, while flapping their arms and rubbing their hair, to remove the dry agent from clothing and hair. With heavy exposure individuals can decontaminate themselves with soap and water. Water may reactivate OC in the skin and cause pain. If water is used, it must be in a continuous plentiful flow. For OC decontamination, it is best to wash with baby shampo oil to help break up the resin and help neutralize the action of OC. INCAPACITATING AGENTS
BZ, Fentanil Derivatives Signs and Symptoms: BZ: dilated pupils; dry
mouth; dry skin that is red and warm to touch;
short attention span; impaired memory; distorted
perception – sees objects as being distorted or
larger in size or quantity. Fentanil/Carfentanil:
sleepy, unconscious, vomiting, decreased
breathing.

Detection: no detector.

Decontamination: BZ: it can be in a powder
form, decontaminate with soap and water;
Fentanil/ Carfentanil: not needed.
Management: BZ: Antidote: physostigmine.
Fentanil: Naloxone/naltrexone. Both:
supportive care: monitoring of vital signs. With
Fentanil, maintaining the airway is critical until
effects wear off.

INCAPACITATING AGENTS
These chemical agents are designed to act on the nervous syste m to affect an individual' mental alertness so they cannot perform their work activities. Several nat .S., developed these we apons, but in the 1970s the U.S. destroyed their stockpiles of these agents. Two incapacitating agents recently employed were the anticholinergic BZ (in the same drug family as atropine), allegedly used by the Serbians in 1980; and a Fentanil derivative, a narcotic opioid, possibly carfentanil (an approved veterinary sedative), susp s used by the Russians to Che hen terrorists during the 2003 Moscow theater host PHYSICAL CHARACTERISTICS
BZ is a crystalline solid at temperature and pressure. Its high melting point makes it ideal for dispersal in explosive munitions. Suspended in solvents, it can contaminate food or be absorbed through the skin. Fentanil derivatives can be aerosolized and suspended in a gas, such as halothane, an DETECTION
There are no detectors for these agents. BZ interferes with the cholinergic synaps s in the CNS causing disruptions of memory, problem solving, attention and comprehension. Signs of anticholinergic poisoning progress as follows: increased body temperature (hot as a hare); no sweating causing the skin to be the touch (dry as a bone) and red (red as a beet); slurred speech, stumbling gate, slowness of movement and thinking, delirium (mad as a hatter). Patient delusions are characteri based on real objects: for instance they may see one's hand as holding a hamburger and e person's hand; they may shoot at clo g they are flocks of ducks; or hide, thinking small animals or shadows are l rge, wild animals. Movement will be clumsy, and thinking slowed. Symptoms are seen several hours after exposure and progress in int for several days until the toxin is eliminated in the urine from the body and recovery begins. Fentanil derivatives, such as ca ey rapidly cause a state of euphoria followed, within seconds to minutes, by sleep and unconsciousness, depending on the dose. In high doses they can ca se vomiting, which can obstruct the airway and interfere with brain function needed to regulate breathing. SELF-AID AND BUDDY AID
Those exposed to BZ have difficulty performing their duties and following instructions. Weapons and other harmful items must be removed from these individuals. In a chemical environment patients will need others to help them mask in the event of a follow-on chemical attack. Protective ensemble must be worn by those assisting the contaminated patient until decontamination is accomplished. The ability to sweat is diminished, making the patient susceptible to heat stress. Patients should be moved to the shade and cooled with water or damp cloths. Evacuation to the rear should be considered as early as the situation permits. Fentanil derivatives cause drowsiness a sleep. Casualties must be moved from the contaminated area as soon as possible. Patients must be positioned to maintain an ope n their side, with frequent checks to ensure that vomitous does not obstruct the airway. COMBAT LIFESAVER/MEDIC ACT
BZ casualties may act on their delusions so kept safe from harming themselves or others. Behavioral symptoms will worsen over the course of a day or more, so patients should be evacuated to a medical facility as soon feasible. Heat stress is also a real concern. If available, the antidote physostigmine can be given by injection (45 mcg/kg in adults / 20 mcg/kg in children) or orally, mixed with flavored drink, if the patient is cooperative. IV administration should be avoided as overdose symptoms, similar to nerve agent, can result if not closely monitored. The antidote must be re-administered every hour an d titrated to behavio The antidote is primarily given to manage behavior during transport. Fentanil derivatives will cause death if the respiratory system is compromised. Properly positioning the patient on their side is critical to ensure that the tongue and vomitous does not obstruct the airway. Supplemental oxygen always appropriate. Intubation is indicated if respirations are depressed. The opioid antagonist naloxone or naltrexone (given routinely for heroin overdose) is an effective ch rapidly reduces the symptoms CASUALTY DECONTAMINATION
BZ casualties must be decontaminated, as dry particles of the agent can still remain on outer clothing, on the skin, or in the hair. Removal of the outer clothing, accompanied by a water, or soap and water, wash is the best solution. Decontamination with wate to cool the patient.Those providing decontamination must wear protective ma and protective clothing. Fentanil derivatives do not require decontamination as they quickly evaporate. Emergency responders do not require respiratory protection if the area has adequate ventilation. BIOLOGICAL AGENTS
The course of human history has been greatly affected by naturally occurring diseases. AIDS, influenza, malaria, cholera, tuberculosis, plague, and smallpox have killed hundreds of millions of people and profoundly disrupted or destroyed cultures, societies, and civilizations. From ancient times, man has tried to harness the destructive potential of biological agents. With the modern advent of the Germ Theory of Disease and worldwide industrialization, our ability to unleash the destructive potential of biological agents on a large scale has grown considerably. Today, in the Global War on Terrorism ), the threat of biological attacks continues. Technological advances in chemistry, microbiology, and particularly genetic engineering are making it easier for potential terrorists to develop or acquire novel biological agents or highly infectious "superbugs" that are resistant to antibiotics and vaccines. Due to their relatively low cost and high lethality, biological weapons have been referred to as the "Poor Man's A-Bomb." To minimize these threats and conserve the fighting strength, military health care providers must be knowledgeable about biological weapons, the medical management of biological casualties, and ensure appropriate ntermeasures are taken. CHARACTERISTICS OF
BIOLOGICAL AGENTS
Biological weapons are developed from living organisms and viruses capable of causing disease and death in humans, animals, or plants. Weapons associated with high mo are referred to as lethal agents, and those that usually produce severe illn ess, but not death, are referred to as incapacitating agents. Categories of agents. The three general
categories of bio-agents are: biological toxins, biological modulators, and pathogens. Biological toxins or biotoxins are poisons
derived from plants, animals, and microorganisms. Like the chemical agen onset of action is usually quite rapid. Examples include the staphylococcal enterotoxin B, botulinum, and ricin toxins. Bio-modulators or bio-regulators are
proteins or peptides produced in small q in the human body to help regulate the nervous and endocrine systems. They affect many bodily functions including pain sensation, blood pressure, respiration, emotions, memory, and sleep. For example, endogenous opi bio-modulators produced in our bodies in small quantities to help us cope exogenous doses, however, can profoundly depress respiration and lead to death. Further discussion of this category of agents is e the scope of this handbook.

Pathogens
are microorganisms that cause disease, such as viruses, bacteria, ricketts and fungi. They are the classical agents of biological warfare and the focus of this chapter. These organisms differ from the other cal and chemical warfare age they can infect and replicate within a su host, have an incubation period of days to weeks before clinical sign may go on to infect subsequent ts long after the initial exposure. Portals of Entry. Biological warfare (BW)
agents can gain access into susceptible hosts through three portals of entry, depending on how they are weaponized. The respiratory tract is susceptible to aerosols. Example: pneumonic plague. The digestive tract is susceptible to infection from intentionally contaminated food and Example: cholera. The skin is susceptible when direct contact with pathogens occurs in non-intact areas
damaged by cuts, punctures, or abrasions.
Example: cutaneous anthrax.


Psychological Manifestations. Bio-agents
can also have a profound effect on the human mind. Expect numerous indirect casualties from psychogenic illnesses when there is an actual or perceived BW threat. Educating and counseling troops about the threat, instituting appropriate countermeasures, and employing stress control teams early on can significantly reduce combat stress reactions and lessen demand for medical services. RECOGNITION OF A BIOLOGICAL
WEAPONS ATTACK
Biological warfare uses unconventional weapons, and most methods of dissemination will be covert and difficult to identify early on. Outdoors, aerosols st likely to be sprayed g the hours of limited visibility between dusk to dawn. This is when UV exposure hat can kill the organisms is minimal, and temperature inversions help to keep aerosols near ground level with less dispersion. Indoors, bio-aerosols elude the senses by being essentially odorle steless, and invisible. Food and water contaminated just prior to consumption would be very difficult to detect. Aerosols can be disseminated by jets, missiles, crop dusters, agricultural sprayers, and modified chemical warfare munitions, such as artillery shells, bomblets, or mines. More techniques may involve the use of hand pumped
sprayers, aerosol spray cans, modified fire
extinguishers, small aerosol generators with
timers, and sprayers placed on automobiles or
boats to look like exhaust emissions.

Appearance of Weaponized Agents.
Unlike many chemical agents, liquid bio-agents are non-oily and will typically be translucent and lightly more visco us than milk. Unless dyed, bacterial agents in the form of a liquid or po de e a light brown or ambe arance. Only sophisticated production and purification methods will produce a white bacterial powder. Dried and liquid viral agents can be of several colors depending on their growth medium; they may be off-white, yellow, brown, or pinkish-red. DETECTION
Limited real-time aerosol detection is technically possible in the field with the Biological Integrated Detection System that a small number of units may have access to. Rapid identification of BW agent possible if samples can be examined from s spicious ordinance, spraying devices, residues or powders. For efficient environmental detection, teamwork is necessary. Nuclear/biological/chemical (NBC) reconnaissance team s collect aerosol samp s. Preventive medicine personnel collect susp contaminated water samples. Veterinary personnel collect suspect food sample and cimens. Medical personnel collect patient specimens. Supporting labs evaluate
samples for evidence of pathogenic organisms
or biotoxins.

Laboratory Evaluation for a BW Attack.
Quick tests can be performed in the field to help rule in or out the possibility of a biological exposure. Samples can be tested with litmus paper or a pH meter. If the pH is near neutrality (7.0), viable organisms could be present. The greater the acidity or alkalinity, the less likely it is that any human pathogens will be found. Qualitative Ninhydrin tests may show the presence of amino acids. If pH and protein tests are consistent with biologi cal agent samples m y be sent to a lab for further testing. If t sample is unlikely to be a biological agent, it should be evaluated as a potential chemical agent. Clothing and equipment are unlikely to reveal significant contamination from an but if suspicious powd rs o r liquids are found, place samples of the contam double zip-locked plastic bags for further testing. Soon after a C/B attack, consi er ta baseline serum samples of all personnel who may have been exposed. Serial serum samples may show changes over time, which hel the identification of biological and chemical agent exposure. The results may be usef to epidemiologists evaluating post-deplo syndromes, and assist casualties applying for servic d disability claims. Draw 20-ml of blood into a tiger top tube centrifuge for 10 minutes. If these are unavailable, use red top tubes. If clinically indicated, throat swabs, aerobic and anaerob cultures, sputum, urine, tissue, feces, scraping and other specimens should be submitted to a higher lab where they may undergo various confirmatory tests such as ELISA, PCR, t x assays, microscopic exami they appear to have no current clinical value, they may be useful later in important epidemiological investigations. The human respiratory system acts like a d filtration system for air, making the nares, cheeks, and hairy portions of the face of people exposed to an aerosol good loca find the organisms. Taking early post-exposure samples with synthetic swabs made is preferable, but field expedient sampling with Q-tips® will also work. All samples should be sent as soon as the tactical situation permits and given thorough
documentation to include person, place, time,
and circumstances of possible exposure.
Medical
Intelligence. Intelligence sources
may indicate that a BW attack has occurred, prompting a unit to initiate education, vaccination, chemoprophylaxis, treatments, use ctive equipment, or other countermeasures to mitigate risk. Epidemiology. In the absence of direct
evidence of a BW attack or solid medical
intelligence indicating that an attack has
occurred, recognition of BW agents must be
based on investigations of outbreaks to find a
common source of exposure.


The first indication that a BW attack has occurred may be the appearance of a large number of personnel at sick-call presenting with r signs and symptoms. Soldiers with increased susceptibility, or who were ex higher doses of the pathogens, become ill first and act as "sentinel canaries." If medics maintain a high index of suspicion, they may be able to diagnose the exposure early on, and quickly institute BW treatment and countermeasures that can save many lives. Many animals can act as "sentinel canaries" for human pathogens and provide clues of a BW attack. Consult with veterinary personnel of suspicious animal deaths and illness occur. Epidemiologic clues of a possible BW
• Tight cluster of casualties • High infection rate • Unusual geography • Apparent aerosol route of infection • Infection with more than one BW agent • Unusual clinical presentation • Unusual munitions • Animal epizootics • Sentinel dead animals of multiple • Lower attack rates among the protected
Syndromic
Surveillance. Surveillance is
the cornerstone of epidemiology. Medics contribute by accurately documenting patient care and DNBI data, and assisting with pre- and post-deployment health assessments. Many BW agents will present with non- specific flu-like signs and symptoms, but presentations will nar diagnosis: Non-specific Tularemia, brucellosis, Q- fever, viral equine encephalitis (VEE) Pneumonia – Tularemia, plague, staphylococcal enterotoxin B (SEB) Neuromuscular – Botulism, VEE Bleeding – Ricin, plague, viral hemorrhagic Dermatologic – Smallpox, plague, VHF, T-2 A B OLOGICAL
AGENT ATTACK
Immediate action to a susp aerosol is the same as for chemi conjunction with biological agents or use multiple BW agents simultaneously. MOPP gear provides excellent protection against all biological agent aerosols. Since the primary routes of entry will be through the mou and nose, masking by itself may be sufficient t prevent illness. Effective field expedient respiratory filters can be improvised by breathing h two or more layers of the BDU T-shirt or several layers of tissue paper. Primary BW aerosols of the ideal size can behave as gases that are readily inhaled lungs. Fortunately, these aerosoli are very unlikely to adhere to people, clothing, or equipment. This reduces the need for extensive decontamination. Larger particles are much less infectious via the inhalation route and quickly fall to the earth where they are likely to adhere to various surfaces and significantly reduce the risk of re-aerosolization or secondary contamination. Whether in the air or on the ground, BW agents undergo biological decay from environmental variables such as UV radi temperature, and humidity. Air currents promote dilution, reducing their effectiveness. With the exception of anthrax spores that cause Q-fever, most BW agents will pose little threat of infection after approximately 24 hours of environmental exposure outdoors. Therefore, most biological agents are considered non-persistent. With chemical and biological agent exposure, decon casualties quickly and as close to the areas where they were contaminated as possible. Patients must be clean treatment area at an MTF or undergoing medical evacuation. Soap and water is sufficient for patient decontamination of most biological agents. A 0.5% Cl solution can also be used. Disinfect wounds with betadine or iodine if available. Sterilize materiel as indicated with full strength bleach, stea er, or dry heat. Place washed clothing outdoors for one week if possible to be dried and decontaminated by the sun and wind. Field expedient mass decontamination of BW casualties can be done in uncontaminated lakes and streams, large stationary or small portable swimming pools, and water buffaloes with hyperchlorinated water. Consider showering in fixed facilities, with fire and water trucks, or garden hoses. When possible, use hot water if outdoor temperatures are cold. TRIAGE AND EVACUATION
Triage of BW agent casualties may differ significantly from that of chemical a casualties. With chemica large number of casualties presenting at about the same time. With biological agents, the variable incubation period of pathogens and the delayed onset of action of many biotoxins mean that casualties will present over a period of hours to weeks. Therefore, most BW casualties will be triaged as "Delay Continue to monitor casualties and change their triage category accordingly. Provide reassurance and psycholo gical first aid while patient is awaiting further treatment and evacuation to a higher level of medical care. The evacuation category will dep patient's current status and prognosis. When calling in a 9-line medevac request during wartime, use brevity code "B" in line 9 for biological contamination. Evacuation platforms with good fron ventilation significantly lower the risk of contamination to the vehicle and its oc Inhalational Anthrax (Bacillus anthracis)
Anthrax is an acute bacterial infection of the skin, lungs, or gastrointestinal tract. Primary
threat is from an aerosol causing the inhalational
form of anthrax.
Characteristics. Lethal agent. Aerobic,
spore forming, rod-shaped, gram + bacteria.
Case Fatality Rate (CFR) if untreated: 5%
(cutaneous), 30% (GI), and 90% (inhalational).

Incubation periods are typically 1 to 6 days, with
an average of 48 hours. Spores can survive in
the environment and remain viable for years.
Pathogenesis. Aerosolized agent enters
body through the lungs and is engulfed by
macrophages in which spores germinate,
reproduce, and release toxins that cause cellular
necrosis, edema, and hemorrhage in the lungs
and mediastinal lymph nodes. Frequently
s to the meninges. Death results from sis, hemorrhagic shock, or respirator
Symptoms. Malaise, fatigue, myalgia,
headache, dyspnea, shortness of breathe
pain.
Signs. Fever, cough, tachypnea,
hypotension, meningitis, stridor, diaph esi
cyanosis. Pathognomic widened mediastinum secondary to hilar adenopathy and hemorrhagic mediastinitis.
Differential
Diagnosis. Pneumonia,
pneumonic plague, Tularemia, gram negative
sepsis, SEB inhalation.
Chemoprophylaxis. Oral ciprofloxacin or
doxycycline for known or imminent exposu

Chemotherapy.
Ciprofloxacin 400 mg IV q12, or doxycycline 200 mg IV loading dose followed by 100 mg IV q12. Multi-drug regimens may be more effective than single antibiotic therapy. Use oral ciprofloxacin, doxycycline, r penicillin as tolerated if IV meds are not available in the field.
Precautions. Standard precautions only. No
person-to-person transmission.
Prevention. Biothrax anthrax vaccine
absorbed. Six shot series given oven an 18-
month period, followed by yearly boosters. After
wn exposure, start series in unimmunized personnel, and give booster shot who are not current in the series. Cholera (Vibrio cholerae)
Cholera is an acute bacterial infection of the gastrointestinal tract. Primary BW threat is from sabotage of food and water supplies. Incapacitating agent. Gram negative, crescent shaped, motile rod. Incubation period of 4 hours to 5 days, with an average of 2 to 3 days. Diarrheal illness sts 3 to 5 days. Most illnesses are subclinical and the CFR is only 1% if treated approp Untreated, severe diarrhea can cause death urs and the CFR can be as high as
Pathogenesis. Agent enters the GI tract
after consumption of contaminated food and
water. Organisms adhere to the intestinal
mucosa and secrete an enterotoxin, which elicits
a secretory diarrhea that can lead to severe
dehydration, electrolyte imbalances,
hypovolemic shock, and death.
Symptoms. Painless diarrhea, abdominal
discomfort, nausea, LH, malaise, thirst,
weakness.
Signs. Profuse rice-water stools, emesis,
increased or decreased BS, non-tender
abdomen, fever, hypotension, dehydration,
hypovolemic shock.
DDx. Shigella, E. coli, salmonella,
ICAMpylobacter, norovirus.
Chemoprophylaxis. Reserve antibiotics for
symptomatic personnel.

Chemotherapy. Aggressive rehydration
with: Oral rehydration solution (ORS) or IV
Ringers Lactate. Doxycycline 100 mg PO BID
for 3 days. Alternates: TMP-SMX, tetracycline,
ciprofloxacin.
Precautions. Enteric precautions, person-
to-per

Prevention. Secure approved food and
water sources from sabotage. Enforce proper
field sanitation and hygiene. Cholera vacci
have limited efficacy, and none are currently sold in the U.S. Plague (Yersinia pestis)
Plague is a bacterial disease known in the middle ages as the Black Death, and has killed hundreds of millions. Primary threat is from an aerosol causing primary pneumonic plague. Secondary threat is from the release of infected fleas causing bubonic plague, whic through the lymphatics and blood stream to
cause septicemic plague.
Characteristics. Lethal agent. Bipolar
"safety pin" appearance on
Incubation period 1 to 8 days, with an average of 2 to 4 days. If untreated, the CFR for bubonic plague is 60 >

Pathogenesis. Aerosolized agent enters
body through the lungs where virulence
can cause a necrotizing pneumonia. Organisms traveling through the bloodstream can lead to sis, spread to the liver, spleen and CNS and cause further damage. Death results from respiratory failure, circulator Flea bites lead to inflamed, hemorrhagic, and exquisitely painful lymph nodes called "buboes." Organisms travel from the lymphati to the blood stre ding to systemic disease.
Symptoms. Fever, chills, malaise chest
and painful lymph nodes called buboes, headache, meningitis.
Signs. High fever, buboes, severe
pneumonia, cough, hemoptysis, cyanosis,
convulsions, shock, hemorrhagic skin changes
and blackening of skin at extremities, DIC, septic
shock. Chest x-ray is vari
able but will likely s consolidated bila eral infiltrates.
Differential
Diagnosis. Pneumonia, ARDS,
meningitis.

Chemoprophylaxis. Doxycycline 100 mg
PO BID for 7days. Alternat
es: ciprofloxacin tetracycline (TCN).

Chemotherapy. IV/IM streptomycin.
Alternates: 200mg IV doxycycline once, then
100 IV BID for 14 days, gentamicin,
ciprofloxacin. If IV/IM medications are not
available in the field, use PO meds.

