Page 125 - Journal of Special Operations Medicine - Fall 2017

Houston area, these drugs are distributed in mass quantities hostages held by Islamic militant Chechen terrorists, the Rus-
throughout the United States and Canada. Drug dealers are not sian Special Forces from the Spetsnaz of the Federal Security
held to purity standards, so another risk to users is inadequate Service pumped an unknown gas to neutralize the situation
mixing of carfentanil, resulting in samples with disproportion- without direct engagement of the terrorists. Although the ex-
2
ate amounts of the toxic substance. act composition of the gas is still unknown, toxicology results
from victims’ clothing samples and urine toxicology indicate a
To illustrate the hazards to law enforcement, two detectives very potent narcotic and a lesser potent opioid combined with
from Atlantic County, New Jersey, were inadvertently exposed a volatile anesthetic gas. The most plausible combination
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to fentanyl (1/100th of the potency of carfentanil) during evi- would be carfentanil along with a faster-acting narcotic drug,
dence recovery and processing. They described the exposure, remifentanil, and the anesthetic gas halothane. Some reports
which occurred upon sealing an evidence bag, as feeling as if state that ambulance personnel were told to bring a narcotic
they were dying and their bodies were shutting down. The antagonist like naloxone. Physiological asphyxiation was the
3
4
DEA has an officer safety alert video for responding officers cause of death of those who died at the theater. It is plausible
about fentanyl (http://go.usa.gov/chBgh); the video includes a that victims who became unconscious in the theater seats did
reminder that police dogs can also experience the hazardous not die because they were sitting upright and able to main-
effects of these potent agents during screening. Some agencies tain their own airway. The fatalities were mainly those who
in epidemic areas have requested that officers not conduct field were able to ambulate and then lay down in a supine posi-
testing of heroin, to reduce the risk of carfentanil exposure. tion; airway collapse from relaxation of the tongue against the
Carfentanil should be handled like any other hazardous mate- posterior pharynx subsequently occurred. Theater occupants
rial and precautions should be taken to protect the responders who were treated with mechanical ventilator support were
from respiratory or contact exposures. discharged without significant sequelae. These same survivors
reported that they had a peculiar lack of any pain, even dur-
Rescue from unintended contact with carfentanil powder or ing needle sticks and other medical procedures typically asso-
with patients who have the drug in their system can be ac- ciated with pain. Unfortunately, due to secrecy, ambulance
11
complished by using naloxone or naltrexone. One published personnel and emergency physicians were not given informa-
case from an accidental exposure to carfentanil at a veteri- tion about the agents used and these rescuers had to rely on
nary facility had a successful rescue from administration of physical examination findings such as pupillary constriction
100mg of naltrexone. Animal studies recommend a dose of and respiratory depression to formulate an appropriate treat-
5
100mg naltrexone for every 1mg of carfentanil administered. ment for the victims. The final death toll was 33 terrorists and
Large doses of naloxone are needed to counter the effects of 127 hostages; 125 died from inadequate rescue and treatment;
this strong medication. In October 2016, the U.S. Food and 650 hostages required hospitalization. Other logistical issues
Drug Administration Anesthetic and Analgesic Drug Products such as a bottleneck created by cars parked on the street, which
Advisory Committee and the Drug Safety and Risk Manage- restricted the traffic flow of responding ambulances, also con-
ment Advisory Committee voted to allow the previous initial tributed to the medical mismanagement of the situation. 12
dose of intravenous (IV) naloxone of 0.4mg to be increased in
suspected cases of fentanyl and fentanyl analogue overdoses. Conclusion
6
Some have discussed a starting dose of 2mg IV in suspected
cases. Rescuers should consult local protocols and also fol- In summary, forward Operators, whether serving on the home
low regional guidance and intelligence about the prevalence front or abroad, should maintain awareness of the likelihood
of carfentanil overdoses in their area of jurisdiction and ad- of carfentanil exposure and follow information and intelli-
just naloxone doses accordingly. Another clinical phenomenon gence provided with respect to carfentanil and other synthetic
with carfentanil is “narcotic recycling,” where tissue redistri- fentanyl derivatives. Forces should also have the proper per-
bution occurs after the antagonist naloxone has worn off, re- sonal protective equipment when handling drug powders for
sulting in resedation of the patient. 2 evidence processing or field testing, or even handling over-
dose patients in regions known or suspected for the presence
In July 2016, carfentanil was detected in people who had over- of carfentanil. Higher doses of naloxone should be available
dosed in Cuyahoga County, Ohio, where 50 reported deaths for those working in regions with carfentanil to administer to
from carfentanil in that area occurred over a brief period. In both the overdose patient and for workers who might be inad-
7
2015, Cincinnati experienced 238 deaths attributed to carfent- vertently exposed to fentanyl and fentanyl derivatives.
anil, making Ohio the epicenter of this powerful synthetic nar-
cotic. Another 20 deaths were related to the potent narcotic in Disclosures
3
the Detroit, Michigan, area. The Orange-Osceola Medical Ex- The authors have nothing to disclose.
8
aminer’s office in Florida is getting ahead of the threat to their
staff by keeping high quantities of naloxone on hand in their References
facilities in case of inadvertent contact with carfentanil during 1. DrugBank. Carfentanil. https://www.drugbank.ca/drugs/DB01
autopsy of people who had overdosed. The Georgia Bureau 535. Accessed 18 August 2017.
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of Investigation has plans to increase the size of their morgue 2. Wax PM, Becker CE, Curry SC. Unexpected “gas” casual-
to meet the increased demands caused by synthetic narcotics. 10 ties in Moscow: a medical toxicology perspective. Ann Emerg
Med. 2003;41(5):700–705.
3. Hamilton K. Beyond deadly: ultra-potent synthetic heroin
Special Forces Operators should also familiarize themselves is spreading across America. 18 October 2016. https://news
with carfentanil because the drug was likely one of the agents .vice.com/story/ultra-potent-synthetic-heroin-is-spreading-
used to chemically immobilize the occupants of the Dubrovka across-america. Accessed 18 August 2017.
Theater in Moscow, Russia, during a 2002 hostage crisis. To 4. U.S. Drug Enforcement Administration. DEA issues carfent-
end the takeover of the theater and to release the nearly 800 anil warning to police and public. 22 September 2016. https://

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