Nerve agents are the most toxic of the known chemical warfare agents. They are chemically similar to organophosphate pesticides and exert their biological effects by inhibiting acetylcholinesterase enzymes.

• Nerve agents can cause loss of consciousness and convulsions within seconds and death from respiratory failure within minutes of exposure.

Volatile Nerve Agents (vapor)

• Nerve agent vapor is readily absorbed by inhalation and ocular contact and produces rapid local and systemic effects.
• G-type agents are clear colorless and tasteless liquids that are miscible in water and most organic solvents.
• GB is odorless and is the most volatile nerve agent; however, it evaporates at about the same rate as water. GA has a slightly fruity odor and GD has a slight camphor-like odor.

Low Volatility Nerve Agents (liquid)

• Liquid nerve agent is readily absorbed through the skin; however, effects may be delayed for several minutes to up to18 hours.
• VX is a clear, amber-colored, odorless, oily liquid. It is miscible with water and soluble in all solvents. It is the least volatile nerve agent.
• Responders should obtain assistance in identifying the chemical(s) from container shapes, placards, labels, shipping papers, and analytical tests. General information on these identification techniques is located in Emergency Response Guidebook.
• Identification Tools - CHEMM-IST, WISER, Nerve Agents Chemical Properties
• Devices - M8, M9 chemical agent detector paper (liquid agents), M18A3 chemical agent detectors (vapor), M256A1 chemical agent detector kit (liquid and vapor), Draeger CDS Kit (vapor and aerosol), Hazmat Smart Strips (qualitative), Chemical Agent Detector C2 Kit (liquid and vapor), Chemical Agent Monitor (CAM) (vapor)
• A comprehensive source for the selection of chemical identification equipment is the Guide for the Selection of Chemical Detection Equipment for Emergency First Responders, Guide 100-06, January 2007, 3rd Edition published by the Department of Homeland Security to assist with this process.

Nerve Agent is a highly toxic systemic poison that is absorbed well by inhalation and through the skin. Victims exposed only to nerve agent vapor do not pose secondary contamination risks to rescuers, but do not attempt resuscitation without a barrier. Victims whose clothing or skin is contaminated with liquid nerve agent can secondarily contaminate response personnel by direct contact or through off-gassing vapor. Avoid dermal contact with nerve agent contaminated victims or with gastric contents of victims who may have ingested nerve agent-containing materials.

PPE required level A

Respiratory Protection: Positive-pressure, self-contained breathing apparatus (SCBA) is recommended in response situations that involve exposure to potentially unsafe levels of nerve agent.

Skin Protection: Chemical-protective clothing is recommended because both nerve agent vapor (high exposure doses) and liquid can be absorbed through the skin to produce systemic toxicity.

• Level A - protective clothing is the highest level of protection. Level A includes a Self Contained Breathing Apparatus(SCBA) with a fully encapsulating vapor tight suit with gloves and booties attached to the suit (tanks last from 1/2 hour to 1 hour).
• Link to reference section for acute event PPE related safety information

Chemical casualty triage is based on walking feasibility, respiratory status, age, and additional conventional injuries. The triage officer must know the natural course of a given injury, the medical resources immediately available, the current and likely casualty flow, and the medical evacuation capabilities.

For the victim esposed to nerve agent who presents with severe multisystem symptoms, antidotes and supportive care can be lifesaving if initiated immediately.