Precautions. Standard precautions for
bubonic plague, respirator
y droplet precaution for suspected pneumonic plague. Quarantine.
Prevention.
No FDA vaccine is currently licensed in the U.S. Q-Fever (Coxiella burnetti)
Q-fever is an acute and occasionally chronic rickettsial disease that presents as a n n- specific febrile illness or atypical pneumonia.The
threat is from an aerosol or contamination of
food.
Characteristics. Incapacitating agents are
highly infectious and environmentally persistent
rickettsial organism, with an incubation period of
7 to 41 days, average 2 to 3 weeks. Acute form
is a self-limited febrile illness 2 to 14 days in
duration.
Pathogenesis.
Agent ente s the body h the lungs or GI tract, replicates within phagolysosomes, and spreads throughout the body eliciting systemic illness and numerous non-specific signs and symp
Symptoms. Severe headache chill
myalgia, and fatigue. Less common symptoms are nausea, vomiting, diarrhea, abdominal and chest pain.
Signs. High fever, dry cough, sweats, and
myalgia. PE of chest is usually normal, but
ratory rales may be present, and consolidation may be seen on chest x-ray.
Differential
Diagnosis. Atypical
pneumonias, bacterial and viral pneumo ias.
Chemoprophylaxis. Doxycycline 100mg
PO BID for 5 days. Alternate: TCN.

Chemotherapy:
Try to start antibiotic therapy 8 to12 days post-exposure. Doxycycline
100 mg PO BID for 14 to 21 days. Alternates:
TCN, ciprofloxacin, TMP-SMX.
Precautions. Standard precautions. Rare
person-to-person transmission, but secondary
aerosols from fomites, such as blankets, can
spread the disease.
Prevention. Secure approved food and
water sources from sabotage. Enforce proper
field sanitation and hygiene. No FDA approved
vaccines currently available in U.S.
Smallpox (Variola major)
Smallpox is a systemic vira l illness that killed millions before it was eradicated from nature by
1980. Primary threat is by an aerosol release of
smallpox acquired from laboratory specimens.
Characteristics. Lethal agent, highly
contagious virus with a 30% CFR. Incu
period 7 to 19 days, with an average of 12 days.
Duration of illness-4 weeks.
Pathogenesis. Aerosolized agent enters
body through the lungs. Replication with
can lead to an overwhelmi of circulating immune complexes, with illness
and death attributed to toxemia.
Symptoms. Malaise, rigors, headache,
backache.
Signs. Macular-papular rash that
progresses to characteristic vesicular pustules,
which become scabs and scars, high fever,
vomiting, pros

Differential
Diagnosis. Chickenpox,
monkeypox, allergic contact dermatitis,
erythema multiforme with bullae.

Chemoprophylaxis. None.

Chemotherapy. No effective medications,
portive treatment only.
Precautions. Respiratory precautions, strict
quarantine of patients and close contacts.
Prevention. Wyeth Dryvax vaccine is very
effective when given prior to exposure. If given
after an exposure, but prior to onset of
symptoms, can prevent or significantly reduce
Tularemia (Francisella tularensis)
Tularemia is bacterial disease with multiple manifestations depending on the portal of entry. The pneumonic and typhoidal forms could occur after an aerosol exposure and have a CFR of 30-60
Characteristics. Lethal agent. Highly
infectious, gram negative coccobacillus.
Incubation period 1 to 21 days, with an average
of 3 to 6 days.
Pathogenesis. Agent can enter an
the body through all three portals causing local lymphadenop sepsis which can lead to death. ymptoms. Fever, chills, malaise, myalgia,
fatigue, respiratory distress.
Fever, tachycardia, tachypnea, non- productive cough, mucous membrane lesions, hypotension, prostration, sepsis. Chest x-ray may show effusions, lobar consolidation, hilar adenopathy.
Differential
Diagnosis. Pneumonia, gram
negative sepsis, mononucleosis, rickett ial diseases, malaria, ARDS. rophylaxis. Ciprofloxacin 500 mg
PO BID for 14day. Alternate: Doxycycl
Chemotherapy. Ciprofloxacin 400 mg IV
q12 x 10d. Alternate: IV/IM Doxycycline, TCN,
streptomycin, gentamicin. Oral ciprofloxacin or
doxycycline if the IV/IM form is not available in
the field.
Precautions. No person-to-person
transmission.
Prev
ention No FDA approved vaccine is
Viral Hemorrhagic Fevers (VHF)
A variety of viruses that cause fever and ng of varying severity. Examples include: Ebola, Marburg, Hanta, dengue, yellow fever, Lassa fever, Rift Valley fever hemorrhagic fever, Argentinean, Bolivian, Venezuelan, and Korean hemorrhagic fevers. Threat exists that these viruses may be weaponized for aerosol dispersal, or that large numbers of infected biting insects are rel ased.
Characteristics. Lethal and incapacitating
agents. Incubation period can be days to
months. CFR <10% (HFRS) up to 90% (Ebola).
Definitive diagnosis is often only possible with sophisticated lab tests not readily available
in the field.
Pathogenesis. Poorly understood and
varies among the viruses.
Symptoms. Fever, myalgia, malaise,

Signs. Fever, conjunctival injection,
petechiae, hypotension. Severe illness may
ock, multiple organ system failure, disseminated intravascular coagulation (DIC),
and death.
Differential
Diagnosis. Viral syndrome.

Chemoprophylaxis. Ribavirin 500 mg PO
qid for 7 days, if available, may be somewhat
useful for post-exposure prophylaxis to some
VHF agents.
Chemotherapy. IV ribavirin, if available,
may have some efficacy.

Precautions. Contact isolation and possibly
uarantine. Droplet p recautions should include use of a mask and eyewear or face shields. Thorough disinfection. ention. The only FDA licensed VHF
cine is for yellow fever. Botulinum Toxin, Ricin, SEB, etc.

Signs and Symptoms: These depend upon the
specific toxins. Botulinum toxins cause descending
weakness and paralysis (including respiratory-muscle
paralysis) along with dry mouth and dilated pupils.
Ricin and SEB cause different presentations
depending upon the route of exposure.

Detection: No field detectors commonly available.
Detection of exposure is mainly by a high index of
suspicion and by clinical recognition of signs and
symptoms.
Decontamination: Clothing removal and skin
cleansing using water (with or without soap) is
generally sufficient.
Management: For almost all toxins, treatment is
supportive only. This includes the potential necessity
of ventilatory support for weeks following exposure to
botulinum toxins, although a botulinum toxoid is
effective if given before signs and symptoms appear.
Active immunization with botulinum toxoid is available
only as a pre-exposure measure for those at
demonstrated high risk.
toxin is sometimes used as a general synonym for poison, it is more strictly defined as a poisonous chemical produced by a nism. Unlike biological organisms, toxins do not replicate inside hosts or cause infection (rather, they produce "intoxication," or poisoning); and victims of toxins are not "contagious." CLASSIFICATION AND
MECHANISMS OF ACTION
There are hundreds of toxins, but mo not been developed for use as mass-casualty weapons. Toxins can be grouped according to source as bacterial, algal, fungal, plant, marine dinoflagellate, marine soft coral, arthropod, n, and vertebrate toxins. Additionally, they can be divided by mechanism of acti neurotoxins (toxins that affect neurotransmissio by affecting the release of neurotransmitters from the ends of neurons), cell-damaging and superantigen toxins (which nonspecifically activate the immune system). DETECTION
Advanced laboratory instruments that can detect toxins in the environment or in biological samples are not gene rest primarily upon a high index of suspicion and clinical recognition of signs and symptoms. PHYSICAL PROPERTIES AND
PROTECTION
Toxins can be dissolved in various other substances or spread as aerosols and may not be visible or irritating; expo without the knowledge of t toxin would be inhaled or could settle on he s n, although only a few toxins are de active.Toxin could also be ingested or injected. Protection against inhalation and skin contact is provided by the chemical/ biological protective mask and by any clothing that covers the skin. Removal and laundering of clothing and skin cleansing using water (with or without soap) is all that is usually necessary. Because toxins are poisons rather than living organisms, disinfection and sterilization are not ap Specific Toxins

Botulinum
toxins. Botulinum toxins, a
group of seven related neurotoxins produced by the bacterium Clostridium botulinum, are the most potent poisons known and cause botulism after ingestion or by toxin production in wounds. Victims exhibit descending skeletal-muscle weakness (beginning with blurred vision, inability to open the eyelids fully, and difficulty swallowing) within 12 to 36 sol, or up to several days after ingestion. The pupils dilate and the mouth is dry. Eventually, respiratory paralysis leads to death, unless ventilatory support can be establis and maintained for several weeks. Intravenous and intramuscular administration of botu antitoxin is effective during the latent peri rapidly becomes ineffective after signs and symptoms begin to appear. A toxoid is available to vaccina kers at known risk of te laboratory wor extracted from the castor bean plant (Ricin munis), has been used in covert assassination attempts by injection. It binds to ribosomes and impairs protein synthesis. Ingestion produces mainly gastrointestinal effects, inhalation causes damage to both the central and peripheral compartments of the respiratory tract (leading to pulmon ry edema), and inje res the respiratory tract widespread organ necrosis and disseminated intravascular coagulation. No antitoxin (for passive immunization after exposure) or (to produce active immunization prior to exposure) is available in humans, so treatment is supportive only. SEB is a superantigen toxin that is seldom lethal
but causes incapacitating (although self-limited),
abrupt-onset abdominal pain, vomiting, and
diarrhea after ingestion. Difficulty breathing,
nonproductive coughing, fever, chills, and
headache appear beginning 3 to 12 hours after
inhalation of aerosolized toxin. Treatment is
supportive.
T-2
toxin. T-2 toxin is one of the
trichothecene mycotoxins (mycotoxins are toxins
produced by fungi) and was alleged to have
been used as "yellow rain" in Laos and
ICAMbodia in the 1970s. Within 10 to 30
minutes after inhalation or ingestion, it can
cause bloody vomiting and diarrhea, chest pain,
and dizziness. Skin blisters can appear after
skin contact. Death can follow weeks later from
bone-marrow suppression, liver failure, or
internal bleeding. Treatment is supportive.
Aflatoxins. Aflatoxins, once stockpiled by
Iraq, are fungal toxins that are acutely toxic as
well as being immunosuppressive, mutagenic,
and carcinogenic. Acute effects include

abdominal distress, pulmonary edema, and
convulsions. Treatment is supportive.
Abrin. Abrin is a cell-damaging toxin found
ans. It is similar to ricin but in mice is 75 times more toxic. Treatment is Epsilon toxin from Clostridium
perfringens: Epsilon toxin from the bacterium
Clostridium perfringens was investigated by Iraq
as a potential mass-casualty weapon. It is a cell-
damaging toxin that, when ingested, increases
the permeability of the small intestine and leads
to increased absorption and damage to blood
specially in the kidney, liver, and brain. Inhalation would presumably damage pulmonary
blood vessels as well. It is also dermally active
and can cause skin lesions. Treatment is
supportive.
Domoic
acid. Domoic acid is an excitatory
neurotoxin responsible for amnesic shellfish poisoning (ASP). Seizures may be part of the clinical picture. Treatment is supportive. Epibatidine, anatoxin-a, and anatoxin-
a(s). Epibatidine (produced in the skin of
poisonous frogs) and anatoxin-a (from
cyanobacterial, or blue-green algae) produce the
nicotinic effects of nerve agents; anatoxin-a(s),
another cyanobacterial toxin, produces both the
nicotinic and the muscarinic effects of nerve
agents. Treatment is identic al to that for nerv agents.
Saxitoxins. Saxitoxins (STX) are
cyanobacterial (blue-green algal) toxins that
cause paralytic shellfish poisoning, or PSP. It
has been considered for coating bullets and can
cause death within 10 seconds via paralysis.
Treatment is supportive.
Tetrodotoxin. Tetrodotoxin (TTX) is a
marine neurotoxin found in certain saltwater fish
(such as puffer fish), crabs, starfish, blue-ringed
octopi, newts, and salamanders. It could be
inhaled or ingested and causes death via
paralysis. Treatment is supportive.
Palytoxin. Palytoxin is a cyanobacterial
(blue-green algal) toxin concentrated in corals. It
rly as potent as botulinum toxins and causes cardiotoxicity and vascular collapse. Intracardiac injection of vasodilators ma FIELD MANAGEMENT
OF CASUALTIES ON THE
CONTAMINATED BATTLEFIELD
The single most important concern for the combat lifesaver/medic during operations on the contaminated battlefield is the timely and t of casualtie . Providing timely and proper management must begin with preparations long before deployment. The required preparations can be divided into several elements. • Training individual unit members to correctly identify chemical agent exposure based on signs or symptoms and to correctly perform self-aid or buddy-aid and decontamination • Training the combat lifesaver and medic to correctly identify chemical agents based on observed signs or symptoms experien • Complete understanding of the severity of ased on signs and symptoms. • Correct identification of route(s) of entry of the agent and method of exposure (from liquid and/or vapor) based on signs and symptoms. • Triage chemical casualties or mixed conventionally wounded and chemically contaminated for mass casualty situations. • Correct treatment of casu alty in resp nse to symptom(s), proper use of antidotes, and other supportive care that may be required during or after initial treatment (i.e., assisted ventilation or airway suction). • Complete understanding of the various casualty types that can be encountered on the contaminated battlefield. • Complete understanding of ambulatory and litter casualty deconta • Identification of personn port of casualty decontamination and treatment. • Understanding the impact and/or decontaminated casualties on evacua on Once deployment is complete, the combat lifesaver/medic must be aware of additional elements that also impact NBC contaminated ca agement operations. These battlefield elements, at a minimum, are as follows: • Current enemy chemical capabilities, enemy chemical employment capabilities (i.e., artillery, rockets, or spray), and anticipated enemy chemical employment. • Tactical intelligence gathe verified enemy use of chemical agents. • Current protective posture of the unit and how vigorously it is maintained. • Current status of unit and individual chemical defense readiness. • Morale and confidence of individual unit members, both in the unit and each other. • Complete understanding of current and near-term combat ope All of these elements, when considered together, allow the combat lifesaver/medic to take a proactive readiness posture for casualty management operations on the contaminated battlefield. The following sections will expand on these elements. TRAINING
Medical personnel and non-medical augmentees who are involved in the patient
decontamination effort must be trained or show
proficiency in the following:

NOTE: The list below is suggested as a guide
for a training program to support casualty
decontamination operations. The list has
obvious tasks that are medical only and should
only be taught to medical pe
some tasks are applicable to all and should be taught to all. • Drink from a canteen while wearing the protective mask. • Recognize signs or symptoms of heat • Identify liquid chemical agents using M8 Chemical Detector Paper. • Detect chemical agents using M9 Chemical Agent Detector • Evaluate a casualty. • Prepare decontamination solutions for patient decontamination operations. • Recognize signs and symptoms of chemical exposure. • Administer nerve agent antidote to self • Administer ne CANA to buddy (buddy-aid).

• Transport litter casualties using both two- man and four-man litter carries. • Conduct casualty litter exchange using log-roll method. Remove litter casualty • Perform litter casualty's skin decontamination. • Operate Chemical Agent Monitor (ICAM). • Wound or injury management during litter and ambulatory patient decontamination. • Remove ambulatory casualty's • Monitor patient for residual contamin mination process. • Prepare the M22 ACADA for operation .
2 ACADA in operation to monitor the clean treatment area and the MTF. • Conduct unmasking procedures using the M256A1 Chemical Agen • Decontaminate open wounds. • Describe and perform emer treatment required to stabil • Identify triage requirements based on signs or • Transcribe patient field medical card at the Hot Line and shuffle pit. • Chemically protected shelter (CPS) exit/entrance procedures. • MOPP gear exchange. EXPOSURE HISTORY
An important informational link between the Soldier and the MTF will be the history surrounding the exposure, the Soldier's activities since the exposure, and the progression of symptoms. The following questions may be helpful:
At Time of Exposure:

• Did M9 Chemical Detector Paper react? • Was agent verified in liquid or vapor or a combination of both? • How was the agent identified and verified? • What actions occurred and when did they ur in relation to the time of detection? (i.e., skin decon, flushing eyes, etc.) • What level of MOPP wa wearing at the time of exposure? • If not at any MOPP level, did the casu lty don the IPE over his exposed battle uniform?
• What was the exposure time in the
environment?
After Onset of Symp
• Were MARK I Kits/ATNAA and/or ed, and if so, whe in relation to the onset of symptoms? • Has the Soldier been taking the Nerve Agent Pretreatment Pill (NAPP)? When did he take the last one and how many? • How long since the last onset of • What symptoms has the casualty • What activities has the individual engaged since the initial exposure? • What level of MOPP was the casualty in when symptoms began? Knowing the Soldier's protective posture at the time of exposure, the time taken to react to the exposure, and the actions taken by the Soldier in response to the exposure will assist the triage effort and subsequent treatme at the MTF. Obtaining as complete a hi possible, coupled with unit chemical survey data, will enhance the triage and treatm for the casualty at the MTF. Providing too information on the field medical card is far better The combat lifesaver/m re of the various factors influencing production of the casualty types. These factors are as follows: • The protective posture of the unit at the time they encountered the chemical agent. unter a result of mo through the chemical contamination or a result of direct attack on the unit? • Was movement through th contamination deliberate or unintentional? • Was the unit in contact with enemy forces at the time of the encounter? • Did the unit encounter chemical agents in id form, or a com s the unit's chem cal survey team Understanding the circumstances that produce the casualty will help the combat lifesaver/medic in the casualty's triage, treatment, and evacuation. CASUALTY EVALUATION
The combat lifesaver/medic will encounter seven general categories of casualties on the contaminated • Exposed and contaminated • Exposed and not contaminated • Conventionally wounded, exposed, and y wounded, exposed, and • Conventionally wounded, not exposed, and contaminated • Conventionally wounded, not exposed, and not contaminated • Psychological This list may seem obvious at first, but it is presented for a reason. The proper management of casualties in-depth understanding of the various types of casualties and the specific treatment needs of each. When the combat lifesaver/medic is with one or more casualties on the contaminated battlefield, a deliberate de making process must begin. Taking deliberate steps to evaluate the casualty, regardless of condition, will orrect category. This, in turn, will optimize the casualty's care and his cha At times, the medic will need to decide which course of action to follow. The deciding factor will always be to trea poses the most immediate The most critical step of the decision-making process is triage. TRIAGE ON THE
CONTAMINATED BATTLEFIELD
Triage is defined as the classification of patients according to type and seriousness of y in order to prov e the most orderl ly, and efficient u while providing maximal casualty care. Triage is necessary during a mass casualty situation or when the casualty load overwhelms medical resources. Under this circumstance, it is necessary to sort and prioritize patients for care. When the number of casualties does not edical resources, triage is not During a mass casualty situation, the goal is to provide the best care for the most casualties.
Ideally, care would be provided first to those who are in immediate danger of dying because of their wounds. However, this can be d if resources to provide this care are available
and if the care will not require an undue
ent caring for other Chemical casualties may also have conventional wounds, and standard guidelines for the initial survey of a casualty must also be followed. These guidelines should be discussed with the medical officer in your unit and modified ccordingly. Guideli nes for surveying a chemical casualty prior to triage are provided Surveying the Casualty
• Look for any field medical card that was • Look for empty antidote autoinjector(s) attached to overgarment. • Question the casualty's buddy regarding -- Type of agent and how it was -- Conventional wounds noted in casualty by buddy and buddy-assisted first aid rendered. -- Prior treatment for suspected chemical exposure and/or conventional wounds. -- Use of nerve agent pretreatment drug (pyridostigmine). • Observe the casualty's protective clothing and equipment for signs of liquid chemical contamination. • Survey casualty for conventional injuries. • Survey casualty for continued signs/symptoms of chemical agent poisoning. • Determine whether or not the casualty can respond to a command. -- Ask the casualty to describe signs and -- Observe whether or not the casualty responds in an orderly fashion when following simple directions. Suspect shock or CNS involvement if he cannot. • Observe the casualty for the following -- "Sweating" through the overga through exposed skin; this could indicate a skin exposure to liquid nerve agent under the "sweat." se by placing fingers on carotid. Feeling through the hoo aerosolized agent is still in the air, the triage officer, wearing the tactile chemical protective gloves, might reach under the hood and feel for the pulse on bare skin. The tactile gloves and the skin on the neck must be decontaminated before feeling for the carotid pulse. • Check for pupil reactivity by covering both eye lenses with gloved hands, then uncovering
and observing for pupil reaction.
Triage the patient.

Triage categories are delayed, immediate,
minimal, and expectant (DIME).

