eMedicine Specialties > Emergency Medicine > Warfare - Chemical, Biological, Radiological, Nuclear and Explosives

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

Author: Daniel C Keyes, MD, MPH, Director of Terrorism Response Education, John Peter Smith Hospital; Clinical Associate Professor, Department of Surgery, Division of Emergency Medicine and Toxicology, University of Texas Southwestern School of Medicine
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; 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
Contributor Information and Disclosures

Updated: Dec 19, 2007

Follow-up

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.

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.

Inpatient & Outpatient Medications

  • Generally, none are needed.

Complications

  • Patients with status epilepticus may suffer from anoxic brain injury.

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.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Careful documentation of physical findings, response to treatment, and laboratory parameters is important.
    • In a terrorist attack, any evidence collected can be used to prosecute the perpetrators.
    • In occupational accidents, data are needed to make recommendations for follow-up care and for determining dates for possible return to work. Documentation of an occupational exposure to a nerve agent such as VX also helps to improve safety in the workplace.

Special Concerns

  • Special concerns (pregnant, pediatric, geriatric): Information from nerve agents has been gathered mainly from accidental exposures or volunteer studies in military personnel. Little information exists regarding effects or outcome for children or other special populations.
 


More on CBRNE - Nerve Agents, V-series: Ve, Vg, Vm, Vx

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Differential Diagnoses & Workup: CBRNE - Nerve Agents, V-series: Ve, Vg, Vm, Vx
Treatment & Medication: CBRNE - Nerve Agents, V-series: Ve, Vg, Vm, Vx
Follow-up: CBRNE - Nerve Agents, V-series: Ve, Vg, Vm, Vx
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References
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References

  1. Marrs TC, Maynard RL, Sidell FR. Chemical Warfare Agents: Toxicology and Treatment. England: John Wiley and Sons; 1996.

  2. Abou-Donia MB. Organophosphorus ester-induced chronic neurotoxicity. Arch Environ Health. Aug 2003;58(8):484-97. [Medline].

  3. Bajgar J, Kuca K, Fusek J, Karasova J, Kassa J, Cabal J. Inhibition of blood cholinesterases following intoxication with VX and its derivatives. J Appl Toxicol. Sep-Oct 2007;27(5):458-63. [Medline].

  4. Baker MD. Antidotes for nerve agent poisoning: should we differentiate children from adults?. Curr Opin Pediatr. Apr 2007;19(2):211-5. [Medline].

  5. Bowers MB Jr, Goodman E, Sim VM. Some behavioral changes in man following anticholinesterase administration. J Nerv Ment Dis. Apr 1964;138:383-9. [Medline].

  6. Chilcott RP, Dalton CH, Hill I. In vivo skin absorption and distribution of the nerve agent VX (O-ethyl-S-[2(diisopropylamino)ethyl]methylphosphonothioate) in the domestic white pig. Hum Exp Toxicol. Jul 2005;24(7):347-52. [Medline].

  7. Corvino TF, Nahata MC, Angelos MG, Tschampel MM, Morosco RS, Zerkle J. Availability, stability, and sterility of pralidoxime for mass casualty use. Ann Emerg Med. Mar 2006;47(3):272-7. [Medline].

  8. Cresthull P, Konn WS, Musselman NP. Percutaneous exposure of the arm or the forearm of a man to VX vapor. CRDLR 3176. 1963.

  9. Dunn MA, Sidell FR. Progress in medical defense against nerve agents. JAMA. Aug 4 1989;262(5):649-52. [Medline].

  10. Foltin G, Tunik M, Curran J, Marshall L, Bove J, van Amerongen R. Pediatric nerve agent poisoning: medical and operational considerations for emergency medical services in a large American city. Pediatr Emerg Care. Apr 2006;22(4):239-44. [Medline].

  11. Freeman G, Ludamann H, Cornblath M. Cardiovascular and respiratory effects of an acute parathion poisoning in dogs with particular regard to ventricular fibrillation. Medical Laboratory Research Report 303. AD042287. 1954.

  12. Hamilton MG, Hill I, Conley J. Clinical aspects of percutaneous poisoning by the chemical warfare agent VX:effects of application site and decontamination. Mil Med. Nov 2004;169(11):856-62. [Medline].

  13. Harris LW, Stitcher DL. Reactivation of VX-inhibited cholinesterase by 2-PAM and HS-6 in rats. Drug Chem Toxicol. 1983;6(3):235-40. [Medline].

  14. Henderson JD, Higgins RJ, Dacre JC, Wilson BW. Neurotoxicity of acute and repeated treatments of tabun, paraoxon, diisopropyl fluorophosphate and isofenphos to the hen. Toxicology. 1992;72(2):117-29. [Medline].

  15. Kales SN, Christiani DC. Acute chemical emergencies. N Engl J Med. Feb 19 2004;350(8):800-8. [Medline].

  16. Keyes DC, Burstein JL, Schwartz RC, Swienton R. Medical Response to Terrorism: Preparedness and Clinical Practice. 2004:449.

  17. Kimura KK, McNamara BP, Sim VM. Intravenous administration of VX in man. CRDLR 3017. 1960.

  18. Kuca K, Jun D, Bajgar J. Currently used cholinesterase reactivators against nerve agent intoxication: comparison of their effectivity in vitro. Drug Chem Toxicol. 2007;30(1):31-40. [Medline].

