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U.S. Army Medical Research Institute of Chemical 

Defense (USAMRICD)

FIELD MANAGEMENT

OF CHEMICAL CASUALTIES

 

HANDBOOK

Chemical Casualty Care Division

USAMRICD 

MCMR-UV-ZM 

3100 Ricketts Point Rd.

Aberdeen Proving Ground, MD 21010-5400 

SECOND EDITION

July 2000 
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

Introduction 1

Nerve Agents 3

Vesicants 27

Cyanide 43

Lung-Damaging Agents 48

Biological Agents 55

Field Management 79

Patient Decontamination 96

Chemical Defense Equipment 154

Appendices 184
INTRODUCTION

 With the end of the Soviet Union as a global superpower, the world as 

we knew it ended, and a long, drawn-out 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. This historic shift 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 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 ten 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 not as a one-time occurrence, but the first of many C/B threats the U.S. military will 

face. Throughout the world, nations 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

NERVE AGENTS

 Nerve agents are considered the primary agents of 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 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 is the product of the concentration (C) of a vapor or aerosol to 

which one is exposed and the time (t) to which one is exposed to that 

concentration (C). The units are usually mg/m3 for C and minutes for t. 

One can be exposed to a 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.

 

 The 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 is that causing severe effects, 

including convulsions.

 Table I shows the estimated LCt50, estimated ICt50, and Ct that will 

cause pinpointing of the pupils (miosis) in half of the population (MCt50). 

Units of the Cts are mg-min/m3. 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

mg-min/m3
Agent LCt50 ICt50 MCt50

GA 400 300 2-3

GB 100 75 3.0

GD 70 UNK <1.0

GF UNK UNK <1.0

VX 50 35 0.04

TABLE II. LD50 on Skin

Agent Amount

GA 1000 mg

GB 1700 mg

GD 50 mg

GF 30 mg

VX 10 mg

MECHANISM OF ACTION

 When a soldier is poisoned by a nerve agent, the action of the enzyme 

acetylcholinesterase is blocked. The normal function of 

acetylcholinesterase is to break down or hydolyze the chemical 

acetylcholine. Acetylcholine is a neurotransmitter, or messenger chemical. 

Nerve paths, which are divided into sections with gaps between the nerve 

endings and between the nerve ending and the target organ, are used to 

pass a command from the central nervous system to various organs. These 

gaps are crossed by acetylcholine, the messenger, which relays the 

command on to the next step and finally to the target. Under normal 

conditions, when the required action at each step is completed, the 

acetylcholine is broken down by the acetylcholinesterase, thus stopping the 

action. However, when a nerve agent inhibits the acetylcholinesterase, this 
enzyme cannot perform its normal function of hydrolyzing the 

acetylcholine. Acetylcholine then accumulates along the nerve path, and 

the target organ’s action continues uncontrolled. Muscles become 

hyperactive and twitch uncontrollably, and glands secrete copiously.

NERVE AGENT EFFECTS

 The nerve agent’s mechanism of action is to inhibit the enzyme 

acetylcholinesterase. Inhibition of this enzyme allows the neurotransmitter. 

acetylcholine, to accumulate at the nerve endings where it causes 

excessive stimulation of the target organ. The parts of the body that are 

affected by excessive acetylcholine accumulation are as follows:

 • Eyes

 • Nose (glands)

 • Mouth (glands)

 • Respiratory tract

 • Gastrointestinal tract

 • Cardiac muscle

 • Sweat glands

 • Skeletal muscle

 • Central nervous system

 The primary concern of the soldier medic/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 a vapor or liquid nerve agent exposure has on the soldier.

 Eyes. The eyes will be affected by direct contact with a nerve agent 

vapor or aerosol. 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. Pinpointing causes a complaint of dim vision that is more 

pronounced in low light conditions. Frontal headache, mild aching around 

the eye, or severe pains are common complaints in a soldier exposed to a 

moderate concentration of agent. 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 increase in aching behind the eyes due to light sensitivity.

 Nose and Mouth. The secretory glands of the nose and mouth are as 

sensitive or more sensitive to nerve agent vapor or aerosol than the 

eyes are. When 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. When exposed to a nerve agent vapor 

or aerosol, the nose will begin to run. 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, rhinnorhea may be severe.

 The mouth will secrete excessive amounts of saliva that may be 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 

acetylcholine 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 caused by stimulation 

of the airway glands by the excessive acetylcholine will compound 

breathing difficulty. These secretions can obstruct the airway and cause 

difficulty in moving air into and out of the lungs with prolonged expiration a 

noticeable effect.

 Gastrointestinal (GI) Tract. After exposure to a large but sublethal 

concentration of vapor, the soldier will complain of nausea and may vomit. 

Also, 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 not begin 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. The heart rate in nerve 

agent poisoning will not aid the soldier medic/combat lifesaver in choosing 

the care needed.

 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 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 (fasciculations). 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.

 Central Nervous System (CNS). 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.

 When exposed systemically to low amounts of nerve agent, the soldier 

may complain of generalized weakness.

 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

Mild

 Eyes Small pupils (miosis)

 Dim vision

 Headache

 Nose Runny nose (rhinnorhea)

 Mouth Salivation

 Lungs Tightness in the chest

 Time of onset: seconds to minutes after exposure

 Self-aid: 1 MARK I Kit

 Buddy-aid: stand by

Severe

 All of the above, plus

 Severe breathing difficulty or cessation of respiration

 Generalized muscular twitching, weakness, or paralysis

 Convulsions

 Loss of consciousness

 Loss of bladder, bowel control

 Time of onset: seconds to minutes after exposure

 Self-aid: none; soldier will be unable to help himself

 Buddy-aid: three MARK I Kits and diazepam immediately

TABLE IV. Liquid on Skin
Mild/Moderate

 Muscle twitching at site of exposure

 Sweating at site of exposure

 Nausea, vomiting

 Feeling of weakness

 Time of onset: 10 minutes to 18 hours after exposure

 Self-aid: 1-2 MARK I Kits, depending on severity of symptoms

 Buddy-aid: stand by

Severe

 All of the above, plus

 Breathing difficulty or cessation of breathing

 Generalized muscular twitching, weakness, or paralysis

 Convulsions

 Loss of consciousness

 Loss of bladder and bowel control

 Time of onset: minutes to an hour after exposure

 Self-aid: none; soldier will be unable to help himself

Buddy-aid: three MARK I Kits and diazepam immediately

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 understand 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. It must be stressed 

that timely and correct first aid actions are critical to enhance the 

casualty’s chances for survival.

 It must be emphasized during training that, when the effects progress 

to more than one organ system, the situation is moving rapidly 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 

diazepam autoinjector must be administered.

 Self- or buddy-aid must be promptly followed by Level 1 medical care.

SOLDIER MEDIC/COMBAT LIFESAVER TREATMENT OF

NERVE AGENT POISONING

 The Level 1 care provider (medic) 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

PROTECTIVE POSTURE

DURING TREATMENT

 First, protect yourself by donning MOPP Level IV. 
CASUALTY DECONTAMINATION

 

 Next, assist the casualty in performing decontamination of exposed 

skin in the following order:

 • face

 • neck area

 • chest area

 • abdomen

 • 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/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 sweat inhibition 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.

Mild and Improving Symptoms

 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.

 Pain in the eyes, twitching of the eyelids, redness, and miosis cannot 

be treated in the field setting by the soldier medic/combat lifesaver. 

However, 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. Diazepam 

should always be administered when the three MARK I Kits are given 

together. Additionally, more atropine (2 mg, Atropen) should be given 

every five minutes until secretions decrease or the casualty is 

breathing easier (or it is easier to ventilate him). 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 difficulty, 

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 rhinnorhea. 

Atropine (2 mg) should be administered at three to five-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.

 Discontinue atropine when:

 • Secretions of the mouth, nose, and lungs are minimized.

 • The casualty tells you that breathing is easier, or it is easier to 

administer assisted ventilation.

 Pralidoxime Chloride (2-PAMCl) in the autoinjector (600 mg, 2 ml) is 

the second drug for use in nerve agent poisoning cases. The 2-PAMCl 
removes nerve agent from the enzyme acetylcholinesterase. The 2-PAMCl 

(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 should be given immediately. Additional 2-PAMCl 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-

PAMCl autoinjectors should be administered. More than two sets of three 

2-PAMCl (six total) must not be used. Excess 2-PAMCl may harm the 

casualty by dangerously raising the blood pressure.

 Discontinue the use of 2-PAMCl after symptoms of respiratory distress 

have eased.

 Diazepam 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, 

and severe casualties cannot self-administer it. 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/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 ten minutes.

 • Turn the casualty on his/her side to facilitate breathing.

 • Pad areas to prevent other injuries.

 • Restrain if necessary.

 • If still convulsing after ten minutes, give the second 

diazepam autoinjector.

 Following the second injection (medical aid):
 • Observe the casualty for five to ten minutes.

 • If still convulsing after five to ten minutes, give a third 

diazepam autoinjector.

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.

PRETREATMENT

 The U.S. military has adopted the policy of pretreating soldiers against 

the nerve agent’s effect on acetylcholinesterase 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 should not be taken on a continuous basis for longer than 14 

days.

 Pyridostigmine bromide shields the acetylcholinesterase 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-PAMCl 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 
acetylcholinesterase but require many hours to do so, and the binding does 

not affect therapy.

 Pretreatment alone will not protect the soldier and does not reduce the effects from 

the nerve agent. Pretreatment is not an antidote. 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 is still warranted.
MUSTARD 

HD, L

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 –13oF. 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 “wargame” 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, M8 and 

M9 Chemical Detection Papers, the M256A1 Chemical Detection Kit, and 

the CAM.

 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 

CAM will detect mustard in concentrations of 0.03 mg/m3 to 30 mg/m3.

EFFECTS

 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 

nonmedical 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, or onion.

 • Color change in M9 detector tape.

 • Overt indications such as enemy helicopters spraying liquid, indirect 

artillery fire which detonates with dull or muffled explosions.

 • An oily feeling of “rain” as it impacts on exposed skin.

 • 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 because 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 EFFECTS ONSET
Eye Mild Tearing

Itchy

Burning

Gritty feeling

4-12 

hours

Moderate Above, plus

Reddening

Swelling of lids

Moderate pain

3-6 

hours

Severe Marked swelling of 

lids

Possible cornea 

damage

Severe pain

1-2 

hours

Airways Mild Runny nose

Sneezing

Nosebleed

Hoarseness

Hacking cough

12-24 

hours

Severe Above, plus

Severe productive 

cough

Shortness of breath 

(mild to severe)

2-4 

hours

Skin Erythema (redness)

Blisters

2-24 

hours

COMBAT LIFESAVER/MEDIC ACTIONS

 The initial medical treatment actions required by the combat 

lifesaver/soldier medic at the time of exposure is 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 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.

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.

 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 or 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 deroofed, 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. The area should then be 

covered by a petrolatum gauze bandage.

 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.
FIGURE

Estimation of body surface area by the use of the Rule of 9s. (Copied 

from FM 8-230)
CYANIDE

AC, CK

 

 

 
CYANIDE

(CYANOGENS; BLOOD AGENTS)

 The two agents of most concern in the 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 level.

PHYSICAL CHARACTERISTICS

 These agents have a very high vapor 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 vapor initially on the ground will quickly expand outward and up. The 

high volatility will, within a very short time, cause the vapor to lose its 

lethal concentration near the point of delivery. Within a short period of 

time, it will pose little threat downwind from the release point. It is 

because of this quick dissipation of the vapor that they agents are called 

nonpersistent.

DETECTION

 The only detection available to the soldier is the M256A1 Chemical 

Detection Kit Detector Sampler. The first indication of contact with the 

agent AC might be the smell of bitter almonds, or in the case of agent CK, 

the sudden irritation of the nose and throat.

EFFECTS

 Cyanide causes very few signs and symptoms in man. Death occurs 

within minutes after inhalation of a large amount. Inhalation of a 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 breathing

 • Dizziness

 • Nausea, vomiting

 • Headache

 • 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 seconds

 • 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.

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.

COMBAT LIFESAVER/MEDIC ACTIONS

 The rapid onset of symptoms may preclude the combat 

lifesaver/soldier medic from rendering aid. The symptoms shown in the 

table may occur within moments and lead rapidly to death.
 Rapid evacuation to Level 1 medical care and administration of the 

cyanide treatment set will improve the casualty’s chances for survival.

 If the casualty can still talk and walk without difficulty after exposure 

and presents at the battalion aid station (BAS), he will survive.
LUNG-DAMAGING AGENTS

 Lung-damaging agents are not commonly mentioned as major 

chemical threats. Phosgene, a lung-damaging agent, was a major threat in 

World War I until mustard was introduced. Phosgene and similar agents 

have not been used on the battlefield since, primarily because other 

agents are more effective.

 Although they are not considered threat agents, the military 

medic/combat lifesaver should know something about lung-damaging 

agents because the soldier might become exposed even though the enemy 

does not use the agents. Lung-damaging agents are hazards of the 

battlefield for other reasons. The primary lung-damaging agents and their 

possible sources are as follows:

 Phosgene. As stated earlier, phosgene was a major threat agent in 

World War I until mustard was introduced. Today it is an industrial hazard 

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 presenting 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).

 Perfluroisobutylene (PFIB). PFIB is given off when Teflon burns. 

Although we know that Teflon is used in many cooking devices, it is less 

commonly known that it lines the interior of many military vehicles, 

particularly armored vehicles. Fires in these vehicles release PFIB. 

Survivors of vehicle fires who are short of breath should be questioned 

carefully regarding their exposure to the smoke.

 Oxides of Nitrogen. Oxides of nitrogen, or NOx, are products of 

burning gunpowder. These substances can build up to high 

concentrations with repetitive firing of large artillery. Soldiers who 

become short of breath after heavy firing should be suspected of exposure 

to this lung-damaging agent.
 HC Smoke. HC smoke is used in training and for obscuration. It 

contains two components, including zinc, which can cause lung damage if 

inhaled in toxic amounts. Appropriate precautions must be taken when 

HC smoke is used.

DETECTION

 Phosgene smells like newly cut grass or freshly cut hay, but odor is 

not a reliable detection method. There are no field detection devices for 

these compounds.

PHYSICAL PROPERTIES

 Phosgene is very volatile. Under temperate conditions, it evaporates 

very quickly. Liquid phosgene may get on clothing and continue to release 

vapor. 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

 Phosgene is the most studied compound in this category. 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 the capillaries from the air in the 

alveoli, but when the membranes are damaged, they cannot do this. 

Blood, or at least the liquid part 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 oxygen 

depends 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 fluid 

from the blood, not from an external source. For this reason, phosgene 

poisoning is sometimes referred to as “dry land drowning.”

 Although the mechanism may not be exactly identical, the other 

compounds in this category cause very similar effects by a similar 

mechanism.

CLINICAL EFFECTS

 Very shortly after exposure to phosgene, the casualty may notice 

irritation of the eyes, nose, and throat. More commonly, there may be no 

effects during or immediately after exposure. The major effects from 

phosgene (and the other compounds), like the effects from mustard, do 

not occur until hours later.

 The casualty will notice 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. As 

the damage progresses, the dyspnea will become more severe, and soon a 

cough will develop. If the damage is severe, the casualty will start 

coughing up a 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 

compounds) will develop dyspnea 6 to 24 hours after exposure. He will 

notice if first after heavy exertion; however, later he will become 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 several hours after 

exposure. Within four to six hours after exposure, he will find it 

increasingly difficult to breathe, even at rest. He may not do well, even 
with intensive pulmonary care.

 The average casualty from a lung-damaging agent will be in between 

these two extreme cases. He will have the onset of dyspnea within six to 

eight hours after exposure and may progress to have dyspnea while at 

rest. However, with good pulmonary care beginning early after the onset 

of effects, he will recover completely.

FIELD CARE

 

 The medic/lifesaver should be alert to the possibility of exposure to a 

lung-damaging agent even when chemical agents are not being used. 

According to present threat estimates, exposure will be unlikely from the 

enemy. However, as noted above, exposure is likely from common 

military operations.

 A casualty who complains of shortness of breath should be 

questioned extensively about exposure to smoke from burning Teflon, 

gunpowder, or other chemicals.

 The most important things to do for such a casualty are to ensure he 

is free from contamination (he is out of the smoke or wearing his mask) 

and is kept completely at rest. Complete rest is extremely important. 

There were instances in World War I in which phosgene casualties who 

were breathing comfortably at rest collapsed and died after walking a few 

yards. Even a little exertion can greatly intensify the effects of these 

agents. A casualty who is short of breath requires assisted 

ventilation with oxygen, or oxygen alone.

 A dyspneic casualty must be evacuated as quickly as possible to a 

medical facility that can provide intensive pulmonary care. A casualty 

who becomes dyspneic within the first few hours after exposure will 

probably not survive, even with intensive care.
BIOLOGICAL AGENTS

 The potential use of biological agents on the future battlefield is based 

on numerous historical precedents. The earliest documented use of a 

biological agent was in the 6th century B.C. by the Assyrians. The 

Assyrians poisoned enemy water wells with rye ergot to induce severe 

gastrointestinal effects. The Black Plague that decimated Europe during 

the Middle Ages may have begun when the survivors of the siege of Kaffa 

returned to Europe. During the siege of Kaffa, the besieging Tartar army 

experienced an outbreak of bubonic plague, and in an effort to induce the 

surrender of Kaffa, hurled corpses of the bubonic plague victims into the 

city. This tactic resulted in the surrender of Kaffa and the introduction of 

the Bubonic Plague, which infected a portion of the defenders.

