The authors explain the effects of exposure to respiratory irritants, vesicants, asphyxiants (including cyanide), and cholinergic agents (organophosphate insecticides and military nerve agents).

ABSTRACTHaving sufficient medical countermeasures (MCMs) available for the treatment of acetylcholinesterase-inhibiting nerve agent poisoned patients following a mass chemical exposure is a challenge for communities. After stockpiles containing auto-injectors are exhausted, communities need to be aware of alternative pharmaceutical options. The Department of Homeland Security Chemical Defense Program convened a federal interagency working group consisting of first responders, clinicians, and experts from the fields of medical toxicology, pharmacology, and emergency management. A literature review of pharmaceutical alternatives for treating nerve agent toxicity was performed. Pharmaceuticals that met the federal Public Health Emergency Medical Countermeasures Enterprise Product Specific Requirements were prioritized. Food and Drug Administration approval for one indication, market availability, and alignment to government procurement strategy were considered. This article summarizes the literature on comparative pharmacokinetics and efficacy against nerve agents (where available) of Food and Drug Administration approved drugs with muscarinic acetylcholine receptor antagonist and gamma-aminobutyric acid receptor agonist effects. This work is intended to serve as a resource of pharmaceutical options that may be available to communities (ie, emergency managers, planners, clinicians, and poison centers) when faced with a mass human exposure to a nerve agent and inadequate supplies of MCMs. (Disaster Med Public Health Preparedness. 2019;13:605-612)

History and Epidemiology Cyanide exposure is associated with smoke inhalation, laboratory mishaps, industrial incidents, suicide attempts, and criminal activity.39,113Cyanide is a chemical group that consists of one atom of carbon bound to one atom of nitrogen by three molecular bonds (C≡N). Inorganic cyanides (also known as cyanide salts) contain cyanide in the anion form (CN–) and are used in numerous industries, such as metallurgy, photographic developing, plastic manufacturing, fumigation, and mining. Common cyanide salts include sodium cyanide (NaCN) and potassium cyanide (KCN). Sodium salts react readily with water to form hydrogen cyanide. Organic compounds that have a cyano group bonded to an alkyl residue are called nitriles. For example, methyl cyanide is also known as acetonitrile (CH3CN). Hydrogen cyanide (HCN) is a colorless gas at standard temperature and pressure with a reported bitter odor. Cyanogen gas, a dimer of cyanide, reacts with water and breaks down into the cyanide anion. Cyanogen chloride (CNCl) is a colorless gas that is easily condensed; it is a listed agent by the Chemical Weapons Convention.

Abstract Decontaminating patients who have been exposed to hazardous chemicals can directly benefit the patients’ health by saving lives and reducing the severity of toxicity. While the importance of decontaminating patients to prevent the spread of contamination has long been recognized, its role in improving patient health outcomes has not been as widely appreciated. Acute chemical toxicity may manifest rapidly—often minutes to hours after exposure. Patient decontamination and emergency medical treatment must be initiated as early as possible to terminate further exposure and treat the effects of the dose already absorbed. In a mass exposure chemical incident, responders and receivers are faced with the challenges of determining the type of care that each patient needs (including medical treatment, decontamination, and behavioral health support), providing that care within the effective window of time, and protecting themselves from harm. The US Department of Health and Human Services and Department of Homeland Security have led the development of national planning guidance for mass patient decontamination in a chemical incident to help local communities meet these multiple, time-sensitive health demands. This report summarizes the science on which the guidance is based and the principles that form the core of the updated approach. (Disaster Med Public Health Preparedness. 2014;0:1–7)

Most approaches toward chemical and radiological/nuclear (CRN) incidents focus on the clinical skills of the first receiver. These skills are certainly important and are addressed throughout this article. Management skills are often overlooked. The following are basic competencies in information management for the emergency medicine physician to handle large-scale CRN incidents: planning information; incident management information; toxicant management; disposition/definitive care management; and recovery management. Information management and synthesis are crucial throughout the phases of the disaster cycle: planning, response, mitigation, and recovery.

Drug-induced prolongation of the QT interval is frequently encountered after medication overdose. Such toxicity can result in degeneration to torsades de pointes (TdP) and require overdrive pacing. We present 3 cases in which intentional medication overdose resulted in QTc prolongation with subsequent degeneration to TdP. Despite appropriate care, including magnesium therapy, each case required overdrive pacing for resolution of TdP. Although rarely encountered, patients with drug-induced TdP can be successfully managed with overdrive pacing.

An accident or a deliberate terrorism attack releasing hazardous chemicals will create chaos, confusion, and seeming unpredictability that complicates the emergency response. Clinicians are challenged to urgently treat patients needing care, even before a chemical is confirmed. Emergency response planning that focuses on preparing for predictable challenges to the health care system and applies basic toxicologic principles to clinical decision-making can bring a sense of order to the chaos and provide medical care that will be best for the most victims of an incident.

There is well-founded concern that a chemical or radioactive agent will at some point be used as a weapon of terror. There are several antidotes that, if used correctly in a timely fashion, can help lessen the harm caused by these agents. This article is meant to introduce the clinician to several such agents, along with the antidotes useful in the management of exposure to these. It covers the indications, administration, and precautions for using these antidotes.

