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Essential Lessons in a Potential Sarin Attack Disaster Plan for a Resource-Constrained Environment

Published online by Cambridge University Press:  18 May 2017

Matthew John Watermeyer Open the ORCID record for Matthew John Watermeyer [Opens in a new window] ,
Nicole Dippenaar ,
Nelly Clotildea Tchouambou Simo ,
Sean Buchanan  and
Abdullah Ebrahim Laher
Matthew John Watermeyer*
Affiliation:
University of the Witwatersrand Faculty of Health Sciences, Department of Emergency Medicine, Johannesburg, South Africa
Nicole Dippenaar
Affiliation:
University of the Witwatersrand Faculty of Health Sciences, Department of Emergency Medicine, Johannesburg, South Africa
Nelly Clotildea Tchouambou Simo
Affiliation:
University of the Witwatersrand Faculty of Health Sciences, Department of Emergency Medicine, Johannesburg, South Africa
Sean Buchanan
Affiliation:
University of the Witwatersrand Faculty of Health Sciences, Department of Emergency Medicine, Johannesburg, South Africa
Abdullah Ebrahim Laher
Affiliation:
University of the Witwatersrand Faculty of Health Sciences, Departments of Emergency Medicine and Critical Care, Johannesburg, South Africa
*
Correspondence and reprint requests to Matthew John Watermeyer, University of the Witwatersrand Faculty of Health Sciences, Department of Emergency Medicine, Johannesburg, South Africa 2050 (e-mail: mjwatermeyer@gmail.com).
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Abstract

Sarin is a potent nerve agent chemical weapon that was originally designed for military purposes as a fast-acting anti-personnel weapon that would kill or disable large numbers of enemy troops. Its potent toxicity, ease of deployment, and rapid degradation allow for rapid deployment by an attacking force, who can safely enter the area of deployment a short while after its release. Sarin has been produced and stockpiled by a number of countries, and large quantities of it still exist despite collective agreements to cease manufacture and destroy stockpiles. Sarin’s ease of synthesis, which is easily disseminated across the Internet, increases the risk that terrorist organizations may use sarin to attack civilians. Sarin has been used in a number of terrorist attacks in Japan, and more recently in attacks in the Middle East, where nonmilitary organizations have led much of the disaster relief and provision of medical care. In the present article, we examine and discuss the available literature on sarin’s historical use, delivery methods, chemical properties, mechanism of action, decontamination process, and treatment. We present a management guideline to assist with the recognition of an attack and management of victims by medical professionals and disaster relief organizations, specifically in resource-constrained and austere environments. (Disaster Med Public Health Preparedness. 2018;12:249–256)

Keywords

sarinweapons of mass destructiondisaster planningmass casualty incidents
Type
Concepts in Disaster Medicine
Information
Disaster Medicine and Public Health Preparedness , Volume 12 , Issue 2 , April 2018 , pp. 249 - 256
Copyright
Copyright © Society for Disaster Medicine and Public Health, Inc. 2017 

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References

REFERENCES

1. Yanagisawa, N, Morita, H, Nakajima, T. Sarin experiences in Japan: acute toxicity and long-term effects. J Neurol Sci. 2006;249(1):76-85. https://doi.org/10.1016/j.jns.2006.06.007.CrossRefGoogle ScholarPubMed
2. Tokuda, Y, Kikuchi, M, Takahashi, O, et al. Prehospital management of sarin nerve gas terrorism in urban settings: 10 years of progress after the Tokyo subway sarin attack. Resuscitation. 2006;68(2):193-202. https://doi.org/10.1016/j.resuscitation.2005.05.023.CrossRefGoogle ScholarPubMed
