CBRNE - Nerve Agents, V-series - Ve, Vg, Vm, Vx Follow-up

  • Author: Daniel C Keyes, MD, MPH; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Mar 16, 2010
 

Further Inpatient Care

Admit patients with liquid exposures for observation after completion of proper decontamination. Onset of symptoms with these exposures has been observed to be delayed as long as 18 hours. This differs from vapor exposures, in which the symptoms have an almost immediate onset. In a patient with a vapor exposure and only minimal symptoms, the patient usually can be discharged home.

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Further Outpatient Care

Patients who are discharged from the hospital generally do not require further care. Nerve agents have not been associated with organophosphate-induced delayed neuropathy. Advise patients with miosis not to drive at night until this symptom resolves.

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Inpatient & Outpatient Medications

Generally, none are needed.

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Complications

Patients with status epilepticus may suffer from anoxic brain injury.

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Prognosis

If patients recover from the acute effects of exposure, chronic effects should not occur. Subtle behavioral and cognitive changes have been noted to persist for days to weeks after the initial exposure. Patients may have permanent sequelae if they suffered from anoxia during the acute phase of poisoning.

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Patient Education

For excellent patient education resources, visit eMedicine's Bioterrorism and Warfare Center. Also, see eMedicine's patient education articles Chemical Warfare and Personal Protective Equipment.

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Contributor Information and Disclosures
Author

Daniel C Keyes, MD, MPH  Vice Chair, Academic Affairs, Department of Emergency Medicine, John Peter Smith Health Network; Clinical Associate Professor, Department of Surgery, Division of Emergency Medicine and Toxicology, University of Texas Southwestern School of Medicine

Daniel C Keyes, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, and American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Fernando L Benitez, MD  Assistant Medical Director, Dallas Metropolitan BioTel (EMS) System; Associate Professor in Emergency Medicine, Department of Surgery, Division of Emergency Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital

Fernando L Benitez, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and National Association of EMS Physicians

Disclosure: Nothing to disclose.

Larissa I Velez-Daubon, MD  Associate Professor, Associate Program Director, Department of Surgery, Division of Emergency Medicine, University of Texas Southwestern Medical School, Parkland Memorial Hospital; Associate Program Director and Staff Toxicologist, Department of Surgery, Division of Emergency Medicine, North Texas Poison Center, Parkland Memorial Hospital

Larissa I Velez-Daubon, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

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  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.

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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.
Table 1. Code and Chemical Names for the V-Series Agents
Code NameChemical Name
VXO-Ethyl-S-[2(diisopropylamino)ethyl] methylphosphonothioate
VEO-Ethyl-S-[2-(diethylamino)ethyl] ethylphosphonothioate
VGO,O-Diethyl-S-[2-(diethylamino)ethyl] phosphorothioate
VMO-Ethyl-S-[2-(diethylamino)ethyl] methylphosphonothioate
V-gasRussian equivalent of VX
Table 2
AgentLCt50 (mg·min/m3)LD50 (mg)Aging Half-Life
Tabun (GA)400100046 h
Sarin (GB)10017005.2-12 h
Soman (GD)5010040 sec to 10 min
VX101050-60 h
Table 3. Pharmacologic Effects of Nerve Agents*
Receptor InvolvedClinical Effect
Acetylcholine, GABA, N -methyl-D -aspartate: Central (CNS)Anxiety, restlessness, seizures, failure to concentrate, depression, coma, apnea
Acetylcholine: Muscarinic



Postganglionic parasympathetic



"DUMBELS" (commonly used mnemonic)



D - Diarrhea



U - Urination



M - Miosis



B - Bronchorrhea, bronchoconstriction



E - Emesis



L - Lacrimation



S - Salivation



Note: The other commonly used mnemonic "SLUDGE" is not used here, as it does not include an important sign and symptom: bronchorrhea and bronchoconstriction.



Acetylcholine: Nicotinic



Motor endplate



Sympathetic and parasympathetic ganglia



Pallor, tachycardia, hypertension, muscle weakness and/or paralysis, fasciculations



Note: Some use the days of the week as an easy mnemonic for these:



M - Mydriasis



T - Tachycardia



W - Weakness



tH - Hypertension



F - Fasciculations



* Adapted from Marrs, Maynard, and Sidell.[1]
Table 4. Severity of Toxicity from Liquid and Vapor Exposures
Severity of ExposureSigns and Symptoms - LiquidSigns and Symptoms - Vapor
Onset of symptomsPossibly delayed toxicityRapidly manifesting toxicity
MinimalLocalized sweating at site



Localized fasciculations at site



Miosis



Rhinorrhea



Mild dyspnea



ModerateFasciculations



Diaphoresis



Nausea, vomiting, and diarrhea



Generalized weakness



Above symptoms and the following:



Moderate-to-marked dyspnea (bronchorrhea and/or bronchoconstriction)



SevereAbove symptoms and the following:



Loss of consciousness



Seizures



Generalized fasciculations



Flaccid paralysis and apnea



Above symptoms and the following:



Loss of consciousness



Seizures



Generalized fasciculations



Flaccid paralysis and apnea



Table 5. Drugs Used to Treat Nerve Agent–Poisoned Patients*
DrugDoseRouteIndicationsContraindications
Atropine2 mg q5-10min prn



Note: the Mark 1 kit contains 2 mg of atropine



IV/IM/ETTExcessive muscarinic symptomsRelative - IV route in hypoxia has been associated with ventricular fibrillation
2-PAM Cl (pralidoxime chloride, Protopam)15-25 mg/kg over 20 min; can be repeated after 1 h



Note: The Mark 1 kit contains 600 mg of pralidoxime.



IV/IMSymptomatic nerve agent poisoningRapid infusion may result in hypertension
Diazepam (Valium)2-5 mg IV or 10 mg IMIV/IMActive seizures; administer as prophylaxis if moderate or severe signs of poisoning are presentNone
*Adapted from Sidell.
Table 6. Summary of Treatment Modalities According to Severity of Exposure*
Severity/Route of ExposureAtropine2-PAM ClDiazepamOther
SuspectedNoNoNoDecontamination and 18-h observation for liquid exposures
Mild2 mg for severe rhinorrhea or dyspnea; may repeat prnAdminister if patient has nonimproving dyspnea or GI symptomsNoDecontamination and 18-h observation for liquid exposures; oxygen
Moderate6 mg; may require repeat dosesAdminister with atropineAdminister even in absence of seizuresDecontamination, oxygen
SevereStart with 6 mg; may need to repeatAdminister with atropine; should repeat once or twiceAdminister even in absence of seizuresABCs, decontamination
*Adapted from Sidell.
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