Responding to chemical weapons violations in Syria: legal, health, and humanitarian recommendations

A longitudinal MRI and TSPO PET-based investigation of brain region-specific neuroprotection by diazepam versus midazolam following organophosphate-induced seizures

Acute poisoning with organophosphorus cholinesterase inhibitors (OPs), such as OP nerve agents and pesticides, can cause life threatening cholinergic crisis and status epilepticus (SE). Survivors often experience significant morbidity, including brain injury, acquired epilepsy, and cognitive deficits. Current medical countermeasures for acute OP poisoning include a benzodiazepine to mitigate seizures. Diazepam was long the benzodiazepine included in autoinjectors used to treat OP-induced seizures, but it is now being replaced in many guidelines by midazolam, which terminates seizures more quickly, particularly when administered intramuscularly. While a direct correlation between seizure duration and the extent of brain injury has been widely reported, there are limited data comparing the neuroprotective efficacy of diazepam versus midazolam following acute OP intoxication. To address this data gap, we used non-invasive imaging techniques to longitudinally quantify neuropathology in a rat model of acute intoxication with the OP diisopropylfluorophosphate (DFP) with and without post-exposure intervention with diazepam or midazolam. Magnetic resonance imaging (MRI) was used to monitor neuropathology and brain atrophy, while positron emission tomography (PET) with a radiotracer targeting translocator protein (TSPO) was utilized to assess neuroinflammation. Animals were scanned at 3, 7, 28, 65, 91, and 168 days post-DFP and imaging metrics were quantitated for the hippocampus, amygdala, piriform cortex, thalamus, cerebral cortex and lateral ventricles. In the DFP-intoxicated rat, neuroinflammation persisted for the duration of the study coincident with progressive atrophy and ongoing tissue remodeling. Benzodiazepines attenuated neuropathology in a region-dependent manner, but neither benzodiazepine was effective in attenuating long-term neuroinflammation as detected by TSPO PET. Diffusion MRI and TSPO PET metrics were highly correlated with seizure severity, and early MRI and PET metrics were positively correlated with long-term brain atrophy. Collectively, these results suggest that anti-seizure therapy alone is insufficient to prevent long-lasting neuroinflammation and tissue remodeling.

Respiratory health and the Syrian conflict: a scoping literature review

Conflict adversely affects respiratory health in both direct and indirect ways among populations whose health is already compromised through the compounding effects of conflict. Our aim is to review academic and grey literature relevant to respiratory health in the Syrian conflict (now more than a decade in duration) to explore its impacts on populations across Syria. We performed a scoping literature review of academic and grey literature on respiratory health in Syria between March 2011 (taken as the start of the conflict for practicality) and December 2023. Of 11,472 papers screened, 34 met the inclusion criteria, of which 29 were peer reviewed. Key themes identified included the impact of conflict on asthma diagnosis and management; the burden of respiratory tract infections (RTIs) and COVID-19; the impact of chemical weapon use and the impact of destruction and interruptions to the health system(s) across Syria on respiratory health. This review highlights the need for more in-depth exploration of the impact of conflict on respiratory health in Syria with focus on social determinants, for example, shelter, public health interventions, smoking cessation, and supporting early diagnosis and treatment of respiratory conditions to counter the effects that conflict has had on respiratory health.

Public Health Responses to CBRN Terrorism in the Middle East and North Africa

OBJECTIVE

Escalating global challenges (such as disasters, conflict, and climate change) underline the importance of addressing Chemical, Biological, Radiological, and Nuclear (CBRN) terrorism for sustainable public health strategies. This study aims to provide a comprehensive epidemiological analysis of CBRN incidents in the Middle East and North Africa (MENA) region, emphasizing the necessity of sustainable responses to safeguard healthcare infrastructures.

METHOD

Utilizing a retrospective approach, this research analyzes data from the Global Terrorism Database (GTD) covering the period from 2003 to 2020. The study focuses on examining the frequency, characteristics, and consequences of CBRN incidents in the MENA region to identify patterns and trends that pose significant challenges to public health systems.

RESULTS

The analysis revealed a significant clustering of CBRN incidents in Iraq and Syria, with a predominant involvement of chemical agents. These findings indicate the extensive impact of CBRN terrorism on healthcare infrastructures, highlighting the challenges in providing immediate health responses and the necessity for long-term recovery strategies.

