briefing incapacitating agents.pdf

7/29/2019 BRIEFING INCAPACITATING AGENTS.pdf

1/61

Incapacitating Agents

USAMRICDUSAMRICDPROTECT, PROJECT, SUSTAINPROTECT, PROJECT, SUSTAIN


U.S. Army Medical Research Institute of Chemical DefenseU.S. Army Medical Research Institute of Chemical Defense

Chemical Casualty Care DivisionChemical Casualty Care Division


2/61


M_Incaps 2


Objectives

DefinitionDefinition

HistoryHistory

Representative compoundsRepresentative compounds

Glycolate anticholinergics: BZ and Agent 15Glycolate anticholinergics: BZ and Agent 15

HistoryHistory

Physicochemical propertiesPhysicochemical properties

Pharmacokinetics (ADBE)Pharmacokinetics (ADBE)

Mechanism of action (pharmacodynamics)Mechanism of action (pharmacodynamics)

Clinical presentation of casualtiesClinical presentation of casualties

TreatmentTreatment


3/61


M_Incaps 3


Incapacitating Agents: Definition

CW agents designed not to injure or kill but to induceCW agents designed not to injure or kill but to induce

disorientationdisorientation ororother temporary effectsother temporary effects leading toleading to

impaired performanceimpaired performance

IncapacitatingIncapacitating unfortunately anunfortunately an ambiguousambiguous termterm

Rendering powerless; debilitatingRendering powerless; debilitating, as in, as inan incapaci tat ing dis easean incapaci tat ing dis ease

Showing an expected toxic effectShowing an expected toxic effect, as in, as inICtICt5050= incapac i ta t ing Ct= incapac i ta t ing Ct5050 (better: ECt(better: ECt5050 for effective Ctfor effective Ct5050))

Referring to a specific class of chemicalReferring to a specific class of chemical--warfare agentswarfare agents, as in, as in

incapac i ta t ing agents incapac i ta t ing agents


4/61


M_Incaps 4


Classification of Official CW Agents

Tox ic agentsTox ic agents(causing injury or death)(causing injury or death)

Nerve AgentsNerve Agents

GAGA,, GBGB,, GDGD,, GFGF,, VXVX

VesicantsVesicants HH,, HDHD,, HTHT,, LL,, HLHL,, TLTL,, CXCX, [riot control agents] [T, [riot control agents] [T--2 mycotoxins]2 mycotoxins]

Pulmonary agentsPulmonary agents Phosgene (Phosgene (CGCG), diphosgene (), diphosgene (DPDP), chlorine, [PFIB] [smokes] [vesicants]), chlorine, [PFIB] [smokes] [vesicants]

Blood agentsBlood agents

Hydrogen cyanide (Hydrogen cyanide (ACAC), cyanogen chloride (), cyanogen chloride (CKCK))

Inc apaci tating agentsInc apaci tat ing agents(causing temporary nonlethal effects)(causing temporary nonlethal effects)

BZBZ, others, others


5/61


M_Incaps 5


Agents Excluded by FM 8-285

HerbicidesHerbicides

Smoke and FlameSmoke and Flame

RiotRiot--control Agentscontrol Agents


6/61


M_Incaps 6


Incapacitating Agents and Incapacitation

SignificantSignificant incapacitation (limits combat ability)incapacitation (limits combat ability)

TemporaryTemporary incapacitation (hours to days)incapacitation (hours to days)

NonfatalNonfatal incapacitationincapacitation


7/61


M_Incaps 7


Types of Temporary Incapacitation

PhysiologicalPhysiological

DiarrheaDiarrhea

HyperthermiaHyperthermia MucousMucous--membrane irritationmembrane irritation

Mental (psychochemical, behavioral)Mental (psychochemical, behavioral)

ConfusionConfusion HallucinationsHallucinations

Loss of motivationLoss of motivation


8/61


M_Incaps 8


Potential Agents for Civilian Use RiotRiot--control agentscontrol agents

Rapidly actingRapidly acting volatile anesthetic agentsvolatile anesthetic agents

