Recognition of toxic syndromes described in this document early in the response is key to preventing further exposures to hospital personnel.

PPE required:

Most likely level B-C PPEs will be adequate for hospital purposes.

If the hospital is notified of a chemical event, regardless of the chemical type, hospital personnel should immediately don chemical protective clothing (specifically, nonporous chemical protective suit, chemical goggles and chemical protective gloves (such as nitrile). Gloves worn double-layered will help ensure appropriate outer glove replacement while decreasing risk of dermal exposure due to glove tearing or during glove removal/replacement process.

Respiratory protection at a minimum is an air-purifying respirator that is CBRN tested and approved by the National Institute for Occupational Safety and Health. Wearers should already have complied with OSHA 29 CFR 1910.134 for medical qualification, training and fit-testing (for the appropriately sized respirator). Powered Air Purifying Respirators (PAPR) is permissible if they are CBRN tested and approved by NIOSH.

• 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).
• Level B - requires the use of SCBA but has lesser skin protection. Levels Bs are chemical resistant suits that are designed for splashes of liquids, but not for gas or vapor hazards. A young soldier can last about 2 hours on a hot day with an external air hose.
• Level C is similar to B with the exception of the type of respiratory protection. The SCBA is replaced with an Air Purifying Respirator (see above).
• Level D protective clothing is utilized when there are no respiratory hazards and no major skin hazard considerations. Level D for hospital personnel includes scrubs, safety glasses, shoe covers, and possibly a face shield. These devices offer no protection from liquid or vapor nerve agent exposures.

Upon notification, the hospital needs to establish its own decontamination process outside of the ED, or request assistance from supporting hazardous materials response units, as appropriate.

After completion of ED medical treatment of all chemical casualties, hospital personnel will then process through decontamination with their PPE and respiratory protection. Only after executing the appropriate decontamination process can hospital personnel remove PPE and respiratory protection.

If you are an Emergency Responder and you think you have been exposed, see either Sarin Specific Triage or Clinical Signs and Symptoms, Decontamination.

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.

Perform decontamination triage by separating and prioritizing victims into categories in preparation for mass decontamination:

• Ambulatory and symptomatic (e.g., instruct victim to proceed to decontamination)
• Non-ambulatory (e.g., assist victim through decontamination)
• Ambulatory and non-symptomatic, but exposed to contaminant (e.g., instruct victim to proceed to decontamination)
• Ambulatory and non-symptomatic, with no obvious exposure to contaminant (e.g., instruct victim to proceed to Safe Refuge/Observation Area)

ENCOURAGE VICTIMS TO REMOVE AS MUCH CLOTHING AS POSSIBLE, BUT AT LEAST REMOVE OUTER GARMENTS DOWN TO UNDERWEAR. Cutting and/or unbuttoning is preferred to pulling clothing over the head.

If clothes must be lifted over the head, instruct victims to do so carefully by placing hands and arms inside the garment and using the hands to pull the head opening away from the face and head as much as possible.

• The Model Uniform Core Criteria (MUCC)
• START Adult Triage Algorithm
• JumpSTART Pediatric Triage Algorithm

• Severe symptoms - these include unconsciousness, convulsions, apnea, and flaccid paralysis.
• Mild/ Moderate symptoms - these include localized swelling, muscle fasciculations, nausea and vomiting, weakness, shortness of breath.
• Patients who are conscious and have full muscular control will need minimal care.
• Patients with a history of possible exposure to vapor only (with no possibility of liquid exposure) who have no signs of exposure by the time they reach the medical facility have not been exposed (because these effects occur within seconds to minutes after exposure). They can be discharged.
• Delayed Effects from skin exposure to liquid nerve agent may not develop for up to 18 hours following exposure. Therefore, patients exposed primarily through skin, had conducted skin decontamination and were initially asymptomatic need awareness that NA symptoms may occur up to 18 hours later.
• Patients who have inhalation exposure and who complain of chest pain, chest tightness, or cough should be observed and examined periodically for 6 to 12 hours to detect delayed-onset bronchitis, pneumonia, pulmonary edema, or respiratory failure.
• Patients exposed to nerve agent vapor that have only miosis and/or mild rhinorrhea when they reach the medical facility do not need to be admitted. All other symptomatic patients who have had exposure to nerve agent should be hospitalized and observed closely.

