Tokyo subway sarin attack

Okumura, T., Suzuki, K., Fukuda, A. (1998). The Tokyo subway sarin attack Disaster management. Part 2 Hospital response. Academic Emergency Medicine, 5, 625-628. 

Okumura, T., Takasu, N., Ishimatsu, S. (1996). Report on 640 victims of the Tokyo subway sarin attack. Annals of Emergency Medicine, 28, 129-135. 

The Tokyo Subway Sarin Attack Toxicological Whole Truth... 

The Tokyo subway sarin attack occurred in 1995, following the Matsumoto sarin attack, and served as a wake-up call for anti-NBC (nuclear, biological, and chemical) terrorism policy throughout the world. In the 10 years since the attack, efforts to combat NBC terrorism have focused on rapid and effective measures to respond to attacks employing nerve agents such as sarin. 

In victims of the Tokyo subway sarin attack, endotracheal intubation was not difficult. The Japanese medical literature describes the standard treatment for sarin toxicity as... 

After the Tokyo subway sarin attack, St Luke s Hospital, which treated 640 victims, used about 700 ampules of PAM and 2,800 ampules of atropine (Okumura et al, 1998). This calculates out to 550 mg of PAM and 2.2 mg of atropine for each victim. The route of administration was intravenous in all cases with a total dose of atropine in severe cases 1.5 mg to 9 mg (Okumura et al, 1996) doses which reflect the low concentration and passive means of sarin dispersal used in the Tokyo attack. 

Based on the experience of Iranian physicians who treated sarin toxicity during the Iran-Iraq war (Newmark, 2004), PAM was not available on the front lines and atropine alone was used for treatment. The doses of atropine used were considerably higher than those used in the Tokyo subway sarin attack, or that are generally recommended in the USA (Medical Letter, 2002). The Iranian protocol called for initial administration of 4 mg intravenously. If no atropine effects (improvement in dyspnea or decrease in airway secretions) were seen after 1 to 2 min, 5 mg was then administered intravenously over 5 min while heart rate was monitored. A rise in heart rate of 20 to 30 beats per min was regarded as an atropine effect. In severe cases, 20 mg to 200 mg was given. Regardless of dose, the key to saving lives, in their opinion, was how soon the atropine was administered. 

According to inpatient records from St Luke s Hospital, the most common laboratory finding related to sarin toxicity was a decrease in plasma cholinesterase (ChE) levels in 74% of patients. In patients with more severe toxicity, plasma ChE levels tended to be lower, but a more accurate indication of ChE inhibition is measurement of erythrocyte ChE, as erythrocyte ChE (AChE) is considered true ChE and plasma ChE is pseudo ChE . However, erythrocyte ChE is not routinely measured, whereas plasma ChE is included in many clinical chemistry panels thus, it can be used as a simple index for ChE activity. In both the Matsumoto and Tokyo subway sarin attacks, plasma ChE served as a useful index of sarin exposure. In 92% of hospitalized patients, plasma ChE levels returned to normal on the following day. In addition, inpatient records from... 

Given the low concentration and means of dispersal, the Tokyo subway sarin attack can be referred to as a passive attack. The implication of such an assumption is therefore that mankind has not yet witnessed a full-scale sarin attack in any major city. While valuable information can certainly be gained from the Tokyo subway sarin attack, the experience obtained from the more aggressive Matsumoto sarin attack and the Iran-Iraq war should also be considered when developing initiatives directed at dealing with a potential full-scale attack in the future where the effects will be more serious. 

We wish to thank the many people who have devoted their lives to research of chemical weapons treatment since the Tokyo subway sarin attack and who provided valuable advice in preparing tbis chapter. This chapter is dedicated to the memory of Dr Frederick Sided at the United States Army Medical Research Institute. 

Chigusa, H. (1995). The Tokyo subway sarin attack. n Disaster Medicine Learned from the Cases (T. Ukai, Y. Takabasshi, M. Aono, eds), pp. 98-102. Nanko-do, Tokyo. 

Matsui, Y., Ishimatsu, S., Kawana, N., Tamaki, S., Sugata, K. (2002). Official Report of Ministry of Welfare and Labor Science Project Sequelae in the Tokyo Subway Sarin Attack Victims. 

Miyaki, K., Nishiwaki, Y., Maekawa, K., Ogawa, Y., Asukai, N., Yoshimura, K., Etoh, N., Matsumoto, Y., Kikuchi, Y., Kumagai N., Omae, K. (2005). Effects of sarin on the nervous system of subway workers seven years after the Tokyo subway sarin attack. J. Occup. Health 47(4) 299-304. 

Okumura, T., Nomura, T., Suzuki, T., Sugita, M., Takeuchi, Y., Naito, T., Okumora, S. et al. (2007). The dark morning the experiences and lessons learned from the Tokyo subway sarin attack. In Chemical Warfare Agents Toxicology and Treatment, 2nd edition (T.C. Marrs, R.L. Maynard, F.R. Sidell, eds), pp. 277-303. John Wiley and Sons, Chichester, UK. 

The only published study of the brain structural effects of nerve agent exposure in a human population focused on longterm changes induced in victims of the 1995 Tokyo subway sarin attack (Yamasue et al, 2007). In this event, which resulted in 12 deaths, approximately 5,500 victims were exposed to sarin, and essentially all patients exhibited typical symptoms of acute intoxication (Lee, 2003 Ohbu et al. 

Araki, T., Kasai, K., Yamasue, H., Kato, N., Kudo, N., Ohanti, T., Nakagome, K., Kirihara, K., Yamada, H., Abe, O., Iwanami, A. (2005). Association between lower P300 amplitude and smaller anterior cingulate cortex volume in patients with posttraumatic stress disorder a study of victims of Tokyo subway sarin attack. Neuroimage 25 43-50. 

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