 The use of smallpox as a weapon has been well documented. The 

British army used smallpox against the Native Americans who were loyal 

to the French during the French and Indian War with devastating results. 

The American army, during the subjugation of the Native Americans of 

Great Plains, used smallpox infected blankets in the same way the British 

had and with similarly devastating results.

 The end of World War II brought the revelation of the intensive 

research effort by the Imperial Japanese army into the effective means of 

biological agent production, the medical effects of biological agent 

exposure, and the best method for delivering these agents to a target.

 The most recent indication of offensive biological warfare capability 

came from Team 7 of the United Nations Special Commission who 

conducted inspections of Iraqi biological warfare research and 

development. The Iraqi government announced that prior to Operation 

Desert Storm, research had been conducted into the use of Bacillus 

antracis (anthrax), botulinum toxins, and Clostridium perfringens. Thus, 

had the air war not been so effective, Coalition ground forces may have 

faced biological warfare agents.

CLASSIFICATION OF

BIOLOGICAL AGENTS

 The U.S. classifies biological agents into three general categories – 

pathogens, toxins, or other agents of biological origin.
 • Pathogens are disease-producing microorganisms such as 

bacteria, mycoplasma, rickettsia, fungi, or viruses. These microorganisms 

may be naturally occurring or “engineered” by manipulation of recombinant 

deoxyribonucleic acid (DNA).

 • Toxins are poisons naturally produced through the activities of living 

organisms. Toxins can be produced by plants, microorganisms, and 

animals. Due to the feasibility of using some form of biochemical 

engineering to produce toxins, the U.S. has also classified toxins as a 

biological agent. Examples of these naturally occurring organic chemical 

compounds are proteins, polypeptides, and alkaloids.

 • Other agents of biological origin are a class of biological agent that 

can be found in the human body in very small quantities, but if introduced 

in large quantities, causes severe adverse effects or death. The most 

notable examples of this class are the bioregulators/modulators (BRM). 

The BRMs can be small molecules of peptides that act as neurotransmitters 

and/or modifiers of neural responses.

CHARACTERISTICS OF 

BIOLOGICAL AGENTS

 The qualities that are most advantageous to have in a biological agent 

and in the target population are high infectivity or toxic properties, desired 

contagiousness, severity of effects, short incubation period, and 

susceptibility of target population. The identification of biological attack 

and identification of a specific agent present serious problems in a tactical 

situation.

 • High infectivity or toxic properties. A highly desirable characteristic 

would be the ability of the agent to produce an effect with the smallest 

number of organisms or the least amount of agent (e.g., toxins in gram 

weights) possible.

 • Desired contagiousness. Being able to predict the agent’s effect on 

the target population, the spread of the agent out of the target area, and 

the length of the agent’s ability to cause the desired effect are all critical 

criteria of a biological agent. Although the ability of an agent to cause 

contagious transmission between humans has been seen as an undesirable 

trait, the use of these types of agents in “ethnic cleansing” style 

operations cannot be dismissed.
 • Severity of effects. The use of a biological agent may be 

contemplated to cause only incapacitating effects in the target 

populations, or devastating lethal effects may be desired. The 

predictability of the end result of a biological agent release is critical.

 • Susceptibility of target population. The introduction of any 

biological organism into a population that has little or no resistance or has 

not been immunized will wreak havoc, even if the selected agent causes 

only incapacitating effects.

TACTICAL AND MEDICAL IMPLICATIONS OF 

BIOLOGICAL WARFARE

 The tactical and medical impact of biological weapons employment 

can be minimized if medical personnel are familiar with the operational 

aspects of biological agent exposure. The operational aspects are listed 

below.

 

 • Potential methods of dissemination

 • Routes of entry

 • Protection

 • Decontamination

 • Detection

 The medical aspects of biological agent exposure are as follows:

 • Potential biological agents

 • Symptoms of exposure

 • Transmission of infectious agent

 • Incubation period of infectious agent

 • Treatment of disease

 • Vaccination

OPERATIONAL ASPECTS OF BIOLOGICAL WARFARE

 Potential methods of dissemination. The ability to produce biological 

agents and the means of employment are feasible with minimal resources. 

The traditional methods of dissemination are by aerosol, large liquid drops, 

dry powders, and arthropod vectors. Employment of one or more of these 
methods is not beyond the capability of most moderately industrialized 

nations. Also, dissemination by covert means, whether in a tactical 

environment or by terrorists, must also be considered.

 • Aerosol dissemination. A live microorganism cultured in a moist 

environment can be introduced into the air in a wet aerosol. The use of an 

aerosol is considered more likely than any of the remaining methods.

 • Large liquid drops (cutaneous). Using large liquid drops of agent, 

usually toxins will cause ground contamination similar to that of a 

persistent chemical agent.

 • Dry powder. By employing a process similar to freeze drying, 

microbiological materials can be stored as a dry powder. This dry powder 

state causes a drastic increase in the stability of the agent in the open 

environment and makes dissemination much easier. In addition to dry 

powder, a pathogen can be protected by micro-encapsulation, and its use 

would be similar to a dry powder.

 • Arthropod vector. This method of dissemination is the least likely to 

be used because of the cost of producing the vectors, controlling the 

vectors after their release, and natural predators that might destroy them. 

However, a vector might be able to circumvent protective clothing and 

mask.

 • Covert. The use of a biological agent by a terrorist group is a 

potential threat. Any of these dissemination methods might be used 

against large population centers or military or political targets.

 Routes of entry. Generally speaking, certain methods of dissemination 

are designed to achieve a desired effect through one primary route of 

entry. Effects that are achieved as a result of a secondary route of entry 

are considered a bonus. The physical form in which the biological agent is 

disseminated can be generally associated with a particular route of entry.

 • Respiratory. Live microorganisms that remain suspended in the 

air in a wet aerosol pose an extremely effective method of introducing a 

disease into the target organism through the respiratory tract. Biological 

agents in a dry powder and microencapsulated can also be used to infect 

the target organism or population through a respiratory means.

 • Cutaneous. The use of large liquid drops could deny terrain and 

cause secondary effects in humans who enter the area unaware of the 

threat through cutaneous means or by ingestion. Biological agents in a dry 

powder state and micro-encapsulated can also be used to infect the target 

population through a cutaneous means.

 • Ingestion. The introduction of a biological agent into a drinking 
water supply or food production facilities could have a significant impact 

on a target population. The use of a dry powder or micro-encapsulated 

pathogen against a target population, although employed primarily for 

respiratory effects, has the additional bonus effect of infecting the target 

organism by being swallowed or introduced through touch.

 Protection. The topic of protection is fairly simple when limited to the 

physical protection afforded by the Battle Dress Overgarment (BDO), 

chemical protective boots and gloves, and M40 series of protective 

masks. When fully encapsulated at MOPP IV, the soldier has complete 

respiratory and physical protection against all known biological agents.

 The first action that all soldiers can take to better protect themselves 

from a biological agent is to understand and maintain good personal health 

while in garrison and in the field. At a minimum, this should include 

maintaining good physical fitness and proper weight, keeping 

immunizations up to date, practicing good personal hygiene, following field 

sanitation guidelines, and training on individual and collective 

nuclear/biological/

chemical (NBC) defense tasks.

 Prior to deployment, medical, chemical, and command staffs must 

completely understand the threat’s ability in order to conduct biological 

warfare operations.

 Detection. The U.S. Army has not fielded equipment capable of 

detecting and identifying biological agents; we have no remote biological 

agent detection capability. This lack of equipment increases the soldier’s 

need to be aware of certain indicators (listed below) that suggest an attack 

is occurring or has already taken place.

 • Mist or fog sprayed by slow moving aircraft or helicopter.

 • Aerial bombs that pop, rather than explode.

 • Artillery shells that detonate with less powerful explosions than HE 

rounds.

 • Mysterious illness in both the soldier and civilian population that 

approaches epidemic numbers.

 • Large numbers of dead wild and domestic animals.

 • Unusual concentrations of insects or sighting of insects not normally 

found in the geographical region.
 Some of these indicators are the same as those that could be found 

after a chemical attack, but with one critical difference. After taking 

immediate action to protect themselves, soldiers will be unable to detect 

and identify chemical agents vapors or liquids. In the absence of 

reactions, a NBC-4 (Biological) report must be sent to higher headquarters.

 Decontamination. Biological agents pose a contact hazard to soldiers 

by direct deposit on the skin and by indirect transfer from a contaminated 

surface to the soldier’s skin, mouth, nose, or respiratory tract. When the 

soldier suspects that he has come in contact with contamination from a 

biological attack, he must decontaminate immediately.

 Decontamination of exposed skin can be accomplished with the 

M291 SDK. When biological contamination is suspected, a 0.5% chlorine 

solution or warm soapy water can be used to remove the suspected agent 

from the skin.

 Performing operator spray-down with the M11 or M13 portable 

decon apparatus and hasty decontamination with power-driven 

decontamination apparatus will flush biological agents from the surface of 

equipment and lower the direct and indirect transfer hazard.

 The critical point to understand about biological agent contamination is 

not that the decontamination process destroys the agent, but that it is 

physically removed from the skin or equipment. Removal of the agent 

significantly decreases the hazard to the soldier.

MEDICAL ASPECTS OF 

BIOLOGICAL AGENT EXPOSURE

 Potential biological agents. The biological agents discussed in this 

section are listed below. These agents can be disseminated as an 

aerosol to specifically induce an effective dose via the respiratory tract.

 • Smallpox

 • Tularemia

 • Cholera

 • Bubonic Plague

 • Anthrax
 • Botulism

 • Staphylococcal Enterotoxin B (SEB)

 • Toxins

 The following topics will be covered for each potential biological 

agent:

 • Symptoms of exposure

 • Transmission of infectious agent

 • Incubation period of infectious agent

 • Treatment of disease

 • Vaccination

NOTE: Page numbers in the following text refer to FM 8-33, Control of 

Communicable Diseases in Man, 16th Edition, The American Public Health 

Association, Washington, D.C., 1995.

Smallpox

 This systemic viral disease was declared globally eradicated in 1979 

by the World Health Organization. The only known samples of the diseasecausing Variola Virus are in the “hot” labs at the Centers for Disease 

Control (CDC) in Atlanta, GA, and in the CDC’s Russian counterpart in 

Moscow. Vaccines are stockpiled. (page 425)

 Symptoms of exposure are sudden onset of fever, headache, severe 

backache, malaise, rigors, and occasionally, abdominal pain. After two to 

three days, temperature falls and a rash appears. The rash develops into 

macules, papules, vesicles, pustules, and finally, scabs. The casualty is 

infectious during the entire term of the disease, which is usually three to 

four weeks. The first work is the worst.

 Transmission of infectious agent. Transmission of the disease is by 

respiratory discharge, bed linens, the patient’s clothing, or skin contact 

with the scabs. Complete sterile handling should be enforced with 

complete quarantine for up to four weeks after the rash appears.

 Incubation period of infectious agent averages from 7 to 12 days, with 

10 to 12 days before onset of illness, and 2 to 4 days more to onset of 

rash.
 Treatment of disease: none, other than supportive care.

Tularemia

 Tularemia is a zoonotic, bacterial disease with a variety of clinical 

manifestations related to route of introduction and the virulence of the 

disease agent. Stockpiles of vaccines for large usage do not exist. The 

only vaccine presently available is at the U.S. Army Medical Research 

Institute of Infectious Diseases, Fort Detrick, MD. (page 501)

 Symptoms of exposure. Usually presents as an indolent ulcer at the 

site of introduction of the organism with swelling of the regional lymph 

nodes. There may be only one or more enlarged and painful lymph nodes 

that may rupture and leak. Ingestion of organisms may produce a painful 

pharyngitis, abdominal pain, diarrhea, and vomiting. Inhalation of 

organisms may cause a pneumonia-like illness or systemic, febrile, 

septicemic syndrome. All forms may be complicated by pneumonia.

 Transmission of infectious agent. The bacteria which causes 

Tularemia naturally infects numerous wild animals, especially rabbits, 

hares, muskrats, beavers, and some hard ticks. It is transmitted to man 

through the bite of arthropod vectors, though ingesting or handling 

contaminated water and flesh, or by inhaling contaminated dust.

 Incubation period of infectious agent ranges from 1 to 14 days, 

usually 3 to 5 days.

 Treatment of disease. Streptomycin or gentamycin given for 7 to 14 

days are the drugs of choice; the tetracyclines and chloramphenicol are 

bacteriostatic and effective when continued for no less than 14 days. 

Aspiration, incision and drainage, or biopsy of an inflamed lymph node can 

spread the infection and must be covered with prompt and specific 

antibiotics. 

Cholera

 Cholera is an acute, bacterial enteric disease. Vaccines of moderate, 

short-term effect (three to six months) are stockpiled. (page 97)
 Symptoms of exposure are sudden onset of profuse, painless, watery 

stools, occasional vomiting, rapid dehydration, acidosis, and circulatory 

collapse.

 Transmission of infectious agent. The primary sources are waterborne contamination, fecal matter, or the ingestion of contaminated foods.

 Incubation period of infectious agent is a few hours to five days; 

usually two to three days.

 Treatment of disease. Prompt fluid therapy with volumes of 

electrolyte solution adequate to correct dehydration, acidosis, and 

hypokalemia is the keystone of cholera treatment. Mild to moderate 

dehydration should be treated with oral rehydration solutions; severe 

dehydration should be treated with IV. Tetracycline or TMP-SMX shortens 

the duration of diarrhea and reduces the volume of fluid lost.

Plague

 Plague is a specific zoonosis involving rodents and their fleas, which 

transfer the bacterial infection to people. Vaccination is protective against 

the bubonic form of the disease, but not against the primary 

respiratory form. (page 355)

 Symptoms of exposure. Initial signs and symptoms may be 

nonspecific with fever, chills, malaise, myalgia, nausea, prostration, sore 

throat, and headache. Commonly a lymphadenitis develops in those lymph 

nodes receiving draining from the site of the fleabite (Bubonic Plague). 

Bubonic Plague can progress through the bloodstream to diverse parts of 

the body to cause meningitis, shock, bleeding, and pneumonia (secondary 

pneumonic plague). 

 Transmission of infectious agent. The most frequent source of human 

exposure is the bite of infected fleas. Other important sources include 

handling of tissues of infected animals. Persons with secondary 

pneumonic plague can spread the disease from person to person through 

respiratory droplets to cause primary pneumonic or pharyngeal plague.
 Incubation period of infectious agent is from one to seven days but 

may be longer in immunized individuals; two to four days for primary 

pneumonia.

 Treatment of disease. Streptomycin is the drug of choice; gentamycin 

is an alternate. Tetracyclines and chloramphenicol are other alternatives. 

All are effective if used early in the course of disease.

Anthrax

 Anthrax is an acute bacterial zoonotic disease that usually affects the 

skin but may also involve the mediastinum or intestinal tract. Vaccines are 

stockpiled. (page 20)

 Symptoms of exposure. Skin exposure: itching of exposed 

skin surface, followed by a lesion that at first becomes papular, then 

vesculated, and develops into a depressed black eschar in two to six days. 

This eschar is usually surrounded by mild to moderate edema and 

sometimes small secondary vesicles. The inhaled anthrax presents 

symptoms resembling a common upper respiratory tract infection (URI) at 

first, with acute symptoms of respiratory distress following. X-ray 

evidence of mediastinal widening, fever, and shock follow in three to five 

days, with death ensuing shortly thereafter. Ingested anthrax presents 

with abdominal distress followed by fever, signs of septicemia, and then 

death in a typical case.

 Transmission of infectious agent. Cutaneous exposure occurs when 

handling dying infected animal tissue, contaminated hair, wool, hides, or 

products made from infected, slaughtered animals. Inhalation anthrax 

results from inhaling anthrax spores. Intestinal exposure is caused by 

ingestion of infected meat.

 Incubation period of infectious agent is from a few hours to 7 days, 

with most cases occurring within 48 hours after exposure.

 Treatment of disease. Penicillin is the drug of choice and is given for 

five to seven days. Tetracyclines, erythromycin, and chloramphenicol are 

also effective.

Rickettsia – Query Fever (Q Fever)
 Q Fever is an acute rickettsia disease characterized by fever. Vaccines 

are not stockpiled for general use, but can be obtained from the U.S. Army 

Medical Research Institute of Infectious Diseases, Fort Detrick, MD. (page 

281)

 Symptoms of exposure are sudden onset of headache behind the 

eyeballs, general weakness, and severe sweats, chills, and malaise.

 Transmission of infectious agent: carried by domestic animals (cattle, 

sheep, goats) and ticks. Spread by airborne dissemination of infected 

excreta and also by direct contact with infected animal products (wool, 

straw, milk) and excreta.