CONCLUSIONS

The study underscores the need for improved healthcare preparedness, robust emergency response systems, and the development of sustainable public health policies. Advocating for international collaboration, the research contributes to the strategic adaptation of healthcare systems to mitigate the impacts of CBRN terrorism, ensuring preparedness for future incidents in the MENA region and beyond.

Cardiovascular responses of adult male Sprague-Dawley rats following acute organophosphate intoxication and post-exposure treatment with midazolam with or without allopregnanolone

Recent experimental evidence suggests combined treatment with midazolam and allopregnanolone is more effective than midazolam alone in terminating seizures triggered by acute organophosphate (OP) intoxication. However, there are concerns that combined midazolam and allopregnanolone increases risk of adverse cardiovascular events. To address this, we used telemetry devices to record cardiovascular responses in adult male Sprague-Dawley rats acutely intoxicated with diisopropylfluorophosphate (DFP). Animals were administered DFP (4 mg/kg, sc), followed immediately by atropine (2 mg/kg, i.m.) and 2-PAM (25 mg/kg, i.m.). At 40 min post-exposure, a subset of animals received midazolam (0.65 mg/kg, im); at 50 min, these rats received a second dose of midazolam or allopregnanolone (12 mg/kg, im). DFP significantly increased blood pressure by ~ 80 mmHg and pulse pressure by ~ 34 mmHg that peaked within 12 min. DFP also increased core temperature by ~ 3.5 °C and heart rate by ~ 250 bpm that peaked at ~ 2 h. Heart rate variability (HRV), an index of autonomic function, was reduced by ~ 80%. All acute (within 15 min of exposure) and two-thirds of delayed (hours after exposure) mortalities were associated with non-ventricular cardiac events within 10 min of cardiovascular collapse, suggesting that non-ventricular events should be closely monitored in OP-poisoned patients. Compared to rats that survived DFP intoxication without treatment, midazolam significantly improved recovery of cardiovascular parameters and HRV, an effect enhanced by allopregnanolone. These data demonstrate that midazolam improved recovery of cardiovascular and autonomic function and that the combination of midazolam and allopregnanolone may be a better therapeutic strategy than midazolam alone.

The lesion site of organophosphorus-induced central apnea and the effects of antidotes

Organophosphorus poisoning kills individuals by causing central apnea; however, the underlying cause of death remains unclear. Following findings that the pre-Bötzinger complex impairment alone does not account for central apnea, we analyzed the effect of paraoxon on the brainstem-spinal cord preparation, spanning the lower medulla oblongata to phrenic nucleus. Respiratory bursts were recorded by connecting electrodes to the ventral 4th cervical nerve root of excised brainstem-spinal cord preparations obtained from 6-day-old Sprague-Dawley rats. We observed changes in respiratory bursts when paraoxon, neostigmine, atropine, and 2-pyridine aldoxime methiodide were administered via bath application. The percentage of burst extinction in the paraoxon-poisoning group was 50% compared with 0% and 18.2% in the atropine and 2-pyridine aldoxime methiodide treatment groups, respectively. Both treatments notably mitigated the paraoxon-induced reduction in respiratory bursts. In the neostigmine group, similar to paraoxon, bursts stopped in 66.7% of cases but were fully reversed by atropine. This indicates that the primary cause of central apnea is muscarinic receptor-mediated in response to acetylcholine excess. Paraoxon-induced central apnea is hypothesized to result from neural abnormalities within the inferior medulla oblongata to the phrenic nucleus, excluding pre-Bötzinger complex. These antidotes antagonize central apnea, suggesting that they may be beneficial therapeutic agents.

Sustainable ionic liquids-based molecular platforms for designing acetylcholinesterase reactivators

We report a green chemistry approach for preparation of oxime-functionalized ILs as AChE reactivators: amide/ester linked IL, l-alanine, and l-phenylalanine derived salts bearing pyridinium aldoxime moiety. The reactivation capacities of the novel oximes were evaluated towards AChE inhibited by typical toxic organophosphates, sarin (GB), VX, and paraoxon (PON). The studied compounds are mostly non-toxic up to the highest concentrations screened (2 mM) towards Gram-negative and Gram-positive bacteria cell lines and both filamentous fungi and yeasts in the in vitro screening experiments as well as towards the eukaryotic cell (CHO-K1 cell line). Introduction of the oxime moiety in initially biodegradable structure decreases its ability to biodegradation. The compound 3d was shown to reveal remarkable activity against the AChE inhibited by VX, exceeding conventional reactivators 2-PAM and obidoxime. The regularities on antidotal activity, cell viability, plasma stability, biodegradability as well as molecular docking study of the newly synthesized oximes will be used for further improvement of their structures.

