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Chemical agents and 'indiscriminate' use

by Prof. Ravindra Fernando, Head, National Poisons Information Centre, National Hospital of Sri Lanka

Chemical agents have been used previously on numerous occasions, from World War I to the recent one, Gulf War.

The development and use of poison gas was necessitated by the requirement of wartime armies to find new ways of overcoming the stalemate of unexpected trench warfare.

Although it is popularly believed that the German army was the first to use gas it was in fact initially deployed by the French. They fired tear-gas grenades (xylyl bromide) against the Germans in the first month of the war in 1914. Later the German army used it on a large scale.

In modern warfare, substances that are likely to be used as chemical warfare agents include sarin, phosgene and sulfur mustard.

Sarin is an organophosphorus compound like the insecticide malathion. Sarin is a highly toxic nerve agent that can be fatal within minutes to hours.

Sarin nerve gas was used first in peacetime as a weapon of terrorism in Japan. The subway sarin attacks were the first large-scale disasters caused by nerve gas. In 1994 and 1995, a religious cult released sarin gas into subway commuter trains in Matsumoto and Tokyo killing 19 and injuring more than 6000.

Compounds similar to sarin are tabun, soman and VX.

Phosgene is also known as carbonyl chloride. This is a lethal type of choking gas. It is corrosive to the eyes, skin and the respiratory tract.

Sulfur mustard is a heavy oily liquid which is readily absorbed from skin, cornea, conjunctivae and respiratory epithelia. It is one of the major chemical warfare agents developed and used during World War I.

The clinical picture of poisoning is well known from the thousands of victims during World War I. In the Iran-Iraq war, sulfur mustard was heavily used.

Even today, about 30,000 victims suffer from late effects of the agent having chronic obstructive lung disease, lung fibrosis, recurrent corneal ulcer disease, chronic conjunctivitis, abnormal pigmentation of the skin, and several forms of cancer.

These agents may be used alone, or more likely during an attack with firearms and explosives. If any unusual symptoms, such as difficulty in breathing, excessive tearing, burning sensation of eyes, nose or skin, occur in such a situation, an attack with chemical agents should be considered.

Clinical Features

Sarin

If inhaled, early effects include nasal secretions, visual disturbances, headache, increase salivation and breathing difficulty.

Skin absorption leads to excessive local sweating and local muscular twitching.Pupillary constriction occurs early in vapour exposure. Other eye effects include pain, frontal headache and injection of conjunctivae.

Later effects include nausea, vomiting, urinary and faecal incontinence, bronchopneumonia, rhythm disturbances of the heart, fits and respiratory failure.

Phosgene

If inhaled, there will be a burning sensation, cough, difficulty in breathing, shortness of breath, sore throat and collection of water in lungs (pulmonary oedema).

Usually, features of pulmonary oedema become apparent after few hours and they are aggravated by physical effort. Skin exposure will cause redness, skin burns and frost bite on contact with liquid form.

Eye exposure will cause redness, pain and blurred vision. Exposure to high concentrations may result in death. Long term effects include fibrosis of the lungs causing impaired lung function.

Lung collapse

Skin exposure will cause redness and swelling. Prolonged exposure will give rise to large blisters and vesicles. They rupture leaving necrotic erosive lesions which heal slowly in 1 to 2 months time.

Eye contact will give rise to photophobia, conjunctivitis and possible corneal erosions. Severe lesions cause corneal scarring. Oedema and excessive secretions in the respiratory tract lead to difficulty in breathing, cough and bleeding into larynx and pharynx.

Pseudomembrane formation can cause occlusion of small bronchi and may lead to lung collapse with compensatory emphysema. Systemic effects such as bone marrow depression with diminished blood cells.

First aid

Toxic fumes, gases or vapours can cause poisoning by inhalation. Therefore, before doing anything else, victims of exposed to these agents should be removed from further exposure.

All contaminated clothing should be removed.

The victims should be rested and reassured. Transport to the nearest dispensary or hospital should be arranged as soon as possible. **

If the victim is semiconscious or unconscious, turn him to left side, and keep the head at a lower position than the body, to prevent any vomitus entering air passages.

If eyes are exposed they should be washed thoroughly for 15 minutes with running water. The victim should blink during the procedure. If blurring of vision, pain or redness persists an ophthalmologist should be consulted. Chemical antidotes should never be used locally on the eye.

