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CBRNE - Nerve Agents, Binary - GB2, VX2 Follow-up

  • Author: Larissa I Velez-Daubon, MD; Chief Editor: Duane C Caneva, MD, MSc  more...
Updated: Apr 28, 2015

Further Outpatient Care

See the list below:

  • Patients who are discharged from the hospital do not usually require further instructions or care. Nerve agents have not been associated with organophosphate-induced delayed neuropathy. Advise patients with miosis not to drive at night until their visual deficit resolves, which may take several weeks.
  • Posttraumatic stress disorder is common after terrorist events; patients may need a psychiatric evaluation or referral.

Further Inpatient Care

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  • Admit all patients with liquid exposures for observation, even if initially asymptomatic. Onset of symptoms with these exposures may be delayed as long as 18 hours.
  • After a vapor exposure with only minimal symptoms, the patient can usually be discharged home.
  • Admit patients who have more than simple miosis for observation and further inpatient care.

Inpatient & Outpatient Medications

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  • The cornerstone of management is the early use of antidotes (atropine and pralidoxime). No evidence supports the use of long-term therapy after the acute phase is over.


See the list below:

  • Prompt delivery of antidotes is of foremost importance in these patients. Transfer to a higher level of care facility may be arranged after decontamination, antidote administration, and stabilization of the patient.


See the list below:

  • Patients with status epilepticus or hypoxemia may experience anoxic brain injury.
  • Delayed or insufficient use of pralidoxime can lead to protracted muscle weakness.


See the list below:

  • If patients recover from the acute effects of the exposure, chronic effects are generally not expected. 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 experienced anoxia during the acute phase of the poisoning.

Patient Education

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Contributor Information and Disclosures

Larissa I Velez-Daubon, MD Professor, Program Director, Department of Surgery, Division of Emergency Medicine, University of Texas Southwestern Medical School, Parkland Memorial Hospital; 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 Medical Toxicology, Society for Academic Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.


Daniel C Keyes, MD, MPH Associate Chair, Academic Affairs, Department of Emergency Medicine, St Joseph Mercy Hospital; Clinical Faculty, Emergency Medicine Residency, University of Michigan Medical School; 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, American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

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, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Duane C Caneva, MD, MSc Senior Medical Advisor to Customs and Border Protection, Department of Homeland Security (DHS) Office of Health Affairs; Federal Co-Chair, Health, Medical, Responder Safety Subgroup, Interagency Board (IAB)

Disclosure: Nothing to disclose.

Additional Contributors

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.

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

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

  3. Sidell FR. Clinical considerations in nerve agent intoxications. Chemical Warfare Agents. San Diego, CA: Academic Press, Inc; 1992.

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

  5. Borbely AA, Tunod U, Hopft W. Studies on the protective action of atropine and obidoxime against sarin poisoning in mice. Cholinergic Mechanisms. Philadelphia, Pa: Lippincott-Raven; 1975.

  6. Christensen MK, Crethull P, Crook JW, et al. Resuscitation of dogs poisoned by inhalation of the nerve gas GB. Mil Med. 1956 Dec. 119(6):377-86. [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. 2006 Mar. 47(3):272-7. [Medline].

  8. Department of the Army. Binary chemical munitions program. Programmatic Environmental Impact Statement ARCSL-EIS-8101. 1981:1-7.

  9. 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. 2006 Apr. 22(4):239-44. [Medline].

  10. Freeman G, Marzulli FN, Craig AB. The toxicity of liquid GB applied to the skin of man. MLRR. 1954:217.

  11. Grob D, Harvey AM. The effects and treatment of nerve gas poisoning. Am J Med. 1953 Jan. 14(1):52-63. [Medline].

  12. Harris LW, Fleisher JH, Clark J, Cliff WJ. Dealkylation and loss of capacity for reactivation of cholinesterase inhibited by sarin. Science. 1966 Oct 21. 154(747):404-7. [Medline].

  13. 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].

  14. Inns RH, Leadbeater L. The efficacy of bispyridinium derivatives in the treatment of organophosphonate poisoning in the guinea-pig. J Pharm Pharmacol. 1983 Jul. 35(7):427-33. [Medline].

  15. Keim ME, Pesik N, Twum-Danso NA. Lack of hospital preparedness for chemical terrorism in a major US city: 1996-2000. Prehospital Disaster Med. 2003 Jul-Sep. 18(3):193-9. [Medline].

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

  17. Lallement G, Clarencon D, Masqueliez C, et al. Nerve agent poisoning in primates: antilethal, anti-epileptic and neuroprotective effects of GK-11. Arch Toxicol. 1998. 72(2):84-92. [Medline].

  18. 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].

  19. Lee EC. Clinical manifestations of sarin nerve gas exposure. JAMA. 2003 Aug 6. 290(5):659-62. [Medline].

  20. Marrs TC. The role of diazepam in the treatment of nerve agent poisoning in a civilian population. Toxicol Rev. 2004. 23(3):145-57. [Medline].