3. Okudera, H, Morita, H, Iwashita, T, et al. Unexpected nerve gas exposure in the city of Matsumoto: report of rescue activity in the first sarin gas terrorism. Am J Emerg Med. 1997;15(5):527-528. https://doi.org/10.1016/S0735-6757(97)90201-1.CrossRefGoogle ScholarPubMed
4. UN chemical weapons watchdog finds traces of sarin gas exposure in Syria. The Guardian. http://www.theguardian.com/world/2016/jan/05/un-chemical-weapons-watchdog-finds-traces-of-sarin-gas-exposure-in-syria. Published January 4, 2016. Accessed April 9, 2017.Google Scholar
5. Charbonneau, L, Nichols, M. U.N. confirms sarin used in Syria attack; US, UK, France blame Assad. Reuters. http://www.reuters.com/article/2013/09/16/us-syria-crisis-un-idUSBRE98F0ED20130916. Published September 16, 2013. Accessed July 2, 2015.Google Scholar
6. Okumura, T, Suzuki, K, Fukuda, A, et al. The Tokyo Subway sarin attack: disaster management, part 1: community emergency response. Acad Emerg Med. 1998;5(6):613-617. https://doi.org/10.1111/j.1553-2712.1998.tb02470.x.CrossRefGoogle ScholarPubMed
7. Okumura, T, Takasu, N, Ishimatsu, S, et al. Report on 640 Victims of the Tokyo Subway Sarin Attack. Ann Emerg Med. 1996;28(2):129-135. https://doi.org/10.1016/S0196-0644(96)70052-5.CrossRefGoogle ScholarPubMed
8. Nozaki, H, Hori, S, Shinozawa, Y, et al. Secondary exposure of medical staff to sarin vapor in the emergency room. Intensive Care Med. 1995;21(12):1032-1035. https://doi.org/10.1007/BF01700667.CrossRefGoogle ScholarPubMed
9. Centers for Disease Control and Prevention. Facts About Sarin. CDC website. https://emergency.cdc.gov/agent/sarin/basics/facts.asp. Last updated November 18, 2015. Accessed April 9, 2017.Google Scholar
10. Sarin Gas. Facts, information, pictures. Encyclopedia.com website. http://www.encyclopedia.com/topic/Sarin_Gas.aspx. Accessed July 1, 2015.Google Scholar
11. Laub, Z. Sarin. Council on Foreign Relations website. http://www.cfr.org/weapons-of-mass-destruction/sarin/p9553. Last updated March 13, 2014. Accessed July 1, 2015.Google Scholar
12. Croddy, E. Weapons of Mass Destruction: An Encyclopaedia of worldwide policy, Technology and History. Santa Barbara, CA: ABC-CLIO; 2005.Google Scholar
13. Domres, BD, Rashid, A, Grundgeiger, J, et al. European survey on decontamination in mass casualty incidents. Am J Disaster Med. 2009;4(3):147-152.CrossRefGoogle ScholarPubMed
14. Dolgin, E. Syrian gas attack reinforces need for better anti-sarin drugs. Nat Med. 2013;19(10):1194-1195. https://doi.org/10.1038/nm1013-1194.CrossRefGoogle ScholarPubMed
15. Watson, A, Opresko, D, Young, R, et al. Development and application of acute exposure guideline levels (AEGLs) for chemical warfare nerve and sulfur mustard agents. J Toxicol Environ Health B Crit Rev. 2006;9(3):173-263. https://doi.org/10.1080/15287390500194441.CrossRefGoogle ScholarPubMed
16. Physicians for Human Rights. Fact sheet for the recognition and treatment of Sarin. https://s3.amazonaws.com/PHR_other/PHR_Sarin_Fact_Sheet_04-13.pdf. Accessed July 1, 2015.Google Scholar
17. Baker, DJ. Advanced life support for acute toxic injury (TOXALS). Eur J Emerg Med. 1996;3(4):256-262.CrossRefGoogle ScholarPubMed
18. Crawford, I, Mackway-Jones, K, Russell, D. Specification and selection of chemical personal protective equipment (CPPE) for health service first responders: the United Kingdom approach. Prehosp Disaster Med. 2002;17(S2):S58. https://doi.org/10.1017/S1049023X00010426.CrossRefGoogle Scholar