• DELAYED
delayed casualty is one who needs
further medical care but can wait for that without risk of compromising his successful recovery. He may require extensive surgical proced ures nd long-term hospitalization, but he is resently stable and requires no immediate care. A casualty with a leg wound or fracture is an example of a conventional casualty who woul ayed. A casualty recovering from severe nerve agent poisoni sicant burns will Most casualties with ve • IMMEDIATE
A casualty classified as immediate has an
injury that will be fatal if he does not receive immediate care. In a non-mass casualty situation, he would be the first casualty to receive care. However, in a mass casualty situation, particularly in a far-forward medical treatment facility, he may not receive this care. The required care may not be available at that level (e.g., a casualty may need major chest surgery, and that cannot be done at a BAS) or the time needed to provide that care might be so prolonged that other casualties would suffer. Examples of immediate casualties are provided below. -- Casualties who are not displaying signs and symptoms of chemical agent exposure but have a life-threatening conventional injury (i.e., gross external bleeding, sucking chest wound, flail chest, airway obstruction, tension pneumothorax, maxillofacial wounds in which asphyxia exists or is likely to occur, or severe head or spinal cord injuries where an expectant outcome is likely). -- Severe nerve agent casualties with or without conventional wounds. This would include those who have labored breathing or just stopped breathing but still have adequate circulation (a good blood pressure) and those who are convulsing or have convulsed. -- Casualties from cyanide poisoning who are gasping or just stopped breathing, but still have adequate circulation. -- Casualties in respiratory distress from phosgene, a phosgene-like substance, or a vesicant. The care required for these casualties exceeds that at the lower echelon medical treatment facilities. They should be triaged as immediate only if they can be quickly evacuated to a pulmonary treatment facility for intensive care. • MINIMAL
A casualty who would be classified as minimal is one who (1) can be treated by a
es not need to see a physician or PA, (2) will not be evacuated, and (3) will return to duty within a day or so. Such casualties might be as follows: -- Casualties with moderate to mild nerve agent poisoning who have taken the antidote, are recovering, and are not in distress. -- Casualties who have minor conventional wounds. amount of erythema or a few small blisters in noncritical areas. • EXPECTANT
expectant casu lty is one for wh
medical care cannot be prov ided at the medic treatment facility and cannot be evacua more advanced care in time to save his life. This category is used only during mass casualty situations. This category does not mean that these casualties will not receive medical care. • Transfer casualties for cuation based on established -- Casualties who have been classified as "IMMEDIATE" are transferred to the contaminated medical treatment area for stabilization. After stabiliz ation, these casualties are taken to the litter patient decontamination area. s who have been categorized as "DELAYED" may or may not require treatment in the collective protection treatment area before evacuatio n. If they need to e ter this n area for treatment, they are se t to the w chever is appropriate. If they do not need treatment in this area, they are sent dire -- Casualties who have been categorized ceive treatment in the collective protection treatment shelter or the contaminated emergency treatment area. If they minated emergency rea and they have no break in their chemical protective overgarment (CPO), they will return to duty from this area. If they require treatment in the clean treatment area, they will be sent to one of the decontamination areas before entry into the clean treatment area. Casualties who have been categorized as XPECTANT" will be trans ferred to designated contaminated holding area will be constantly monitored while in this comfort measures. They may require treatment not readily available at the lowest level of care. AMBULATORY AND LITTER
PATIENT DECONTAMINATION
(FM 4-02.7, Health Service Suppo Patient decontamination is a labor- intensive undertaking and will require augmentation personnel, additional or specialized equipment, and training for all personnel involved. Proactive planning will go far to minimize the impact on your unit and ensure the overall medical mission is not impaired. With a little ingenuity, training, and xecution, an effective patient decontamination procedure can be established. There are three levels of patient decontamination. Immediate decontamination: Primarily
performed to protect the individual. Here the contaminated person removes contamination from their individual protective ensemble (IPE), equipment, and the skin as quickly as possible after exposure. Another individual (buddy) provides immediate decontamination for a person who is unable to do it for him/herself. Patient operational decontamination:
Performed to protect operators of transport vehicles. Unit members remove as much contamination as possible from the casualty's IPE, equipment, and skin, without removing the IPE. This is done to prepare the individual for transport on designated "dirty" evacuation assets to the next level of medical care. Patient thorough decontamination:
Operators of the patient decontamination station
(PDS) perform this to protect medical facility
staff and equipment and to reduce patient
contamination. It involves removal of
contaminated IPE and a thorough
decontamination of any contaminated skin prior
to a patient entering a medical treatment facility
(MTF).
NOTE: It may be possible that the patient
triaged as minimal or delayed never goes
through patient thorough decontamination at the
battalion aid station (BAS) or other far forward
MTF. Instead, they may be treated in the "dirty"
treatment area and returned to their unit. Other
patients with more severe conditions, once
stabilized, may have their IPE decontaminated
but not removed. They are then "dirty"
evacuated to the next level of care withou
inside the BAS. At the larger MTF, they will undergo patient thorough decontamination before admission inside that MTF. KEY ELEMENTS
When planning for patient decontamination operations, the following key elements mu • The mission of the unit • Wind direction • Security of decon site • Access control to decontamination site • Knowing the number of casualties to be • Equipment sets/supplies • Personnel requirements • Work/rest considerations • Litter casualty decontamination • Ambulatory casualty decontamination • Disestablishing a patient decontamination • Dirty evacuation assets Wind Direction
Wind direction and speed are critical factors in planning because of the vapor hazard that will
be present downwind from the Patient
Decontamination Station (PDS). When
planning for patient decont assumption must be made that, after decontamination operations begin, chemical agents in vapor and liquid form will be presen nation site (i.e., open dirty arrival and triage area, etc.). sideration must be giv o the effect that wind-driven chemical agent vapors have on other unit operations or on units. A valid concern of other unit com and your commander will be the uncontrolled effect vapors have. This one factor may cause you to plan for decontamin Knowing the anticipated wind direction and wind speed, plus the estimated duration direction and speed, will allow for a swift response to incoming chem ical casualt es. The wind information you will need can be obtained from the chemical officer or NBC NCO cal Downwind Message (CDM). This data can also be obtained from the The decontaminat ion site will therefore initially be set up to take ad revailing wind, with the clean area operations palways being upwi wind data shows a radical wind shift is predicted during decontamination operations, your set-up should be adaptable to allow for quick rearrangement. Keeping track of the existing wind di ction during the decontaminatio responsibility of the site Noncommissioned Officer in Charge (NCOIC). One of the best means of doing this is to attach short strips of the yellow marking ribbon to mounting from the M274 Contaminat ion Sign Kit or white engineering tape to tent poles, tent rope One of these wind direction devices must be visible from the Hot Line when looking in any direction. Moving the PDS must be considered if the wind shifts more than 30o from the prevailing wind direction. Wind shifts often are transient, so it is advisable to wait 10 to 15 minutes to see if the wind goes back to its original direction. Coordination for the disrupt and diversion during this waiting period should be considered in the preplanning phase. Often wind speed will be less than 5 MPH for long periods. During these calm atmospheric conditions, chemical agent vapors will drift in almost any direction. This lack of wind direction will also require the planner to consider moving the decontamination site well outside the base cluster or support areas so that it will not adversely affect other units or the on-going conventional medical missi Security of Decontamination Site
The same security considerations apply when choosing a decontamination site as with any other medical operation. A decontamination site has the same potential attack risks as the MTF. The Officer-in-Charge (OIC)/NCOIC can evaluate the risk by asking the following questions: • What is the commander's estimate of possible enemy contact? • What is the S2's intelligence on enemy weapons and tactics? • What available terrain or structures can enhance the defense of the decontamination site? • Can the site be defended? • Is the site overly accessible, e.g., is it sitting on a hill or dire ctly adjacent to a bu road where access is not controlled; can the site be visually acquired from a distance? • Can the site be quickly evacuated if • Can key locations be sandbagged for added protection? • Will the site be located in an area under light discipline? • Will the decontami nation operation be al in complete darkness? • Are communication means available for medical or operational emergencies? • Can protection for the PDS primary supported unit and be augmented as needed? ty" evacuation assets be available ambulance or rotor wing aircraft, to take some patients for decontaminati on at the next le Access Control to Site
entry control point (ECP) must be
established to control movement of all facilities into the MTF or the PDS. (FM 4-02.7, Health Service Support in a Nuclear, Biological, and Chemical Environment). Engineering controls, such as concertina wire or other sturdy fencing material should be used when available to restrict travel across the Hot Line to the clean area, except through guarded entry control points. The ECP should be located at a distance far enough from the MTF to minimize any vapor hazard that m y occur from contaminated vehicles stopping at this point. Without extensive chemical agent monitoring ability, rapid decisions must be made as to which vehicles and vehicle contents are contaminated and must proceed to the decontaminati and which are clean and may proceed directly to the MTF. To facilitate identification of evacuation vehicles carrying clean or contaminated casualties, prior direct coordination be MTF and supporting evacua tion units, oth air and ground, on a standardized identification method must occur. This coordination should happen prior to deployment. One may also consider any vehicle to be contaminated or that it carried exposed Soldiers, despite actual risk. This will allow for increased flow through the ambulatory decontamination line and possibly dental "clean side" exposure. One solution is to use fabricated metal triangles with the NATO standard dimensions of 28 cm x 20 cm x 20 cm. To maximize ICAMouflage, paint the triangles with flat green chemical agent resistant coating (CARC) pai t. On the three separate triangles, paint the words ATOM, BIO, or GAS in flat black CARC paint. This will give the evacuation vehicle crew the ability to designate what casualty type is on board. Attach the triangles to the front end of the evacuation vehicle so the ECP personnel can observe it at a distance. Use chemlights for night operations. Show a yellow chemlight for chemical casualties, a blue light for biological casualties, and a red light for radiation casualties. Attach the che mlight to the front of the vehicle, below the level of the hood, to preclude its interference with the driver's night vision. The Soldiers manning the ECP should be equipped with a pair of binoculars and night vision goggles (NVG) for standoff inspec the approaching evacuation vehicle. Once the vehicle halts at the ECP, the ECP personnel should conduct a cautious approach of the vehicle. They should note the MOPP level the evacuation vehicle crew is in and, rega MOPP level, question the crew about any patient signs or symptoms related to agent nd about the vehicle's contamination status. The personnel at the ECP are in Use M8 or M9 paper to make a rapid determination of whether or not a liquid chemica agent is present on, or in, a vehicle. Use the IICAM to detect vapor coming from any liquid contamination on, or in, a vehicle. Visually inspect the vehicle at the ECP and test any suspect liquids on the vehicle with M8 paper: results are sent to the Casualty Deconta Center (CDC). Areas likely to have liquid contamination are the vehicle's wheel well areas, tires, and rear portion of the vehicle. If the outside of the vehicle is contaminated and the patient needs to be transported to the next level of care, plans must be in place to transfer the casualty from that vehicle, which has outside contamination, to another without outside nation.The "dirty" vehicle with outside contamination would then return to the battlefield to pick up more contaminated patients. Non-standard evacuation platforms can be used if adequate ambulance assets are not available to transport casualties to the next level of care. Th commander may want to restrict vehicles exterior contamination from moving throu unit area. Litter teams may also be utilized to transfer casualties. As a final resort, the contaminated evacuation vehicl into the casualty decontamination site on a route that has minimal impact on vehicle movement into the MTF. Control of vehicle movement to specific
routes and areas within the decontamina is a critical safety issue, even during combat operations. This can involve routing vehicles along a clearly marked, one-way path for the ECP to the chemical casualty decontam site. Then, ideally, return to the ECP sh along the same route. If vehicles are no the proper path, clean areas are likely to become contaminated, and both patients and personnel are subject to being run over du ng night operations. Planning for vehicle movement must always include night operations and operations in low visibility conditions. Control of personnel movement is
necessary to ensure that casualties and personnel do not accidentally cross the without first being decontaminated and to secure the PDS and MTF sites fro m enemy infiltrator Concertina wire works well to keep personnel in the desired areas, and a clearly marked, one-way route helps to ensure that correct entry and exit points are used. To reinforce the physical barriers in place, night operations must also use visual control measures that conform to light discipline guidelines. Numbers of Casualties to be Treated
Having an advanced knowledge of the numbers of casualties and types of injuries expected is very helpful in logistical planning, but not always possible. Practicing procedures for the resupply of the PDS from the clean side of the Hot Line is important. Position some supplies in the PDS area, but a majority be covered, and pre-positioned in kits, on the clean side of the Hot Line. They are handed to personnel working at the PDS, as needed, to replace used supplies as the numbers of patients increase. This may prevent unnecessary disposal of large numbers of medical supplies that might be considered contaminated if they were positioned in contaminated PDS area and never us Equipment and Supplies
A suggested minimum list of additional items needed to support the casualty decontamination site is provided at Appendix B. The sets will service specific numbers of Soldiers based upon the facility's level of care. Typical BAS sets for Chemical Treatment and Decontamination will cover 30 and 60 patients, respectively. Typical trauma and sick call will cover for 3 to 5 days' worth of patients. Personnel Requirements
Provided below is a minimum suggested list of personnel to staff the CDC. Although a effective litter decontamination proced performed by just two augmentees and triage can be handled with minimal staff, planning must include staffing for both the operational and support staff. The in-depth planni operating the decontamination site must inclu the anticipated casualty load, day or night operations, weather conditions, work and rest rates for personnel, logistical support for and the acceptable impact on conventio rations that are still ongo ng.
Site Command and Control Cell:

1 NCOIC (will also serve as safety officer)
NOTE: The individual ap o
p inted as the safety officer must be able to move freely throughout the dirty area of the PDS to check with personnel to ensure that they are not sh symptoms of heat stress and are following safe
patient handling procedures.
Triage/Emergency Medical Treatment Area:

1 EMT NCO as Triage Officer or DDS 16 litter bearers (two 8-man teams)
Litter Casualty Decontamination Area (at
least 2 teams with the following):

1 Improved Chemical Agent Monitor 4 Decontamination Augmentees
NOTE: The four augmentees perform patient
decontamination. They can also replace litter
bearers during casualty decontamination as
needed, remove contaminated litters, and
replace clean litters during transfers between
clothing removal and skin decontamination.
Additionally, the augmentees ba
ntamination area, replace bleach atients, and pour old ch solutions onto waste in the bags, thus g the liquid to absorb into the clothing.
Ambulatory Casualty Decontamination Area:

4 Decontamination Augmentees itter Was
hing/Decontamination Point:

NOTE: In the event of chemical or biological
agent contamination, augmentees
decontaminate any decontaminable (mesh)
litters by scrubbing a 5% bleach solution over
the entire surface of the litter, including handles.
They then should allow the litter to dry for 15
minutes and then rinse it with fresh
wait time will allow the bleach to neutralize any chemical agent on the litter. If canvas litters are used, the augmentees will remove any barrier materials (plastic sheeting) used to protect the wooden handles and canvas cover and place these materials in a plastic bag. If the barrie material is in short supply, the plastic sheeting can be scrubbed with 5% blea for 15 minutes, and then rinsed canvas litter handles will be wiped with a 5% bleach solution. Do not use the bleach solution directly on the canvas as it will destroy the material. Canvas litters should only be us transport of patients in the dirty area and not brought into the MTF if they have been on the dirty side of the Hot Line. Contaminated canvas litters cannot be thoroughly decontaminated as the wood and canvas will absorb chemical agents. When not decontaminating a litter, two of the augmen tees will transport waste to the d

Clean Treatment Area:

2 Litter Bearers
Logistical Support Point:
1 Medical Supply NCO TOTAL: 27 to 40 Soldiers
Work/Rest Considerations
This single consideration will have a direct impact on the efficiency of personnel and replacement needs of personnel. A complete rstanding of the available information on this subject, coupled xperience, will enhance the planning process s work force eeds. Establishing a endent on several factors, as listed below. • How rested ar • Have the Soldiers been acclimated? • Has a command drinking policy been in MOPP Level, thus a how well hydrated the Soldiers are? • What is the anticipated relative humidity? • What is the anticipated temperature? • Will overhead cover (shade) be available? • How many heat casualties will the commander accept? Suggested background information can be found in FM 3-11.4 Multi Service, Tactics, Techniques, and Procedures for Nuclear, Biological and Chemical (NBC) Protection. Establish a Patient Decontaminat
ion Station
The care of contaminated casualties, although more complicated than that of conventional casualties, must not stop the ongoing medical mission. Medical officers and medical NCOs must develop realistic, battle-focused plans. They must then refine and validate these plans in challenging training if health service support (HSS) on the future battlefield is to be uccessful. Historically, the single area of contaminated casualty care that has caused the greatest amount of trouble for medical units has been the actual decontamination effort. Beginning with this section, through the final section on disestablishing a decontamination site, you will be presented with materi al derived from rece conducted tests, doctrinal procedures, and the practical experiences of medical and chemical NCOs. The following section presents gestions or "food for thought" on how to successfully conduct contaminated casualty decontamination. Each level of medical care must have an operational PDS function. Before we get into the actual material on establishing a decontamination site, it is important to discuss where these contaminated casualties originate. A picture of the C/B battlefield is required if planning is to anticipate, with some degree of accuracy, the appropriate level of preparation requi d for ca decontamination and care.
The C/B Battlefield
Chemical agents can be introduced into the environment as one of the following, depending on the weapon system used: • Gases/Aerosols Biological agents can be introduced into the environment in wet or dry form. Examples are provided below. • A slurry mix (wet) • Large thick drops • A dry powder Regardless of which fo when introduced, there is one commo chemical or biological weapons will cont personnel, terrain, and equipment on the ground. However, it is not enough to say that contamination occurs. It is also important to discuss the extent of the contamination and how long it will last. hemical Co
ntamination
The most common misconception people have about chemical contamination is that vast areas of the battlefield will be contaminated by liquid chemical agents. Another misconception is that everything in the contaminated area will be "dripping" with chemical agents. The method for predicting the affected areas from a chemical attack is presented in FM -3, Chemical and Biological Contamination Avoidance, Chapter 3. The contamination prediction tells two important things about a chemical attack. First, it shows the attack area, i.e. the area in which liquid nation can be found. Second, it shows the hazard area, i.e. the area downwind from the attack area that can be affected by chemical vapors originating in the attack area. The prediction also show air contamina ing atta ck (Type A), which has ntamination on the ground, or a ground contaminating attack (Type B). Contaminated casualties coming from the attack area can pose both a liquid hazard from liquid on their clothing and equipment, and a vapor hazard from evaporating liquid agent as well as vapors trapped in clothing fabric and hair. Casualties in the attack area will pose the greatest risk during initial medical treatment and patient decontamination because of the potential liquid contamination that may be cross-transferred to the Soldier medic/combat lifesaver, the interior of evacuation vehicles, or to non-medical augmentees performin decontamination. Because of these liquid and vapor problems, it is important to understand as much as possible about the attack and hazard areas. Exposure to a vapor will pose less of a hazard to decontamination operators than exposure to liquid agent or concentrated aerosols. Often vapor exposures, predominant in a Type A attack, will quickly volatilize (evaporate) before the patient reaches the decontamination station. In these cases, removal of clothing and a brisk rubbing or washing of the hair (if the hair was exposed and unprotected by IPE) may be all that is needed to release the trapped vapors. Most toxic industrial chemical (TIC) releases that involve a vapor plume can be categorized as a Type A attack. The dimensions of the attack area based on the type of agent employed and weapon system used is provided in FM 3-3. The dimensions represent an area that will be larger than the actual area contaminated by a liquid chemical agent. The following illustrates this point:
NOTE: In the spray attack or artillery attack
by several artillery regiments, the Type B attack
area is predicted to be shaped like a cylinder.
Although it can be several kilometers in length, it
will be no more than 2 km wide at any point.
This type of attack will contaminate the greatest
area of all the attack types shown.
The Type A attack occurs when threat forces believe that a large concentration of chemical agent vapors will surprise U.S. forces and cause casualties through inhalation.
attack usually is conducted by firing large numbers of highly volatile (non-persistent) chemical agent munitions into a relatively small area or through the purpo sabotage of industrial chemical storage tanks creating a toxic cloud of TIC. These nonpersistent agents are: Nerve Agents – GB, GD Pulmonary Agent – CG Vesicating Agent – CX Cyanide Agents – AC, CK Most TICs release with resulting vapor The Type A attack will not normally be placed on a unit's position but will occur "off-target," i.e. at some distance away from maximize the develo pment of a vapor cloud and the number of casualties through inhalation. This will be particularly true of an attack that uses the G-series nerve agents, the pulmona agent CG, the vesicating agent CX, or the purposeful destruction of storage facilities to release TIC. If a cyanide agent is used, the attack will most likely be in cation because of the rapid expansion of cyanide vapor in the air and the ability of cyanide vapor to mix easily with the su air causing its rapid dilution. Cyanide is most effective in enclosed spaces, such as building . A casualty in the Type B attack area presents a potential liquid hazard, as well as an off-gassing vapor hazard, while the ca the Type A hazard area will pose only an off-gassing hazard. However, in most ca liquid chemical agent found on this casualty will ue to the rapid evaporation of the highly volatile (non-persisten t) liquid che ical agents from the outer ma protective ensemble (IPE). Although the M9 chemical detection tape e attack area will show a re ction upon exposure to any liquid chem al t may be difficult to detect an sing M8 detection paper during triage at the decontamination site because of evaporation. The IICAM may be useful here. The Type B attack occurs when threat forces believe that terrain denial or the creation of a chemical barrier will slow U.S. forces or cause our forces to maneuver around the obstacle, potentially into a pre-planned killing zone. The use of a Type B attack on choke points (i.e., narrow points in a valley, road junctions, or crossing points at water obstacles) can be expected, especially if U.S. forces are in these locations. Threat forces will use persistent chemical agents. These have a low volatility, taking more than 24 hours to fully evaporate. The persistent chemical agents are as follows: Nerve Agents - TGD (thickened GD), VX
Vesicating Agents - L, H, HD
The Type B attack area can be several times larger than the Type A area. The Type B attack represents the worst case scenario for medical support because of the long-term hazard posed by liquid chemical agents. The Type B attack is used for planning purposes until deliberate chemical surveys indicate a Type A attack has occurred. Also, the Type B attack is most likely to be placed on or near our units to maximize the effect liquid and heavy vapor contamination will have on our personnel and equipment. A casualty caught in the open without overhead cover during a Type B attack will have easily visible, oily splashes or a large nu oily spots of varying sizes on their IPE. The mask carrier and load-bearing equipment (LBE) will also have spots or smears that result of perspiration. The M9 detection tape may also have positive indications of chemical agent drops (some as small as 100 microns) and a few streaks. After the actual attack has stopped, the individual will probably contact objects, such as plants or equipment that ha ve agent on them. This can smear agent on IPE and protective sing oily smears or spots of varying sizes. The M9 detection tape will have more streaks than spots, which coul casualty brushed against the liquid while moving. Casualties in the hazard ar attack will pose the same hazard as a Ty casualty, i.e., off-gassing vapors from the IPE.
Biological Contamination
While the information available on chemical contamination is extensive, the same cannot be said for the incubation period of biological agents. Our forces may not know that a biological attack has occurred, or even which biological agent was used , until several day a week after the attack has actually occurred. This basically means that the prediction method in Chapter 4 of FM 3-3 will be used what terrain was potentially contaminated, which units were present in the predicted area or contamination, and how long these units remained in the affected area. Knowing which units were in the area will allow for a medical response that is appropriate for the agent used cipated casualty load. In Chapter 4 of FM 3-3, two types of biological attack are presented, the Type A attack (air contaminating attack) and the Type B attack (ground contaminating attack). The Type A attack is considered the worst case and is used for planning purposes because this type of attack will contaminate the great mount of terrain nd affect the greatest number of nel. The attack area for a Type A attack is always 1 km in diameter (unless a larger size is observed or determined through a survey), while the total downwind distan can vary from 32 km out to several hundred kilometers. The total downwind distance will produce a hazard area of enormous proportions. Any casualty from any location within the attack area or hazard area that requires medical support must be considered contaminated and handled appropriately. This standard response should continue until deliberate biological sampling has taken place and the laboratory analysis of the samples indicates that the biological threat no longer exists. The Type B attack will have only an a area, which is shown on a map as a circle, with a minimum diameter of 5 km unless a larger is determined through a survey or by observation. Any personn r attack area who require medical support must be considered contaminated and handled
appropriately.

