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Southern Medical Journal:
doi: 10.1097/SMJ.0b013e31827cd12d
Healthcare System Preparedness

Sarin Exposure: A Simulation Case Scenario

Eason, Martin P. MD, JD

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Author Information

From the Quillen College of Medicine, Center for Experiential Learning, East Tennessee State University, Johnson City.

Reprint requests to Dr Martin P. Eason, Quillen College of Medicine, East Tennessee State University, PO Box 70571, Johnson City, TN 37614. Email: eason@etsu.edu

This work was funded by departmental funding at the Quillen College of Medicine.

M.P.E. is a consultant for Meharrry Medical College. He holds a patent with and receives royalties from Gaumard, Simulators for Health Care Education.

Accepted October 3, 2012.

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Abstract

Abstract: Given the current geopolitical tensions, the risk of a terrorist attack on the United States is constant and increasing. Chemical terrorism, specifically the use of nerve agents, has occurred in other nations. Because of the ease of manufacture, the ability to conceal them, and the lethality of these agents, they pose a potential threat as a weapon of terror. Nerve agent exposure requires prompt recognition, a series of actions to mitigate further exposure to others, and management of the physiological sequelae of exposure. Many civilian healthcare providers are unprepared to manage injuries from nerve exposure. Failure to recognize the signs of nerve agent exposure will increase mortality and morbidity in victims and place healthcare providers at risk. Simulation is an effective methodology to train healthcare personnel in disaster preparedness. This article presents a simulation scenario that reviews the presentation of nerve agent exposure, its management, and a recipe for performing this simulation in a training exercise.

Key Points

* Sarin is a lethal nerve agent that exerts its effect through blockage of anticholestinerase, leading to an excess of cholinergic activity. Toxicity results in muscle spasms, bronchoconstriction, seizures, and apnea.

* Appropriate responses include alerting the appropriate civil and military authorities, isolating and decontaminating the victim(s), preventing exposure to others, including healthcare providers, and instituting resuscitative measures.

* Medical management includes the administration of atropine, benzodiazepines, and pralidoxime. Atropine reverses cholinergic activity at the muscarinic receptor, benzodiazepines attenuate fasciculations and seizures, and pralidoxime prevents the formation of permanent bonds between sarin and anticholestinerase.

On a beautiful Friday afternoon after Thanksgiving at the mall in Midtown, USA, the shoppers were hurriedly snapping up bargains. Midtown is proud of its mall, one of the largest in the United States. In the store nearest to the ventilation system, several customers suddenly began coughing, some lost their balance, and others were actively seizing. This scene was repeated in neighboring stores. The mall patrons, realizing that something was wrong, began to panic and run for the available exits. The stampede toward the exits caused people to fall and trample each other, resulting in trauma injuries to many. The crowd at the exits slowed the egress, trapping more people in the poisoned air of the mall and preventing first responders from accessing the site. The first responders to enter quickly succumbed to the effects of the air. Medic 22 was on its way to the mall when the staff received a call to investigate a driver at a stoplight who appeared ill. At the location, they noted a car stopped, with its engine running. Inside, the driver was a 30-year-old man who appeared diaphoretic, teary, with a runny nose, and confused. The first responders noted that he was “twitchy.” The patient’s status was reported to the emergency department via radio. The emergency medical services (EMS) team moved him to an ambulance and began transporting him to the nearest hospital.

The definition of chemical warfare is the “use of any synthetic compound or material designed and used for the purpose of harming others.”1 Chemicals have been used since the ancient Greeks to offer an advantage in warfare. During the Peloponnesian War, the Spartans used wood saturated with pitch and sulfur to generate arsenic smoke to defeat the Athenians. The Romans used a toxic smoke similar to phosgene to defeat the Charakitanes in 72 BC.2 The deadliest use of chemical warfare was experienced during World War I, when mustard gas, chlorine, and phosgene gas were used by all sides. Since then, research has continued to create even deadlier compounds, which have been used in war (Iraq against the Kurds in the 1980s).1 The concern regarding the use of chemical weapons in war grew, leading to the first Chemical Weapons Convention in 1993, a multilateral treaty banning chemical weapons and providing for verification of the destruction of chemical weapons;3 however, it is the use of these weapons in terrorism that creates the greatest concern.