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 may be required to enable ventilation. Stabilize the cervical spine with a decontaminable collar and a backboard if trauma is suspected. Avoid supine hypotension syndrome in pregnant women by maintaining a left lateral tilt. Direct pressure should be applied to control heavy bleeding, if present.

• Link to Nerve Agent Antidote/Seizure Medication Treatment section
• 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, nausea & vomiting (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.
• 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 induced 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

Supportive - link to Basic and Advanced Life Support reference section

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 possible, a system should be employed to track antidotes administered.

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 (use autoinjectors, if available).
  
  

  	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 autoinjectors, if available. May use a 600 mg 2PAM Cl autoinjector in an infant as small as 12 kg.
  
  

  	Atropine Autoinjector/IM† *	2-PAM Cl 600mg 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 IM or 25 mg/kg IV over 20-30 minutes
  Child (3-7 yrs)	1 mg 1 (1mg) autoinjector/IM	15 mg/kg/IM May use 1 autoinjector/IM (600mg)‡ or 25 mg/kg IV over 20-30 minutes
  Child (8-14 yrs) 26-50 kg	2 mg 1 (2mg) autoinjector/IM	15 mg/kg/IM May use 1 autoinjector/IM (600mg)‡ or 25 mg/kg IV over 20-30 minutes
  Adolescent/Adult	2-4 mg 1-2 (2mg) autoinjector(s)/IM	1 autoinjector/IM (600mg) or (1 gm) IV over 20-30 minutes
  Pregnant Women	2-4 mg 1-2 (2mg) autoinjector(s)/IM	1 autoinjector/IM (600mg) or (1 gm) IV over 20-30 minutes
  Seniors	2 mg 1 (2mg) autoinjector/IM	10 mg/kg IM 1 autoinjector/IM (600mg) or 10 mg/kg IV over 20-30 minutes

• Repeat initial dose (2 mg max) of atropine 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† *	2-PAM Cl† *
Infant (0-2 yrs)	0.1 mg/kg given IM or via autoinjector (0.25 and 0.50 mg sizes are available) or 0.1 mg/kg IV	45 mg/kg IM 50 mg/kg IV over 20-30 minutes
Child (3-7 yrs) 13-25 kg	0.1 mg/kg IM/IV 1 (2 mg) autoinjector/IM	45 mg/kg IM Use 1 autoinjector (600 mg)‡ or 50 mg/kg IV over 20-30 minutes
Child (8-14 yrs) 26-50 kg	4 mg IM/IV 2 (2 mg) autoinjectors/IM	45 mg/kg IM Use 2 autoinjectors (1200 mg)‡ or 50 mg/kg over 20-30 minutes (max 2 gm)
Adolescent (>14yrs)/Adult	6 mg IM/5 mg IV 3 (2 mg) autoinjectors	Use 3 autoinjectors (1800 mg) or 50 mg/kg over 20-30 minutes (max 2 gm)
Pregnant Women	6 mg IM/5 mg IV 3 (2 mg) autoinjectors	Use 3 autoinjectors (1800 mg) 50 mg/kg over 20-30 minutes (max 2 gm)
Seniors	2-4 mg IM/IV 1-2 (2 mg) autoinjector	25 mg/kg IM Use 2-3 autoinjectors (1200-1800 mg) 25 mg/kg IV over 20-30 minutes

• Repeat atropine 2 mg (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.
  
  Initial Dosing:
  

  Initial Dosing
  	Diazepam† *	Midazolam ‡ *
  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
  	X2, 0.2-0.5 mg/kg IV/IO Q15-30 minutes	X 1
  	Total max dose 5 mg (<5yrs)	Total max dose 0.3 mg/kg, not to exceed 20 mg
  	Total max dose 10 mg (≥5yrs) 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 Q15 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 Q15 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 Q15 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 Q15 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

The key to successful mass casualty decontamination is to use the tiered approach that will cause the least harm and do the most good for the majority of the people. The tiered approach consists of three tiers of decontamination: self-care, gross patient decontamination and technical patient decontamination.