Rapidly actingRapidly acting barbituratesbarbiturates

MethohexitalMethohexital

Fentanyl congenersFentanyl congeners (e.g.,(e.g., sufentani lsufentani l))

Effects reversed by naloxoneEffects reversed by naloxone

Antipsychotic compoundsAntipsychotic compounds (e.g.,(e.g., haloper idolhaloper idol))

Anticholinergic compoundsAnticholinergic compounds


9/61


M_Incaps 9


Settings for Possible Use Military settingsMilitary settings

LargeLarge--scale battlefield usescale battlefield use

Special ForcesSpecial Forces

Civilian settingsCivilian settings

Terrorist useTerrorist use

Prison riotsPrison riots

HijackingsHijackings Hostage situationsHostage situations

Recalcitrant sequestered individuals or groupsRecalcitrant sequestered individuals or groups


10/61


M_Incaps 10


Military Criteria for a Good Incapacitant

High potencyHigh potency

High safety ratioHigh safety ratio

Logistically feasibleLogistically feasible (easily disseminated)(easily disseminated)

Duration of hours to daysDuration of hours to days (to disrupt combat ability)(to disrupt combat ability)

Effects: Impairment of higher CNS functionsEffects: Impairment of higher CNS functions

Confusion, disorientation, and behavioral disruptionConfusion, disorientation, and behavioral disruption

Effects reproducible and predictableEffects reproducible and predictable


11/61


M_Incaps 11


Civilian Criteria for a Good Incapicitant

Very high safety ratioVery high safety ratio

Very short onset time (seconds to minutes)Very short onset time (seconds to minutes)

Very short duration of effects (10 to 60 minutes)Very short duration of effects (10 to 60 minutes) Amenable to treatment with specific antidoteAmenable to treatment with specific antidote

Feasible for smallFeasible for small--scale use against mixed groupsscale use against mixed groups

Criminals with hostagesCriminals with hostages

Effects need not be primarily on CNSEffects need not be primarily on CNS Immobilization, diarrhea, loss of coordination, blindness,Immobilization, diarrhea, loss of coordination, blindness,

loss of consciousness, disorientationloss of consciousness, disorientation

Effects reproducible and predictableEffects reproducible and predictable


12/61


M_Incaps 12


Early Military Use 600 BC: Solon600 BC: Solon

HelleboreHellebore roots thrown into river diarrhearoots thrown into river diarrhea

200 BC: Carthaginians200 BC: Carthaginians MandragoraMandragora--laced wine narcosislaced wine narcosis

184 BC: Hannibal184 BC: Hannibal

SnakeSnake--filled pots thrown onto decks panic, confusionfilled pots thrown onto decks panic, confusion

Belladonna alkaloidsBelladonna alkaloids disorientationdisorientation

AD 1500s and 1600s: MoslemsAD 1500s and 1600s: Moslems

HashishHashish used on own troops to foster fearlessnessused on own troops to foster fearlessness


13/61


M_Incaps 13


Alleged Modern Use

Soviet use in Afghanistan?Soviet use in Afghanistan?

Soviet use internally in the former Soviet Union?Soviet use internally in the former Soviet Union?

Brainwashing of POWs in North Korea?Brainwashing of POWs in North Korea?

Other instances?Other instances?


14/61


M_Incaps 14


U.S. Interest in Incapacitants

Military interest in possibilities ofMilitary interest in possibilities ofLSDLSD--2525

Military research and developmentMilitary research and development

Antipsychotic tranquilizersAntipsychotic tranquilizers

Cannabinoids (marijuana congeners)Cannabinoids (marijuana congeners)

Indoles (LSD and congeners)Indoles (LSD and congeners)

Anticholinergic compoundsAnticholinergic compounds

BZBZ manufactured and stockpiledmanufactured and stockpiled

CIACIA interest ininterest in psychotomimeticspsychotomimetics from early 1950sfrom early 1950s


15/61


M_Incaps 15


A New Twist London, Feb 9, 1998 (Reuters):London, Feb 9, 1998 (Reuters):

Britain on Monday released what it said was new information on cBritain on Monday released what it said was new information on chemicalhemical

weapons which were in Iraqs arsenal at the time of the 1991 Gulweapons which were in Iraqs arsenal at the time of the 1991 Gulf War. . . .f War. . . .