• SALT Mass Casualty Triage - United States Government Recommendation
• START Adult Triage Algorithm
• JumpSTART Pediatric Triage Algorithm

• Check triage tag/card for any previous treatment or triage.
• Survey for evidence of associated traumatic/blast injuries.
• Observe for sweating, labored breathing, coughing/vomiting, secretions.
• Severe casualty triaged as immediate if assisted breathing is required.
• Blast injuries or other trauma, where there is question whether there is chemical exposure, victims must be tagged as immediate in most cases. Blast victim's evidence delayed effects such as ARDS, etc.
• Mild/moderate casualty: self/buddy aid, triaged as delayed or minimal and release is based on strict follow up and instructions.
• If there are chemical exposure situations which may cause delayed but serious signs and symptoms, then over-triage is considered appropriate to the proper facilities that can observe and manage any delayed onset symptoms.
• Expectant categories in multi-casualty events are those victims who have experienced a cardiac arrest, respiratory arrest, or continued seizures immediately. Resources should not be expended on these casualties if there are large numbers of casualties requiring care and transport with minimal or scant resources available.
• In a given category prioritize a child, pregnant woman over a non-pregnant adult.

Triage for Nerve Agent Casualties
Immediate (1)	Effects - Unconscious, talking but not walking, moderate to severe effects in two or systems more systems (e.g., respiratory, GI, cardiac arrest. muscular, CNS)
	Clinical Signs - seizing or postictal, severe respiratory distress, recent cardiac arrest
Delayed (2)	Effects - recovering from agent exposure or antidote
	Clinical Signs - diminished secretions, improving respiration.
Minimal (3)	Effects - walking and talking
	Clinical Signs - pinpoint pupils, runny nose, and mild to moderate difficulty breathing.
Expectant (4) (limited resources)	Effects - Unconscious
	Clinical Signs - Cardiac/respiratory arrest of long duration.

Quickly access for a patent airway, ensure adequate respiration and pulse (document pulse ox if possible). If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Apply direct pressure to stop arterial bleeding (if present).

• Link to Basic and Advanced Life Support
• Link to Pediatric Basic and Advanced Life Support
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Primary and Secondary Survey

• Inhalation - nerve agents are readily absorbed from the respiratory tract. Runny nose and tightness in the throat or chest begin within seconds to minutes after exposure. Nerve agent vapors are heavier than air. Odor does not provide adequate warning of detection.
• Skin/Eye Contact - nerve agent liquids are readily absorbed from the skin and eyes. Vapors are not absorbed through the skin except at very high concentrations. Ocular effects may result from both direct contact and systemic absorption. The nature and timing of symptoms following dermal contact with liquid nerve agents depend on exposure dose; effects may be delayed for several hours.
• Ingestion - ingestion of nerve agents is expected to be relatively rare compared to inhalation exposure or skin contact; however, they are readily absorbed from the GI tract and are highly toxic.

Nerve agent's primary means of inducing toxicity is through inhalation and skin/eye contact. Occasionally ingestion can occur.

The onset of action with inhaled vapor can be almost instantaneous causing local and systemic effects. Liquid which is readily absorbed thru the skin can cause system effects in minutes and up to 18 hours later.

• Respiratory: Inhalation of nerve agent vapor causes respiratory tract effects within seconds to minutes. Symptoms include increased, rhinorrhea, and bronchial secretions, chest tightness secondary to bronchial muscle contraction.
• CNS: High dose - seizures, loss of consciousness, apnea. Other signs and symptoms include; irritability, memory loss, fatigue, memory loss, behavioral and psychological changes.
• Cardiovascular: Potentially up to three phases in variable length - transient tachycardia/with or without hypertension (minutes) followed by bradycardia and hypotension. The final phase starts hours to days after exposure with QT prolongation and a tendency toward malignant dysrhythmias. In one Organophosphate toxicity study 42 % had cardiac arrhythmias with torsades de pointe occurring in 37 % of the cases.
• Gastrointestinal: Abdominal pain, N&V, diarrhea are common manifestations of any exposure. It may be the first systemic effects of skin exposure. If GI symptoms occur within one hour of dermal contamination severe intoxication is present.
• Skeletal Muscles; Nerve agents stimulate skeletal muscles producing twitching and fasciculations. This leads to fatigue and flaccid paralysis.
• Metabolic: Sweating.
• Ocular: Symptoms may occur from local effects secondary to vapor exposure or as a manifestation of systemic absorption. Pinpoint pupils, eye pain, conjunctivitis, and increased tearing are common (with systemic absorption pinpoint pupils may not occur immediately).
• Link to Toxic Syndromes
• Link to Primary and Secondary Survey

