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CBRNE - Nerve Agents, Binary - GB2, VX2 Treatment & Management

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

Prehospital Care

Keep in mind that rescue personnel may themselves become affected by nerve agents. The cornerstones of prehospital management are based on rapid termination of exposure (ie, evacuation and decontamination), treatment of life-threatening emergencies, and administration of antidotes, if available. Whenever possible, decontamination should take place prior to transportation of the patient to a clean area. This prevents cross-contamination and additional exposures.

  • Decontamination techniques vary according to the extent and route of exposure.
    • After exposure to any toxic vapor, evacuation and provision of fresh air is the most important first step. Clothes should be removed, since they can trap enough vapor to cause secondary victims. In the Tokyo subway attack, 10% of the caregivers at the hospital developed miosis after exposure to nondecontaminated victims.
    • In dermal exposures, the patient should be undressed. Any visible droplets should be blotted away. Abrasion of the skin by vigorous scrubbing increases absorption of the agent and should be avoided. Nerve agents can be neutralized with alkaline solutions such as soap and water or 0.5% hypochlorite solution (which releases chlorine), followed by a water rinse. However, decontamination should not be delayed to seek hypochlorite or other special solutions; copious water is generally good enough for decontamination.
  • The military has autoinjector kits (MARK 1) that contain 2 antidotes, an oxime (AChE reactivator) and atropine. Some ambulance systems and hazardous materials (HAZMAT) teams also have these kits available for use in the prehospital setting.
  • During a mass casualty incident, most patients arrive to the emergency department without the benefit of prior emergency medical services (EMS) or HAZMAT intervention. According to the 1998 report by Okumura et al, in the Tokyo subway sarin attack, 85% of patients arrived to the ED by private car.[2] This means that the emergency department must be prepared to treat potentially large numbers of contaminated individuals.

Emergency Department Care

If decontamination has not occurred, the emergency department should be able to provide this service prior to the patient's entrance to the hospital. If weather permits, decontamination stations can be set up outside. All hospital personnel in contact with contaminated individuals must wear full protective gowns (eg, rubber apron, rubber gloves, protective mask). Medical management is discussed in Medication.



Contact the regional poison center (1-800-222-1222) whenever nerve agent poisoning is suspected. In case of a multiple casualty incident, activate the hospital emergency plan and notify local authorities for advice and support.

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.

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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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