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File: 970613_ww32_90a_90_txt_0001.txt
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[b.2.]

SUBJECT: AFMIC SPECIAL WEEKLY WIRE 32-90(A) (U)

1. (U) GENERAL
(U) THIS MESSAGE CONSISTS OF SCIENTIFIC, TECHNICAL, AND GENERAL
MEDICAL INTELLIGENCE. IT IS INTENDED TO PROVIDE A TIMELY SUMMARY OF
CURRENT DISEASE INTELLIGENCE FINDINGS AND ANALYSES. THE REMARKS ARE

PRELIMINARY AND SUBJECT TO REVISION AND DO NOT NECESSARILY
REPRESENT
AN AGREED DOD POSITION. CLINICAL REVIEW HAS BEEN PROVIDED BY THE
AFMIC-SG [b.6.]
2. (U) THIS SPECIAL WIRE IS INTENDED TO PROVIDE CLARIFICATION AND
FURTHER DISSEMINATION OF MEDICAL INTELLIGENCE ON A SUBJECT OF
CURRENT
INTEREST.
3.           IRAN/IRAQ: CHEMICAL WARFARE (CW) CASUALTY CARE AND
EVACUATION
          IRAQ IS KNOWN TO HAVE EMPLOYED THE NERVE AGENTS TABUN
(GA)
AND SARIN (GB) (ALSO REPORTED TO HAVE THE CAPABILITY FOR VX; AN
OIL-
BASED ORGANOPHOSPHATE, WHICH IS MAINLY EFFECTIVE THROUGH SKIN
ABSORPTION), BLISTER AGENTS, MUSTARD GAS, "DUSTY" MUSTARD C35
PERCENT
GROUND SILICATE, 65 PERCENT SULFUR MUSTARD), POSSIBLY LEWISITE, AND
PROBABLY A BLOOD AGENT, CYANIDE GAS. THE VAST MAJORITY OF
CASUALTIES
RESULTED FROM MUSTARD AGENTS, AND MOST MEDICAL DATA AND TREATMENT
OBTAINED PERTAINS TO MUSTARD AGENTS.
                        SUFFICIENT IRANIAN RESOURCES WERE NOT
AVAILABLE TO COPE WITH THE TENS OF THOUSANDS OF CASUALTIES THAT
OCCURRED YEARLY IN THE WAR WITH IRAQ. AS A RESULT OF POOR MEDICAL
CAPABILITIES, MANY CASUALTIES RECEIVED IMPROPER OR INCOMPLETE
TREATMENT; OTHERS RECEIVED NONE AT ALL. INSUFFICIENT PROTECTIVE
CLOTHING AND MASKS, RELUCTANCE TO WEAR PROTECTIVE CLOTHING BECAUSE
OF
THE HOT ENVIRONMENT, AND THE INABILITY TO DON PROTECTIVE CLOTHING
RAPIDLY ENOUGH ALL CONTRIBUTED TO MASSIVE CW EXPOSURES. COLLECTIVE
PROTECTION WAS NONEXISTENT, AND FREQUENTLY, CASUALTIES WOULD WALK
INTO FIRST AID STATIONS THAT WERE OPEN TO THE ENVIRONMENT AND
ENVELOPED IN THE CHEMICAL CLOUD. OPEN WATER SOURCES BECAME
CONTAMINATED DURING CW ATTACKS, AND WITH NO PROTECTED WATER SOURCES
IN FORWARD AREAS, MANY SOLDIERS ATTEMPTED TO DECONTAMINATE
THEMSELVES
WITH THE CHEMICALLY CONTAMINATED WATER. MANY WOUNDED WERE LEFT
UNATTENDED ON THE BATTLEFIELD. ALTHOUGH CONVENTIONAL WEAPONS CAUSED
FAR GREATER CASUALTIES, AND NERVE AGENTS WERE MORE TOXIC, MUSTARD
GAS
AGENTS HAD THE GREATEST PSYCHOLOGICAL VALUE IN CREATING PANIC AND
FEAR AMONG TROOPS. ADDITIONALLY, MUSTARD AGENTS CAUSED GREATER
MORBIDITY, THUS TYING UP ASSETS, AND WERE CREDITED AS A MAJOR
INFLUENCE IN THE OUTCOME OF THE WAR.
          IRANIAN TROOPS WERE PROVIDED WITH ATROPINE AUTOINJECTORS
AND AMYL NITRITE CAPSULES, ANTIDOTES FOR NERVE AGENTS AND INITIAL

