Sarin

CAS RN:107-44-8

Treatment Overview

0.4.2 ORAL/PARENTERAL EXPOSURE
  • A) Treatment should include recommendations listed in the INHALATION EXPOSURE section.
0.4.3 INHALATION EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Treatment is symptomatic and supportive, including treatment with atropine and oximes (eg, pralidoxime in the US and obidoxime and HI-6 internationally). Treatment is the same regardless of the route of exposure. Monitor the patient for respiratory distress (from bronchospasm, increased bronchial secretion, or muscle weakness). Administer IV fluids and electrolytes as needed to replace fluid losses. Administer atropine for muscarinic manifestations (eg, salivation, diarrhea, bronchospasm, bronchorrhea, bradycardia) and pralidoxime for nicotinic manifestations (eg, weakness, fasciculations). If atropine is unavailable or if central anticholinergic toxicity is present, glycopyrrolate is a reasonable alternative. Supplemental therapy with oxygen and beta-2 adrenergic agonist aerosols (eg, albuterol) may be helpful.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) Treatment is symptomatic and supportive, including treatment with atropine and oximes (eg, pralidoxime in the US and obidoxime and HI-6 internationally). Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation, and replace fluids and electrolytes as required. Treatment is the same regardless of the route of exposure. Monitor the patient for respiratory distress (from bronchospasm, increased bronchial secretion, or muscle weakness). Administer atropine for muscarinic manifestations (eg, salivation, diarrhea, bronchospasm, bronchorrhea, bradycardia) and pralidoxime for nicotinic manifestations (eg, weakness, fasciculations). If atropine is unavailable or if central anticholinergic toxicity is present, glycopyrrolate is a reasonable alternative. Supplemental therapy with oxygen and beta-2 adrenergic agonist aerosols (eg, albuterol) may be helpful. If induction of paralysis with muscle relaxing agents is required for intubation, succinylcholine should be avoided because of potential for prolonged duration of paralysis. In contrast, nondepolarizing neuromuscular blockers such as pancuronium may protect the neuromuscular junction from injury. If seizure develops, administer a benzodiazepine IV. Consider phenobarbital or propofol if seizures recur. Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.
  • C) DECONTAMINATION
    • 1) UNIVERSAL PRECAUTIONS should be followed by all staff members caring for the patient; nitrile gloves are suggested.
    • 2) PREHOSPITAL: Induction of emesis is not recommended. Move patient from the toxic environment to fresh air. Patients who may have passed through a droplet cloud should have external decontamination. Potentially contaminated clothing should be removed and the skin, face, and hair washed with soap and water or a dilute (less than 1%) sodium hypochlorite solution. Monitor for respiratory distress. Following eye exposure, remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persists after 15 minutes of irrigation, an ophthalmologic examination should be performed. Do not instill sodium hypochlorite into the eye. Ocular symptoms caused by local absorption of nerve agents do not respond to systemic administration of atropine.
    • 3) HOSPITAL: ORAL EXPOSURE: Induction of emesis is not recommended. Administration of activated charcoal is not recommended due to the rapidity of absorption and the risk of charcoal aspirations. INHALATION EXPOSURE: After external decontamination (see above), carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary. EYE EXPOSURE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persists after 15 minutes of irrigation, an ophthalmologic examination should be performed. Do not instill sodium hypochlorite into the eye. Ocular symptoms caused by local absorption of nerve agents do not respond to systemic administration of atropine; symptomatic miosis may be relieved by local instillation of 2% homatropine or 1% atropine or 1% cyclopentolate hydrochloride or an eye mixture of 0.5% tropicamide and 0.5% phenylephrine hydrochloride, repeated several times daily for up to 3 days. Carefully observe patients with eye exposure for the development of systemic toxicity. DERMAL EXPOSURE: After external decontamination (see above), a physician may need to examine the area if irritation or pain persists. Discard contaminated clothing. Carefully observe patient for the development of systemic toxicity. Other alternatives are the following: M291 Skin Decontaminating Kit (for military and civil defense use manufactured by Rohm and Haas). Diluted hypochlorite (household bleach 1:10 in water) followed by a thorough water rinse. 0.5% Hypochlorite solution (prepared by adding one 6 ounce bottle of calcium hypochlorite granules to 5 gallons of water).
  • D) AIRWAY MANAGEMENT
    • 1) Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer IV or IM atropine and inhaled beta-2 adrenergic agonists if bronchospasm develops. Give atropine to reduce hypersecretion and bronchial secretion. Avoid succinylcholine for rapid sequence intubation as prolonged paralysis may result.
  • E) ANTIDOTE
    • 1) Main classes of antidotes: ATROPINE (muscarinic antagonist) and OXIMES (pralidoxime in the US, or obidoxime in some other countries) to reverse neuromuscular blockade. BENZODIAZEPINES are indicated for agitation and seizures. PREHOSPITAL TREATMENT: Autoinjectors (DuoDote(R), MARK 1 (Note: the MARK I autoinjector kit was last produced by Meridian Medical Technologies, Columbia, MD in 2008. This product may still be available in some locations.), AtroPen(R), and ATNAA) may be used. PROPHYLACTIC ANTIDOTE: Pretreatment (prior to nerve agent exposure) with pyridostigmine bromide 30 mg every 8 hours can provide some protection against nerve agents (especially SOMAN) by reversibly binding up to 30% of acetylcholinesterase and protecting it from aging. At this dose, only minimal adverse effects have been noted. This use of pyridostigmine is limited to military settings where exposure to specific military agents, especially soman, are considered likely.
