Management of Nerve Agent Exposure

3 Specific Treatment Measures for Toxic Trauma 8.3.1 Management of Nerve Agent Exposure 

Nerve agents have a short latency and can rapidly produce life-threatening effects. The immediate assessment of a nerve agent victim should focus on the patient s clinical condition and the route of exposure as noted in Chap. 7. Vapour exposure usually causes immediate symptoms. Symptom onset can be significantly delayed after dermal exposure. 

Resuscitation with airway clearance and artificial ventilation must begin immediately following a significant inhalational exposure. Life-threatening symptoms can begin less than 5 min after exposure and death can occur within 5 min after the onset of seizures and respiratory arrest. 

Atropine and praUdoxime are essential antidotes for the resuscitation and treatment of victims of nerve agent poisoning. Control of convulsions, if there is a significant central nervous system (CNS) involvement, must be achieved quickly with benzodiazepines. 

2 summarises the approach towards the emergency clinical management 

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Pfaff, B. L. (1998). Emergency department management of nerve agent exposure. International Journal of Trauma Nursing, 4(3), 71-78. 

Rotenberg, J.S. (2003b). Diagnosis and management of nerve agent exposure. Pediatr. Ann. 32 242-50. 

Pfaff, B.L. Emergen cy Department Management of Nerve Agent Exposure, International Journal of Trauma Nursing, July-September, 1998. 

Box 8.4 summarises the management of nerve agent exposures in terms of the clinical effects produced. It is important that the treatment given should match the severity of the signs and S3miptoms displayed. 

Box 8.4 Management of nerve agent exposures in terms of the clinical effects produced... 

Table 3.4 Treatment of nerve agent exposure hospital management CDC Recommendations for nerve agent therapy in the emergency department...

Although our military experience managing toxicity from nerve agent exposure is limited, exposures to related chemicals such as the OP class occur commonly each year in the USA. In 2006, there were a total of approximately 5,400 OP exposures across the USA (Bronstein et al, 2007). OPs, such as malathion, are commonly used as pesticides. OP toxicity manifests in a similar fashion as toxicity from nerve agents however, this chemical class is considerably less toxic. One case series of 16 children who experienced poisonings with OPs confirmed that pediatric patients present with toxicity differently than adults (Lifshitz et al, 1999). These children often did not manifest the classic muscarinic effects (such as salivary secretions and diarrhea) seen in adults. 

Nerve agent exposures must be handled quickly and efficiently. When children are exposed, it is important to remember that antidote dosing will be determined by the patient s weight and the severity of exposure. Progress has been made to provide pediatric-specific autoinjectors however, since 2-PAM Cl is not yet available in a pediatric autoinjector form, it is possible to carefiilly use adult autoinjectors to manage pediatric patients. 

TABLE 61.3. Management of mild/moderate nerve agent exposures (Rotenberg and Newmark, 2003 Anon, 2002)... 

Pediatric exposures to vesicants can be quite toxic however, in contrast to nerve agent exposures, HD causes significantly greater morbidity than mortality. While mustard did not cause many deaths in WWI, death from HD exposure is usually due to massive pulmonary damage complicated by infection (bronchopneumonia) and sepsis. Children often show a quicker onset and greater severity of toxicity. Skin and eye toxicity occurs in the form of blisters or irritation that can result in blindness for the most severe cases. Except for lewisite, vesicant exposures must be managed with supportive care and rapid decontamination. 

Although our military experience managing toxicity from nerve agent exposure is limited, exposures to related chemicals such as the OP class occur commonly each year in the United States. In 2006, there were a total of approximately 5,400 OP exposures across the United States (Bronstein et al., 2007). OPs, such as malathion, are... 

TABLE 68.3 Management of Mild/Moderate Nerve Agent Exposures... 

The first volume. Fundamental Aspects, covers the fundamentals of the toxicology of nerve agents and vesicants whilst the second volume. Management of Poisoning, describes aspects of the treatment after exposure to these and other chemical warfare agents. 

Managing nerve agent-induced convulsions Patients exhibiting convulsions following nerve agent exposure should be treated as quickly as possible using a benzodiazepine compound. Diazepam has been used for many years and included in military autojectors in a form compounded with lysine to improve solubility. Central convulsions can worsen cerebral hypoxia which has been precipitated by respiratory failure. The use of benzodiazepines must therefore be associated with respiratory support. 

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