TREATMENT FOR CYANIDE POISONING, RESPECTIVELY. THE SECOND PHASE OF
TREATMENT FOR CYANIDE AT AID STATIONS CONSISTED OF 20 GRAMS SODIUM
THIOSULFATE SOLUTION ADMINISTERED INTRAVENOUSLY OVER 20 MINUTES.
IRANIAN SOLDIERS FREQUENTLY SELF-ADMINISTERED ATROPINE FOLLOWING
EXPOSURE TO MUSTARD AGENTS BECAUSE OF LACK OF TRAINING IN CW
PROTECTIVE MEASURES AND INABILITY TO IDENTIFY THE AGENT USED.
    PYRIDOSTIGMINE PRETREATMENT FOR NERVE AGENT EXPOSURE WAS NOT
USED
BY IRANIAN TROOPS, AND SOLDIERS NOT WEARING PROTECTIVE CLOTHING AND
TIGHT-FITTING MASKS (BEARDS PREVENT A TIGHT SEAL) USUALLY DIED IN
FORWARD AREAS AND THUS WERE SELF-TRIAGING. NERVE AGENT CASUALTIES
WERE DECONTAMINATED AT THE MEDICAL TREATMENT POINT BY WASHING WITH
SOAP AND WATER AND SHAVING BODY HAIR. MOST NERVE AGENT CASUALTIES
RECEIVED ONLY ATROPINE INJECTIONS (2 MILLIGRAMS PER 8 HOURS) AND
RESPIRATORY SUPPORT AS REQUIRED. COMATOSE CASUALTIES WITHOUT
CARDIOVASCULAR PROBLEMS AND ARRIVING AT THE AID STATION WITHIN 20
TO
60 MINUTES OF EXPOSURE WERE TREATED WITH VERY LARGE DOSES OF
ATROPINE
AND THE ACETYLCHOLINESTERASE REACTIVATOR, TOXOGONIN (SIMILAR, BUT
NOT
IDENTICAL, TO 2 PAM CHLORIDE). COMATOSE CASUALTIES WITH
CARDIOVASCULAR DETERIORATION (BRADYCARDIA DESPITE 2 MILLIGRAMS
ATROPINE) WERE NOT TREATED FURTHER AS EXPERIENCE INDICATED THEY
WOULD
NOT RECOVER (1 TO 2 PERCENT OF THE CASUALTIES RECEIVED AT THE
MOBILE
MEDICAL POINTS). PATIENTS EXPERIENCING CRAMPS WERE GIVEN 30
MILLIGRAMS DIAZEPAM. SOLDIERS WITH MINOR EXPOSURES SPENT 1 TO 3
DAYS
UNDER OBSERVATION AT A FIELD HOSPITAL AND THEN WERE RETURNED TO THE
FRONT.
       IRAQ POSSESSES PROTECTIVE MASKS AND SUITS (QUANTITIES
UNKNOWN). IN THE PAST, EACH SOLDIER WAS REPORTEDLY ISSUED A FIRST
AID/NUCLEAR, BIOLOGICAL, AND CHEMICAL (NBC) KIT. IN LATE 1988, IRAQ
MADE CONTRACTS TO PURCHASE 10,000 PYRIDOSTIGMINE AND VALIUM
(DIAZEPAM) TABLETS AND 100,000 AUTOINJECTORS (CONTENTS THOUGHT TO
BE
ATROPINE AND TOXOGONIN). THEY ALSO PURCHASED ANTICYANIDE KITS FROM
AN
UNKNOWN SOURCE.
    CW-INJURED IRAQIS ADMINISTER SELF-AID, IF POSSIBLE, OR BUDDY
AID
WHEN REQUIRED. LITTER BEARERS COLLECT ALL CASUALTIES AND EVACUATE
TO
FIELD FIRST AID UNITS BY ANY AVAILABLE MEANS. THE FIELD MEDICAL
UNIT
IS RESPONSIBLE FOR COLLECTING, TRIAGING (PRIORITIZING), TREATING,
AND
EVACUATING INJURED TO THE NEAREST GENERAL FIELD HOSPITAL.
CASUALTIES
ARE PRIORITIZED INTO THOSE REQUIRING IMMEDIATE CARE (PRIORITY
EVACUATION TO THE REAR AREA), THOSE REQUIRING SURGERY, AND ALL
OTHERS. CASUALTIES REQUIRING ADDITIONAL MEDICAL CARE ARE EVACUATED
TO
CIVILIAN OR MILITARY HOSPITALS IN THE AREA. THE AIR FORCE MEDICAL
UNIT IS RESPONSIBLE FOR PROVIDING MEDICAL CARE TO ALL PATIENTS
EVACUATED BY AIR; TRANSPORT PLANES ARE EQUIPPED TO TRANSPORT LITTER
CASES. THE IRAQI MEDICAL SYSTEM HAS LIMITED CAPABILITY TO
ACCOMPLISH
ITS EVACUATION MISSION IN A CONVENTIONAL WARFARE SITUATION, AND
WOULD
LIKELY BE OVERWHELMED WITH LARGE NUMBERS OF CHEMICAL CASUALTIES.
       AT THE BEGINNING OF THE IRAQI CW ATTACKS, IRANIAN CW
CASUALTY
CARE VARIED GREATLY. WITH NO KNOWN ANTIDOTES FOR MUSTARD AGENTS,
IMMEDIATE DECONTAMINATION (30 SECONDS TO 2 MINUTES) IS ESSENTIAL TO
PREVENT INJURY. IMMEDIATE DECONTAMINATION OF IRANIAN CW CASUALTIES
WAS INADEQUATE TO NONEXISTENT. MEDICAL PERSONNEL EVENTUALLY
DEVELOPED
A STANDARD TREATMENT PROTOCOL FOR MUSTARD CASUALTIES WHICH CAN BE
SUMMARIZED AS FOLLOWS.
           EYES: RINSED WITH RINGERS' SOLUTION, THEN 1 PERCENT
CYCLOPLEGIC EYE DROPS AND 20 PERCENT SULFACETAMIDE EYE DROPS
APPLIED.
EYES WERE BANDAGED FOR 24 TO 48 HOURS FOR IRRITATION AND
PHOTOPHOBIA.
IN ADDITION TO SULFACETAMIDE, OTHER TOPICAL ANTIBIOTICS
(GENTAMICIN,
TETRACYCLINE, OR CHLORAMPHENICOL) AND STEROIDAL AGENTS