19. Sarin. PubChem Compound Database: CID=7871. National Centre for Biotechnology Information website. https://pubchem.ncbi.nlm.nih.gov/compound/7871. Accessed August 4, 2016.Google Scholar
20. Sarin. Chemical Sampling Information. US Department of Labor website. https://www.osha.gov/dts/chemicalsampling/data/CH_266495.html. Accessed July 2, 2015.Google Scholar
21. Material Safety Data Sheet – Lethal Nerve Agent Sarin (GB). http://www.gulfweb.org/bigdoc/report/appgb.html. Accessed July 2, 2015.Google Scholar
22. Arduini, F, Amine, A, Moscone, D, et al. Fast, sensitive and cost-effective detection of nerve agents in the gas phase using a portable instrument and an electrochemical biosensor. Anal Bioanal Chem. 2007;388(5-6):1049-1057. https://doi.org/10.1007/s00216-007-1330-z.CrossRefGoogle Scholar
23. PubChem Compound Database; CID=225316. Ethyl Malathion. National Center for Biotechnology Information website. https://pubchem.ncbi.nlm.nih.gov/compound/225316. Accessed August 4, 2016.Google Scholar
24. Thiermann, H, Worek, F, Kehe, K. Limitations and challenges in treatment of acute chemical warfare agent poisoning. Chem Biol Interact. 2013;206(3):435-443. https://doi.org/10.1016/j.cbi.2013.09.015.CrossRefGoogle ScholarPubMed
25. Sarin Nerve Gas. North Dakota Department of Health. https://www.ndhealth.gov/EPR/HealthHotline/view.aspx. Accessed April 9, 2017.Google Scholar
26. Okudera, H. Clinical features on nerve gas terrorism in Matsumoto. J Clin Neurosci. 2002;9(1):17-21. https://doi.org/10.1054/jocn.2001.1020.CrossRefGoogle ScholarPubMed
27. Woodard, C. Erythrocyte and plasma cholinesterase activity in male and female rhesus monkeys before and after exposure to sarin. Fundam Appl Toxicol. 1994;23(3):342-347. https://doi.org/10.1006/faat.1994.1114.CrossRefGoogle ScholarPubMed
28. Ohbu, S, Yamashina, A, Takasu, N. Sarin Poisoning on Tokyo Subway. http://nointervention.com/archive/military/ABC/sarin_tokyo/97june3.htm. Accessed July 1, 2015.Google Scholar
29. Yamasaki, Y, Sakamoto, K, Watada, H, et al. The Arg 192 isoform of paraoxonase with low sarin-hydrolyzing activity is dominant in the Japanese. Hum Genet. 1997;101(1):67-68. https://doi.org/10.1007/s004390050588.CrossRefGoogle Scholar
30. Yanagisawa, N. [The nerve agent sarin: history, clinical manifestations, and treatment]. [Brain and Nerve] Shinkei kenkyū no shinpo. 2014;66(5):561-569.Google ScholarPubMed
31. Vučemilović, A. Toxicological effects of weapons of mass destruction and noxious agents in modern warfare and terorrism. Arh Hig Rada Toksikol. 2010;61(2):247-256. https://doi.org/10.2478/10004-1254-61-2010-1995.CrossRefGoogle Scholar
32. Emergency Preparedness and Response. OSHA/NIOSH Interim Guidance (April 2005) - Chemical - Biological - Radiological - Nuclear (CBRN) Personal Protective Equipment Selection Matrix for Emergency Responders. Nerve Agents. https://www.osha.gov/SLTC/emergencypreparedness/cbrnmatrix/nerve.html. Accessed July 3, 2015.Google Scholar
33. Approved Respirator Standards. Powered, Air-Purifying Respirators (PAPR) To Protect Emergency Responders Against CBRN Agents. CDC website. http://www.cdc.gov/niosh/npptl/standardsdev/cbrn/papr/. Accessed August 4, 2016.Google Scholar
34. The National Institute for Occupational Safety and Health (NIOSH). CDC website. https://www.cdc.gov/niosh/. Accessed August 4, 2016.Google Scholar
35. National Disaster Life Support Foundation. https://www.ndlsf.org/. Accessed April 18, 2017.Google Scholar
36. US Department of Justice. Guide for the Selection of Personal Protective Equipment for Emergency First Responders. https://www.ncjrs.gov/pdffiles1/nij/191519.pdf. Accessed July 2, 2015.Google Scholar
