Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Aspects of Chemical Warfarereminiscence of nerve agent and sulfur mustard casualtycare in a series of articles in the Farsi-languageKowsar Medical Journal in the late 1990s. 218–227 Thelessons Foroutan learned have been summarizedin an English-language review paper. 12 Among theconclusions this analysis reached, Foroutan determinedthe differential diagnosis included cyanidepoisoning, heat stroke, infectious diseases, fatigue,and psychiatric diagnoses, including combat s tress.At the time, the Iranians thought Iraq had also usedcyanide, but that was never proven.Foroutan used large amounts of atropine in histreatment protocols. This may have resulted from thelack of oxime therapy far forward; Iranian soldiersdid not carry oxime with them, and even physicianshad a very small supply to use. It may also havebeen due to Foroutan ’ s inability to guarantee thatatropine would be given during medical evacuationto the rear of his location. In a few cases, Foroutanactually gave 200 mg of atropine IV in a 10-minuteto 15-minute period.Although miosis is a poor guide to atropinization,due to the relative disconnection between the papillarymuscle and the circulation, Foroutan noted that thedisappearance of miosis or even the appearance of mydriasiswas one indication to decrease atropine, “evenif the patient ’ s mouth has not completely dried.”Psychogenic casualties, whether those with actualpsychiatric diagnoses or simply “worried well,” were amajor problem for Foroutan, just as they were in the civilianvictims of the Tokyo subway attack. He stressedthe need to identify them and remove them from thesymptomatic patients requiring immediate attention.He also stressed the need to treat patients as quickly aspossible in order to achieve optimal outcomes.Foroutan’s experience shows that a robust evacuationand triage system saves lives on the battlefield.In the Hosseiniyeh attack, the one which most overwhelmedhis aid station, he received over 300 “severe”patients within 5 hours, along with 1,700 less severelyaffected patients. One aid station was not equipped totreat all of these patients. This illustrates the need toplan a robust and redundant system that can deal withmass casualties of nerve agent exposure.Foroutan felt that the numbers of nerve agent casualtieshad been underestimated by the media and thegovernment of Iran because, unlike sulfur mustardcasualties, nerve agent casualties rapidly becamewell or died. As such, nerve agent survivors had nopropaganda value, unlike the photogenic mustardcasualties who were evacuated to Europe. He believedthat there had been between 45,000 and 100,000 nerveagent casualties in the war, several times the UnitedNations estimate.JapanThere is considerable literature on the medicalaspects of the two terrorist attacks in Japan, in Matsumotoin 1994 and on the Tokyo subway system in1995. 53,78,143,165,228–244 One of the major lessons from theJapanese attacks is that 80% of the patients who presentedfor medical attention were not found to haveany signs or symptoms of sarin poisoning. This figurehas become a major point in the teaching of mass casualtymanagement of a future nerve agent attack. InTokyo, for example, the combined figures show about1,100 of the 5,500 people presenting to medical attentionhaving signs and symptoms of sarin poisoning,ranging from extremely severe to extremely mild. Theothers could be considered the “worried well.” 228 Eventhose patients who actually did have sarin poisoningsymptoms tended to have mild symptoms. For example,at Saint Luke ’ s International Hospital, whichsaw more patients than any other hospital (641), only5 patients were deemed “critical.” 165,229The physicians in the first attack, in the small cityof Matsumoto, were able to make the diagnosis oforganophosphate poisoning (cholinergic crisis) earlyby syndromic reasoning. In that part of central Japaninsecticide poisoning is common, so the patients couldbe treated without knowing the specific organophosphate.230 By contrast, in the later, larger Tokyo attack,diagnosis lagged considerably at many hospitals thatwere unaccustomed to seeing this condition.In both the Matsumoto and the Tokyo subway attacks,miosis was the most common symptom. 53,165,229,231,232Many of the patients had no demonstrated depressionof ChE. This reinforces the principle that patientsshould be treated symptomatically, as laboratory valuesare not as effective a guide to their conditions asis the clinical examination. At Toranomon Hospital,ChE activity was also found to be a poor guide to theseverity of poisoning, based on correlations with clinicalpicture and other values in 213 patients seen afterthe Tokyo attack. 233Four pregnant women, all with slightly decreasedChE levels, were among the patients evaluated at SaintLuke ’ s International Hospital. 229 They were between 9and 36 weeks’ gestation at the time of poisoning. Alldelivered healthy infants on schedule and withoutcomplications. This may be the only series of pregnantexposed patients ever recorded.The Japanese experience with acute nerve agentantidotal treatment is highly reassuring because evenwith delays of diagnosis, the standard protocols usingatropine, oximes, and anticonvulsants saved manypatients. 229,234,235 Those patients receiving 3 g or moreof pralidoxime iodide recovered their ChE levels faster196