• The diagnosis in a severely intoxicated individual is straight forward. The combination of miosis, copious secretions, bronchospasm, generalized muscle fasciculations, and seizures is characteristic.
• Look carefully for miosis (if present will be helpful). Miosis may not be present initially following a low volatility nerve agent exposure.
• A mild vapor exposure may mimic a child having allergic rhinitis/conjunctivitis in combination with an asthmatic episode.
• GI symptoms by themselves could be confusing and they could be the only presenting signs.
• Opiod abuse can include miosis, apnea, seizures, etc.
• Link to Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST)

• Nerve Agents may penetrate the blood brain barrier more easily in children than adults. Children may only exhibit CNS effects.
• Children under four years of age with status epilepticus have the highest risk of death.
• A child's smaller mass alone reduces the dose of nerve agent required for toxic/lethal effects. Animal studies have shown that the lethal dose of nerve agent in an immature vs. adult animal is 10 %.
• With higher respiratory rates and minute volumes than adults a child will inhale a greater dose of nerve agent.
• The smaller airway diameter, anatomic subglottic narrowing, omega shaped epiglottic structure, relatively large tongue size, less rigid ribs and trachea make them more vulnerable to nerve agent induces pathology i.e. bronchospasm, copious secretions.
• There are few case reports regarding fetal toxicity from nerve agent/organophosphate exposure.
• There is a high incidence of premature labor following organophosphate exposure in which maternal treatment has been delayed.
• Link to Primary and Secondary Survey

Antidote/Seizure Medication Dosing: (Autoinjector Instructions)

Consult with a medical toxicologist or a poison center at the national toll-free number 1-800-222-1222 for further guidance on appropriate antidote dosing.
Currently two atropine/pralidoxime autoinjector formulations exist:

• Mark 1 Kit - each kit contains one 600 mg pralidoxime autoinjector, one 2 mg atropine autoinjector
• Duodote - a single autoinjector contains approximately 600 mg of pralidoxime and 2 mg of atropine
• In general treatment of severe nerve agent poisoning requires lower total doses of atropine than required for treatment of organophosphorous compounds
• In severe cases of nerve agent toxicity following vapor exposure (i.e. apneic and unconscious) it may take up to 15 mg of atropine to restore consciousness and breathing. Typically atropine has not been required for more than 3 hours to treat the life threatening effects. Non-life threatening effects such as nausea and vomiting have required atropine for 6-36 hours.
• Organophosphate ingestions have required hundreds of mgs a day of atropine
• If traditional countermeasures are not available, see Contingency Medical Countermeasures for Treating Nerve Agent Poisoning (PDF - 511 KB) (HHS/ASPR)

Mild effects:

• Miosis alone (no respiratory symptoms)- No antidotes. However, if eye/head pain or N&V (in the absence of other systemic signs suggesting a liquid exposure) are severe use atropine ophthalmic drops
• Miosis and severe rhinorrhea - Atropine
  
  

  	Atropine Autoinjector/IM† *
  Infant (0-2 yrs)	0.05 mg/kg given IM or via autoinjector (0.25 and 0.50 mg sizes are available)
  Child (3-7 yrs)	1 mg autoinjector/IM
  Child (8-14 yrs)	2 mg autoinjector/IM
  Adolescent/Adult	2 mg autoinjector/IM
  Pregnant women	2 mg autoinjector/IM
  Senior	1 mg autoinjector/IM

Mild/Moderate effects:

• These include localized swelling, muscle fasciculations, nausea and vomiting, weakness, shortness of breath. Utilize auto-injectors if available. May use a 600 mg 2PAM Cl auto-injector in an infant as small as 12 kg.
  