  19. Kunkel AM, O'Leary JF, Jones AH. Atropine-induced ventricular fibrillation during cyanosis caused by organophosphorus poisoning. AD758441. Edgewood Arsenal Technical Report 4711. 1973.

  20. LeBlanc FN, Benson BE, Gilg AD. A severe organophosphate poisoning requiring the use of an atropine drip. J Toxicol Clin Toxicol. 1986;24(1):69-76. [Medline].

  21. Lubash GD, Clark BJ. Some metabolic studies in humans following percutaneous exposure to VX. CRDLR 3033. 1960.

  22. Marrs TC, Rice P, Vale JA. The role of oximes in the treatment of nerve agent poisoning in civilian casualties. Toxicol Rev. 2006;25(4):297-323. [Medline].

  23. McDonough JH, McLeod CG, Nipwoda MT. Direct microinjection of soman or VX into the amygdala produces repetitive limbic convulsions and neuropathology. Brain Res. Dec 1 1987;435(1-2):123-37. [Medline].

  24. Newmark J. The birth of nerve agent warfare: lessons from Syed Abbas Foroutan. Neurology. May 11 2004;62(9):1590-6. [Medline].

  25. Newmark J. Therapy for nerve agent poisoning. Arch Neurol. May 2004;61(5):649-52. [Medline].

  26. Newmark J, Hurst CG. Acute chemical emergencies. N Engl J Med. May 13 2004;350(20):2102-4; author reply 2102-4. [Medline].

  27. Nozaki H, Aikawa N, Fujishima S, et al. A case of VX poisoning and the difference from sarin. Lancet. Sep 9 1995;346(8976):698-9. [Medline].

  28. Oberst FW, Ross RS, Christensen MK. Resuscitation of dogs poisoned by inhalation of the nerve gas GB. Mil Med. 1956;119:377-386.

  29. Okudera H. Clinical features on nerve gas terrorism in Matsumoto. J Clin Neurosci. Jan 2002;9(1):17-21. [Medline].

  30. Okumura T, Suzuki K, Fukuda A, et al. The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response. Acad Emerg Med. Jun 1998;5(6):613-7. [Medline].

  31. Parker RM, Crowell JA, Bucci TJ. Negative delayed neuropathy study in chickens after treatment with isopropyl methylphosphonofluoridate (sarin, type 1). Toxicologist. 1988;8:248.

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

  33. Robineau P, Guittin P. Effects of an organophosphorous compound on cardiac rhythm and haemodynamics in anaesthetized and conscious beagle dogs. Toxicol Lett. Jun 1987;37(1):95-102. [Medline].

  34. Schier JG, Ravikumar PR, Nelson LS, Heller MB, Howland MA, Hoffman RS. Preparing for chemical terrorism: stability of injectable atropine sulfate. Acad Emerg Med. Apr 2004;11(4):329-34. [Medline].

  35. Shih TM, Rowland TC, McDonough JH. Anticonvulsants for nerve agent-induced seizures: The influence of the therapeutic dose of atropine. J Pharmacol Exp Ther. Jan 2007;320(1):154-61. [Medline].

  36. Sidell FR. Clinical considerations in nerve agent intoxication. In: Somani SM, ed. Chemical Warfare Agents. San Diego: Harcourt Brace Jovanovich; 1992.

  37. Sidell FR. Human responses to intravenous VX. EATR 4082. 1967.

  38. Sidell FR. Soman and sarin: clinical manifestations and treatment of accidental poisoning by organophosphates. Clin Toxicol. 1974;7(1):1-17. [Medline].

  39. Sidell FR, Groff WA. The reactivatibility of cholinesterase inhibited by VX and sarin in man. Toxicol Appl Pharmacol. Feb 1974;27(2):241-52. [Medline].

  40. Sim VM. Variability of different intact human skin sites to the penetration of VX. CRDLR 3122. AD271163. 1962.

  41. Sim VM, Stubbs JL. VX percutaneous studies in man. CRDLR 3015. AD318533. 1960.

  42. Tokuda Y, Kikuchi M, Takahashi O, Stein GH. 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].

  43. Volans GN, Karalliedde L. Long-term effects of chemical weapons. Lancet. Dec 2002;360 Suppl:s35-6. [Medline].

  44. Wills JH, DeArmon IA. A statistical study of the Ademek report. Medical Laboratory Special Report 54. AD045106.

  45. Wright PG. An analysis of the central and peripheral components of respiratory failure produced by anticholinesterase poisoning in the rabbit. J Physiol. Oct 28 1954;126(1):52-70. [Medline].

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Further Reading

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Keywords

persistent agents, G agents, VX, O-ethyl S-(2-diisopropylaminoethyl) methylphosphonothioate, nerve agents, chemical warfare, V-series agents, Vx, Ve, Vg, Vm, V-series weapons, V agents

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Contributor Information and Disclosures

Author

Daniel C Keyes, MD, MPH, Director of Terrorism Response Education, John Peter Smith Hospital; 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.

Medical Editor

Fred Henretig, MD, Medical Director, Delaware Valley Regional Poison Control Center, Departments of Emergency Medicine and Pediatrics, Director, Section of Clinical Toxicology, Professor, University of Pennsylvania School of Medicine, Children's Hospital
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

CME Editor

John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School
John Halamka, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP, Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; 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, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

 
 
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