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-