Original Article

Bhopal Gas Tragedy Preparedness and Management of Chemical Disaster.

Nupur Chakravorty* M.D., R.K. Jain** M.D., R.C. Agarwal*** M.D., D.A.,

Abstract:
Massive releases of agents intentionally or unintentionally can be disruptive to the lines of individuals at
many levels. In 1984, the release of toxic Methylisocyanate gas had occurred suddenly and without warning
from the union carbide plant in Bhopal. This disaster had created thousands of casualties thereby overwhelming
local, health and medical resources.
We have discussed causes of the accident, and role of Methylisocyanate in the causation of health effects. We
present an overview of preparedness and response to the chemical disaster and emergency medical management.
Key Words: Chemical disaster; Preparedness; Chemical Warfare Agents.
Introduction

here is a growing list of chemical disasters in the

world today, but in terms of injury, morbidity and death
none can compare with the worlds industrial cataclysm
that occurred in the early morning hours of December 3,
1984, at the Union Carbide plant in Bhopal, India.
Threat of exposure to chemical warfare agents has
traditionally been considered a military issue. Several
events have demonstrated that civilians may also be
exposed to these agents.1 The intentional or unintentional
release of chemical warfare agents in a civilian community
has the potential to create thousand of casualties, thereby
overwhelming local health and medical resources.

An acute chemical emergency can occur as a result of

industrial disaster, 2 occupational 3 exposure, natural
catastrophe,4 chemical warfare and acts of terrorism.5
Bhopal Gas disaster
The worlds worst industrial disaster occured in India
in the early morning hours of December 3, 1984. The
accident took place at the union carbide Plant situated in
Bhopal, the capital city of Madhya Pradesh. The accident
was apparently initiated by introduction of water into
Methyl Iso Cyanate (MIC) storage tank, resulting in an
uncontrollable reaction with liberation of heat and escape

* Assistant Professor. Dept. of Anaesthesiology & Critical Care, Bhopal Memorial Hospital & Research Centre, Bhopal.
** Associate Professor. Dept. of Anaesthesiology & Critical Care, Bhopal Memorial Hospital & Research Centre, Bhopal.
*** Professor & Head. Dept. of Anaesthesiology & Critical Care, Bhopal Memorial Hospital & Research Centre, Bhopal.
Address for Correspondence: Dr. R.C. Agarwal, M.D., D.A., Prof. & Head, Dept. of Anaesthesiology & Critical Care, Bhopal
Memorial Hospital & Research Centre, Bhopal - 462 038. Madhya Pradesh, India.
Ph.No. 0755 - 2742212-16 Ext. 5104. Mobile: 98260 - 74278. E - Mail: colrca@hotmail.com
Received for publication on 01.12.06

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of MIC in the form of gas. Safety systems like flare tower

(to burn excess of gas),caustic soda scrubber (for
neutralisation) and the refrigeration unit were either not
functioning or inadequate to deal with large volume of
escaping chemical.6
Manufacturing process of MIC
The process begins with a mixture of carbon - monoxide
and chlorine to form phosgene. Phosgene is then combined
with monomethylamine to form MIC. MIC is further mixed
with naphthol to produce the end product carbaryl.7
(Table 1)
Table - 1
CO + Cl2

COCl 2 ( Phosgene)

COCl2 + CH3 NH2

CH3 NHCOCl + HCl

CH3 NHCOCl

HCl + CH3 NCO (Methyl Isoacyanate)

Report on scientific studies on the factors related to Bhopal gas leakage.

New Delhi, India, Govt. of India. 1985.

Exposure Conditions
MIC is highly irritant to the skin, eyes and mucous
membranes of the respiratory tract. The irritant property
is based on its reactivity with water which enables it to
penetrate tissue and interact with protein. Absorption
through skin is known to occur.8

Factors which had contributed for human exposure

were atmospheric (low wind speed), distance of residential
from the plant, duration of exposure, activity during
exposure. Acute irritant effects of MIC created panic,
great anxiety and disorientation, resulting in running, that
in turn resulted in increased ventilatory rate, thereby
increasing dose of chemical delivered to respiratory
system.9
Health effects of the tragedy
In the early period following the accident, clinical
treatment of the injured took priority over the planning
and conduct of population-based studies to study the health
effects of the gas release. Almost all the epidemiology
for the late recovery period has been conducted by the
ICMR - branch Bhopal Gas Disaster Research Center.
About 10 epidemiological studies were initiated to monitor
long term trends in morbidity and mortality. However,
results from these studies are not yet known.