 The incubation period of infectious agent depends on the size of the 

infecting dose; however the usual incubation period is 2 to 14 days. Q 

Fever generally occurs as a self-limiting, febrile illness lasting two days to 

two weeks.

 Treatment of disease: tetracyclines administered orally and continued 

for several days after the patient is afebrile; reinstitute if relapse occurs.

Toxins

 Toxins are chemical compounds of biological origin that may be lethal 

or incapacitating on skin contact or when inhaled or ingested. They are 

high molecular weight proteins capable of reacting with the human immune 

system antibodies. The recognition of a toxin attack and identification of a 

specific toxin present serious problems in a tactical deployment.

 Sources of toxins. Toxins are naturally produced by bacteria, marine 

plankton (dinoflagellate), marine animals, plants, and fungi.

 Mechanism of action. Generally speaking, toxins affect the body 

through mechanisms which cause reactions similar to nerve, blister, 

vomiting, and choking agents.

 • Cytotoxin. Toxins that destroy or interfere with metabolic 

processes fall into this general description. A cytotoxin can affect the 

digestive tract, respiratory system, circulatory system, or the skin. Some 

effects may appear associated with blister, choking, or vomiting agents.
 • Neurotoxin. The neurotoxins that are postsynaptic 

acetylcholinesterase inhibitors will induce nerve agent like symptoms. 

These postsynaptic neurotoxins cause ion channel permeability. 

Convulsions and pinpointing of pupils are the most noticeable symptoms. 

Some neurotoxins that are presynaptic inhibitors block the release of 

acetylcholine. Usually the symptoms associated with these presynaptic 

inhibitors are flaccid or limp paralysis, blurred vision, light sensitivity due to 

dilation of pupils, tremors, and confused behavior.

 

 Medical care. In a field environment, only supportive care is available. 

The critical fact to remember is that antitoxins for many toxins are 

available, but specific identification of the toxin must occur, and this will 

not happen in a field setting. If toxin exposure is suspected, evacuation 

must occur as rapidly as possible.

Botulism

 Botulism is a severe intoxication resulting from ingestion of botulism 

toxin. Ingestion usually occurs as a result of eating contaminated food.

 Symptoms of exposure. The symptoms are related primarily to effects 

on the nervous system. Blurred or double vision, difficulty swallowing, and 

dry mouth are the most common initial complaints. After the initial 

symptoms, an alert casualty can experience progressive, flaccid 

paralysis that moves downward through his body affecting the entire body 

evenly. The casualty may also experience vomiting, constipation, or 

diarrhea.

 Transmission of infectious agent. The classic method of transmission 

of the botulism toxin is by ingesting contaminated food. The toxin grows 

in airtight packaging containing food products that have been improperly 

processed. Boiling destroys the toxin. No known person-to-person 

transmission of this toxic has ever been documented.

 Incubation period of infectious agent. Neurological symptoms can 

appear within 12 to 36 hours and up to several days after ingestion of the 

toxin. The shorter the onset of symptoms, the more severe the disease 

and the higher the fatality rate.

 Treatment of disease: intravenous and intramuscular administration as 
soon as possible of trivalent botulinum anti-toxin (types A, B, and E). The 

most critical aspect of effective treatment is placing the casualty in an 

intensive care unit so that respiratory failure, the usual cause of death, can 

be properly managed should it occur. The anti-toxin is available from the 

Centers for Disease Control (CDC).

Staphylococcal Enterotoxin B (SEB)

 The toxin SEB is one of several exotoxins (toxins found outside the 

bacterial cell) that are produced by Staphylococcus aureus. When 

ingested, SEB can produce symptoms of food poisoning. When inhaled, 

SEB causes a reaction described below which causes significant morbidity 

and potential mortality. (page 402)

 Symptoms of exposure. Symptoms of respiratory exposure to SEB 

begin within 3 to 12 hours. The casualty can experience sudden onset of 

fever, chills, headaches, muscle pain, and nonproductive cough. When a 

severe exposure occurs, the casualty will have difficulty breathing and 

experience pain behind the sternum. Fever may reach 103oF to 106oF and 

last two to five days. Cough can last one to four weeks.

 Transmission of infectious agent. Soldiers may be exposed to SEB 

after an aerosol attack because of the relative stability of the SEB toxin in 

air.

 Incubation period of infectious agent. Symptoms occur within 3 to 12 

hours after inhalation.

 Treatment of disease. Treatment is limited to 

supportive care, including treatment of shock and lower hypoxia.

 Trichothecene mycotoxins. These toxins act immediately on the 

eyes and skin by causing irritation, followed rapidly by death or a 

prolonged period of continued illness with death occurring weeks later. 

Death is usually caused by bone marrow suppression, liver failure, or 

internal bleeding. Within 10 to 30 minutes after exposure, the individual 

experiences vomiting, dizziness, rapid heart beat, and chest pain. Within 

hours, the individual can experience bloody vomiting, bloody diarrhea, and 

if the exposure was on the skin, blistering.
Other Toxins

 • Saxitoxin. Produced naturally by the dinoflagellate plankton, this 

toxin kills within ten seconds.

 • Tetrodotoxin. Produced by the newt, puffer fish, and blue-ringed 

octopus, this toxin is a rapid, lethal, neuromuscular blocker that acts 

within five minutes to one hour.

 • Palytoxin. Produced by the coelenterate (soft coral animal), this 

toxin is a very rapid-acting, lethal neurotoxin that acts within five minutes. 

Symptoms are rapid muscle paralysis and collapse.

 • Ricin. Produced from the castor bean seed, the activity of this toxin 

is delayed by 1 to 12 hours, but is a lethal cytotoxin that causes 

weakness, fever, cough, vomiting, and severe cramps. Ricin has been 

characterized as being 100 times more deadly than cobra venom.

 • Mycotoxins (fungus toxins). Typical of this group of toxins is the 

trichlothecene group that contains T2, nivalenol, and deoxynivalenol. 

Severe poisoning of these toxins causes ataxia, shock, collapse, vomiting, 

diarrhea, and death.
FIELD MANAGEMENT OF CASUALTIES 

ON THE CONTAMINATED BATTLEFIELD

 The single most important concern for the combat lifesaver/soldier 

medic during operations on the contaminated battlefield is the timely and 

proper management of casualties. 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 selfaid or buddy-aid and decontamination.

 • Training the combat lifesaver and soldier medic to correctly identify 

any chemical agent based on observed signs or symptoms experienced by 

the casualty.

 • Complete understanding of the severity of exposure based 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 and/or poisoned casualties for mass casualty 

situations.

 • Correct treatment of agent effects, 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.

 • Identification of required casualty decontamination, both at the 

initial treatment location and at the MTF.

 • Complete understanding of ambulatory and litter casualty 

decontamination operations at the MTF.

 • Identification of personnel limitations and equipment shortfalls in 

support of casualty decontamination and treatment.

 • Understanding the impact of contaminated and/or decontaminated 

casualties on evacuation operations.

 Once deployment is complete, the combat lifesaver/soldier medic 

must be aware of additional elements that also impact on management 

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 gathered after the 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 

operations.

 All of these elements, when considered together, allow the combat 

lifesaver/soldier medic to take a proactive readiness posture for 

management operations on the contaminated battlefield. The following 

sections will expand on these elements.

TRAINING

 All individuals, both medical personnel and nonmedical augmentees, 

who are involved in the patient decontamination effort must be trained in, 

or show proficiency in the following:

 • Drink from canteen while wearing your protective mask.

 • Recognize signs or symptoms of heat injury.

 • Recognize liquid chemical agent.

 • Detect and identify chemical agent using M8 Chemical Detection 

Paper or M9 Chemical Detection Tape.

 • Evaluate a casualty.

 • Prepare decontamination solutions.

 • Recognize signs or symptoms of chemical poisoning.

 • Administer nerve agent antidote to self (self-aid).

 • Administer nerve agent antidote and CANA to buddy (buddy-aid).

 • Transport litter casualties using both two-man and four-man litter 

carries.

 • Move casualty using logroll method.

 • Remove litter casualty’s contaminated clothing.

 • Perform litter casualty’s skin decontamination.
 • Use Chemical Agent Monitor (CAM).

 • Wound or injury management during litter and ambulatory 

decontamination.

 • After initial treatment, route casualties to litter patient decon area.

 • Remove ambulatory casualty’s contaminated clothing.

 • Monitor litter and ambulatory casualties for residual contamination 

after completion of decontamination process.

 • Prepare the M8A1 Automatic Chemical Agent Alarm (ACAA) and/or 

the M22 ACADA for operation.

 • Place the M8A1 ACAA and/or the M22 ACADA in operation.

 • Use the M256A1 Chemical Detection Kit.

 • Conduct unmasking procedures using the M256A1 Chemical 

Detection Kit.

 • Decontaminate open wounds.

 • Identify chemical agent causing signs or symptoms.

 • Treat chemical agent poisoning.

 • Describe and perform emergency medical treatment required to 

stabilize a casualty for the decon process.

 • Identify triage requirements based on signs or symptoms.

 The list above is suggested as a starting point 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 

personnel. However, some tasks are applicable to all and should be 

taught to all.

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 Detection tape 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 occur in relation to the 

time of detection? (i.e., skin decon, flushing eyes, etc.)

 • What level of MOPP was the casualty wearing at the time of 

exposure?

 • If not at any MOPP level, did the casualty don the MOPP over his 

exposed BDU?

After Onset of Symptoms:

 • Were MARK I Kits and/or diazepam used, and if so, when 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?

 • How long since the last onset of symptoms?

 • What symptoms has the casualty experienced?

 • What activities has the individual engaged in since the initial 

exposure?

 • What was the casualty doing when the symptoms began?

 • 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 

treatment effort at the MTF. Obtaining as complete a history as possible, 

coupled with unit chemical survey data, will enhance the triage and 

treatment effort for the casualty at the MTF. Providing too much 

information on the field medical card is far better than not providing 

enough.

 The combat lifesaver/soldier medic must also be aware 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.

 • To what extent was the unit surprised by the encounter, regardless 

of how the encounter happened?

 • Was the encounter a result of movement through the chemical 

contamination or a result of direct attack on the unit?
 • Was movement through the chemical 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 vapor form only, liquid 

form, or a combination of both?

 • Has the unit’s chemical survey team verified the agent?

 Understanding the circumstances surrounding the production of the 

casualty will help the combat lifesaver/soldier medic in the casualty’s 

triage, treatment, and evacuation.

CASUALTY EVALUATION

 The combat lifesaver/soldier medic will encounter seven general 

categories of casualties on the contaminated battlefield. They are listed 

below.

 • Poisoned and contaminated

 • Poisoned and not contaminated

 • Conventionally wounded, poisoned, and contaminated

 • Conventionally wounded, poisoned, and not contaminated

 • Conventionally wounded, not poisoned, and contaminated

 • Conventionally wounded, not poisoned, and not contaminated

 • Psychological

 This list may seem obvious at first, but it is presented for a reason. 

The proper management of casualties must begin with an in-depth 

understanding of the various types of casualties and the specific treatment 

needs of each.

 When the combat lifesaver/soldier medic is confronted with one or 

more casualties on the contaminated battlefield, a deliberate decisionmaking process must begin. Taking deliberate steps to evaluate the 

casualty, regardless of condition, will allow him to be triaged into the 

correct category. This, in turn, will optimize the casualty’s care and his 

chance of eventual return to duty.

 At times, the combat lifesaver will need to decide which course of 

action to follow. The deciding factor will always be to treat the condition 

that poses the most immediate threat to life and limb. 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 injury in order to provide the most orderly, timely, and 

efficient use of medical resources 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 overwhelm medical resources, triage is not necessary.

 During a mass casualty situation, the goal is to provide the best care 

for the most casualties. Ideally, care would be provided first for those 

who are in immediate danger of dying because of their wounds. However, 

this can be done only if resources to provide this care are available and if 

the care will not require an undue amount of time that might be spent 

caring for other casualties.

 Guidelines for surveying a chemical casualty prior to triage are 

provided below. 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 accordingly.

Surveying the Casualty

 • Observe the self-aid or buddy-aid rendered for both conventional 

wounds and/or chemical agent poisoning.

 • Question the casualty’s buddy regarding the following:

 -- Type of agent and how it was identified

 -- Initial signs/symptoms

 -- Conventional wounds noted in casualty by buddy and buddyassisted first aid rendered

 -- Prior treatment for suspected chemical poisoning 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.
 • Observe the casualty’s M9 Chemical Agent Detector Paper for pink, 

red, reddish brown, or purple color changes. The generation of a wound 

at the time of chemical agent exposure may also result in liquid agent 

being deposited into the wound, in which case the liquid chemical agent 

probably has begun to absorb into the tissue. Exposed skin may also be 

absorbing agent.

 • Observe the casualty closely for small liquid droplets on butyl 

rubber surfaces (protective boots, gloves, mask hood, and helmet cover). 

Survey the casualty’s weapon for liquid droplets. Place M8 Chemical 

Detection Paper on the liquid. Refer to the M8 booklet cover for liquid 

agent identification based on color change.

 (Perform this step only if evidence of liquid chemical agent 

contamination is observed on the M9 paper, BDO, or equipment and has 

not been identified by the section or platoon chemical survey team. This 

step can wait until triage action on the casualty is complete and must be 

performed by the combat lifesaver/soldier medic. Results must be written 

on the Field Medical Card.)

 • 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 symptoms.

 -- 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 symptoms:

 -- “Sweating” through the overgarment or through exposed skin; 

this could indicate a skin exposure to liquid nerve agent under the 

”sweat.”

 -- Labored breathing

 -- Coughing

 -- Vomiting

 • Check pulse by placing fingers on carotid. This might be done by 

feeling through the hood. If no 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. After unfastening the 

arm strap of the hood and unzipping the hood, the tactile gloves and the 

skin on the neck should 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 immediate, delayed, minimal, and expectant.

 • 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 

echelon (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 may 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 poisoning 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).

 -- 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.

 • DELAYED

 A delayed casualty is one who needs further medical care but can 

wait for that care without risk of compromising his successful recovery. 
He may require extensive surgical procedures and long-term 

hospitalization, but he is presently stable and requires no immediate care. 

A casualty with a leg wound or fracture is an example of a conventional 

casualty who would be delayed. A casualty recovering from severe nerve 

agent poisoning will be delayed. Most casualties with vesicant burns will 

be delayed.

 • MINIMAL

 A casualty who would be classified as minimal is one who (1) can 

be treated by a medic and does not need to see a physician or physician’s 

assistant, (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.

 -- Blister agent casualties with a small amount of erythema or a 

few small blisters in noncritical areas.

 • EXPECTANT

 The expectant casualty is one for whom medical care cannot be 

provided at the medical treatment facility and cannot be evacuated for 

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 treatment/evacuation based on established 

priorities for treatment.

 -- Casualties who have been classified as “IMMEDIATE” are 

transferred to the contaminated medical treatment area for stabilization. 

After stabilization, these casualties are taken to the litter patient 

decontamination area.

 -- Casualties who have been categorized as “DELAYED” may or 

may not require treatment in the collective protection treatment area 

before evacuation. If they need to enter this clean area for treatment, 

they are sent to the ambulatory or litter decontamination line, whichever is 

appropriate. If they do not need treatment in this area, they are sent 

directly to the evacuation holding area.
 -- Casualties who have been categorized as “MINIMAL” may 

receive treatment in the collective protection treatment shelter or the 

contaminated emergency treatment area. If they can be treated in the 

contaminated emergency treatment area and they have no break in their 

BDO, they will be returned to duty from this area. If they require 

treatment in the clean treatment area, they will need to be sent to one of 

the decontamination areas before entry into the area. If there is a break in 

their BDO, they will need resupply. They must go through 

decontamination to the clean treatment area for resupply (resupply will be 

their own second BDO; if they do not have a second BDO, they will 

require evacuation for resupply).

 -- Casualties who have been categorized as “EXPECTANT” will be 

transferred to designated contaminated holding areas. These casualties 

will be constantly monitored while in this area and provided with available 

comfort measures.
AMBULATORY AND LITTER

 PATIENT DECONTAMINATION

 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 aggressive execution, 

an effective litter patient decontamination procedure can be established.

KEY ELEMENTS

 When planning for patient decontamination operations, the following 

key elements must be considered:

 • Wind direction

 • Security of decon site

 • Access control to decontamination site

 • Equipment/supplies

 • Personnel requirements

 • Work/rest considerations

 • Establishing a patient decontamination station

 • Litter casualty decontamination procedures

 • Ambulatory casualty decontamination procedures

 • Disestablishing a patient decontamination station

Wind Direction

 Wind direction and speed are critical factors in planning because of 

the vapor hazard that will be present downwind from the Chemical 

Decontamination Center (CDC). When planning for patient 

decontamination, the assumption must be made that, after 

decontamination operations begin, chemical agents in vapor and liquid 

form will be present in the patient decontamination site (i.e., open dirty 

dump, patient arrival and triage area, etc.). Consideration must be given 

to the effect that wind-driven chemical agent vapors have on other unit 

operations or on other co-located units. A valid concern of other unit 

commanders and your commander will be the uncontrolled effect vapors 

have. This one factor may cause you to plan for decontamination outside 
the unit area.