  • F) ATROPINE
    • 1) Titrate to resolution of bronchospasm, bronchorrhea, and severe bradycardia. Double dose as needed; no maximum dose. IV route is preferred if available. Autoinjectors may also be used. Primarily effective for muscarinic effects. It will not reverse nicotinic effects. DOSING: IV/IM does: MILD TO MODERATE EFFECTS: ADULT AND ADOLESCENTS: 2 to 4 mg IM; CHILD: Infant 0 to 2 years: 0.05 mg/kg IM; child 3 to 7 years: 1 mg IM; child 8 to 14 years: 2 mg IM. Seniors: 2 mg IM. SEVERE EFFECTS: ADULT AND ADOLESCENTS: 6 mg IM or 5 mg IV; CHILD: Infant 0 to 2 years: 0.1 mg/kg IM/IV; child 3 to 7 years: 0.1 mg/kg IM/IV; child 8 to 14 years: 4 mg IM/IV. Repeat initial atropine dose (2 mg max) every 5 to 10 minutes until symptoms have decreased. Therapeutic effects of IM atropine doses may appear in 20 to 25 minutes (versus 8 minutes following the use of an autoinjector).
  • G) OXIMES
    • 1) PRALIDOXIME: Available in US. IV AND IM DOSING: MILD TO MODERATE EFFECTS: ADULTS AND ADOLESCENTS: 600 mg IM or 1 g IV over 20 to 30 min. CHILD: Infants 0 to 14 years: 15 mg/kg IM or 25 mg/kg IV over 20 to 30 min. SEVERE EFFECTS: ADULTS AND ADOLESCENTS: 1800 mg IM or 50 mg/kg over 20 to 30 min (MAX 2 grams). CHILD: Infants 0 to 14 years: 45 mg/kg IM or 50 mg/kg IV over 20 to 30 min. Repeat pralidoxime chloride dose hourly x 2; if clinically possible, start via continuous infusion.
    • 2) OBIDOXIME DICHLORIDE: Not available in US. INITIAL DOSE: Obidoxime may be given as an IV bolus of 250 mg and may be repeated once or twice at 2 hour intervals. ALTERNATIVE DOSE: 250 mg IV or IM bolus, followed by a continuous intravenous infusion of 750 mg/day.
  • H) PATIENT DISPOSITION
    • 1) OBSERVATION CRITERIA: Observe nerve agent casualties in a controlled setting or medical facility for at least 18 hours or until free of symptoms, except miosis.
    • 2) ADMISSION CRITERIA: Patients with severe symptoms should be admitted for treatment and monitoring. Patients with respiratory failure or unstable vital signs should be admitted to an ICU setting.
    • 3) CONSULT CRITERIA: All confirmed and highly probable cases MUST be reported to local or state public health departments. Contact your local poison center for a toxicology consult for any patient with severe toxicity. For patients with eye exposure, consult your ophthalmologist for assistance with ophthalmic examination if needed.
  • I) PITFALLS
    • 1) Failure to detect airway compromise and properly manage airways. Failure to detect dysrhythmias or hypotension.
  • J) PHARMACOKINETICS
    • 1) These agents are readily absorbed and can cause systemic effects by the inhalation, dermal, oral, or ocular routes. Inhalation of nerve agent vapor will have initial effects on the airways within seconds. Inhalation of a large amount of the vapor will result in sudden loss of consciousness followed by seizures within seconds. Within minutes of inhalation of a large amount, apnea and flaccid paralysis will occur. Following ingestion, initial symptoms begin in 20 to 30 minutes and are usually gastrointestinal symptoms. Dermal exposure to a large drop or more will result in clinical effects within 30 minutes and exposure to a very small drop will result in clinical effects anytime up to 18 hours later. A larger exposure is absorbed dermally and will cause loss of consciousness, seizures, apnea, and paralysis.
  • K) DIFFERENTIAL DIAGNOSIS
    • 1) Acute asthmatic attack, COPD with acute exacerbation, Grayanotoxin toxicity, riot control agent exposure (eg, pepper spray), irritant gas exposure, organophosphate or carbamate insecticide poisoning, medicinal carbamate poisoning (eg, pyridostigmine, neostigmine, rivastigmine).
0.4.4 EYE EXPOSURE
  • A) Treatment should include recommendations listed in the INHALATION EXPOSURE section.
  • B) Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persists after 15 minutes of irrigation, an ophthalmologic examination should be performed. Do not instill sodium hypochlorite into the eye. Ocular symptoms caused by local absorption of nerve agents do not respond to systemic administration of atropine; symptomatic miosis may be relieved by local instillation of 2% homatropine or 1% atropine or 1% cyclopentolate hydrochloride or an eye mixture of 0.5% tropicamide and 0.5% phenylephrine hydrochloride, repeated several times daily for up to 3 days. Carefully observe patients with eye exposure for the development of systemic toxicity.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) Dermal exposure may cause severe toxicity; treatment should include recommendations listed in the INHALATION EXPOSURE section.
    • 2) Remove contaminated clothing and jewelry. Wash the skin, face, nails, and hair repeatedly and vigorously with soap and water. A physician may need to examine the area if irritation or pain persists. Discard contaminated clothing. Carefully observe patient for the development of systemic toxicity. Other alternatives are the following:
      • a) M291 Skin Decontaminating Kit (for military and civil defense use manufactured by Rohm and Haas).
      • b) Diluted hypochlorite (household bleach 1:10 in water) followed by a thorough water rinse.
      • c) 0.5% Hypochlorite solution (prepared by adding one 6 ounce bottle of calcium hypochlorite granules to 5 gallons of water).
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