KEY POINTS

1. The management of a CBW injury is a process continuing from the site of release to the hospital. The anesthesiologist may be involved at all stages in the provision of essential early life support through ICU care.
2. CBW management requires advanced life support and other specialized skills that are part of the anesthesiologist's sphere of operation.
3. CBW injury should not be approached in isolation from the many clinical lessons that already exist from accidental HAZMAT releases and natural epidemic infections. CBW agent release poses a risk to medical responders, and they should be trained and equipped to operate safely in a contaminated or infected zone.
4. Chemical and biological hazards form part of a continuous hazard spectrum. Agents from different parts of the spectrum may have common effects on susceptible somatic systems. Because detection of a released agent may not be immediate, response should be based on presenting signs and symptoms and may require the provision of life support.
5. Each hazard in the spectrum has four key properties: toxicity, latency, persistency, and transmissibility. The first two determine the management of the patient, and the second two determine the management of the incident.
6. A wide range of suggested potential hazards (often translated uncritically as threats) have been suggested in a climate of apprehension because of the possibility of terrorist attack. On the basis of preexisting military and intelligence information, these can be refined to provide a framework of genuine hazards and management protocols that can be applied across the hazard spectrum.
7. CBW agents should not be regarded medically as WMDs; instead, they are agents that may cause mass injury. Early life support and specific therapy can break the link between mass injury and mass loss of life.
8. Most of the toxic hazards likely in civil life are part of the United Nations HAZMAT classification. Planning for accidental industrial releases is relevant to the management of deliberate CBW agent release.
9. Toxic agents have been used in military and civil releases over the past 30 years and should be regarded as potential terrorist threats.

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10. Management of exposed patients depends on the protection of medical responders, early provision of life support, and specific antidote and antimicrobial therapy. Decontamination of patients may cause delays in starting treatment and is not always necessary. TOXALS should be given during decontamination if required.
11. Military chemical warfare agents such as nerve agents, vesicants, pulmonary edemagens, cyanides, and certain toxins pose the greatest hazard in civil releases. There are many industrial chemicals that are equally hazardous.
12. Classic biological warfare agents such as anthrax and plague manifest as a deliberately induced epidemic with far longer latencies than a chemical weapon attack. Anesthetic involvement is usually at the intensive care stage.
13. Lessons learned from the current fears of deliberate toxic release will have value for the management of the increasing number of accidental individual and mass toxic exposures that form the greater risk for human life in the 21st century.