Pharmacologic Agents and Agents of Biologic Origin

The events in the Moscow theater siege in 2002 highlighted the use of substances originally developed as anesthetic agents or adjuncts as "knock-down weapons." In the siege, a substance was released by special forces entering the theater, which led to the deaths from respiratory failure of several hundred of the hostages. The event emphasized the need for immediate life support after a toxic attack with short-latency agents. The Russian government, after challenge, declared that the agent used was "fentanyl." Many fentanyls have been synthesized apart from those familiar in clinical practice, and some are too toxic for general use. The fact that naloxone, which was apparently used in the hospital treatment of the casualties, was ineffective casts doubt on this version of events. Another possibility is the use of a short-chain neuropeptide such as delta sleep-inducing peptide. Considerable research went into investigating such compounds during the last days of the USSR, ^[15] and anesthesiologists should be aware of their existence. Agents such as BZ (also initially considered as a possible cause of the theatre casualties) have been known for many years and are centrally acting anticholinergic agents. Phencyclidine compounds (related to ketamine) and other hallucinogens were tested during the early days of chemical weapons research during the Cold War and should be considered as part of the differential diagnosis of patients presenting with central nervous system symptoms after a possible toxic attack.