As a weapon of terror, chemical agents are favored because chemicals are ubiquitous, inexpensive, and more stable than other weapons of mass destruction. In addition, the technology to produce these agents is relatively simple for experienced chemists. Moreover, the ability of these weapons to cause injury in a stealthy, potent, and dramatic fashion can create fear in any society. Chemical weapons can be more potent than conventional explosive weapons, allowing them to cause the most damage against unprotected populations. The most notable use of chemical terrorism involved the use of sarin gas by the religious cult, Aum Shinrikyo, in a Tokyo, Japan, subway in 1995. The well-financed sect manufactured and delivered sarin via pierced bags. As the gas evaporated, it spread to affect passengers at 15 stations. As a result 12 people were killed, 54 were critically injured, and 900 were hospitalized (including 135 emergency workers). Symptoms experienced by the victims included nasal and oral bleeding, nausea, vomiting, dyspnea, coma, convulsions, extreme light sensitivity, flu-like symptoms, loss of consciousness, loss of memory, loss of vision, paralysis, seizures, and uncontrollable trembling. Some survivors suffered these problems permanently, in addition to disturbed sleep, nightmares and posttraumatic stress disorder. In addition, more than 5500 “worried well” sought screening and treatment at hospitals. It is estimated that during a 5-year span, the cult attempted 17 different chemical attacks.4

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As the Aum Shinrikyo case illustrates, given the current geopolitical tensions, the risk of a chemical attack against the United States is significant and highlights the importance of community preparedness in addressing a potential attack. Al Quaeda has been implicated in attempts to obtain chemical weapons.4 US President Bill Clinton signed Presidential Directives 39 and 62, which outline policy for deterring and responding to incidents in which weapons of mass destruction are deployed.5,6 Since the terrorist attacks on September 11, 2001, organizations and government agencies both at local and federal levels have promoted preparedness. In 2001, The Joint Commission (formerly the Joint Commission on Accreditation of Health Care Organizations) promoted training and education for healthcare providers in the management of catastrophic incidents.7 Simulation has been used successfully in training healthcare personnel for disaster management and has been perceived by learners as closely mimicking real-life situations.8,9 The following is a case scenario that uses simulation, which was created for training healthcare providers in the recognition and management of a nerve agent attack. The format used is one promulgated by Duke University and is universally recognized as the standard format for simulation scenarios.10 The objectives for the learners are to recognize the signs and symptoms of nerve agent exposure and to take appropriate management steps for the treatment of nerve agent exposure.

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Curricular Information

Educational Rationale

The terrorist attacks in New York on September 11, 2001 highlighted the potential threat of domestic terrorism to civilian populations. Civilian agencies and the Department of Defense have since promoted awareness and preparation in communities (including healthcare organizations and providers) for repeat attacks.11 Because of the ease of manufacture, the ability to conceal them, and the lethality of these agents, they pose a threat as a weapon of terror. Nerve agent exposure requires prompt recognition, a series of actions to mitigate further exposure to others, and management of the physiological sequelae of exposure. Many civilian healthcare providers are unprepared to manage injuries from nerve exposure. Failure to recognize the signs of nerve agent exposure increases mortality and morbidity in victims and places healthcare providers at risk.

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Learning Objectives

Learners are assessed on the following Accreditation Council for Graduate Medical Education core competencies: medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The objectives of the training are as follows:

1. Recognize the clinical presentation of nerve agent exposure.

2. Understand the mechanism of action of nerve agents.

3. Understand the physiological effects of nerve agent exposure.

4. Understand the mechanism of action of the antidotes for nerve agent exposure.

5. Understand and use the appropriate civil procedural steps when a nerve agent attack is suspected.

6. Understand the necessity and use of personal protective equipment (PPE) when caring for a victim of a nerve agent attack.