Skin contact can be harmful if it is absorbed through the intact skin or if the skin is inflamed or damaged by disease or injury. The contaminated skin should be washed thoroughly with soap and water. If possible, water from a tap, a hose or a shower should be used to wash the body or water may be poured from a bucket.

Clothing should be removed carefully while bathing the skin with a stream of water. Chemical antidotes to neutralise a poison should not be used locally on the skin. It is necessary to identify the specific gas the victim is exposed to further management in a healthcare facility.

If this is not possible, after the steps mentioned above are taken, the airway should be cleared and administering oxygen and assisted ventilation should be considered.

Drugs such as intravenous aminophylline or salbutamol by nebulizer should be administered if bronchospasm is present.

Specific Treatment

Sarin

The first 6 hours is the most critical period in poisoning. If a victim improves during the initial treatment, survival is assured with adequate and careful therapy and monitoring.

Airway should be cleared of secretions. If respiration is impaired oxygen therapy and assisted ventilation may be life saving and should be done before other therapeutic procedures.

Drugs such as atropine and pralidoxime have to be given intravenously. Intravenous diazepam or phenytoin may be required to control fits. Bronchopneumonia should be treated with appropriate antibiotics. Chest physiotherapy may be necessary.

In severe poisoning management in an intensive care unit is life saving. Temporary pacing may be necessary to terminate rhythm disturbances of the heart.

Victims should be carefully observed in hospital for 2 to 3 days in mild poisoning and up to a week in moderate and severe poisoning.

Phosgene

Victims should be removed from the source of poison and deep breathing of fresh air should be encouraged. Eyes and skin should be washed with copious amounts of water as mentioned earlier.

If respiration is impaired victims need oxygen and assisted ventilation. In severe poisoning, assess the condition with determination of arterial blood gases and a chest x-ray.

Bronchospasm should be treated with salbutamol inhalations or other bronchodilators. Prednisolone 60 mg daily for a week or more is recommended to relieve pulmonary complications.

General symptomatic therapy is used for cough, bronchitis and sore throat.

Sulfur mustard

Treatment of sulfur mustard lesions is symptomatic and aimed at the prevention of secondary infections and to promote skin healing. Antibiotic ointments for ocular lesions and silver sulphadiazine on skin lesions have been used.

Systemic infections are treated with appropriate antibiotics following antibiotic sensitivity tests. Serum electrolytes and renal function must be checked and corrected. Assisted ventilation and cardio-vascular support may be required.

The need for assisted ventilation and occurrence of severe reduction of white blood cells indicate poor prognosis. In most cases erosive skin lesions are compared to superficial second degree burns.

New hope for stem cell transplants

by Rosanne Koelmeyer Anderson

As acute leukemia still remains a big challenge there is hope with Haematopoietic Stem Cell Transplant or Bone Marrow Transplant for patients and it can be done provided you have the State-of-the-art technology and the expertise to do the transplant ,Dr Patrick Tan observed delivering the keynote address at the 40th Annual Scientific Sessions of the College of Physicians which was held at Cinnamon Grand Hotel, Colombo recently.

Dr. Patrick Tan was invited to Sri Lanka to address the Sessions as part of a medical expertise exchange programme Singapore had entered into with Sri Lanka in a bid to impart expertise and training for local doctors to meet challenges facing critical illnesses which require the application of the very latest medical techniques and after care.

Presently, there is a collaboration between the Singaporean doctors and local doctors to address the issue of blood stem transplants which has a less than one per cent mortality rate if done under State-of-the-art technology and good after care.

Previously incurable or possibly fatal blood disorders such as multiple myeloma, chronic lymphatic leukemia and thalassaemia major could not have been cured using conventional therapy such as chemotherapy and radiotherapy Dr Tan observed.

However, in recent years there have been dramatic breakthroughs in the field of haematology and stem cell transplant that offer new therapies which help patients live longer and lead better quality lives.

In the case of acute leukemias transplants are performed for haematological malignancies, lymphomas as well as in some cases of life threatening non-malignant disorders such as the auto-immune disorders and certain solid tumours where classical matched siblings and the matched unrelated donor transplants have proved to be a success and can go in for blood stem transplants.

In the case of severe aplastic anaemias, the myelodysplasias, chronic leukemias, thalassaemias ,lymphomas and myelomas, stem cell transplants are done mainly for older patients while the umbilical blood stem cell transplants are done not only for paediatric patients but also for the older patients.

