| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
| ||||||||||||||
| ||||||||||||||
|
|
|
|
||||||||||||
|
||||||||||||||
From the Department of Anaesthesia & Intensive Care Medicine, Landspitali University Hospital, Reykjavik, Iceland
Address correspondence and reprint requests to Gisli H. Sigurdsson, MD, PhD, Professor & Chairman, Department of Anaesthesia & Intensive Care Medicine, Landspitali University Hospital, Hringbraut, IS 101 Reykjavik, Iceland. Address email to gisli{at}doctor.com
In recent years the intentions and behavior of terrorist organizations appear to have changed. With the chemical nerve gas attack in the Tokyo subway system in 1995 and two simultaneous bomb blasts at United States embassies in East Africa in 1998, it became evident that these organizations were ready to sacrifice thousands of civilians for their causes. At that time there were already those saying that we had to prepare ourselves for living in a world increasingly at risk from terrorist attacks. And if anyone was still in doubt, this was confirmed by the terrible events on September 11, 2001.
After the nerve gas attack in Tokyo (1,2), both civil and military authorities in several countries started pursuing a number of activities to counter paramilitary and terrorist threats from nuclear, biological, and chemical agents. Several review articles on the management of victims exposed to chemical weapons appeared in the medical literature (3–7). Since the September 11, 2001 attacks and the subsequent anthrax scare, there has been growing concern about the risk of terrorist use of chemical and biological agents (7–12).
As a part of continuing preparation for this new reality, many governments have been preparing guidelines on how to respond to this new threat (3), and some local communities have conducted simulated terrorist incidents (drills) to provide training for the primary response teams and hospital staff (13–15). Important lessons can be learned from these drills, and the knowledge gained could have widespread applicability in health care delivery systems worldwide, especially in the areas of decontamination, triage, on-site medical care, and transportation (14).
The threat of exposure to chemical warfare agents has traditionally been considered a military issue. In most countries the resources needed to treat a major chemical catastrophe are stockpiled in centralized locations by the armed forces and are therefore not immediately available in many urban areas. However, as recent events have demonstrated, civilians may also be exposed to these agents. The dispersal of a chemical warfare agent (intentional or accidental) in an urban area has the potential to cause thousands of casualties, rapidly overwhelming local health and medical resources. Not unexpectedly, recent studies conducted in the United States suggest that hospitals are not prepared to handle biological or chemical events, especially in areas such as mass decontamination, mass medical response, information and training among health care professionals, health communications, and security issues (9,10). In the past, local communities have primarily been prepared to respond to chemical incidents involving industrial agents. Today, the growing threat of chemical terrorism requires that local communities increase their stocks of antidote and expand their expertise in areas such as incident management, agent detection, protection of emergency personnel, and clinical management (10).
Chemical terrorism is causing such concern for the local community-based authorities responsible for civil emergency issues because chemical agents, especially nerve gases, are fast-acting and can cause mass casualties in urban areas within a very short time. Counter-measures can save many lives but require appropriate emergency response at the scene with detoxification facilities, administration of antidotes, and emergency life-support. As nerve agents have such rapid action, the counter-measures must be available within minutes rather than hours. This means that basic decontamination and protection equipment, supplies of antidote, and trained rescue and medical teams, must be available without delay in urban areas. To offer reasonably good safety coverage for urban communities, major hospitals would have to be equipped to take care of victims who have been exposed to chemical nerve agents.
Although paramedics and emergency department staff would, in most cases, be in the front line in a major chemical warfare incident, they would soon be overwhelmed and anesthesiologists would certainly be the next in line because of their ability to respond to the need for life-support (11). Anesthesiologists’ extensive knowledge of physiology and pharmacology helps them to understand the effects of chemical nerve agents. They should also know the basic principles of treatment of mass casualties after exposure to chemical nerve agents, as their expertise may be needed when a mass terrorism event occurs and such an event may occur virtually anywhere, anytime.
The so-called nerve agents, or acetylcholinesterase blockers, are the most dangerous chemical weapons today. They have acquired their name because of their effects on the nervous system: they prevent the breakdown of acetylcholine, causing widespread peripheral and central neuronal paralysis, which can be rapidly fatal without timely administration of antidotes (11–12). The nerve agents, including tabun, sarin, soman, and VX, are all organophosphorous compounds closely related to the organophosphate pesticides. They are chemically rather stable, easily dispersed, highly toxic, and are effective within minutes when absorbed either through the skin or through the airways. Nerve agents can be manufactured using fairly simple chemical techniques in improvised laboratories. The raw materials are inexpensive and generally readily available. In addition, these agents are easy to transport and difficult for controlling authorities to detect.