 Knowing the anticipated wind direction and wind speed, plus the 

estimated duration for the direction and speed, will allow for a swift 

response to incoming chemical casualties. The wind information you will 

need can be obtained from the chemical officer or NBC NCO who get this 

data from the Chemical Downwind Message (CDM). This data can also be 

obtained from the S2/G2. The decontamination site will therefore initially 

be set up to take advantage of the prevailing wind, with clean area 

operations always upwind. In the event the predicted wind data shows a 

radical wind shift is predicted during decontamination operations, your setup should be adaptable to allow for quick rearrangement.

 Keeping track of the existing wind direction during the 

decontamination operation is the 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 stakes from the M274 NBC Marking Set or white engineering 

tape to tent poles, tent ropes, etc. One of these wind direction devices 

must be visible from the hotline when looking in any direction.

 If the wind shifts more than 30o from the prevailing wind direction, 

consideration must be given to shifting the decontamination site. 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 

disruption of patient flow and diversion during this waiting period should 

be considered in the preplanning phase.

 Often wind speed will be less than 5 KPH for long periods of time. 

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 as to not adversely affect other units or the ongoing conventional medical mission of the MTF.

Security of Decontamination Site

 When choosing a decontamination site, the same security 

considerations must be given as for any other site chosen for medical 

operations. The decontamination site is at the same potential risk from 
attack 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 terrain or structures can be used to 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; can the site 

be visually acquired from a distance?

 • Can the site be quickly evacuated if necessary?

 • Can key locations be sandbagged for added protection?

 • Will the site be located in an area under light discipline?

 • Will the decontamination operation be functional in complete 

darkness?

 • Are communication means available for medical or operational 

emergencies?

Access Control to Decontamination Site

 An entry control point (ECP) must be established to control movement 

of all facilities into the MTF or the CDC. The ECP should be located at a 

distance far enough from the MTF to minimize any vapor hazard that may 

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 decontamination site, 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 between the MTF and supporting evacuation units, both air 

and ground, on a standardized identification method must occur. This 

coordination should happen prior to deployment.

 One solution is to use fabricated metal triangles with the NATO 

standard dimensions of 28 cm x 20 cm x 20 cm. To maximize 

camouflage, the triangles should be painted with flat green CARC paint. 

On the three separate triangles, the words ATOM, BIO, or GAS would be 

painted in flat black CARC paint. This will give the evacuation vehicle 

crew the ability to designate what casualty type is on board. The triangle 

would be attached to the front end of the evacuation vehicle so the ECP 
personnel could observe it at a distance. For night operations, chem-lights 

can be used. A yellow chem-light is used for chemical casualties, blue for 

biological casualties, and red for radiation casualties. The chem-light 

would be attached to the front end of the vehicle below the level of the 

hood to preclude its interference with the driver/TC’s night vision.

 The soldiers manning the ECP should be equipped with a pair of 

binoculars and night vision goggles (NVG) for standoff inspection of 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 

(regardless of MOPP Level) question the crew about any signs or 

symptoms of agent exposure and about the vehicle’s contamination 

status.

 M8 or M9 paper may be used to make a rapid and accurate 

determination of whether or not a liquid chemical agent is present on or in 

a vehicle. Visual inspection of the vehicle can be done at the ECP. When 

suspect liquids are found, M8 paper should be placed in the liquid and the 

results noted and sent to the MTF Headquarters. Areas likely to have 

liquid contamination are the vehicle’s wheel well areas, tires, and rear 

portion of the vehicle. If patient decontamination is to be accomplished 

within the unit area and the evacuation vehicle is found to have exterior 

contamination, plans must be established to transfer casualties to the 

casualty decontamination site via clean 2-1/2 or 5 ton trucks. The 

commander may want to restrict vehicles with exterior contamination from 

moving through the unit area. Litter teams may also be utilized to transfer 

casualties. As a final resort, the contaminated evacuation vehicle may be 

routed into the casualty decontamination site on a route that has minimal 

impact on vehicle movement into the MTF after decontamination 

operations are concluded.

 Control of vehicle movement to specific routes and areas within the 

decontamination site is a critical safety issue, even during combat 

operations. This can involve routing vehicles along a clearly marked, oneway path for the ECP to the chemical casualty decontamination site. 

Then, ideally, return to the ECP should be along the same route. If 

vehicles are not kept on the proper path, clean areas are likely to become 

contaminated, and both patients and personnel are subject to being run 

over during night operations. Planning for vehicle movement must always 
include night operations and low visibility conditions.

 Control of personnel movement is necessary to ensure that casualties 

and site personnel do not accidentally cross the hotline without first being 

decontaminated. 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 physical barriers, night 

operations must rely more on visual control measures that conform to light 

discipline guidelines.

Equipment and Supplies

 A suggested minimum list of additional items needed to support the 

casualty decontamination site is provided at Appendix B.

Personnel Requirements

 Provided below is a minimum suggested list of personnel to staff the 

CDC. Although a fully effective litter decontamination procedure can be 

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 planning required for manning the 

decontamination site must include the anticipated casualty load, day or 

night operations, weather conditions, work and rest rates for personnel, 

logistical support for the site, and the acceptable impact on conventional 

medical operations that are still on-going.

Site Command and Control Cell:

 1 Officer

 1 NCOIC

Triage/Emergency Medical Treatment Area:

 1 EMT NCO as Triage Officer

 1 EMT

 8 Litter Bearers

Litter Casualty Decontamination Area:
 1 Chemical Agent Monitor (CAM)

 4 Decontamination Augmentees

 1 EMT

NOTE: The four decontamination augmentees assist in moving patients 

between clothing removal and skin decontamination litters. 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 

bag waste from the litter decontamination area, replace chlorine solutions 

after every two patients, and pour old chlorine solutions onto waste in the 

bags, thus allowing the liquid to absorb into the clothing.

Ambulatory Casualty Decontamination Area:

 

 4 Decontamination Augmentees

 1 Medic

Litter Decontamination Point:

 Not manned

NOTE: Augmentees decontaminate the litters by scrubbing a 5% chlorine 

solution over the entire surface. If canvas litters are used, the 

augmentees will remove any barrier materials used to protect the wooden 

handles and canvas cover and place these materials in a plastic bag. The 

augmentees must scrub the canvas litter with 5% chlorine solution and 

reapply new barrier materials. Separate litter cycles must be maintained. 

Clothing removal litters must not be used as skin decontamination litters. 

When not decontaminating a litter, two of the augmentees will transport 

waste to the dirty dump.

Clean Treatment Area:

 2 Litter Bearers

 1 EMT

Logistical Support Point:
 1 Medical Supply NCO

 1 Soldier

 TOTAL: 27 Soldiers

Work/Rest Considerations

 This single consideration will impact directly on the efficiency of 

personnel and replacement needs of personnel. A complete understanding 

of the available information on this subject, coupled with common sense 

and experience, will enhance the planning process and address manpower 

needs. Establishing a work/rest cycle is dependent on several factors, as 

listed below.

 • How rested are the soldiers?

 • Have the soldiers been acclimated?

 • Has a command drinking policy been in effect regardless of 

MOPP Level, thus affecting 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 3-4, NBC 

Protection, Chapter 2, MOPP Analysis.

Establish a Patient Decontamination Station

 Medical support on the future battlefield will be robust, versatile, and 

extremely mobile, regardless of the echelon of Health Service Support 

(HSS). The care of contaminated casualties, although more complicated 

than that of conventional casualties, must not stop the on-going medical 

mission. Medical officers and medical NCOs must develop realistic, battlefocused plans. They must then refine and validate these plans in 

challenging training if HSS on the future battlefield is to be successful.

 The single area of contaminated casualty care that has in the past 

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 material derived from recently conducted tests, doctrinal 

procedures, and the practical experiences of medical and chemical NCOs. 

The following section presents suggestions or “food for thought” on how 

to successfully conduct contaminated casualty decontamination.

 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 required for casualty decontamination and care.

The C/B Battlefield

 Initially, all chemical agents are disseminated as liquids or solids. 

Chemical agents can be introduced into the environment as one of the 

following, depending on the weapon system used:

 • Solids

 • Liquids

 • Gases/Aerosols

 

 Biological agents can be introduced into the environment in wet or dry 

form. Examples are provided below.

 • Aerosols

 • A slurry mix (wet)

 • Large thick drops

 • A dry powder

 • Spores

 • Vectors

 Regardless of which form a C/B agent is in when introduced, there is 

one common result – chemical or biological weapons will contaminate 

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.

Chemical Contamination

 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 

3-3, 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 

contamination 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 shows whether 

the attack was an air contaminating attack (Type A), which has little or no 

liquid contamination on the ground, or a ground contaminating attack 

(Type B).

 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 nonmedical 

augmentees performing patient decontamination. Casualties in the hazard 

area do not pose liquid chemical agent complications; however, they do 

pose a problem from off-gassing chemical vapors trapped by the BDO. 

Because of these liquid and vapor problems, it is important to understand 

as much as possible about the attack and hazard areas.

 The dimensions of the attack area based on the type of agent 

employed and weapon system used are 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:

Type A Attack

Artillery shells or Attack area

multiple rocket launchers radius = 1 

km 

Type B Attack

Artillery shells Attack area 

 radius = 1 km
Missile attack with Attack area

high airburst radius >1 km,

 but <2 km

Spray attack or Attack area

regimental radius = 2 km

artillery attack Attack length > 2 km

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. This attack usually is conducted by firing 

large numbers of highly volatile (nonpersistent) chemical agent munitions 

into a relatively small area. 

These nonpersistent agents are:

 Nerve Agents – GB, GD

 Pulmonary Agent – CG

 Vesicating Agent – CX

 Cyanide Agents – AC, CK

 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 the unit so as to 

maximize the development 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 pulmonary agent CG, or the vesicating agent 

CX. However, should a cyanide agent be used, the attack will most likely 

be in or extremely close to a unit’s location because of the rapid 

expansion of cyanide vapor in the air and the ability of cyanide vapor to 

mix easily with the surrounding air.

 A casualty in the Type A attack area presents a potential liquid hazard 
as well as an off-gassing vapor hazard, while the casualty in the Type A 

hazard area will pose only an off-gassing hazard. However, in most cases, 

any liquid chemical agent found on this casualty will be minimal due to the 

rapid evaporation of the highly volatile (nonpersistent) liquid chemical 

agents from the outer material of the BDO. Although the M9 chemical 

detection tape worn by casualties in the attack area will show a positive 

color reaction to any liquid chemical agents that he has been exposed to, 

it may be difficult to detect and identify the agent using M8 detection 

paper during triage at the decontamination site because of evaporation.

 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 chemical agents with a low volatility (persistent). 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 worse 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 number of oily 

spots of varying sizes on the BDO. The mask carrier, load-bearing 

equipment (LBE), and protective mask hood will also have spots or smears 

that cannot be a 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 agent may smear on the 

casualty’s BDO and appear entirely different than perspiration. The liquid 
chemical agent may also appear on the mask carrier, LBE, and protective 

hood as an oily smear or singular oily spots of varying size. The 

M9 detection tape will have more streaks than spots, which could indicate 

the casualty brushed against the liquid while moving or being carried.

 Casualties in the hazard area of the Type B attack will pose the same 

hazard as a Type A casualty, i.e., off-gassing vapors from the BDO.

Biological Contamination

 While the information available on chemical contamination is 

extensive, the same cannot be said for biological contamination. Because 

of 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 days to 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 to assess 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 and the anticipated 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 scenario and is used for planning purposes because this type of 

attack will contaminate the great amount of terrain and affect the greatest 

number of personnel. 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 distance of the Type B hazard 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 attack area, which will be shown 

as a circle with a minimum diameter of 5 km unless a larger size is 

determined through a survey or by observation. Any personnel from 

within this circular 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 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 can indicate 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 evaluation will be 

based on the following:

 • The location of all units supported by the 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 any unit inside the predicted attack area 

and/or predicted hazard area.

 -- What MOPP level was the affected unit in?

 -- What type of terrain has the unit occupied?

 Built-up (urban) terrain could indicate that overhead cover was 

available to shield personnel against the initial liquid contamination. 

Wooded terrain could also indicate some overhead cover provided by the 

forest canopy. Desert terrain indicates very little overhead cover.

 -- How long had the unit been in its position?

 -- If nerve agent is suspected, was the unit taking Nerve Agent 

Pyridostigmine Pretreatment (NAPP)?

 -- If nerve agent is reported, how was the agent verified? M8A1, 

M22 ACADA, and/or M256A1 detector sampler indicates ONLY a vapor 

hazard. M8 detector paper indicates ONLY a liquid hazard. Any 

combination of M8 detector paper, the M8A1, M22 ACADA, and M256A1 

detector ticket indicates both a liquid and vapor hazard.

 • Is the attack only a chemical attack, or are conventional High 

Explosive (HE) munitions being used alone or along with a ground attack?

 • If a biological attack is suspected, what were the indicators?

 -- Did any suspicious liquid fail to cause a reaction on M9 or 

M8 paper?

 -- If aerosols were observed being disseminated, did the 

M8A1 ACAA, M256A1 chemical detection sampler, or CAM fail to 

indicate a chemical agent?

 These questions are by no means all that can be asked but are critical 

in determining a hasty plan of action. The unit's executive officer must be 

notified that contaminated casualties will be arriving and that some 

evacuation assets may be contaminated. The executive officer will, in 

most situations, make the final decision if the decontamination of 

casualties will take place within the unit area or if it must take place at a 

location outside the unit area that will not affect ongoing support 

operations.

Establish the Decontamination Site

 The ability of the medical platoon, or more specifically the treatment 

squad, to establish the decontamination site will depend greatly on unit 
support. Long before the medical platoon deploys, the unit commander, 

first sergeant, and executive officer must understand the need for 

manpower and equipment support. Also, when possible, the commander 

should pre-designate in the tactical SOP (TSOP) which sections of the 

headquarters unit will provide personnel or equipment. 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.

 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.

 Outside a 1 km stand-off distance from the edge of the predicted 

downwind hazard area, all personnel can remain in MOPP II during the setup 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 both the M8A1 ACAA, or the 

M22 ACADA and M256A1 chemical detector kit regardless of what agent 

has been reported. Initial NBC-1 Observers’ Reports received at the TOC 

during testing scenarios and field training exercises often contain incorrect 

information on which agent was actually encountered. As long as the 

monitor continues to report no contact with chemical agent vapors, all 

personnel can remain in MOPP II until the first casualties are five to ten 

minutes away.

 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 III 

or MOPP IV during site set-up. Modification of the MOPP level based on 

temperature and expected workload during set-up can be accomplished as 

described in FM 3-4, NBC Protection, Chapter 2, pages 2-5. If the site 

must be set up in the vapor hazard area, it is critical that the selected site 

be free of liquid contamination. As long as the team sent to the selected 

site remains completely outside the predicted liquid hazard area, and 

optimally outside the stand-off distance, a point chemical survey should 

take no longer than a few minutes using M8 chemical detector paper.
Site Preparation Phase

 The preparation of the site 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 laborintensive 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 

driven, points along the route requiring direction indicators identified, and 

any ground obstacles identified for removal. The arrival/triage area must 

be surveyed to ensure it can handle the evacuation vehicles moving into 

and out of the area, plus the activities of the triage officer and the 

litter teams. Both the litter decon and ambulatory decon areas must 

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 must also be evaluated for night operations.

 When preparing the site, three shuffle pits need to be prepared, each 

requiring at least two 50 lb drums of Super Tropical Bleach (STB) each. 

These pits, depending on the amount of use they get, must be refreshed 

with the STB once every hour or after ten personnel have shuffled through 

them. To refresh a shuffle pit, mix half the original ratio of two shovels of 

STB and three shovels of each 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.

 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 sites), then dedicated engineering tools 

must be available to assist in digging the dirty dump. Pick axes and long 

handled shovels are more appropriate than individual entrancing tools.

 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 shovels should be dedicated for this 

work.

NOTE: The dedicated tools mentioned in this section must be obtained 

prior to deployment and used exclusively by the medical treatment squad 

for site preparation. This will ensure that tools are available at the critical 

time.

 After site preparation is complete, all tools must be kept on the 

"clean" side of the hot line.

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 support 

patient decon should be set up on the soon 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 conduct of decon operations, any resupply items should 

be obtained from the clean side of the hot line on as needed basis. By 

keeping equipment and supplies to the barest minimum required, the site 

OIC/NCOIC will ensure that only minimal items must be dealt with during 

disestablishment of the decontamination site.

 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 Chem Agent Patient 

Decontamination.

 • Arrival/Triage Area

 -- 1 bk - Field Medical Card (carried by triage officer)

 -- 2 ea - M291 SDK (carried by triage officer)

 -- 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)
 -- 4 ea - Patient Protective Wraps

 If organic ambulances are used to transport casualties from collection 

points that are inside 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 echelon of HSS. In this situation, remove from each 

ambulance the 4 patient protective wrappers (PPW) authorized per vehicle 

and hold them on the clean side of the hot line. Incoming litter casualties 

may be placed on these PPWs at the arrival/triage area if the number of 

litter casualties exceeds the number of available litters. The need to 

protect the casualty from possible liquid chemical contamination while 

waiting for a litter is met by using the available PPWs. Also, the PPW will 

allow transport of the litter casualty within the patient decontamination 

site, as needed.

