Chemical Warfare in Syria and Chemical Terrorism: The Clinical Perspective

Alexander Garza, MD, MPH


September 18, 2013

In This Article

Guidance for Health Professionals

Decontamination. Victims of a nerve agent attack need decontamination before transport to the emergency department. There have been reports of healthcare workers succumbing to the effects of nerve agents while treating victims because of exposure to the nerve agent that persisted on clothing. The use of proper personal protective equipment and training in treating victims of a nerve agent is essential.

After following the protocol for protecting yourself, remove the victim's clothing. If you suspect that the chemical agent may be on clothing, cut the victim's clothes off instead of pulling over the head. Dispose of clothing in double plastic bags. Wash the patient's body thoroughly with soap and water or 10% hypochlorite solution, and if the agent contacts eyes, irrigate them thoroughly. If the agent is ingested, do not induce vomiting.

Presentation and testing. Victims of a terrorist attack, particularly when weapons-grade chemicals have been used, usually will have both inhalational and dermal exposures. Hours after treatment/decontamination, the agent may still be in transit through the skin and will have the potential to produce sudden and severe symptoms. Victims who survive a chemical exposure may be symptomatic for up to 2 weeks after exposure, particularly with central nervous system manifestations.

There is no test to definitively rule in exposure to nerve agents; treatment is dictated by the physical presentation and a high degree of suspicion. Specialized laboratories, including the Centers for Disease Control and Prevention (CDC) Laboratory Response Network for Chemical Threats, as well as the Department of Defense and the Department of Homeland Security, have capabilities to perform sophisticated testing of clinical and environmental samples to confirm that a nerve agent was used.

Special considerations and resources. DuoDote® injections, or Mark 1 kits, which are widely available, contain atropine 2 mg plus pralidoxime chloride 600 mg and should be used by out-of-hospital providers at the scene. Diazepam or another benzodiazepine should be used to control seizures. These medications are available in most emergency departments. Note that massive amounts of antidote may be required to treat the victims of a chemical exposure, especially in instances of mass casualty.

Many communities participate in the CHEMPACK stockpile program, which provides these antidotes to first responders.

For detailed clinical guidance on medical management, see the CDC Website, Medical Management Guidelines for Nerve Agents: Tabun (GA); Sarin (GB); Soman (GD); and VX.

Nerve agents are formidable weapons that have been banned by the vast majority of nations. The recent use of these weapons by Syria is alarming in both its scope and brazenness of the attack. There are significant policy decisions that will be debated by the United States and the rest of the world, including the appropriate response against the Assad regime. Permitting a regime to use these types of weapons with impunity may embolden other rogue states or terrorist organizations, such as what was seen in Iraq. There are also concerns of a broader use of these weapons or other terrorist attacks were the United States to retaliate. What is clear, however, is that these weapons are inhumane and overwhelmingly repudiated. The goal of all should be to prevent their use in any form.

Web Resources

NIOSH: The Emergency Response Safety and Health Database

NIOSH: The Emergency Response Safety and Health Database (Nerve Agents)

Agency for Toxic Substances and Disease Registry (ATSDR)


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