Dr Patrick Tan observed that blood cell transplant if done earlier in life, below the age of ten in the case of children is best, lest they may survive for only a year or two if not treated.

The on-going training local doctors could avail themselves of now, will be beneficial and a breakthrough in the field of stem cell transplants in Sri Lanka.

What are haematopoietic stem cell

Stem cells are blood cells at the earliest stage of development in the bone marrow. Within the bone marrow , stem cells develop into the different blood cells (red blood cells and white blood cells and platelets)

When cells are fully mature, they are released into the bloodstream. Usually most of the stem cells in the body are in the bone marrow and there are only very small numbers in the bloodstream.

However, it is possible to stimulate the stem cells to move into the bloodstream using injections of a special protein known as growth factor. Blood stems can be collected from the bone marrow or bloodstream.

With allogeneic stem cell transplant , cure rates for some of these previously incurable disorders are as high as 90 per cent. Besides increasing survival rates ,quality of life is also enhanced.

Stem cell transplantation allows for much higher doses of chemotherapy than usual to achieve significantly higher cure rates.

Dr. Patrick Tan is a renowned doctor who has several firsts achieved such as the first successful case of unrelated blood stem cell transplant for Thalassaemia Major, the first unrelated cord blood transplant for Thalassaemia Major, the first non-myelo ablative double cord blood transplant for acute myeloid leukemia and the first unrelated non-myelo-ablative cord blood steam cell transplant for multiple myeloma.

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Hey guys you too need to care your skin

To many, many men skin care is the last priority on their list. Shaving their face would be the closet thing to skin care that they would come too, however times have changed and there are many men that are taking the steps to better skin care and showing their skin just a little bit more love and care.

Here in this article I will go over the basic skin care tips for men. Taking care of your skin is important and many men have realized that the skin is the outer most layer to protecting their look for the future as well as the largest defense organ against outside bacteria and sickness.

As people age our skin tends to lose the elasticity and wrinkles and fine line began to appear. Skin care for men does not take out hours from the day but just a few minutes each day. A simple antibacterial skin soap and cleanser. Just wash you face with warm water and rinse dry with cold water.

This is to close the pores after washing.

The daily weather can also pose harm to a mans skin and all mean should before when going out into the earths elements should be wearing at least an SPF 15 protective sun-screen before stepping outside. This can help with preventing wrinkles in the future as well as help the fight against the potential skin cancer as well.

Eating right will also do wonders for your skin. Some things that you should and need to stay away from would be foods that are high in saturated fats things such as fried food, French fries, chips and other foods with a lot of processed ingredients. By staying away from these foods you can reduce the level of toxins that can build up your pores that can cause breakouts.

One of the best ways a many can help his skin as well in the consumption of water drinking water not only helps your body rejuvenate but it also helps to keep the skins surface hydrated and moisturized which is highly important when it comes to skin care.

You should just know that a man's skin care is just as important as any one else's and have to be treated with the up do most respect and following through with a daily skin care plan is vital to much success with you and all of your skin care needs.

Work stress linked to heart risk

People who go back to a stressful job after a heart attack are more prone to a second attack than those whose work is not stressful - a study says. Canadian researchers followed some 1,000 patients returning to work. In six years, over 200 suffered heart problems again. Those with job strain were twice as likely to fall ill.

The Journal of the American Medical Association study defined job strain as having a high pressure workload but few decision-making powers.

Studies have also shown a link between job strain and a first heart attack, but researchers at Laval University in Quebec said little was known about the association with subsequent heart problems.

They said their findings on Canadian patients held up even after other risk factors had been accounted for, including lifestyle, socio-economic group and clinical prognosis. It is well known that people are more likely to feel stressed when they have little control over their work situation but have a lot of demands placed on them.

Although further studies were still required, "information about the results of this study should be disseminated in cardiac practice and in occupational health services with the aim of reducing job strain for workers returning to work after a heart attack," the authors wrote.

June Davison, a cardiac nurse at the British Heart Foundation, said: "It is well known that people are more likely to feel stressed when they have little control over their work situation but have a lot of demands placed on them.

"We still need to further our understanding about how stress affects our heart and circulation. In the mean time, we can all help ourselves by recognising what stresses us and learning how to cope with stressful situations."