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Countering chemical agents.

errorism has become a clear and present danger.
Doubt no longer exists that terrorist groups are will-
ing to use chemical agents as weapons against civilian pop-
ulations. The enormous potential of such warfare is
illustrated by the 1995 Tokyo subway sarin gas attack,
which killed 12 people and injured thousands.1
weapons are a serious threat that we must prepare to man-
age, and EMS plays a vital role in responding to mass casu-
alty incidents involving such agents. To ensure a rapid and
effective response to a sudden surge in victims, EMS per-
sonnel need accurate and specific guidelines for the man-
agement of victims of chemical terrorism.
The release of chemical weapons by terrorists would
present an enormous challenge for the medical and public
safety communities. EMS personnel would be confronted
with a large volume of patients displaying atypical medical
conditions, such as wide-spread chemical burns, blistering,
blurred vision or blindness.2
Although the probability of an attack is small, improper
patient handling because of inaccurate, presumptive diag-
noses can lead to contamination of health-care providers.3
Therefore, the availability of clear and specific guidelines for
prehospital care providers will help ensure prompt treat-
ment of victims if and when a chemical attack occurs.
Most clinical publications regarding chemical warfare
agents have been scholarly reviews. Although this format
Multi-specialty panel presents
consensus guidelines for prehospital
management of mass casualties
from chemical warfare agents
By Richard C. Dart, Armando Bevelaqua, Craig DeAtley, Frederick Sidell, Lewis Goldfrank,
James Madsen, Richard Alcorta, Mark Keim, Erik Auf der Heide, Steven Joyce, Michael Shannon,
Jefferey Burgess, Mark Kirk, Fred Henretig, Richard Thomas, Robert Geller, Alvin C. Bronstein,
Edward Eitzen, Edwin Kilbourne, David Fenton, Dori Reisman, Robert Gum, Matthew Tarosky,
Philip Edelman, Andrew Erdman & Gregory M. Bogdan
has an important role, a review does not lend itself to prac-
tical clinical application. Thus, the guidelines developed by
this consensus process focus on critical actions rather than
a review of the topic. The guidelines are for the treatment
of patients exposed to nerve agents, chlorine, cyanide,
phosgene and sulfur mustard agents—the five chemical
substances commonly designated as potential terrorist
warfare agents.4
Development of treatment guidelines
These important triage guidelines were developed under
a grant from the Office of Public Health Emergency
Preparedness in the U.S. Department of Health and
Human Services, using evidence from the published medical
literature and from the clinical knowledge of a national
consensus panel with expertise in chemical warfare agents.
The panel conducted an extensive literature search (of
1966–2002 Medline data), including articles from all lan-
guages. The medical subject headings for the literature
search consisted of each agent name with sub-headings
“toxicity,” “poisoning” and “adverse effects”; text word
searches consisted of each agent name paired with “poison-
ing,” “toxicity,” “ingestion” or “inhalation.” The authors
also searched bibliographies of the collected articles and
current toxicology textbooks for additional citations, in-
cluding those prior to 1966.
EMS 37
At chemical incidents,
EMS crews must wait
for involved patients to
be processed through
the decon process.
Articles chosen for inclusion contained patient data from
human exposure to the agent of focus. Reviews, chapters,
editorials and commentaries were included only if they doc-
umented the diagnosis, management or outcome of at least
one patient exposed to the particular agent of focus.
Despite our extensive search, we found little data regard-
ing the prehospital treatment of victims of chemical warfare
in the medical literature. The original search identified a
total of 1,011 articles, of which 364 included patient data:
212 involved hospital management, and 14 involved pre-
hospital management (see Table 1, above).5-18
We assessed each article for data relevant to diagnosis, as-
sessment or treatment of a patient in the prehospital setting
by a physician reviewer not involved in the consensus
process. The non-voting panel chair drafted each outline al-
gorithm to include these questions:
1. What assessment of a patient should be made in the
prehospital arena?
a. What critical historical information should be
collected during prehospital care?
b. What critical components of the physical exam
should be performed during prehospital care?
c. Is there other critical assessment information that
should be collected during prehospital care?
2. Should treatment be performed during prehospital
a. What are the indications for treatment?
b. What is the dosage and dosing schedule?
c. How should the patient’s response be monitored?