  

  	Atropine Autoinjector/IM† *	2-PAM Cl - 600 mg Autoinjector/IM† *
  Infant (0-2 yrs)	0.05 mg/kg given IM or via autoinjector (0.25 and 0.50 mg sizes are available)	15 mg/kg‡
  Child (3-7 yrs) 13-25 kg	1 mg autoinjector/IM	15 mg/kg May use 1 autoinjector (600 mg)‡
  Child (8-14 yrs) 26-50 kg	2 mg autoinjector/IM	15 mg/kg May use 1 autoinjector (600 mg)‡
  Adolescent/Adult	2-4 mg autoinjector/IM	1 autoinjector (600 mg)
  Pregnant Women	2-4 mg autoinjector/IM	1 autoinjector (600 mg)
  Seniors, frail	2 mg autoinjector/IM	10 mg/kg IM 1 autoinjector (600 mg)

• Repeat initial dose (2 mg max) of atropine via autoinjector (preferable) or IM every 5 - 10 minutes until dyspnea, resistance to ventilation, and secretions are minimized.
• If resistance to ventilation is significant , requiring repeat dosing in less than 5 minutes utilize the higher doses and increase frequency depicted in the severe effects section below
• Treat vomiting and diarrhea from a liquid exposure in a similar way.
• Regular IM atropine dosing may take 20-25 minutes to have a therapeutic effect (vs. 8 minutes with an autoinjector).
• May repeat pralidoxime - up to a total of 45 mg/kg during the first hour
• May repeat pralidoxime - up to 45 mg/kg 1 hour after initial treatment

Severe Effects - Initial Dosing:

• These include unconsciousness, convulsions, apnea, flaccid paralysis and requiring assisted ventilation (severe respiratory distress). I.V. atropine has produced ventricular fibrillation in hypoxic animals with nerve agent poisoning. Therefore it is recommended that hypoxia be corrected prior to atropine administration. However atropine should not be withheld due to fears of this complication. It would be preferable to utilize an atropine autoinjector for the first dose in the hypoxic nerve agent exposed patient.


 

	Atropine Autoinjector/IM† *	2-PAM Cl Autoinjector/IM† *
Infant (0-3 yrs)	0.1 mg/kg given IM or via autoinjector (0.25 and 0.50 mg sizes are available)	45 mg/kg IM‡
Child (3-7 yrs) 13-25 kg	0.1 mg/kg IM 1 (2 mg) autoinjector	45 mg/kg Use 1 autoinjector (600 mg)‡
Child (8-14 yrs) 26-50 kg	4 mg 2 (2 mg) autoinjector	45 mg/kg IM Use 2 autoinjector (1200 mg)‡
Adolescent (>14 yrs)	6 mg 3 (2 mg) autoinjectors	Use 3 autoinjectors (1800 mg)
Adult	6 mg 3 (2mg) autoinjectors	Use 3 autoinjectors (1800 mg)
Pregnant Women	6 mg 3 (2 mg) autoinjectors	Use 3 autoinjectors (1800 mg)
Seniors, frail	2-4 mg 1-2 (2 mg) autoinjectors	25 mg/kg IM Use 2-3 autoinjectors (1200-1800 mg)

• Repeat atropine 2 mg via autoinjector (preferable) or IM (child 8-14, adolescents, adults, pregnant women, and seniors), 0.05 mg/kg (0.25 mg - 0.50 mg) (infant 0-3) and 1 mg (child 3-7) at 2 -5 minute intervals until secretions have diminished, breathing is comfortable, and airway resistance has returned to normal.
• Repeat 2PAM Cl dose hourly X 2, if clinically possible start 2 PAM Cl via continuous infusion
  Link to Advanced Treatment Emergency Department/Hospital Management

Treatment of seizures:

• Diazepam or midazolam should be given to all patients having seizure activity, unconsciousness, diffuse muscle twitching, and if >1 organ is involved. The military gives diazepam as part of initial therapy for any seriously ill NA exposed patients. Utilized early, atropine may function as an anticonvulsant. The benzodiazepines are the most effective seizure medication for nerve agent toxicity.
• If available, IV administration of diazepam is the preferable route for treatment of seizures.
  
