Disaster and Terrorism/Special Contribution
Unexpected “gas” casualties in Moscow: A medical toxicology perspective,☆☆

https://doi.org/10.1067/mem.2003.148Get rights and content

Abstract

In October 2002, the Russian military used a mysterious “gas” to incapacitate Chechen rebels at a Moscow theater. Despite increased interest in the potential use of lethal chemical weapons in recent years, the medical community has paid little attention to the development of incapacitating, calmative, and “less than lethal” technologies. In this analysis, we review the events surrounding the use of a calmative “gas” during the Russian military action and discuss what is currently known about fentanyl derivatives, their aerosolization, and the rationale for their use as incapacitating agents. Collectively, the available evidence strongly suggests that a combination of a potent aerosolized fentanyl derivative, such as carfentanil, and an inhalational anesthetic, such as halothane, was used. The paper also assesses potential errors leading to the loss of a substantial number of hostages. Several lessons can be learned from this surprising and novel use of an incapacitating gas. [Ann Emerg Med. 2003;41:700-705.]

Introduction

On October 26, 2002, more than 120 hostages held at the Moscow Dubrovka Theater Center by Chechen rebels died during a rescue attempt by Russian military special forces. First reports suggested that a “poison” gas had been used by the elite spotznaz in order to subdue the rebels and rescue the hostages. But what gas was it? According to press reports, Russian physicians were told that an anesthetic gas had been pumped into the theater, but the gas was not identified.1 Perhaps concerns regarding the restrictions in the recently ratified Chemical Weapons Convention contributed to the cloak of secrecy surrounding the identity of the toxic agent.2

Medical toxicologists are familiar with many of the toxicologic issues surrounding chemical warfare agents; however, our assumption about which agents were used during this daring hostage rescue did not fit with the reported clinical effects. In this age of terrorism, the element of surprise is an important tool. Just as few people expected that hijacked jet aircraft would be transformed into offensive missiles of mass destruction, medical providers likely expected to receive victims suffering from bullet wounds, not a mysterious intoxication. Despite visits by military medics to some Moscow hospitals several hours before the raid, advising health care providers to increase their supplies of naloxone,3 the emergency medical system was not adequately prepared to receive hundreds of casualties suffering from opioid intoxication.

Section snippets

What happened?

On October 23, 2002, more than 800 people attending a stage show were taken captive by some 50 Chechen rebels. The rebels repeatedly threatened to blow up the theater if their political demands were not met. The Russian military stormed the theater early in the morning of October 26. An unidentified “gas” was introduced into the theater through the ventilation system approximately 15 minutes before the military offensive.4 Hundreds of hostages were taken to local hospitals suffering from

Aerosols of fentanyl and fentanyl derivatives

A large number of fentanyl derivatives have been developed. Many are more potent than fentanyl. Like fentanyl and meperidine, these agents all have a phenylpiperidine structure, are structurally dissimilar to natural opiates, and are potent agonists at μ opioid receptors. Depending on the dose, fentanyl and its derivatives produce analgesia, respiratory depression, central nervous system depression, and miosis.

The Russian acknowledgment that the gas was a fentanyl derivative raised a number of

Carfentanil

Carfentanil is another fentanyl derivative with very high potency and a high therapeutic index. It is a one of a series of N-4-substituted 1-(2-arylethyl)-4-piperidinyl-N-phenylpropanamide compounds. It is the only opioid approved in the United States for immobilizing large exotic animals; it is not approved for use in human beings.19 Known as Wildnil, it is used primarily as an incapacitating agent for large animals, such as elephants, rhinoceroses, wolves,20 seals,21 and polar bears.22 A

Unexpected deaths

If carfentanil was used, why did more than 120 hostages die? Carfentanil has a therapeutic index of 10,600. Shortly after the tragedy, it was reported that the consensus of Russian health experts was that “this drug could not have caused death.”8 Given the extraordinarily high therapeutic index of carfentanil, reactions among Russian officials suggest that the large number of deaths from gas poisoning was not anticipated.

Several factors may explain the deaths. Unpredictable uptake of opioids

Lessons learned

It seems likely that the 800 hostages were about to be killed by Chechen rebels. To rescue them, the Russian military used a calmative agent in an attempt to subdue the rebels. The intent was likely to win control of the theater with as little loss of life as possible. Given the large number of explosives in the hands of the hostage takers, a conventional assault or the use of more toxic chemical agents might have significantly increased the number of casualties. Although it may seem excessive

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    Editor's note: This article was first published on Annals' Web site (www.mosby.com/AnnEmergMed ) on March 3, 2003. Articles of particular interest are published on the Web site in advance of their appearance in the print journal. In the future, an increasing percentage of our content will be published first on the Web, predating the print publication as a service to our readers.

    ☆☆

    Address for reprints: Paul M. Wax, MD, Department of Medical Toxicology, 925 East McDowell Road, 2nd Floor, Phoenix, AZ 85006; 602-239-2353, fax 602-239-4138; E-mail [email protected] .

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