Atropine/pralidoxime 2-PAM

Nerve Agent Antidote Kit (NAAK or MARK I) consists of an atropine auto-injector (2 mg), a pralidoxime chloride auto-injector (2-Pam-Cl, 600 mg), the plastic clip joining the two injectors, and a foam case. The kit serve as a countermeasure to nerve agents, including tabun (GA), sarin (GB), soman (GD), GF, and VX. Military personnel can receive three MARK I for self/buddy aid. Possible side effects of atropine and/or 2-PAM-C1 are deemed insignificant in a nerve agent casualty. Intravenous atropine and 2-PAM-C1 can also be made available. The MARK I kit is manufactured by Survival Technology, Inc., Rockville, Maryland. 

Atropine sulfate, in conjunction with pralidoxime (2-PAM), can be administered as an antidote. Atropine should be administered by intravenous injection. Intramuscular injection can be used if IV injection is not possible. Atropine dosage Adults 0.4-2.0 mg... 

Atropine administered repeatedly as necessary and pralidoxime (2-PAM Cl) are antidotes for nerve agent toxicity. Although atropine has no effect on nicotinic receptors, and therefore will not reverse muscle weakness or paralysis, it can reduce morbidity and mortahty by reversing some of the muscarinic effects such as bron-chospasm, bradycardia, sahvation, diaphoresis, diarrhea, and vomiting (2). These antidotes may not be available in the field, especially in or near the site of attack. If mihtary Mark 1 kits are available, they provide autoinjectors that automatically dehver 2mg of atropine and 600mg pralidoxime (9). 

The use of PB is always to be accompanied by immediate treatment after OP exposure with atropine and an oxime such as pralidoxime (2-PAM), the current doctrinal treatments after exposure. PB was chosen not to cross the blood-brain barrier to avoid possible CNS impairment or incapacitation, an effect particularly undesirable in soldiers engaged in combat, at least those not being exposed to OPs. Several other anti-ChEs that do cross the blood-barrier, including physostigmine. 

M blockers such as atropine (enters CNS), plus pralidoxime (2-PAM), may regenerate AChE, particularly at the skeletal neuromuscular junction (NMJ). Because time-dependent aging of the phosphorylated enzyme may decrease the effectiveness of the regenerator, 2-PAM should be used ASAP. 

Therapy for acute poisoning by AChE inhibitors includes administration of M blockers (atropine) and pralidoxime (2-PAM), which helps reactivate AChE. 

There are only a few reports in the open literature on the effect of oximes in nerve agent-exposed humans. Pralidoxime chloride was very effective in reactivating erythrocyte AChE in individuals exposed to sublethal intravenous or oral VX while this oxime was substantially less effective in humans exposed to IV sarin (Sidell and Groff, 1974). Accidental sarin exposure by inhalation resulted in an initial progressive deterioration (coma, apnea) of the patient despite atropine and 2-PAM treatmentand substantial recovery of erythrocyte AChE activity (Sidell, 1974). It took several hours until the patient s condition improved. Sidell also reported an accidental oral soman exposure. A lethal dose of diluted soman splashed into and around the mouth of an individual, resulting in coma, bronchoconstriction and respiratory depression, which was successfully treated with repeated atropine injections. 2-PAM (2 g IV) had no effect on inhibited erythrocyte AChE. 

Treatment Atropine is used in large doses to control muscarinic excess pralidoxime (2-PAM) is used to regenerate cholinesterase. Mechanical ventilation may be necessary. 

Assistant Clinical Professor, University of California, San Francisco School of Medicine Medical Director, California Poison Control System, Fresno Division Section II Disulfiram Selenium Paraquat and Diquat Section III Atropine and Glycopyrrolate Pralidoxime (2-PAM) Other Oximes... 

DuoDote has both the atropine and 2-PAM in the same syringe. DuoDote has only recently been made available to civilians. Some kits may also contain a diazepam or CANA injector (Figure S3.2). You must be able to identify the symptoms and signs that require use of the NAAK, select the appropriate dosage, and administer the atropine, pralidoxime, and diazepam as required. 

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