• Self-care actions involve informing exposed patients on performing decontamination actions while awaiting for gross and technical decontamination. This includes clothing removal, and wiping away visible contamination on skin. Clothing removal should require maintaining privacy between genders and appropriate legal/parental guidance of children.
• Gross patient decontamination involves a shower design, which could involve a fire department Ladder Pipe Decontamination System, to provide low pressure, high volume water flow as well as spot decontamination on skin using appropriate adsorbent material. The purpose here is a rapid reduction in contamination.
• Technical patient decontamination involves assistance of first responders or trained hospital staff to achieve contamination reduction to a level that is as low as possible. Actions include evaluating the effectiveness of the gross and self-care decontamination efforts, and if required, providing additional high-volume, low pressure water with the use of soap (for oily substances still remaining on skin), and gentle rubbing with soft cloth or sponge.

Rapid decontamination is critical to prevent further absorption by the patient and to prevent exposure to others. However, some nerve agent may remain in the hair or clothing and should be decontaminated if not previously done.

• Non-liquid If hospital providers suspect the contamination is biological, radiological, or a gas/vapor, a water-only shower is typically adequate. Persons whose skin is exposed only to nerve agent vapor pose no risk of secondary contamination; however, clothing and hair can trap vapor and this can lead to secondary contamination.
• When liquid contamination is involved, soap should be included as soon as possible in the process, HOWEVER, not to the extent that application delays initial decontamination with water. Soap may be delayed until secondary decontamination if adding it would delay initial decontamination.

Decontamination Setup

Link to Decontamination Setup- Prehospital

• Use pictorial and written posted instructions for victims to self-decontaminate 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 if possible, 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...
• Disposable clothing kits should be available
• 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

Primary Decontamination

Primary Decontamination - If the hospital is going to function as the initial/primary decontamination site - link to prehospital decontamination

Secondary Decontamination Primary Decontamination for Liquid Nerve Agent (if time and resources allow)

Clothing Removal: While it is not critical that victims remove their clothing for this process; it should be recommended that victims do so to the point of their own comfort level. Removal of all clothing would be most effective. Making this action a requirement may cause many citizens to be- come uncooperative and potentially delay the mass decontamination process. No delay should be caused by arguing the point.

• Removal of clothing down to the underwear is an effective compromise for all situations, with the exception of liquid contamination that has saturated outer clothing and contacted undergarments.
• Note: The effectiveness of disrobing prior to decontamination rapidly decreases with time, following exposure.
• If clothes must be lifted over the head, instruct victims to do so carefully by closing their mouth to avoid ingestion or inhalation, and by placing hands and arms on the inside of the garment and using the hands to pull the head opening away from the face and head as much as possible. These precautions will reduce the chance of exposing the head, face and eyes to inhalation or ingestion contamination. Whenever possible, victims should unbutton or cut clothes away rather than lift them over their head. This will reduce the chance of exposing the head, face and eyes to contamination.
• Link to Prehospital Pictorial Removal of Clothing
• Rubbing without the aid of soap is not recommended, as it may increase spread of the liquid agent over a larger surface area of the body, resulting in increased medical risk.
• 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. - modify for time limitations
• When removing liquid chemical contamination (e.g., sulfur mustard), use of a wash cloth may significantly aid in decontamination by gently rubbing the contaminated area. Caution should still be exercised to prevent the spread of contamination.
• Ideally 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 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. Continue irrigation post decon if possible
• 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).
• 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.

