Riot-control agents, also called lacrimators (“tear gas”), include several
compounds, the most important of which are CS (o-chlorobenzylidene
malononitrile), CN (1-chloroacetophenone, also marketed as Mace), and OC
(oleoresin capsicum, or pepper spray). All three are solids and are typically
dispersed as an aerosol of fine particles (e.g., smokes) or droplets (e.g., sprays).
These agents are widely available, cause significant incapacitating effects in
closed spaces, and could conceivably be used in a terrorist attack.
CS and CN generate bradykinins leading to pain without significant tissue
injury; OC binds to VR1 (TRPV1) receptors on sensory neurons and causes the
release of substance P, which leads to neurogenic inflammation with vasodilation,
hyperemia, and plasma extravasation as well as pain. All these agents can cause
transient ocular burning sensation, tearing, blepharospasm, and photophobia;
irritation of the nose, throat, and upper airway; and skin burning, erythema, and
sometimes vesication. A few riot-control agents, such as Adamsite (DM), are
referred to as vomiting agents because they cause pronounced vomiting in
addition to delayed-onset irritation of the eyes and the upper airway.
Most victims under usual circumstances of exposure become symptomatic
within seconds from the traditional lacrimating agents (irritation after exposure to
DM may take up to 20 minutes to develop) but remain so for only 20 to 60
minutes. However, high concentrations in closed spaces or after discharge of
agent close to the victim’s face have been associated with serious medical
complications, including severe ocular toxicity, dermal burns, and pulmonary
failure. A few lethal cases have been described in which death was caused by
severe tracheobronchitis with pseudomembrane formation and pulmonary edema.
Management includes careful ocular and dermal decontamination. The skin
should be washed with soap and water, although this may cause transient
increased pain. Hypochlorite solution should not be used because it may
exacerbate dermal burns via the creation of toxic by-products. The eyes should be
thoroughly irrigated after a single dose of topical anesthetic.
Respiratory complications must be managed supportively, as previously
described for mustard and pulmonary-agent toxicity. Because severe respiratory

effects may not manifest for 12 to 24 hours, patients with dyspnea or any
objective findings should probably be observed in the hospital. Severe respiratory
complications from exposure to riot-control agents have been described in at least
two young infants, one of whom was in a house into which CS was sprayed. A
canister of pepper spray was accidentally discharged directly into the face of the
other infant. Both survived with prolonged care, the latter requiring ventilatory
support, including 5 days of extracorporeal membrane oxygenation. A few cases


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-


casualty situations. Predisaster planning for both intentional and unintentional
chemical releases must take such factors into account. The National Response
Framework and the National Disaster Medical System, augmented if necessary by
military medical assets from the Department of Defense, provide a framework for
activating medical assistance at the federal level.
Availability of specific antidotes and medications in the context of planning for
a chemical exposure event involving mass casualties is an additional challenge.
Stockpiling pharmaceuticals such as the Cyanokit may be prohibitively
expensive. HAZMAT incident planning should establish some mechanism for
local or regional stockpiling of these critical medications and as a means to

replenish initial stores. Table 132.7 offer an attempt to quantify the amount of
antidotal medications that might be needed in one ED for the management of a
nerve agent or cyanide attack involving both pediatric and adult victims on a
scale of the Tokyo sarin attack. A biologic agent attack would place similar
enormous demands on the hospital pharmacy for antibiotics, vaccines, and
antitoxins. A federal system for stockpiling pharmaceuticals and emergency
medical supplies, managed through the CDC, has been created to augment local
resources in this critical logistical arena. The first large-scale deployment of this
Strategic National Stockpile occurred in the hours following the September 11,
2001 attacks on New York and Washington, DC. However, because prompt
treatment is crucial in chemical emergencies, national stockpiles should be
viewed as a resupply source and do not obviate the need for each hospital to
develop its own stockpile of antidotes that might be needed during the first few
hours after such a mass-casualty incident.


TABLE 132.6
REPRESENTATIVE CLASSES OF INDUSTRIAL CHEMICALS—
SUMMARY OF PEDIATRIC MANAGEMENT CONSIDERATIONS

Critical ongoing issues regarding ED preparedness for a biologic or chemical
agent attack include (i) optimal decontamination techniques, especially for young
children; (ii) optimal PPE for ED staff; (iii) logistics of patient and hospital staff
flow and isolation, in the context of a potentially lethal, contagious disease (e.g.,
smallpox, plague, and viral hemorrhagic fevers); (iv) safety of decontamination
water runoff into public drainage systems; (v) community-wide needs for
education and training; and (vi) financial considerations for individual hospital
and regional planners. Continued activity on an expert consensus basis, as well as
new research, should help to address many of these issues.