Nerve agents patient management

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. 

The successful management of patients affected by nerve agent poisoning depends on the clinician ... 

The principles of care for a casualty with nerve agent intoxication include termination of exposure, maintenance of ventilation, administration of antidotes, and supportive therapy. For successful medical management, early and intense therapy after severe exposure to nerve agents is necessary to prevent death. The condition of the patient will dictate the need for specific treatment procedures and the order of administration. It is of utmost importance that medical care providers are protected from contamination by use of appropriate protective clothing, otherwise they may become additional casualties. ... 

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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