7. Understand and use the appropriate medical management steps for treating a victim of a nerve agent attack.

8. Understand and use the appropriate medications to reverse the effects of nerve agent exposure.

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Guided Study Questions

1. What are the categories of chemical weapons?

2. What are the common nerve agents?

3. How do nerve agents exert their effects?

4. What are the results of nerve agent exposure?

5. What is the clinical presentation of nerve agent exposure?

6. What immediate actions should be taken when nerve agent exposure is suspected?

7. What are the antidotes to nerve agent exposure and how do they exert their effects?

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Assessment Checklist

The following items/activities must occur when assessing the site of a chemical weapons attack:

1. Obtain history

2. Perform physical examination

a. Vital signs

b. General assessment (ABCs [airway, breathing, circulation])

c. Cardiac

d. Pulmonary

3. Recognize nerve agent exposure

4. Don PPE

5. Notify authorities

6. Decontaminate patient/remove clothing

7. Give ventilatory support

8. Order telemetry

9. Order oxygen

10. Order intravenous (IV) access if not yet available

11. Order atropine in appropriate doses

12. Order diazepam in appropriate doses

13. Order pralidoxime in appropriate doses

14. Treat respiratory failure

15. Reassess for delayed exposure

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Equipment Checklist

The monitors required are as follows:

1. Pulse oximeter

2. Telemetry

3. Noninvasive blood pressure cuff

The other equipment required is as follows:

1. Bag valve mask

2. Oxygen tubing

3. Laryngoscope

4. Endotracheal tube

5. IV setup

6. PPE (optional: participants may state that they are wearing it)

7. Simulated drugs

The personnel who are required are as follows:

1. One “paramedic”

2. One nurse

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Simulation platform

1. Adult high-fidelity simulator

The supporting documentation is as follows:

2. Normal chest radiograph

3. Electrocardiogram showing sinus tachycardia

4. Laboratory datasheets

5. Arterial blood gas indicating hypoxemia and hypercarbia

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The duration of simulation steps is as follows:

1. Setup: 30 minutes

2. Preparation: 15 minutes

3. Simulation: 30 minutes

4. Debriefing: 30 minutes

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Case Stem

The patient is a 30-year-old man who was found in distress when he failed to continue driving after stopping at a traffic light located approximately two blocks from Midtown Mall. This man is actually a terrorist who released sarin nerve toxin into the ventilation system of Midtown Mall. The chemical he released was unknown to him, and he had accidently spilled some of the toxin on his clothing. EMS found him to be diaphoretic, have runny eyes and nose, and to be confused. They noted that he was “twitchy.” His status was reported to the emergency department (ED) via radio and he was transported to the local hospital via ambulance. The EMS team had heard a report of numerous ill shoppers at the mall and indicated to the ED that there may be a connection between that report and the patient being transported. When the learners obtain the report from the paramedic and nurse on the EMS team, the paramedic is noticeably sick, saying he felt nauseated and mildly short of breath.

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Patient Data Background and Debriefing Information (for Facilitator’s/Coordinator’s Eyes Only)

This simulation deals with a patient who has been exposed to a chemical agent. Chemical agents can be classified as blister agents (mustard gas), lung irritants (chlorine, phosgene), blood agents (hydrogen cyanide), nerve agents (tabun, sarin, VX [O-ethyl S-{2-(diisopropylamino)ethyl} methylphosphonothioate], soman), and incapacitants (belladonna, lysergic acid diethylamide).1 Recognition and timely treatment are important because these agents act quickly and, depending on the degree of exposure, can be lethal. Nerve agents are volatile liquids that affect their victims by systemic absorption. They can come in contact with the mucous membranes or be absorbed through the eyes, nose, and/or skin; skin absorption is responsible for the delayed and prolonged effect of these agents.12 The archetypal agent is sarin but others include tabun, soman, cyclosarin, and VX. VX is the most toxic agent, exerting its effect mainly through skin exposure, thus bypassing protective masks. It is 1000 times more toxic than sarin when exposed to the skin and three times more toxic when inhaled. A pinhead-size drop on the skin is lethal within 15 minutes. Nerve agents exert their effects by binding to and blocking the enzyme acetylcholinesterase (AChE), which is responsible for breaking down the enzyme acetylcholine (ACh), which acts as a neurotransmitter in both the peripheral and central nervous systems.13 The initial bond is reversible, but over time, depending on the agent, it may bind to AChE permanently, a process called aging. The result is a relative increase in ACh, leading to symptoms of excess ACh. ACh can affect both the nicotinic and muscarinic receptors, and the symptomatology is reflective of the effects at these receptors. The symptoms resulting from muscarinic effects include bronchoconstriction (wheezing), miosis, hyperpersistalsis (nausea, diarrhea, cramping, and vomiting), sweating, lacrimation, and salivation (“wet all over”). The effects on neurons result in hyperstimulation manifesting as seizures and fatigue of the respiratory center leading to central apnea. Skeletal muscle stimulation leads to twitching and fasciculations, eventually progressing to fatigue and paralysis; the latter can lead to respiratory arrest. Whereas bradycardia would be expected by excess muscarinic stimulation, ACh also induces the release of norepinephrine from sympathetic ganglia. In humans, tachycardia and hypertension are seen frequently. This grouping of symptoms is known as the cholinergic toxidrome and is pathognomonic for nerve agent poisoning.14 Management protocols include identifying nerve agent exposure, alerting appropriate agencies, protecting healthcare providers, removing any residual nerve agent, and medically treating the exposed patient.15