37. Clarke, SFJ, Chilcott, RP, Wilson, JC, et al. Decontamination of multiple casualties who are chemically contaminated: a challenge for acute hospitals. Prehospital Disaster Med. 2008;23(2):175-181.CrossRefGoogle ScholarPubMed
38. Comfort, LK, Ko, K, Zagorecki, A. Coordination in rapidly evolving disaster response systems: the role of information. Am Behav Sci. 2004;48(3):295-313. https://doi.org/10.1177/0002764204268987.CrossRefGoogle Scholar
39. Balasubramanian, V, Massaguer, D, Mehrotra, S, Venkatasubramanian, N. DrillSim: A Simulation Framework for Emergency Response Drills. Berlin: Springer; 2006:237-248.Google Scholar
40. Jokanović, M. Medical treatment of acute poisoning with organophosphorus and carbamate pesticides. Toxicol Lett. 2009;190(2):107-115. https://doi.org/10.1016/j.toxlet.2009.07.025.CrossRefGoogle ScholarPubMed
41. Mercey, G, Verdelet, T, Renou, J, et al. Reactivators of acetylcholinesterase inhibited by organophosphorus nerve agents. Acc Chem Res. 2012;45(5):756-766. https://doi.org/10.1021/ar2002864.CrossRefGoogle ScholarPubMed
42. Atropine - FDA prescribing information, side effects and uses. Drugs.com website. http://www.drugs.com/pro/atropine.html. Accessed July 2, 2015.Google Scholar
43. Choi, PTL, Quinonez, LG, Cook, DJ, et al. The use of glycopyrrolate in a case of intermediate syndrome following acute organophosphate poisoning. Can J Anaesth. 1998;45(4):337-340. https://doi.org/10.1007/BF03012025.CrossRefGoogle Scholar
44. Bardin, PG, Van Eeden, SF. Organophosphate poisoning: grading the severity and comparing treatment between atropine and glycopyrrolate. Crit Care Med. 1990;18(9):956-960. https://doi.org/10.1097/00003246-199009000-00010.CrossRefGoogle ScholarPubMed
45. Piplani, S, Handa, A, Aggrawal, R, et al. Organophosphorous poisoning with intermediate syndrome. Med J Armed Forces India. 2002;58(1):81-83. https://doi.org/10.1016/S0377-1237(02)80022-3.CrossRefGoogle ScholarPubMed
46. Jokanović, M, Prostran, M. Pyridinium oximes as cholinesterase reactivators. Structure-activity relationship and efficacy in the treatment of poisoning with organophosphorus compounds. Curr Med Chem. 2009;16(17):2177-2188. https://doi.org/10.2174/092986709788612729.CrossRefGoogle ScholarPubMed
47. Corvino, TF, Nahata, MC, Angelos, MG, et al. Availability, stability, and sterility of pralidoxime for mass casualty use. Ann Emerg Med. 2006;47(3):272-277. doi: 10.1016/j.annemergmed.2005.10.020.CrossRefGoogle ScholarPubMed
48. Centers for Disease Control and Prevention. CHEMPACK program. https://blogs.cdc.gov/publichealthmatters/2015/02/cdcs-chempack-program-the-stockpile-that-may-protect-you-from-a-chemical-attack/. Accessed December 15, 2016.Google Scholar
49. Deacon, L. French emergency services stockpile sarin gas antidote in preparation for chemical warfare with Isis. Breitbart London. Published November 19, 2015.Google Scholar
50. Marrs, TC. The role of diazepam in the treatment of nerve agent poisoning in a civilian population. Toxicol Rev. 2004;23(3):145-157. https://doi.org/10.2165/00139709-200423030-00002.CrossRefGoogle Scholar
51. US Department of Health and Human Services. Nerve Agent Treatment -- Autoinjector Instructions. CHEMM website. http://chemm.nlm.nih.gov/antidote_nerveagents.htm. Cited July 2, 2015.Google Scholar
52. Reddy, SD, Reddy, DS. Midazolam as an anticonvulsant antidote for organophosphate intoxication--A pharmacotherapeutic appraisal. Epilepsia. 2015;56(6):813-821. https://doi.org/10.1111/epi.12989.CrossRefGoogle ScholarPubMed
53. Brigo, F, Nardone, R, Tezzon, F, et al. Nonintravenous midazolam versus intravenous or rectal diazepam for the treatment of early status epilepticus: a systematic review with meta-analysis. Epilepsy Behav. 2015;49:325-336. https://doi.org/10.1016/j.yebeh.2015.02.030.CrossRefGoogle ScholarPubMed
