eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

CBRNE - Incapacitating Agents, Opioids/Benzodiazepines: Differential Diagnoses & Workup

Author: Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health
Coauthor(s): Jennifer S Boyle, MD, PharmD, Fellow in Toxicology, University of Virginia Health System
Contributor Information and Disclosures

Updated: Feb 5, 2009

Differential Diagnoses

CBRNE - Chemical Warfare Agents
Toxicity, Barbiturate
CBRNE - Cyanides, Hydrogen
Toxicity, Benzodiazepine
CBRNE - Incapacitating Agents, 3-Quinuclidinyl Benzilate
Toxicity, Clonidine
CBRNE - Incapacitating Agents, Agent 15
Toxicity, Cyanide
CBRNE - Incapacitating Agents, Cannabinoids
Toxicity, Gamma-Hydroxybutyrate
CBRNE - Incapacitating Agents, LSD
Toxicity, Hallucinogen
CBRNE - Nerve Agents, Binary: GB2, VX2
Toxicity, Narcotics
CBRNE - Nerve Agents, G-series: Tabun, Sarin, Soman
Toxicity, Organophosphate and Carbamate
CBRNE - Nerve Agents, V-series: Ve, Vg, Vm, Vx

Workup

Laboratory Studies

  • The use of laboratory studies in the treatment of patients potentially exposed to opioid or benzodiazepine incapacitating agents should initially focus on the potential complications associated with those sedatives. Additional laboratory tests can also be conducted in an attempt to identify the diagnosis of the incapacitating agent if the specific agent is unknown to the clinicians.
  • Rapid urine drug screenings (immunoassays) are available and may assist health care professionals in making a diagnosis. However, these immunoassays do have a number of limitations. Opioid immunoassays are directed toward morphine. Many synthetic opioids, such as fentanyl, show no cross-reactivity with these assays. Testing for benzodiazepines is complicated because numerous benzodiazepines have substantially different structures. Results may be positive for diazepam, but negative for other benzodiazepines (eg, clonazepam).
  • Performing a complete blood count, electrolyte tests, clotting studies, and renal and liver function tests is reasonable in any person who has potentially been exposed to an incapacitating agent.
  • If the patient is comatose, performing a urine myoglobin and/or creatine phosphokinase test is warranted to exclude rhabdomyolysis. Hyperkalemia, hyperphosphatemia, and hypocalcemia may occur in association with rhabdomyolysis. The lactate level may also be elevated in these patients.
  • If the incapacitating agent is unknown, obtain extra blood and urine samples. Subsequent testing can be performed to confirm the causative agent.

Imaging Studies

  • A patient who has potentially been exposed to an opioid or a benzodiazepine incapacitating agent and who is comatose may be at risk for aspiration pneumonia. Obtain a chest radiograph.
  • If the etiology of a patient's altered mental status is uncertain, performing a head CT scan to exclude other intracranial processes is reasonable.

Other Tests

  • Both opioids and benzodiazepines may be associated with bradycardia. However, stress occurring in response to a situation associated with an exposure to aerosolized opioids or benzodiazepines may lead to tachycardia. Patients who are exposed to these agents and have preexisting cardiac disease may be at risk for cardiac ischemia. Perform an ECG to exclude these potential problems.

More on CBRNE - Incapacitating Agents, Opioids/Benzodiazepines

Overview: CBRNE - Incapacitating Agents, Opioids/Benzodiazepines
Differential Diagnoses & Workup: CBRNE - Incapacitating Agents, Opioids/Benzodiazepines
Treatment & Medication: CBRNE - Incapacitating Agents, Opioids/Benzodiazepines
Follow-up: CBRNE - Incapacitating Agents, Opioids/Benzodiazepines
References
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References

  1. Stone A. Chemical weapons. U.S. research on sedatives in combat sets off alarms. Science. Aug 2 2002;297(5582):764. [Medline].