Nerve agent exposure is suspected when patients present with the classic presentation of diarrhea, urinary incontinence, miosis/muscle fasciculations, bronchorrhea, bronchospasm, emesis, lacrimation, and salivation (DUMBBELS).12 Once nerve agent exposure is suspected, providers should contact agencies to help manage this event to contain the affected area and prevent escalating casualties. The emergency management authorities include police, EMS, and local health departments (hazardous materials team), the Department of Homeland Security, the Department of Defense, and the Centers for Disease Control and Prevention. Providers who are exposed to residual agents should don PPE. PPE includes skin protection and pressure demand self-contained breathing apparatus. All potentially contaminated areas should be cleared and secured and entrances should be secured to prevent further exposure. Because any residual liquid agent may continue to be absorbed by the patient and contaminate staff, the patient should be decontaminated promptly before entering the facility after an assessment and administration of general supportive care (ABCs). Steps include the removal of all clothing and promptly washing with soap and water. The latter should be done outside the facility, if possible.16 Medical management is based on the degree of exposure and involves attenuating the effects of excess ACh and preventing “aging” of the agent. Mild exposure is defined as including miosis, rhinorrhea, and shortness of breath or a combination of these symptoms; moderate exposure is significant shortness of breath; and severe exposure includes loss of consciousness, seizures, and severe shortness of breath. Latent symptoms (symptoms following exposure after a relative period of mild symptoms) reflect systemic effects from agents absorbed through the skin. This should be kept in mind when patients initially respond then worsen clinically. The recommended therapeutic medications include atropine as a muscarinic blocker, diazepam to mitigate fasciculations and seizures, and pralidoxime. Atropine is given incrementally depending on the severity of symptoms, with an initial dose of 2 mg intramuscularly (IM) or intravenously (IV), which can be increased to 20 mg. Atropine has no effect at the nicotinic receptors. Doses may be repeated every 5 minutes until improvement (decreased secretions and resolution of shortness of breath) is seen. Severe respiratory distress may require assisted ventilation and intubation. Pralidoxime acts to break the bond between the nerve agent and AChE and prevents aging; however, it is ineffective once aging has occurred. It should not be withheld for fear that aging has occurred and should be administered in cases of moderate to severe exposure. For moderate symptoms associated with liquid exposure, the recommended dose is 600 mg IM, and for severe symptoms for both liquid and vapor exposure, the recommended dose is 1.8 g IM. Patients should be reevaluated every 3 to 5 minutes for signs of worsening symptoms, and steps should also be taken to ensure that supplies of atropine and pralidoxime are adequate and available.12

The purpose of this exercise is for participants to learn to recognize the presentation of nerve agent exposure. Learners will be presented with a patient who appears to have cholinergic syndrome and will be provided with the findings of the EMS team: a confused man, with miosis, urinary and fecal incontinence, diaphoresis, and tachypnea. The challenges for the learners are as follows:

1. Recognizing the signs of nerve agent exposure

2. Notifying authorities, including hospital staff, emergency response agency, CDC, and Department of Defense

3. Decontaminating patient

4. Donning of PPE, if patient not decontaminated

5. Timely managing nerve agent exposure

6. Recognizing respiratory failure

7. Managing respiratory failure

The sequence of the scenario is as follows:

1. Clinical presentation of nerve exposure in a patient who still has residual toxin on his clothes

2. If the learners do not don PPE and do not remove the patient’s clothing (decontaminate the patient), then after 10 minutes they are told that they are exposed and the scenario ends.