  Initial Dosing:
  

  	Diazepam† *	Midazolam ‡ *
  	Initial Dosing
  Infant	0.2-0.5 mg/kg IM repeat Q2-5 min	0.15 mg/kg IM, repeat PRN 10 minutes
  	X 2, 0.2-0.5 mg/kg IV/IO Q15-30 minutes	X 1
  	Total max dose 5 mg	Total max dose 0.3 mg/kg
  Child	0.2-0.5 mg/kg IM repeat Q2-5 min	0.15 mg/kg IM, not to exceed 10 mg, repeat PRN 10 minutes
  	X 2, 0.2-0.5 mg/kg IV/IO Q15-30 minutes	x 1
  	Total max dose 5 mg (<5 yrs)	Total max dose 0.3 mg/kg, not to exceed 20 mg
  	Total max dose 10 mg (≥5 yrs) 1 CANA autoinjector
  Adolescent	2-3 CANA autoinjectors	0.15 mg/kg IM, max 10 mg, repeat PRN 10 minutes
  	5-10 mg IV/IO Q10-15 min	X 1
  	Total max dose 30 mg	Total max dose 20 mg
  Adult	2-3 CANA autoinjectors	10 mg IM, repeat PRN 10 minutes
  	5-10 mg IV/IO Q10-15 min	X 1
  	Total max dose 30 mg	Total max dose 20 mg
  Pregnant Women	2-3 CANA autoinjectors	10 mg IM, repeat PRN 10 minutes
  	5-10 mg IV/IO Q10-15 min	X 1
  	Total max dose 30 mg	Total max dose 20 mg, Category D *
  Senior	2-3 CANA autoinjectors	10 mg IM, repeat PRN 10 minutes
  	5-10 mg IV/IO Q10-15 min	X 1
  	Total max dose 30 mg	Total max dose 20 mg

  Note: 1 CANA autoinjector contains 10 mg diazepam
  
  

  † FDA approved for this indication

  2-PAM auto-injector usage in pediatrics is off-label

  ‡ Not FDA approved for this indication/Off-label use

  * Pregnancy Categories: Refer to DailyMed regarding Pregnancy Categories and additional pregnancy-related information.

If victims can walk, lead them out of the Hot/Warm Zones to the Decontamination Zone. Victims who are unable to walk may be removed on backboards or gurneys; if these are not available, carefully carry or drag victims to safety. Should there be a large number of casualties, and if decontamination resources permit, separate decontamination corridors should be established for ambulatory and non-ambulatory victims.

Consider appropriate management of chemically contaminated children, such as measures to reduce separation anxiety if a child is separated from a parent or other adult.

• Link to Management of the Deceased

Personnel should continue to wear the same level of protection as required in the Hot/Warm Zones.

Link to Hot/Warm Zones - Rescuer Protection

If exposure levels are determined to be safe, decontamination may be conducted by personnel wearing a lower level of protection than that worn in the Hot/Warm Zones. However, do not attempt resuscitation without a barrier.

Speed is critical. If the victim is symptomatic, immediately institute emergency life support measures including the use nerve agent specific antidotes. Treatment should be given simultaneously with decontamination procedures. Quickly ensure that the victim has a patent airway and is ventilating well. Assist ventilation with a bag-valve-mask device equipped with a canister or air filter if necessary Maintain adequate circulation. Atropine administration will very likely will be required to enable ventilation. Stabilize the cervical spine with a decontaminable collar and a backboard if trauma is suspected. Direct pressure should be applied to control heavy bleeding, if present.

• Link to Basic and Advanced Life Support
• Link to Pediatric Basic and Advanced Life Support
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Primary and Secondary Survey

If clinically indicated, administer initial or repeat dosing of atropine, pralidoxime and seizure medications. If possible, a system should be employed to track antidotes administered.