 • Emergency Treatment Area

 -- 1 bx - M291 SDK

 -- 6 ea - MARK I, Nerve Agent Antidote Kits

 -- 6 ea - Atropine autoinjectors

 -- 4 ea - Convulsant Antidote for Nerve Agent

 -- 5 ea - 50 ml syringes

 -- 1 ea - Stethoscope, Adult

 -- 1 ea - Flashlight

 -- 2 ea - Field I.V. poles

 -- 4 ea - I.V. bags

 -- 6 ea - I.V. sets

 -- 10 ea - Catheter/needle units

 -- 1 pg - Providine iodine pads

 -- 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 I.V.)

 -- 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, individual chemical (RDIC) would be the best 

hand-operated resuscitator for use on the dirty side of the hot line. The 

RDIC can be found in each ground ambulance and in the MES Chemical 

Agent Patient Treatment.

 • Litter Decontamination Area

 -- 4 pr - Litter support stands

 -- 8 ea - 12 qt utility pails (4 for the clothing removal points and 4 

for the skin decontamination points)

 -- 2 ea - Sponges or rags per 12 qt utility pail

 -- 2 ea - 7.25" angled bandage scissors

 -- 1 pr - Chemical protective glove set per augmentee

 -- 2 pr - TACTILE chemical protective gloves for medics (1 pair is 

worn, and 1 pair is carried)

 -- 1 ea - Butyl rubber apron worn by each augmentee working 

with the litter patients

 -- 24 ea - "Zip-lock" bags for FMC and personal items from each 

patient

 -- 12 ea - Plastic garbage bags

 -- 1 ea - CAM (if available) to survey suspected contamination or 

verify completeness of decon; the CAM is kept in the skin decon area)

 -- 2 ea - M8 chemical detection paper booklets

Litter Patient Decontamination

Dirty Dump

 The dirty dump is located a minimum of 75 yards downwind from the 

triage and emergency medical treatment areas. Prepare the dump ahead 

of time; this will be a manual, labor-intensive job if you have no 

engineering support. The dirty dump initially is a hole 5 feet deep by 4 

feet wide by 4 feet long. After closing the decontamination site and backfilling the dirty dump, the location must be reported to higher headquarters 

as a contaminated site with an eight or ten digit grid coordinate. The 

report format used to transmit the dirty dump's location is the NBC-4. All 

personnel working in and around the dirty dump will be at MOPP IV once 

casualties begin to arrive at the site.
Triage Point

 Field ambulances approach the triage point from a downwind 

direction. Patients are off-loaded from the ambulances and taken to the 

triage point. Once casualties are inbound, personnel working in the triage 

area are at MOPP IV. The patients are triaged and visibly marked with 

prepared tags using the following colors to denote triage casualties: 

 Immediate - Red

 Delayed - Yellow

 Minimal - Green

 Expectant - Black

 The use of these colors can extend into night operations with the use 

of "chem-lights" in the colors mentioned above, with the exception that 

the "expectant" casualty would be marked with a blue chem-light. 

Unmasked patients who arrive at this area must be masked immediately if 

wounds do not preclude this. After the arrival of casualties, the entire 

decontamination site on the downwind side of the hot line must be 

considered a liquid/vapor hazard area.

 Both litter and ambulatory casualties remove, or have removed for 

them, all military gear (protective mask carrier, kevlar vest and helmet, 

LBE, weapon, and all types of armament. Search the litter casualty's 

pockets). After he has been triaged, the casualty will be directed to either 

the ambulatory decontamination line, litter casualty decontamination line, 

or the contaminated EMT station.

Emergency Medical Treatment (EMT)

 Treatment at the EMT station is limited to the administration of MARK 

I Kits and diazepam, application of pressure dressings, establishing a 

patient airway, and starting an I.V. 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. 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 perpendicular to the prevailing 

wind direction. The EMT station should be positioned as far to the side of 

the decontamination site as is practical. This set-up will allow the EMT 

station to be away from the heaviest concentration of vapor resulting from 

the evaporation of liquid chemical agents concentrated at the triage point. 

All personnel rendering EMT 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. It is suggested that all soldiers working in the casualty 

decontamination areas wear only the Battle Dress Overgarment (BDO). 

Any additional gear (i.e., helmets and body armor, LBE, protective 

mask carrier) should be kept on the clean side of the hot line. Each 

worker should carry in the cargo pockets of the BDO trousers three MARK 

I Kits, one Diazepam Autoinjector (CANA), one M291 SDK, and one 

booklet of M8 detection paper.

 NOTE: Two people will work with each patient, tracking the patient 

from Step 1 to hand-over at the hot line.

 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.

 Two different concentrations of chlorine (Cl) solution are used in the 

patient decontamination procedure. A 0.5% Cl solution is used for all 

skin decontamination. A 5% Cl solution is used to decontaminate the 

casualty's protective mask and hood, scissors, TAP aprons, and the 

gloves of personnel working in patient decontamination area plus litters. 

Approximately 10 quarts of the chlorine solution are placed in 12-quart 

stainless steel buckets for use in this area. The buckets should be 

distinctly marked to distinguish between the two solutions. Preparation of 

these solutions is covered in Appendix C. Chlorine evaporates quickly at 

high temperatures, so the solutions should be prepared shortly before they 

are needed.
Step 1. Clothing Removal Point

1. Decontaminate hood.

 a. Cover inlet port of filter canister to prevent wetting by the 5% Cl 

solution.

 b. Sponge down the voicemitter, eyelets outserts, and sides and top 

of hood with 5% Cl solution.

 NOTE: When the 5% Cl solution is not available, use the 

M291 SDK or the M295.

 NOTE: After every complete cut, the scissors must be immersed, 

along with the gloved hands of the soldier doing the cutting, in a 5% Cl 

solution. While immersed, quickly scrub the cutting edges of the 

scissors. If the 5% Cl solution is not available, use the M291 or M295 on 

the scissors and the worker's gloved hands.

2. Remove hood.

 a. Immerse and scrub scissors in 5% Cl solution

 b. Cut off hood.

 (1) Cut zipper cord.

 (2) Cut neck draw cord.

 (3) Cut hood shoulder straps.

 (4) Unzip the hood zipper.

 (5) Cut the zipper below the voicemitter.

 (6) Proceed cutting upward toward the inlet valve covers. Cut 

close to the covers and proceed toward the eyelets outserts.

 (7) Cut upward to top of eyelets outsert.

 (8) Cut across forehead to the outer edge of the next 

eye outsert.

 (9) Cut downward toward patient's shoulder staying close to 

the remaining eyelets outsert and inlet valve cover.

 (10) Cut across the lower part of the voicemitter to the zipper.

 (11) Immerse and scrub scissors in 5% Cl solution.

 (12) Cut from the center of the forehead over the top of the 

head.

 (13) Fold left and right sides of the hood to the side of the 

patient's head, laying the sides on the litter.

3. Decontaminate protective mask/face.

 a. Use 0.5% Cl solution, the M291 or the M295.
 b. Cover inlet port of filter canister to prevent wetting by 0.5% Cl 

solution.

 c. Wipe external portions of mask.

 d. Wipe exposed areas of patient's face.

 (1) Chin

 (2) Neck

 (3) Back of ears

 NOTE: Medic should view the FMC prior to removal.

4. Cut FMC tie wire.

 a. Allow the FMC to fall into a "zip-lock" plastic bag.

 b. Seal the plastic bag and wash with 0.5% Cl solution.

 c. Place the plastic bag under the back of head harness straps.

5. Remove personal articles from pockets of BDO.

 a. Place in "zip-lock" bags.

 b. Mark the bags and remove to the contaminated holding area.

6. Cut casualty's BDO. Cut overgarment around tourniquets, bandages, 

and splints. Two people will be cutting the BDO at the same time. 

Immerse and scrub scissors in 5% Cl solution after each complete cut to 

avoid contaminating inner or under clothing.

 a. Remove BDO jacket by cutting.

 (1) Unfasten velcro closure at the wrist and cut from wrist area 

of sleeves along the inseam of the sleeve up to the armpits, and then to 

neck area.

 (2) Repeat cutting procedure for the other side of the jacket.

 (3) Starting at jacket drawstring, cut the drawstring, unfasten 

the velcro closures, moving from waist to neck, then unzip the jacket.

 (4) If the casualty is able, instruct him to hold his arms up and 

away from his body, and drape the left and right chest sections of the 

jacket over the outside of the litter.

 (5) Direct the casualty to hold his arms away from his upper 

body until told otherwise.

 (6) If the casualty is unable to perform this instruction, one 

augmentee will hold the casualty's gloved hand and perform this action. 

Another augmentee folds the chest sections over the outside of the litter.

 b. Remove the BDO trousers by cutting.

 (1) Cut the leg closure cord at the cuff.

 (2) Cut along the inseam of the left trouser leg until the crotch 
area is reached, then cut across into the zipper.

 (3) Cut along the inseam of the right trouser leg until the crotch 

area is reached, then go sideways into the first cut.

 (4) Unsnap the trouser waistband and unzip the trousers.

 (5) Allow trouser halves to drape over the side of the litter.

 (6) Tuck the remaining cloth between the legs ensuring that 

only the black BDO lining is showing.

7. Remove outer gloves. Do not remove the inner gloves.

 a. Decontaminate the casualty's gloves with 5% Cl solution.

 b. 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.

 c. Grasp the cuff of the glove.

 d. Pull the cuff over the fingers, turning the glove inside out.

 e. Tell the casualty to carefully lower his arm(s) across the chest 

after the glove(s) is removed. If the casualty is unable to do this, 

decontaminate your chemical gloves and do it for him.

 CAUTION: Do not allow the arms to contact the exterior 

(camouflage) side of the overgarment.

 f. Dispose of the contaminated gloves by placing them in a trash 

bag.

 g. Immerse and scrub your own gloves in 5% Cl solution.

8. Remove black vinyl overboots (BVO).

 a. Unfasten the three elastic closures.

 b. Gently pull the BVO by the heel until it is removed.

 c. If the BVO will not come off, cut the boot from top to bottom 

along the center line of the boot. Fold the BVO down and gently pull the 

heel until it is removed.

9. Remove personal effects from BDU.

 a. Place personal effects in "zip lock" plastic bag.

 b. Remove the bag to the contaminated holding area.

10. Remove combat boots without touching body surfaces.

 a. Cut the bootlaces along the tongue.

 b. Pull the boots downward and toward you until removed.
 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 following the same procedure as for 

fatigues. If the patient is wearing a brassiere, cut it between the cups. 

Both shoulder straps are cut where they attach to the cups and are laid 

back off the shoulders. Place the undergarments into the plastic garbage 

bag containing the other contaminated items.

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

14. Remove inner gloves. Place in the plastic garbage bag.

 NOTE: Waste material from two litter patients should be placed into 

one 35 gallon trash bag along with the used 5% and 0.5% Cl solutions 

used on the two patients. The bag must be tied shut and transported to 

the dirty dump.

15. Workers should decontaminate their own TAP aprons, gloves, and 

lower portion of protective hood in 5% Cl solution.

 

 A three-man patient lift is now used to remove the nude patient from 

the contaminated clothing removal litter to the clean skin decontamination 

litter. The three workers lifting the patient slide their clean arms under the 

patient in forklift fashion supporting the casualty's neck, torso/lower back, 

and distal legs using the straight back knee-lift technique. After the 

casualty is lifted up, he is rolled slightly inward against the lifters' chests 

to make holding the casualty up less of an effort. Before and during the 

lift, the leader explains to the casualty exactly what is going to happen. 

The dirty litter and its content of clothing are removed from under the 

casualty, and a clean decontaminable litter, if available, is placed under 

the patient. If decontaminable litters are not available, use a plastic 

covered canvas litter (or, less desirable, a single use of an uncovered 

canvas litter). The cut BDO, BDU, and undergarments are now placed in 

the plastic garbage bag with the other waste from the casualty. The 
patient is then carefully laid back on the stretcher. The dirty litter must be 

decontaminated with 5% Cl solution and reused only for transfer of 

casualties from the triage area to the clothing removal point.

Step 2. Skin and Wound Decontamination

 The casualty is now spot deconned with the M258A1/M291 SDK only 

at points that could be potentially contaminated (i.e., tears or holes in the 

BDO, the neck and lower face, wrists, etc.).

 An alternate method is to decontaminate the entire skin surface by 

lightly wiping the skin with a sponge and 0.5% Cl solution. The casualty 

is washed from the midline outward, constantly washing from clean to 

dirty and not placing a dirty sponge back on a clean area without first 

rinsing it in the 0.5% Cl solution. The complete topside of the casualty is 

washed in this manner, paying particular attention to hairy areas of the 

body (groin and axillary regions) and sweaty areas (belt-line, just above 

the boots, the crease of the buttocks, and wrists). The back side of the 

casualty will be washed after he is log-rolled onto his side. The casualty's 

back is washed from the shoulders to over halfway down the backside, 

taking care not to miss any areas. The upper side of the litter is deconned 

prior to laying the casualty down again. The opposite side of the casualty 

is washed in exactly the same manner, and the litter is deconned again. 

After the casualty is deconned, the medic removes dressings and replaces 

them only if needed.

 Superficial wounds (not body cavities, eyes, or nervous tissue) are 

flushed with 0.5% Cl solution, and new dressings are applied if needed. 

Cover massive wounds with plastic. The medic places new tourniquets 

0.5 to 1 inch proximal to the original tourniquet and removes the old 

ones. Splints are not removed, but are saturated to the skin with 0.5% Cl 

solution. If the splint cannot be saturated (air splint or canvas splint), it 

must be removed sufficiently to enable everything under it to be saturated 

with the 0.5% Cl solution.

Step 3. Monitor for Completeness of Decontamination

 The CAM should be used for this step. If it is not available, M8 or 

M9 paper may be used instead, although the ability of the papers to 

detect any agent at this point is highly unlikely. Once the casualty is 
confirmed clean of any active chemical agent residue, he is carried to the 

hot line using the three-man patient carry. Prior to transfer of the 

casualty, the dirty team washes their TAP aprons, gloves, and lower part 

of the protective hood with the 5% Cl solution. The team members 

should wash each other, with each member being deconnned standing 

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.

 NOTE: Immediately after the dirty team has handed off the patient, 

they move to the litter decon point and assist in any decontamination that 

has not been accomplished by other augmentees.

 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 shuffle pit should be 

deep enough to cover the bottom of the protective overboots and large 

enough that the dirty team, two litter stands supporting a clean litter, and 

the clean team can occupy it at one time.

Clean Side Actions

 NOTE: As the dirty team prepares to bring the casualty to the hot 

line, the clean team opens a blanket or other covering appropriate for the 

environmental conditions.

 1. The dirty team brings the decontaminated casualty to the hot line 

on the litter and places the litter on the stands. Three dirty team members 

log-roll 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 moves away.

 2. 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.

 3. In the clean treatment area, the patient can now be retriaged, 

treated, and evacuated. In a hot climate, the patient will probably be 

significantly dehydrated, the rehydration process must begin immediately. 

Overhead cover should be provided for casualties in the holding area.

Logistical Support Point
 Of equal importance to the casualty decontamination effort is the 

logistical support of the ongoing operation. A logistics support point 

should be established upwind between 30 to 50 meters of the hot line. 

At this point, the Cl solutions are prepared and 1 or 2 quart canteens are 

also stockpiled for use by all the soldiers manning the site. The logistics 

support point should have one 400 gallon water buffalo or initially, twenty 

5 gallon water cans. Medical supplies, chemical casualty treatment, and 

decontamination MESs can be located at this point along with additional 

decontamination supplies.

Rest/Rehydration Point

 A point should be established 50 meters perpendicular 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% Cl solution and doff the apron near the decontamination line. 

Next, they must decontaminate the chemical protective boots and 

gloves using a wet or dry mix of Super Tropical Bleach (STB), and using 

the M295 SDK or the M291 SDK, decontaminate the protective hood. 

After completion of this decontamination process, the soldiers move to the 

rest/rehydration point. The CAM should be used to monitor the boots, 

lower leg area of the BDO, gloves, and lower sleeve area of the BDO, and 

finally, the hood. If all indications are that these areas are vapor free, then 

the soldiers conduct an unmasking exercise and begin to rehydrate. The 

soldiers should not group together, but should maintain three meters 

distance from one another. If possible, this rest point should have 

overhead cover for shade.

Ambulatory Casualty Decontamination

 Decontamination of ambulatory casualties closely follows the method 

described in FM 3-5, NBC Decontamination, Chapter 9, under “Patient 

Decontamination” with a few differences: (a) gear drop is done at the 

triage area, (b) the hood is removed by cutting during casualty 

decontamination, (c) there is medical attention during the decontamination 

process for casualties, (d) the order of removal of the boots and trousers 

is different in the two procedures, and (e) spot decontamination of the 

BDU may be done with the ambulatory casualty as long as the chemical 

contamination is confined to a small area.
 NOTE: An augmentee must be stationed at the hood and protective 

mask decontamination station to perform the decontamination and cutting, 

if necessary. This action is conducted in a shuffle pit using two parts STB 

mixed with three parts earth (by volume). The shuffle pit should be large 

enough for two casualties to stand in and deep enough to cover the 

overboots.