3. The patient will have worsening respiratory distress/seizure/ cardiac arrest if he is not treated appropriately with two 2-mg doses of atropine.

4. If the patient is treated appropriately, then he will improve initially then experience symptoms of delayed absorption (eg, recurring bronchospasm, hypoxemia, seizures), which must be treated with another additional 4-mg dose of atropine.

5. Respiratory support will attenuate the rate of hypoxemia decline, but it will not resolve it. Failure to provide respiratory support will result in an accelerated decline in the patient’s condition.

6. Appropriate treatment results in the resolution of symptoms and an end to the scenario.

Although the steps in the scenario delineate the sequence of action as the scenario develops, no scenario design can account for all potential actions of learners and consequent outcomes. Facilitators are, therefore, encouraged to use this scenario as a guide only and improvise as necessary, depending on the events of the simulation as they unfold.

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Case Option

To reinforce the logistical issues involved with this type of emergency and to increase the complexity of the case, session facilitators may have the learners address the paramedic’s exposure to the toxin. Because his exposure is not as severe (inhalational only) as that of the patient, he will require much less intense management. Alternatively, the scenario could be altered to reflect cutaneous exposure (when he touched the victim’s wet clothing) and, therefore, a much more serious degree of toxicity. Doing so addresses issues of asset management, prioritization, and triage. The second victim could be the EMS personnel tending to the patient, whose symptoms were delayed because of the cutaneous exposure.

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Debriefing Points

1. Types of chemical agents

2. Types of nerve agents

3. Mechanism of action of nerve agents

4. Clinical presentation of nerve agent exposure

5. Physiological effects of nerve agent exposure and clinical implications

6. Management of nerve agent exposure

a. Logistical

(1) Isolate treatment area

(2) Notification of staff, administration, law enforcement, and emergency authorities

(3) Ensure adequate medical supplies

b. Importance of PPE

c. Medical management

(1) Atropine

(2) Diazepam

(3) Pralidoxime

(4) Supportive care

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Patient Data Background and Baseline State (to Share With Learners)

Patient History

The patient history is to be discussed with learners before the patient is examined. The patient is a 30-year-old man who was found in distress when he failed to continue driving after stopping at a traffic light located approximately two blocks from Midtown Mall. This man is actually a terrorist who released sarin nerve toxin into the ventilation system of Midtown Mall. The chemical he released was unknown to him, and he had accidently spilled some of the toxin on his clothing. EMS found him to be diaphoretic, have runny eyes and nose, and to be confused. They noted that he was “twitchy.” His status was reported to the ED via radio and he was transported to the local hospital via ambulance. The EMS team had heard a report of numerous ill shoppers at the mall and indicated to the ED that there may be a connection between that report and the patient being transported. When the learners obtain the report from the paramedic and nurse on the EMS team, the paramedic is noticeably sick, saying he felt nauseated and mildly short of breath.

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Review of Systems

Unknown, except that the patient told EMS that he was short of breath and had lost control of his bladder and bowels.

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Physical Examination

* General: Confused patient in moderate distress; diaphoretic, drooling, and rhinorrhea is present; incontinent of bladder and bowel; clothing appears as though the patient spilled something on his shirt. He has an IV in place.

* Weight and height: 67 in. and 80 kg

* Vital signs: blood pressure 165/95, heart rate 125, respiratory rate 28, oxygen saturation 89%, temperature 98°

* Head, ears, eyes, nose, and throat: lacrimating profusely, pupils pinpoint

* Heart: S1 and S2 normal with no gallops or murmurs; patient is tachycardic

* Lungs: bilateral wheezing

* Telemetry, if requested, shows sinus tachycardia

* Complete blood count: within normal limits

* Chemistry: normal values

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Baseline Simulator State

* Vital signs: blood pressure 165/95, heart rate 125, respiratory rate 28, oxygen saturation 89%