54. Tan, HY, Loke, WK, Nguyen, N-T, et al. Lab-on-a-chip for rapid electrochemical detection of nerve agent Sarin. Biomed Microdevices. 2014;16(2):269-275. https://doi.org/10.1007/s10544-013-9830-4.CrossRefGoogle ScholarPubMed
55. Sekiguchi, H, Matsushita, K, Yamashiro, S, et al. On-site determination of nerve and mustard gases using a field-portable gas chromatograph-mass spectrometer. Forensic Toxicol. 2006;24(1):17-22. https://doi.org/10.1007/s11419-006-0004-4.CrossRefGoogle Scholar
56. Yan, C, Qi, F, Li, S, et al. Functionalized photonic crystal for the sensing of Sarin agents. Talanta. 2016;159:412-417. https://doi.org/10.1016/j.talanta.2016.06.045.CrossRefGoogle ScholarPubMed
57. Appel, AS, Logue, BA. Analysis of nerve agent metabolites from nail clippings by liquid chromatography tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci. 2016;1031:116-122. https://doi.org/10.1016/j.jchromb.2016.07.034.CrossRefGoogle ScholarPubMed
58. Pohanka, M, Karasova, JZ, Kuca, K, et al. Colorimetric dipstick for assay of organophosphate pesticides and nerve agents represented by paraoxon, sarin and VX. Talanta. 2010;81(1-2):621-624. https://doi.org/10.1016/j.talanta.2009.12.052.CrossRefGoogle ScholarPubMed
59. Liang, M, Fan, K, Pan, Y, et al. Fe3O4 magnetic nanoparticle peroxidase mimetic-based colorimetric assay for the rapid detection of organophosphorus pesticide and nerve agent. Anal Chem. 2013;85(1):308-312. https://doi.org/10.1021/ac302781r.CrossRefGoogle ScholarPubMed
60. Jakobsen, MH, Uthuppu, B. Microfluidic amperometric biosensor for pesticide detection in ground water. http://www.nanotech.dtu.dk/Research-mega/Forskningsgrupper/Surface_Engineering/Research/Amp-biosensor. Accessed August 1, 2016.Google Scholar
61. Xia, N, Wang, Q, Liu, L. Nanomaterials-based optical techniques for the detection of acetylcholinesterase and pesticides. Sensors (Basel). 2015;15(1):499-514. https://doi.org/10.3390/s150100499.CrossRefGoogle Scholar
62. Tan, HY, Loke, WK, Tan, YT, et al. A lab-on-a-chip for detection of nerve agent sarin in blood. Lab Chip. 2008;8(6):885-891. https://doi.org/10.1039/b800438b.CrossRefGoogle ScholarPubMed
63. Climent, E, Biyikal, M, Gawlitza, K, et al. A rapid and sensitive strip-based quick test for nerve agents tabun, sarin, and soman using BODIPY-modified silica materials. Chemistry. 2016;22(32):11138-11142. https://doi.org/10.1002/chem.201601269.CrossRefGoogle ScholarPubMed
64. Organisation for the Prohibition of Chemical Weapons. About OPCW. http://www.opcw.org/about-opcw/. Accessed July 1, 2015.Google Scholar
65. M687. Binary Chemical weapon delivery artillery shell. Wikipedia. https://en.wikipedia.org/wiki/M687. Accessed July 2, 2015.Google Scholar
66. Gulland, A. Lack of atropine in Syria hampers treatment after gas attacks. BMJ. 2013;347(sep03 1):f5413. https://doi.org/10.1136/bmj.f5413.CrossRefGoogle ScholarPubMed
67. Jain, S, McLean, C. Simulation for emergency response: a framework for modeling and simulation for emergency response. In: Proceedings of the 35th Conference on Winter Simulation: Driving Innovation. Winter Simulation Conference. 2004;1:1068–76. http://dl.acm.org/citation.cfm?id=1030818.1030960. doi: 10.1109/WSC.2003.1261532.CrossRefGoogle Scholar
68. Chick, SE, ed. Proceedings of the 2003 Winter Simulation Conference: WSC’03; December 7-10, 2003; New Orleans, La, U.S.A. New York: Association for Computing Machinery; 2003.Google Scholar
69. Emergency & Disaster Triage Tags & Supplies. Mass Casualty Incident. SOS Survival Products. http://www.sosproducts.com/emergency-triage-s/1938.htm. Accessed July 2, 2015.Google Scholar