Cold Weather Guidelines

• Even in cold weather conditions, it is still most practical to conduct decontamination outdoors. In general, the human body can withstand very low temperatures for a brief amount of time. Children and the elderly are at increased risk for hypothermia.
• The recommended methods for mass casualty decontamination, immediate clothing removal and a high-volume, low-pressure shower, remain the same for outdoor air temperatures as low as 36º F. Once victims are decontaminated, they should be provided with clothing/cover and moved to a heated facility.
• For outdoor air temperatures 35º F and below, removal of clothing and a "dry" decontamination method for removal of liquid contamination is recommended, such as blotting with paper towel, followed by high-volume, low-pressure water shower at a heated facility.
• Symptoms of hypothermia include sensation of cold, exhaustion, and numbness. Signs of hypothermia include shivering, pallor (i.e., deficiency of color, especially of the face; aka paleness) in adults, flushed skin in children, decrease hand coordination, confusion, and slurred speech. Diagnosis is made when the core body temperature is <95° F (<35° C). Hypothermia can be mild (90° F to 95° F [32° C to 35° C]), moderate (82.5° F to 90° F [28° C to 32° C]), or severe (<82.5° F [<28° C]).
• Mild hypothermia can be treated with passive re-warming by using blankets. Moderate hypothermia requires active re-warming with warm intravenous fluids, oxygen, lavage, or immersion baths. Severe hypothermia might require both active re-warming and cardiopulmonary bypass. The core body temperature should be re-warmed by 2° to 4° F [1° to 2° C] per hour. As needed, cardiopulmonary resuscitation and supportive care should be provided, cardiac rhythm monitored, and electrolytes replenished.

Link to - Cold weather decontaminations pictorial guidelines

Link to - Decontamination of first responders

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

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.

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; or

(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.

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).

Quickly assess airway patency. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Avoid supine hypotension syndrome in pregnant women by maintaining a left lateral tilt. 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.

Supportive - Link to supportive treatment in the hot/warm zones

Clinical Signs and Symptoms - Link to clinical signs and symptoms

Medical management for partially/non-responsive severe exposure

• If IV access/drips are unavailable for adults and adolescents - repeat atropine autoinjector/IM every 2- 5 minutes (infants and children every 5 minutes) utilizing initial dosing until dyspnea, resistance to ventilation, and secretions are minimized.
• If drips are unavailable repeat 2PAM Cl dose hourly X 2 PRN, then repeat Q6-12 h PRN.
• Review Airway, Breathing, Circulation, Disability, and Exposure. Place patient in the Left Lateral Position, preferably with head lower than the feet, to reduce the risk of aspirating stomach contents. Provide high flow oxygen, if available. Intubate the patient if their airway or breathing is compromised. Treat complicating injuries.

If resources allow;

Atropine

Pralidoxime

• Give pralidoxime chloride†* 1- 2 g IV over 20-30 mins (25-50 mg/kg) into a second cannula; follow with an infusion of pralidoxime 0.5-1 g/hr (10-20mg/kg) in 0.9 % normal saline. If drips are unavailable repeat 2PAM Cl dose hourly X 2 PRN, then repeat Q6-12  h PRN.
• Continue the oxime infusion until atropine has not been required for 12-24 hrs and the patient extubated.
• Continue to review respiratory function. Intubate and ventilate patients when the tidal volume or vital capacity fall below 5 ml/kg or 15 ml/kg, respectively, have apneic spells, or PaO2 <8 kPa (60 mmHg) on FiO2 of >60 %.
  Link to Advanced Life Support reference

Treatment of Seizures

• 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. Once seizures are under control, may repeat doses of diazepam or midazolam Q2-4 h PRN. If one benzodiazepine doesn't work initially, try the other. Consider continuous infusion of midazolam, ketamine/anesthesia for non-responsive status. EEG monitoring on a PRN basis.

Scopolamine???

