Vol. 21 •Issue 14 • Page 16
On the Attack
Terrorist Weapons May Include Incapacitating Gases
Lessons learned from the 2002 Dubrovka Theater siege in Moscow have broad implications for those planning medical and emergency responses. In that incident, 40 to 50 armed guerrillas held nearly 800 theater-goers hostage, demanding an end to the war in Chechnya.
The standoff went on for three days. When hopes for a peaceful resolution faded, elite Russian special forces launched a daring and unprecedented hostage-rescue mission using what Russian officials claimed was an aerosolized incapacitating agent based on synthetic opioid fentanyl.
Experts say the mystery gas likely was fentanyl in conjunction with an anesthetic gas that includes halothane, commonly used during surgery.
Due to the potency of the compound, however, the aerosolized agent was effective—and lethal. All the Chechen militant terrorists were killed in the mission, and approximately 120 hostages died as well.
Russian Minister of Health Yuri Shevchenko later asserted that emergency medical personnel were prepared with more than 1,000 doses of naloxone (Narcan), the antidote for opiate/opioid toxicity. Despite the availability of antidotal therapy, many victims extricated from the theater were positioned improperly on the ground or in buses where their airways were compromised and they succumbed to the physiological effects of the fentanyl exposure, according to government sources.
To this day, controversy continues as to whether local hospitals and medical personnel were adequately informed about the agent used during the tactical assault.
Historic Use of Drugs
Opiates themselves, of course, are not new. Pure opium is a mixture of alkaloids from the sap of the Papaver somniferous, or opium poppy, which has been cultivated for medicinal purposes since 300 B.C. Natural derivatives include heroin, codeine and morphine.
Arguably, the pain-killing and suppressant effects of both morphine and codeine are among the greatest discoveries of medicine. But they were not alone in use.
By the 1830s, chloroform became the drug of choice for sedation and pain control until it was replaced by ether and then, in turn, by safer, nonflammable agents like halothane and nitrous oxide.
Halothane has been superseded by halogenated ethers like isoflurane and enflurane, largely due to the hepatotoxic and cardiotoxic effects of halothane anesthesia.
By the late 1800s, morphine gained popularity as an anesthetic agent. Unfortunately, lethal complications of using it led to its partial discontinuance and clinical phase-out in anesthesia practice.
With the advent of synthetic merperidine (Demerol) in 1939 and its improved safety profile, there was a renewed interest in the use of opiate anesthesia.
Eventually, the synthesis of fentanyl as an important opiate-type drug in medicine led to fentanyl analogues including sufentanil, alfentanil and remifentanil.
Then drugs like carfentanil, 10,000 times more potent than morphine, hit the scene. Carfentanil has an effective dose of 0.0034 mg/kg and a lethal dose of 3.4 mg/kg and is used as a large mammal anesthetic in veterinary medicine.
Belladonna alkaloids (or anticholinergics/antimuscarinics) like atropine and BZ (3-quinuclidinyl benzilate) also have been widely studied in the intervening years; and atropine continues to be employed as a ubiquitous pharmacological agent in a variety of medical settings.
Atropine is administered as a component of the Mark-I Nerve Agent Antidote KitÊautoinjector system and is used to reverse the muscarinic effects of militarized nerve agents and organophosphate pesticide toxicity.
While atropine is the prototypical anticholinergic/antimuscarinic agent, BZ, known as “Agent 15” within the former Iraqi regime, is a prototype military incapacitating agent capable of being dispersed easily and resisting environmental degradation.
Due to its unique physiochemical properties, BZ is used as a research marker in Alzheimer’s disease. But it has been alleged that Bosnian Serbs used BZ in 1995 against 15,000 Bosnian civilians fleeing from Srebrenica to Tuzla.
Over the years, research has continued on numerous drugs. For example, Albert Hofmann discovered d-lysergic acid diethylamide (LSD) in 1938 and was accidentally intoxicated by the drug five years later.
Three days later, he intentionally ingested LSD, and that action later paved the way for neuropsychiatric studies. By 1951, the U.S. Central Intelligence Agency used LSD for human experimentation.
Other indole psychoactive and mind-altering compounds like psilocybin, derived from hallucinogenic “magic” mushrooms, also gained popularity as recreational and “mind-expanding” drugs, and they too can be used in covert attacks.
Added to the mix are riot-control agents like CN, CS, CA, CR and OC or “pepper spray.” These agents are more commonly known as irritants, lacrimators, harassing agents and tear gas. These compounds cause rapid-onset discomfort, have a short duration and are relatively safe.
Diphenylaminearsine is a vomiting agent also used for riot control. However, it has a delayed onset and lesser dermal effects.
Technically, all of the aforementioned agents can accomplish significant incapacitating effects; and depending on dose and other factors, they can be lethal. For example, prisoners with reactive airways have died of such agents while in police custody.
While many of these compounds have legitimate uses in medicine, tactical-law enforcement and military training operations, all classes of these compounds can be developed as chemical weapons and used by terrorists to cause mass casualties among civilian populations and combatants alike.
As such, the possible use of these agents as weapons poses novel and unique challenges for planning for emergency medical responses.
Amidst some of these potential threats, we need to ask:
- How would we handle an incident like the Dubrovka Theater siege in the U.S.?
- Are our health care delivery systems prepared for unconventional and covert warfare and terrorism?
- Would local health care facilities and EMS systems possess sufficient oxygen, pharmaceuticals, airway management and positive-pressure ventilatory support for medical management?
The Moscow theater incident vividly demonstrates that the use of analgesics, anesthetics and incapacitating agents as mass-casualty weapons is feasible and can trigger a major medical disaster.
The possible use of agents like these must be incorporated into health care system emergency preparedness plans, especially in metropolitan or high-profile areas.
To successfully meet the challenges, clinicians must understand the toxidromes associated with many of the agents in this discussion to aid them in recognition and appropriate treatment.
Unfortunately, many clinicians may not be able to distinguish signs and symptoms of opioid toxicity from nerve agent exposure, especially during a mass-casualty event.
The importance of immediate attention to airway and ventilation cannot be overemphasized, in addition to the appropriate use of pharmacotherapy to reverse adverse toxicological effects like respiratory depression, apnea and ultimately respiratory failure, all prominent in the aftermath of the Dubrovka Theater event.
In addition to potential drug exposures, caregivers need to assess patients for concomitant crush and penetrating and blunt trauma injuries due to mass stampedes, projectiles and falls.
While some of this may appear complex, it is important to remember that proper preparation and planning can minimize morbidity and mortality in all mass-casualty events, and mass incapacitating agent exposures are no exception.
For a list of resources, visit www.advanceweb.com/rcp and click on the “magazine” tab.
Frank G. Rando is an expert on toxic inhalations, tactical, special operations and disaster medicine, HAZMAT emergency responses and terrorism. He is affiliated with Homeland Security programs and may be reached at [email protected].