Tactical Planning
When a C/B attack occurs on or near the unit, a medical platoon is supporting the medical platoon leader (field administrative assistant) and the medical platoon sergeant must be prepared to quickly and efficiently transition from conventional casualty operations to contaminated casualty operations. To accomplish this transition, the medical platoon leader or medical platoon sergeant must be alerted almost as quickly as the unit commander that a C/B attack has occurred. In order for this information to be obtained in the quickest fashion, one of these personnel must be located in the unit tactical operations center (TOC). He or she must monitor both the unit's internal command (COM) radio net and/or the admin/log (A/L) radio net. When an attack occurs, a NBC-1 (CHEMICAL) Observers Report will be sent, or a code word will be sent via the COM or A/L radio net. This will alert the unit that a chemical attack has occurred. Because the unit NBC NCO or chemical officer will lack vital C/B survey information during the first hour or so after an attack has occurred, it must be assumed that, in the case of a chemical attack, a Type B attack has occurred. Likewise, in the event a biological attack is suspected, a Type A attack must be assumed. The medical response must begin with a hasty evaluation of the attack, the factors that dicate the type of casualties most likely to be seen, and the type of contamination these casualties will bring in with them--liquid vs. vapor, chemical vs. biological. This eval will be based on the following: • The location of all units su medical platoon. • The location of the attack (Line F of the NBC-1 Observers Report). • The type of agent and type of attack (Line H of the NBC-1 Observers Report). If Line H is unknown, then assume a Type B attack. • Which units are in the attack area. • Which units are in the hazard area. • The readiness posture of an the predicted attack area and/or predicted hazard area. -- What MOPP level was the affected unit -- What type of terrain has the unit Built-up (urban) terrain could indicate that overhead cover was available to shield personnel against the initial liquid contam Wooded terrain could also indicate some overhead cover provided by the forest canopy sert terra indicates very little overhead -- How long had the unit been in its -- If nerve agent is suspected, was the unit taking Nerve Agent Pyridostigmine Pretreatment (NAPP)? This will not alter treatment. -- If nerve agent is reported, how was the agent verified? M22 ACADA, or M256A1
detector sampler indicate ONLY a vapor/aerosol
hazard. M9 tape indicates an aerosol or liquid
hazard, M8 detector paper indicates ONLY a
liquid hazard. Any combination of M8 detector
paper, the M22 ACADA, and M256A1 detector-
sam e
pl r indicates both a liquid and vapor • Is the attack only a chemical attack, or are conventional High Explosive (HE) muniti with a ground attack? • If a biological attack is suspected, what -- Did any suspicious liquid fail to cause a reaction on M9 tape or M8 paper? -- If aerosols were observed being disseminated, did the M22 ACADA, M256A1 chemical detection sa mpler, or IICAM fa indicate a chemical agent? -- Did any biological agent rapid de ction field tests indicate a possible biological agent? stions are by no means all that e asked but are critical in determining a hasty plan of action. The un ed that contaminated casualties will be arriving and that some evacuation may be contaminated. The executive of in most situations, make the final decision if the ties will take place area or if it must take place at a location outside the unit area that will not affect
ongoing support operations.
NOTE: Biological casualties who arrive at the
MTF with flu-like symptoms and have bat
the last day or two have already decontam themselves. Most biological agents do not live on clothing for more than a day or two and are at or sunlight exposure. The exception is anthrax spores, which remain a hazard for months to years, and can be
in clothing fibers and hair if it has not been
changed or washed since the attack.

Establish the Decontami
The ability of the medical platoon, or mo specifically the treatment squad, to esta decontamination site will d d greatly on unit support. Long before the medical platoon deploys, the unit commander, first serg xecutive officer m ust understand the need for manpower and equipment support. Addi when possible, the commander should pre-
designate in the tactical standing operating
procedures (TSOP) which sections of the
headquarters unit will provide personnel or
equipment to the medical decontamination site.
The medical platoon leader should ensure that
the sections tasked to provide personnel are
trained prior to deployment and that after
deployment, these sections receive quick
refresher training when possible.
Log of Assigned Personnel
When a C/B attack occurs, the required personnel and equipment must be available almost immediately. The medical platoon leader or platoon sergeant must maintain a current status of required support equipment and a continuously updated roster (by name) to ensure that gathering of personnel and equipment can
occur when a timely response is critical to
patient care.

Battalion Level

Outside a 1 km stand-off distance from
the edge of the predicted downwind hazard
area, all personnel can remain in MOPP 2
during the set-up of the decontamination site. In
this area, the site should be free from both liquid
and vapor contamination. It is recommended
that one Soldier in MOPP IV conduct continuous
monitoring during site set-up at a location at
least 1 km away. This Soldier should use the
M22 ACADA regardless of what agent has been
reported. Initial NBC-1 Observers' Reports
received at the tactical operations center (TOC)
during testing scenarios and field training
exercises often contain incorrect information
about which agent was actually encountered.
As long as the monitor continues to report no
contact with chemical agent vapors, all
nel can remain in MOPP 2 until the first casualties are 5 to 10 minutes away. The r of casualties is reported at this time so that initial supplies can be positioned in If the selected site is within the 1 km
stand-off distance or within the predicted
downwind vapor hazard area, all personnel
must be in MOPP 3 or MOPP IV during site set-
up. Modification of the MOPP level based on temperature workload during set- up can be accomplished as described in FM 3- 11.4 MultiService ctics, Techniques, and Procedures for NBC Protection, Chapter IV. If the site must be set up in the vapor hazard ar it is critical that the selected site be free contamination. As long as the team sent selected site remains completely outside the predicted liquid hazard area, and optimally outside the stand-off distance, a point ch survey should take no longer than a few minutes
using M8 chemical detector paper.

Site Preparation Phase
Site preparation will require time for shuffle pit preparation, dirty dump preparation, and removal of any ground obstacles. If the medical platoon has the luxury of time to accomplish any of this labor-intensive work prior to activating a patient decontamination site, it will greatly increase the accomplishment of the decon mission. If preparation prior to actual use cannot be done, at the very least a ground recon must take place prior to site activation. All vehicle movement routes must be marked, points along the route requiring direction indicators identified, and any ground ob identified for removal. The arrival/triage area must be surveyed to ensure it can handle the evacuation vehicles moving into and out of the activities of the triage officer and the litter teams. Both the litter decon and ambulatory decon areas must be surveyed to ensure ease of movement by augmentees, medical personnel, and ambulatory patients. The ambulatory decon area must be evaluated for direction indicators that might facilitate easy movement of ambulatory patients through the various steps and likewise for any obstacle that might impede foot traffic. The site mu evaluated for night operations. repared, each requiring at least 2 50-lb drums of Super Tropical Bleach (STB) pits, depending on the amount of use they get, must be refreshed with the STB
once every hour or after 10 personnel have
shuffled through them. To refresh a shuffle pit,
mix half the original ratio of two shovels of STB
and three shovels of dirt back into the pit. For
example, if a shuffle pit originally took 30
shovels of STB and 45 shovels of earth to
construct, 15 shovels of STB and 22 shovels of
earth (the 22.5 was rounded down for safety)
would be needed to refresh the pit.
NOTE: If Reactive Skin Decontamination
Lotion (RSDL) is used for patient
decontamination, it must not be stored near the
STB powder as it will cause the full strength,
highly reactive STB powder to ignite. RSDL can
be applied to a casualty on a litter stand that is above the shuffle pit, as it will not cause a violent reaction with the diluted shuffle pit mixture. The preparation of the dirty dump is the most labor-intensive effort in the preparation phase. If engineer support is not available (in combat, engineers will have more important missions than digging a hole in the ground at patient decontamination site eering tools must be available to assist in digging the dirty dump. Pick axes and long-handled shovels are more appropriate than individual entrenching tools. The us equipment, if available, will expedite the set-up. When setting up in a forest location, it may become necessary to clear low hanging branches, brush, or other ground obstacles. Saws, axes, pry bars, and long-handled should be dedicated for this work. Also, a site for supplies should be made near the treatment area for rapid replace The supplies could be covered to pr contamination and allow for reprocessing.
NOTE: The dedicated tools mentioned in
this section must be obtained prior to
deployment and used exclus
ively by the medi treatment squad for site preparation. This will ensure that tools are available at the critical time. paration is complete, all tools must be kept on the "clean" side of the Hot Line. NOTE: Ideally, tentage should be set u
over the decontamination and decontamination
check areas of the decontamination line to
shield unclothed patients against the elements.
Suggested Equipment Minimums
During the site set-up, the saying "Do more with less!" should be followed. Only the minimum amount of equipment needed to port patient decon should be set up on the n to be dirty side of the Hot Line. Additionally, only the minimum amount of medical supplies needed to support the contaminated emergency treatment point should be set out. During the con operations, any resupply items should be obtained from the clean side of the Hot Line o as needed basis. By keeping equipment and supplies to the barest minimum required will ensure that only minimal ite alt with during disestablishment of the decontamination site. The decon and treatment sets will be opened prior to the arrival of the first casualty. A suggested minimum list of equipment needed to set up a litter decon area and ambulatory decon area is provided below. Most of this equipment is provided in the MES Chemical Agent Patient Decontamination. • Arrival/Triage Area
-- 1 bk - Field Medical Card (carried by -- 2 ea - M291 SDK (carried by triage -- 4 ea - Litters (decontaminable or canvas litters with sacrificial coverings) -- 2 pr - TACTILE chemical protective gloves (1 worn and 1 carried by the triage officer) -- 11 bk - M8 chemical detection paper (1 booklet carried by one member of each litter team and 1 carried by the triage officer) If organic ambulances are used to transport casualties from collection points that are sid the attack area or hazard area to the patient decontamination site, it is highly unlikely that these same ambulances, which may require decontamination, would be used to evacuate clean casualties to the next level of HSS.
situation, remove from each ambulan patient protective wraps (PPW) authorized per vehicle and ho Hot Line for use in transporting decontaminated, nude casualties in designated "dirty" evacuation assets, or through possible areas of contamination, to the next level of care. • Emergency Treatment Areas
-- 6 ea - MARK I, Nerve Agent Antidote -- 6 ea - Atropine autoinjectors -- 4 ea - Convulsant Antidote for Nerve -- 1 ea - Stethoscope, Adult -- 1 ea - Flashlight -- 2 ea - Field I.V. poles -- 10 ea - Catheter/needle units -- 10 ea - Constricting band (one patient use only; impossible to ensure that decon between each patient is complete) -- 2 ro - Adhesive tape (to secure the IV) -- 10 ea - Field dressings -- 4 ea - First-aid dressing, 11-3/4" -- 4 ea - 7.25" angled bandage scissors -- 2 ea - Crichothyroidotomy cannula kits -- 2 ea - Airway pharyngeal, LARGE -- 2 ea - Airway pharyngeal, SMALL -- 1 ea - Resuscitator, hand-operated The resuscitation device, in (RDIC) would be the best hand-operated r for use on the dirty side of the Hot Line. The RDIC can be found in ea Litter Patient Decontamination
The dirty dump is located a minimum of 75 meters downwind from the triage and r ency medical treatment areas. Prepare job if you have n dirty dump i itially is a hole 5 feet deep, by 4 feet wide, by feet long. After closing the decontaminati the dirty dump, the location must be re orted to er headquarters as a contaminated an 8 or 10-digit grid coordinate. The re format used to transmit the dirty dum s location is the NBC-4 report. All personnel working in and around the dirty dump once casualties begin to arrive at the site. Triage Point/ Collection Point
Field ambulances approach the triage point from a downwind direction. Patients are off- d from the ambulances and taken to the triage point. Once casualties are inbound, personnel working in the triage area are MOPP IV. The patients are triaged and visibly marked with prepared tags or adhesive tapes using the following colors to denote triage casualties: Immediate Delayed - Yellow Expectant - Black The use of these colors can extend into night operations with the use of "chemlights" in the colors mentioned above, with the exceptio that the "expectant" casualty would be marked
with a blue chemlight. Unless the casualty is in
respiratory distress, requiring intubation on the
dirty side, or has wounds that prohibit masking,
unmasked patients must be masked
immediately at this point. After the arrival of
casualties, the entire decontamination
the downwind side of the Hot Line must be considered a liquid/vapor hazard area. Both litter and ambulatory casualties move, or have removed for them, all military regear (protective mask carrier, Kevlar vest and helmet, LBE, weapon, and all types of armament. A pat down search of the casualty's body, especially the chest and all pocket important to locate any ordinance carried by the Soldier or possible explosive devices carried by disguised terrorists. After triage, the casualty will be directed to either the ambulatory decontamination line, litter casualty decontamination line, or the dirty side E station. The mask is kept on the patient unless removal is clinically indicated. Treatment (EMT)
MT station is limited to stration of MARK I Kits and diazepam, application of pressure dressings, establ patient airway, and starting an IV infusion. If immediate clearing of the airway must be done at this point to save a life, the airway is cleared and the mask replaced, or the patient is intubated. After this lifesaving procedure, it may or may not be necessary to change the triage category of the patient to reflect the increased burden of the exposure or the improved condition of the casualty. The EMT station should be established upwind from the triage point and to the side of the decontamination site perpendicula prevailing wind direction. The EMT station should be positioned as far to the side of the decontamination site as is prac tical. Th s set-up will allow the EMT station to be away from the heaviest concentration of vapor resulting the evaporation of liquid chemical agents concentrated at the triage point. It should also be an area that is expandable, depending on the influx of patients that need stabilized. All personnel renderi assistance will be at MOPP Level IV. Litter Casualty Decontamination
Personnel working in the litter casualty decontamination areas will be at MOPP Level IV. Only the Soldiers performing litter patient decontamination should wear the Toxicological Agent Protective (TAP) apron over thei keep it dry. Any additional gear (i.e., helmets and body armor, LBE, protective mask carrier, and weapons) should be kept on the cle of the Hot Line. Each worker should carry in the cargo pockets of the JSLIST/BDO trou MARK I Kits, one Diazepam Auto-injector (CANA), one M291 SDK, and one bookl t of M8 detection paper.
NOTE: Two people (not including litter
team) will work with each patient, tracking the
patient from Step 1 to hand-over
The step-by-step procedure outlined below is the prescribed doctrine for decontaminating a litter patient, but it is by no means the only method. Knowing this method, however, ensures that correct and essential steps are not omitted, and when they are, other measures are taken to preclude a hazardous outcome. The M291 Skin Decontami and water, or 0.5% bleach solution rinse is used to remove chemical contamination n the skin. A 0.5% hypoch lorite solution is useful if water is limited and other altern are not available. A bleach solution greater than
0.5% should never be used on skin. A 5%
bleach (hypochlorite) solution will irritate and
burn the skin, which will allow agents to enter
the skin more rapidly.
NOTE: RSDL is expected to replace the
M291 Kit and can be used on skin, when
where the M291 is noted. Two different concentrations of bleach solution are used in the patient decontam ation procedure. A 5% bleach solution is used to decontamin sualty's protective mask and quick doff hood (if attached), scissors and other cutting devices, TAP aprons, and the gloves of personnel working in patient decontamination area plus litters. Approximately 10 quarts of the bleach solution are placed in 12-quart stainless steal buckets for use in this area. The buckets should be distinctly marked to distinguish the 5% solution from either 0.5% bleach solution or soap and water. Preparation of these solutions is covered in Appendix C. Bleach evaporates quickly at high temperatures and loses its oxidation ability over me, so the solution s should be prepared shortly before they are needed. Litter Patient Decontamination Area
Supplies
-- 4 pr - Litter support stands -- 8 ea - 12 qt utility pails (4 for the clothing removal points and 4 for the skin decontamination points) -- 4 ea - Sponges or rags per 12 qt utility -- 4 ea - 7.25" angled bandage scissors -- 4 ea - J-Knife/long-handled seatbelt cutter -- 1 pr - Chemical protective glove set per augmentee (16) -- 2 pr - TACTILE chemical protective gloves for medics (1 pair is worn, and 1 pair is carried) -- 1 ea - Butyl rubber apron augmentee working with th e litter patients (1 ) -- 24 ea - "Zip-lock" bags for FMC and personal items from each patient -- 12 ea - Plastic garbage bags -- 2 ea - M8 chemical detection paper booklets -- 1 ea - IICAM (if available) to survey suspected contamination or verify completeness of decon; the IICAM is kept in the skin deco Step 1. Clothing Removal (Litter Patient)
Decontaminate mask and hood.
a. Wipe/sponge down the voicemitter, eyelets, and outserts with the M291 or 5% bleach solution. While wiping around the filter, cover the inlet of the C2A1 filter canister with a hand or gauze momentarily to keep liqui the inside of the canister charcoal, reduce filter efficiency, and clog the filter.
b. To decon the hood (quick doff hood or integrate ded overgarment), wipe down the hood using M291 SDK or 5% bleach solution (starting at the top of the head and wipin down towards the litter and shoulders).
NOTE: After every complete segmental cut,
the cutting tools are decontaminated, along with
the gloved hands of the Soldier doing the
cutting. Do this by dipping gloved hands and
cutting tools in a bucket of 5% bleach, or if
ample supplies of the M295
available, and water is limited, these can be used to scrub the cutting tools.
2. Remove

NOTE: To cut the hood and JSLIST/BDO,
use scissors or a long-handled seat belt
cutter. You must replace the cutting tools
once they n
o longer make a smooth
a. Remove the quick doff ho (1) Dip the cutting device in a 5% bleach solution or decon/scrub-cutting tool with the M295 or M291. (2) Cut the hood shoulder straps. (3) Cut the neck cord, hood straps and (4) Cut the quick-doff hood from the front bottom center to the chin through the elastic band under the chin. (5) Cut the hood straps that conne t the hood to the mask. (6) Finally, cut from the center of the forehead, over the top of the head toward the litter, so that the hood will lay flat on the litter. b. Remove the hood of the JSLIST. (1) Dip the cutting device in a 5% bleach solution or decon/scrub-cutting with the M295 or M291. d starting at the front center and continue cutting across the top of the head toward the litter. (3) Fold the left and right side hood away from the head on the litter. : Use soap and water, M291, or 0.5%
bleach solution on skin or equipment items
that will contact skin.

