CBRNE - Nerve Agents, G-series - Tabun, Sarin, Soman Follow-up

  • Author: Kermit D Huebner, MD, FACEP; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Apr 18, 2011
 

Further Inpatient Care

  • Severely poisoned patients in respiratory arrest may need ventilatory assistance for several hours despite aggressive antidotal therapy. Patients in critical condition caused by complications of nerve agent poisoning, such as hypoxic brain injury, may require prolonged intensive care.
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Further Outpatient Care

Toxic effects of GB usually peak within minutes to hours and resolve within 24 hours. Patients who inhale nerve agent vapor suffer peak toxic effects before arriving in the ED. Patients who present to the ED with only ocular findings following vapor exposure can be discharged home safely. Refer patients discharged home with miosis or other eye complaints to an ophthalmologist.

Onset of signs and symptoms in patients with dermal exposure to liquid GB may be delayed for as long as 18 hours. Observe these patients in the ED or hospital for at least 18 hours. As discussed in Lab Studies, RBC or plasma cholinesterase activity alone never should determine disposition and always must be correlated with the patient's clinical status.

A variety of neurobehavioral symptoms may persist in patients exposed to nerve agents. Such patients may benefit from neurologic consultation.

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Transfer

  • Transfer patients only after performing appropriate decontamination and appropriately addressing the need for an airway and ventilation.
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Complications

  • Little data are available describing long-term effects of nerve agent exposure.
  • Structural brain damage in animals has been attributed to nerve agent–induced seizures. A consensus panel of experts concluded that structural brain damage does not occur until seizures have lasted longer than 45 minutes.
  • Miosis-related visual problems in dim light and mental lapses have been reported as long as 6-8 months after nerve agent exposure.
  • Some information about long-term sequelae has emerged from studies of victims of the Tokyo Subway GB attack.[13] Postural imbalance has been reported 8 months after exposure to GB. Fatigue, asthenia, nausea, shoulder stiffness, and blurred vision have been reported 3 years after exposure to GB.[14]
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Prognosis

  • Patients who survive nerve agent exposure have a good prognosis.
  • A study by Chao et al examined long-term effects of sarin exposure on brain function in 40 soldiers with suspected exposure.[15] No cognitive effects were noted.
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Patient Education

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Contributor Information and Disclosures
Author

Kermit D Huebner, MD, FACEP  Research Director, Carl R Darnall Army Medical Center

Kermit D Huebner, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, Association of Military Surgeons of the US, Society for Academic Emergency Medicine, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey L Arnold, MD, FACEP  Chairman, Department of Emergency Medicine, Santa Clara Valley Medical Center

Jeffrey L Arnold, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Fred Henretig, MD  Director, Section of Clinical Toxicology, Professor, Medical Director, Delaware Valley Regional Poison Control Center, Departments of Emergency Medicine and Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

References

  1. Holstege CP, Kirk M, Sidell FR. Chemical warfare. Nerve agent poisoning. Crit Care Clin. Oct 1997;13(4):923-42. [Medline].

  2. Sidell FR. Nerve agents. In: Medical Aspects of Chemical and Biological Warfare. 1987:129-179.

  3. Kato T, Hamanaka T. Ocular signs and symptoms caused by exposure to sarin gas. Am J Ophthalmol. Feb 1996;121(2):209-10. [Medline].

  4. Nozaki H, Hori S, Shinozawa Y, et al. Relationship between pupil size and acetylcholinesterase activity in patients exposed to sarin vapor. Intensive Care Med. Sep 1997;23(9):1005-7. [Medline].

  5. Rickett DL, Glenn JF, Beers ET. Central respiratory effects versus neuromuscular actions of nerve agents. Neurotoxicology. Spring 1986;7(1):225-36. [Medline].

  6. Nakajima T, Sato S, Morita H, Yanagisawa N. Sarin poisoning of a rescue team in the Matsumoto sarin incident in Japan. Occup Environ Med. Oct 1997;54(10):697-701. [Medline].

  7. Okumura T, Takasu N, Ishimatsu S, et al. Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med. Aug 1996;28(2):129-35. [Medline].

  8. Sidell FR, Borak J. Chemical warfare agents: II. Nerve agents. Ann Emerg Med. Jul 1992;21(7):865-71. [Medline].

  9. Tokuda Y, Kikuchi M, Takahashi O. Prehospital management of sarin nerve gas terrorism in urban settings: 10 years of progress after the Tokyo subway sarin attack. Resuscitation. Feb 2006;68(2):193-202. [Medline].

  10. National Center for Disaster Preparedness. Atropine Use in Children After Nerve Gas Exposure. Pediatric Expert Advisory Panel (PEAP) Info Brief. Spring 2004;1:[Full Text].

  11. McDonough JH. Midazolam: An Improved Anticonvulsant Treatment for Nerve Agent Induced Seizures. Defense Technical Information Center. JAN 2002;[Full Text].

  12. Dunn MA, Hackley BE, Sidell FR. Pretreatment for nerve agent exposure. In: Medical Aspects of Chemical and Biological Warfare. 1987:181-196.

  13. Yokoyama K, Araki S, Murata K, et al. A preliminary study on delayed vestibulo-cerebellar effects of Tokyo Subway Sarin Poisoning in relation to gender difference: frequency analysis of postural sway. J Occup Environ Med. Jan 1998;40(1):17-21. [Medline].

  14. Nakajima T, Ohta S, Fukushima Y, Yanagisawa N. Sequelae of sarin toxicity at one and three years after exposure in Matsumoto, Japan. J Epidemiol. Nov 1999;9(5):337-43. [Medline].

  15. Chao LL, Rothlind JC, Cardenas VA, Meyerhoff DJ, Weiner MW. Effects of low-level exposure to sarin and cyclosarin during the 1991 Gulf War on brain function and brain structure in US veterans. Neurotoxicology. Sep 2010;31(5):493-501. [Medline]. [Full Text].

 
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Chemical Terrorism Agents and Syndromes. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/chemical.html.
 
 
 
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