Link to Treatment in the Hot/Warm Zones

Set up Considerations

• Use pictorial and written posted instructions for victims to self decon when able, use locale-appropriate multilingual signage.
• Double bag contaminated clothing etc. (place hearing aids, valuables in small bag). Place bag in container by showers.
• Victims who are able may assist with their own decontamination.
• Children and the elderly are at increased risk for hypothermia - provide warm showers, blankets.
• Privacy must be considered, if possible.
• The decontamination system should be designed for use in children of all ages, by parentless children, the non-ambulatory child, the child with special needs, and also allow families to stay together.
• Use step-by-step child friendly instructions that explain to the children and parents what they need to do, why they are doing it, and what to expect.
• Take into consideration that infants when wet are slippery and will need a way to get them through the decontamination process - i.e. plastic buckets, car seats, stretchers...
• Designate a holding area and provide staff to support and supervise the children.
• Recommended age appropriate staffing ratios for untended children:
  • 1 adult to 4 infants
  • 1 adult to 10 preschool children
  • 1 adult to 20 school-age children

Washing Instructions

• If there will be significant delay to decontamination, have the victims rinse off with water exposed skin surfaces and disrobe (disposable clothing kits should be available).
• Remove all clothing (at least down to their undergarments) and place the clothing in a labeled durable 6-mil polyethylene bag (removal of clothing, at least to the undergarment level will reduce victim's contamination by 85 %).
• If exposure to liquid agent is suspected, cut and remove all clothing and wash skin immediately with soap and water.
• If exposure to vapor only is certain, remove outer clothing and wash exposed skin with soap and water.
• The eyes must be decontaminated within minutes of exposure to liquid nerve agent to limit injury. Flush the eyes immediately with water for about 5 to 10 minutes by tilting the head to the side, pulling eyelids apart with fingers, and pouring water slowly into eyes. There is no need to flush the eyes following exposure to nerve agent vapor. Remove contact lenses if easily removable without additional trauma to the eye.
• If clothes have been exposed to contamination, then extreme care must be taken when undressing to avoid transferring chemical agents to the skin - i.e. any clothing that has to be pulled over your head should be cut off instead of being pulled over your head.
• Scraping with a wooden stick, i.e. a tongue depressor or popsicle stick, can remove bulk agent.
• Cover all open wounds with plastic wrap prior to performing head to toe decontamination (particular attention should be made to open wounds because cyanide is readily absorbed through abraded skin).
• Flush the exposed skin and hair with plain water for 2 to 3 minutes then wash twice with mild soap. Rinse thoroughly with water. Be careful not to break the patient/victim's skin during the decontamination process.
• Caution - many people shower as they do it at home rather than conducting a rapid decontamination of their bodies. Too aggressive scrubbing can lead to further damage to skin and open wounds.
• Irrigate exposed or irritated eyes with plain water or saline for 5 minutes. Continue eye irrigation during other basic care or transport. Remove contact lenses if easily removable without additional trauma to the eye.
• Utilizing large amounts of water by itself is very effective (limit pressure in infants).
• If water supplies are limited, and showers are not available an alternative form of decontamination is to use absorbent powders such as flour, talcum powder, or Fuller's earth (0.5% sodium hypochlorite solution is contraindicated).
• Sodium hypochlorite is not recommended for use in infants and young children.
• Certification of decontamination is accomplished by any of the following: processing through the decontamination facility; M8, M9 tape; M256A1 ticket; or by the Chemical Agent Monitor (CAM).
• If still contaminated repeat shower procedure.

In cases of ingestion, do not induce emesis. If the victim is alert, asymptomatic, and has a gag reflex, administer slurry of activated charcoal (administer at 1 gm/kg, usual adult dose 60-90 g, child dose 25-50 g). A soda can and a straw may be of assistance when offering charcoal to a child (consider naso-gastric tube - if possible contact ED prior to use of NG tube in infants and children [risk vs. benefit of inducing emesis with NG tube placement]).