3. ec
ontaminate
a. Use soap and water, M291, or 0.5% bleach solution. b. Patient wears mask. Cover inlet port of filter canister to prevent wetting or congesting. c. Wipe any exposed areas of patient's face that were not protected by the hood. (1)
4. Remove the Field Medical Card (FMC)

a. The medic at the litter patient decontamination station should view the FMC prior to removal. b. Cut FMC tie wire. c. Allow the FMC to fall into a "zip-lock" plastic bag. d. Seal the plastic bag and decontaminate the outside of the bag. e. Place the plastic bag under the back of the patient's mask head harness straps. Remove personal articles from pockets
of BDO/JSLIST.

a. Place in "zip-lock" bags. b. Mark the bags with the patient's name and identifying number and retain for inclusion of
other items from inside pockets later in the
process.
c. Decontamination team must
decontaminate their gloves before and after
handling the bag.
NOTE: The patient's identification tags stay
around the patient's neck throughout the
decontamination process. They are
decontaminated with soap and water, M291,
or 0.5% bleach.
6. Remove casualty's BDO/JSLIST.
a. Cut overgarment around tourniquets, bandages, and splints. Two people will be
cutting the IPE at the same time.
NOTE: Dip cutting devi
in a bucket of 5
bleach solution after each complete line of
cut to av
contaminati
ng inner parts of the
clothing or exposed skin. If bleach solution

is not available, then cutting tools must be
scrubbed using the M295 or M291.

b. Remove BDO/JSLIST jacket by cutting. (1) Unfasten/cut Velcro closure at the (2) Make two cuts, one up each sleeve from the wrist to the shoulder, and then to the collar. Keep the cuts close to the inside of the arms so that most of the sleeve material is folded outward. (3) Cut the jacket drawstring at the bottom of the jacket and unfasten Velcro closures, moving from waist to neck, and then unzip the jacket. (4) If the casualty is able, instruct him to hold his arms up and away from his body drape the left and right chest sections jacket over the outside of the litter. (5) Inst c ru t the patient to keep his hands to his sides, away from the areas where the BDO/JSLIST have been removed. (6) If the casualty is unable to lift his arms, one augmentee will hold the casualty's gloved hand and perform this ac augmentee folds the chest sections over the outside of the litter. The patient's arms are then lowered to the sides, keeping the gloves away from the area where the jacket has been removed. Remove the BDO/JSLIST trousers b
cutting.

(1) Cut the suspenders. (2) Cut the leg closure cord at the ankle (4) Cut from the ankle along the inseam of the left trouser leg until the crotch area is reached, then cut across into the zipper. (5) Cut along the inseam of th ideways into the first cut. (6) Allow trouser halves to drape over the side of the litter. (7) Tuck the remaining cloth between the legs by rolling it, while ensuring that only the
black lining is showing.
7. Remove outer gloves. Do not remove the
inner gloves.
a. Decontaminate your own gloves with the M295, M291, or 5% bleach solution. b. Decontaminate the casualty's gloves with the M295, M291, or 5% bleach solution. c. Instruct the casualty to hold his arms away from the litter and upper body or, if he cannot comply with instructions, hold his gloves by the fingers.
NOTE: Always remove the gloves over the
sides of the litter.

d. Grasp the cuff of the glove, turning the glove inside out and remove it. e. Carefully lower the patient's arm(s) across his chest as each glove is removed. Avoid touching the patient's cloth gl arm with your rubber glove. CAUTION: Do not allow the arms to contact
the exterior (ICAMouflage) side of the overgarment. f. Dispose of the contaminated gloves by placing them in a trash bag. g. Decontaminate your own gloves with the M295, M291, or 5% bleach solution.
8. Remove black vinyl overboots (BVO) or
Multi-purpose overboot (MULO).

a.
b. Gently pull the overboot by the heel until c. If the overboot will not come off, cut the boot from top to bottom along the centerli the boot or along the inside of the boot. Fold the overboot down and gently pull the heel until it is removed.
9. Remove personal effects from
BDU/JSLIST.
NOTE:
Remember to decontaminate your a. Place personal effects in "zip lo
10. Remove combat boots withou
body surfaces.

a. Cut the boot laces along the tongue. b. Pull the boots downward and toward you c. Place the boots in the plastic bag containing the chemical overboots and gloves.
11. Remove inner clothing.

a. Cut or unbuckle belt. b. Cut the BDU pants following the same procedures as for the overgarment trousers. c. Cut the BDU jacket following the same procedures as for the overgarment jacket.
12. Remove undergarments
a.
Remove the patient's T-shirt.
with the M295 r M29 1, or immerse cutting ucket of 5% bleach solution between each cut. Cut up the fro t of the patient's T- t up to the collar. (3) Cut both sleeves from the inside, elbow, up to the shoulder, and then to the collar. und bandages or splints, (5) Next, gently peel the T-shirt away ading contamination nt on undergarment. Remove the patient's brassiere.
(1)
nate gloves and scissors. (2) Cut brassiere between the cups. (3) Cut both shoulder straps wher s and remove the brassiere. Remove the patient's under-
(1) Decontaminate gloves and sci (2) Cut from the lower side of the hip to the wai t on both sides. (3) Place the undergarments into the c garbage bag containing the other contaminated items.

14. Remove socks. Place in the plastic
garbage bag.

15. Remove inner gloves. Place in the plastic
garbage bag.
TE Workers must decontaminate each
other's TAP aprons, gloves prote tive hood with the M291 or 0.5% solutio between each patient and before any litter transfe each other, with each member being decontaminated stan din with his arms spread out to the sides, allowing the team member performing the decontamination to get into all the folds of the TAP apron Step 2. Litter Transfer and Decontamination
1. After decontaminating one another's TAP aprons, augmentees will now use a patient-lift to move the nude patient to a clean litter where s n decontamination will occur. 2. Decontamination team me er on one side of the litter and three on the other. 3. The lone augmentee rolls the patient toward him. 4. The three augmentees lifting the patient slide their clean arms unde wer back, and distal legs. The medic, if present, will provide superv in neck stabili at The patient is then rolled back onto the three augmentees' forearms. 6. The medi , or individual at the patient' mand "prepare to lift." If ready to lift, the other me mbers reply "ready.
The medic then commands "lift." 7. Augmentees keep their backs as straight as possible and perpendicular to the ground, and lift using their legs and arms to ensure a sa lift. 8. The patient is lifted up and rolled slightly inward against the lifters' chests to make holdin the casualty up less of an effort and to better support the patient. Before and during the lift, the leader explains to the casualty exactly what is going to happen. 9. The dirty litter and its contaminated clothing are removed from the litter stands, and a clean, decontaminable litter is placed under the If decontaminable litters are not available, use a plastic covered canvas litter. 10. The medic then gives the command "prepare to lower." If ready, the other augmentees respond "ready." The command "lower" is then given and t lowered onto the clean litter. 11. The cut BDO, BDU, and undergarments are now placed in the plastic garbage ba other waste from the casualty. 12. The dirty litter is decontaminated with an M295, M291, or a 5% bleach solution with a water rinse. It remains on the dirty side for the transfer of casualties om the triage area to the
litter patient decontamination point.
NOTE: Contaminated material from two litter
patients can be placed into one 35-gallon trash
bag. The remaining 5% bleach solution and
soapy water (if used) can be poured into the
bags. The bag must be tied shut and
transported to the dirty dump.
Step 3. Skin and Wound Decontamination
1. The casualty is now decontaminated with soap and water, the M291, or 0.5% bleach solution. 2. If the patient was wearing a CPO, the best method is to decontaminate only those skin areas where there was a break in the IPE (e.g., around wounds, areas where the underlying uniform is wet with agent, or where there is a tear in the BDO/JSLIST). 3. If the patient is not wearing IPE or had significant uniform tears or damaged underlying uniform, an alternate meth decontaminate the entire skin surface by wiping the skin with a sponge and soapy water or 0.5 % bleach solution with a water rinse. Wash the casualty from the midline outward, constantly washing from clean to dirty and not placing a dirty sponge back on a clean area without first rinsing the sponge. The complete topside of the casualty is washed in this manne r attention to hairy areas of the body (groin and axillary regions) and sweaty areas (belt-line, just above the boots, the crea buttocks, and wrists). After log-rolling the patient onto their side, wash the backsid casualty. Then wash the casualty's b ck from s to over halfway d ng care not to miss any areas. The upper side of the litter is deconned prior to rolling the patient to their back again. Wash the opposite side of the casual ty in exactly the sam manner and decontamin ate the litter with so p , 0.5% bleach, or M291 befo to their back again. 4. After the casualty is decon removes dressings and replaces them only if needed. a. wounds (not body cavities,
eyes, or nervous tissue) are deconned with the M291, flushed with soapy water, or 0.5% bleach solution, and new dressings are applied if needed. b. Larger wounds are irrigated, if contaminated, with sterile water or IV saline to remove contaminants. Then cover the wounds with a large dressing and plastic if there is a fear of additional contamination getting into the wound. replaced by the medic. The new tourniq placed 0.5 to 1 inch proximal to the original tourniquet. The old, contaminated tourniquet is removed and put in the waste bag. d. Splints are not removed by augmentees, but are deconned with the M291 or satu the skin with 0.5% hypochlorite solution and rinsed thoroughly with soap y water. If the spli cannot be saturated (air splint or canvas splint), it must be removed sufficiently or be re the medic to enable everything under it to be decontaminated. Step 4. Monitor for Completeness of
1. An area is established between the decontamination area and the Hot Line to check for thoroughness of patient decontamination before the patient crosses the Hot Line. 2. Use the IICAM or M8 paper in this area to check for chemical agent contamination and other appropriate monitoring instruments to c he k radiological contamination. 3. If contamination is detected, use appropriate decontaminants (M291, soap and water, or 0.5% bleach) to spot decon suspected area(s). 4. Once the casualty is confirmed cle NBC contamination, the decontamination team again helps one another to ensur aprons and gloves are decontaminated and then take s the litter patient to the Hot Line
NOTE: As the dirty team prepares to bring the
casualty to the Hot Line, the clea
blanket or other covering appropriate for the environmental conditions Step 5. The Hot Line and Clean Side
Litter Patient
Straddling the Hot Line is the casu over point, which is in a sh osed of two parts Super Tropical Bleach (STB) and three parts ea The shuffle pit should be deep enough to cover the bottom of the protective overboots an enough that the dirty team, two litter sta ds porting a clean litter, and the clean team can occupy it at one time. It must be recharg 10 casualties. 1. The dirty team brings the c sualty to the Hot Line on the litter and places the litter on the stands. 2. In the shuffle pit, the patient's field medical card is transcribed by the medic on a ne dirty one is taken back to the dirty side by the decon team. 3. Three dirty team members logroll the casualty up and off the litter. A fourth dirty team member removes the litter. The clean team replaces the litter. The dirty team lowers the casualty onto the clean litter and mo 4. After the dirty team moves away, the blanket
is folded over the casualty, and the casualty is
moved from the pass-over point to a holding
area 30 to 50 meters upwind.
5. In the clean treatment area, the patient can
now be etri
aged, treated, and evacuated. In a hot climate, the patient will probably be significantly dehydrated. The rehydr process must begin immediately. Overhead cover should be provided for casualties in the holding area. It is here that the mask may be removed for treatment unless circumstances dictate that the casualty remain closer to the Hot Line. Ambulatory Casualty Decontamination
Decontamination of ambulatory casualties s described in FM 4- 02.7 Health Service Support in an NBC Environment and FM 3-5, NBC Decontamination. The step-by-step procedure outlined below is the prescribed doctrine for decontaminating an ambulatory patient, but it is by no means the only method. Knowing this method, however, ensures that correct and essential step omitted, and when they are, other measures are taken to preclude a hazardous outcome. The M291 Skin Decontamination Kit or a soap solution and water are used for chemical contamination on the skin. [The least desired alternative for skin decontamination is bleach (hypochlorite solution)]. A solution with water rinse is useful if water is limited and the M291 kits are not availab a 0.5% hypochlorite solution decontamination; higher concentrations wi irritate and burn the skin, allowing agents to enter the skin more rapidly. The M295 Individual Equipment Decontamination Kit is used to remove obvious contam nation from the patient and help to control the spread of contamination on IPE (MOPP ensemble) and other equipmen then either soap solution or a field- expedient adsorbent material, such as clean, dry earth or flour, can be substituted. Step 1. Clothing Removal (Ambulatory
Patient)
1. Decontaminate the mask and hood.


a. Wipe/sponge down the voicemitter, eyelets, and outserts with the M291 or 5% bleach solution. While wiping around the filter, cover the inlet of the C2A1 canister with a hand or gauze momentarily to keep liquid out f the e of the canister where it could wet the rcoal, reduce filter efficiency, and clog the b. Hoods are of two types: those that ar part of the overgarment and those attached to the mask. (1) For integral hoods that are the overgarment, such as the JSLIST, no decontamination of this hood is necessary. (2) For quick doff hoods attached to the pe down the hood using 5% bleach solution, wiping the mask and then the hood
(starting at the top of the head wiping down
towards the shoulders).
NOTE: When the M295 or M291 are not
available or are in limited supply, use the 5%
bleach solution on equipment.
Remove hood.
(1) Dip the cutting device in a 5% bleach solution or decon/scrub-cutting tool with the M295 or M291. (2) Cut the hood shoulder straps. (3) Cut the neck cord, hood straps, and b. Remove the hood of the JSLIST. (1) Dip the cutting device in a lution or decon/scrub-cutting tool ith the M295 or M291. (2) Cut the hood starting at the front center, and continue cutting across the top of the head to (3) Fold the left and right sides of the hood away from the head and place on the
shoulders.
NOTE: After every complete segmental cut,
decontaminate the scissors and seat belt cutter
along with the gloved hands of the Sold
the cutting. This is done by dipping gloved
hands and cutting tools in a bucket of 5%
bleach. If ample supplies are available and
water is limited, the M295 or M291 can be used.
2. Decontaminate
a. Use soap and water, M291, or 0.5% b. Cover inlet port of filter canister to t wetting or cong esting it. The patient tinues to wear their mask until they cross the face that were not protected by the hood. After completing the hood removal, instruct the casualty to move to the next station for the following steps. This station should be 10 to 20 meters upwind from Remove the Field Medical Card (FMC).
a. The medic at the litter patient decontamination station should view the FMC prior to removal. b. Cut FMC tie wire. c. Allow the FMC to fall into a "zip-lock" plastic bag. d. Seal the plastic bag and decontaminate the outside of the bag. e. Place the plastic bag under the back of the patient's mask head harness straps.
4. Remove
personal artic s from pockets
of BDO/JSLIST.
the BDO/JSLIST jacket and trousers and ace them in a "zip-lock" bag. b. Mark the bag with a name and mber and then move with the patient to the next step in the ambulatory decontamination line. c. The patient must decontaminate their
NOTE: The patient's identification tags stay
around the patient's neck throughout the
decontamination process. They are
decontaminated with soap and water, M291,
M295, or 0.5% bleach.

Remove casualty's BDO/JSLIST.
a. Cut overgarment around tourniquets, bandages, and splints. One augmentee medic,
or an augmentee, will supervise the patients to
cut off one another's overgarments if there are
not adequate numbers of augmentees to assist.
NOTE: Dip cutting device in a bucket of 5%
bleach solution after each complete line of
cut to avoid contaminating inner parts of the
clothing or expose
d skin. If bleach so
is not available, then cutting tools must be
scrubbed using the M295 or M291.
Remove BDO/JSLIST jacket by
(1) The casualty is standing and can hold on to a support, such as a chair or i stand. (2) The individual with a cu (scissors or long-handled seat belt cutter) stands in front of the casualty and cuts the patient's IPE. (3) First, cut around all bandages and (4) Cut the Velcro wrist closures. (5) Cut the BDO jacket draw the JSLIST draw cord at the jacket bottom. On the BDO, un zip the 3 sna s that connect the ack of the BDO ja (5) Cut the BDO/JSLIST jacket tarting nd cut toward the collar in a line l to the zipper. Alternate ways are: unfasten the Velcro and unzip the zipper. Instead of cutting the front, cut from the collar down the back of the BDO, or with the JSLIST, continue the cut from the hood down the back, r of the jacket. This is best done using a seatbelt cutter. (6) To remove the jacket: if the jack cut at the front or unzipped, move to the rear of the casualty. If the jacket is cut along the back, move to the front of the casualty. (7) Instruct the casualty to cl nc fists; stand with arms held down and extended backward at about a 30o angle if the jacket was unzipped or cut in the front. If the jacket was cut along the rear, have the patient extend the arms forw r a d at about a 30o angle. (8) The patient positions their feet ulde width apart. (9) Grasp the jacket collar at the sides (10) Peel jacket off the shoulders in a way motion, smoothly pulling the jacket inside out over the casualty's fists. lace the BDO jacket in a plasti trash bag.
NOTE: The jacket may need to be cut a
sleeve if bandages are in the way and sleeves cannot be rolled over the banda Remove the BDO/JSLIST trousers by
cutting.
(1)
behind the casualty and, if available, another at the front of the casualty. The casualty should have an object to help steady them in standing, such as a chair or litter stand. N TE: Do not cut the trouser suspenders until
the end of the process so that the trousers do
not fall during cutting and get in the way of the
cutter.
t way to cut the trousers is from the front. Keep the pants zipped. Unfa Velcro ankle fasteners and begin cutting at the ankle. Cut along the inseam, moving up toward the waist of the trouse trouser legs from ankle to waist, cut each suspender and allow the trousers to fall to the ground. Take the trou sers and lay them on the ground, blac side up, next to the patient. Later the patient will step onto this as they remove their overboots. (3) An alternate method is to trousers from the rear. In this case, first unfaste st tabs. Start the cut at e and move to the waist. Once the cuts on both legs are complete from ankle to waist, cut the suspenders below the suspender cross points and then above the cross points, allowing the trou ers to fall to the ground. Lay the trousers on the ground, black side up, next to the patien
NOTE: After each long cut, dip the cutting
device in a bucket of 5% bleach solution or
decon/scrub-cutting tool with the M295 or
Remove the overboots.
a. Unfasten all boot closures. b. Step on the heel of the boot and have the patient step out of the overboot and onto the black side of the cut trousers that are lying on the ground. Repeat this process for both boots. These overboots can be decontaminated and issued to other individuals. c. If the overboot will not come off, cut the boot from top to bottom along the centerline of the boot until the boot is loose enou
7. Remove outer gloves. Do not remove the
inner glove liners.
a. Decontaminate your own gloves with the M295, M291, or 5% bleach solution. b. Decontaminate the casualty's gloves with the M295, M291, or 5% bleach solution. c. Instruct the casualty to hold his arms u , if possible, and away from his upper body. patient cannot do this, then hold his gloves at the fingers. d. Grasp the cuff of the glove. e. Pull the cuff over the fingers, turning the glove inside out. f. Dispose of the contaminated gloves by placing them in a trash bag. g. Decontaminate your own gloves again with the M295, M291, or 5% bleach solution.
8. Remove inner gloves.

a. The patient should remove reduce the possibility of spreading contamination. The augmentee instructs the casualty to remove the white glove inner liner using the following guidance: touching exposed skin. c. Peel liner downward and off. d. Drop it into the plastic trash bag. e. Remove the remaining liner in the same f. Drop it into the plastic trash bag. g. The patient then moves to the monitoring station.
NOTE: Waste material from two ambulatory
patients, including the cut trousers, are placed
into one 35-gallon trash bag along with the used
5% bleach and soapy water used on the two
patients. Tie the bag shut and transport it to the
dirty dump.
Step 2. Monitor BDU

1. Monitor with IICAM or M8 detection paper.
2. Check all areas of the casualty's clothing
and combat boots. Pay particular attention to:
a.
b. The protective mask c. Hair and neck area g. Areas under tears in BDO h. Areas around dressings and splints 3. If clean, send the casualty to the Hot Line. 4. If contaminated areas ar found, decontaminate the areas using the M291, M295, or soap and water. If the BDOs are taminated, they must be remove (see following). After decontamination or BD removal, recheck the area again with the IICAM or the M8 detection paper. Step 3. Remove the BDO
Remove personal effects from BDU.
a. Have the casualty remove BDU and deposit them into a "zip-lock" bag. b. Check for contamination. If not nate , they remain with the patient. If nated, they are moved to a contaminated item holding area.
2. Remove inner clothing (if contaminated).

a. Cut or unbuckle belt. b. Cut the BDU pants following the same for the overgar ent trousers. c. Cut the BDU jack procedures as for the overgarment jacket.
3. Remove undergarments (if contaminated)

a. Remove the patient's T-shirt. (1) Dip cutting devices in 5% bleach solution or scrub them with M291 between each cut. (2) Cut around bandage leaving them in place. (3) Cut up the front of the patient's T- shirt from the waist up to the collar. (4) Cut both sleeves from the elbow to the shoulder and then to the collar. (5) Next, peel the T-shirt awa from the body to avoid spreading contamination. b. Remove the patient's brassiere. (1) Cut it between the cups. (2) Cut both shoulder straps where they attach to the cups and remove the brassiere. c. underpants/panties. (1) Cut from the lower s st on both sides. (2) Place the undergarments into the plastic garbage bag containing the other
contaminated items.
4. Check Patient for Contamination.
a. After the patient's BDU and underwear n removed, check the skin, hair, and boots for contamination by using M8 detector b. Carefully survey all areas of patient's skin, paying particular attention to
areas around the neck, wrist, ears, dressings,
and splints.
5. Final Decont
. Use the M291,
soap and water, or a 0.5% hypochlorite followed by a water rinse, at check area for any places on the patient indicate contamination.
6. Remove any contaminated banda
tourniquets (the medic does this procedure).