  2. Hess L, Schreiberova J, Fusek J. Pharmacological non-lethal weapons. 3rd European Symposium on Non-Lethal Weapons. May 10-12, 2005. Available at http://www.non-lethal-weapons.com/sy03abstracts/V23.pdf. Accessed January 10, 2009.

  3. Xi LY, Zheng WM, Zhen SM, Xian NS. Rapid arrest of seizures with an inhalation aerosol containing diazepam. Epilepsia. Mar-Apr 1994;35(2):356-8. [Medline].

  4. Hung OR, Whynot SC, Varvel JR, et al. Pharmacokinetics of inhaled liposome-encapsulated fentanyl. Anesthesiology. Aug 1995;83(2):277-84. [Medline].

  5. Wax PM, Becker CE, Curry SC. Unexpected "gas" casualties in Moscow: a medical toxicology perspective. Ann Emerg Med. May 2003;41(5):700-5. [Medline].

  6. Booij LH. [The agent used to free the hostages in Moscow and the insufficient Dutch preparations in case of a terrorist chemical disaster]. Ned Tijdschr Geneeskd. Dec 14 2002;146(50):2396-401. [Medline].

  7. Brooks M. Knockout gas: Chemical weapons in disguise?. New Scientist. October 2007;[Full Text].

  8. Coupland RM. Incapacitating chemical weapons: a year after the Moscow theatre siege. Lancet. Oct 25 2003;362(9393):1346. [Medline].

  9. Enserink M, Stone R. Toxicology. Questions swirl over knockout gas used in hostage crisis. Science. Nov 8 2002;298(5596):1150-1. [Medline].

  10. Gudmundsdottir H, Sigurjonsdottir JF, Masson M, et al. Intranasal administration of midazolam in a cyclodextrin based formulation: bioavailability and clinical evaluation in humans. Pharmazie. Dec 2001;56(12):963-6. [Medline].

  11. Ljungman G, Kreuger A, Andreasson S, et al. Midazolam nasal spray reduces procedural anxiety in children. Pediatrics. Jan 2000;105(1 Pt 1):73-8. [Medline].

  12. Loftsson T, Gudmundsdottir H, Sigurjonsdottir JF, et al. Cyclodextrin solubilization of benzodiazepines: formulation of midazolam nasal spray. Int J Pharm. Jan 5 2001;212(1):29-40. [Medline].

  13. Mather LE, Woodhouse A, Ward ME. Pulmonary administration of aerosolised fentanyl: pharmacokinetic analysis of systemic delivery. Br J Clin Pharmacol. Jul 1998;46(1):37-43. [Medline].

  14. Rieder J, Keller C, Hoffmann G. Moscow theatre siege and anaesthetic drugs. Lancet. Mar 29 2003;361(9363):1131. [Medline].

  15. Schiermeier Q. Hostage deaths put gas weapons in spotlight. Nature. Nov 7 2002;420(6911):7. [Medline].

  16. Weinberger S. Czech Research Stirs Chemical Weapons Debate. October 17, 2007. Wired. Available at http://blog.wired.com/defense/2007/10/czech-research-.html. Accessed January 10, 2009.

  17. Worsley MH, MacLeod AD, Brodie MJ, et al. Inhaled fentanyl as a method of analgesia. Anaesthesia. Jun 1990;45(6):449-51. [Medline].

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Further Reading

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Keywords

incapacitating agent, opioid, benzodiazepine, fentanyl, carfentanil, alfentanil, sufentanil, diazepam, chemical warfare agents, chemical threat agents, biological threat agents, radiological threat agents, nuclear threat agents, explosive threat agents, chemical weapons, benzodiazepine toxicity, opioid toxicity

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Contributor Information and Disclosures

Author

Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health
Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Association for the Advancement of Science, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Medical Society of Virginia, Society for Academic Emergency Medicine, Society of Toxicology, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Jennifer S Boyle, MD, PharmD, Fellow in Toxicology, University of Virginia Health System
Disclosure: Nothing to disclose.

Medical Editor

Suzanne White, MD, Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine
Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP, Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine
Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

 
 
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