We have recently received intelligence indicating that . . . IrWe have recently received intelligence indicating that . . . Iraq may haveaq may have

possessed large quantities ofpossessed large quantities ofa chemical warfare mental incapacitant agenta chemical warfare mental incapacitant agent

known asknown as Agent 15Agent 15, [Defence Minister George] Robertson said. . . ., [Defence Minister George] Robertson said. . . .

The Ministry of Defence described Agent 15 as one of a large groThe Ministry of Defence described Agent 15 as one of a large group ofup of

chemicals calledchemicals called glycollatesglycollates which interfered with the central andwhich interfered with the central andperipheral nervous system.peripheral nervous system.


16/61


M_Incaps 16


Classification IrritantsIrritants

RiotRiot--control agents (CS, CN, etc.); pepper spraycontrol agents (CS, CN, etc.); pepper spray

CNS stimulantsCNS stimulants

Amphetamines, cocaine, caffeine, nicotine, strychnine, metrazoleAmphetamines, cocaine, caffeine, nicotine, strychnine, metrazole

CNS depressantsCNS depressants

Barbiturates, opiods, antipsychotics, benzodiazepinesBarbiturates, opiods, antipsychotics, benzodiazepines

PsychedelicsPsychedelics

LSDLSD--25, psilocybin, ibogaine, harmine25, psilocybin, ibogaine, harmine

MDMA (ecstasy), PCPMDMA (ecstasy), PCP

DeliriantsDeliriants

Many drugs, but especially anticholinergics (BZ, Agent 15)Many drugs, but especially anticholinergics (BZ, Agent 15)


17/61


M_Incaps 17


Riot-control Agents

CS

CN (commercial); Mace

CA (WW I, buried)

CR (British agent; U.S. Army approved)

DM (vomiting agent)

Pepper sprays


18/61


M_Incaps 18


Riot-control Agents: Characteristics

Aerosolized solidsAerosolized solids

Low effective amountLow effective amount

High lethal amountHigh lethal amount

High safety ratioHigh safety ratio

Rapid onsetRapid onset

Short durationShort duration


19/61


M_Incaps 19


PedunclePeduncle

Calyx MarginCalyx Margin

BaseBaseCapsaicin & Capsaicinoid GlandsCapsaicin & Capsaicinoid Glands

Placental WallPlacental Wall

PlacentaPlacenta

Exocarp (Skin)Exocarp (Skin)

MesocarpMesocarp

EndocarpEndocarp

Apex (Blossom End)Apex (Blossom End)

SeedsSeeds

ShoulderShoulder

CalyxCalyx

Pepper Sprays: Capsaicin


20/61


M_Incaps 20


Riot Control Agents: General Used for riot control in 1912 in France and becameUsed for riot control in 1912 in France and became

the first noxious chemicals used in World War I (Aug 1914);the first noxious chemicals used in World War I (Aug 1914);

CSCS andand CNCN (Mace(Mace) still widely used) still widely used

Not recognized by the U.S.Not recognized by the U.S. as official chemical agentsas official chemical agents

VeryVery persistentpersistent agents usually dispersed asagents usually dispersed as solidssolids or inor in solutionsolution;;

low volatilitylow volatility, so, so nono appreciable vapor hazardappreciable vapor hazard


21/61


M_Incaps 21


Riot Control Agents: General LacrimatorsLacrimators ((CACA,, CNCN,, CSCS,, CRCR) and) and a vomiting agenta vomiting agent ((DMDM) with) with

short onsetshort onset,, short durationshort duration, and, and high safety ratioshigh safety ratios

Usually selfUsually self--limited effectslimited effects (irritation, pain, lacrimation, coughing,(irritation, pain, lacrimation, coughing,

etc.) onetc.) on eyeseyes,, respiratory mucosarespiratory mucosa, and, and skinskin (plus vomiting with DM);(plus vomiting with DM);

longlong--term sequelae uncommonterm sequelae uncommon

When decontamination is required,When decontamination is required, avoid bleachavoid bleach!!