Medical aid to war victims in Syria in 2019: a report of organized healthcare support from a charity organization

Background

In 2011, a civil war started in Syria, which is on-going and has reached a death toll of over 400,000 people. Humanitarian organizations, including Aid to The Church in Need (ACN), have strived to provide help and medical support to the civilian victims.

Methods

We performed a retrospective analysis of data gathered in ACN projects in Syria in 2019. The datasets included descriptions of diseases, treatments, costs, cities, and hospitals. For each patient, we assigned the following additional categories: type of help (treatment, diagnosis, or nonmedical), type of treatment (medical or surgical), medical specialty, gross anatomic region, and presence of trauma.

Results

A total of 3835 patients benefited from ACN support in Syria in 2019. The majority of financial support went towards treatment (78.4%), while other support went towards nonmedical help (15.7%) or providing a diagnosis (5.9%). Among treatments, 66.6% were medical and 33.4% surgical. The most common medical specialty was internal medicine (48.4%), followed by public health (13.7%) and surgery (7.3%). Anatomic region was undefined in 68.3% of cases and, when defined, was most commonly the abdominal cavity and pelvis (13%). The vast majority of cases 95.1%) were not associated with trauma. Procedural costs were highest in the Valley of Christians region, and lowest in Tartous. Network graphs were used to visualize the three most common diagnoses and treatments for each medical specialty.

Conclusions

The present report describes the treatment of war victims in Syria in 2019. The patients lacked the most basic medical or surgical healthcare. Charity organizations, like ACN, constitute a valuable source of information about the healthcare of war victims. Unfortunately, the methods of describing medical treatment provided to civilian victims remain underdeveloped. Future studies will require the cooperation of healthcare providers, humanists, and social workers. The present findings can help to optimize the provision of humanitarian help by charity organizations, by tailoring projects to the specific needs of Syrian war victims.

Computational design of a sensitive, selective phase-changing sensor protein for the VX nerve agent

The VX nerve agent is one of the deadliest chemical warfare agents. Specific, sensitive, real-time detection methods for this neurotoxin have not been reported. The creation of proteins that use biological recognition to fulfill these requirements using directed evolution or library screening methods has been hampered because its toxicity makes laboratory experimentation extraordinarily expensive. A pair of VX-binding proteins were designed using a supercharged scaffold that couples a large-scale phase change from unstructured to folded upon ligand binding, enabling fully internal binding sites that present the maximum surface area possible for high affinity and specificity in target recognition. Binding site residues were chosen using a new distributed evolutionary algorithm implementation in protCAD. Both designs detect VX at parts per billion concentrations with high specificity. Computational design of fully buried molecular recognition sites, in combination with supercharged phase-changing chassis proteins, enables the ready development of a new generation of small-molecule biosensors.

Assessment of the effectiveness of a course in major chemical incidents for front line health care providers: a pilot study from Saudi Arabia

BACKGROUND

Mass chemical exposure emergencies are infrequent but can cause injury, illness, or loss of life for large numbers of victims. These emergencies can stretch and challenge the available resources of healthcare systems within the community. Political unrest in the Middle East, including chemical terrorist attacks against civilians in Syria and increasing chemical industry accidents, have highlighted the lack of hospital preparedness for chemical incidents in the region. This study aimed to evaluate the effectiveness of a course designed to empower frontline healthcare providers involved in mass casualty incidents with the basic knowledge and essential operational skills for mass chemical exposure incidents in Saudi Arabia.

METHODS

A mixed-methods approach was used to develop a blended learning, simulation enhanced, competency-based course for major chemical incidents for front line healthcare providers. The course was designed by experts from different disciplines (disaster medicine, poisoning / toxicology, and Hazard Material Threat - HAZMAT team) in four stages. The course was piloted over five days at the Officers Club of the Ministry of Interior (Riyadh, Saudi Arabia). The 41 participants were from different government health discipline sectors in the country. Pre- and post-tests were used to assess learner knowledge while debriefing sessions after the decontamination triage session and simulation-enhanced exercises were used for team performance assessment.