Consensus panel & process
To develop these important guidelines,
a panel of 24 experienced clinicians and
researchers was assembled that was na-
tional in scope, addressed pediatric and
adult age groups, had expertise in
chemical agents, included multiple lev-
els of medical training (e.g., para-
medics, doctors of pharmacy and
physicians), and provided a broad cov-
erage of medical expertise: prehospital
care, pediatrics, emergency medicine,
military medicine, preventive medicine, infectious disease and
medical toxicology. (A detailed list of the panel is available
The consensus process (Figure 1, below left) involved
an initial meeting of the entire panel, followed by a mod-
ified Delphi approach using an electronic communication
process based on electronic mail, which included struc-
tured information flow, feedback to the participants and
anonymity for the participants.
The panel was asked to employ its expertise when re-
sponding to each round of the draft guidelines and to pro-
vide comments and pertinent additional literature citations.
Near the end of the process, a final meeting of the panel
participants was held to evaluate remaining issues and
achieve final panel consensus. The panel approved a final
version of each guideline by vote.
Each guideline begins with diagnosis of a chemical expo-
sure and provides specific clinical guidelines that address the
initial care of the poisoned patient, typically until the patient
has completed the emergency phase of care. Each guideline
also includes a clear decision point when the diagnosis is re-
considered: “Evidence of [agent name] exposure present?”
If the answer to this question is negative, the user is di-
rected to consider alternative diagnoses.
Table 2 (p. 39) presents the guidelines for prehospital
treatment of patients exposed to nerve agents. Additional
guidelines for the treatment of patients exposed to chlorine,
cyanide, phosgene and sulfur mustard agents can be down-
loaded from
At the instruction of the sponsor, guidelines for patient de-
contamination and personal protective equipment (PPE)
for providers were not developed by this group. Agencies
should comply with applicable state and federal guidelines
or standards for PPE for health-care providers.
A large volume of literature has emerged concerning
decontamination of the chemically contaminated patient,
but many have concluded that simple decontamination
by disrobing and copious flushing with water, with or
without soap, is appropriate and adequate for nearly all
chemical casualties.19
The ability of EMS or an emergency department (ED) to
accommodate patients could vary substantially depending
Primary Medline
Search Terms Chlorine Phosgene
hydrogen cyanide,
potassium cyanide,
sodium cyanide
Nerve agents,
sarin, soman,
tabun, VX, GB,
Total articles 241 94 276 79 321
Articles containing
patient data 74 37 71 18 1 64
Management site:
TABLE 1: Evidence Basis for Consensus Process
*References 5–7; **References 818
Selection of guidelines for development
Literature search and information collection
Preparation of background information
Preparation of first outline for each guideline
Electronic distribution of draft guidelines and evaluation form to panel members
Evaluation of responses from panel
Revision and redistribution of guidelines
Repetition of process until consensus was reached
FIGURE 1: Guideline Development Process
EMS 39
History Interpretation
Has patient received adequate decontamination? Appropriate decontamination must be performed before proceeding.
Multiple casualties? Common with exposure to nerve agent gas/mist.
Was this vapor or liquid/dermal exposure? Toxicity develops quickly after vapor exposure, but may require hours
after a dermal exposure.
Blurred, dark or dim vision? Common with nerve agent with vapor exposure.
Chest pain, tightness or shortness of breath? Common with nerve agent with vapor exposure.
Lacrimation, salivation, rhinorrhea,
diarrhea or tenesmus, sweating? All except tenesmus and diarrhea are common with nerve agent exposure.
Finding Interpretation
Miosis (pupillary contraction) Presence indicates nerve agent effect.
Signs of respiratory system effects
(wheezing/bronchoconstriction, apnea, cyanosis, hypoxia) Presence indicates clinically significant nerve agent effects.
Neurological effects (seizure, depressed level of
consciousness, weakness, decreased reflexes) Presence indicates clinically significant nerve agent effects.
Muscle fasciculations, twitching, spasms Local effect indicates that liquid agent has penetrated skin.
Systemic effect indicates severe systemic toxicity.
Signs of increased secretory activity (salvation,
lacrimation, rhinorrhea, profuse sweating) Presence indicates clinically significant nerve agent effects.
Evidence of Nerve
Agent Exposure
Test Capacity Adequate Capacity Exceeded
Pulse oximetry Recommended, if available. As patient volume allows.
Electrocardiogram (ECG) In selected patients with chest pain. As patient volume allows.
Capacity Adequate Capacity Exceeded
Severe: Comatose, seizures, apnea or severe
respiratory distress, generalized fasciculations
High-flow oxygen and atropine*
and 2-PAM* for confirmed nerve agent
Same as capacity adequate,
but IM route of administration
may be preferred, especially
if autoinjector used.