a. Place new tourniquets 1/2 to 1 inch above the old tourniquets. b. Remove old tourniquets. c. Decontaminate the exposed skin area. d. Cut away bandages. na e the exposed skin area. Replace bandages only to control g. Decontaminate exposed skin.
7. Conduct final check for completeness of
ation with the IICAM or M8 detection Move to the Hot Line. The augmentee
instructs the patient to move 10 to 30 meters to the shuffle pit/Hot Line. Step 4. The Hot-Line and Clean Side
Actions for the Ambulatory Patient
NOTE: Straddling the Hot Line is the
casualty pass-over point, which is in a shuffle pit. The shuffle pit is composed of two parts super tropical bleach (STB) and three parts earth (by volume). The ambulatory patient shuffle pit should be wide enough for the ry patient and two assistants. 1. At the shuffle pit, an augmentee from the clean side meets the patient and opens a blanket or other covering for the patient appropriate for the environ The patient shuffles through the shuffle pit ring combat boots. Once across the vapor cont y p tient can remove their mask. clean treatment area, the patient is
now retriaged, treated, and evacuated. a. In a hot climate, the patient will probably be sign ifica tly dehydrated. The rehydration process must begin immediately. b. Overhead cover should be casualties in the holding area. It is here that the mask may be removed for treatment unless circumstances dictate that the casualty remain closer to the Hot Line. c. Personnel on the "clean" side, past the
Logistical Support Point
Of equal importance to the casualty decontamination effort is the logistical support of the ongoing operation. A logistics support point is established upwind within 30 to 50 meters of the Hot Line. At this point, the soap hypochlorite (bleach) solutions are prepared. All the Soldiers manning the site also stoc 2 quart canteens for use by decontamination
team members. The logistics support point
should have one 400-gallon water buffalo, or
initially 20 5-gallon water cans. Medical
supplies, chemical casualty treatment, and
decontamination medical equipment sets
(MESs) can be located in this area along with
additional decontamination supplies.
Dirty Side Rest/Rehydration Point
An area should be esta blished 50 me rs per endicular to the litter casualty decontamination line and approximately 5 meters from the Hot Line for workers to use as a rest and rehydration point. Prior to using this point, workers must decontaminate the TAP aprons they are wearing using a 5% bleach solution and doff the apron near the decontamin ask quick doff ho worn, should also be decontaminated. Before removing the apron ated with either M295, M291, or 5% bleach solution. The apron n air out and be worn again. Next, they must decontaminate their chemical protective boots by using an M295 or move through a shuffle pit dug for this area. After completion of this decontamination process, the Soldiers move to the rest/rehydration point. The IICAM must be used to monitor the hood, gloves, lower sleeve area of the BDO, lower leg area of the BDO/JSLIST, and boots. If all indications are that these areas are vapor free, the Soldiers conduct an unmasking exer begin to rehydrate. If it is not safe to re ove the mask, Soldiers can rehydrate using their mask drink tubes. The Soldiers should not group together, but should maintain three meters distance from one another. If possible, this rest ould have overhead cover for shade. Disestablish the Patient
Decontamination Station
The closure of the patient decon site will pose as difficult a mission as the actual decontamination effort itself, due in large the physical condition of the medical person el and the non-medical augmentee the disestablishment of the site carefully to prevent heat casualties among the augmentees and medical personnel. Fatigue will cause site personnel to move slower and ma Regardless of the number of times command drinking was accomplished, most of the site personnel will be dehydrated. Dehydrati lower performance and stamina, while increasing the likelihood of heat injuries. Prolonged encapsulation in distort tempers, attitudes, and motivation. Any plans made to disestablish the decon site must be simple and quick; personnel will not be able to sustain an involved and detailed process. The three areas of concern during closure are equipment recovery, site closure, and personnel recovery. A prioritization of effort is established to optimize th e recovery of essentia equipment versus expendable equipmen deny threat forces tactical intelligence, and ensure that site personnel complete required work and get out of total encapsulation as safely as possible.
Equipment Recovery/Site Closure
A list of recommended equipment needed for recovery is provided below. These items can be recovered by decontamination with a slurry mix of STB or a 5% bleach solution. To prepare the STB slurry mix, use two parts STB mixed into three parts water (by weight). For example, 6 parts of water weighs 42 lbs (1 gallon = 7 pounds), and mixed with 28 pounds of STB, gives you the required slurry mixture. The slurry mixture or 5% bleach solution must be scrubbed onto the items requiring decontamination and allowed to remain on the surface for 30 minutes. After this contact time, the items must be flushed with clean water. • Litter support stands • 12-quart steel utility pails • Field IV poles • Resuscitation Device Individual Chemic l • Chemical Agent Monitor (IICAM) (if Decontamination and monitoring of the equipment can take place adjacent to the Hot d 50 meters to the left or right of the nute contact time has elapsed and all items have been flushed with clean wa item must be monitored with the IICAM before it is passed over the Hot Line. When monitoring with the IICAM, ensure that cracks, joints/seams, bolts, porous materials, and any openings are monitored, in addition to su areas of the equipment items. While waiting for the 30-minute contact time to elapse, all other items on the dirty side Hot Line can be placed in a plastic garbage bag and put in the dirty dump. The dump is covered with earth, marked with hazard signs, and is marked on a map with coordinates relayed to higher headquarters. Several personnel must ice call of the litter de ambulatory decon area, an arrival/tria
Personnel Recovery
Upon completion of equipment recovery/site c sure, all personnel except for two will conduct MOPP gear ex ge. The site NCOIC/OIC will ct a position adjacent to the Hot Line sed to decontaminate ent. All personnel will perform MOPP gear exchange with the unit supplying re support. After completing MOPP gear exchange, the two remaining personnel all discarded MOPP gear into plastic bags an place them in the dirty dump. Additionally, they will backfill the dirty dump, ICAMouflage it as much as possible, and mark the contaminated area with the NATO NBC marking then move back to the Hot Line an perf MOPP gear exchange. The remaining tw of discarded MOPP gear are left in place and ICAMouflaged. NOTE: It is strongly suggested that two
personnel from the clean side of the Hot Line are detailed to complete the actions outlined above as those who have been on the dirty side will be very fatigued.
INDIVIDUAL PROTECTIVE
This overview is divided into four sections: • Individual Protection • Individual Decontamination • Detection and Alarms • Patient Protective Equipment INDIVIDUAL PROTECTION
This section includes standard "A" Individual Protective Equipment (IPE) issued to each Soldier depending on their MOS and consisting of the following: • M40 Series Field Protective Mask • M42A2 Combat Vehicle Protective Mask • M45 Air Crew/Land Warrior Chem-Bio Mask • MCU-2A/P Protective Mask • Battle Dress Overgarment • Joint Service Lightweight Integrated Suit • Chemical Protective Gloves and Overboots • Skin Exposure Reduction Paste Against Chemical Warfare Agents (SERPACWA)
Chemical-Biological Mask
M
TM - 3-4240-346-10
This section focus on three variations of protective masks--the M40A1, M42A2, and the M45. These masks share stics, capabilities, and features. Each mask has been designed for cific mission requirements, such as aircraft or combat vehicle operation. This section is not designed to highlight specific mask operational capabilities; it is intended to provide technical information pertaining to Protective masks provide users with respiratory, eye, and face protection against CB agents and radioactive fallout partials. If a mask is ro p perly fitted and worn correctly, it provides a gas-tight face seal, whic contaminated air from reaching the wearer's respiratory, ocular, and dermal systems. Masks described in this section have no been designed for use in TIC environments and are known to be ineffective against chemicals, such as ammonia and carbon monoxide. The masks are also not suitable for confined spaces where oxygen is insufficient to support life. Each mask is constructed of silicone rubber with an in-turned sealing surface so it can form a comfortable seal on the wearer's face, an external second skin for additional protection. Binocular eye lens system is used for improved vision, and clear and tinted outserts to provide eye protection against laser and low speed fragmentation. Optical inserts may be inse if the user requires corrective lenses head harness secures the mask to the user's face. Other common features include front and side voicemitters to allow for face-to-face and phone communications. Each of the masks is furnished with drinking tubes to allow for hydration. A key design feature of each of the discussed protective masks is the use of a standard C2/C2A1 NATO threaded filter canister. The C2 filter canister contains Chromium VI. Damaged or unusable canisters are considered hazardous waste and are known to be carcinoge swallowed. The C2A1 canister is Chromium free but must be disposed of in accordance with tate and local environ mental laws. Both canisters are qualified to withstand and protect against a maximum of 15 nerve, choking, and blister agent attacks. The canister is externally mounted and may be mounted on the left or
right side of the user's face, depending on the
preference of the user. Additionally, a quick-doff
hood is used to provide protection to the user's
head and neck.
MCU-2A/P Protective Mask
Air Force Technical Order 14P4-15-1
The MCU-2A/P Series Mask is designed to protect the face, eyes, and respiratory tract of the user from tactical concentrations of chemical and biological agents, toxins, and radioactive fallout particles. The mask has a unimolded, silicone rubber face piece and a single flexible lens bonded onto the face piece. The large len gives the user a wide field of vision. It has a single filter and two voicemitters, one on the front of the mask for speaking directly into a telephone or radio handset and one at the side to allow personnel nearby to hear. A nose cup with two inlet valves fits over the nose and mouth. It directs incoming air across the inside of the lens to reduce fogging. The mask has a drinking tube that connects to a canteen with an M1 cap. The mask is not authorized fo during TIC spills, and the mask is not effective against chemicals such as ammonia, chlorine, or even carbon monoxide fumes. The mask is not effective in confined spaces where oxygen levels are insufficient to sustain life.
Battle Dress Overgarment (BDO)
TM 10-8415-209-10
rred to as the BDO. The BDO chemical protective overgarmen overgarment consisting of a coat and separate trousers. The BDO is available in a factory sealed, vacuum packaged vapor barrier (VB) bag. The VB bag assists in protecting the BDO from environmental impacts associated Each VB bag contains a jacket and trousers. The suit is composed of an outer layer constructed of 50/50 nylon cotton tightly woven material that has been treated with water resistant sealant. The liner or inner layer is constructed of charcoal impregnated polyurethane foam nylon tricot laminate. BDOs are available in various ICAMouflage pa with sizes ranging from extra extra small (XXXS) to double extra large (XXL). Once the BDO has been removed from the vacuum-sealed packaging, the suit offers 22 days of we slight increase in risk, commanders may increase wear time to 30 days. Wear time for the BDO begins when the seal is broken on the VB bag. To properly maintain the BDO when use, it should be sealed in the origin other similar material bag. To seal the bag, close with duct tape, 100 mile per hour tape, or other suitable tape. Donning the the amount of time within a 24-hour period, constitutes a day of use. The BDO is currently qualified to offer 24 hours of protection against CB agents in solid, liquid, or vapor form. The suit also protects against alpha and beta radioactive particles. oint Serv
ice Lightweight Integrated Suit
Technology (JSLIST)
TM 10-8415-220-10
The Joint Service Lightweight Integrated Suit Technology (JSLIST) will hereafter be referred to as the Chemical Protective Overgarment CPO or JSLI ST. The JSLIST CPO has been designed to replace its predecessor, the battle dress overgarment (BDO). The JSLIST CPO is a two-piece overgarment consisting of a coat with an integrated hood and separate trousers. The CPO has been designed to be lighter weight, more flexible, and have the ability to be laundered up to six times. Additionally, the system has been designed to reduce the stresses of protective gear. The JSLIST CPO is available in four-color wo and three-color desert ICAMouflage patterns. The JSLIST suit is composed of an outer layer of 50/50 nylon/cotton poplin rip stop material with ICAMouflage pattern facing outward. The liner, or inner layer, is polyester knit coated with activated carbon spherical absorbers co a nonwoven laminate that is bonded to a tricot knit back. Unlike the BDO, JSLIST suit packaged as sets. JSLIST suits consist of a coat and trousers. Each component is separately packaged in a factory sealed, vacuum bag containing the ensemble it bag. JSLIST suits ar able in seven sizes, ng from short extra small (SXS) to large long (LL). The JSLIST overgarment is qualified to offer 24 hou rs of prote tion against r vapor form. The suit will also protec t again t alpha and beta radioactive particles. Once the CPO has b vacuum-sealed packaging, the suit offers 45 days of wear and 120 days of service life. To properly maintain and store when not in use, it should be placed in t resealable bag that is furnished with each component of the ensemble. Both the BDO/JSLIST ensemble will be worn in all environments when under threat of an imminent nuclear, biological, or chemical attack or after chemical operations have been initiated. Once the suit has been contam the Soldier must replace the suit by using the MOPP gear exchange procedure describ STP 21-1-SMCT, Soldier's Manual of Common Tasks, October 2003, Task #031-503-1023, Exchange MOPP Gear. The BDO/JSLIST adds weight to the Soldier's workload. In addi BDO/JSLIST prevents heat exchange with the environment and may add, depending on the Soldier's level of exertion, 10-15oF to his ambient temperature and heat burd wearing the BDO/JS LIST at MOPP 1 or MOPP 2 and complete encapsulation is not required, certain modifications to the uniform are authorized: • The trouser leg closures may be unzipped. • The waist tabs may be loosened. • The jacket ma be unzi • The sleeve Velcro closures may be This overall loosening of the BDO/JSLIST will allow heat to escape as walking and other
movements induce a bellows action of the suit
against underlying clothing and skin.

Suit, Contamination Avoidance and Liquid
Protective (SCALP)
TM 10-8415-209-10


The SCALP is an impermeable, lightweight, inexpensive, disposable ensemble. The suit provides supplemental liquid protection. The SCALP is a four- piece ensemble that consists of a jacket, trousers, and two footwear is designed to be worn over the BDO or JSLIST with protective overboots. The footwear covers are constructed with 12 mil embossed polyethylene soles. The SCALP ensemble provides protection from gross liquid contamination for up to one hour. O the SCALP is used to protect personnel conducting decontamination procedures from becoming soaked during decon operations. Chemical P otective Gloves and Overboots
• Green/Black Vinyl Overboots (GVO)/ • Multipurpose Overboot (M • Gloves, 0.025-inch thickness 4-inch thickness • Gloves, 0.007-inch thickness Green or Black Vinyl Overboots (GVO) (BV )
The overboots have been desi worn over combat boots to protect the user's feet and are available in sizes 3 to 14. The GVO/BVO is constructed of vinyl making it impervious to all known chemical, biological agents, alpha and beta radiological particles. They also protect against environmental effects, such as rain, mud, and snow. Both boots are similar except for the color and enlarged elastic pull tab fasteners on the BVO. The GVO/BVO is qualified to offer 60 days of protection. If the GVO/BVO becomes contaminated, it provides 24 hours of protection. Following contam use a 5% HTH and water solution or a 5% household bleach and water solution to decontamin ate the GVO/BVO. Ensure oots are serviceable and no signs of deterioration are
present after the decontamination process. If
boots are deemed to be unserviceable, replace
them.

The Multipurpose Overboot (MULO)
T e Multipurpose Rain/Sno (MULO) replaces the older black vinyl overboot/ green vinyl overboot (BVO/GVO). The made by injection molding an elastom r blend, compounded to provide the characte stic chemical and environmental protec It incorporates two quick-release si and is designed to be worn over the standard issue combat boot, jungle boot, and intermediate cold/wet boot. The MULO 60 days of durability and 24 hours of protectio against liquid chemical agents. The MULO is capable of being decontaminated to an operationally safe level using standard field decontaminates. Environmental protection is provided against water, snow and mud, in addition to petroleum, oil, and lubricant (POL) and flame resistance. Chemical Protective Glove Set
Chemical protective glove sets are qualified to offer protection against chemical and biological agents, and alpha and beta radiological particles. The chemical protective glove set consists of an outer glove for protection and an inner glove for absorption of perspiration. The outer gloves are made from bber and are impermeable to chemical agents. The inner gloves are made of thin, white cotton. Glove sets are available in three thicknesses, 7-mil to 25-mil and in sizes ranging from extra small (XS) to extra large (XL). 25-mil gloves offer the most durable protection and may be ut combat tasks or other types of heavy labor. 14-mil gloves are less durable and are used in an environment where much less ph demand is placed on the glove. Such users could include vehicle mechanics, aviators, or weapons crews. If either glove beco es contaminated, decontaminate or replace it within 24 hours after exposure. Contaminated gloves may be decontaminated with a 5% chlorine solution or a 5% HTH and water solution. 7-mil gloves offer the most tactility and are us d by individuals who require extreme sensitivity to accomplish tasks without subjecting the glove to harsh treatm 7-mil glove becomes contaminated, replace or decontaminate it after 6 hours of expo Contaminated gloves may be decontaminated
with a 5% chlorine solution or a 5% HTH and
water solution.
Skin Exposu
re Re uction Paste Against
e Agents (SERPACWA)
NSN: 6505-01-483-7162 SERPACWA is used by service mem unction with MOPP gear to enhance protection against chemical warfare agents. Approved by the FDA for military use only, it is a cream containing chemically inert perfluo olymers. It is appli ed to susceptible areas of the skin before donning MOPP gear. Not intended for use by itself, SERPACWA will provide additional protection at those lo where the MOPP is susceptible to leakage or separation, includi g, the waist, groin, a w sts, ankles and neck. In conjunction with personal decontaminating materials, the SERPACWA will prevent or reduce the toxicity resulting from exposure to chemical warfare agents. When used as directed, SERPACWA
will provide between 5 and 8 hours of
protection.
For further information on thes
s, see
Multiservice Tactics, Techniques, and
Procedure for Nuclear, Biological, and
Chemical (NBC) Protection FM 3-11.4 June
2003, Chapters VI, Appendix A.
INDIVIDUAL DECONTAMINATION
The preceding section prov of the primary items of IPE which, when correctly, will prevent act with agent in typical battlefield concentrations. The problem of decontamination arises when some Soldiers, because of bad training, bad disciplin luck, become exposed to liquid agent despite the availability of protective masks and clothing. This section addresses two decontamination kits curren tly in the invent The M291 Decontaminating Kit, and M295 Decontamination Kit Individual Equipment. The kits are fairly simple in design and function, and instructions for their use ar e straightforward and easily committed to memory. Because of the potency of liquid nerve agents and the rapidly occurring tissue damage caused by vesicants, every Soldier must be able to conduct an effective decontamination of all exposed skin
without referring to the instructions printed on
the kits.
Decontaminating Kit, Skin: M291
NSN 4230-01-276-1905
TM 3-4230-229-10


The M291 Decontamination Kit consists of a rrying pouch containing six individually sealed decontamination app s. Each pad is filled with FDA approved Ambergard XE-555 decontaminating resin. Each kit allows personnel to decontaminate th of liquid nerve and vesicant agents through physical removal, absorption, and neutralization of chemical agents. The M291 kit is nontoxic and has been designed for external us be slightly irritating to the eyes or skin. Decontamination powder should be kept out of s, and wounds. Inhalation of the powder should be avoide Each of the individual decontamination p is capable of providing decontamination coverage to the face and hands or an equivalent area of skin from exposure to chemical a Effective decontamination will result in blacking of decontaminated skin areas.
Decontamination Kit, Individual Equipment:
M295 (DKIE)
NSN 4230-01-357-8456
TM 3-4230-235-10
nation Kit Individual nt consists of a pouch containing four individually sealed, wipe-down mitts. Each wipe-down mitt is comprised of a sorbent decontaminating powder containing Silica. Each kit allows personnel to decontaminate their individual equipment through sorption of contamination by both the pad and the decontaminating powder. Decontamination is effective against liquid nerve and vesicant chemical agents. Kits are worn over protective ensembles and are capable of decontaminating approxima feet. M291 kits may be used to decontaminate such items as the following: CB mask an hood, gloves, footwear, weapons, helmet, and load-beari M295 kits are issues in boxes of 20 kits. The kits should be stored at box capable of being decontaminated. DETECTION AND ALARMS
This section will describe the equipment issued for detection and identification of chemical agent liquid and vapor in the environment. For both the individual Soldier an uipment (listed below) are the primary means of identifying the presence and type of chemicals on the battlefield and determining when a safe co dition exists. • Paper, CM Agent Detector: M9 • Paper, CM Agent Detector: M8 • Chemical Agent Detector Kit: M256A1 • Improved Chemical Ag • Automatic Chemical Agent Alarm: M8A1 • Water Test Kit, Chemical Agents: M272 • M22 Automatic Ch
Paper, CM Agent Detector: M9
NSN- 6665-01-049-8982
TM- 3-6665-311-10
M9 detector paper is placed on personnel and equipment to detect and identify the p sence of liquid nerve or blister agents in exposures as small as 100 microns in di The paper contains an indicator chemical dye that will turn pink, red, reddish brown, o e when exposed to liquid agents. The paper is capable of detecting but cannot identif cific agents. M9 paper is manufactured in 30 feet x 2 inch adhesive backed rolls of du white, cream-colored paper. The rolls ar packaged with a reusable, plastic storage bag in a vacuum-sealed vapor barrier package. The detector paper dye may be a potential carcinogen; chemical protective gloves should be worn when handling M9 detector paper. Placement of M9 is dictated ser is right-handed. M9 r paper should be placed around the right upper arm, left wrist, and right ankle is left-handed, M9 detector paper should be placed around the left upper arm, right wrist, and left ankle. If a color change is indicated, proper masking, decontamination, and MOPP p cedures must be followed.
NOTE: *M9 Chemical Agent Detector Paper
ill not detect cyanide. own to cause false onses o M9 paper. The following are common false positive indicators: antifreeze, liquid insecticide, or petroleum products. Attention to possible interfering substanc s the battlefield can help in the later interp of a color change on the M9 paper in the absence of confirmation tests for agents. This does not relieve the service member of the obligation to mask and take other appropriate measures.
Paper, CM Agent Detector: M8
NSN -6665-00-050-8529


