Nerve Agents Part II: Response Considerations

NERVE AGENTS PART 2: Response Considerations

David Millstein, May 2017

If you recall from the first part of this article we focused on VX, a particularly hazardous WMD nerve agent. Although designed for use in military operations, nerve agent use has been on the decline for decades, but through clandestine synthesis, theft, or military use, they should remain (or be raised to) a major concern for responders. Nerve agents, including VX, are manmade organophosphates. They are typically colorless and have no or very faint odors. Lethality varies, but consider these all to be VERY toxic via inhalation, ingestion, and absorption exposures.

Part one of this article began with a story about an incident in an airport. Loosely based upon the actual events surrounding a recent use of VX nerve agent, it set the stage for the responder perspective we will be covering now. Changing our view slightly, we will talk about some basic concepts for the recognition of nerve agent or WMD events (these can really be applied to any CBRNE event, whether it is considered malicious or not.) Additionally we will talk briefly about some of the instrumentation/detection equipment commonly used for suspected nerve agent events and touch on some agencies that can provide assistance.

A common analysis concept in management draws a parallel between one’s level in an organization (Recruit, Captain, Chief, e.g.) and their corresponding level of their organizational and outward view. Where the recruit might view things at 500 feet, the Chief might view things at 10,000 feet. Understanding vantage point combats tunnel vision and allows one to see the BIG PICTURE. For those involved in a CBRNE/WMD event, it is crucial that we stay out of the tunnel and maintain as high a vantage point as possible. Keep this concept in mind as you read on and as you respond to incidents. What follows is not specific to nerve agents, but can be applied to any incident and is especially useful for low-frequency high-risk WMD incidents.

In the age of potent drugs such as carfentanil, pandemic diseases such as Ebola or Zika, and terrorism incidents, we face many threats and critical decisions on a regular basis. How then can we determine at the time of dispatch whether an event is a WMD, let alone a nerve agent event? In short: we can’t, but there are some things to consider that can assist in framing the incident from a higher vantage point. Simply put, consider the Who, What, Where, When, Why, and How. Distilled even further, Location/Occupancy, Time, and Presentation (LTP.) This is the time to be a detective, to use experience, training, and common sense to assist in framing in the incident. It’s time to rapidly analyze some data.

Location/Occupancy. There are certain locations that could (should) raise warning flags: Government or military facilities, large gathering locations such as sporting events or concerts, medical facilities such as hospitals, critical infrastructure, transportation: structures and vehicles of all types, and areas of significant importance to society, such as monuments or museums. This is not an exhaustive or all-inclusive list, only a sample.
Exercise: List the ten highest priority areas nearest to you. How would you handle a significant event at one of these locations? Are they pre-planned?

What we knew in 1942 – click for article

Time. Consider the Location when thinking about the time of day. Certain facilities only operate during a normal work-day schedule of 9-5, whereas others are 24-hour operations. When is it likely there is the highest density of people? Remember the goals of terrorism to disrupt societal norms and cause panic, which is typically achieved through attacking large numbers of people.

Does a chemical incident at 3 AM on a Tuesday at a Federal government building have the same meaning to you as the same incident at 11 AM the same morning? Could a cleaning/maintenance crew at 3AM have inadvertently combined chemicals causing an off-gassing of a toxic chemical such as chlorine? In the early AM hours, the building is likely empty and nearing noon, the building is likely fairly full. NOTE: The opposite of this logic at infrastructure facilities should be considered carefully. An attack on critical infrastructure, such as power or communications would likely involve the use of a tactic to disrupt the service, not injure or kill people.
Exercise: With your list of priority areas covered above, record the time-frames of highest occupancy for each (or lowest, for unmonitored infrastructure.) This can often be obtained during the pre-planning process.

Presentation. How the incident was reported, how many reported it, and initial size-up are critical data elements here. Numerous callers about the same incident should raise a serious warning flag as to the validity and potential seriousness. Before even arriving to the scene, consider the pre-arrival information, Time, and Location as this begins to set the stage for the entire incident. Remember, the first 5 minutes are often the most critical and deciphering all of the data can be a daunting task. Please remember, that for all incidents, especially those suspected as being related to any type of terrorism, suspect secondary or tertiary devices. Be cautious. Be methodical.
Let’s turn to size up. What is the scene presentation? Are there casualties? A lot? A few? Begin working backwards from what you have RIGHT now compared to what the scene was before this event. What could have potentially caused the change? All details here are important, from weather to your “gut” feeling, so don’t discount anything yet.
Exercise: Using the Location and Time exercises above, consider the worst event you could imagine at each Location during the Time of highest occupancy. Record resources you need and how many. Now is the time to really take that 10,000 foot view and consider all of the agencies that would be needed to mitigate the incident. Write them all down. Do you have contacts there? How do you request them? It is important to really take the time here to identify all of the interagency partners that could be needed. Some examples: Emergency Management, HazMat, fire/rescue, EMS, hospitals, Metropolitan Medical Response System, Public Health, Incident Management Support Teams, National Guard WMD-CST, Department of the Environment, FBI JTTF, law enforcement, Laboratory Response Network, etc.