22/61


M_Incaps 22


Anticholinergics: General

All areAll are glycolatesglycolates

((esters o f glycol ic acidesters of g lyco l ic acid, HOCH, HOCH22COOH)COOH)

ContainContain --COHCOH--COCO--OO-- moietymoiety Usually contain aromatic moietiesUsually contain aromatic moieties

Wide varietyWide variety of compoundsof compounds

BZBZ is a stable crystalline solidis a stable crystalline solid

m.p. 164m.p. 164--167 C167 C

Can be dispersed even by heatCan be dispersed even by heat--producing munitionsproducing munitions


23/61


M_Incaps 23


Other Anticholinergic Glycolates

AtropineAtropine

ScopolamineScopolamine

Oxybutynin (Ditropan)Oxybutynin (Ditropan)

Anticholinergic antihistaminesAnticholinergic antihistamines

BenactyzineBenactyzine

One component of 1970s nerveOne component of 1970s nerve--agent antidote TABagent antidote TAB

((TTMBMB--4,4, aatropine, andtropine, and bbenactyzine)enactyzine)


24/61


M_Incaps 24


Anticholinergics: Actions

Block acetylcholine (ACh)Block acetylcholine (ACh)

Opposite effects from nerve agentsOpposite effects from nerve agents

PeripheralPeripheralmuscarinic effectsmuscarinic effects

At muscarinic receptors (At muscarinic receptors (mAChRmAChR) in) in

Smooth muscleSmooth muscle

Exocrine glandsExocrine glands

CentralCentralmuscarinic effectsmuscarinic effects On muscarinic ACh receptors (On muscarinic ACh receptors (mAChRmAChR) in the) in the CNSCNS


25/61


M_Incaps 25


Nerve Transmission

ACh


26/61


M_Incaps 26


Nerve Transmission

ACh


27/61


M_Incaps 27


Nerve Transmission

ACh


28/61


M_Incaps 28


Impulse Termination

ACh

AChE


29/61


M_Incaps 29


Impulse Termination

ACh

AChE


30/61


M_Incaps 30


Exposure to Nerve Agent

ACh

AChE


31/61


M_Incaps 31


Exposure to Nerve Agent

ACh

AChE


32/61


M_Incaps 32


Effects on Smooth and Cardiac Muscle

ACh

AChE


33/61


M_Incaps 33


Effects on Exocrine Glands

ACh

AChE


34/61


M_Incaps 34


ACh at Receptors

ACh

ACh ACh

ACh

Nicotinic Nicotinic

Muscarinic Muscarinic


35/61


M_Incaps 35


Atropine at ReceptorsNicotinicNicotinic

Muscarinic Muscarinic

AtropineAtropine

Atropine Atropine


36/61


M_Incaps 36


ACh and Atropine at Receptors

ACh

ACh

ACh

Nicotinic

Muscarinic

Atropine

Nicotinic

Muscarinic

Atropine


37/61


M_Incaps 37


Effects of Atropine on Smooth Muscle

ACh

AChE

Atr

Atr

Atr

Atr

Atr

Atr

Atr

Atr

Atr

Atr

Atr

Atr

AtrAtr

Atr

Atr

Atr

Atr

Atr

Nerve agent present;

too much ACh in NMJ


38/61


M_Incaps 38


Effects of Atropine on Exocrine GlandsNerve agent present;

too much ACh in NGJ

Atr

ACh

AChE

Atr

Atr

Atr

Atr

Atr

Atr

AtrAtr

Atr

Atr

Atr

Atr

Atr


39/61


M_Incaps 39


Effects of Atropine on Skeletal Muscle: None!