M8 Chemical Agent Detector Paper is used to detect the presence of liquid V type nerve, G type nerve, and H type blister agents. M8 paper is issued in booklets containing 25 tan-colored sheets of chemically treated dye impregnated paper. Each page is perforated and staple bound for easy removal. The reverse side of the front cover contains a color comparison bar chart for color comparison agent recognition. If M8 paper is exposed to chemical agents, the dye-impregnated paper will convert from tan to an agent specific color, depending on the agent. The following agents will cause the dye to change to one of three colors. • G: Nonpersistent Nerve: Yellow • H: Blister: Red • V: Persistent Nerve: Olive Green r Bla
NOTE: *M8 Chemical Agent Detector Paper
will not detect cyanide.
If indicated by M9 chemical agent detector paper or encountering a liquid suspected of being a chemical agent, service members must follow proper masking, decontamination, and MOPP procedures. To prepare M8 paper to conduct agent identification, tear one half sheet from the booklet and affix the sheet to a stick or other object. Use the stick paper onto the unkno wn li uid, and wait 30 seconds. Once 30 seconds has elapsed, compare the tested M8 paper to the color comparison bar chart located on the inside cover of the booklet. The following are common false positive indicators: antifreeze, liquid insecticide, or petroleum products. Attention to possible interfering substances on the battlefield in the later interpretation of a color change on the
Improved Chemical Agent Detector Kit:
M256A1
NSN - 6665-01-133-4964
TM # 3-6665-307-10
The M256A1 Chemical Agent Detection Kit is designed to detect and identify chemical agents in liquid or vapor and consists of the following: • A booklet of M8 paper (previously described) to detect agents in liquid form, and • 12 foil-wrapped detector tickets containing eel enzymes as reagents to detect very low concentrations of chemical vapors. Instructions for the use of the detector tickets appear on the outside of each of the foil packets and in a separate instruction booklet in the kit. The following chart shows the agents detected by the M256A1 Kit: Detected
AC "Blood" CK "Blood" Mustard H Blister Lewisite L Blister By following the directions on the foil packets or in the instruction booklet, service members can conduct a complete test with the liquid-sensitive M8 paper and the vapor-sensitive detector ticket in approximately 20 minutes. During the test, the sampler must be ept out of direct su evaporation of the reagents. Waving the detector sampler in the air also accelerates evaporation, so the sampler should be held stationary during all parts of
Simulator, Detector Tickets,
Chemical Ag
en : Trainin M256
TM 3-6665-320-10 t iner simulator was de to provide rea stic train ing while avoiding unnecessary xposure carcinogenic reagents in the M256A1 detector kit. The M256 trainer contains 36 pre-engineered detector tickets and an instruction booklet. The pre-enginee red dete tor tickets show color changes comparable to those seen when the M256A1 detec r kit is u TM 3-6665-331-12&P The IICAM, which is used to detect nerve and blister agents as vapors only, uses a 10-mCi nickel-63 (Ni63) beta-particle radiation source to ionize airborne agent molecules that ha drawn into the unit by a pump. The result clusters vary in mass and charge and th s al travel at different rates in an applied electrical field. Comparison of the m obilities of the diffe ionic species to electronically stored standards allows an on-board microcomputer to determine the type of agent and its relative concentration. A liquid crystal display (LCD) presents these data as a series of concentration G mode for G agents and VX, and in an H mode for blister agents. The IICAM detects agent vapor in that volume of air drawn by the pump into the sampling chamber of the instrument. It fo that the inlet port mu st not come into a suspected area of evaporating agent on a surface but must nevertheless approach within a few inches of the site of suspected contamination. Because of the variation in age concentration from one spot to another, depending upon wind velocity and other environmental factors, num agent concentration in typical units would be impractical and unreliable. Accordingly, the display warns of a low vapor hazard (1 to 3 bars visible), a high rd (4 to 6 bars visible), or a very high vapor ha za (7 to 8 bars visible).
M22 Automatic Chemical Agent
Alarm (ACADA)
NSN 6665-01-438-6963
TM 3-6665-321-12&P


The M22 is an automatic agent alarm system capable of detecting and identifying standard blister and nerve agents. The system is man-portable, operates independently after system start-up, and provides an audible and visual alarm. The M22 system also provides communications interface for automatic battlefield warning. The system consists of the M88 detector, as rm units, a confidence sample, protective caps, square inlet, rain caps, a carrying case, and various power supplies. The M22 ACADA samples the air for the presence of nerve agent vapors (GA, GB, GD, VX) and blister agent and provides simultaneous detection and warning of these agents. It operates and hot climates (-30oF to +125oF). The M88 detectors normally are placed facing into the wind no more than 150 meters outside of the unit perimeter, with no more than 300 meters between detectors. They are connected to the alarm units with WD-1/TT telephone wire; whenever possible, the ce between the detector units and the alarm units should not exceed 40 mete The following items can interfere with sound a false alarm: • Aqueous Fire Fighting Foam • M18 Marking Grenade (Red and Violet)
Water Testing Kit, Chemical Agents: M272
NSN 6665-01-134-0885
TM 3-6665-319-10


The M272 water test kit was designed and fielded to answer the need for a test to detect water contamination by nerve agent, blister agent, cyanide ("blood" agent), or Lewi kit will operate between 32oF and 125oF.
enclosed instruction card enables the Soldier to conduct all the tests required to identify the threat agents.
The kit will detect the chem agents at the concentrations indicated on the following chart. Chemical
entrat on
Symbol(s)
(mg/l)-*
*Concentration reliably detected by kit tests. Water containing agents in lesser concentrations is permissible for short-term use (up to 7 days) in both cold and warm regions as lon daily consumption per person does not exceed 5 quarts. Each kit contains enough reagents for tests on 25 operator can easily uct the full range of tests in 20 minutes when the temperature is between 50oF and 105oF; at lower temperatures, the water samples and the nerve agent ticket should both be warmed for 10 minutes before beginning testing. Water that is too hot may cause foaming in the detector tubes for Lewisite, mustard, and cyanide; therefore, water at temperatures between 105oF and 125oF should be cooled for at least 5 minutes to reduce its temperature to 105o or cooler. PATIENT PROTECTIVE EQUIPMENT
have been fielded will be di n Device Individual Chemica
Patient Protective Wrap
Wrap, Patient, Chemical Protective
(NSN 6530-01-383-6260)
Blower, Lightweight
(NSN 4240-01-442-8415
Hose Assembly
(NSN 4240-01-442-2314
Many protective garments have been developed for military personnel; however, protection for patients who are unable to wear standard chemical protective garments was lacking. The Chemical Warfare Patient Protective Wrap was developed to satisfy this requirement. The addition of the blower unit serves as a modification for the improvement of the performance of the Patient Wrap by increasing airflow to the patient. The Wrap resembles a lightweight sleeping bag. It is 107cm wide x 249cm long and weighs 2.7kg. It is constructed of a permeable sheet of carbon-impregnated fabric and an impermeable bottom sheet. The top sheet has an impermeable, rent window to permit observation of the patient during transit. A port to provide a protective entryway for the ins rtion of IV tubing is located at each side of the window. The blower un lightweight unit w of clean, filtered air for bre thing. The benefit of the addition of this item is a considerable reduction in the danger of heat stress on the casualty, and an increase in stem cons sts of the following: mical Protective (NS Wrap, Patient, Che 6530-01-383-6260) • Blower, Lightweight (NSN 4240-01-442- • Hose Assembly (NSN 4240-01-442-2314 Patients should not be left in the wrap longer than six hours.

Decontaminable Litter
NSN 6530-01-290-9964
Contaminated casualties arriving at a medical treatment location will in most cases require decontamination prior to definitive treatment. This decontamination process will require the use of the limited supplies of equipment organic to the treatment unit. Ideally, equipment in limited supply should be capable of complete decontamination using field-available methods. However, in tests conducted by the U.S. Army Soldier and Biological Chemical Command, canvas litters exposed to liquid blister agents and then decontaminated desorbed vapors for 72 hours after all surface contaminants were removed. The decontaminable litter was developed to vas litters. The ne w litter is made lament polypropylene that has high tensile strength and low elas fabric does not absorb liquid chemical agents and is not degraded by de ontami solutions. The fabric is flame retardant, hstand exposure to weather and sunlight. The fabric has a honeycomb weave, which results in a rough, non-slip surface, and liquids easily pass through the 40% of surface area that is open. The andles retract into the metal pole frame for a closed total le gth of 83.5 inches ding the litter onto the UH-60 helicopter. The handles have TWO open positions, 90.0 inches (228.1 cm) and 91.6 inches (232.7 cm). The first position is a NATO standard, and litter bearers provide position to allow increased gripping comfort. The
aluminum poles have been designed to provide
direct gripping surfaces for litter stanchions. All
metal parts have been painted with Chemical
Agent Resistant Coating (CARC) paint.
Resuscitation Device, Individual Chemical
NSN 6515-01-338-6602
The Resuscitation Device, Individual Chemical (RDIC) is a ventilatory system consisting of a compressible butyl rubber bag, a NATO standard C2 canister filter, a non- rebreathing valve, a cricothyroid cannula adapter, and a flexible hose connected to an oropharyngeal mask. The mask is remo from the distal end of the flexible hose for connection of the hose to the cannula adapter. The butyl rubber bag resists the penetration of liquid chemical agent that may be on the chemical protective gloves of operator and is easily decontaminated. The elasticity of the outer cover limits airway pressure to a value of 70 cm H2O (70 mbar). The device will deliver up to 600 ml of filtered air per cycle at a rate of 30 cycles per minute. APPENDIX A
Shown on the foldout is a summary of the chemical agents, the effects they cause, and the first-aid therapy. APPENDIX B
Equipment List
tive Mask
Item Size
MCU-2A/P Protective S 4240-01-327-4148 MCU-2A/P Protective M 4240-01-327-4149 MCU-2A/P Protective L 4240-01-327-4150 M40-A1 Protective Mask
Item Size
S 4240-01-258-0061 M 4240-01-258-0062 L 4240-01-258-0063 Item Size
S 4240-01-413-4100 M 4240-01-413-4101 L 4240-01-413-4102 M45 Protecti e
XS 4240-01-414-4034 S 4240-01-414-4035 M 4240-01-414-4051 L 4240-01-414-4052 Desert JSLIST Coat
Item Size
415-01-505-1616 415-01-509-8314 415-01-505-1622 3XLL 8415-01-506-7710 LL 8415-01-444-6131 LR 8415-01-444-6138 ML 8415-01-444-6131 MR 8415-01-444-5926 MS 8415-01-444-5913 SS 8415-01-444-5905 SXS 8415-01-444-5902 Desert JSLIST Trousers
Item Size
XLL 8415-01-505-1567 XLR 8415-01-509-8269 2XLL 8415-01-505-1591 3XLL 8415-01-506-7713 LL 8415-01-444-5900 LR 8415-01-444-5898 ML 8415-01-444-5892 8415-01-444-5893 SS 8415-01-444-5504 SXS 8415-01-444-5417 d JSLIST Coat
Item Size
XLL 8415-01-444-1241 XLR 8415-01-509-8296 2XLL 8415-01-505-1591 3XLL 8415-01-506-7546 LL 8415-01-444-1270 LR 8415-01-444-1265 ML 8415-01-444-1249 MR 8415-01-444-1238 MS 8415-01-444-1200 SS 8415-01-444-1169 SXS 8415-01-444-1163 SLIST Trousers
Item Size
XLR 8415-01-509-8265 LL 8415-01-444-2338 MR 8415-01-444-2310 SS 8415-01-444-1439 SXS 8415-01-444-1435 Item Size NSN
8415-01-137-1707 8415-01-137-1706 8415-01-137-1705 8415-01-137-1704 8415-01-137-1703 8415-01-137-1702 8415-01-137-1701 8415-01-137-1700 DBDO (Three-Color Desert ICAMouflage
Pattern)
8415-01-327-5353 8415-01-327-5352 8415-01-327-5351 8415-01-327-5350 8415-01-327-5349 8415-01-327-5347 8415-01-327-5346 Suit Contamination Avoidance and Liquid
SM 8430-01-364-3458 M/L 8430-01-364-3459 Covers, Liquid Contamination 8430-01-364-3460 Clothing Outfit, Liquid Contaminati n, Trousers, Poncho Attached Hood (Green) Clothing Outfit, M/L 8415-01-364-3321 Liquid Contamination, Trousers, Poncho Attached Hood (Green) Clothing Outfit, 8415-01-364-3322 Liquid Contaminati n, Trousers, Poncho Attached Hood (Green) Clothing Outfit, Trousers, Poncho Attached Hood (Tan) Clothing Outfit, 8415-01-333-0988 Liquid Contamination, Trousers, Poncho Attached Hood (Tan) Clothing Outfit, 8415-01-333-0989 Contamination, Trousers, Poncho Attached Hood (Tan) otective Glove Sets
XS 8415-01-144-1862 Gloves with liners Butyl SM 8415-01-033-3517 Gloves with liners Butyl MD 8415-01-033-3518 Gloves with liners Butyl LG 8415-01-033-3519 Gloves with liners Butyl XL 8415-01-033-3520 Gloves with liners Butyl SM 8415-01-138-2497 Gloves with liners Butyl MD 8415-01-138-2498 Gloves with liners Butyl LG 8415-01-138-2499 Gloves with liners Butyl XL 8415-01-138-2500 Gloves with liners Butyl MD 8415-01-138-2502 LG 8415-01-138-2503 XL 8415-01-138-2504 Chemical Protective Overboots ( MULO)
3 8430-01-464-9453 (Black) Multipurpose 4 8430-01-464-9458 (Black) Multipurpose 5 8430-01-464-9459 (Black) Multipurpose 6 8430-01-464-9461 (Black) Multipurpose 7 8430-01-464-9462 (Black) Multipurpose 8 8430-01-464-9464 (Black) Multipurpose 9 8430-01-464-9474 (Black) Multipurpose 10 8430-01-464-9475 (Black) Multipurpose 11 8430-01-464-9477 (Black) Multipurpose 12 8430-01-464-9480 13 8430-01-464-9479 (Black) Multipurpose 14 8430-01-464-9484 (Black) Multipurpose Chemical Pr
tive Overboots ( BVO)
3 8430-01-317-3374 4 8430-01-317-3375 5 8430-01-317-3376 6 8430-01-317-3377 7 8430-01-317-3378 8 8430-01-317-3379 9 8430-01-317-3380 10 8430-01-317-3381 11 8430-01-317-3382 12 8430-01-317-3383 13 8430-01-317-3384 14 8430-01-317-3385 tiv Overboots ( GVO)
3 8430-01-084-6305 4 8430-01-084-6306 5 8430-01-049-0878 6 8430-01-049-0879 7 8430-01-049-0880 8 8430-01-049-0881 9 8430-01-049-0882 10 8430-01-049-0883 11 8430-01-049-0884 12 8430-01-049-0885 13 8430-01-049-0886 14 8430-01-049-0887 1Removing BDOs, BDUs, hood y cutting will ruin one rs for every two Repla e sponge when Cl solution is replaced. Cl solution d be replaced after being used on two casualties. nge and water solution after APPENDIX C
PREPARATION OF PATIENT
SOLUTIONS
(0.5 & 5.0% Hypochlorite)
hypochlorite solutions will require mixing the solutions in a container that can be closed after comple tion. By closing th solution will remain at the required strength far longer than if allowed to stand in an open container. The recommended mixing container is a 5-gallon water can. The hypochlorite granules must be completely dissolved in the water. The most effective method for mixing is to agitate the granules as they are poured into the water, and then allow the solution to sit for 20 minutes to ensure the granules dissolve. 0.5% Hypochlorite Solution
Use 6-ounce bottles of calcium hypochlorite granules found in the Chemical Agent Patient Decon MES, and mix one 6-ounce bottle into 5 gallons of water. When using a bulk package of calcium hypochlorite, retain one empty 6-ounce bottle from the Chemical Agent Patient Decon MES to measure the correct amount of dry calcium hypochlorite granules and mix as descri If you must use household bleach (i.e., Clorox or Purex), use the following The bleach should be packag bottles or 1-gallon jugs when received from supply. Only 4.5 gallons of water will be used. Mix 2 quarts of bleach into 4.5 gallons of water, and store the solution in a closed container until ready to use. 5.0% Hypochlorite Solution
Use 6-ounce bottles of calcium hypochlor granules found in the Chemical Agent Patient Decon MES, and mix 8 of the 6-ounce bo calcium hypochlorite into 5 gallons of water. If using calcium hypochlorit package, retain one empty 6-ou the Chemical Agent Patient Decon MES to measure the correct amount of dry calcium hypochlorite granules. usehold bleach, use the ch straight from the bottle; do not mix in APPENDIX D
MEDICAL EQUIPMENT SET
CHEMICAL AGENT PATIENT TREATMENT
(30 patients)
6545-01-5187565, MES CHEM AG TR
4720014061637 HOSE METALLIC EA 12 6505014578901 ANTIDOTE EA 6530015196886 STERILIZATION 6640015007717 CARTRIDGE EA MEDICAL EQUIPMENT SET
CHEMICAL AGENT DECONTAMINATION
(60 patients)
6564-01-15187568, CHEM AGT PA-2003
BANDAGE7.25" 7540014608995 FORM PR 8105001913902 BAG PLASTIC PLASTIC SHEET RO 8415002817813 APRON TAP SMALL EA 2 8415002817815 APRON TAP LARGE EA 2 APPENDIX E
Shown in the foldout is a casualty re area for contaminated casualties. This area must be the recei treatment area that receives contaminated casualties.
APPENDIX F
GLOSSARY OF MEDICAL Acetylcholine (ACh). A chemical released by
certain nerves that stimulates a muscle, gland,
or another nerve. This is one of a number of
neurotransmitters in the body that carry
"messages" from nerves to other organs.
Acetylcholinesterase). An enzyme (a protein
produced in the cells) that stops the action of
acetylcholine by destroying it. This action
occurs as soon as acetylcholine has produced a
muscle contraction or stimulated a gland or
nerve. Nerve agents combine with
acetylcholinesterase to prevent it from
destroying acetylcholine; acetylcholine
accumulates in excess and continues to
stimulate the muscle, gland, or nerve.
Acid. A substance with a pH less than 7.
Aerosol. A gaseous suspension of fine solid or
liquid particles.
Alkali. A substance with a pH greater than 7. A
base.
Alveoli. Microscopic air sac in the lungs where
oxygen and carbon dioxide diffusion (movement)
takes place through the alveolar walls.
Anesthetic. Any agent that causes
unconsciousness or an insensitivity to pain.

Anorexia. Loss of appetite.
Anoxemia. Inadequate ox
blood.
Anoxia. Lack of oxygen.
Antibiotic. A natural or sy
that inhibits the growth of or de microorganisms. Used extensively in the
treatment of infectious diseases in plants,
animals, and humans.
Anticholinergic. An agent or chemical that
blocks or impedes the action of acetylcholine,
such as the antidote atropine.
Anticholinesterase. A substance that blocks
the action of cholinesterase
(acetylcholinesterase), such as nerve agents.
Aphonia. Inability to phonate or produce
speech sounds.
Aplasia. Failure of production of cellular
products from an organ or tissue, such as blood
cells from the bone marrow, after a toxic dose of
mustard.
Apnea. Absence or cessation of breathing
Asphyxiation. Unconsciousness or death
caused by lack of oxygen.
Ataxia (ataxic). A staggering or unsteady gait;
inability to walk a straight line.
Atelectasis. Collapse of the alveoli of the lungs
secondary to mucous plugs, foreign bodies, and
secretions. Frequently associated with
pneumonia, best treated by vigorou
and breathing exercises, as well as Positive Pressure Breathing with PEEP.
Bradycardia. A slow heart rate (less than 60
beats per minute).
asm. A twitching or spasmodic
contraction of muscles ar und the eye; if severe, can lead to closure of the eyes.
Bronchi. The finer, smaller divisions of the wind
pipe into the lungs.
Bronchoconstriction/Bronchspasm.
Constriction of the bronchial tubes making it
difficult to move air in and out of the lungs.
Bronchopneumonia. Inflammation of the
terminal bronchioles and alveoli, causing edema
and consolidation of alveoli.
Capillaries. Small blood vessels.
Carfentanil. A drug used by veterinarians to
anesthetize large animals.
Central airway. The main airway that
transports air from the nose and mouth to the
lungs.
Cilia. Hair-like cells in the respiratory and GI
Tract that assist with mucous mobilization.
Ciliary. Pertaining to certain structures in the
eye, such as the ciliary muscles.
Conjunctiva. The delicate membrane that lines
the eyelids and covers the exposed surface of
the sclera.
Conjunctival. Pertaining to conjunctiva.
Conjunctivitis. Inflammation of the conjunctiva.
Cornea, corneal. The clear, transparent,
anterior portion of the eye comprising about one-
sixth of its surface through which light passes to
transmit images to the retina. It is continuous at

its periphery with the sclera and composed of
five layers.
Cyanosis. Slightly bluish, grayish, slate-like, or
dark purple discoloration of the skin due to
oxygen in the blood.
Cyclitis. Inflammation of the ciliary body of the
eye.
Dermis. The deeper layer of the skin under the
epidermis. It contains the hair follicles, sweat
glands, and sebaceous glands.
Dermatitis. An inflammation or infection of the
skin.
Dyspnea. Labored breathing resulting from an
increased need for oxygen
exchange in the lungs.
Edema. Swelling of the tissues because of fluid.
Emphysema. Process of trapping air in the
alveoli, associated with loss of elasticity of the
lung tissues and resulting in inability to
completely exhale.
Epidermis. The outer layer of the skin.
Epithelium. The inner layer of tissue in hollow
organs.
Erythema. Red area of skin caused by heat or
cold injury, trauma, or inflammation. May be
localized or generalized.
Fasciculation. Localized contraction of muscle
fibers, usually visible through the skin.
Fentanil. An anesthetic commonly used in a
liquid form for injection under controlled
conditions in an operating room.

