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

Medical DiagnosticsStorageUpon arrival, the receiving laboratory should maintaina proper chain of custody. If the samples are notprocessed immediately, they should be stored as soonas possible after arriving at the receiving laboratory.Storing samples either before or after they are shippedshould be in accordance with conditions dictated bythe sample type. Blood should be stored refrigeratedat 4°C. Plasma or serum should be stored frozen at–70°C. RBCs can be stored refrigerated at 4°C or frozenat –70°C; freezing is preferred for long-term storage.Avoid repeated cycles that move samples from frozento thawed or refrigerated to room temperature.summaryThe general class of agents involved in severe intoxication(ie, OP nerve agents, vesicants, etc) can often berecognized by symptom presentation. However, testingis necessary to identify the specific agent involved.In cases where poisoning is suspected at low levels andsymptoms do not clearly indicate intoxication with aspecific chemical warfare agent, testing can provideadditional information to help consider or rule out anexposure. In general, confirmatory analyses shouldnot be initiated in the absence of other informationthat suggests a potential exposure has taken place;other evidence, such as patient signs or symptoms,environmental monitoring and testing, and threat intelligenceinformation should also be considered. Thisinformation should be used to guide decisions aboutwhat agent or class of agents should be the focus oftesting and it should ultimately be used in conjunctionwith test results to determine whether or not anexposure has occurred.Analytical methods for verifying chemical agent exposuredo not employ instrumentation that is routinelyused for standard clinical testing, such as automatedclinical analyzers. With the exception of cholinesteraseanalysis, instrumentation typically involves MSsystems with either GC or LC techniques to separatethe analyte from other matrix components. Althoughthe methods are desirable because they afford a highlevel of confidence for identifying the analyte, theyare time and labor intensive. Consequently the turnaroundtime for analyses is greater than that expectedfor standard clinical tests.Chemical warfare agents have been used againstboth military and civilian populations. In many ofthese cases, healthcare providers have learned thatit is critical to rapidly identify exposed personnelto facilitate appropriate medical treatment and support.Incidents involving large numbers of personnelhave shown that is also important to determine thosenot exposed to avoid unnecessary psychologicalstress and overburdening the medical system. Inaddition to medical issues, the political and legalramifications of chemical agent use by rogue nationsor terrorist organizations can be devastating.Therefore, it is important that accurate and sensitiveanalytical techniques be employed and appropriatelyinterpreted.REFERENCES1. Matsuda Y, Nagao M, Takatori T, et al. Detection of the sarin hydrolysis product in formalin-fixed brain tissues ofvictims of the Tokyo subway terrorist attack. Toxicol Appl Pharmacol. 1998;150:310–320.2. Department of the US Army. Assay Techniques for Detection of Exposure to Sulfur Mustard, Cholinesterase Inhibitors, Sarin,Soman, GF, and Cyanide. Washington, DC: DA; 1996. Technical Bulletin Medical 296.3. Taylor P. Anticholinesterase agents. In: Brunton LL, Lazo JS, Parker KL, eds. Goodman and Gilman’s the PharmacologicalBasis of Therapeutics. 11th ed. New York, NY: McGraw-Hill; 2006:201–216.4. Sidell FR. Nerve agents. In: Sidell FR, Takafuji ET, Franz DR, eds. Medical Aspects of Chemical and Biological Warfare. In:Zajtchuk R, Bellamy RF, eds. The Textbooks of Military Medicine. Part I. Washington, DC: Borden Institute; 1997:129–179.5. Harris R, Paxman J. A Higher Form of Killing: the Secret Story of Chemical and Biological Warfare. New York, NY: Hill andWang; 1982: 53.6. Degenhardt CE, Pleijsier K, van der Schans MJ, et al. Improvements of the fluoride reactivation method for the verificationof nerve agent exposure. J Anal Toxicol. 2004;28:364–371.741