1. Decontaminate and remove the hood.

 a. Cover inlet port of canister filter to prevent wetting by the 5% Cl 

solution.

 b. Sponge down the front, sides, and top of the hood with 5% Cl 

solution.

 c. Cut the underarm straps and the neck draw cord, and unzip the 

zipper.

 d. Remove the hood by cutting or, with the quick doff hood or 

similar hoods, by loosening the hood from the mask attachment points.

 e. Remove the FMC and place it in a plastic bag. Decontaminate 

the bag with 0.5% Cl solution and place it under the protective 

mask harness.

 NOTE: After completing the hood removal, the casualty is instructed 

to move to the next step, which should be 10 to 20 meters upwind from 

the hood removal station.

2. Remove personal effects from BDO. Have the casualty remove all 

items from the BDO jacket and trousers and place them in a "zip-lock" 

bag. The bag is marked and moved to the contaminated holding area.

3. Remove BDO jacket.

 a. Stand in front of the casualty.

 b. Cut or untie the BDO jacket drawstring.

 c. Unfasten the BDO jacket velcro closures starting at the bottom.

 d. Unzip the BDO jacket front.

 e. Move to the rear of the casualty.

 f. Unfasten the velcro wrist closures.

 g. Unfasten the three snaps on the BDO jacket.

 h. Instruct the casualty to do the following, if able:
 (1) Clench fists.

 (2) Stand with arms held straight down.

 (3) Extend arms backward at about a 30 degree angle.

 (4) Place feet shoulder width apart.

 i. Grasp the jacket collar at the sides of the neck.

 j. Peel jacket off the shoulders in a down and away motion, 

smoothly pulling the jacket inside out over the casualty's fists.

 k. Place the BDO jacket in a plastic trash bag.

 NOTE: Cut the BDO jacket to aid removal if necessary.

4. Remove Butyl Rubber Gloves.

 a. Augmentee washes gloved hands in 5% Cl solution.

 b. Use thumbs and forefingers of both hands.

 c. Grasp the heel of the casualty's glove at the top and bottom of 

the forearm.

 d. Peel the glove off inside out with a smooth motion.

 e. Place the gloves in a plastic trash bag.

5. Remove glove inner liners. The patient should remove the liners to 

reduce the possibility of spreading contamination. The augmentee 

instructs the casualty to remove the white glove inner liner using the 

following guidance:

 a. Grasp heel of glove liner without touching exposed skin.

 b. Peel liner downward and off.

 c. Drop it into the plastic trash bag.

 d. Remove the remaining liner in the same manner.

 e. Drop it into the plastic trash bag.

6. Remove casualty's black vinyl overboots (BVO).

 NOTE: Follow the same instructions for removing the BVO worn by a 

litter casualty. 

7. Remove BDO trouser.

 a. In order, unfasten or cut both trouser cuff draw cords, unsnap 

the outer button, loosen the two waist adjustable tabs over the hips, unzip 

the trousers, and unfasten the inner snap.
 b. Grasp trousers at the waist.

 c. Peel trousers down over the casualty's overboots.

 d. Cut the trousers to aid removal if necessary using the following 

procedure:

 (1) Cut around all bandages and tourniquets first.

 (2) Cut up the front of both trouser legs to the waist. Prior to 

the final cut on the trouser leg, grasp the BDO material at the buttocks 

area, and as the final cut is made, pull the trousers off toward the rear.

 e. Place the BDO trousers into the plastic trash bag.

 NOTE: After completing BDO removal, the casualty is instructed to 

move 10 to 30 meters to the liquid contamination control line.

8. Remove personal effects from BDU. Have the casualty remove all 

items from his BDU and deposit them into a "zip-lock" bag. The bag is 

moved to the contaminated holding area. Have the casualty move 10 

meters upwind to the monitoring point.

9. Monitor BDU.

 a. Monitor with CAM or M8 detection paper.

 b. Check all areas of the casualty's clothing and combat boots.

 c. Pay particular attention to:

 • Hair and neck area

 • Discolored areas

 • Damp spots

 • Wrist closure area

 • Areas under tears in BDO

 • Around dressings

 d. If clean, send the casualty to the hot line.

 e. If contaminated, complete the following.

10. Spot Decon. Remove spots by using the 0.5% Cl solution, pads from 

the M291 Kit, or M295 Kit, or by cutting away the contaminated area. 

Always dip and scrub the scissors after each complete cut. Recheck the 

area with the CAM or the M8 detection paper.

11. Remove bandages and tourniquets (this procedure is done by a 

medic).

 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.

 e. Decontaminate the exposed skin area.

 f. Replace bandages only to control bleeding.

 g. Decontaminate exposed skin.

12. Conduct final check for completeness of decontamination with the 

CAM or M8 detection paper.

13. The augmentee instructs the casualty to move across the hot line 

through a shuffle pit to the patient holding area.

Disestablish the Patient

 Decontamination Station

 The closure of the patient decontamination site will pose as difficult a 

mission as the actual decontamination effort itself, due in large part to the 

physical condition of the medical personnel and the nonmedical 

augmentees. The disestablishment of the site must be accomplished 

carefully to prevent additional casualties from the augmentees and medical 

personnel. Fatigue will cause site personnel to move slower and make 

mistakes. Regardless of the number of times command drinking was 

accomplished, most of the site personnel will be dehydrated. Dehydration 

will lower performance and stamina while increasing the likelihood of heat 

injuries. Prolonged encapsulation in the MOPP gear may 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 must be 

established to optimize the recovery of essential equipment versus 

expendable equipment to deny threat forces tactical intelligence and 

ensure that site personnel are able to complete required work and get out 

of total encapsulation as quickly and safely as possible.

Equipment Recovery/Site Closure
 A list of recommended equipment for recovery is provided below. 

These items can be recovered by decontamination with a slurry mix of 

STB or a 5% Cl solution.

 To prepare the STB slurry mix, use four parts STB mixed into six 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% Cl 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.

 • Decontaminable litters

 • Litter support stands

 • 12-quart utility pails

 • Butyl rubber aprons

 • Field I.V. poles

 • Flashlight

 • Resuscitation Device Individual Chemical (RDIC)

 • Chemical Agent Monitor (CAM) (if available)

 Decontamination and monitoring of the equipment can take place 

adjacent to the hot line and 50 meters to the left or right of the 

litter/ambulatory decontamination area. After the 30-minute contact time 

has elapsed and all items have been flushed with clean water, each item 

must be monitored with the CAM before it is passed over the hot line. 

When monitoring with the CAM, ensure that cracks, joints/seams, bolts, 

porous materials, and any openings are monitored, in addition to surface 

areas of the equipment items.

 While waiting for the 30-minute contact time to elapse, all other items 

on the dirty side of the hot line can be placed in a plastic garbage bag and 

put in the dirty dump. Each shuffle pit needs to be camouflaged with dirt 

or other available materials. Several personnel must conduct a police call 

of the litter decon area, ambulatory decon area, and arrival/triage area. 

These final actions are designed to deny threat forces any tactical 

intelligence on the effect their C/B weapon had on our forces. Any 

direction indicators for vehicles or personnel must be taken down and 

placed in the dirty dump.
Personnel Recovery

 Upon completion of equipment recovery/site closure, all personnel 

except for two will conduct MOPP gear exchange. The site NCOIC/OIC 

will select a position adjacent to the hot line and 50 meters opposite the 

side used to decontaminate equipment. All personnel will perform MOPP 

gear exchange with the unit supplying required support. After completing 

MOPP gear exchange, the two remaining personnel will put all discarded 

MOPP gear into plastic bags and place them in the dirty dump. 

Additionally, they will backfill the dirty dump, camouflage it as much as 

possible, and mask the contaminated area with the NATO NBC marking 

set. They will then move back to the hot line and perform MOPP gear 

exchange. The remaining two sets of discarded MOPP gear are left in 

place and camouflaged.

 NOTE: It is strongly suggested that two personnel from the clean side 

of the hot line are detailed to complete the actions outlined above.
CHEMICAL DEFENSE EQUIPMENT

 This overview is divided into four sections:

 • Individual Protection

 • Individual Decontamination

 • Detection and Alarms

 • Patient Protective Equipment

 

INDIVIDUAL PROTECTION

 This section includes standard "A" chemical defense equipment (CDE) 

issued to each soldier depending on their MOS and consisting of the 

following:

 • M40 Series Field Protective Mask

 • M42A2 Combat Vehicle Protective Mask

 • M48 Chem-Bio Aircraft Mask 

 • M45 Air Crew Chem-Bio Mask System

 • Battle Dress Overgarment

 • Chemical Protective Gloves and Overboots

Chemical-Biological Mask: Field M40

4240--01--258--0061 - 

Small

4240--01--258--0062 - 

Medium

4240--01--258--0063 - 

Large

 Chemical-Biological Mask:

Combat Vehicle M42A2
4240--01--258--0064 - Small

4240--01--258--0065 - 

Medium

4240--01--258--0066 - Large

TM 3--4240--300--10

TM 3--4240--300--20&P

 

 When properly fitted and worn, each of these masks will protect the 

wearer's face, eyes, and respiratory tract from field concentrations of all 

known chemical, biological, and riot-control agents. The CB hood (4240-

01-260-8723) affords additional protection for the head, neck, and 

shoulders.

 Because both the M40 and M42 masks have drinking tubes positioned 

around the outlet valve assembly, it is possible to drink water in a 

chemically contaminated environment. First, the soldier must use 

M8 paper to verify that the M-1 canteen cap is not contaminated before 

attaching the drinking tube to the cap. Soldiers operating armored vehicles 

will thus be able to drink water in a contaminated environment.

 The M17 optical insert (6540-01-060-0611), which has a wire frame, 

is the only approved optical insert for use with the M40 series and M42A2 

masks for personnel requiring visual correction.

 Innovations in these masks include the following: 

 • Each mask is molded with two voicemitters, one in the front of the 

mask and one over the cheek. The cheek voicemitter allows the use of the 

radiotelephone handset without any interference from the protective mask 

and is interchangeable with the cheek filter canister.

 • Each mask uses a NATO standard external filter canister 

(4240-01-119-2315) of the same type used by Germany and England. The 

unit nuclear/biological/chemical (NBC) noncommissioned officer (NCO) may 

position the canister either on the soldier's right cheek or on his left cheek 

to allow him to fire the M16A2 rifle from his left or right shoulder, 

respectively.

 • Each protective mask is molded in silicone rubber to allow easy 

fitting of all wearers, including those who require an extra small 

M17A2 mask.

 • Each mask is made with an in-turned-sealing surface around the 
entire inner edge of the mask. This allows for a more comfortable seal on 

the soldier's face.

 • The eye lenses in each of these masks are 35% larger than the 

M17A2 mask eye lens and permit greater range of vision.

M45 Aircrew Chemical-Biological

Mask System

 The M45 Aircrew Chemical-Biological Mask was developed to protect 

aircrew personnel against all known chemical and biological agents and 

radiological particulates. It provides a microphone pass-through for 

aircraft communications, a drink tube pass-through for liquid nutrients, 

close-fitting eye lenses, front and side voicemitters for face-to-face and 

phone communications, low-profile canister interoperability hose assembly 

for both hose and face-mounted configurations, and interchangeable nosecups mounted in a silicone rubber facepiece with an in-turned peripheral 

seal. The M45 Aircrew Mask provides respiratory, eye, and face 

protection. It replaces the Army’s M24 and M49 Mask System. The 

mask provides the required chemical and biological protection without the 

aid of forced-ventilation air, while maintaining compatibility with rotarywing aircraft sighting systems and night vision devices.

M48 Chemical-Biological Aircraft Mask

 The M48 Chemical-Biological Aircraft Mask was developed for the AH64 Apache helicopter aviators and provides face, eye, and 

respiratory protection against chemical-biological agents and radioactive 

particles. The M48 was designed for compatibility with the Integrated 

Helmet and Display Sighting System and the Optical Relay Tube, 

subsystems of the Apache. The M48 mask has a lightweight motor 

blower that can be mounted on the user. The motor blower provides 

filtered, breathable air that keeps the head cool and prevents the eye lens 

from fogging. While wearing the M48 mask, crew members can perform 

their mission in a NBC environment inside or outside of the aircraft.

 The M48 mask has a form-fitting facepiece with lenses mounted close 

to the eyes; an integrally-attached CB hood and skull-type suspension 

system; an inhalation air distribution assembly for regulating the flow of air 

to the facepiece and hood; a valve assembly that maintains overpressure 

in the mask and hood; an electronic microphone; and a portable, batterypowered motor blower filter assembly. The M48 is a product 

improvement of the M43 mask, which is currently used by the Apache 
crew; this product improvement incorporated user-requested features. 

The blower does not require an aircraft mounting bracket and can operate 

continuously for eight hours on a single, standard issue battery. The M48 

will replace the M43 mask and will only be worn by Apache Helicopter 

Aviators.

 Key features include:

 • Pilot-mounted motor blower; no aircraft modification required

 • Standard U.S. Army battery

 • Improved NBC survivability

 • 69% weight reduction over the currently fielded motor blower with 

battery

Battle Dress Overgarment (BDO)

8415-01-137-1700: 

XXX-Small

8415-01-137-1701: 

XX-Small

8415-01-137-1702: 

X-Small

8415-01-137-1703: 

Small

8415-01-137-1704: 

Medium

8415-01-137-1705: 

Large

8415-01-137-1706: 

X-Large

8415-01-137-1707: 

XX-Large

 

Desert Battle Dress Overgarment (DBDO)

6-Color

8415-01-324-3084: 

XXX-Small

8415-01-324-3085: 

XX-Small

8415-01-324-3086: XSmall

8415-01-324-3097: 

Small

8415-01-324-3088: 

Medium

8415-01-324-3089: 

Large

8415-01-324-3090: XLarge

8415-01-324-3091: XXLarge

Desert Battle Dress Overgarment (DBDO)

3-Color
8415-01-327-5346: 

XXX-Small

8415-01-327-5347: 

XX-Small

8415-01-327-5348: XSmall

8415-01-327-5349: 

Small

8415-01-327-5350: 

Medium

8415-01-327-5351: 

Large

8415-01-327-5352: XLarge

8415-01-327-5353: XXLarge

 The BDO and DBDO have been designed with new features that 

increase protection in a chemical environment and make wearing the suit 

less of a heat burden. The suit has more activated charcoal than the 

previous model, a novel outer cloth weave, and an outer cloth 

"scotchguard" type treatment resistant to liquid chemical agents. Because 

of the increased amount of charcoal, the BDO and DBDO can now be worn 

in an uncontaminated environment for 30 days following removal of the 

garment from its vapor-protective bag. This wear time may be extended 

past 30 days at the discretion of the unit commander. The suit may be 

worn for 24 hours in a contaminated area. Once the suit has been 

contaminated, the soldier must replace the suit by using the MOPP gear 

exchange procedure described in STP 21-1-SMCT, Soldier's Manual of 

Common Tasks, October 1990, Task #031-503-1023, Exchange MOPP 

Gear. The discarded BDO must be incinerated or buried.

 The BDO and DBDO are presently produced in both woodland and 

desert camouflage patterns. The suits have large butyl rubber patches 

sewn into the elbows and knees to prevent liquid chemical agents from 

penetrating the suit in these areas.

 The BDO and DBDO add approximately 11 pounds to the soldier’s 

weight. In addition, the BDO prevents heat exchange with the environment 

and may add, depending on the soldier's level of exertion,10oF to 15oF to 

his ambient temperature and heat burden. When wearing the BDO or DBDO 

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 may be unzipped.

 • The sleeve Velcro closures may be opened.

 This overall loosening of the BDO/DBDO will allow heat to escape as 

walking and other movements induce a bellows action of the suit against 

underlying clothing and skin. Because of the weight of the BDO/DBDO, 

field suspenders (8440-00-221-0852) should be used to allow support of 

the trousers and as much comfort as possible.

Chemical Protective Gloves and Overboots

Gloves, 0.025-inch thickness

8415-01-144-1862 - X-Small

8415--01--033--3517 - Small

8415--01--033--3518 - Medium

8415--01--033--3519 - Large

8415--01--033--3520 - X-Large

Gloves, 0.014-inch thickness

8415-01-138-2497 - Small

8415-01-138-2498 - 

Medium

8415-01-138-2499 - Large

8415-01-138-2500 - XLarge

Gloves, Tactile 0.007-inch thickness

8415-01-138-2501 - Small

8415-01-138-2502 - Medium

8415-01-138-2503 - Large

8415-01-138-2504 - X-Large

Black Vinyl Overboots (BVO)
8430-01-048-6305 - 

Size 3

8430-01-048-6306 - 

Size 4

8430-01-049-0878 - 

Size 5

8430-01-049-0879 - 

Size 6

8430-01-049-0880 - 

Size 7

8430-01-049-0881 - 

Size 8

8430-01-049-0882 - 

Size 9

8430-01-049-0883 - 

Size 10

8430-01-049-0884 - 

Size 11

8430-01-049-0885 - 

Size 12

8430-01-049-0886 - 

Size 13

8430-01-049-0887 - 

Size 14

 The chemical protective gloves are made from butyl rubber and are 

impermeable to chemical agents. The BVO is made from vinyl that will 

protect the soldier against NBC agents and environmental effects. Both 

may also be decontaminated and reissued. Both the 0.025-inch thick and 

0.014-inch thick gloves and BVO boots, when worn with the leather 

combat boot, can be used for 24 hours in a contaminated environment. 

