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CBRNE - Vomiting Agents - Dm, Da, Dc Workup

  • Author: Christopher P Holstege, MD; Chief Editor: Zygmunt F Dembek, PhD, MPH, MS, LHD  more...
Updated: Aug 06, 2015

Laboratory Studies

No rapid tests are available that enable health care providers to definitively determine exposure to vomiting agents. Consider these agents when exposure to an unknown substance inflicts pulmonary and ophthalmic irritation and then progresses to nausea, vomiting, abdominal cramps, and diarrhea.

Obtain a complete blood count, electrolytes, clotting studies, and renal and liver function tests in any person who potentially was exposed to a chemical warfare agent.

If a patient is markedly agitated or comatose, obtain a urine myoglobin and/or creatine phosphokinase to exclude rhabdomyolysis.

If considering chemical warfare agent poisoning in the differential, obtain extra blood and urine samples for subsequent toxicologic testing.

After absorption, diphenylchlorarsine (Da) and diphenylcyanoarsine (Dc) are rapidly hydrolyzed to diphenylarsinic (DPAA), then conjugated to glutathione (DPAA-GS), and finally excreted. Therefore, blood and urine samples should be collected within 24 hours. Current methods can quantitate DPAA and DPAA-GS levels within hours, using gas chromatography and mass spectroscopy analysis (GC-MS/MS).

Inadequate data are available regarding the metabolic products of diphenylaminearsine (Dm, adamsite), thereby limiting GC-MS/MS methods to the parental Dm molecule and creating a shorter collection window, predominantly from blood samples. The collection window can be widened significantly when measuring organic arsenic levels as opposed to specific metabolites in blood or tissue samples using gas chromatography mass spectroscopy (GC-MS). Arsenic levels in combination with a patient’s cytogenetic profile and clinical presentation may help pinpoint exposure to specific organoarsenic agents.


Imaging Studies

A chest radiograph may need to be obtained to exclude chemical pneumonitis in a patient exposed to vomiting agents who presents with marked pulmonary irritation. Rarely, vomiting agents may cause altered mental status. If the etiology is uncertain, obtain a head computed tomography (CT) scan to exclude other intracranial pathology.



Vomiting agents are not reported to cause significant cardiac dysrhythmias. Sinus tachycardia may result from the stress of the event. However, in symptomatic persons at risk for coronary artery disease or in those with preexisting disease, obtain an electrocardiogram (ECG) to exclude evidence of ischemia. When the causative agent is not identified definitively, obtaining an ECG is a reasonable approach to exclude conductive disturbances induced by other toxins.

Contributor Information and Disclosures

Christopher P Holstege, MD Professor of Emergency Medicine and Pediatrics, University of Virginia School of Medicine; Chief, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Center

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

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

Zygmunt F Dembek, PhD, MPH, MS, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Zygmunt F Dembek, PhD, MPH, MS, LHD is a member of the following medical societies: American Chemical Society, New York Academy of Sciences

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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