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Mortality
Of the more than 2 lakh persons exposed to the gas,
the initial death toll within a week following the accident
was over 2500. In November 1989, the department of relief
and rehabilitation, Government of Madhya Pradesh, placed
a toll at 3598, and by 1994, the toll was estimated to be over
6000 (Dept. of relief and rehabilitation, Bhopal Gas
Tragedy. Govt. of Madhya Pradesh. India. 1989). Most
of the later deaths appear to be occurring from respiratory
complications. Mortality rates had declined but are still
slightly higher in the severely exposed area (8.75/1000) in
comparison with the control area (7.5/1000)during May 1989
- March 1990. (Indian Council of Medical Research.
Bhopal Gas Disaster Research Centre.Annual Report.
Bhopal, India. 1991).10
Morbidity
ICMR symptom prevalence survey clearly indicate that
morbidity was higher in the exposed area (26%) as
compared with the control areas (18%) when assessed
during the period, Nov 1988 - Mar 1990.11
Though respiratory, ocular and gastrointestinal
symptoms accounted for most of the morbidity till late
report of 1990 (Indian Council Of Medical Research.
Bhopal Gas Disaster Research Center. Annual Report.
1991), the 1994 report showed that a large number of
subjects reported general health problems (exposed 94%
v/s unexposed 52%) and episodes of fever (exposed 7.5/
year v/s unexposed 2.5/year). Respiratory, neurological,
psychiatric and ophthalmic symptoms also showed a strong
gradient by exposure category.12
Issues In disaster preparedness
A review of health effects of the 1984 disaster shows
continuing morbidity of a multisystemic nature in the
exposed population. The complexity of the Bhopal crisis
was underscored by the severe mortality and morbidity as
well as its occurrence in a developing nation that had little
experience in dealing with chemical disasters. It is widely
acknowledged that most prehospital and emergency
medical personal even in USA are currently not well
prepared, trained or equipped to deal with incidents
involving chemical trauma. The disaster exposed serious
deficiencies in preparedness and major problems of
coordination.13,14

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Disaster Preparedness
Any emergency medical or public response to a major
incident involving chemical agent will require co-ordination
and co-operation among local, state and federal bodies.
Relevant issues in disaster preparedness for acute chemical
exposure include education and training of emergency
personnel, disaster planning, public education, deployment
of specialized disaster planning, deployment of specialized
team and stock filling of appropriate antidotes.15
Education and Training
A limited number of opportunity currently exist for
civilian professionals to learn about characteristics, clinical
assessment and management of patients exposed to
chemical agents. Currently training programme is running
for emergency responders and hospital personnel at
disaster management institute at Bhopal. Defense ministry
is also playing leading role in coordinating training
programme. Task force should be appointed by the
government to develop the strategy that aims to establish
effective, sustainable training opportunities for prehospital
personnel, emergency nurses and physicians.
Disaster Plans and Exercises
It is essential that training to be conducted in parallel
with review of preparedness of hospital personnel and
general public. Issue of special relevance to acute
chemical emergencies includes command and control,
equipment, triage, decontamination, and population
evacuation. Patient treatment and disposition should be
addressed. Once disaster plan has been updated, it is
necessary to conduct exercises to evaluate planning,
training and readiness to respond to chemical disaster.16
Public Education
Public education activities are necessary to keep the
community well informed and to counter the spread of
misinformation. This is especially important for community
located near military stockpile sites or chemical industries.
Appropriate instructional methods are community
seminars, distribution of publications and presentation on
local radio and television.17
Specialized Response Team
A variety of Chemical / Biological incidence response
force have been established in United States. Metropolitan

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medical response system is established in 27 major cities

