The reports are acrimonious, the video clips horrifying, and the jury is all but adjourned; nerve gas has been used again in Syria. At least 58 people, many of them children, died a gruesome death yesterday. It is a type of death that should not be experienced by anybody. Humanity recognized the brutality of chemical weapons after widespread use in Word War I by banning them during the 1925 Geneva Protocol. During World War II, general morality prevailed and chemical weapons were used only sporadically, predominantly by the Imperial Japanese Army against Chinese forces. In 1972, the International Biological Weapons Convention prohibited the development, production, and stockpiling of chemical weapons. After Saddam Hussein’s 1988 chemical massacre that killed an estimated 5,000 people, the 1993 Chemical Weapons Convention re-affirmed these implementations and also required the destruction of all chemical weapons. The use of chemical weapons clearly violates international law, but history has shown us that moral restraints are tenuous.
If cruel, unusual, and barbaric punishment exists, death by nerve gas would certainly be it. Nerve agents are classified as organophosphates, and can be thought of as extremely potent and lethal insecticides, or humanicides. The first nerve agents created—tabun, sarin, and soman—were made in World War II by German scientists. Later in 1952, British scientists manufactured VX, or venomous agent-X. While chemically similar to the organophosphate insecticides, these agents are used in warfare because very low concentrations are needed to cause death in humans.
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Nerve agents work by binding to and inactivating acetylcholinesterase, an enzyme that resides in between nerve endings, whose sole job is to break down the important neurotransmitter acetylcholine. When acetylcholinesterase is inactivated, acetylcholine builds up at nerve sites, leading to excessive stimulation of the downstream gland or muscle. This results in two detrimental cascades.
First, acetylcholine activates many glandular secretions and intestinal processes. Excessive acetylcholine corroborates what has been reported and seen in the videos taken just after the attack, including uncontrolled salivation that will cause “foaming at the mouth,” vomiting, tearing, involuntary defecation and urination, tiny pinpoint pupils, and a slow heart rate that will cause fainting.
Secondly, acetylcholine is also used to signal skeletal muscles to contract. With excessive acetylcholine, involuntary and painful muscle contractions and spasms occur, leading to profound muscular weakness. Muscles rapidly become so overstimulated that complete paralysis ensues. The diaphragm (the main muscle responsible for breathing) is not spared by this body-wide attack, thus breathing becomes shallow and eventually halts. The muscles of the larynx and throat also become paralyzed, and victims are unable to swallow, cough, or clear the suffocating amount of saliva produced. Death by a nerve agent is usually caused by choking on one’s own saliva, and accompanied by paralysis, sometimes with the victim still lucid. It is gruesome, barbaric, and criminal.
Nerve gas also penetrates the blood brain barrier; for the lucky ones this happens before suffocation and respiratory collapse. It results in a coma that will mercifully alleviate the sensation of drowning, but can also induce difficult-to-control seizures.
Treatment of nerve agent poisoning starts with decontamination, in which victims are stripped naked and aggressively hosed off with water. This is imperative, as continued poisoning will occur without proper decontamination, and also puts treating medical staff at risk.
Thankfully, antidotes to nerve agents do exist, and are aimed at halting the two cascades mentioned above. Injections of the drug Atropine will slow salivation, vomiting, defecation and the involuntary glandular activities. Pralidoxime will reverse the contractions and paralysis, but if sarin gas was used, pralidoxime must be given within five to eight minutes to prevent irreversible chemical binding. Most military ground forces will carry auto injectors that contain both antidotes.
Unfortunately, this is not the first time chemical weapons have been used in Syria. UN investigators found the Al-Assad regime responsible for up to three previous chlorine gas attacks, and in 2013 the death of more than 800 civilians by sarin gas in a Damascus suburb nearly prompted a ground invasion by British and American forces. ISIS fighters have also been accused of using mustard gas. Initial reports of yesterday’s attack point to an air bombing by either Syrian or Russian forces, but neither side has taken responsibility. Whoever is found guilty will be internationally condemned, but will anything actually be done about it?
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UPDATE 4/6/17: This story has been updated to reflect the fact that nerve gas penetrates the blood-brain barrier.
Darragh O’Carroll, MD, is an emergency physician in Hawaii.
