Emergency War Surgery NATO Handbook: Part I: Types of Wounds and Injuries: Chapter VI: Chemical Injury

Incapacitation (INCAP) Agents

United States Department of Defense

Incapacitation agents (incaps) are a heterogeneous group of chemical agents with potent CNS effects that seriously impair normal function but do not endanger life or cause permanent tissue damage in operationally effective doses. Atropine and scopolamine were early forerunners; other cholinolytics such as benactyzine followed. Quinuclidinyl benzilate (BZ or QND) is a potent glycolate representative of this class. The diagnosis of in cap exposure may be extremely difficult to make in isolated instances due to the paucity of distinct diagnostic signs and criteria.

An essential precaution with these confused, perhaps disturbed, casualties is immediate removal of firearms and other weapons to insure the safety of themselves, other patients, and nearby personnel. Be aware that interaction between incaps and pharmacologic agents such as analgesics, antidotes, and anesthetics is probable, but little specific information is available. Caution in their use is advisable.

Belladonna-type drugs: These cholinolytics cause widely dilated pupils, tachycardia, dry mouth, hot dry skin, and decreased intestinal motility and bladder tone. The CNS symptoms and signs run the gamut from inattention, confusion, anxiety, restlessness, and hallucinations on up to delirium.

Recommended treatment is physostigmine, given IM in 2-3 mg doses every 45 minutes. Since the CNS effects of BZ may persist for days, close observation and continued treatment with 3-4 mg physostigmine orally every 1-2 hours are essential elements in managing toxic delirium. Titrate therapeutic dosage against clearing of mental status, should heart rate fall below 70, in which case dosage may be decreased, but physostigmine should not be discontinued. The ability of the body to thermoregulate is damaged by cholinolytics. This is of concern, particularly with personnel in protective clothing Administering fluids, recording body temperature and urine output, and catherizing the bladder to relieve distention are key supportive measures.

CNS Depressants. In this group are cannabinols, barbiturates, and morphine-like compounds that destroy motivation and produce tranquillity and sedation. If treatment of severe indolence is required, CNS stimulants such as the amphetamines have been effective.

CNS Excitants. These agents incapacitate by raising the level of neurotransmitters, causing cerebral hyperstimulation. Indoles such as lysergic acid diethylamide (LSD) produce inappropriate behavior, restlessness, fear, perceptual aberrations, and a general schizoid psychosis-like syndrome. In hyperexcitable casualties, sedative barbiturate or chlorpromazine administration has been proposed. Benzodiazepines may be useful, with Valium having the advantage of ready oral absorption.

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Operational Medicine 2001

Health Care in Military Settings

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