RESULTS

The overall knowledge scores were significantly higher in the post-test (69.47%) than the pre-test (46.3%). All four knowledge domains also had significant differences between pre- and post-test results. There were no differences in the pre and post-test scores for healthcare providers from the different health disciplines. A one-year post-event survey demonstrated that participants were satisfied with their knowledge retention. Interestingly, 38.3% had the opportunity to put this knowledge into practice in relation to mass chemical exposure incidents.

CONCLUSION

Delivering a foundation level competency-based blended learning course with enhanced simulation training in major chemical incidents for front line healthcare providers may improve their knowledge and skills in response to such incidents. This in turn can improve the level of national preparedness and staff availability and make a crucial difference in reducing the health impacts among victims.

Experimental and Established Oximes as Pretreatment before Acute Exposure to Azinphos-Methyl

Poisoning with organophosphorus compounds (OPCs) represents an ongoing threat to civilians and rescue personal. We have previously shown that oximes, when administered prophylactically before exposure to the OPC paraoxon, are able to protect from its toxic effects. In the present study, we have assessed to what degree experimental (K-27; K-48; K-53; K-74; K-75) or established oximes (pralidoxime, obidoxime), when given as pretreatment at an equitoxic dosage of 25% of LD01, are able to reduce mortality induced by the OPC azinphos-methyl. Their efficacy was compared with that of pyridostigmine, the only FDA-approved substance for such prophylaxis. Efficacy was quantified in rats by Cox analysis, calculating the relative risk of death (RR), with RR=1 for the reference group given only azinphos-methyl, but no prophylaxis. All tested compounds significantly (p ≤ 0.05) reduced azinphos-methyl-induced mortality. In addition, the efficacy of all tested experimental and established oximes except K-53 was significantly superior to the FDA-approved compound pyridostigmine. Best protection was observed for the oximes K-48 (RR = 0.20), K-27 (RR = 0.23), and obidoxime (RR = 0.21), which were significantly more efficacious than pralidoxime and pyridostigmine. The second-best group of prophylactic compounds consisted of K-74 (RR = 0.26), K-75 (RR = 0.35) and pralidoxime (RR = 0.37), which were significantly more efficacious than pyridostigmine. Pretreatment with K-53 (RR = 0.37) and pyridostigmine (RR = 0.52) was the least efficacious. Our present data, together with previous results on other OPCs, indicate that the experimental oximes K-27 and K-48 are very promising pretreatment compounds. When penetration into the brain is undesirable, obidoxime is the most efficacious prophylactic agent already approved for clinical use.

Five Decades of Global Chemical Terror Attacks: Data Analysis to Inform Training and Preparedness

BACKGROUND

Chemical weapons attacks during the recent conflict in Syria and Iraq highlight the need to better understand the changing epidemiology of chemical weapons use, especially among non-state actors. Public health professionals and policy-makers require this data to prioritize funding, training, chemical weapons preparedness, disaster response, and recovery. The purpose of this investigation is to provide descriptive data that can be used by policy-makers and public safety officials to better prepare for these potential attacks.

METHODS

A five-decade descriptive retrospective review of The Global Terrorism Database, maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism, was conducted to understand trends in chemical agents, targets, and routes of exposure. We reviewed and analyzed data specific to these documented chemical attacks between 1970 and 2017.

RESULTS

383 terror attacks involved chemical weapons over the study period. A specific agent was named in 154 incidents, while 124 incidents could be classified into traditional chemical weapons categories (eg, vesicant, choking agents). A route of exposure was identified in 242 attacks, with the most common routes of exposure being dermal-mucosal and inhalational. Caustic agents were used in the highest portion of attacks (25%) where the route of exposure was known. Explosive devices were used in 21% of attacks to deliver these chemical agents. Of particular note, private citizens and educational facilities were targeted in 25% and 12% of attacks, respectively. The average number of attacks increased from 6 per year between 1970 and 2011 to 24.9 per year between 2011 and 2017 (coinciding with the start of the Syria conflict). The most commonly utilized chemicals were chlorine (26.0%), tear gas (20.8%), and cyanide (15.6%). Blood agent incidents declined from 32.6% before the September 11, 2001 attacks to 13.6% after 2001, while nerve agent attacks fell from 9.3% to 1.2%. In contrast, choking (namely chlorine) and vesicant (mustard) agent use increased from 7% to 48.1% and from 2.3% to 6.2% of attacks, respectively.