Supportive

• Review flexor neck strength regularly in conscious patients by asking them to lift their head off the bed and keep it there when pressure is applied to their forehead. Any sign of weakness is a sign that the patient is at risk of developing peripheral respiratory failure (intermediate syndrome - seen occasionally with organophosphate toxicity/ not associated with nerve agent). The tidal volume should be checked in such patients every 4 hrs. Values less than 5 ml/kg are an indication for intubation and ventilation.
• Treat agitation by reviewing the dose of atropine being administered and giving adequate sedation with benzodiazepines. An antipsychotic, such as haloperidol, can be used but may be less effective for alcohol withdrawal, a frequent co-morbidity in self-poisoned patients. Physical restraint of agitated patients in warm conditions risks severe hyperthermia - this is exacerbated greatly by atropine which inhibits normal thermoregulatory responses, including sweating. Adequate sedation is therefore important.
• Respiratory - bronchospasm - clinically appears like status asthmaticus, pulmonary edema - utilize oxygen, bronchodilators (watch for increased vulnerability to arrhythmias) ventilator etc. - link to ALS
• Cardiac - monitor for arrhythmias - link to ALS
• Fluids, electrolytes, nutrition - children have lower reserves of fluid and are more vulnerable to GI loses, correct acidosis, nursing mothers should pump and discard breast milk until cleared medically.
• Eye care - treat eye pain, miosis (atropine will not reverse miosis).
• Monitor frequently for recurring cholinergic crises due to leaching of fat soluble OPs from fat stores. Such crises can occur for several days to weeks post-ingestion of some OPs. Patients with recurring cholinergic features will need reloading with atropine.
• While this has not been demonstrated with nerve agent exposure, monitor for the potential development of intermediate syndrome (IMS). This is a syndrome of muscular paralysis occurring in conscious patients typically 24-96 hours (it may occur earlier or later) following ingestion of certain organophosphate agents (following the acute cholinergic syndrome which was treated with atropine). Muscle weakness affects predominantly the proximal limb muscles and those supplied by the cranial nerves. IMS is often associated with respiratory failure.
• Ingestion Exposure - Do not induce emesis because of the risk of pulmonary aspiration of gastric contents which may result from abrupt respiratory arrest, seizures, or vomiting. Consideration of decontamination should only be considered after the patient has been stabilized and treated with oxygen, atropine, and an oxime. If the patient is alert and charcoal has not been given previously, administer slurry of activated charcoal (questionable efficacy). If the patient's condition is evaluated within two hours after ingestion of a substantial amount of OP and the patient is fully alert or intubated, consider gastric lavage (some Chinese studies recommend multiple lavages) [Gastric contents should be considered potentially hazardous by skin contact or inhalation and should be quickly isolated].
• Link to Key Acute Care Adult Medications section
• Link to Key Acute Care Pediatric Medications section
• Link to Nerve Agent Treatment - Autoinjector Instructions

† 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.

Cholinesterase assays

• A diagnosis of OP/NA poisoning should be ideally confirmed with an assay to measure BuChE activity in the plasma. However the lack of an assay or delay of access to an assay should not delay treatment.
• Some OPs inhibit BuChE more effectively than they inhibit AChE. Since BuChE activity does not relate to the severity of the poisoning, BuChE inhibition cannot be used to assess severity. It can however be used as a sensitive marker of 1) exposure to most OPs or other ChE-inhibiting compound and 2) when the OP has been eliminated from the body.
• Red cell AChE is a good marker of synaptic function and atropine requirements in OP/NA poisoned patients and, therefore, a good marker of severity. Severe symptoms of toxicity are usually present when more than 70 % of RBC cholinesterase is inhibited. However, there is no correlation between cholinesterase activity and severity of topical signs and symptoms (e.g., miosis, rhinorrhea, dyspnea). A major problem with AChE assays is that the interaction between OP, AChE, and oximes continues to occur if the sample is left at room temperature for even a few minutes. To get reliable results, it is essential to stop the reaction immediately when the blood sample is taken from the patient, by cooling and diluting it. Otherwise differences in time to sample cooling of only a few minutes for repeated sampling will cause marked variation and make interpretation difficult.

Routine laboratory studies for all admitted patients include CBC, glucose, and serum electrolyte determinations. Chest X-ray and pulse oximetry (or ABG measurements) are recommended for severe exposures.

Patient Release and Follow-up

Patients who have severe exposure should be evaluated for persistent CNS signs and symptoms. Refer patients with neuropsychiatric sequelae appropriately as these are likely secondary to nerve agent. Patients should be advised to avoid organophosphate insecticide exposure such as avoidance of any household or commercial insecticides until sequential RBC cholinesterase activity (measured at weekly to monthly intervals) has stabilized in the normal range, a process that may take 3 to 4 months after severe poisoning.

Link to Sarin Specific Triage

Link to Neuro/Psych Reference

Link to Surveillance for Possible Chemical Emergencies

Link to Management of the Deceased

Follow-up Instructions

Adapted from Medical Management Guidelines for Nerve Agents: Tabun (GA); Sarin (GB); Soman (GD); and VX (ATSDR/CDC)

PDF documents can be viewed with the free Adobe® Reader™