/****** BEGINNING OF SECTION 002 ******/
(BETAMETHASONE, HYDROCORTISONE, OR DEXAMETHASONE) WERE USED IN
CONJUNCTION TO TREAT SERIOUS CORNEAL INJURIES. SKIN: DECONTAMINATED
BY THOROUGH WASHING, THEN 2 PERCENT SODIUM THIOSULFATE TOPICAL
SOLUTION APPLIED AND 20 GRAMS OF SODIUM THIOSULFATE SOLUTION
ADMINISTERED INTRAVENOUSLY. (SODIUM THIOSULFATE WAS NOT AN ACCEPTED
THERAPY, BUT WAS USED EMPIRICALLY, AND WAS REPORTEDLY EFFECTIVE
ONLY
IF INITIATED WITHIN 3 HOURS OF EXPOSURE.) INJURED AREAS WERE BATHED
DAILY WITH TAP WATER AND RINSED WITH PHYSIOLOGICAL SALINE. BLISTERS
WERE DRAINED IN A STERILE MANNER AND TREATED WITH SILVER
SULFADIAZINE.  HYDROCORTISONE WAS USED IN CASES OF SEVERE
INFLAMMATION AND ANTIBIOTIC CREMES AND OINTMENTS CONTAINING
GENTAMICIN, TETRACYCLINE, CHLORAMPHENICOL, AND NITROFURANTOIN WERE
APPLIED AS NEEDED. LUNGS: MUSTARD CAUSES THE BREAKDOWN OF THE
ALVEOLAR MEMBRANES, RESULTING IN EXUDATIVE EFFUSION. VAPORIZERS
WERE
USED AND EXPECTORANTS (FREQUENTLY BENILYN) AND COUGH SUPPRESSANTS
(SYRUPS CONTAINING CODEINE WERE USED ONLY WHEN OTHER SYRUPS WERE
INEFFECTIVE) WERE ADMINISTERED. OXYGEN, BRONCHODILATORS, AND
ANTIBIOTICS (ABOUT 80 PERCENT ADMINISTERED PARENTERALLY) WERE
ADMINISTERED AS NEEDED WHEN BRONCHOPNEUMONIA DEVELOPED. SEVERE
RESPIRATORY INJURY WITH CONGESTION, INFILTRATION, AND DYSPNEA WAS
TREATED WITH ENDOTRACHEAL INTUBATION AND ARTIFICIAL RESPIRATION AS
NEEDED. BONE MARROW SUPPRESSION: WHEN LEUKOCYTE COUNTS DROPPED
BELOW
1,200, LEUKOCYTE TRANSFUSIONS WERE ADMINISTERED. IF ISOLATED
LEUKOCYTES WERE NOT AVAILABLE, WHOLE BLOOD TRANSFUSIONS WERE
ADMINISTERED. THESE PATIENTS WERE ISOLATED AND GIVEN BROAD SPECTRUM
ANTIBIOTICS. GENERAL MEASURES: INTRAVENOUS (IV) FLUID REPLACEMENT,
IV
GLUCOSE, AND IV HYPERALIMENTATION THERAPY WERE USUALLY REQUIRED AS
A
RESULT OF PERSISTENT NAUSEA, VOMITING, AND DIARRHEA THAT BEGAN
WITHIN
HOURS OF EXPOSURE AND CONTINUED FOR DAYS. PARENTERAL ANTIBIOTIC
TREATMENTS USED FOR SEPTIC SHOCK INCLUDED AMPICILLIN (6 TO 10 GRAMS
PER 24 HOURS), CHLORAMPHENICOL (4 TO 6 GRAMS PER 24 HOURS),
GENTAMICIN (80 MILLIGRAMS/3 TIMES PER DAY), OR CARBENICILLIN (25 TO
30 MILLIGRAMS PER 24 HOURS). THE USE OF STEROID THERAPY IN THE
TREATMENT OF SEPTIC SHOCK WAS HIGHLY CONTROVERSIAL BECAUSE OF RISK
OF
ADVERSE EFFECTS. EUROPEAN HEALTH CARE PROFESSIONALS INDICATED THAT
THIS TREATMENT PROTOCOL WAS RELATIVELY EFFECTIVE. 
[B.6.]?

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