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Chemical terrorism: Rapid recognition and initial medical management

James M Madsen, MD, MPH, FCAP, FACOEM, COL (ret), MC-FS, USA
Section Editors
Richard D Zane, MD
Stephen J Traub, MD
Michele M Burns, MD, MPH
Deputy Editor
James F Wiley, II, MD, MPH


Potential actions by terrorist groups span the chemical, biological, radiological, nuclear, and high explosive (CBRNE) threat spectrum [1]. This topic provides guidance for the rapid recognition and initial management of patients exposed to the chemical agents that are most likely to be used in warfare or by terrorists.

Bioterrorism and clinical features and treatment of radiation exposure, including exposure cause by acts of nuclear terrorism, are reviewed separately. (See "Identifying and managing casualties of biological terrorism" and "Clinical features of radiation exposure in children" and "Biology and clinical features of radiation injury in adults" and "Management of radiation exposure in children following a nuclear disaster" and "Treatment of radiation injury in the adult".)

Planning and preparation for field and medical response to weapons of mass destruction are beyond the scope of this topic but are reviewed elsewhere [2-11].


The use of chemical weapons violates current international law and is governed by treaties administered by the United Nations (UN). Since 1997, the Convention on the Prohibition of the Development, Production, Stockpiling and Use of Chemical Weapons and on Their Destruction, or Chemical Weapons Convention (CWC), has been in force. The CWC is administered by the Organisation for the Prohibition of Chemical Weapons (OPCW), in The Hague, Netherlands [12].

Despite international prohibitions against the use of chemical weapons, large amounts of various agents remain available in national stockpiles in several countries, and their use against military and civilian populations has been documented as follows:

