Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Events
Recognition
CBRNE events often present as clusters of similar symptoms with a common time and place. Chemical agents cause rapid onset; biological agents have an incubation period and present days later; radiological events may show no immediate symptoms. Know the classic toxidromes: nerve agents (SLUDGE: salivation, lacrimation, urination, diarrhea, GI cramping, emesis; miosis, bradycardia) treated with atropine and pralidoxime; vesicants (blistering); blood agents (cyanide-bitter almond, treat with hydroxocobalamin); choking agents (pulmonary edema).
Decontamination
Decontamination (remove clothing, wash with soap and water) precedes treatment except for immediate lifesaving. Staff must wear appropriate PPE (Level A–D). A frequent trap: treating contaminated patients inside the ED and contaminating the facility-establish a decontamination corridor outside or at a controlled entrance.
Biological and radiological
Know Category A bioterrorism agents (anthrax, smallpox, plague, botulism, tularemia, viral hemorrhagic fevers) and that smallpox requires isolation and contact/droplet precautions. For radiation, understand time, distance, shielding, and that acute radiation syndrome requires high doses; potassium iodide protects the thyroid only against radioactive iodine.
Explosives
Recognize blast injury phases (primary barotrauma, secondary fragmentation, tertiary displacement, quaternary burns/other) and the risk of secondary devices.
Rule of thumb: If multiple patients present with the same unusual syndrome, think CBRNE and isolate/decontaminate before diagnosing.