Physicians and health care systems need to establish strategies for recognizing and responding to the unlikely occurrence of chemical-weapons attacks, according to the author of a new review.

“As a public health system we must make the realization that chemical-warfare agents are now a civilian and not just military problem, take the necessary steps to better train our emergency medical services (EMS) and hospital-based healthcare providers, and prepare for what will hopefully never come; the use of chemical weapons in downtown Boston, New York, Chicago,” and elsewhere, Dr. Gregory R. Ciottone from Beth Israel Deaconess Medical Center, Harvard Medical School, in Boston, told Reuters Health by email.

“It is time to be proactive and not just reactive,” he said, noting that, “Our current state of readiness for chemical attack on the civilian side is very poor.”

In his review in the April 26, 2018, issue of The New England Journal of Medicine, Dr. Ciottone describes chemical-warfare agents likely to be used in a civilian attack and the clinical syndromes (“toxidromes”) associated with them, as well as a rapid triage system based on early identification of the class of agent likely to be involved.

The likely suspects of chemical-warfare agents range from anesthetics to nerve agents to opioid agents to pulmonary agents, and include asphyxiants, anticholinergics, and vesicants, among others.

Presenting symptoms—confusion, muscle weakness, respiratory distress, skin irritation, and the like—can be useful for narrowing down the large range of possibilities into one or a few classes of agents, Dr. Ciottone writes.

The review includes detailed tables that cover these classes, their toxidromes, and their emergency treatment.

Dr. Ciottone also provides an algorithm that could be used in the acute phase of a chemical-warfare attack. It advocates rapid detection of victims who require emergency antidote administration and treatment first, followed by identification of those who require initial decontamination and urgent treatment concurrently.

“In my mind, it is good for all physicians to have a working knowledge of this,” he said. “Clearly, however, it is most important for the physicians, nurses, and EMS personnel who are on the front lines [at the scene of an event and in the emergency department], as the goal is rapid identification of agent class.”

“As in all disasters, we can no longer think ‘It won’t happen to us,'” Dr. Ciottone said. “More importantly, because these agents are so rapidly deadly without safe and efficient treatment, it is our responsibility as health care personnel to the communities we serve to be ready for the unlikely but possible use of these agents in a nearby attack. Part of our stewardship and responsibility for the well-being of our communities is to prepare for these low-frequency, high-acuity events.”

Dr. Rohini Haar from the University of California, Berkeley, who has reviewed the health impacts of chemical irritants and projectiles used for crowd control, told Reuters Health by email, “The toxidrome and class of agent are more important to identify than the specific agent. Agents can be mixed, chemical weapons can and have been used both for indiscriminate warfare and for individual attack, and algorithms can be useful to get on the right path early on.”

“The article reviews why it’s important to remember these basic toxidromes, although they are almost never seen by most physicians,” he said. “The emphasis should be: you won’t recognize it unless you know about it, so reviewing a paper like this is important for physicians.”