Recent news from Syria on a possible use of
chemical warfare agents made the headlines. Furthermore, the motivation of terrorists to cause maximal harm shifts these agents into the public focus. For incidents with mass casualties appropriate medical countermeasures must be available. At present, the most important threats arise from
nerve agents and
sulfur mustard. At first, self-protection and protection of medical units from contamination is of utmost importance. Volatile
nerve agent exposure, e.g.
sarin, results in fast development of
cholinergic crisis. Immediate clinical diagnosis can be confirmed on-site by assessment of
acetylcholinesterase activity. Treatment with autoinjectors that are filled with 2mg
atropine and an
oxime (at present
obidoxime,
pralidoxime, TMB-4 or
HI-6) are not effective against all
nerve agents. A more aggressive atropinisation has to be considered and more effective
oximes (if possible with a broad spectrum or a combination of different
oximes) as well as alternative strategies to cope with high
acetylcholine levels at synaptic sites should be developed. A further gap exists for the treatment of patients with sustained
cholinergic crisis that has to be expected after exposure to persistent
nerve agents, e.g.
VX. The requirement for long-lasting artificial ventilation can be reduced with an
oxime therapy that is optimized by using the
cholinesterase status for guidance or by measures (e.g. scavengers) that are able to reduce the
poison load substantially in the patients. For
sulfur mustard poisoning no specific
antidote is available until now. Symptomatic measures as used for treatment of
burns are recommended together with surgical or
laser debridement. Thus, huge amounts of resources are expected to be consumed as wound healing is impaired. Possible depots of
sulfur mustard in tissues may aggravate the situation. More basic knowledge is necessary to improve substantially therapeutic options. The use of stem cells may provide a new and promising option.