ACh

AChE

Atr

Atr

Atr

Atr

Atr

Atr

Atr

Atr

Nerve agent present;

too much ACh in NMJ


40/61


M_Incaps 40


Peripheral Effects of Anticholinergics When ACh isWhen ACh is notnot present in excess in the synapse, the NMJ, or the NGJ,present in excess in the synapse, the NMJ, or the NGJ,

anticholinergics stillanticholinergics still decrease the effective concentration of ACh at thedecrease the effective concentration of ACh at the

muscarinic receptormuscarinic receptor((mAChRmAChR))

Insufficient AChInsufficient ACh reaching the end organ; reaching the end organ; not enough green dotsnot enough green dots

Under these circumstances, the peripheral effects at muscarinicUnder these circumstances, the peripheral effects at muscarinic sitessites

are those ofare those ofunderstimulation of end organsunderstimulation of end organs (smooth muscle and exocrine(smooth muscle and exocrine

glands)glands)

No direct effects at nicotinic sites (skeletal muscle)No direct effects at nicotinic sites (skeletal muscle)


41/61


M_Incaps 41


Effects on Heart Rate Qualitatively different between compoundsQualitatively different between compounds

AtropineAtropine Initial brief tachycardiaInitial brief tachycardia pronounced tachycardiapronounced tachycardia

ScopolamineScopolamine

Moderate tachycardia prolonged tachycardiaModerate tachycardia prolonged tachycardia

BZBZ

Tachycardia x 1Tachycardia x 1--2 days normal rate or mild bradycardia2 days normal rate or mild bradycardia


42/61


M_Incaps 42


Central Effects of Anticholinergics Qualitatively similarQualitatively similar

Effective doses varyEffective doses vary between compoundsbetween compounds

Marked confusionMarked confusion results fromresults from

1212--14 mg of14 mg ofatropineatropine

2 mg of2 mg ofscopolaminescopolamine

1 mg or less of1 mg or less ofBZBZ

? of? ofAgent 15Agent 15


43/61


M_Incaps 43


BZ (QNB) 33--Quinuclidinyl benzilate (QNB); OksilidinQuinuclidinyl benzilate (QNB); Oksilidin

Developed by a pharmaceutical company during aDeveloped by a pharmaceutical company during a

search for a new GI drugsearch for a new GI drug

CalledCalled BZBZ because ofbecause ofbenzilatebenzilate and also because of itsand also because of its

buzzbuzz (~3 Mark I injections without nerve agent) (~3 Mark I injections without nerve agent)

The only incapacitating agent weaponized by the U.S.The only incapacitating agent weaponized by the U.S.

DemilitarizationDemilitarization of BZ stockpiles began in 1988of BZ stockpiles began in 1988


44/61


M_Incaps 44


BZ: Physical Properties Molecular formulaMolecular formula CC2121HH2323NONO33;; MWMW 337.41337.41

White crystalline solid; m.p.White crystalline solid; m.p. 164164--167 C;167 C; b.p.b.p. 320 C320 C

Odorless;Odorless; negligible vapor pressure and volatilitynegligible vapor pressure and volatility

Stable in most materialsStable in most materials HalfHalf--life is 3life is 3--4 weeks in moist air4 weeks in moist air

Very persistent in soil and water and on most surfacesVery persistent in soil and water and on most surfaces


45/61


M_Incaps 45


BZ: Dispersal, Absorption, and Detection

Dispersal usually as a solid suspended in airDispersal usually as a solid suspended in air

(aerosol)(aerosol)

Routes of entry (absorption)Routes of entry (absorption)

Inhalation (primary route)Inhalation (primary route)

Ingestion (effective secondary route)Ingestion (effective secondary route)

Percutaneous absorption (especiallyPercutaneous absorption (especiallywith DMSO or other appropriate solvents)with DMSO or other appropriate solvents)

DetectionDetection

No detector currently availableNo detector currently available


46/61


M_Incaps 46


BZ: Physiological Data LCtLCt5050:: 200,000 mg200,000 mg min / mmin / m

33

ICtICt5050:: 112 mg112 mg min / mmin / m33

Onset of effectsOnset of effects

0.50.5--4 hours after ingestion or inhalation4 hours after ingestion or inhalation(mean 2 hours; range 0.5(mean 2 hours; range 0.5--20 hours)20 hours)

Effects may not appear until 36 hours after skin exposureEffects may not appear until 36 hours after skin exposure

Duration of effectsDuration of effects 7272--96 hours; dose96 hours; dose--dependentdependent

