CBRNE - Vomiting Agents - Dm, Da, Dc Treatment & Management

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

Prehospital Care

  • A military or terrorist event involving the exposure of military personnel or civilians to vomiting agents would create confusion and panic. Large numbers of potential casualties may overwhelm emergency response teams. Chaos may occur. (See Disaster Planning and Medscape's Disaster Preparedness and Aftermath Resource Center.)
  • Prehospital care providers must place their personal safety first before the treatment of potentially contaminated patients. With aerosolized exposure, secondary contamination of health care providers is unlikely.
  • Perform general supportive measures such as obtaining intravenous (IV) access and administering oxygen to those with signs of respiratory irritation.
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Emergency Department Care

The initial care of patients exposed to vomiting agents primarily is supportive. No specific antidotes are available. Focus care on relieving irritant and systemic effects.

  • Respiratory irritation
    • These effects typically are transient and resolve soon after exposure ceases. Duration of irritation depends on the dose of agent inhaled and the premorbid status of the patient.
    • Patients with preexisting lung disease (eg, asthma, emphysema) may develop exacerbations of these diseases that are slow to resolve.
    • If a patient has dyspnea with wheezing, albuterol nebulizations may be necessary. Steroids may be considered.
    • In most patients without preexisting lung disease, symptoms abate spontaneously.
  • Ophthalmic irritation
    • Consider eye irrigation in patients sustaining chemical exposure and subsequent ocular irritation. Appropriate irrigant choices include water, normal saline, and lactated Ringer solution.
    • The objective of irrigation is to dilute the offending agent and remove it. Perform irrigation with 1-2 L of irrigant per affected eye.
    • Examine the eyes using a slit lamp and fluorescein.
    • If a corneal abrasion is noted, consider cycloplegics and topical antibiotics.
  • Emesis: Treat patients with repetitive emesis with IV hydration and antiemetics. Numerous antiemetics are available. No specific agent is documented as superior.
  • Central nervous system depression
    • Acute mental status changes rarely have been reported. One death after DM exposure is documented, but complete information on this fatality has not been released.
    • If a patient presents in marked respiratory distress with mental status changes, intubation and mechanical ventilation may be necessary.
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Consultations

The following consultations may be necessary:

  • Intensivist: In the rare event that a patient exposed to vomiting agents presents with acute respiratory distress or acute mental status changes, early consultation with a physician trained in critical care medicine may be necessary.
  • Poison control center and/or local health department: Report adverse events caused by toxins to the local poison control center and health department. This allows coordination of information with other health care facilities and expedites assistance in determining the etiology of the poisoning.
  • Law enforcement: If the cause of the exposure is unknown or believed to be a terrorist act, contact local and federal law enforcement.
  • Ophthalmologist: If significant eye exposure has occurred and the patient develops persistent ophthalmologic signs and symptoms or evidence of corneal damage, contact an ophthalmologist.
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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 Association for the Advancement of Science, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, 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

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Rick Kulkarni, MD  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

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. Sanderson H, Fauser P, Thomsen M, Sorensen PB. Screening level fish community risk assessment of chemical warfare agents in the Baltic Sea. J Hazard Mater. Jun 15 2008;154(1-3):846-57. [Medline].

  2. Ishii K, Tamaoka A, Otsuka F, et al. Diphenylarsinic acid poisoning from chemical weapons in Kamisu, Japan. Ann Neurol. Nov 2004;56(5):741-5. [Medline].

  3. Kato K, Mizoi M, An Y, et al. Oral administration of diphenylarsinic acid, a degradation product of chemical warfare agents, induces oxidative and nitrosative stress in cerebellar Purkinje cells. Life Sci. Nov 10 2007;81(21-22):1518-25. [Medline].

  4. Compton, JAF. Military Chemical and Biological Agents: Chemical and Toxicological Properties. 1988:194-204.

  5. Ellison DH. Vomiting agents. In: Handbook of Chemical and Biological Warfare Agents. 2000:149-150.

  6. Haas R, Tsivunchyk O, Steinbach K. Conversion of adamsite (phenarsarzin chloride) by fungal manganese peroxidase. Appl Microbiol Biotechnol. Feb 2004;63(5):564-6. [Medline].

  7. Henriksson J, Johannisson A, Bergqvist PA, Norrgren L. The toxicity of organoarsenic-based warfare agents: in vitro and in vivo studies. Arch Environ Contam Toxicol. Feb 1996;30(2):213-9. [Medline].

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

  9. Hu H, Somani SM, eds. Toxicodynamics of riot-control agents (lacrimators). In: Chemical Warfare Agents. 1992:271-288.

  10. Kohler M, Hofmann K, Volsgen F. Bacterial release of arsenic ions and organoarsenic compounds from soil contaminated by chemical warfare agents. Chemosphere. Feb 2001;42(4):425-9. [Medline].

  11. Pitten FA, Muller G, Konig P, et al. Risk assessment of a former military base contaminated with organoarsenic-based warfare agents: uptake of arsenic by terrestrial plants. Sci Total Environ. Feb 9 1999;226(2-3):237-45. [Medline].

  12. Sidell FR. Riot control agents. In: Management of Chemical Warfare Agent Casualties. 1995:93-99.

  13. Tornes JA, Opstad AM, Johnsen BA. Determination of organoarsenic warfare agents in sediment samples from Skagerrak by gas chromatography-mass spectrometry. Sci Total Environ. Mar 1 2006;356(1-3):235-46. [Medline].

  14. Zajtchuck R, ed. Riot control agents. In: Textbook of Military Medicine. 1997:308-324.

 
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