in United States. 18 Pre-deployment of specialized
response teams are indicated in events that has got potential
terrorist target such as major sporting events, political
conventions and visits of prominent world leaders. This
unit consists of approximately 300 personnel skilled in the
provision of security and area isolation, agent detection
and identification, patient decontamination and medical
support.19
Stock Piling of Antidotes and Antibiotics
The stock piling of the antidotes are necessary to treat
large number of casualties after terrorist or industrially
induced chemical biological disaster.20
There are several problems associated with
development of antidotes stock piles like appropriate
quantities of the drugs to be stored, rapid distribution of
antidotes to the victims and cost effectiveness to develop
stock piles.
Principals of Emergency Response
Any event of chemical disaster whether resulting from
terrorism or industrial accident, multidisciplinary approach
will be necessary. Co-ordination among the pre hospital
personnel, law enforcement agencies, emergency
physician, toxicologist, laboratorians, environmental
specialist, and security personnel will be required.
Levels of Response
Local responders will generally be the first on the scene
after the chemical disaster, but their capabilities and
resources to respond to this incidence is severely limited
in most of the cities. The primary goal of domestic
preparedness program is therefore to increase the capacity
of local emergency response system. Larger incidents
will require assistance from neighboring cities and national
resources.21
Command and Control
In United States co-ordination and response activities
after disaster is generally organized under Incident
Command System (ICS). This system promotes coordination and communication between responding
agencies and minimizes duplication of effort. A major
advantage of this system is provision of a unified command
to oversee various agencies and disciplines responding to
disaster.22

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Personal Protective Equipment

Responders must take measures to protect themselves
before entering the contaminated area. Use of Personal
Protective Equipment (PPE) to protect airway, skin and
eyes is an indispensable component of emergency
response. Limitations to the use of PPE are restriction of
physical activity, dehydration, heat related illness and
psychological effect.23 To avoid this, emergency personnel
should be trained to use PPE appropriately. PPE includes
clothing and respiratory gears that is used to shield an
individual from assortment of chemical, biological and
physical hazard that may be encountered during incident.
Assessment
Principles of rapid assessment after chemical disaster
are similar to those following any disaster. The rapid
assessment aims to determine the nature and magnitude
of the emergency, presence of ongoing hazard, extent or
risk of injury to the population, the availability of local
resources and need of external resources. 24 This
assessment will assist in determining appropriate patient
care including mass decontamination, use of antidotes and
need for evacuation.
Demarcation of the contaminated Area
The contaminated areas are clearly marked as Hot
Zone or Warm Zone. The Cold Zone serve as Clean,
uncontaminated, patient treatment, dispatch area. It is
positioned upwind of Hot Zone and 50 yards or more from
Warm Zone.25
Agent detection & Identification
Definitive identification of agent will require resources
of analytical laboratory and will generally take several
hours. Therefore it is necessary to have medical
interventions based on clinical judgment. Clinical
symptoms and signs in exposed individual may be the most
useful indicators of the likely agent and will be critical in
guiding emergency medical care.26 In addition, samples
of air, soil, water & biological specimens may be required
to identify the agents precisely and to quantify levels of
exposure.
Triage of individual exposed to chemical disaster poses
several challenges but underlying principals are the same
as for any mass casualty. Triage at the scene should be

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conducted by the specially trained emergency medical

personnel who are familiar with chemical agents and use
of PPE.
Decontamination
Decontamination should be performed as close to scene
as possible i.e. warm zone and ideally before patient
transportation. Most simple way of decontamination is
washing with soap and water. Commonly used agent for
skin decontamination is 1-2% or Hypo-chlorite.27
Preparedness of Emergency department
Emergency department personnel require training in
the recognition and clinical management of chemical
casualties. Specialized team who are skilled in use of
PPE and decontamination procedure should be used. Steps
must be taken to ensure that staff and patients already
within the hospital area are not at risk of secondary
exposure to chemical agents.28
Protecting the Public
Evacuation of patients may not be possible in case of
sudden release of chemical agent affecting large
population. By use of public warning and information
systems population should be advised to stay in sheltered
place and adopting measures like sealing of windows and
doors and use of distributed gas masks.29
Management of Chemical Disaster
Treatment of the casualties begin with ending the
exposure, which can be accomplished by evacuating or
extricating affected person and then by thorough
decontamination. Persons in the vicinity of a chemical
release can themselves take several steps like moving
away upwind of chemical release point. If they are indoors
they should close all windows and doors and shut down
both heating and cooling systems. Person suspected to
have sustained exposure should remove their clothings
and shower thoroughly with soap and water as soon as
possible.30
Emergency personnel or reserve personnel should
reach affected site by using appropriate personnel
protective equipment. Before transporting casualties to
the hospital, the contaminated clothing of victims should
be removed and injured person should be irrigated with
water then washed with soap and water.31