(from an ICt(from an ICt5050, severe effects last 36 hours;, severe effects last 36 hours;mild effects persist for 45 hours)mild effects persist for 45 hours)


47/61


M_Incaps 47


BZ: Peripheral Effects I Ocular effectsOcular effects

Mydriasis (dilated pupils) lasting several daysMydriasis (dilated pupils) lasting several days

Paralysis of accommodation impairment of near visionParalysis of accommodation impairment of near vision

Oral effectsOral effects

Xerostomia (dry mouth); drying of secretions; thirstXerostomia (dry mouth); drying of secretions; thirst ((dry as a bonedry as a bone))

Cardiac effectsCardiac effects

Heart rate labile (tachycardia x 1Heart rate labile (tachycardia x 1--2 days normal or bradycardia);2 days normal or bradycardia);

not useful in diagnosisnot useful in diagnosis

Gastrointestinal effectsGastrointestinal effects

Decreased motility and decreased secretionsDecreased motility and decreased secretions


48/61


M_Incaps 48


BZ: Peripheral Effects II Cutaneous effectsCutaneous effects

Decreased sweatingDecreased sweating ((dry as a bonedry as a bone))

Atropine flushAtropine flush ((red as a beetred as a beet))

Heat retention hyperthermiaHeat retention hyperthermia ((hot as a harehot as a hare))

Genitourinary effectsGenitourinary effects

Decreased bladder tone and decreased urinary forceDecreased bladder tone and decreased urinary force ((dry as . . .dry as . . .))

Severe bladder distentionSevere bladder distention

Neuromuscular effectsNeuromuscular effects Incoordination, heightened stretch reflexes, ataxia, andIncoordination, heightened stretch reflexes, ataxia, and

muscle weakness (why?)muscle weakness (why?)


49/61


M_Incaps 49


BZ: Central Effects I DoseDose--dependent decrease in level of consciousnessdependent decrease in level of consciousness

Drowsiness sedation stuporDrowsiness sedation stupor comacoma

Perceptual disturbancesPerceptual disturbances ((mad as a hattermad as a hatter)) IllusionsIllusions

Visual hallucinations (realistic, distinct, panoramic,Visual hallucinations (realistic, distinct, panoramic,

and decreasing in size over time)and decreasing in size over time)

Disturbances in judgment and insightDisturbances in judgment and insight

Lack of social restraint profanity and vulgarityLack of social restraint profanity and vulgarity

Inability to use perceptual cuesInability to use perceptual cues

Denial and confabulationDenial and confabulation


50/61


M_Incaps 50


BZ: Central Effects II Attention and memory deficitsAttention and memory deficits

Easy distractibilityEasy distractibility

ShortShort--term memory lossterm memory loss

Deficits of expression and comprehensionDeficits of expression and comprehension

Slurred, often senseless speechSlurred, often senseless speech

Flat, uninflected tone of voiceFlat, uninflected tone of voice

PerseverationPerseveration

Concrete, semiautomatic speech with colloquialisms, clichs,Concrete, semiautomatic speech with colloquialisms, clichs,and profanityand profanity

Handwriting deteriorationHandwriting deterioration

Inability to converse meaningfullyInability to converse meaningfully


51/61


M_Incaps 51


BZ: Central Effects III Disorientation to time and placeDisorientation to time and place

Disrobing, mumbling, and picking (woolgathering)Disrobing, mumbling, and picking (woolgathering)

AtaxiaAtaxia

Behavioral labilityBehavioral lability

Swings between quiet confusion and combativenessSwings between quiet confusion and combativeness

Paranoia as other symptoms are resolvingParanoia as other symptoms are resolving


52/61


M_Incaps 52


Psychosocial Aspects Sharing of illusions andSharing of illusions and

hallucinationshallucinations

Folie deuxFolie deux

Folie en familleFolie en famille Mass hysteriaMass hysteria

Similarity to psychogenicSimilarity to psychogenic

conditionsconditions

May prove hazardousMay prove hazardous


53/61


M_Incaps 53


BZ: Clinical Course 1. Onset (induction): 01. Onset (induction): 0--4 hours after exposure4 hours after exposure

