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

Author: 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
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; 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
Contributor Information and Disclosures

Updated: Dec 19, 2007

Follow-up

Further Inpatient Care

  • 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.

Further Outpatient Care

  • 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.

Inpatient & Outpatient Medications

  • 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.

Transfer

  • 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.

Complications

  • Patients with status epilepticus or hypoxemia may experience anoxic brain injury.

Prognosis

  • 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

Miscellaneous

Medicolegal Pitfalls

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

Special Concerns

  • Information regarding nerve agents has been gathered mainly from accidental exposures or volunteer studies in military personnel. No experience is available on the difference in effects or outcome for special populations such as pregnant, pediatric, or geriatric populations.
 


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Treatment & Medication: CBRNE - Nerve Agents, Binary: GB2, VX2
Follow-up: CBRNE - Nerve Agents, Binary: GB2, VX2
Multimedia: CBRNE - Nerve Agents, Binary: GB2, VX2
References
Further Reading
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Further Reading

For a discussion about Novichok agents, see Chemical Weapons Disarmament in Russia: Problems and Prospects.

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Keywords

nerve agents, binary agents, GB2, VX2, sarin, chemical warfare, acetylcholinesterase inhibitors, AChE inhibitors, GA, tabun, GD, soman, chemical weapons, GB, VX, GD2, acetylcholine, cholinergic overstimulation, organophosphate, carbamate, pralidoxime chloride, Protopam, 2-PAM, anticholinergics, oximes, AChE reactivator, muscarinic receptor

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Contributor Information and Disclosures

Author

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.

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.

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.

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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