3-Quinuclidinyl Benzilate Poisoning Workup

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

Laboratory Studies

  • No rapid tests enable a health care provider to diagnose exposure to QNB. Consider QNB if a number of persons arrive after an exposure to an unknown substance and manifest an anticholinergic syndrome.
  • Obtaining a complete blood count, electrolytes, clotting studies, and renal and liver function tests is reasonable in any person who potentially was exposed to a chemical warfare agent.
  • If the patient is markedly agitated or comatose, obtaining a urine myoglobin and/or creatine phosphokinase is warranted to exclude rhabdomyolysis. Hyperkalemia, hyperphosphatemia, and hypocalcemia may occur in association with rhabdomyolysis. The agitated patient also may develop an elevated lactate.
  • If QNB is considered in the differential, obtain extra blood and urine samples. Tests have been developed to confirm human exposure to QNB.
  • Disseminated intravascular coagulation is a potential complication in a patient with marked agitation and/or hyperthermia. Obtain clotting studies (eg, prothrombin time, activated partial thromboplastin time, international normalized ratio) in these patients. If clotting studies are elevated, then fibrinogen, fibrin split products, and a peripheral smear looking for evidence of hemolysis may be necessary.
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Imaging Studies

  • A patient exposed to QNB who is comatose may be at risk for aspiration pneumonia; obtain a chest radiograph.
  • If the etiology of the altered mental status is uncertain, obtaining a head CT scan to exclude other intracranial processes is reasonable.
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Other Tests

  • ECG: QNB is associated with sinus tachycardia. Patients exposed to QNB who have preexisting cardiac disease may be at risk for cardiac ischemia as their heart rates increase. Other anticholinergic agents are associated with QT prolongation, QRS widening, and various tachydysrhythmias. Obtain an ECG to exclude these potential problems.
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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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