* Neurological examination: Awake but confused and anxious/agitated

* Respiratory: tachypneic with bilateral wheezing

* Cardiovascular: tachycardic

* Gastrointestinal examination: hyperactive bowel sounds

* Environment: he is wearing clothes of a maintenance worker; there is a wet spot on his trouser leg and at his crotch and thighs; an IV with normal saline is running in his right arm

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Conclusions

With international tensions high, the threat of terrorism in the form of chemical weapons is a real and distinct possibility. Nerve agents such as sarin are efficient, lethal weapons and have been used with success against civilian populations. The potential for high numbers of injured and dead exists if healthcare providers are unprepared to recognize and manage such attacks. These numbers can be mitigated with proper training in the management of a chemical weapons attack. This simulation exercise is one method that can be used to train providers in the management issues, both clinical and administrative, that are associated with a terrorist attack using the chemical weapon sarin.

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References

1. Hilmas CJ, Smart JK, Hill BA. History of chemical warfare, in Tuorinsky SD (ed): Medical Aspects of Chemical Warfare. Washington, DC, Borden Institute, 2008, pp 9–75.

2. UK Ministry of Defense. Defending against the threat of biological and chemical weapons. Outline history of biological & chemical weapons. http://webarchive.nationalarchives.gov.uk/+/http://www.mod.uk:80/issues/cbw/history.htm. Accessed July 1, 2012.

3. Organization for the Prohibition of Chemical Weapons. Background of chemical disarmament. http://www.opcw.org/news-publications/publications/history-of-the-chemical-weapons-convention. Accessed July 1, 2012.

4. Smart JK, Mauroni A, Hil BA, et al.. History of the chemical threat, chemical terrorism, and its implications for military medicine, in Tuorinsky SD (ed): Medical Aspects of Chemical Warfare. Washington, DC, Borden Institute, 2008, pp 115–153.

5. Office of the Press Secretary, White House. Presidential Decision Directive 39: US policy on counterterrorism. http://www.fas.org/irp/offdocs/pdd39.htm. Published June 21, 1995. Accessed November 5, 2012.

6. Office of the Press Secretary, White House. Presidential Decision Directive 62: combating terrorism. http://www.fas.org/irp/offdocs/pdd-62.htm. Published May 22, 1998. Accessed November 5, 2012.

7. Rubin JN. Recurring pitfalls in hospital preparedness and response. In: McIsaac III JH, ed. Hospital Preparation for Bioterror. New York: Academic Press; 2006.

8. Wilkerson W, Avstreih D, Gruppen L, et al.. Using immersive simulation for training first responders for mass casualty incidents. Acad Emerg Med 2008; 15: 1152–1159.

9. Billett B, Peckler B, Sinert R, et al.. Simulation in a disaster drill: comparison of high-fidelity simulators versus trained actors. Acad Emerg Med 2008; 15: 1144–1151.

10. Duke University Human Simulation and Patient Safety Center. Duke University simulation development template. http://simcenter.duke.edu/support.html. Accessed June 29, 2012.

11. Bossone CA, Despain K, Tuorinsky S. History of chemical warfare, domestic preparedness, in Tuorinsky SD (ed): Medical Aspects of Chemical Warfare. Washington, DC, Borden Institute, 2008, pp 753–773.

12. Madssen JM. Terrorism and disaster—what clinicians need to know: sarin. http://www.medscape.org/viewprogram/4362. Accessed May 31, 2012.

13. Velez-Daubon LI. CBRNE—Nerve agents, binary—GB2, VX2. http://emedicine.medscape.com/article/831901-overview. Accessed May 2, 2012.

14. Lee EC. Clinical manifestations of sarin nerve gas exposure. JAMA 2003; 290: 659–662.

15. Centers for Disease Control and Prevention. Emergency room procedures in chemical hazard emergencies: a job aid. http://www.cdc.gov/nceh/demil/articles/initialtreat.htm. Accessed July 2, 2012.

16. Agency for Toxic Substances and Disease Registry. Toxic substances portal—nerve agents (GA, GB, GD, VX). http://www.atsdr.cdc.gov/MMG/MMG.asp?id=523&tid=93. Accessed July 2, 2012.

Keywords:

anticholinesterase; antidote; antimuscarinic agent; chemical terrorism; decontamination; nerve agent; sarin

© 2013 Southern Medical Association

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