Fibrosis. Scar tissue; replacement by fibrous
tissue.
Flaccid paralysis. Loss of muscle tone and
capability to function; limp. Nerve agents cause
this condition.
GI. Gastrointestinal; gut.
Granulocytopenia. Decrease in white cells of
the granulocyte series in the bloodstream.
Halothane. A gaseous anesthetic used for
surgery. that could be used to help aerosolize
Fentanil.
tic. Pertaining to production and
development of blood cells.
Hemoconcentration. A relative increase in the
number of red blood cells, usually resulting from
a decrease in the volume of plasma.
Hyperemia. Redness of the skin.
Hypertension. High blood pressure.
Hypotension. Low blood pressure; if blood
pressure is too low, shock and death may occur.
Hypovolemic shock. Insufficient blood volume
to maintain adequate tissue oxygenation and
aerob
Hypoxemia (hypoxia). Insufficient oxygen in
the circulatory system to adequately supply
tissue cells. May be caused by lack of oxygen,
inadequate hemoglobin to carry oxygen, or
interference with transfer
Intubation. The process of enhancing
respiration by providing an artificial airway.
Iritis. Inflammation of the iris with
accompanying pain, photophobia, lacrimation,

and diminution with transfer of oxygen to the
cells.
Laryngospasm. Spasmodic closure of the
larynx (voice box at the top of the trachea/wind
pipe).
Larynx. Voice box and vocal cords.
Leukocytosis. Above normal increase of white
blood cells.
Leukopenia. Less than normal number of white
blood cells.
Lymphadenitis. Inflammation of lymph nodes,
usually caused by a focus of infection distal to
the node.
Malaise. A feeling of illness or depression.
Miosis. Small, "pinpoint" pupils.
Mydriasis. Large or dilated pupils.
Naloxone/naltrexone. An opioid antagonist that
rapidly reverses the effect
routinely in emergency rooms for heroin
overdose.
Nasopharynx. The area of the nose and upper
airway.
Necrosis. Death of tissue.
Necrotic. Pertaining to necrosis, end result of
necrosis, dead.
Opioid. A class of narcotic compounds that
affect the brain and cause sedation and reduce
pain sensation; includes morphine, and Fentanil
derivatives.
Oropharynx. The mouth and upper airway.
Physostigmine. A carbamate that reverses the

effects of anticholinergic glycolate compounds
like BZ and atropine.
Pruritis. Itching.
Pulmonary edema. Fluid in the lungs;
associated with an outpouring of fluids from the
capillaries into the pulmonary spaces
or alveoli) producing severe shortness of breath. uces expectoration of frothy, pink, serious fluid and cyanosis.
Resin. A semi-solid substance, sometimes
sticky, that is produced by plants.
Rhinitis. Inflammation of nasal mucosa.
Rhinorrhea. Thin watery discharge from the
nose; runny nose.
Tachycardia. A rapid heart rate (over 100
beats per minute).
Thrombocytopenia. An absolute decrease in
the circulating platelets in the blood.
Trachea. Wind pipe.
Urticant. Something that causes itching or
stinging and a raised area on the skin (wheal).
. Formation of a space.
Vapor. Fumes given off by a liquid.
Vascularization. Development of new blood
vessels in a structure.
Vasoconstriction. Diminution of interior size of
a blood vessel with resultant decrease in blood
flow.
Vertigo. Dizziness where space seems to move
around.
Vesicant. Something that causes a vesicle
(blister). Many things will do this, such as
poison ivy and certain animal stings. Some chemical agents (mus rd and Lewisite) are vesicants.
Vesication. Blistering.
Zoonosis. A disease of animals that may be
transmitted to man under natural conditions.
Zoonotic. Transmissible from animals to man
under natural conditions; pertaining to or
constituting a zoonosis.
APPENDIX G
Glossary of Military Terms
ACAA. Automatic Chemical Agent Alarm
ACADA. Automatic Chemical Agent Detector
Alarm
AMEDD. Army Medical
BDO. Battle Dress Overgarment
BDU Battle Dress Uniform
BIDS. Biological Integrated Detection System
BW. Biological warfare.
BZ. An anticholinergic incapacitating agent 3-
quinuclidinyl benzilate.
C2A1 filter canister. The standard filter used
on the military mask.
ICAM. Chemical Agent Monitor
CANA. Convulsive Antidote, Nerve Agent
CARC. Chemical Agent Resistant Coating
C/B. Chemical/Biological
CBPS. Chemically Biologically Protected
Shelter
CDC. Chemical Decontamination Center
CG. Phosgene
CN. Riot control agent 1-chloroacetophenone
CPS. Collective Protection Shelter
CS. Riot control agent o-chlorobenzylidene
malononitrile
CR. Riot control agent dibenz (b,f)-1:4-
oxazepine
DBDO. Desert Battle Dress Overgarment

DKIE. Decont
amination Kit, Individu Equipment
DM. Riot control agent diphenylamin
vomiting agent.
DTD. Detailed Troop Decontamination
ECP. Entry Control Point
FMC. Field Medical Card
GA. Tabun
GB. Sarin
GD. Soman
GREGG. Graves Registration
HC smoke. Military tactical smoke
HD. Mustard
HTH. High Test Hypochlorite
HSS. Health Service Support
KPH. Kilometers Per Hour
LBE. Load Bearing Equipment
LCL. Liquid Control Line
MES. Medical Equipment Set
MOPP. Mission Oriented Protective Po
MTF. Medical Treatment Facility
MTO&E. Modified Table of Organization nd
Equipment
NAAK. Nerve Agent Antidote Kit
NATO. North Atlantic Treaty Organization
NCO. Noncommissioned Officer
NCOIC. Noncommissioned Officer-in-Char
NOx. Toxic smoke, which can cause pulmonary
edema; produces by exploding munitio s
industrial smoke, and in grain silos as prod of grain fermentation.
OC. Oleoresin of capsicum.

OIC. Officer-in-Charge
PFIB.
otutylene; toxic smoke produced by Teflon® burning at more than
700oF
SDK. Skin Decontamination Kit
SERPACWA. Skin Exposure Reduction Paste
Against Chemical Warfare Agents
TAP.
Toxico ogical Agent Protective (e.g., TAP Apron)
TC. Traini
TIC. Toxic Industrial Chemical
VCL. Vapor Control Line
2
autoinjector · 18, 22, 2-PAM Cl · 22, 24, 26, B
A
BAS · 21, 49, 122, 127, BDO · 125, 145, 147, AC · 45, 46, 47, 48, 146, 149, 166, 172, 173, 174, 179, 180, 188, acetylcholine · 7, 8, 10, 189, 190, 191, 194, acetylcholinesterase · BDU · 115, 176, 179, blister · 27, 31, 32, 33, AChE · 7, 8, 27 34, 37, 40, 41, 42, 43, aerosol · 4, 9, 10, 51, 224, 225, 226, 227, 82, 83, 84, 85, 86, 87, 90, 94, 96, 98, 99, blister agent · 31, 32, 38, 219, 221, 225 airway · 3, 10, 11, 20, blood · 11, 24, 46, 58, 22, 26, 35, 39, 48, 51, 60, 122, 227, 247 53, 58, 59, 65, 67, botulinum · 79, 103, 111, 122, 165, 232 alveoli · 58, 60, 246 breathing · 3, 10, 11, anthrax · 81, 88, 90, 92, 13, 15, 16, 21, 22, 23, 25, 47, 48, 50, 51, 56, antidote · 17, 28, 72, 58, 59, 62, 70, 72, 75, 76, 111, 113, 119, 87, 107, 120, 122, buddy-aid · 14, 15, 16, 197, 198, 199, 229, 17, 18, 19, 25, 36, 37, 38, 48, 110, 113 cessation · 10, 15, 16, BV · 175, 192, 212, cholera · 78, 80, 92, 94 BW · 80, 81, 83, 85, 86, CK · 45, 46, 47, 48, 223 87, 88, 89, 90, 92 CNS · 9, 13, 74, 94, 120 11, 12, 14, 17, 19, 20, C
21, 23, 25, 32, 33, 40, 41, 43, 44, 48, 51, 61, 69, 7 , 110, 111, 112, CAM · 3, 34, 35, 113, 116, 117, 118, 145 138, 154, 168, 183, convulsions · 3, 5, 15, 194, 197, 202, 224, 17, 24, 48, 95, 108 casualty · 3, 11, 12, 14, CX 146, 147, 223 16, 17, 18, 19, 20, 21, cyanogen chloride · 22, 23, 24, 25, 26, 33, 70, 77, 104, 108, 110, 111, 112, 113, 114, D
115, 116, 117, 118, 119, 120, 121, 122, decon · 88, 114, 115, 123, 124, 127, 128, 128, 157, 158, 160, 133, 134, 135, 136, 161, 162, 169, 170, 137, 138, 139, 142, 182, 183, 186, 187, 143, 147, 148, 149, 192, 201, 203, 212 150, 151, 159, 160, decontamination · 3, 164, 165, 166, 167, 40, 50, 64, 72, 77, 172, 173, 174, 178, 103, 128, 131, 132, 179, 180, 181, 183, 134, 137, 138, 139, 184, 188, 189, 190, 142, 155, 158, 161, 191, 193, 194, 195, 163, 166, 168, 172, 178, 180 185, 196, 200, 202, gastrointestinal tract · diazepam · 3, 16, 17, GB · 3, 4, 6, 28, 146, 18, 22, 23, 24, 25, GD · 3, 4, 6, 27, 28, 146, distilled mustard · 223 GF · 3, 4, 6, 28 GI tract · 93, 96 gloves · 121, 149, 161, E
167, 168, 172, 173, 174, 175, 176, 177, 178, 183, 189, 193, erythema · 35, 36, 39, 214, 215, 218, 220, ey (s) · 4, 8, 9, 10, 15, 21, 34, 35, 36, 37, 38, 39, 41, 42, 47, 48, 60, H
64, 68, 70, 115, 121, 181, 205, 206, 207, H · 30, 31, 32, 34, 35, 148, 221, 223, 225 53, 58, 148, 223, 226, F
heart · 11 HL · 30, 31, 32, 34, 36 fasciculations · 12 Fentanil · 72, 73, 74, 75, hood · 121, 133, 149, 167, 169, 170, 171, 178, 185, 186, 187, 188, 190, 207, 209, G
hydrogen cyanide · 46, G · 147, 221, 223, 225, I
M
M256A1 · 3, 34, 46, 114, 153, 154, 156, 219, 222, 223, 224 J
M272 · 227 M291 · 3, 37, 38, 40, 161, 162, 166, 167, JSLIST · 166, 170, 173, 169, 170, 171, 172, 180, 186, 187, 188, 173, 174, 175, 177, 190, 200, 209, 210, 178, 180, 181, 182, 211, 228, 229, 230, 185, 186, 187, 189, 192, 193, 194, 195, 196, 199, 216, 217, L
M29 · 3, 40, 169, 170, 173, 174, 175, 177, Lewisite · 31, 32, 36, 179, 185, 186, 187, 189, 192, 193, 194, liquid · 3, 16, 21, 37, 57, 195, 199, 216, 218 M40 · 170, 186, 204, litter · 62, 111, 113, 124, M8 · 3, 34, 113, 134, 126, 128, 135, 137, 147, 153, 154, 157, 138, 139, 140, 158, 161, 166, 168, 183, 159, 161, 162, 163, 194, 197, 219, 221, 170, 171, 173, 174, M8A1 · 154, 156, 219 175, 178, 179, 180, M9 · 3, 34, 37, 1 181, 183, 184, 188, 134, 147, 149, 153, 189, 191, 194, 198, 154, 183, 219, 220, 199, 202, 203, 228, MARK I · 3, 15, 16, 17, 18, 21, 22, 23, 24, 26, 28, 115, 162, 165, nerve agent · 3, 4, 8, 12, 13, 17, 18, 20, 28, 31, 108, 109, 146, 147, 148, 216, 223, 77, 102, 105, 113, 149, 164, 165, 166, 167, 169, 170, 171, nose · 3, 8, 9, 0 23, 34, 39, 47, 48 188, 194, 198, 200, 59, 60, 69, 87, 207 203, 205, 206, 207, NOx · 50, 55, 56 MOPP · 19, 36, 40, 87, 114, 115, 116, 134, O
141, 153, 156, 163, 164, 166 overboots · 175, 176, 200, 203, 210, 211, 183, 192, 198, 211, mou · 3, 8, 9, 10, 15, oxides of nitrogen · 55 23, 52, 69, 70, 72 103, 106, 207, 245 MTF · 41, 42, 44, 89, 111, 114, 116, 127, P
130, 131, 132, 133, 134, 135, 136, 139, ys · 3, 12, 15, 16, muscle · 1, 7, 9, 10, 12, PFIB · 54, 55, 56 13, 20, 22, 103, 106 gene · 54, 56, 57, 58, 59, 60, 61, 123, 223 N
photophobia · 247 plague · 78, 80, 87, 91, NAPP · 115, 153 pralidoxime · 3, 23 nausea · 3, 9, 11, 93, pretreatment · 26, 27, protective wrap · 161, SDK · 37, 38, 16 pyridostigmine · 26, 27, SEB · 87, 91, 103, 107 28, 29, 120, 153 secretions · 3, 10, 11, self-aid · 15, 16, 17, 18, Q
21, 36, 37, 40, 43, 48, 69, 70, 75, 110, 113 Q-fever · 87, 88, 96 signs · 3, 17, 18, 24, 35, 41, 47, 50, 51, 56, 64, R
72, 74, 80, 85, 86, 87, RDIC · 26, 163, 202, 99, 101, 103, 105, 106, 110, 113, 114, resin · 67, 68, 69 skin · 3, 4, 5, 6, 9, 10, respiration · 10, 13, 15, 11, 12, 16, 19, 20, 26, 48, 52, 76, 79, 80, 31, 32, 33, 34, 35, 36, respiratory · 3, 4, 22, 24, 34, 36, 44, 123 72, 73, 74, 77, 81, 90, respiratory tract · 9, 10, 95, 103, 105, 107, 53, 80, 106, 207 108, 113, 115, 120, resuscitation · 27, 50, 167, 168, 169, 171, ricin · 79, 87, 103, 106, 172, 178, 180, 182, 185, 189, 193, 196, RSD · 3, 158, 167, 179 197, 206, 211, 215, 216, 217 S
suction · 3, 84, 111 sweat · 9, 12, 75, 97, sweating · 3, 12, 16, 20, V
symptoms · 3, 14, 16, 17, 18, 20, 21, 22, 23, vapor · 3, 4, 5, 6, 8, 9, 24, 28, 29, 35, 40, 41, 10, 11, 12, 15, 18, 19, 47, 48, 51, 56, 64, 72, 21, 31, 32, 33, 34, 36, 74, 76, 80, 85, 87, 91, 46, 47, 50, 51, 57, 110, 115, 117, 128, 101, 103, 105, 106, 132, 134, 144, 145, 110, 113, 114, 115, 146, 147, 148, 152, 116, 120, 122, 134, 153, 156, 164, 165, 198, 200, 208, 210, 218, 220, 222, 223, 225 T
ventilation · 3, 23, 26, 27, 55, 62, 77, 90, 111 vomiting · 3, 11, 16, 47 Teflon · 54, 62 TIC · 51, 52, 53, 54, 55, 56, 57, 58, 60, 62, 145, 146, 147, 205 triage · 41, 89, 90, 110, W
114, 116, 117, 118, 119, 121, 129, 137, 138, 147, 157, 158, weakness · 3, 12, 13, 161, 162, 163, 164, 15, 16, 93, 103, 106 165, 166, 179, 203 Tularemia · 87, 91, 99 U
unconscious · 22, 72 NERVE AGENTS
GA, GB, GD, GF, VX
Signs and Symptoms:
Small exposure—small pupils, runny nose,
difficulty breathing. Large exposure—sudden loss of
consciousness, convulsions, no breathing, flaccid paralysis, copious secretions from nose, mouth and lungs, small pupils. Liquid on skin:

Small to moderate amount—localized sweating,
nausea, vomiting, feeling of weakness. Large amount—sudden loss of consciousness,
convulsions, no breathing, flaccid paralysis, copious secretions from nose, mouth, and lungs. Detection: M256A1; Improved Chemical Agent
M
onitor (IICAM); M8 p paper; M22 (ACADA). Decontamination: M291; large amounts of water and
soap; RSDL, 0.5% h p
y ochlorite bleach, M295. [Note: bleach on skin!] Immediate management: administration of MARK I
kits or ATNAA; diazepam (Convulsive Antidote Nerve
Agent-CANA). In addition, if casualty's symptoms are
severe, ventilation and suction of airways for
respiratory distress.
H, HD, L, HL
Signs and Symptoms: asymptomatic
latent period (hours). Erythema and blisters on the skin; irritation, conjunctivitis
and corneal opacity and dam eyes; mild upper respiratory signs to
marked airway damage; also
gastrointestinal effects and bone marrow ssion. Fever is not typically associated with the agents.
Detection: M256A1; ICAM; M8 paper; M9
paper.
Decontamination: M291; water/soap in
large amounts. M295 for equipment.
Management: Decontamination
immediately after exposure is the only way
to prevent damage. Symptomatic
management of lesions.
LEWISITE
Signs and Symptoms: Lewisite causes
immediate pain or irritation of skin and mucous
membranes. Erythema and blisters on t
and eye and airway damage simila seen after mustard exposures develop later.
Detection: M256A1, M272 water testing kit,
and ICAM.
Decontamination: M291, 0.5% hypochlorite,
water in large amounts.
Management: immediate decontamination;
symptomatic management of lesions the same
as for mustard lesions; a specific
will decrease systemic effects. Signs and Sy
mptoms: few. After
igh Ct, seizures, respiratory and cardiac arrest. M256A1 Detector Kit. Skin decontamination is usually not necessary because the agents evaporate ra clothing should be removed rlying skin decontaminated with water or other st Management:
Antidote: intravenous
Soduim Nitrite and Sodium
Supportive: oxygen;
correct acidosis. LUNG-DAMAGING AGENTS AND
TOXIC INDUSTRIAL CHEMICALS
Ammonia, CG, Cl, HC Smoke, NOx
Signs and Symptoms: sudden laryngospasm
and collapse. Central airway: breathing
difficulty, wheezing; sne
hoarseness when talking. Peripheral airway:
breathing difficulty, chest tightness.
Detection: Odor of newly mown hay or freshly
cut grass or green corn. There are no specific
military field detection devices for these
compounds;
e ACADA can detect battlefield agent vapors when deployed area surveillance tool.
Decontamination: Vap
copious water irrigation.

Management: termination of exposure, ABCs
of resuscitation, enforced rest and observation,
oxygen with or without positive airway pressure
for signs of respiratory distress, other supportive
therapy as needed.
RIOT CONTROL AGENTS
CN, CS, CR, OC, and DM
Signs and Symptoms: CN, CS, CR, and OC:
tingling and pain on exposed skin and mucous
membranes, burning in the nostrils and tearing
of the eyes. With severe exposure:
laryngospasm. CN, CS, CR: with severe
exposure: respiratory discomfort and skin
burning, blistering. DM: delayed skin irritation,
vomiting, and malaise.
Detection: no detector.
Decontamination: CN, CS, CR, and DM:
eyes: thoroughly flush with water, saline, or
similar substance. Skin: flush with copious
amounts of water, soap is beneficial. Generally,
decontamination is not needed if the wind is
brisk. OC: Pain may increase if water used for
decontamination of OC. This is best
decontaminated using baby shampoo, milk, or
vegetable oil.
Management: Usually none is needed; effects
are self-limiting.
Botulinum Toxin, Ricin, SEB, etc.

Signs and Symptoms: These depend upon the
specific toxins. Botulinum toxins cause descending
weakness and paralysis (including respiratory-muscle
paralysis) along with dry mouth and dilated pupils.
Ricin and SEB cause different presentations
depending upon the route of exposure.

Detection: No field detectors commonly available.
Detection of exposure is mainly by a high index of
suspicion and by clinical recognition of signs and
symptoms.
Decontamination: Clothing removal and skin
cleansing using water (with or without soap) is
generally sufficient.
Management: For almost all toxins, treatment is
supportive only. This includes the potential necessity
of ventilatory support for weeks following exposure to
botulinum toxins, although a botulinum toxoid is
effective if given before signs and symptoms appear.
Active immunization with botulinum toxoid is available
only as a pre-exposure measure for those at
demonstrated high risk.
PHOSGENE OXIME
Signs and Symptoms: immediate burning and
irritation followed by wheal-like skin lesions and
eye and airway damage.
Detection: M256A1, M18A2, M90, M93 Fox,
and the ICAM M256A1.
Decontamination: water in large amounts,
0.5% hypochlorite, M291.
Management: immediate decontamination,
symptomatic management of lesions.
Nerve Agents
esicants
Lung-Damaging Agents and TICs
Riot Control Agents
Incapacitating Agents
Biological Agents
Field Management of Casualties
Patient Decontamination
Chemical Defense Equipment
Appendices

Source: http://strongpointsecurity.co.uk/site/wp-content/uploads/2013/08/Field-Management-of-Chemical-Casualties-3rd-Edition.pdf