The preceding information was intended to refresh some size-up basics and again, is NOT an all-inclusive list of thoughts, ideas, or agencies. Rather, this was provided as a reminder of the basics to help your thought process as it relates to WMD or other large-scale events. The next section focuses a bit more on nerve agents and it follows the same outline as above.
For the sake of time we will assume that the Location and Time fall into the categories of highest concern (Location is identified as a high-hazard target and the Time is of the highest number of people present.) With those assumptions made, let’s focus briefly on Presentation. You have arrived to find a large number of people outside of a government building shortly before noon on Tuesday. Many are running around (and away from) the main entrance. There are no physical indicators from the building, including smoke, fire, steam, or dust. There are numerous people “down” outside and many appear to be in distress. What are your thoughts at this point? Do you suspect anything out of the ordinary? You stage a short distance away and view the scene with your binoculars, paying attention to those that are “down” and in distress. You note many holding their abdomens, some vomiting, some with seizures. Many have wet faces with teary eyes and excess salivation. Remember SLUDGEM?
Lacrimation (tearing)
Gastrointestinal (cramping, e.g.)
Emesis (vomiting)
Muscle spasm (seizures) and/or miosis (pinpoint pupils)

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Now what? At 500 feet this looks like a bad scene with lots of chaos. At 10,000 feet it looks the same way, but by combining Location, Time, and Presentation you can now set the stage for the next steps of the incident because you realize this is significantly more complex and requires interagency assistance. The challenges you face are numerous, what to do first, what resources are needed, how to determine what is REALLY going on. Given the information above, you could classify this as a nerve agent incident (there is nothing wrong with erring on the side of caution,) and begin to scale the resources and command structure.

The following section will briefly review some of the equipment that can be utilized for WMD incidents. By no means is this an all-inclusive list or a recommendation/endorsement of any product. When evaluating incidents with any type of detection equipment, remember that redundancy is important for the confirmation of the presence or absence of “something.”

M9 Tape 2, 4
1. Detects: Chemical/Nerve agents, PRESENCE of agents
2. State: Gas/Vapor
3. Indicators: Red/Pink/Brown: Suspect that a nerve or blister agent present
4. Use: Tape to garment, back, or visible instrument, ankles, etc.
5. Interferences: insecticides, antifreeze, petroleum products

M8 Paper 1, 2, 3
1. Detects: Nerve/Blister Agents, IDENTIFICATION of CLASS
2. State: Liquid
3. Indicators: Yellow: G (nerve), Red: H (blister), Green: V (nerve)
4. Use: Dab, don’t rub onto liquid sample and compare to chart
5. Interferences: insecticides, antifreeze, petroleum products

M256 Kit 2, 5, 6
1. Detects: Chemical/Nerve agents. Detects presence of chemical WMD agents. ID’s certain agents.
2. State: Gas/Vapor
3. Indicators: Blood: AC, CK; Blister: HD, CX, L; Mustard: H, HD, HN, HT; Nerve: G, V
4. Use: Detailed instructions included
5. Notes: ANY color change to sample location indicates possible presence of agent, treat as a POSITIVE test.

SAW: Hazmat CAD 6
1. Detects: Nerve, Blister, Blood, Choking, TICs (Hydrides, Halogens, Blood, Choking gasses)
2. State: Gas/Vapor
a. Surface Acoustic Wave (SAW)
i. SAW sensor for nerve and blister. Thin polymer membrane. Absorption of airborne contaminants. Rapid-acting.
b. Electrochemical cells for blood and choking agents, and TICs
3. Indicators: Device alerts to presence, “High,” “Medium,” “Low” readings
4. Use: Follow manufacturer instructions
5. Notes: Not intrinsically safe.

