Eran Rotman

OP or not OP: the medical challenge at the chemical terrorism scene.

Since the 1995 Tokyo subway sarin attack, terrorist attacks involving weapons of mass destruction or other industrial chemicals present worldwide security and health concerns. On-scene medical triage and treatment in such events is crucial to save as many lives as possible and minimize the deleterious effects of the toxic agent involved. Since there are many chemicals that can be used as potential terrorist weapons, the medical challenge for the emergency medical services (EMS) is a combination of: (1) recognizing that a chemical terrorist attack (non-conventional) has occurred; and (2) identifying the toxic agent followed by proper antidotal treatment. The latter must be done as quickly as possible, preferably on-scene. The most valuable decision at this stage should be whether the agent is organophosphate (OP) or not OP, based on clinical findings observed by pre-trained, first responders. This decision is crucial, since only OP intoxication has readily available, rapidly acting, onscene, specific agents such as atropine and one of the oximes, preferably administered using autoinjectors. Due to the lack of a specific antidote, exposure to other agents (such as industrial chemicals, e.g., chlorine, bromide, or ammonia) should be treated on-scene symptomatically with non-specific measures, such as decontamination and supportive treatment. This paper proposes an algorithm as a cognitive framework for the medical teams on-scene. This algorithm should be part of the medical teams training for preparedness for chemical terrorist attacks, and the team should be trained to use it in drills. Implementing this path of thinking should improve the medical outcome of such an event.

Civilian Adult Self Injections of Atropine – Trimedoxime (TMB4) Auto-Injectors

Introduction. The clinical effects of self injections of atropine–trimedoxime auto-injectors distributed to the civilian population as a field antidote for nerve agent attack were assessed. Methods. Data on self injections by adults (≥18 years) were collected from the Israel Poison Information Center and a hospital Emergency Departments records during a 2-year period. The data included demographics, time interval from injection, type of auto-injector, clinical manifestations and atropinization score. Results. Sixty-five patients, all with unintentional self injections, were reported. Systemic atropine effects were observed in 24 patients, but no severe atropinization. The atropinization score was significantly higher in the 2 mg atropine dose group than in the two lower dose groups, which were in the normal range. No specific adverse effects attributable to trimedoxime were observed. Intravenous fluids and physostigmine were not required. Conclusion. Only mild reactions were observed following self-injection of atropine trimedoxime auto-injectors in adults, attesting to their relative safety under these conditions.