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The use of chemical warfare agents (CWAs) in modern warfare dates back to World War I (WWI). Most recently, sulfur mustard and nerve agents were used by Iraq against the Iranian military and Kurdish civilians. Since the Japanese sarin attacks in 1994–1995 and the terrorist strikes of September 11, 2001, the all too real possibility of chemical or biological terrorism against civilian populations anywhere in the world has attracted increased attention.

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Military planners consider the WWI blistering agent sulfur mustard and the organophosphorus nerve agents as the most likely agents to be used on the battlefield. In a civilian or terrorist scenario, the choice widens considerably. For example, many of the chemical warfare agents of WWI, including chlorine, phosgene, and cyanide, are used today in large amounts in industry. They are produced in chemical plants, are stockpiled in large tanks, and travel up and down highways and railways in large tanker cars. The rupture of any of these agents by accident or purposely could cause many injuries and deaths. Countless hazardous materials (HAZMATs) that are not used on the battlefield can be used as terrorist weapons. Some of them, including insecticides and ammonia, could wreak as much damage and injury as the weaponized chemical agents.

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In a recent example, insurgents in Iraq used chlorine gas released from tankers after explosions as a crude form of chemical weaponry. Using this gas, they killed 12 people and intoxicated more than 140 others in three attacks in February 2007. Table 222-1 describes the physical appearance and initial physiologic effects, and Table 222-2 provides guidelines for immediate treatment of chlorine intoxication. Nonetheless, the focus of this chapter is on the blister and nerve chemical warfare agents, which have been employed in battle and against civilians and have demonstrated a significant public health impact.

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Table 222-1 Recognizing and Diagnosing Health Effects of Chemical Terrorism 

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