Nerve Agents

Treatment in the Hot Zone

Syringe

Treatment

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

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/Adult2 mg autoinjector/IM
    Pregnant women2 mg autoinjector/IM
    Senior1 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/IM15 mg/kg
    May use 1 autoinjector (600 mg)
    Child (8-14 yrs)
    26-50 kg
    2 mg autoinjector/IM15 mg/kg
    May use 1 autoinjector (600 mg)
    Adolescent/Adult 2-4 mg autoinjector/IM1 autoinjector (600 mg)
    Pregnant Women2-4 mg autoinjector/IM1 autoinjector (600 mg)
    Seniors, frail2 mg autoinjector/IM10 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)
    Adult6 mg
    3 (2mg) autoinjectors
    Use 3 autoinjectors (1800 mg)
    Pregnant Women6 mg
    3 (2 mg) autoinjectors
    Use 3 autoinjectors (1800 mg)
    Seniors, frail2-4 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
    Infant0.2-0.5 mg/kg IM repeat Q2-5 min0.15 mg/kg IM, repeat PRN 10 minutes
    X 2, 0.2-0.5 mg/kg IV/IO Q15-30 minutesX 1
    Total max dose 5 mgTotal max dose 0.3 mg/kg
    Child0.2-0.5 mg/kg IM repeat Q2-5 min0.15 mg/kg IM, not to exceed 10 mg, repeat PRN 10 minutes
    X 2, 0.2-0.5 mg/kg IV/IO Q15-30 minutesx 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
    Adolescent2-3 CANA autoinjectors0.15 mg/kg IM, max 10 mg, repeat PRN 10 minutes
    5-10 mg IV/IO Q10-15 minX 1
    Total max dose 30 mgTotal max dose 20 mg
    Adult2-3 CANA autoinjectors10 mg IM, repeat PRN 10 minutes
    5-10 mg IV/IO Q10-15 minX 1
    Total max dose 30 mgTotal max dose 20 mg
    Pregnant Women2-3 CANA autoinjectors10 mg IM, repeat PRN 10 minutes
    5-10 mg IV/IO Q10-15 minX 1
    Total max dose 30 mgTotal max dose 20 mg, Category D *
    Senior2-3 CANA autoinjectors10 mg IM, repeat PRN 10 minutes
    5-10 mg IV/IO Q10-15 minX 1
    Total max dose 30 mgTotal 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.

Find more information on this substance at: PubChem, PubMed