Riot-control agents, also called lacrimators (“tear gas”), include several compounds, the most important of which are CS (o-chlorobenzylidene malononitrile), CN (1-chloroacetophenone, also marketed as Mace), and OC (oleoresin capsicum, or pepper spray) All three are solids and are typically dispersed as an aerosol of fine particles (e.g., smokes) or droplets (e.g., sprays) These agents are widely available, cause significant incapacitating effects in closed spaces, and could conceivably be used in a terrorist attack CS and CN generate bradykinins leading to pain without significant tissue injury; OC binds to VR1 (TRPV1) receptors on sensory neurons and causes the release of substance P, which leads to neurogenic inflammation with vasodilation, hyperemia, and plasma extravasation as well as pain All these agents can cause transient ocular burning sensation, tearing, blepharospasm, and photophobia; irritation of the nose, throat, and upper airway; and skin burning, erythema, and sometimes vesication A few riot-control agents, such as Adamsite (DM), are referred to as vomiting agents because they cause pronounced vomiting in addition to delayed-onset irritation of the eyes and the upper airway Most victims under usual circumstances of exposure become symptomatic within seconds from the traditional lacrimating agents (irritation after exposure to DM may take up to 20 minutes to develop) but remain so for only 20 to 60 minutes However, high concentrations in closed spaces or after discharge of agent close to the victim’s face have been associated with serious medical complications, including severe ocular toxicity, dermal burns, and pulmonary failure A few lethal cases have been described in which death was caused by severe tracheobronchitis with pseudomembrane formation and pulmonary edema Management includes careful ocular and dermal decontamination The skin should be washed with soap and water, although this may cause transient increased pain Hypochlorite solution should not be used because it may exacerbate dermal burns via the creation of toxic by-products The eyes should be thoroughly irrigated after a single dose of topical anesthetic Respiratory complications must be managed supportively, as previously described for mustard and pulmonary-agent toxicity Because severe respiratory effects may not manifest for 12 to 24 hours, patients with dyspnea or any objective findings should probably be observed in the hospital Severe respiratory complications from exposure to riot-control agents have been described in at least two young infants, one of whom was in a house into which CS was sprayed A canister of pepper spray was accidentally discharged directly into the face of the other infant Both survived with prolonged care, the latter requiring ventilatory support, including days of extracorporeal membrane oxygenation A few cases of children ingesting CS powder are known, which resulted only in transient diarrhea and abdominal cramping Miscellaneous Chemicals The potential of a terrorist attack on industrial sources of dangerous chemicals such as factories, railroad and vehicular tank cars, or storage depots expands the list of potential “chemical weapons” considerably In addition, the development of potent incapacitating agents, such as fentanyl derivatives, by law enforcement or military agencies for use in combating terrorist incidents, might unfortunately lead to mass casualties requiring medical treatment, as illustrated by the October 2002 theater hostage incident in Moscow A full discussion of all such possible chemical injuries and their management is beyond the scope of this discussion In general, many of the relevant industrial chemicals (e.g., methyl isocyanate, ammonia, nitrogen dioxide, sulfur oxides) might be expected to induce respiratory effects analogous to those of chlorine or phosgene discussed previously; others (e.g., strong acids or alkalies, hydrogen fluoride, formaldehyde, and acrolein) could cause dermatologic injury from irritant or caustic properties, as well as more systemic effects in severe exposures ( Table 132.5 ) Fentanyl derivatives can be lethal from suppression of the respiratory center in the medulla of the brain Further information is available from standard reference toxicology textbooks and by consultation with the regional poison control center (1-800-222-1222) Emergency Department Preparedness The ED response to chemical exposure incidents should be integrated with the hospital’s All-Hazards Emergency Operations Plan There must be protocols for mass notification of key personnel, using hospital security for patient direction and crowd control at the ED entrance and around the decontamination site, and handling the dissemination of information to the public and news media Hospital spaces that are not routinely used for patient care, such as cafeterias, may be used as holding areas for large numbers of exposed but minimally symptomatic patients Such patients may constitute up to 80% of those seeking medical attention An “upside-down” triage pattern may also be observed: Less critically affected patients may arrive first at the hospital (and begin to overwhelm medical resources), followed later by ambulances transporting the more severely exposed Routine hospital supplies such as gowns and towels may be depleted rapidly in the face of mass casualties Demands for critical care beds, ventilators, and other resources may exceed availability Alternative care facilities (e.g., schools, gymnasiums, or warehouses) staffed by outside help may be needed in mass- casualty situations Predisaster planning for both intentional and unintentional chemical releases must take such factors into account The National Response Framework and the National Disaster Medical System, augmented if necessary by military medical assets from the Department of Defense, provide a framework for activating medical assistance at the federal level Availability of specific antidotes and medications in the context of planning for a chemical exposure event involving mass casualties is an additional challenge Stockpiling pharmaceuticals such as the Cyanokit may be prohibitively expensive HAZMAT incident planning should establish some mechanism for local or regional stockpiling of these critical medications and as a means to replenish initial stores Table 132.7 offer an attempt to quantify the amount of antidotal medications that might be needed in one ED for the management of a nerve agent or cyanide attack involving both pediatric and adult victims on a scale of the Tokyo sarin attack A biologic agent attack would place similar enormous demands on the hospital pharmacy for antibiotics, vaccines, and antitoxins A federal system for stockpiling pharmaceuticals and emergency medical supplies, managed through the CDC, has been created to augment local resources in this critical logistical arena The first large-scale deployment of this Strategic National Stockpile occurred in the hours following the September 11, 2001 attacks on New York and Washington, DC However, because prompt treatment is crucial in chemical emergencies, national stockpiles should be viewed as a resupply source and not obviate the need for each hospital to develop its own stockpile of antidotes that might be needed during the first few hours after such a mass-casualty incident TABLE 132.6 REPRESENTATIVE CLASSES OF INDUSTRIAL CHEMICALS— SUMMARY OF PEDIATRIC MANAGEMENT CONSIDERATIONS Critical ongoing issues regarding ED preparedness for a biologic or chemical agent attack include (i) optimal decontamination techniques, especially for young children; (ii) optimal PPE for ED staff; (iii) logistics of patient and hospital staff flow and isolation, in the context of a potentially lethal, contagious disease (e.g., smallpox, plague, and viral hemorrhagic fevers); (iv) safety of decontamination water runoff into public drainage systems; (v) community-wide needs for education and training; and (vi) financial considerations for individual hospital and regional planners Continued activity on an expert consensus basis, as well as new research, should help to address many of these issues ... control center (1-800-222-1222) Emergency Department Preparedness The ED response to chemical exposure incidents should be integrated with the hospital’s All-Hazards Emergency Operations Plan There... might be needed in one ED for the management of a nerve agent or cyanide attack involving both pediatric and adult victims on a scale of the Tokyo sarin attack A biologic agent attack would place... for antibiotics, vaccines, and antitoxins A federal system for stockpiling pharmaceuticals and emergency medical supplies, managed through the CDC, has been created to augment local resources