The Japanese medical literature describes the standard treatment for sarin toxicity as (A) maintain the airway, (B) assist breathing, and (C) support circulation. However, in the Matsumoto sarin attack, endotracheal intubation was more difficult in many victims because of airway hypersecretion and bronchospasm. This difference in symptoms is attributable to the higher 70% concentration and active means by which the sarin was dispersed at Matsumoto, as opposed to the 33% concentration and passive means of dispersal employed in Tokyo. Dr Fredrick Sidell (now deceased), an expert on chemical terrorism in the USA, advocated decontamination, drugs, airway, breathing, and circulation (DDABC) as the basic treatment for nerve agent poisoning. Even if the so-called ABCs of emergency treatment are followed, initial efforts to achieve adequate ventilation may be in vain. Efforts to achieve adequate ventilation should be made after at least initial administration of atropine to control airway secretions and bronchoconstriction ( Sidell, 1997). If healthcare professionals learn from the Matsumoto attack, they can better recognize early parasympathetic nervous symptoms, including miosis, hypersecretion, and rhinorrhea as common symptoms of chemical terrorism due to nerve agents and institute appropriate treatment with antidotes. In large-scale disasters with many victims, treatment is often deferred in those with cardiopulmonary arrest (so-called “black tag”). However, at St Luke's Hospital, one in three persons with cardiopulmonary arrest and two patients with respiratory arrest made a full recovery and were discharged. This high rate of recovery and return to the community is unlike that seen in other types of disasters. Therefore, if medical resources are available, all victims of a sarin attack should be aggressively treated, including cardiopulmonary resuscitation (CPR) when necessary. The global standard for the treatment of sarin toxicity is the administration of: (1) atropine, (2) an oxime agent like PAM, and (3) diazepam ( Medical Letter, 2002).

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