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

CBRNE - Incapacitating Agents, Opioids/Benzodiazepines: Follow-up

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

Follow-up

Further Inpatient Care

  • See Emergency Department Care. Keep symptomatic patients who were exposed to the aerosolized agents in a monitored setting until their symptoms completely resolve. Use of maintenance intravenous fluids may be necessary. Prolonged intoxication may occur depending on the dose of the agent absorbed.

Transfer

  • Any health care facility that is unable to adequately monitor a patient intoxicated with the agents should consider transfer to a facility that can care for such patients.
  • Smaller health care facilities may be overwhelmed if a large-scale exposure occurs. Disaster-plan implementation and appropriate transfer of patients to less-stressed facilities may be necessary.

Complications

  • Anoxic brain injury: If an exposed person becomes comatose and loses his or her ability to maintain ventilatory function, hypoxia may develop and lead to anoxic brain injury.
  • Aspiration pneumonia: The inability of an exposed patient to maintain his or her airway may result in aspiration of gastric contents into the lungs.
  • Rhabdomyolysis: If a person exposed to these agents develops profound somnolence, pressure tissue necrosis may occur, and rhabdomyolysis may develop. If this remains undiagnosed, myoglobinuric renal failure may develop.

Prognosis

  • The prognosis is good for patients exposed to aerosolized benzodiazepines or opioids if no secondary injuries, such as the complications noted above, develop. Once patients are removed from the exposure and the absorbed drug is metabolized, they should become more lucid. No long-term effects are expected from these agents themselves.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Few pitfalls exist from a medicolegal standpoint. Decontaminating patients and avoiding secondary contamination of health care workers is paramount. If a physician demonstrates good supportive care as discussed in this article, the risk of litigation against the caregivers should be minimal.

Special Concerns

  • Patients at the extremes of age may be more susceptible to toxicity from these agents. Other factors expected to predispose a patient to toxicity and complications include preexisting health problems (eg, chronic obstructive pulmonary disease [COPD]), volume depletion, and concurrent use of medications with sedative properties.
 


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

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  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.

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

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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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