  21. Marrs TC. Toxicology of oximes used in treatment of organophosphate poisoning. Adverse Drug React Toxicol Rev. 1991. 10(1):61-73. [Medline].

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

  23. Mitretek Systems. Binary Chemical Weapons. Noblis. Available at

  24. Newmark J. Nerve agents: pathophysiology and treatment of poisoning. Semin Neurol. 2004 Jun. 24(2):185-96. [Medline].

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

  26. Nozaki H, Hori S, Shinozawa Y, et al. Secondary exposure of medical staff to sarin vapor in the emergency room. Intensive Care Med. 1995 Dec. 21(12):1032-5. [Medline].

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

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

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

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

  31. Rotenberg JS. Diagnosis and management of nerve agent exposure. Pediatr Ann. 2003 Apr. 32(4):242-50. [Medline].

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

  33. Secretariat of the Organisation for the Prohibition of Chemical Weapons. Nerve Agents. ICA Division, OPCW. Organisation for the Prohibition of Chemical Weapons. Available at

  34. Sidell FR. Nerve agents. Textbook of Military Medicine. Washington, DC: TMM Publications; 1997.

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

  36. Sim VM. Variability of different intact human skin sites to the penetration of VX. CRDL Report 3122. 1962.

  37. Sim VM, Stubbs JL. VX percutaneous studies in man. CRDL Report 3015. 1960.

  38. Smart JK. History of Chemical and Biological Warfare Fact Sheets. 1996.

  39. Somani SM, Solana RP, Dube SN. Toxicodynamics of nerve agents. Chemical Warfare Agents. San Diego, CA: Academic Press Inc; 1992.

  40. Thiermann H, Szinicz L, Eyer P, Felgenhauer N, Zilker T, Worek F. Lessons to be learnt from organophosphorus pesticide poisoning for the treatment of nerve agent poisoning. Toxicology. 2007 Apr 20. 233(1-3):145-54. [Medline].

  41. 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. 2006 Feb. 68(2):193-202. [Medline].

  42. Ward FP. Construction and Operation of a 155-mm M687 GB2 Binary Production Facility at Pine Buff Arsenal, Jefferson County, Arkansas. Environmental Assessment ARCSL-EA-8101. 1981:3-7.

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

  44. Worek F, Eyer P, Aurbek N, Szinicz L, Thiermann H. Recent advances in evaluation of oxime efficacy in nerve agent poisoning by in vitro analysis. Toxicol Appl Pharmacol. 2007 Mar. 219(2-3):226-34. [Medline].

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

  46. Young D. CDC rolls out nerve-agent antidote program. Am J Health Syst Pharm. 2004 Sep 15. 61(18):1866-8, 1875. [Medline].

Table 1. Toxicity of Nerve Agents
AgentChemical NameLCt50, mgXmin/m3LD50,


GAEthyl N -dimethylphosphoramidocyanidate4001000
GBIsopropyl methylphosphonofluoridate1001700
GDPinacolyl methylphosphonofluoridate50100
VXO-Ethyl S-2-diisopropylaminoethyl methylphosphonothioate1010
Table 2. Severity of Toxicity From Liquid and Vapor Exposures
Severity of ExposureSigns and Symptoms - Liquid*Signs and Symptoms - Vapor†
MinimalLocalized sweating at site

Localized fasciculations at site



Slight dyspnea

ModerateAbove-mentioned symptoms and the following:

Nausea, vomiting, and diarrhea

Generalized weakness

Above-mentioned symptoms and the following:

Moderate-to-marked dyspnea

(bronchorrhea and/or bronchoconstriction)

SevereAbove-mentioned symptoms and the following:

Loss of consciousness


Generalized fasciculations

Flaccid paralysis and apnea

Above-mentioned symptoms and the following:

Loss of consciousness


Generalized fasciculations

Flaccid paralysis and apnea

* Onset possibly delayed

† Rapid onset of symptoms

Table 3. Drugs Used to Treat Patients With Nerve Agent Poisoning*
DrugDose (Adult)RouteIndicationsContraindications
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.
Pralidoxime chloride (Protopam, 2-PAM)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; may worsen symptoms in carbamate poisoning
Diazepam (Valium)2-5 mg IV

10 mg IM

IV/IMModerate or severe signs of poisoning, seizuresNone
*Adapted from Sidell, 1992.[3]
Table 4. Summary of Treatment Modalities According to Severity of Exposure*
Severity/Route of ExposureAtropine (Adult Dose)PralidoximeDiazepamOther
SuspectedNoNoNoDecontamination and 18-h observation for liquid exposures
Mild2 mg for severe

rhinorrhea or

dyspnea; may be


Administer if dyspnea

is not improving

or if GI

symptoms occur

NoDecontamination and 18-h observation for liquid exposures; oxygen
Moderate6 mg; may need to repeatAdminister 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 seizuresAirway, breathing, and circulation; decontamination
*Adapted from Sidell, 1992.[3]
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