AP4C (4-Channel) 7
1. Detects: Chemical warfare (nerve, blister, blood) agents and TICs
2. State: Liquid, solid (dust), gas/vapor (Interchangeable “tips” for air or liquid sampling)
a. Flame spectrophotometer
i. Sample burned and resulting flame characteristics are analyzed
3. Indicators: 5 warning light levels for each channel. Each corresponding to a higher concentration.
4. Use: Real-time constant sampling
5. Notes: Extremely fast response time

Drager CDS (Colorimetric tubes) 8
1. Detects: Nerve, blood, choking, and irritating agents
2. State: Gas/Vapor
3. Indicators: Scale on side of tubes and chart with instructions.
4. Use: Point of sample detection of agents
5. Notes: Very low concentrations required for readings

IMS: APD2000, LCD 3.3, HGVI 10
1. Detects: Chem warfare agents, TICs
a. Ion Mobility Spectrometry (IMS)
i. Particles become charged and the time travelled through the device is measured against a library of samples.
2. State: Gas/Vapor
3. Indicators: Varies by device
4. Use: Varies by device

M908 (HPMS: High-Pressure Mass Spectrometer) 9
1. Detects: chemical and nerve agents (CWA), TICs, narcotics, explosives
2. State: Solid, liquid, gas/vapor
3. Indicators: On-screen display and identification
4. Use: Continuous monitoring for gas/vapor or individual samples for solids and liquids

In the section on “Presentation” above, we listed several agencies that can provide assistance in the event that local responders become overwhelmed. As with any incident suspected of great complexity, try to obtain that 10,000 foot vantage point early so resources can be requested quickly. Broken down into three categories, they are meant to loosely classify the individual agencies but is not intended to be a complete list. The keys are to know who they are, how they can be requested and through what channel(s), as well as familiarity with interoperability plans for each. Please spend some time reviewing your contacts and interactions with these groups. It can be useful to have a contact and resource list for the agencies you regularly interface with and to refresh the relationships occasionally.
Local Resources. Fire, EMS, HazMat, and law enforcement.
These will vary by jurisdiction, but consider the need for immediate personnel for scene control, triage, reconnaissance, etc.
Regional Resources. Hospital(s), Public Health, Department of the Environment, Emergency Management.
Each of the above have access to plans and resources above the local level and can greatly assist in managing various aspects of the emergency, from patient destination considerations to assessment of environmental and/or health impacts.

State/Federal Resources.
Metropolitan Medical Response System

Incident Management Teams

National Guard WMD-CST (Civil Support Team)

FBI JTTF (Joint Terrorism Task Force) 

Laboratory Response Network

Grants, information and intelligence-sharing, and incident support are some of the benefits each of these agencies provide.


The first part of this two-part article was focused on nerve agents, specifically VX. The intent is to raise awareness of these chemicals and show that they should not be considered emerging threats, but can and have been used on civilian populations. Agent specifics were discussed to help provide a foundation (or refresh previous knowledge) about characteristics and patient presentations.
In the second part we took a broader (or higher) perspective to view the incident, incorporating the LTP (Location, Time, and Perspective) concept to help in the early decision-making process. Recognizing the potential severity of an incident is key to rapidly request additional information and resources, such as incident, treatment, and medication support. Additionally, a brief review of detection equipment that can be used was included as a refresher, including the basic papers to the more advanced HPMS.
Familiarity with nerve agents, how to confirm their presence through size-up and detection equipment, and organizing a coordinated response to mitigate these types of complex incidents is difficult. Hopefully some of the information contained here was useful and will help you in the field. Please feel free to share your thoughts or ideas.

1. Accessed 15 April 2017.
2. Accessed 15 April 2017.
3. Accessed 15 April 2017.
4. Accessed 15 April 2017.
5. Accessed 15 April 2017.
6. Accessed 15 April 2017.
7. Accessed 15 April 2017.
8. Accessed 15 April 2017.
9. Accessed 15 April 2017.
10. Accessed 15 April 2017.

WMD Simulation
David (Dave) Millstein

About The Author

David (Dave) Millstein

David (Dave) Millstein has been involved in the emergency services since 2000 as a volunteer in Pennsylvania. Early in 2004 he began working for the USFA supporting the NFIRS system at the local, state, and federal levels. Later that year he began his career with Frederick County (MD) Fire/Rescue, where he currently serves as a Lieutenant on the HazMat Team. Originally from Massachusetts, he decided to stay in Pennsylvania after obtaining a business degree from Gettysburg College. Dave’s passion is focused on leadership and management in the areas of HazMat/WMD and homeland security. This includes training development and management to prepare personnel for current and future threats/hazards, creating policy and procedure to address real problems, and data-driven decision making. When he is not working, he enjoys hiking, Tae Kwon Do with his family, and reading.