Moderate: Weakness, localized fasciculations, SOB,
chest tightness, wheezing/increased bronchial
secretions, significant GI effects (localized fasci-
culations and sweating indicate dermal exposure)
High-flow oxygen and atropine**
and 2-PAM** for confirmed nerve agent
Same as capacity adequate,
but IM route of administration
may be preferred, especially
if autoinjector used.
Eye pain (isolated miosis does not require therapy) Topical cyclopegic, if available.
NOTE: If the patient is convulsing, comatose or unresponsive—Immediately secure the airway and administer atropine and
pralidoxime as described under severe poisoning in this algorithm.
Chemical Mass Casualty Incident, EMS Nerve Agent Guidelines
• Atropine 6 mg IV or IM (other routes, such as ET, may be considered)
and 2-PAM 1 g IV over 20–30 min (or 1.8 g IM)
• Atropine 2 mg repeated q 2–5 minutes until drying of airway
secretions and improved respiratory status
• 2-PAM 1 g may be repeated in 1 hour
• Benzodiazepines (Lorazepam 2–4 mg or Diazepam 5–10 mg)
to treat seizures
• Atropine 0.05 mg/kg, 2-PAM 15–25 mg/kg IV or IM
• Diazepam 0.3 mg/kg IV
• Lorazepam 0.1 mg/kg IV or IM
• Midazolam 0.2 mg/kg IV or IM
• Atropine 2 mg IV or IM and 2-PAM 1 g IV over 20–30 min
(or 600 mg IM)
• Atropine dose should be repeated q 2–5 minutes until drying of
airway secretions and improved respiratory status
• 2-PAM 1 g may be repeated in 1 hour
• Atropine 0.05 mg/kg, 2-PAM 15–25 mg/kg IV or IM
• Diazepam 0.3 mg/kg IV
• Lorazepam 0.1 mg/kg IV or IM
• Midazolam 0.2 mg/kg IV or IM
Presentation is not typical of nerve agent. Consider other diagnoses.
CAUTION: After a liquid-skin exposure, patients may develop clinically
significant toxicity after an asymptomatic period of up to 18 hours.
on several factors, such as institutional level
of preparedness, time of day and staffing at
the time of presentation. To address this,
we created the concepts of “capacity ade-
quate” and “capacity exceeded” for each
guideline to identify essential recommen-
dations for when EMS or an ED cannot
accommodate the volume and severity of
patients presenting for care.
One limitation regarding guidelines
based on the chemical agent involved is that
the agent may be unidentified or misidenti-
It’s also possible that multiple agents
could be involved simultaneously. An
acronym for assisting the emergency re-
sponder in conducting a thorough, system-
atic assessment of a poisoned casualty—
ASBESTOS (agent, state of agent, body
sites, effects, severity, time course, other di-
agnoses and synergism)—has been previ-
ously described.21
We included a step for the
responder to assess the patient’s clinical
manifestations in the context of the pre-
sumed clinical agent and, if there are incon-
sistencies, to consider alternative diagnoses.
It is the objective of this panel that these
guidelines will be used to consolidate and
advance our preparedness efforts against
terrorism in communities across the nation.
We encourage readers to download the ad-
ditional algorithms at
terrorism-wmdresponse and share them
within their EMS agencies and with other
preparedness response partners. An effec-
tive EMS response is a critical first step in
responding to casualties of chemical agent
exposures, and these guidelines are another
tool to assist EMS responders.
The authors are members of the consensus panel
convened to develop these guidelines or those
that supported their efforts. Their complete
credentials and affiliations are available at
Acknowledgement: Sponsorship and par-
tial financial support for this project was pro-
vided by the Office of Public Health Emergency
Preparedness, United States Department of
Health and Human Services.
For more on WMD:
Chemical exposure guidelines
should be readily available to
EMS and decon teams.
Be sure crews are ready to explain the decon process to patients.
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EMS 41
ResearchGate has not been able to resolve any citations for this publication.
Chemical paint removers containing methylene chloride are widely used in domestic and industrial settings where exposure to a heat source with conversion to phosgene is possible. We describe a case of noncardiogenic pulmonary edema and subsequent hyperreactive airways following such an exposure. In addition, the various problems that have been associated with exposure to methylene chloride and phosgene are reviewed.
Phosgene poisoning can give rise to increased permeability pulmonary oedema and death. The gas was used in chemical warfare during World War I. In peacetime, cases of acute phosgene poisoning have been reported due to accidental exposure resulting from fire extinguisher use, the use of chemical paint removers and the inadvertent use of trichloroethylene during anaesthesia. We report a patient with phosgene poisoning from inhaling smoke grenade emissions.