CONCLUSIONS

Chemical weapon use in global terrorism remains an increasingly common occurrence that requires better characterization. The average number of chemical terrorist attacks per year is increasing, with a large proportion resulting from the conflicts in Iraq and Syria. Choking (chlorine) and vesicant (mustard) agents have become the predominant chemical terror agent since 2001, with a decreased incidence of blood (cyanogenic) and nerve (sarin) agents. Future preparedness initiatives should focus on vulnerable targets such as private citizens and educational institutions. Improving blast injury response is essential, along with prioritizing disaster training focused on choking agents, vesicants, and caustics.

In vitro evaluation of two different types of obidoxime-loaded nanoparticles for cytotoxicity and blood-brain barrier transport

Nerve agents (NA) are chemical warfare munitions and their exposure causes a progressive inhibition of acetylcholinesterase (AChE). This inhibition causes NA-induced brain damage in central nervous system (CNS). Oximes reactivate AChE in both the peripheral nervous system and the CNS. Transport of the oxime across the blood-brain barrier (BBB) in the existed therapeutic concentrations at the brain parenchyma determines the effectiveness of antidote therapy on respiratory depression and NA-induced brain damage. However, oximes could not cross the BBB in therapeutic concentrations. The aim of this study was to load AChE reactivator obidoxime chloride to PLGA and PEG-b-PLGA nanoparticles and to improve the BBB transport of the molecule. Brain microvascular endothelial cells were used as the BBB model. 79.3 ± 4.2% of obidoxime was released from PLGA nanoparticles and 88.2 ± 4.4% of obidoxime was released from PEG-b-PLGA nanoparticles within 24 h. It was found that PEG-b-PLGA nanoparticles were ideal drug carrier because of its low tissue toxicity, few side effects, and controllable drug release profile. Transport efficiency of obidoxime across the BBB is a major challenge in the prevention of the CNS, the effectiveness of NA poisoning and new strategies like using obidoxime-loaded PEG-b-PLGA nanoparticles could overcome this challenge for the management of NA-induced brain damage.

Combined Pre- and Posttreatment of Paraoxon Exposure

AIMS

Organophosphates (OPCs), useful agents as pesticides, also represent a serious health hazard. Standard therapy with atropine and established oxime-type enzyme reactivators is unsatisfactory. Experimental data indicate that superior therapeutic results can be obtained when reversible cholinesterase inhibitors are administered before OPC exposure. Comparing the protective efficacy of five such cholinesterase inhibitors (physostigmine, pyridostigmine, ranitidine, tacrine, or K-27), we observed best protection for the experimental oxime K-27. The present study was undertaken in order to determine if additional administration of K-27 immediately after OPC (paraoxon) exposure can improve the outcome.

METHODS

Therapeutic efficacy was assessed in rats by determining the relative risk of death (RR) by Cox survival analysis over a period of 48 h. Animals that received only pretreatment and paraoxon were compared with those that had received pretreatment and paraoxon followed by K-27 immediately after paraoxon exposure.

RESULTS

Best protection from paraoxon-induced mortality was observed after pretreatment with physostigmine (RR = 0.30) and K-27 (RR = 0.34). Both substances were significantly more efficacious than tacrine (RR = 0.67), ranitidine (RR = 0.72), and pyridostigmine (RR = 0.76), which were less efficacious but still significantly reduced the RR compared to the no-treatment group (paraoxon only). Additional administration of K-27 immediately after paraoxon exposure (posttreatment) did not further reduce mortality. Statistical analysis between pretreatment before paraoxon exposure alone and pretreatment plus K-27 posttreatment did not show any significant difference for any of the pretreatment regimens.

CONCLUSIONS

Best outcome is achieved if physostigmine or K-27 are administered prophylactically before exposure to sublethal paraoxon dosages. Therapeutic outcome is not further improved by additional oxime therapy immediately thereafter.