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Literature review current through: Sep 2017. | This topic last updated: Sep 13, 2017.
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  1. Born CT, Briggs SM, Ciraulo DL, et al. Disasters and mass casualties: II. explosive, biologic, chemical, and nuclear agents. J Am Acad Orthop Surg 2007; 15:461.
  2. Couch D. United States Armed Forces Nuclear, Biological and Chemical Survival Manual, Basic Books, New York 2003.
  3. Henretig FM, Cieslak TJ, Eitzen EM Jr. Biological and chemical terrorism. J Pediatr 2002; 141:311.
  4. Acquista A. The Survival Guide: what to do in a biological, chemical or nuclear emergency, Random House, New York 2003.
  5. Greenfield RA, Brown BR, Hutchins JB, et al. Microbiological, biological, and chemical weapons of warfare and terrorism. Am J Med Sci 2002; 323:326.
  6. Furlow B. Biological, chemical and radiological terrorism. Radiol Technol 2003; 75:91.
  7. Heymann WR. Threats of biological and chemical warfare on civilian populations. J Am Acad Dermatol 2004; 51:452.
  8. Gosden C, Gardener D. Weapons of mass destruction--threats and responses. BMJ 2005; 331:397.
  9. Fry DE. Chemical threats. Surg Clin North Am 2006; 86:637.
  10. Prockop LD. Weapons of mass destruction: Overview of the CBRNEs (Chemical, Biological, Radiological, Nuclear, and Explosives). J Neurol Sci 2006; 249:50.
  11. Bland SA. Chemical, biological and radiation casualties: critical care considerations. J R Army Med Corps 2009; 155:160.
  12. Convention on the Prohibition of the Development, Production, Stockpiling and Use of Chemical Weapons and on their Destruction (Chemical Weapons Convention). http://www.opcw.org/chemical-weapons-convention/ (Accessed on May 21, 2013).
  13. Vogel L. WHO releases guidelines for treating chemical warfare victims after possible Syria attacks. CMAJ 2013; 185:E665.
  14. Report on Allegations of the Use of Chemical Weapons in the Ghouta Area of Damascus on 21 August 2013. United Nations Mission to Investigate Allegations of the Use of Chemical Weapons in the Syrian Arab Republic. United Nations. http://www.un.org/disarmament/content/slideshow/Secretary_General_Report_of_CW_Investigation.pdf. (Accessed on October 01, 2013).
  15. Zarocostas . Syria chemical attacks: preparing for the unconscionable. Lancet 2017.
  16. Kadivar H, Adams SC. Treatment of chemical and biological warfare injuries: insights derived from the 1984 Iraqi attack on Majnoon Island. Mil Med 1991; 156:171.
  17. Hu H, Cook-Deegan R, Shukri A. The use of chemical weapons. Conducting an investigation using survey epidemiology. JAMA 1989; 262:640.
  18. Okumura T, Suzuki K, Fukuda A, et al. The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response. Acad Emerg Med 1998; 5:613.
  19. Okumura T, Suzuki K, Fukuda A, et al. The Tokyo subway sarin attack: disaster management, Part 2: Hospital response. Acad Emerg Med 1998; 5:618.
  20. Jones R, Wills B, Kang C. Chlorine gas: an evolving hazardous material threat and unconventional weapon. West J Emerg Med 2010; 11:151.
  21. Rubin A. Chlorine gas attack by truck bomber kills up to 30 in Iraq. New York Times, April 7, 2007. http://www.nytimes.com/2007/04/07/world/africa/07iht-web-0407-iraq.5182467.html (Accessed on May 04, 2016).
  22. Shaheen K. Assad regime accused of 35 chlorine attacks since mid-march. The Guardian, May 24, 2015. http://www.theguardian.com/world/2015/may/24/syria-regime-accused-of-using-chlorine-bombs-on-civilians. (Accessed on May 04, 2016).
  23. Tucker JB. The current bioweapons threat. In: Biopreparedness and Public Health, Hunger I, Radosavljevic V, Belojevic G Rotz LD (Eds), Springer Netherlands, Amsterdam 2013. p.7.
  24. Anderson PD. Emergency management of chemical weapons injuries. J Pharm Pract 2012; 25:61.
  25. Kuca K, Pohanka M. Chemical warfare agents. EXS 2010; 100:543.
  26. Swaran JSF, Flora G, Saxena G. Arsenicals: Toxicity, their use as chemical warfare agents, and possible remedial measures. In: Handbook of Toxicology of Chemical Warfare Agents, Gupta RC (Ed), Academic Press, 2009. p.109.
  27. Homeland Security Presidential Directive/HSPD-18. http://www.fas.org/irp/offdocs/nspd/hspd-18.html (Accessed on May 10, 2013).
  28. Burklow TR, Yu CE, Madsen JM. Industrial chemicals: terrorist weapons of opportunity. Pediatr Ann 2003; 32:230.
  29. Reedy SJ, Schwartz MD, Morgan BW. Suicide fads: frequency and characteristics of hydrogen sulfide suicides in the United States. West J Emerg Med 2011; 12:300.
  30. Madsen JM. Toxins as weapons of mass destruction. A comparison and contrast with biological-warfare and chemical-warfare agents. Clin Lab Med 2001; 21:593.
  31. Aas P. The threat of mid-spectrum chemical warfare agents. Prehosp Disaster Med 2003; 18:306.
  32. Wormser U. Toxicology of mustard gas. Trends Pharmacol Sci 1991; 12:164.
  33. Patel MM, Schier JG, Belson MG. Recognition of illness associated with covert chemical releases. Pediatr Emerg Care 2006; 22:592.
  34. Cieslak TJ, Rowe JR, Kortepeter MG, et al. A field-expedient algorithmic approach to the clinical management of chemical and biological casualties. Mil Med 2000; 165:659.
  35. Tuorinsky SD, Sciuto AM. Toxic inhalational injury and toxic industrial chemicals. In: Medical aspects of chemical warfare, 2nd ed, Tuorinsky SD (Ed), Office of the Surgeon General,TMM Publications, Washington, DC 2008. p.339.
  36. Hurst CG, Petrali JP, Barillo DJ, et al. Vesicants. In: Medical aspects of chemical warfare, 2nd ed, Tuorinsky SD (Ed), Office of the Surgeon General,TMM Publications, Washington, DC 2008. p.259.
  37. Busl KM, Bleck TP. Treatment of neuroterrorism. Neurotherapeutics 2012; 9:139.