Sarin, which was used in the Tokyo subway blast, is one of the most likely agents to be used by terrorists. It is a colorless and odorless gas/vapor and is more than 20 times more deadly than cyanide gas and potassium cyanide. The vapor is slightly heavier than air; thus it remains close to the ground during calm weather conditions. Although sarin may cause limited harm when dispersed in open air during windy conditions, it can cause great damage if it is spread in enclosed areas such as crowded underground stations, in the air conditioning systems of large buildings, or in airport arrival/departure halls. All this makes sarin attractive to terrorists aiming to causing mass civilian casualties.
This issue of Anesthesia & Analgesia contains an important study by Vardi et al. (16) that deals with emergency management of casualties after exposure to nerve agents classified as chemical weapons. Until now most protocols have suggested the use of IM injection of antidote in the case of mass casualties from chemical nerve agents. However, IM resorption is delayed and insufficient in many cases. It is also usually very difficult to obtain IV access in these victims, and therefore other options for administration of antitoxin, such as intraosseous injection, are needed. The intraosseous needles used in clinical practice in emergency departments are not easily used in the field by personnel dressed in heavy protective clothing. Therefore, an alternative solution has been sought.
Spring-driven, trigger-operated, intraosseous infusion devices have been shown to be easy to use in adults (17), even by nonmedical personnel (18). In the Vardi et al. study the authors simulated a scenario for assessing the viability of using such an intraosseous infusion device to treat chemical warfare casualties. The participants using the device had to wear heavy protective clothing, including thick rubber gloves. The authors found that intraosseous injection was possible within a few minutes in most cases and that the simulated survival rate of the patients treated with the intraosseous device was significantly higher than the rate in the control group.
These results are encouraging. As the risk of terrorist use of chemical and biological agents increases, solutions enabling medical personnel to deal more effectively with terrorist attacks are urgently needed. Emergency preparedness authorities should consider recommending the use of intraosseous infusion devices like the one described by Vardi et al. and should develop plans for providing their emergency response teams with the devices and with the training needed for their use.
Although unconventional terror events such as use of biologic or chemical weapons is a real threat that must be prepared for, increasing numbers of "conventional" terror events, such as explosions, are producing multiple casualties—mainly civilians—in areas of Southeast Asia, the Middle East, and North Africa, as well as in the US.
Also in this issue of Anesthesia & Analgesia is an important report by Shamir et al. (19) describing a Jerusalem trauma center’s handling of 14 multiple-casualty terror events in a 28-month period. This report is somewhat different from most other published surveys on this subject (for example, those describing the bombing of the Federal Building in Oklahoma City or previous reports from bomb attacks in Israel) in that it is not primarily focused on description of the casualties, initial triage, and emergency room management (20–23); instead, it focuses mainly on resource utilization. It deals with organization from the anesthesiologist’s point of view and describes the role of anesthesiologists in the management of casualties of terrorist bombings.
Anesthesiologists are heavily involved in the care of terrorist victims at the 750-bed Hadassah-Hebrew University Medical Center at Ein Kerem. They are on hand for initial resuscitation, therapeutic and diagnostic procedures, surgical procedures, and in the intensive care unit. Each victim is assigned an anesthesiologist who is responsible for continuity of care. In addition, chaos is controlled through a "chain of command" in which senior surgeons and anesthesiologists perform triage, guide the trauma teams, and communicate with professionals in other areas of the hospital.
The report by Shamir et al. points out many important problems that are not well known to most anesthesiologists, and it provides a framework that can be used by other trauma centers dealing with terror events involving multiple casualties.
The fact that Anesthesia & Analgesia received two papers related to terrorism within a period of a few months is sobering. The world is changing, and anesthesiologists need to be prepared to respond to those changes—terrorist attacks may occur virtually anywhere, any time. The articles published in this issue can be of great help to medical centers worldwide as they prepare new emergency plans in the wake of new threats.
 |
References |
|---|
 Top References |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