In the early part of chemical terrorism or hazardous materials events, protective actions and patient care require empirical decisions because reliable and accurate information may not be readily available. It has become increasingly important to identify reliable information resources that are the most likely to be accessed for information during these events. We sought to identify information resources that volunteer Emergency Medical Services (EMS) providers would use during a suspected chemical exposure. Survey questionnaires were completed by 116 of 151 (76.8%) suburban and rural EMS providers. In the past 12 months, most participants used medical journals and textbooks (59.5%), internet sites (57.8%), and poison centers (55.2%) as information resources. For two hypothetical scenarios involving chemical exposures, poison centers were most frequently chosen as likely contacts for information regarding the identity of the agent (case 1: 52.6%, case 2: 48.3%), treatment (74.1%, 64.7%, respectively), and antidote (59.5%, 49.1%, respectively). Fire department hazardous materials team tied with poison centers as the highest for chemical agent in the second scenario (48.3%) and was ranked highest both for decontamination (75.0%, 64.7%, respectively) and personal protection (56.9%, 45.7%, respectively). Poison centers were selected as the best resource for timely information (70.7%), availability (69.0%), and ease of contact (72.4%), and second highest for knowledge of chemical agents (44.0%), after CHEMTREC (56.9%). Finally, poison centers and CHEMTREC received the highest overall ratings (28.4% and 26.7%, respectively). Poison centers are viewed as an important information resource by EMS providers and may be the most commonly sought resource for various information needs during a suspected chemical exposure.

Since September 11, 2001, awareness of potential terrorist targets has increased greatly. Industrial chemicals, either in storage or transport, are now considered dangerously accessible materials that could be used to cause substantial harm. In response to this new threat, emergency organizations are beginning to plan for such possible chemical releases. Currently there is no tool that allows a community to track, analyze, query, and display data about these chemical "weapons of opportunity" and the readiness of the communities around them.Decision support systems are computer environments designed to assist decision makers within a particular problem-solving context. A particular type of DSS, environmental decision support systems (EDSS), assists environmental scientists and planners in making environmental management decisions. A hazardous materials decision support system called "FALCON" will assist emergency organizations by integrating information describing chemical inventories, security, health readiness, geography, and population into one information system. Emergency organizations will be able to assess response readiness of a community for chemical releases and prioritize antidote stockpiling, training, and security. Emergency organizations and first responders will use the FALCON DSS to simulate and prepare for real-time events, assess possible casualties, and receive emergency contact information. And with the help of FALCON, law enforcement and security personnel will be able to evaluate and augment protection of the most dangerous facilities. (c) 2006 Elsevier Ltd. All rights reserved.

Atypical antipsychotics and newer antidepressants are commonly prescribed medications responsible for tens of thousands of adverse drug exposures each year. The emergency medicine physician should have a basic understanding of the pharmacology and toxicity of these agents. This knowledge is crucial to providing proper care and timely management of patients presenting with adverse drug effects from exposure to atypical antipsychotics and newer antidepressants.

Acetaminophen (acetyl-para-amino-phenol or APAP), an antipyretic and analgesic, is a common component in hundreds of over-the counter and prescription medications. The wide usage of this drug results in many potentially toxic exposures. It is therefore critical for the clinician to be comfortable with the diagnosis and treatment of APAP toxicity. Prompt recognition of APAP overdose and institution of appropriate therapy are essential to preventing morbidity and mortality.

Thallium and arsenic have been used as a means of criminal poisoning. Although both manifest characteristically with peripheral neuropathies, thallium is associated with alopecia and arsenic with gastrointestinal symptoms. We describe the symptoms, physical findings, diagnostic test results, and outcomes in a group of men poisoned with thallium and arsenic. Seven patients had evidence of elevated thallium levels, and 2 patients had elevated arsenic and thallium levels. The most commonly reported symptoms included myalgias, arthralgias, paresthesias, and dysesthesias. Five patients developed alopecia. All patients with symptoms and peripheral neuropathies had characteristic blackening of their hair roots. Initially treated with dimercaptosuccinic acid, patients were switched to multiple-dose activated charcoal after testing revealed thallium poisoning. By 6 months, all patients' symptoms and peripheral neuropathies improved, but 5 patients had ongoing psychiatric problems. Thallium remains a means of criminal poisoning and should be considered in any patient with a rapidly progressing peripheral neuropathy with or without alopecia.

A 16-yr-old male attempted suicide by ingesting approximately 4000 mg of flecainide. He developed coma, hypotension, and ventricular tachycardia. In addition to supportive care and antidysrhythmics, he received intravenous sodium bicarbonate for the wide complex dysrhythmia. Animal studies and anecdotal human experience have suggested that increasing the extracellular sodium improves cardiac conduction in flecainide toxicity. The patient's QRS narrowed immediately following sodium bicarbonate infusion. Sodium bicarbonate may be useful in the treatment of widened QRS and ventricular ectopy resulting from flecainide toxicity.