Effective Use of Drugs to Counter Chemical Terrorism

Abstract

In the present international climate, preparedness and effectively responding to chemical terrorism is of serious concern. Given that antidotes are available for chemical agents, such as nerve or blood (cyanide) agents, the key to survival is how quickly and effectively antidotes can be administered in mass casualty events. To counter agents acting on the nervous system, atropine, pralidoxime and diazepam are generally administered, but aside from pralidoxime, no general consensus has been reached regarding the use of oximes, such as obidoxime and HI-6. In addition, the use of diazepam is being investigated in comparison to other benzodiazepines. As antidotes to blood agents, sodium nitrite (or amyl nitrite) and sodium thiosulfate are often used in the United States, but in Europe, dicobalt edetate and hydroxocobalamin are used. In particular, hydroxocobalamin appears to be a promising antidote against blood-agent terrorism. In mass casualty events caused by chemical terrorism, it is also necessary to consider the most effective administration routes of the antidote (intravenous, intramuscular or intraosseous). Hence, it is imperative to adequately discuss when first responders (rescuers) wearing personal protective equipment (PPE) should administer these drugs and who should be in charge of such drug administration. Here these problems are reviewed and discussed with reference to the current literature.

Does wearing CBRN-PPE adversely affect the ability for clinicians to accurately, safely, and speedily draw up drugs?

“…16 There is no maximum dose of atropine 13 as treatment is repeated until respiratory symptoms diminish. Okumura et al 16 state that following exposure to an organophosphate-based compound (to include nerve agents) casualties would require between 2 mg IM (mild symptoms) to more than 10 mg (severe symptoms) of IM atropine during their immediate management. This dosing regime resembles that used by the U.K. military, 17 which is initially based on self/buddy aid with IM atropine.…”

“…Although the onset of symptom relief following IM administration is significantly slower than that following IV administration (2 mg atropine IV onset 1 min vs. 8 min in IM administration) 16 and absorption can be unpredictable in the hypotensive or hypothermic patient. 13 Critically ill/injured patients may require higher doses of antidotes (e.g., atropine) 16 and therefore the availability of prefilled syringes may confer a clinical benefit as both of the prefilled syringes were faster than either the glass or plastic ampoules (Tables 2 and 4). It is noteworthy that at the upper quartile participants took over 2 min to draw up drugs from PA and nearly 3 min from GA.…”