After a complete visual inspection and decontamination with a 5% Cl 

solution, they may be worn again. The 0.007-inch thick tactile gloves 

must be inspected and decontaminated with the 5% HTH solution within 6 

hours after being in a contaminated environment. Once decontaminated, 

the 0.007-inch thick tactile gloves may be re-used. In an uncontaminated 

environment, the gloves and boots can be used for 14 days, and if found 

to be serviceable after a thorough inspection, can be used for 14 days 

more. When working with petroleum products, care must be taken not to 

allow these products to contact the boots and gloves. Should petroleum 

products contaminate the boots and gloves, wipe off and air-dry the boots 

or gloves within two minutes. If this cannot happen within two minutes, 

new boots or gloves must be obtained immediately.

 The gloves and the boots pose safety hazards. The 0.025 inch thick 

and 0.014 inch thick gloves degrade tactile ability and in a cold 

environment will not provide adequate protection against cold injury. The 

0.007-inch thick gloves have been produced to answer the need for 

selected personnel to have excellent tactile ability while wearing these 

gloves, but offer no protection from cold. These thin gloves must be 
issued along with the 0.025-inch thick gloves and worn only while 

performing those tasks requiring good tactile use of the hands and fingers.

 For further information on these items, see FM 3-4, NBC Protection, 

29 May 1992, Chapter 1. Individual Protective Equipment.

INDIVIDUAL DECONTAMINATION

 The preceding section provided an overview of the primary items of 

chemical defense equipment which, when used correctly, will prevent 

contact with agent in typical battlefield concentrations. The problem of 

decontamination arises when some soldiers, because of bad training, bad 

discipline, or bad luck, become exposed to liquid agent despite the 

availability of protective masks and clothing.

 This section addresses the two skin decontamination kits and the 

equipment decontamination kit currently in the inventory.

 The kits are fairly simple in design and function, and instructions for 

their use are 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 automatically and without referring to 

the instructions printed on the kits.

 The kits are as follows:

 • Decontamination Kit, Skin: M291

 • Decontamination Kit, Individual Equipment, M295 

Decontaminating Kit, Skin: M291

4230--01--276--1905

TM 3--4230--229--10

 The introduction of this kit marks a new approach to 

skin decontamination. The M291 Kit consists of six identical packets, each 

containing a mixture of activated resins. This resin mixture both adsorbs 

liquid chemical agents present on the soldier's skin and neutralizes agents. 
The mixture consists of an adsorbent resin, a resin containing sulfonic 

acid, and a hydroxylamine-containing resin. After masking, the soldier 

opens any packet from the kit, removes the applicator pad, and applies an 

even coating of resin powder while scrubbing the entire skin area 

suspected to be contaminated. One applicator pad will decontaminate both 

hands and the face, if necessary. If the face must be decontaminated, then 

the neck (including the throat area) and the ears must also be 

decontaminated using a second applicator pad.

 The black resin powder residue will provide a visual confirmation of 

the thoroughness of application and will not cause any skin irritation, even 

after prolonged contact with skin. However, normal precautions must be 

observed so that the powder does not enter open wounds, the mouth, or 

the eyes. This kit will also be used for training; no training aid will be 

produced. The issue is 20 M291 Skin Decon Kits per box. 

Decontamination Kit, Individual Equipment: M295 (DKIE) 

4230-01-357-8456

TM 3-4230-235-10

 The M295 DKIE allows for the decontamination of individual 

equipment through physical removal and absorption of chemical agent with 

no long-term, harmful side effects. The kit consists of a carrying pouch 

containing four individual decon packets, enough to do two complete 

individual equipment decontaminations. Each packet contains a mitt filled 

with the same decon powder used in the M291SDK. Two packets will 

decontaminate the protective gloves, M16A2 rifle, chemical protective 

helmet cover, protective mask hood, load carrying equipment (LCE) and 

accessories, mask carrying case, and protective boots.

 The decon mitt will only remove surface liquid contamination. The 

equipment that has been decontaminated can still pose a vapor hazard due 

to absorbed liquid chemical agent desorbing as a vapor.

 The M295 DKIE will be issued to the squad at its lowest point of 

issue. The M295 DKIE is packaged in a "squad box" with 80 kits in each 

box. The squad members should be given at least one kit. The packets for 

one complete decontamination can be carried in the cargo pocket of the 

BDO trouser.

 As with the M291 SDK, the M295 DKIE will be used for both training 
and combat.

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 and the unit, these items of equipment (listed 

below) are the primary means of identifying the presence and type of 

chemicals on the battlefield and determining when a safe condition exists.

 • Paper, CM Agent Detector: M8

 • Paper, CM Agent Detector: M9

 • Chemical Agent Detector Kit: M256A1

 • Chemical Agent Monitor

 • Automatic Chemical Agent Alarm: M8A1

 • Water Test Kit, Chemical Agents: M272

Paper, CM Agent Detector: M8

6665--00--050--8529

 The M8 detector paper is the only means of identifying the type of 

chemical agent present in liquid form on the battlefield. Each soldier carries 

one booklet of M8 paper in the interior pocket of the protective 

mask carrier. A soldier encountering an unknown liquid suspected of being 

a chemical agent must don and check his mask within nine seconds and 

quickly don the attached hood, alert others in the vicinity, and then 

proceed to put on all of his chemical protective clothing. He then removes 

the booklet of M8 paper from his mask carrier, tears a half sheet from the 

booklet, and, if possible, affixes the sheet to a stick. Using the stick as a 

handle, the soldier then blots the paper onto the unknown liquid and waits 

for 30 seconds for a color change. The resulting color is then compared to 

the colors on the inside of the front cover of the booklet to identify the 

type of liquid agent encountered.

 • G: Nonpersistent Nerve: Yellow

 • H: Blister: Red

 • V: Persistent Nerve: Olive Green or Black

 False positive can occur if liquid insecticides are on the surface being 
tested. Antifreeze and petroleum products will also cause false positive 

readings.

Paper, CM Agent Detector: M9

6665--01--049--8982

TM 3-4230-229-10

 The M9 detector paper detects the presence of liquid chemical agent, 

but does not identify either the specific agent or the type of agent 

encountered. Each soldier carries one 30-feet long and 2-inch wide roll of 

M9 paper with adhesive backing to facilitate wrapping a strip of the paper 

around a sleeve and a trouser leg of the BDO. (Because the indicator dye in 

the paper is a potential carcinogen, gloves should be worn during 

application, and the paper should not contact the skin.) The paper is a dull, 

off-white or cream color in the absence of liquid agent but contains an 

indicator chemical that, when dissolved in liquid agent, turns a reddish 

color. When the soldier sees this color change, he must immediately mask, 

alert others, and if there is any possibility of skin exposure, proceed 

immediately with skin decontamination.

 The M9 paper will detect nerve agent or blister agent droplets as small 

as 100 microns in diameter. False positive may be seen if the paper is 

exposed to antifreeze, liquid insecticide, or petroleum products. The 

soldier's attention to possible interfering substances on the battlefield can 

help in the later interpretation of a color change in the M9 paper in the 

absence of confirmation tests for agents. This does not relieve him of the 

obligation to mask and take other appropriate measures immediately after 

seeing a color change in the detector paper.

Chemical Agent Detector Kit: M256A1

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:

Agent Detected Symbol Class

Hydrogen 

Cyanide

AC "Blood" 

(cyanide)

Cyanogen 

Chloride

CK "Blood" 

(cyanide)

Mustard H Blister

Nitrogen 

Mustard

HN Blister

Distilled Mustard HD Blister

Phosgene Oxime CX Blister

Lewisite L Blister

Nerve Agents V and 

G Series

Nerve

By following the directions on the foil packets or in the instruction booklet, 

a soldier 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 kept out of direct sunlight, which speeds 

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 the test.

Simulator, Detector Tickets,

Chemical Agents: Training, M256A1

6665--01--112--1644
TM 3--6665--320--10

 The M256 trainer simulator was developed to provide realistic training 

while avoiding unnecessary exposure to potentially carcinogenic reagents 

in the M256A1 detector kit. The M256 trainer contains 36 pre-engineered 

detector tickets and an instruction booklet. The pre-engineered detector 

tickets show color changes comparable to those seen when the M256A1 

detector kit is used in clean or contaminated environments. Each training 

aid detector ticket has a specific code printed on the outside of the foil 

package. A list of codes is also printed on the inside of the training aid box 

under the lid, and instructions for the use of the simulator are also 

included. The codes are shown below.

MARK SIMULATED TEST FOR

T-400 SAFE, "ALL CLEAR" - No NERVE, 

BLISTER, or BLOOD agents

T-401 DANGER - NERVE: G agents or VX

T-402 DANGER - BLISTER: HD (sulfur 

mustard)

T-403 DANGER - BLISTER: CX (phosgene 

oxime)

T-404 DANGER - BLOOD: AC (hydrogen 

cyanide) or CK (cyanogen 

chloride). (STRONG RXN indicates 

AC or CK in HIGH CONC)

T-404A DANGER - BLOOD: AC (hydrogen 

cyanide) or CK (cyanogen 

chloride). (WEAK RXN indicates 

AC or CK in LOW CONC)

Chemical Agent Monitor (CAM)

6665--01--199--4153

TM 3--6665--331--12&P

 The CAM, 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 have been drawn into the unit by a pump. 

The resulting ion clusters vary in mass and charge and thus also travel at 
different rates in an applied electrical field. Comparison of the mobilities of 

the different ionic species to electronically stored standards allows an onboard microcomputer to determine the type of agent and its relative 

concentration. A liquid crystal display (LCD) presents these data as a series 

of concentration-dependent bars in a G mode for G agents and VX and in 

an H mode for blister agents.

 

 The CAM detects agent vapor in that volume of air drawn by the pump 

into the sampling chamber of the instrument. It follows that the inlet port 

must not come into contact with 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 agent concentration 

from one spot to another, depending upon wind velocity and other 

environmental factors, numerical displays of 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 vapor hazard (4 to 6 bars 

visible), or a very high vapor hazard (7 to 8 bars visible).

M22 Automatic Chemical Agent

Alarm (ACADA)

 The M22 is an automatic agent alarm system capable of detecting 

and identifying standard blister and nerve agents. The system is manportable, 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 many as five M42 alarm 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 vapors (HD, L), and provides 

simultaneous detection and warning of these agents. It operates in cold 

and hot climates (-30oF to +125oF). Tactical operations of the M22 

system are basically the same as the M8A1 Automatic Chemical Agent 

Alarm, except for some improvements over the M8A1. 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 WD1/TT telephone wire; whenever possible, the distance between the 
detector units and the alarm units should not exceed 400 meters. 

Improvements over the M8A1 system are as follows:

 • Simultaneous detection and warning of nerve and blister agents

 • Significantly more sensitive than the M8A1 

 • Much less response to interference

 The following items can interfere with the normal operation of the 

M22 ACADA and will sound a false alarm:

 • CS Tear Gas

 • JP8 Fuel

 • Brake Fluid

 • Aqueous Fire Fighting Foam (AFFF)

 • M18 Marking Grenade (Red and Violet)

Chemical Agent Alarm: M8A1

6665--01--105--5623

TM 3--6665--312--12&P

 The M8A1 Automatic Chemical Agent Alarm (ACAA) a remote, 

continuous air sampling alarm, which samples the air for the presence of 

NERVE agent vapors (GA, GB, GD, and VX) only. The M8A1 alarm uses 

0.01 millicurie of americium-241 (Am241), a source of alpha particles, to 

ionize airborne agent molecules drawn into the sampling chamber by a 

pump module. A detector cell analyzes the resulting ion clusters and 

compares their masses and charges with electronically stored standards to 

detect the presence of nerve agent vapors. The operator may specify 

whether the alarm itself is audible, visual, or both.

 The system consists of the M43A1 detector, as many as five M42 

alarm units, and various power supplies. The detector cell and alarm units 

are most commonly found in a fixed-site configuration. Normally the 

M43A1 detectors are placed facing into the wind no more than 150 meters 

outside the unit perimeter, with no more than 300 meters between 

detectors, and when possible, no more than 400 meters between the 

detector cells and the alarm units. WD-1/TT 6145-00-226-8812 telephone 

cable connects the detector cells and the alarm units. The alarm units are 

placed throughout the facility. A typical Mobile Army Surgical Hospital 

(MASH) has three M8A1 ACAAs, and a Combat Support Hospital (CSH) 
has seven M8A1 ACAAs.

Water Testing Kit, Chemical Agents: M272

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 Lewisite. The kit will operate between 32oF and 

125oF. An enclosed instruction card enables the soldier to conduct all the 

tests required to identify the threat agents. The kit will detect the following 

chemical agents at the concentrations indicated on the following chart.

Chemical 

Agent

Symbol(s)

Concentration 

(mg/l)-*

Cyanide AC 20.0 as CNMustard HD 2.0 --

Lewisite L 2.0 as As+++

Nerve G/V 0.02 --

 *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 long as the daily consumption per person 

does not exceed 5 quarts. Each kit contains enough reagents for tests on 

25 separate water samples. The operator can easily conduct 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

 In this section, the following three items that have been fielded will be 

discussed:

 • Patient Protective Wrap
 • Decontaminable Litter 

 • Resuscitation Device Individual Chemical (RDIC)

Patient Protective Wrap

8456-01-079-9875

 Army Medical Department (AMEDD) doctrine calls for the treatment of 

casualties from the integrated battlefield as far forward as possible. 

Because treatment often mandates removal of the BDO and precludes 

donning replacement BDOs, a patient protective wrap has been developed. 

This wrap is sturdy and lightweight, weighing approximately 2.7 kg, and it 

protects the patient from all known chemical agents for up to six hours. It 

is not designed for use by more than one patient and must be discarded 

after use.

 One continuous zipper around the outer edge of the top sheet provides 

easy patient insertion into the wrap, and observation of the patient is 

possible through an impermeable transparent window at the head of the 

wrap. Below the window is a small transparent pocket large enough to 

hold a field medical card or other medical record, and two protected 

sleeves next to the window permit the passage of IV tubing.

 The wrap is designed to be used on a litter but can itself become a 

field-expedient litter if necessary. Along the sides of the wrap are sleeves 

through which poles can be inserted. These sleeves have handholds for 

manual carries when poles are not available. It is recommended that the 

patient wear the mask while in the wrap, but this is not a requirement. 

However, before the casualty is put into the wrap, a cardboard insert must 

first be placed into the wrap to hold the window material away from the 

patient's face. 

 Although the protective wrap is permeable to both oxygen and carbon 

dioxide, the rate at which carbon dioxide is produced by a typical patient 

exceeds, by a small amount, the rate at which this gas passes through the 

wrap. Therefore, the patient should not be left in the wrap for longer than 

the recommended maximum of six hours. 

Decontaminable Litter
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 still desorbed vapors for 72 hours 

after all surface contaminants were removed.

 The decontaminable litter was developed to replace the canvas litters. 

The new litter is made from a monofilament polypropylene that has high 

tensile strength and low elasticity. The fabric does not absorb liquid 

chemical agents and is not degraded by decontaminating solutions. The 

fabric is flame retardant, highly rip resistant, and treated to withstand 

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 carrying handles retract into the 

metal pole frame for a closed total length of 83.5 inches (212.1 cm) to 

allow for loading 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 the second position was 

provided to allow increased gripping comfort by litter bearers. 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

6665-01-338-6602

 The Resuscitation Device, Individual Chemical (RDIC) is a ventilatory 

system consisting of a compressible butyl rubber bag, a NATO standard C2 

canister filter, a nonrebreathing valve, a cricothyroid cannula adapter, and 

a flexible hose connected to an oropharyngeal mask. The mask is 

removable 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 maximal 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.