Parasympathetic blockade and mild CNS effectsParasympathetic blockade and mild CNS effects

2. Second phase: 42. Second phase: 4--20 hours after exposure20 hours after exposure

Stupor (with ataxia and hyperthermia)Stupor (with ataxia and hyperthermia)

3. Third phase: 203. Third phase: 20--96 hours after exposure96 hours after exposure

Delirium (often fluctuating from moment to moment)Delirium (often fluctuating from moment to moment)

4. Fourth phase (resolution): following third phase4. Fourth phase (resolution): following third phase

Paranoia; deep sleepParanoia; deep sleep


54/61


M_Incaps 54


DDx for Incapacitants I Anticholinergic compounds, indoles, cannabinoids,Anticholinergic compounds, indoles, cannabinoids,

anxiety reactions, other intoxications (alcohol,anxiety reactions, other intoxications (alcohol,

bromides, lead, barbiturates)bromides, lead, barbiturates)

Restlessness, lightheadedness, vertigo, failure to obey orders,Restlessness, lightheadedness, vertigo, failure to obey orders,

confusion, erratic behavior, stumbling or staggering, vomitingconfusion, erratic behavior, stumbling or staggering, vomiting

AnticholinergicsAnticholinergics

Dryness of mouth and skin, flushing, hyperthermia, mydriasis,Dryness of mouth and skin, flushing, hyperthermia, mydriasis,

slurred speech, hallucinations (vivid, realistic, decreasing inslurred speech, hallucinations (vivid, realistic, decreasing in size),size),disrobing, phantom behaviors (plucking or picking clothes ordisrobing, phantom behaviors (plucking or picking clothes orair), mumbling, stupor, labile sensoriumair), mumbling, stupor, labile sensorium


55/61


M_Incaps 55


DDx for Incapacitants II Indoles (LSD); schizophrenic psychosisIndoles (LSD); schizophrenic psychosis

Inappropriate smiling or laughing, irrational fear, distractibilInappropriate smiling or laughing, irrational fear, distractibility,ity,

difficulty expressing self, perceptual distortions, stomach cramdifficulty expressing self, perceptual distortions, stomach cramps,ps,

vomiting, labile changes in HR / BP / mydriasisvomiting, labile changes in HR / BP / mydriasis

Cannabinoids (THC)Cannabinoids (THC)

Euphoria, relaxation, dayEuphoria, relaxation, day--dreaming, unconcerned attitude,dreaming, unconcerned attitude,

easy laughter, orthostatic hypotensioneasy laughter, orthostatic hypotension

Anxiety reactionAnxiety reaction Tremor, clinging or pleading, crying, alertness, orientation,Tremor, clinging or pleading, crying, alertness, orientation,

history of nervousness or immaturity, phobias, paralysis,history of nervousness or immaturity, phobias, paralysis,

blindnessblindness


56/61


M_Incaps 56


Incapacitants and ASBESTOS AAgent(s):gent(s): Type(s) and toxicity (including LDType(s) and toxicity (including LD5050))

SState(s):tate(s): Solid?Solid? LiquidLiquid? Gas?? Gas? VaporVapor? Aerosol?? Aerosol?

BBody site(s):ody site(s): Where exposed / Route(s) of entry? [Where exposed / Route(s) of entry? [absorp t ionabsorp t ion]]

EEffects:ffects: Local? Systemic? [Local? Systemic? [d is t r ibu t iond is t r ibu t ion]] SSeverity:everity: Mild? Moderate? Severe?Mild? Moderate? Severe?

TTime course:ime course: Onset of symptoms? Getting better/worse? Prognosis?Onset of symptoms? Getting better/worse? Prognosis?

OOther diagnoses: Instead of? [ther diagnoses: Instead of? [DDxDDx] In addition to?] In addition to?

Synergism: Combined effects of multiple exposures or insults?

Remember the combination of central and peripheral effects!


57/61


M_Incaps 57


BZ: Treatment Protect yourself!Protect yourself!