Decontamination of First Responder

• Begin washing PPE of the first responder using soap and water solution and a soft brush. Always move in a downward motion (from head to toe). Make sure to get into all areas, especially folds in the clothing. Wash and rinse (using cold or warm water) until the contaminant is thoroughly removed.
• Reactive Skin Decontamination Lotion (RSDL) - designed to be carried by First Responders and warfighters, this lotion was found to be highly effective in removing and or neutralizing groups of chemical warfare agents. RSDL performed significantly better than the predicate device against the agents tested. The foam applicator immediately removes the CW agent off the skin and the CW Agent is chemically changed to a non-toxic form. Once the CW Agent is decontaminated, RSDL leaves a non-toxic residue that can be rinsed off when operational conditions allow.
• Avoid combining bleach (hypochlorite) with RSDL - the combination is combustible
• Links - RSDL background information
• Remove PPE by rolling downward (from head to toe) and avoid pulling PPE off over the head. Remove the SCBA after other PPE has been removed.
• Place all PPE in labeled durable 6-mil polyethylene bags.

Decontamination of Infants and Children

• Video: Decontamination of Infants and Children (HHS/AHRQ, Children's Hospital Boston) (Watch video)
  • Decontamination of Children (HHS/AHRQ) provides a step-by-step decontamination demonstration in real time, and trains clinicians about the nuances of treating infants and children, who require special attention during decontamination.

Wound Management

• Link to Wound Management

References

• Medical Management of Chemical Casualties Handbook, 2nd edition, September, 1995
• Braue EH, Boardman CH. Decontamination of Chemical Casualties
• Jagminas L. CBRNE - Chemical Decontamination (eMedicine)

Following decontamination the patient should be reassessed; noting changes in triage category (if any), the need for or the modification of supportive therapy as well as the initiation or continuation of nerve agent specific antidotes (See ABC reminders/Advanced Treatment) .

Quickly access airway patency. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Ensure adequate respiration and pulse. Document oxygen saturation. Place on a cardiac monitor.

Link to Primary and Secondary Survey

If the patient is symptomatic, immediately institute emergency life support measures, including the use of nerve agent specific antidotes.

Advanced Treatment

In cases of respiratory compromise, secure airway and respiration via endotracheal intubation or laryngeal mask airway (LMA) (use Bag Valve Mask (BVM) if unable to secure airway). If clinically indicated, perform cricothyroidotomy or place 14 gauge intracath in the cricothryroid membrane (if equipped and trained to do so).

Link to 14 gauge intracath placement instructions.

Patients who are in cardiorespiratory failure or have seizures should be treated according to advanced life support (ALS) protocols.

Link to Basic and Advanced Life Support

Antidotes

If clinically indicated, initiate/repeat dosing of atropine and pralidoxime.

Link to Antidote Treatment in the Hot/Warm Zones

Only decontaminated patients or patients not requiring decontamination should be transported to a medical facility. "Body bags" are not recommended.

If a nerve agent containing solution has been ingested, prepare the ambulance in case the victim vomits toxic material. Have ready several towels and open plastic bags to quickly clean up and isolate.

Patients exposed to vapor who have miosis and rhinorrhea will need no care unless:

(a) They have eye or head pain or nausea and vomiting; under these circumstances topical atropine or homatropine in the eye should relieve the symptoms and the patient can be discharged within an hour or so.

(b) The rhinorrhea is very severe; under these circumstances, atropine IM (2 mg in adults and 0.05 mg/kg in children) should relieve this and the patient can be discharged in an hour or so.

Topical atropine and homatropine should not be used routinely for miosis because they cause visual impairment for about 24 hours. The patient's names, addresses, and telephone numbers should be recorded. They should be advised to seek medical care promptly if symptoms develop or recur (see Patient Information Sheet ).

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