 The RDIC will be fielded one per air ambulance, one per ground 

ambulance, and one per Chemical Agent Treatment, MES. 
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

5 ton truck 1 ea Doubles as transport 

to MTF

400 gallon 

water trailer

1 ea

5 gallon water 

cans

20 ea 10 for Cl solution 

preparation; 10 for 

refilling canteens

1 quart or 2 

quart canteens

20 ea For use by 

decon personnel

Chemical Agent 

Monitor

2 ea Authorized by 

MTO&E 6665-01-199-

4153

M8A1 ACAA 1 ea Authorized by 

MTO&E

6665-01-105-5623

Decontaminable 

litters

24 ea 6530-01-290-9964

M9 Chemical 

Detector Paper

10 rl 6665-01-049-8982

M8 Chemical 

Detection Paper

1 bx 6665-00-050-8529

M291 SDK 5 bx 4230-01-276-1905

M295 DKIE 2 bx 4230-01-357-8456

Calcium

Hypochlorite

16 bt

25 lb

6810-00-255-0471

6810-00-264-6591
M256A1 Chemical 

Agent Detection 

Kit

5 ea 6665-01-016-8399

Field Medical 

Cards

5 bk

Super Tropical 

Bleach (STB)

5 dr Shuffle pit preparation

Litter Support 

Stands

12 ea 6530-00-914-3490

Carrier, Litter, 

Wheeled

4 ea 6530-00-220-7186

7.25" Bandage 

Scissors1

1 cs 6515-00-935-7135

Sponge2 2 cs 7920-00-240-2559

"Zip-lock" bags 100 ea SSSC

35 gallon trash 

bags

50 ea Packaging waste from 

decon site

Field telephones 2 ea Authorized by 

MTO&E

TAP aprons 3 ea

5 ea

8 ea

4 ea

Small

8415-00-281-7813

Medium

8415-00-281-7814

Large

8415-00-281-7815

X-Large

8415-00-281-7816

Chemical 

protective 

gloves

5 pr

10 pr

10 pr

3 pr

Small

8415-00-033-3517

Medium

8415-00-033-3518

Large

8415-00-033-3519

X-Large

8415-00-033-3520

Chemical 

protective 

tactile gloves

5 pr

10 pr

10 pr

3 pr

Small

8415-01-138-2501

Medium

8415-01-138-2502

Large

8415-01-138-2503

X-Large

8415-01-138-2504
Grease pencils

2 bx SSSC

12 quart steel 

pail

16 ea 7420-00-773-0975

 1Removing BDOs, BDUs, hoods, protective boots, and combat boots by cutting will ruin 1 pair 

of bandage scissors for every two casualties.

 2Replace sponge when Cl solution is replaced. Cl solution should be replaced after being used on 

two casualties.

APPENDIX C

Preparation of Patient Decontamination Solutions

(0.5 & 5.0% Hypochlorite)

Preparation of the 0.5% and 5% hypochlorite solutions will require mixing the solutions in a container 

that can be closed after completion. By closing the container, the 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 described above.

 If you must use household bleach (i.e., Clorox or Purex), use the following procedure. The bleach 

should be packaged in 1-quart 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 hypochlorite granules found in the Chemical Agent Patient Decon 

MES, and mix 8 of the 6-ounce bottles of calcium hypochlorite into 5 gallons of water.

 If using calcium hypochlorite from a bulk package, retain one empty 6-ounce bottle from the 

Chemical Agent Patient Decon MES to measure the correct amount of dry calcium hypochlorite 
granules.

 If you must use household bleach (i.e., Clorox or Purex), use the bleach straight from the bottle; 

do not mix in water.

APPENDIX D

MEDICAL EQUIPMENT SET

CHEMICAL AGENT PATIENT TREATMENT

NOMENCLATURE/NSN AMOUNT

Atropine Inj. 0.70L/6505-00-926-9083 500 ea

Pralidoxime Chloride/6505-01-125-3248 100 ea

Boric Acid 5%/6505-01-153-3012 36 tu

Sodium Nitrite/6505-01-206-6009 12 pg

Sodium Thiosulfate/6505-01-206-6010 12 pg

Diazepam/6505-01-206-6010 3 pg

Atropine Sulfate/6505-01-332-1281 1 pg

Infusion Set Size: 2/6515-00-089-2791 60 ea

Airway Pharyn LGE/6515-00-300-2900 6 ea

Airway Pharyn SM/6515-00-300-2910 6 ea

Syringe Hypo 10 ml/6515-00-754-0412 .6 pg

Needle Hypo 18 ga/6515-01-754-2834 1.2 bx

Suction Apparatus/6515-01-076-3577 4 ea

NOMENCLATURE/NSN AMOUNT

Resuscitator Hand/6515-01-338-6602 4 ea

Syringe Hypo 50 ml/6515-01-076-3577 1 pg

Chest No. 4/6545-00-914-3490 3 ea

Gloves Chem/8415-01-138-2502 2 pr

Gloves Chem/8415-01-138-2503 2 pr

Bag Chem Cas/8465-01-079-9875 12 ea

MEDICAL EQUIPMENT SET

CHEMICAL AGENT PATIENT

DECONTAMINATION

NOMENCLATURE/NSN AMOUNT

M291 SDK/4230-01-276-1905 2 bx

Bandage Scissors/6515-00-935-7138 6 ea

Syringe Hypo/6515-01-280-2320 .6 pg

Litter Support/6530-00-660-0034 4 pr

Chest No. 4/6545-00-914-3490 1 ea
Chest No. 6/6545-00-914-3510 1 ea

M9 Chem Agt Paper/6665-01-049-8982 1 ro

Calcium Hypo/6810-00-255-0471 48 bo

12 qt Pail/7240-00-773-0975 10 ea

Sponge Cellulose/7920-00-884-1115 6 ea

Bag Plastic/8105-00-191-3902 2 ro

Plastic Sheet/8135-00-191-3902 2 ro

Work Gloves MED/8415-00-268-8353 25 pr

Work Gloves SM/8415-00-258-8354 25 pr

Black Pencils/7510-00-240-1526 2 dz

TAP Apron SM/8415-00-281-7813 2 ea

 

NOMENCLATURE/NSN AMOUNT

TAP Apron MED/8415-00-281-7814 4 ea

TAP Apron LRG/8415-00-281-7815 2 ea

Chem Prot Glove/8415-01-033-3517 2 ea

Chem Prot Glove/8415-01-033-3518 4 ea

Chem Prot Glove/8415-01-033-3519 2 ea

Decon Litter/6530-01-290-9964 4 ea

APPENDIX E 

Shown in the foldout is a casualty receiving area for contaminated casualties. This area must be the 

receiving area for any medical treatment area that receives contaminated casualties.

 

APPENDIX F

GLOSSARY OF MEDICAL TERMS

Acetylcholine. 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.

Alveoli. Microscopic air sac in the lungs where oxygen and carbon dioxide diffusion takes place 

through the alveolar walls.

Anorexia. Loss of appetite.

Anoxemia. Inadequate oxygenation of the blood.

Anoxia. Lack of oxygen.

Antibiotic. A natural or synthetic substance that inhibits the growth of or destroys 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. Cessation of breathing.

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 vigorous coughing and breathing 

exercises, as well as Positive Pressure Breathing with PEEP.

Bradycardia. A slow heart rate (less than 60 beats per minute).

Blepharospasm. A twitching or spasmodic contraction of muscles around the eye; if severe, can lead 

to closure of the eyes.

Bronchoconstriction. 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.

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.

Corium. The deeper layer of the skin under the epidermis. It contains the hair follicles, sweat glands, 

and sebaceous glands.

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 schlera 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.

Dermatitis. An inflammation or infection of the skin.

Dyspnea. Labored breathing resulting from an increased need for oxygen or inadequate air 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.

Epithelium. The outer layer of the skin.

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.

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.
Hematopoietic. 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 aerobic 

metabolism.

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 of oxygen to the cells.

Iritis. Inflammation of the iris with accompanying pain, photophobia, lacrimation, and diminution with 

transfer of oxygen to the cells.

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.

Miosis. Small, "pinpoint" pupils.

Mydriasis. Large or dilated pupils.

Necrosis. Death of tissue.

Necrotic. Pertaining to necrosis, end result of necrosis, dead.

Pruritis. Itching.

Pulmonary edema. Fluid in the lungs; associated with an outpouring of fluids from the capillaries into 

the pulmonary spaces (air sacs or alveoli) producing severe shortness of breath. In later stages, 

produces expectoration of frothy, pink, serious fluid and cyanosis.

Rhinitis. Inflammation of nasal mucous.

Rhinorrhea. Thin watery discharge from the nose; runny nose.

Tachycardia. A rapid heart rate (over 90 beats per minute).

Thrombocytopenia. An absolute decrease in the circulating platelets in the blood.

Urticant. Something that causes itching or stinging and a raised area on the skin (wheal).

Vacuolation. Formation of a space.

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 (mustard 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

AMEDD: Army Medical Department

BDO: Battle Dress Overgarment

BDU: Battle Dress Uniform

CAM: Chemical Agent Monitor

CANA: Convulsive Antidote, Nerve Agent

CARC: Chemical Agent Resistant Coating

C/B: Chemical/Biological

CDC: Chemical Decontamination Center

CBPS: Chemical and Biological Protective Shelter

CPS: Chemical Protective Shelter

DBDO: Desert Battle Dress Overgarment

DTD: Detailed Troop Decontamination

ECP: Entry Control Point

FMC: Field Medical Card

GREGG: Graves Registration

HTH: High Test Hypochlorite

KPH: Kilometers Per Hour

LBE: Load Bearing Equipment

LCL: Liquid Control Line

MES: Medical Equipment Set

MOPP: Mission Oriented Protective Posture

MTF: Medical Treatment Facility

MTO&E: Modified Table of Organization and Equipment

NAAK: Nerve Agent Antidote Kit

NATO: North Atlantic Treaty Organization

NCO: Noncommissioned Officer

NCOIC: Noncommissioned Officer-in-Charge

OIC: Officer-in-Charge

SDK: Skin Decontamination Kit

TAP: Toxicological Agent Protective (e.g., TAP Apron)

TC: Training Circular

VCL: Vapor Control Line

APPENDIX H

Shown in the foldout is the set-up for the Personnel Decontamination Station.

INDEX

2-PAMCl · 21, 22, 25
A

AC · 43, 44, 46, 47, 112, 172, 174, 179

acetylcholine · 7, 8, 10, 74, 196

aerosol · 4, 9, 60, 61, 65, 77

airway · 10, 21, 24, 80, 92, 130, 183

airways · 3, 10, 19, 32, 47, 51

alveoli · 51, 52, 197, 198, 200

antidotes · 16, 80

apnea · 10

atropine · 3, 19, 20, 21, 196

autoinjector · 17, 21, 22, 23, 24

B

BAS · 20, 47, 91

BDO · 62, 89, 94, 110, 112, 114, 130, 134, 135, 138, 139, 143, 145, 146, 147, 148, 159, 160, 161, 168, 170, 180, 

202

BDU · 84, 137, 138, 144, 148, 202

blister · 25, 28, 29, 31, 34, 37, 38, 39, 40, 74, 170, 174, 175, 176, 178, 182, 201

blister agent · 29, 35

blister agents · 28, 35, 175

blood · 11, 22, 44, 51, 52, 92, 178, 196, 197, 198, 199, 200, 201

breathing · 3, 10, 14, 15, 19, 20, 21, 23, 46, 54, 76, 90, 92, 197, 198

buddy-aid · 13, 16, 17, 23, 33, 34, 47, 79, 82, 88

BVO · 136, 147, 162, 163

C

CAM · 3, 31, 32, 82, 104, 119, 127, 140, 143, 148, 149, 151, 152, 174, 175, 202

casualties · 2, 79

casualty · 2, 5, 88, 104, 105, 130, 143

central nervous system · 7

cessation · 10, 47, 197

cholinesterase · 197

CK · 43, 44, 45, 46, 47, 112, 172, 174, 3

CNS · 12, 90

combat lifesaver · 8, 11, 12, 13, 16, 19, 20, 21, 23, 29, 37, 38, 40, 41, 47, 48, 79, 80, 81, 85, 86, 87, 90, 110

convulsions · 3, 5, 22, 1

Ct · 4, 5

CX · 112, 172, 174

cyanogen chloride · 44, 174

D

decon · 64, 82, 83, 84, 96, 122, 124, 126, 127, 141, 150, 152, 167, 185, 186

decontamination · 4, 5, 3, 59, 64, 97, 99, 100, 104, 105, 107, 119, 124, 127, 128, 130, 139, 140, 143, 150, 152, 154, 

165, 167, 189, 202, 203, 204

diazepam · 3, 15, 16, 17, 20, 21, 22, 23, 24, 84, 129

distilled mustard · 172

DKIE · 167, 168, 186
E

erythema · 32, 33, 39, 93

eye · 9, 20, 33, 38, 91, 133, 156, 157, 197, 198

eyes · 4, 9, 20, 31, 32, 34, 39, 47, 52, 77, 84, 140, 155, 158, 166, 197

F

fasciculations · 12

G

G · 112, 169, 172, 174, 175, 179, 202

GA · 3, 4, 6, 66, 176, 177, 1

gastrointestinal tract · 8

GB · 3, 4, 6, 25, 112, 176, 177

GD · 3, 4, 6, 25, 26, 112, 113, 176, 177

GF · 3, 4, 6, 25

gloves · 62, 89, 91, 125, 127, 131, 135, 136, 137, 138, 140, 143, 146, 163, 164, 167, 170, 183, 187

H

H · 27, 28, 29, 31, 32, 113, 118, 169, 172, 175, 204

HD · 27, 28, 29, 31, 32, 113, 172, 174, 176, 179

heart · 11, 77, 197, 200

HL · 28, 29, 31, 32, 33

HN · 172

hood · 89, 90, 101, 114, 131, 132, 133, 138, 140, 143, 144, 145, 155, 158, 167, 169

hydrogen cyanide · 44, 174

I

ICt50 · 5, 6

L

Lewisite · 28, 29, 33, 172, 178, 179, 201

liquid · 3, 15, 50, 202

litter · 80, 82, 94, 96, 103, 104, 105, 122, 124, 125, 127, 129, 130, 131, 133, 135, 136, 138, 139, 141, 143, 147, 152, 

181, 182

M

M17A2 · 156

M24 · 157

M256A1 · 3, 31, 44, 83, 118, 119, 121, 168, 171, 173, 186

M258A1 · 139

M272 · 168, 178

M291 · 3, 34, 35, 37, 64, 125, 126, 131, 132, 133, 139, 143, 149, 165, 166, 168, 186, 193

M295 · 3, 37, 132, 133, 143, 149, 165, 167, 168, 186

M40 · 62, 154, 155, 156

M8 · 3, 31, 81, 89, 101, 113, 118, 119, 121, 125, 127, 131, 140, 148, 149, 155, 168, 169, 171, 172, 185

M8A1 · 3, 82, 118, 119, 120, 168, 176, 177, 178, 185
M9 · 3, 31, 34, 81, 84, 89, 101, 112, 114, 119, 140, 168, 170, 185, 193

MARK I · 3, 14, 15, 16, 17, 20, 22, 26, 84, 126, 129, 131

mask · 9, 33, 34, 47, 54, 61, 81, 89, 114, 129, 130, 131, 133, 144, 145, 153, 156, 157, 158, 167, 169, 170, 171, 181, 

183

MOPP · 18, 33, 37, 62, 84, 85, 101, 106, 107, 118, 120, 121, 128, 130, 150, 153, 160, 161, 202

mouth · 8, 9, 14

MTF · 38, 39, 41, 80, 83, 85, 99, 100, 102, 185, 202

muscles · 7, 12

mustard · 27

N

NAAK · 202

NAPP · 84, 118

nausea · 3, 11, 70

nerve agents · 4, 5, 112, 113, 172

nitrogen mustard · 172

nose · 3, 9, 14, 21, 31, 36, 45, 47, 52, 64, 157, 200

NOx · 49

O

overboots · 136, 137, 141, 144, 147

oxides of nitrogen · 49

P

paralysis · 3, 12, 14, 15, 74, 75, 78, 199

PFIB · 49

phosgene oxime · 174

photophobia · 200

pralidoxime · 3

pretreatment · 24, 25, 26, 89

protective wrap · 125, 180

pyridostigmine · 24, 25, 26, 89

R

RDIC · 24, 127, 151, 180, 183

respiration · 12, 14, 47

respirations · 10

respiratory · 3, 4, 20, 22, 31, 32, 41, 61, 62, 64, 65, 67, 70, 71, 74, 76, 92, 155, 157

respiratory tract · 8

resuscitation · 24, 127

S

Sarin · 4

SDK · 34, 35, 64, 125, 126, 131, 132, 139, 143, 168, 186, 193, 203

secretions · 3, 10, 19, 20, 21, 39, 197

self-aid · 14, 15, 34, 37

signs · 3

skin · 3, 4, 5, 9, 10, 11, 12, 18, 19, 28, 29, 30, 31, 32, 33, 34, 37, 39, 50, 64, 65, 67, 71, 73, 74, 77, 82, 84, 89, 90, 
91, 104, 105, 127, 131, 138, 139, 140, 147, 149, 161, 165, 166, 170, 198, 199, 200

soman · 4

suction · 3, 80

sweat · 8, 11

symptoms · 3, 19, 20, 59, 66, 67, 69, 70, 71, 72, 75, 76, 77, 78, 84

T

Tabun · 4

Teflon · 49, 53

triage · 38, 83, 85, 86, 87, 88, 90, 97, 103 113, 122, 125, 128, 130, 139, 144, 152

U

unconscious · 20

V

vapor · 3, 6, 14, 36, 46, 203

ventilation · 3, 21, 24, 54, 80, 157

vomiting · 3, 11, 15, 46, 68, 69, 74, 75, 77, 78, 

VX · 3, 4, 5, 6, 25, 113, 174, 175, 176, 177

W

weakness · 3, 12, 13, 14, 15, 72, 78

NERVE AGENTS

GA, GB, GD, GF, VX
MUSTARD

HD, H

CYANIDE

AC, CK
 

 

PULMONARY AGENTS

CG
 LEWISITE

 L
PHOSGENE OXIME

CX

INCAPACITATING AGENTS

BZ, Agent 15
RIOT-CONTROL AGENTS

CS, CN