General supportive therapyGeneral supportive therapy DecontaminationDecontamination with soap and waterwith soap and water

ObservationObservation and (in 50and (in 50--80% of cases)80% of cases) restraintrestraint

Management of heat stressManagement of heat stress

EarlyEarly evacuationevacuation

Specific antidotal therapySpecific antidotal therapy

PhysostigminePhysostigmine


58/61


M_Incaps 58


Physostigmine AA carbamate anticholinesterasecarbamate anticholinesterase derived fromderived from

elixir of calabar bean (African ordeal poison)elixir of calabar bean (African ordeal poison)

Nonpolar compound, soNonpolar compound, so

crosses bloodcrosses blood

--brain barrierbrain barrier

and thusand thus

can act centrally as well as peripherallycan act centrally as well as peripherally

Eserine (physostigmine)Eserine (physostigmine) andand

Antilirium (physostigmine salicylate)Antilirium (physostigmine salicylate)

Antilirium erroneously called a universal antidoteAntilirium erroneously called a universal antidote

Specific action is toSpecific action is to elevate AChelevate ACh byby inhibiting AChEinhibiting AChE Used to treat poisoning fromUsed to treat poisoning from cholinergic agentscholinergic agents andand TCAsTCAs


59/61


M_Incaps 59


Physostigmine: Pearls of Therapy Minimally effective during first 4 hoursMinimally effective during first 4 hours after exposureafter exposure

Very effective after 4 hoursVery effective after 4 hours when administered IM or POwhen administered IM or PO

Oral dosing requires 1.5 times the dose given IMOral dosing requires 1.5 times the dose given IM

Effects last only about 45Effects last only about 45--60 minutes60 minutes

Redose frequently or start slow IV infusionRedose frequently or start slow IV infusion

Physostigmine does NOT shorten the clinical coursePhysostigmine does NOT shorten the clinical courseof anticholinergic poisoningof anticholinergic poisoning; relapses will occur; relapses will occur

if treatment is discontinued prematurelyif treatment is discontinued prematurely


60/61


M_Incaps 60


Physostigmine: Cautions Side effects: Cholinergic (nerveSide effects: Cholinergic (nerve--agentagent--like)like)

Usually requires only dosage reductionUsually requires only dosage reduction

Moderate overdose:Moderate overdose: DyspneaDyspnea andand decreased vital capacitydecreased vital capacity

Large overdose:Large overdose: ApneaApnea secondary to respiratorysecondary to respiratory--muscle fatiguemuscle fatigue

ComplicationsComplications

ConvulsionsConvulsions and severe cardiacand severe cardiac dysrhythmiasdysrhythmias from IV administrationfrom IV administrationif rate is too rapid or if patient is acidotic or hypoxic (IM roif rate is too rapid or if patient is acidotic or hypoxic (IM route safer)ute safer)

Drug interactions during surgeryDrug interactions during surgery

PromethazinePromethazine may prolong neuromuscular blockademay prolong neuromuscular blockade

AntimuscarinicsAntimuscarinics may antagonize actionmay antagonize action

BarbituratesBarbiturates may cause addictive bronchospasmmay cause addictive bronchospasm

Polarizing and nondepolarizing NM blockersPolarizing and nondepolarizing NM blockers


61/61

USAMRICDUSAMRICDM_Incaps 61


Incapacitating Agents: Summary Designed to createDesigned to create temporary nonlethal performance impairmenttemporary nonlethal performance impairment

(incapacitation)(incapacitation)

Main drawback to military or civilian use:Main drawback to military or civilian use: UnpredictabilityUnpredictability

Only known weaponized agents:Only known weaponized agents: BZBZ (QNB) and(QNB) and Agent 15Agent 15

BZ is a delayedBZ is a delayed--onsetonset anticholinergic glycolateanticholinergic glycolate withwith

both central and peripheral muscarinic effectsboth central and peripheral muscarinic effects

Delayed onsetDelayed onset,, labile presentationlabile presentation, and, and prolonged courseprolonged course

Specific antidote:Specific antidote: PhysostigminePhysostigmine (a carbamate(a carbamate

anticholinesterase that crosses the bloodanticholinesterase that crosses the blood--brain barrier)brain barrier)

briefing incapacitating agents.pdf

Documents