  38. Guidotti TL. Hydrogen sulfide: advances in understanding human toxicity. Int J Toxicol 2010; 29:569.
  39. Rimpel LY, Boehm DE, O'Hern MR, et al. Chemical defense equipment. In: Medical Aspects of Chemical Warfare, 2nd ed, Tuorinsky SD (Ed), United States Department of the Army, Office of the Surgeon General at TMM Publications, Bordent Institute, Washington, DC 2008. p.559.
  40. Capacio BR, Smith JR, Gordon RK, et al. Medical diagnostics. In: Medical Aspects of Chemical Warfare, 2nd ed, Tuorinsky SD (Ed), Unites States, Department of the Army, Office of the Surgeon General, Borden Instittute, Washington, DC 2008. p.691.
  41. Fidder A, Noort D, Hulst AG, et al. Biomonitoring of exposure to lewisite based on adducts to haemoglobin. Arch Toxicol 2000; 74:207.
  42. Chemical hazards emergency medical management. United States Department of Health and Human Services. www.chemm.nlm.nih.gov/onsite.htm (Accessed on August 06, 2013).
  43. General description and discussion of the levels of protection and protective gear. Occupational Safety and Health Standards: Hazardous Materials. Standard number: 1910.120 App B. www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9767 (Accessed on August 07, 2013).
  44. Occupational Safety and Health Administration (OSHA). Best Practices for Protecting EMS Responders during Treatment and Transport of Victims of Hazardous Substance Releases. http://www.osha.gov/Publications/OSHA3370-protecting-EMS-respondersSM.pdf (Accessed on May 10, 2013).
  45. Occupational Safety and Health Administration (OSHA). OSHA Best Practices for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. http://www.osha.gov/dts/osta/bestpractices/html/hospital_first receivers.html and http://www.osha.gov/dits/osta/bestpractices/firstreceivers_hospital.pdf (Accessed on May 10, 2013).
  46. McLaughlin S. Chemical reaction. A look at OSHA's guidance for chemical incident first receivers. Health Facil Manage 2005; 18:36, 38, 40.
  47. Cone DC, Koenig KL. Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emerg Med 2005; 12:287.
  48. Subbarao I, Johnson C, Bond WF, et al. Symptom-based, algorithmic approach for handling the initial encounter with victims of a potential terrorist attack. Prehosp Disaster Med 2005; 20:301.
  49. Ramesh AC, Kumar S. Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents. J Pharm Bioallied Sci 2010; 2:239.
  50. Culley JM, Svendsen E. A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures. Am J Disaster Med 2014; 9:137.
  51. Triage guidelines. Chemical Hazards Medical Management. US Department of Health and Human Services. http://www.chemm.nlm.nih.gov/triage.htm#sec1 (Accessed on August 07, 2013).
  52. Brown JS Jr. Psychiatric issues in toxic exposures. Psychiatr Clin North Am 2007; 30:837.
  53. Lawrence DT, Kirk MA. Chemical terrorism attacks: update on antidotes. Emerg Med Clin North Am 2007; 25:567.
  54. Pettineo C, Aitchison R, Leikin SM, et al. Biological and chemical weapons of mass destruction: updated clinical therapeutic countermeasures since 2003. Am J Ther 2009; 16:35.
  55. Rodgers GC Jr, Condurache CT. Antidotes and treatments for chemical warfare/terrorism agents: an evidence-based review. Clin Pharmacol Ther 2010; 88:318.
  56. Braue EH, Boardman CH, Hurst CG. Decontamination of chemical casualties. In: Medical Aspects of Chemical Warfare, 2nd ed, Tuorinsky SD (Ed), United States Department of the Army, Office of the Surgeon General at TMM Publications, Borden Institute, Washington, DC, 2008, p. 527. https://ke.army.mil/bordeninstitute/published_volumes/chemwarfare/Chem-ch16_pg527-558.pdf (Accessed on August 27, 2013).
  57. Protopam® Injection Supplement S-024 DRAFT Package Insert. Food and Drug Administration, United States of America. http://www.accessdata.fda.gov/drugsatfda_docs/label/2002/14134s24lbl.pdf (Accessed on September 20, 2010).
  58. Schwartz MD, Hurst CG, Kirk MA, et al. Reactive skin decontamination lotion (RSDL) for the decontamination of chemical warfare agent (CWA) dermal exposure. Curr Pharm Biotechnol 2012; 13:1971.
  59. Houston M, Hendrickson RG. Decontamination. Crit Care Clin 2005; 21:653.
  60. Byers M, Russell M, Lockey DJ. Clinical care in the "Hot Zone". Emerg Med J 2008; 25:108.
  61. Macintyre AG, Christopher GW, Eitzen E Jr, et al. Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities. JAMA 2000; 283:242.
  62. Nerve agents - prehospital management. Chemical Hazards Emergency Medical Management. US Department of Health and Human Services. http://www.chemm.nlm.nih.gov/na_prehospital_mmg.htm#top (Accessed on September 07, 2013).
  63. Murray DB, Eddleston M, Thomas S, et al. Rapid and complete bioavailability of antidotes for organophosphorus nerve agent and cyanide poisoning in minipigs after intraosseous administration. Ann Emerg Med 2012; 60:424.
  64. HHS pursues nerve agent anti-seizure drug for children and adults. US Department of Health and Human Services. HHS.gov. http://www.hhs.gov/news/press/2013pres/09/20130925b.html (Accessed on October 07, 2013).
  65. Shih TM, Rowland TC, McDonough JH. Anticonvulsants for nerve agent-induced seizures: The influence of the therapeutic dose of atropine. J Pharmacol Exp Ther 2007; 320:154.
  66. Koplovitz I, Schulz S. Perspectives on the use of scopolamine as an adjunct treatment to enhance survival following organophosphorus nerve agent poisoning. Mil Med 2010; 175:878.
  67. Perkins MW, Pierre Z, Rezk P, et al. Protective effects of aerosolized scopolamine against soman-induced acute respiratory toxicity in guinea pigs. Int J Toxicol 2011; 30:639.
  68. Gourley, SR. US Marine Corps Chemical Biological Incident Response Force. Military Medical Technology 2003; 7:6.