Practical Guidelines for Acute Care of Victims of Bioterrorism: Conventional Injuries and Concomitant Nerve Agent Intoxication

THE potential use of weapons of mass destruction has recently become a real threat even in regions of the world that are remote from areas of ongoing armed conflicts. Episodes of the use of sarin or VX, both potent acetylcholinesterase (AChE) inhibitors that cause cholinergic crisis, in the terrorist attacks against civilians in Japan in 1994 and 1995 which produced several fatalities and hundreds of casualties, 1,2 and the military use of nerve agents (NA) by Iraq against Iran and the Kurdish population during the 1980s are grim examples of the deadly potential of NA. Victims of a mass casualty event can suffer from physical trauma alone or from trauma in combination with gas intoxication. The exposure of a physically injured patient to a toxic substance, in a scenario of mass injury, has recently gained major attention among planners of future protocols for emergency medical services. 3 Furthermore, when a civilian population becomes the prime target of an NA attack, diversity in age and previous health status are expected to increase the extent of the injuries compared with those of healthy adult soldiers by as much as 10-fold. 4 Because rapid deterioration and multiorgan involvement are to be expected after a physically injured individual is exposed to a toxic substance, proper organization and complex but efficient acute medical and surgical care systems must be organized and deployed to ensure a maximal number of saved lives. The various national rescue forces that have traditionally been tasked with models of rapid evacuation and decontamination of large numbers of poisoned civilians from affected areas appear to be only a fraction of future necessities. 5 The proposed management of mass casualty events needs to be based on triage principles and acute care measures. These should include: rapid identification of the offending agent, swift decontamination by wellprotected emergency medical personnel, and triageguided mass evacuation to a nearby medical facility that should be well equipped and staffed with personnel who have been properly trained to deal with such multifaceted events.