CBRNE - Nerve Agents, Binary - GB2, VX2 Treatment & Management

Updated: Jan 11, 2021
  • Author: Larissa I Velez-Daubon, MD; Chief Editor: Duane C Caneva, MD, MSc  more...
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Prehospital Care

Keep in mind that rescue personnel may themselves become affected by nerve agents. The cornerstones of prehospital management are based on rapid termination of exposure (ie, evacuation and decontamination), treatment of life-threatening emergencies, and administration of antidotes, if available. Whenever possible, decontamination should take place prior to transportation of the patient to a clean area. This prevents cross-contamination and additional exposures.

  • Decontamination techniques vary according to the extent and route of exposure. [2]

    • After exposure to any toxic vapor, evacuation and provision of fresh air is the most important first step. Clothes should be removed, since they can trap enough vapor to cause secondary victims. In the Tokyo subway attack, 10% of the caregivers at the hospital developed miosis after exposure to nondecontaminated victims.

    • In dermal exposures, the patient should be undressed. Any visible droplets should be blotted away. Abrasion of the skin by vigorous scrubbing increases absorption of the agent and should be avoided. Nerve agents can be neutralized with alkaline solutions such as soap and water or 0.5% hypochlorite solution (which releases chlorine), followed by a water rinse. [3] However, decontamination should not be delayed to seek hypochlorite or other special solutions; copious water is generally good enough for decontamination.

  • The military has autoinjector kits (MARK 1) that contain 2 antidotes, an oxime (AChE reactivator) and atropine. [4] Some ambulance systems and hazardous materials (HAZMAT) teams also have these kits available for use in the prehospital setting.

  • During a mass casualty incident, most patients arrive to the emergency department without the benefit of prior emergency medical services (EMS) or HAZMAT intervention. According to the 1998 report by Okumura et al, in the Tokyo subway sarin attack, 85% of patients arrived to the ED by private car. [5] This means that the emergency department must be prepared to treat potentially large numbers of contaminated individuals.


Emergency Department Care

If decontamination has not occurred, the emergency department should be able to provide this service prior to the patient's entrance to the hospital. If weather permits, decontamination stations can be set up outside. All hospital personnel in contact with contaminated individuals must wear full protective gowns (eg, rubber apron, rubber gloves, protective mask). Medical management is discussed in Medication.



Contact the regional poison center (1-800-222-1222) whenever nerve agent poisoning is suspected. In case of a multiple casualty incident, activate the hospital emergency plan and notify local authorities for advice and support.