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Chemical disaster involves mass exposure to population

and many of the casualties will remain ambulatory,
therefore, hospital should establish triage centers. At first,
patients should be isolated and decontaminated by removing
clothing followed by shower with soap water.32
The clinical signs of severe chemical injury include
altered mental status, respiratory insufficiency,
cardiovascular instability and unconsciousness or
convulsions. Initial supportive therapy should be focused
on airway patency; ventilation and circulation, at the same
time patients are examined for burns/trauma and other
injuries. When poisoning is suspected routine guidelines
for treatment of poisoning like administration of antidotes
or supportive treatment like administration of naloxone to
patients with respiratory depression or diazepam for
patients with convulsions is done.33,34
Chemical warfare agents are broadly classified as shown
in Table 2.
Table - 2
CATEGORY

COMMON NAME

Nerve agents

Tabun
Sarin
Soman

Vesicants

Sulfur mustard
Lewisite
Phosgene oxime

Pulmonary agents

Phosgene
Chlorine

Cyanides

Hydrogen cyanide
Cyanogen chloride

Nerve Agents
Organic phosphorus pesticides, carbamate pesticides
and organophosphorous compounds are developed as
chemical weapons known as nerve agents. They all inhibit
acetyl cholinesterase resulting in cholinergic over
stimulation with both muscuranic and nicotinic effects.35
Muscuranic symptoms include profuse exocrine
secretions like rhinorrhoea, salivation, bronchorhoea and
sweating. The ophthalmic symptoms are miosis, dim vision,
and headache and eye pain. If large doses of cholinesterase
inhibitors are ingested, they may cause abdominal
cramping, nausea, diarrhea and urinary incontinence.
Nicotinic symptoms include the cardiovascular signs
like tachycardia and hypertension. Benzodiazepenes are
the only effective anticonvulsants drugs for the treatment

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of convulsions. Specific antidotes are atropine and

pralidoxime in large doses.
Pulmonary Irritants
The hazardous material most frequently released in
Industrial accidents are irritants to respiratory tract.36
Other respiratory irritants are tear gas and choking agents.
Highly soluble irritants such as ammonia are absorbed in
the upper respiratory tract whereas less soluble irritants
such as phosgene penetrate more deeply and may cause
acute lung injury. Regardless of degree of solubility
chemical irritant may cause effects on upper respiratory
tract e.g. laryngeal edema or lower respiratory tract e.g.;
acute lung injury.37
Treatment of the respiratory irritants begin with life
support & administration of high flow oxygen. Patients in
whom hoarseness or stridor with wheezing or altered
mental status develop, may require endotracheal intubation.
Bronchodilators and corticosteroids may be added to treat
severe airway reactivity. Patients with acute lung injuries
are treated with ventilatory support and PEEP.38
Vesicants
Vesicants, which are blistering agents, are extremely
irritating to the eyes, skin, and airways.39 Ophthalmic
effects range from conjunctivitis to the corneal damage.40
Dermatological lesions can develop and progress from
erythema to vesicles and bullae.41 Airway involvement
can occur within 24 hrs after exposure and can range from
epistaxis, pharyngitis, laryngitis and hemorrhagic pulmonary
edema.42 Ophthalmic treatment consists of administration
of topical anticholinergic agents, antibiotics and petroleum
to prevent eyelids from striding. Care of burns involves
debridement, administration of antibiotics and analgesics.
Critical care involves treatment of hypocalcaemia,
hypomagnesaemia and ventilatory support.43
Cyanide
High concentrations of cyanide may cause respiratory
distress and seizures in seconds, respiratory arrest within
3 to 5 minutes, and cardiovascular collapse/death within
10 minutes. Lower concentrations may temporarily
incapacitate victims, causing anxiety, dyspnea,
hyperventilation, giddiness, headache, dizziness, nausea,
palpitations, and flushed skin.44

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Cyanide poisoning is treated with 100 percent oxygen

long with sodium nitrite and thiosulfate. Nitrite induces
the formation of methemoglobin, which is bound by cyanide,
yielding cyanomethemoglobin.45
For cyanide poisoning due to smoke inhalation, most
authorities recommend the use of thiosulfate, oxygen, and
supportive measures and recommend reserving nitrites for
patients who are hypotensive, acidemic, or comatose.46
Conclusion
Successful outcome of population who are exposed to
chemical substances depends upon extricitation of casualty,
immediate provision for decontamination and basic life
support followed by excellent supportive care. Community
preparedness for acute chemical emergencies requires
well-organized emergency medical response systems as
well as clinicians and hospitals trained for readiness.

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