The principles of clinical diagnosis and intensive care of patients suffered from chemical agents during terrorist attacks

L.A. Ustinova, N.V. Kurdil, V.I. Saglo, A.A. Yevtodiev, V.M. Padalka, O.V. Ivashchenko


Background. With the onset of the hybrid war in the Donbas, the chemical terrorist threat in Ukraine has become a reality. Under such conditions, the discipline “Military Toxico­logy, Radiology and Medical Protection” became especially re­levant in the training of doctors of various specialties. The study aimed to substantiate the relevance of postgraduate training for doctors in the thematic improvement cycle “Medical protection from chemical agents during terrorist attacks” within the discipline “Military Toxicology, Radiology and Medical Protection”. Material and methods. The sources of scientific information on issues of medical care in case of damage by toxicants used in contemporary military conflicts and terrorist acts were analysed. The recommendations of the World Health Organization, the Defense Threat Reduction Agency (USA), the Organization for the Prohibition of Chemical Weapons, and the National Centre for Biotechnological Information (USA) on these issues were considered. The research methods applied were as follows: a system approach, historical, bibliosemantic methods, content analysis. Results. The necessity of expanding knowledge in the field of modern military toxicology led to the development of a new program of thematic improvement in the direction called “Medical protection from chemical agents during terrorist attacks”. The current organization of the medical care in Ukraine, in the absence of the disaster medicine system, in case of a terrorist chemical incident, relies exclusively on the resour­ces of ambulance teams that can provide emergency assistance and evacuation to the territorial healthcare facilities, staffed by civilian medical staff. In the hybrid war, the specified level of medical care should be provided by highly trained personnel in the field of medical triage, definition and evaluation of the severity of specific toxidromes, emergency response, if necessary, for resuscitation measures, chemical protection measures, etc. However, today we have many problems in this area. Most of the WHO recommended antidotes are currently unavailab­le due to their absence in Ukraine, both in hospitals and in the planned equipment of the military units and brigades of the Armed Forces of Ukraine. Therefore, the main emphasis should be placed on intensive care, which can be carried out in the intensive care unit of any hospital. Firstly, it is necessary to specify the key conditions that can help to save the life of the victim, especially in cases when the toxic agent cannot be timely identified. In this article, we focus on the main problems that may arise in the treatment of patients affected by the chemical agents in the emergency departments and resuscitation and intensive care units of ordinary district and city hospitals. The experience of chemical attacks and catastrophes proves that in most chemical incidents with a large number of injured, up to 35 % of hospitalized patients need help in conditions of a resuscitation unit. The emergency doctor should be well acquainted with the list of modern chemical agents and their hazardous characteristics. In addition to the specific characteristics of chemical agents, the organizational features of the healing process should be taken into account. All patients are a potential source of contamination; the contact with them requires the protection of medical personnel. The patients delivered from a chemical focus may have various causes of health impairment, and other medical problems can be easily missed. Chemical injuries are often combined with traumatic ones; under such conditions, contaminated open wounds are an active source of poisoning. There is a high probability of a combination of biological and chemical agents, and since the action of biological agents tends to manifest later, this could potentially lead to erroneous diagnosis. During the terrorist attacks, victims may develop very different symptoms of a lesion, due to the characteristics of the chemical agent, routes of admission, dose and exposure, concomitant somatic diseases, sex, age, pregnancy, etc. The delayed toxic effects should be taken into account when entering the hospital; at an early stage of poisoning, the victims may appear to be stable, but with time decompensation develops (especially in case of pulmonary agents). In several cases, when they arrive in a hospital, the victims have a clinical picture of the terminal condition, which is confirmed by the signs of severe dysfunction of organs and systems; but under the influence of antidotes and timely integrated therapy, the lost functions of organs and systems can be fully restored. Therefore, for all critical cases without exception, the intensivists should be prepared to provide respiratory system dissection, tracheal intubation, oxygenation and infusion support. The chemical agents can interact with the medicines used in intensive care unit, and the physician should remember this interaction (nerve agents and neuromuscular blockers, respiratory analgesics and narcotic analgesics, fluorocarbon anaesthe­tics and adrenergic agents, and many others). It should be kept in mind that under conditions of alkalosis (against the backdrop of massive haemolysis, for example poisoning with arsenic hydrogen) or acidosis (when poisonings with methaemoglobin gene­rators, for example, salts of nitrous acid, aliphatic nitrites), the effects of many drugs are significantly changed. For any country, acts of chemical terro­rism are extremely costly events that can quickly eliminate operational and reserve resources and block the work of the healthcare system in a separate region, therefore, for the efficient planning of resources, the planned emergency and training activities must be mandatory. Besides medical care, psychological assistance is obligatory. Conclusions. Increasing the awareness of physicians about the peculiarities of the clinical actions of the most commonly used chemical agents is a gua­rantee of timely and effective medical care and preservation of health of medical personnel who are potentially exposed to the risk of chemical damage during their professional activity.


toxicology; acute poisoning; chemical terrorism; chemical weapons


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