3-Quinuclidinyl Benzilate Poisoning Treatment & Management

  • Author: Christopher P Holstege, MD; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Mar 16, 2010
 

Prehospital Care

  • Prehospital care providers must place their personal safety before the treatment of potentially contaminated patients.
    • The US military recommends wearing maximum protection when in contact with QNB contamination. These recommendations include wearing an M9 mask and hood, an M3 butyl rubber suit, M2A1 butyl boots, and M3 or M4 butyl gloves.[2]
    • For civilian paramedics, decontamination of the exposed patients prior to transfer must occur. Dermal absorption and subsequent toxicity is a risk from contact with contaminated patients.
    • Off gassing may occur, and paramedics are at risk for toxicity in the closed confines of an ambulance. Caution must be exercised especially for flight crews, since toxicity of the pilot during mid flight can lead to impaired vision and judgment and subsequent risk of crashing the aircraft.
  • Water can be used for decontamination.
  • After the patients have been decontaminated, transport them to the nearest hospital facility.
  • Perform general supportive measures (eg, intravenous access, airway management).
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Emergency Department Care

Once decontamination has occurred, the primary emphasis simply is supportive care of exposed patients. Emergency department staff must be certain that proper decontamination has occurred. Dermal absorption and off gassing of QNB does occur and can pose a risk to hospital personnel.

  • In patients who are not protecting their airway, perform intubation and mechanical ventilation.
  • Apply soft restraints to patients at risk of harming themselves or health care workers.
  • Intravenous hydration may be necessary; maintain adequate urinary output. If urinary retention is suggested, place a Foley catheter.
  • For patients experiencing marked agitation, consider benzodiazepine administration.
  • In patients with hyperthermia, cooling measures may be necessary.
    • Completely remove the patient's clothing.
    • Insert a Foley catheter or rectal temperature probe.
    • Administer adequate intravenous fluids.
    • Cooling measures such as evaporative cooling using skin wetting with directed circulating fans, ice water immersion, ice packs, and cooling blankets may be necessary.
  • Include continuous cardiac and core temperature monitoring.

See Medscape's Disaster Preparedness and Aftermath Resource Center for more information.

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Consultations

If an exposure to QNB occurs, consider a number of consultations.

  • If the cause of the exposure is a terrorist act against civilians, contact the local health department, poison center, and law enforcement agency immediately. Also contact federal agencies, such as the US Federal Bureau of Investigations (FBI).
  • If a patient sustained eye contact with QNB and subsequently developed eye pain, change in vision, or marked conjunctival injection, consultation with an ophthalmologist may be necessary.
  • For patients requiring intensive care monitoring, consider early consultation with a physician trained in critical medicine.
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Contributor Information and Disclosures
Author

Christopher P Holstege, MD  Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health

Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, European Association of Poisons Centres and Clinical Toxicologists, Medical Society of Virginia, Society for Academic Emergency Medicine, Society of Toxicology, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jennifer S Boyle, MD, PharmD  Fellow in Toxicology, University of Virginia Health System

Disclosure: Nothing to disclose.

Specialty Editor Board

Suzanne White, MD  Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine

Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society

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.

References

  1. Hay A. Surviving the impossible: the long march from Srebrenica. An investigation of the possible use of chemical warfare agents. Med Confl Surviv. Apr-Jun 1998;14(2):120-55. [Medline].

  2. US Army Center for Health Promotion and Preventive Medicine. Psychodelic Agent 3 - Quinuclidinyl Benzilate (BZ). The Deputy for Technical Services' Publication: Detailed Chemical Facts Sheets. 1998;[Full Text].

  3. Byrd GD, Paule RC, Sander LC, et al. Determination of 3-quinuclidinyl benzilate (QNB) and its major metabolites in urine by isotope dilution gas chromatography/mass spectrometry. J Anal Toxicol. May-Jun 1992;16(3):182-7. [Medline].

  4. Gibson RE, Rzeszotarski WJ, Jagoda EM, et al. [125I] 3-quinuclidinyl 4-iodobenzilate: a high affinity, high specific activity radioligand for the M1 and M2-acetylcholine receptors. Life Sci. Jun 4 1984;34(23):2287-96. [Medline].

  5. Glendenning KK. Distribution of muscimol, QNB, and 5HT binding in the vertebrate diencephalon: a comparative study of eight mammals and three non-mammals. Microsc Res Tech. Oct 15 2003;62(3):247-61. [Medline].

  6. Hiramatsu Y, Eckelman WC, Baum BJ. Interaction of iodinated quinuclidinyl benzilate enantiomers with M3 muscarinic receptors. Life Sci. 1994;54(23):1777-83. [Medline].

  7. Holstege CP, Bechtel LK, Reilly TH, Wispelwey BP, Dobmeier SG. Unusual but potential agents of terrorists. Emerg Med Clin North Am. May 2007;25(2):549-66; abstract xi. [Medline].

  8. Hull LA, Rosenblatt DH, Epstein J. 3-Quinuclidinyl benzilate hydrolysis in dilute aqueous solution. J Pharm Sci. Jul 1979;68(7):856-9. [Medline].

  9. J R Army Med Corps. Chemical casualties. Centrally acting incapacitants. J R Army Med Corps. Dec 2002;148(4):388-91. [Medline].

  10. Ketchum JS, Sidell FR. Incapacitating agents. In: Textbook of Military Medicine. 1997:287-305.

  11. McDonough JH Jr, Shih TM. A study of the N-methyl-D-aspartate antagonistic properties of anticholinergic drugs. Pharmacol Biochem Behav. Jun-Jul 1995;51(2-3):249-53. [Medline].

  12. Sorger D, Kampfer I, Schliebs R. Iodo-QNB cortical binding and brain perfusion: effects of a cholinergic basal forebrain lesion in the rat. Nucl Med Biol. Jan 1999;26(1):9-16. [Medline].

 
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