Chemical Terrorism

By James A. Geiling, MD, FCCP

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Objectives

1. Review the history of chemical warfare agents.
2. Examine the pathophysiology of chemical agents.
3. Review detection, protection, and decontamination challenges related to chemical agents.
4. Using a plausible case scenario, review the possible presentation and diagnostic challenges providers may face in a terrorist event employing chemical agents.
5. Outline the presentation and management of a likely chemical warfare agent.

Key words

agent; chemical; history; management; presentation; terrorism

Abbreviations

Ach = acetylcholine; AChE = acetylcholinesterase; EMS = emergency medical services; HAZMAT = hazardous material; ICAD = Individual Chemical Agent Detector; 2-PAMCl = pralidoxime chloride

"If supposedly civilized nations confined their warfare to attacks on the enemy's troops, the matter of defense against warfare chemicals would be a purely military problem, and therefore beyond the scope of this study. But such is far from the case. In these days of total warfare, the civilians, including women and children, are subject to attack at all times."—Colonel Edgar Erskine Hume, Medical Corps, US Army, 1943¹

Why should biological or chemical agents concern pulmonary and critical care physicians? The events of September 11, 2001, and the anthrax cases that followed demonstrate that acts of terrorism, to include those of chemical or biological agents, have come to the forefront of our daily lives. Current governmental reports predict repeated events over time. Only through intensive education and training can physicians adequately prepare to meet the medical challenges imposed by chemical, biological, radiologic, nuclear, and explosive weapons of terror. Much work lies ahead, for > 70% of hospitals may not be prepared to handle such incidents² and only 20% have any plans for managing biological or chemical incidents.³

This review presents a plausible terrorist case scenario as a mechanism to explore the realm of chemical agents, including a review of their history, the biochemical and physiologic effects of the most common chemical warfare agents, detection of their presence, protection from their effects, and management of the casualties who succumb to them.

Biological and chemical weapons have developed into weapons of choice for terrorists because of a variety of characteristics of the agents.⁴ Most important is they can be found in stores everywhere and are available at low cost. Simple components in small amounts can be turned into biological or chemical weapons with minimal education and training; the directions oftentimes are published on the Internet. Once produced, they are usually odorless, colorless, and tasteless, making detection difficult. When they are employed, they do not destroy the target's infrastructure like an explosive device, so the terrorist can deploy the weapon with maximum impact on people. In addition, these agents (particularly biological weapons) often have a latency period.

Knowledgeable experts often have worked for governments involved in developing or employing these weapons around the world. Many of these specialists, now without their government's employment, may be employed by terrorist networks or nations seeking to develop such weapons. These persons often include physicians; four out of five physicians who become involved in terrorist activities engage in biological and chemical terrorism.⁴ Government-sponsored programs normally have extensive supplies of agents, documented procedures, and experimental results to support their efforts. Finally, the notoriety of these agents attracts intensive media attention, often supporting the terrorist's motives in seeking such attention.

Historically, chemical weapons studies are rare in peacetime except for military research efforts. Operation Desert Storm and the sarin gas release in Tokyo reintroduced the chemical weapons concept into the mainstream of society's consciousness. Future terrorist activities will eventually include the use of chemical weapons because "…trained chemists would have no difficulty producing such chemical agents."⁵

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