Sampling and analyses of surfaces contaminated with chemical warfare agents by using a newly developed triple layered composite wipe

A three-layered composite wipe was fabricated by laminating individual layers of non-woven polypropylene, activated carbon fabric (ACF) and aramid fabric for the sampling and investigation of chemical warfare agents (CWA)-contaminated urban porous and non-porous surfaces. The material of main ACF layer was characterized to ascertain its suitability to act as an efficient adsorbent for the surface wipe sampling. The performance of ACF-based composite wipe was determined by evaluating its extraction efficiency, wiping efficacy and adsorption capacity for the sampling of blister and nerve agent class of CWA-contaminated surfaces using gas chromatography-mass spectrometry (GC-MS). Parameters like amount of wipe required, solvent selection, amount of solvent, time of extraction etc. were optimized to achieve the maximum recovery of contaminating analytes required for the forensic investigations. Overall recoveries of contaminating analytes after sampling and extraction were found to be in the range of 45-85% for all types of surfaces. No breakthrough in wiping process was noticed up to contamination density (CD) 1.6 mg/cm² for non-porous surface and 3.2 mg/cm² for porous surfaces. ACF-based wipe was found capable to significantly reduce the vapour hazards from liquid sulphur mustard (HD) and sarin (GB). Contamination from surfaces could be preserved within the wipe up to 15 days for the extended forensic investigation purposes. Limit of detections (LOD) of contaminants was determined in the range of 0.8-6.8 ng/cm² while limit of quantitation (LOQ) was achieved up to the range of 2.4-14.4 ng/cm² for wipe sampling of different surfaces. Graphical abstract.

Neuropathy target esterase (NTE/PNPLA6) and organophosphorus compound-induced delayed neurotoxicity (OPIDN)

Systemic inhibition of neuropathy target esterase (NTE) with certain organophosphorus (OP) compounds produces OP compound-induced delayed neurotoxicity (OPIDN), a distal degeneration of axons in the central nervous system (CNS) and peripheral nervous system (PNS), thereby providing a powerful model for studying a spectrum of neurodegenerative diseases. Axonopathies are important medical entities in their own right, but in addition, illnesses once considered primary neuronopathies are now thought to begin with axonal degeneration. These disorders include Alzheimer's disease, Parkinson's disease, and motor neuron diseases such as amyotrophic lateral sclerosis (ALS). Moreover, conditional knockout of NTE in the mouse CNS produces vacuolation and other degenerative changes in large neurons in the hippocampus, thalamus, and cerebellum, along with degeneration and swelling of axons in ascending and descending spinal cord tracts. In humans, NTE mutations cause a variety of neurodegenerative conditions resulting in a range of deficits including spastic paraplegia and blindness. Mutations in the Drosophila NTE orthologue SwissCheese (SWS) produce neurodegeneration characterized by vacuolization that can be partially rescued by expression of wild-type human NTE, suggesting a potential therapeutic approach for certain human neurological disorders. This chapter defines NTE and OPIDN, presents an overview of OP compounds, provides a rationale for NTE research, and traces the history of discovery of NTE and its relationship to OPIDN. It then briefly describes subsequent studies of NTE, including practical applications of the assay; aspects of its domain structure, subcellular localization, and tissue expression; abnormalities associated with NTE mutations, knockdown, and conventional or conditional knockout; and hypothetical models to help guide future research on elucidating the role of NTE in OPIDN.

Novichok agents: a historical, current, and toxicological perspective

The Novichok, or “newcomer” class of nerve agents are lesser characterized, weaponized organophosphate agents. The use of known Novichok agents in warfare is banned under the Chemical Weapons Convention of 1997. Novichok agents are considered more potent than VX gas and can be applied in unitary and binary forms. Like other nerve agents, Novichok agents irreversibly bind acetylcholinesterase and produce a cholinergic toxidrome. Uniquely, these agents are thought to also target neurons in the peripheral nervous system. Delayed treatment or massive exposure may therefore cause a debilitating neuropathy. The recent 2018 assassination attempt of Russian dissident Sergei Skripal and his daughter Yulia in the United Kingdom highlights the importance of recognizing the potential lethal effects of these nerve agents. Treatment of Novichok agent poisoning is similar to management of other nerve agents. Given increasing worldwide incidents attributed to chemical weapons such as Novichok agents, clinicians should know how to rapidly recognize symptoms of acute poisoning and administer life-saving antidotal therapy, when indicated.