CHEMICAL AGENTS CLINICAL PEARLS AND PITFALLS Chemical agents may secondarily affect first responders or medical providers Providers must address airway, breathing, and circulation while decontaminating the patient Removal of clothing is a simple and effective first step to decontamination Nerve-agent poisoning can resemble cyanide poisoning in certain ways, but nerve agents may have cholinergic symptoms Current Evidence Mass casualties can result from the accidental or intentional release of either traditional chemical warfare agents (CWAs) or toxic industrial chemicals During World War I, chemical agents such as chlorine, phosgene, and sulfur mustard were used on an unprecedented scale These agents are sometimes referred to as first-generation chemical warfare agents The second-generation chemical agents are the G-series nerve agents, so called because Germany developed them before and during World War II After that war, structurally different kinds of nerve agents were developed and were designated V-series nerve agents; these are thirdgeneration chemical agents The G- and V-series nerve agents are also called traditional nerve agents Nerve agents, along with sulfur mustard, were used by Iraq against Iran and against Kurdish villages in Iraq during the Iran–Iraq War of the 1980s In 1995, religious terrorists released sarin in the Tokyo subway system and flooded the local medical system with casualties Tragically, sarin was also used in the Damascus suburb of Ghouta during the Syrian civil war in 2013, killing more than 1,400 civilians, and weaponized chlorine has been used in the same conflict as recently as 2018 Fourth-generation agents (FGAs) are one category of so-called “nontraditional agents (NTAs)” investigated by certain countries after the development of VX Much information about the FGAs (and other NTAs) remains classified The FGAs include the A-series agents, or Novichok compounds, which are low-volatility nerve agents even more persistent than VX One of the A agents was used in the 2018 assassination attempt on Sergei Skripal in Salisbury, UK