Further Outpatient Care
Patients who are discharged from the hospital generally do not require further care. Nerve agents have not been associated with organophosphate-induced delayed neuropathy. Advise patients with miosis not to drive at night until this symptom resolves.
Further Inpatient Care
Admit patients with liquid exposures for observation after completion of proper decontamination. Onset of symptoms with these exposures has been observed to be delayed as long as 18 hours. This differs from vapor exposures, in which the symptoms have an almost immediate onset. In a patient with a vapor exposure and only minimal symptoms, the patient usually can be discharged home.
Complications
Patients with status epilepticus may suffer from anoxic brain injury.
Prognosis
If patients recover from the acute effects of exposure, chronic effects should not occur. Subtle behavioral and cognitive changes have been noted to persist for days to weeks after the initial exposure. Patients may have permanent sequelae if they suffered from anoxia during the acute phase of poisoning.
Patient Education
For patient education information, see the First Aid and Injuries Center, as well as Chemical Warfare and Personal Protective Equipment.
Tables
Code Name |
Chemical Name |
VX |
O-Ethyl-S-[2(diisopropylamino)ethyl] methylphosphonothioate |
VE |
O-Ethyl-S-[2-(diethylamino)ethyl] ethylphosphonothioate |
VG |
O,O-Diethyl-S-[2-(diethylamino)ethyl] phosphorothioate |
VM |
O-Ethyl-S-[2-(diethylamino)ethyl] methylphosphonothioate |
V-gas |
Russian equivalent of VX |
Agent |
LCt50 (mg ⋅ min/m3) |
LD50 (mg) |
Aging Half-Life |
Tabun (GA) |
400 |
1000 |
46 h |
Sarin (GB) |
100 |
1700 |
5.2-12 h |
Soman (GD) |
50 |
100 |
40 sec to 10 min |
VX |
10 |
10 |
50-60 h |
Receptor Involved |
Clinical Effect |
Acetylcholine, GABA, N -methyl-D -aspartate: Central (CNS) |
Anxiety, restlessness, seizures, failure to concentrate, depression, coma, apnea |
Acetylcholine: Muscarinic Postganglionic parasympathetic |
"DUMBELS" (commonly used mnemonic) D - Diarrhea U - Urination M - Miosis B - Bronchorrhea, bronchoconstriction E - Emesis L - Lacrimation S - Salivation Note: The other commonly used mnemonic "SLUDGE" is not used here, as it does not include an important sign and symptom: bronchorrhea and bronchoconstriction. |
Acetylcholine: Nicotinic Motor endplate Sympathetic and parasympathetic ganglia |
Pallor, tachycardia, hypertension, muscle weakness and/or paralysis, fasciculations Note: Some use the days of the week as an easy mnemonic for these: M - Mydriasis T - Tachycardia W - Weakness tH - Hypertension F - Fasciculations |
* Adapted from Marrs, Maynard, and Sidell. [10] |
|
Severity of Exposure |
Signs and Symptoms - Liquid |
Signs and Symptoms - Vapor |
Onset of symptoms |
Possibly delayed toxicity |
Rapidly manifesting toxicity |
Minimal |
Localized sweating at site Localized fasciculations at site |
Miosis Rhinorrhea Mild dyspnea |
Moderate |
Fasciculations Diaphoresis Nausea, vomiting, and diarrhea Generalized weakness |
Above symptoms and the following: Moderate-to-marked dyspnea (bronchorrhea and/or bronchoconstriction) |
Severe |
Above symptoms and the following: Loss of consciousness Seizures Generalized fasciculations Flaccid paralysis and apnea |
Above symptoms and the following: Loss of consciousness Seizures Generalized fasciculations Flaccid paralysis and apnea |
Drug |
Dose |
Route |
Indications |
Contraindications |
Atropine |
2 mg q5-10min prn Note: the Mark 1 kit contains 2 mg of atropine |
IV/IM/ETT |
Excessive muscarinic symptoms |
Relative - IV route in hypoxia has been associated with ventricular fibrillation |
2-PAM Cl (pralidoxime chloride, Protopam) |
15-25 mg/kg over 20 min; can be repeated after 1 h Note: The Mark 1 kit contains 600 mg of pralidoxime. |
IV/IM |
Symptomatic nerve agent poisoning |
Rapid infusion may result in hypertension |
Diazepam (Valium) |
2-5 mg IV or 10 mg IM |
IV/IM |
Active seizures; administer as prophylaxis if moderate or severe signs of poisoning are present |
None |
*Adapted from Sidell. |
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Severity/Route of Exposure |
Atropine |
2-PAM Cl |
Diazepam |
Other |
Suspected |
No |
No |
No |
Decontamination and 18-h observation for liquid exposures |
Mild |
2 mg for severe rhinorrhea or dyspnea; may repeat prn |
Administer if patient has nonimproving dyspnea or GI symptoms |
No |
Decontamination and 18-h observation for liquid exposures; oxygen |
Moderate |
6 mg; may require repeat doses |
Administer with atropine |
Administer even in absence of seizures |
Decontamination, oxygen |
Severe |
Start with 6 mg; may need to repeat |
Administer with atropine; should repeat once or twice |
Administer even in absence of seizures |
ABCs, decontamination |
*Adapted from Sidell. |
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