| Chemical | Mechanism of action | Clinical findings | Decontamination* | ManagementΔ |
Nerve agents:
- Tabun (GA)
- Sarin (GB)
- Soman (GD)
- Cyclosarin (GF)
- VX (O-ethyl S-[2-(diisopropylamino)ethyl] methylphosphonothioate)
| Anticholinesterase: Muscarinic, nicotinic and CNS effects | Cholinergic crisis◊ with either: a) Sudden collapse, coma, apnea, and convulsions OR b) Progression from local effects (see below) to generalized systemic effects (fasciculations, coma, seizures, paralysis):
- Local effects from vapor inhalation: Miosis, rhinorrhea, salivation, difficulty breathing
- Local effects from liquid on skin: Local sweating, twitching, and fasciculations
| Vapor:
- Move to fresh air
- Remove clothes
- Wash hair
Liquid:
- Remove clothes
- Use Reactive Skin Decontamination Liquid for spot decontamination
- Irrigate skin with water or soapy water
- Irrigate eyes and wounds with sterile saline or water
| Do not delay antidotal therapy if nerve agent exposure is suspected§:
- Mild effects: Atropine
- Moderate effects: Atropine¥ and pralidoxime
- Severe effects: Atropine¥‡, pralidoxime, and a benzodiazepine (eg, valium, lorazepam, or midazolam)
For specific dosing and indications refer to UpToDate topics on chemical terrorism |
| Cyanide (AC) | Cytochrome oxidase inhibition: Cellular anoxia, lactic acidosis | - Tachypnea
- Coma
- Seizures
- Apnea
| Fresh air Skin: Soap and wat‡er | Do not delay antidotal therapy if cyanide poisoning is suspected§:
- Hydroxocobalamin (Cyanokit) OR
- Cyanide antidote kit: Amyl nitrite perles for inhalation and intravenous preparations of sodium nitrite and sodium thiosulfate
For specific dosing and indications refer to UpToDate topics on cyanide poisoning and chemical terrorism |
| Pulmonary, type I (central, eg, hydrogen chloride, hydrogen fluoride) or combination agents (eg, chlorine) | Type I: Various mechanisms causing irritation (including irritative laryngospasm) and partial to total airway obstruction Combination: In addition to type I, various reactions causing fluid leakage and pulmonary edema | Type I:
- Airway noise (coughing, sneezing, hoarseness, inspiratory stridor, wheezing)
- Irritation of eyes, nose, and throat
- Irritative laryngospasm
Combination:
- Type I findings
- Delayed onset chest tightness or shortness of breath
| Fresh air Skin: Irrigate with water | - Provide humidified oxygen
- Inhaled racemic epinephrine for stridor or upper airway obstruction
- Pulmonary toilet
- Bronchoscopy for severe upper airway obstruction
- Give antibiotics only after identification and testing of causative organism
- For combination agents, as above, and:
- Strict bed rest
- Positive pressure ventilation, as needed to support breathing
- Admit to a pulmonary ICU
|
| Type II pulmonary agents (eg, phosgene [GG]) or combination agents (eg, chlorine) | Type II: Various reactions causing fluid leakage and pulmonary edema Combination: In addition to type II effects, various mechanisms causing irritation (including irritative laryngospasm) and partial to total airway obstruction | Delayed onset chest tightness and shortness of breath Combination, rapid onset of :
- Airway noise(coughing, sneezing, hoarseness, inspiratory stridor, wheezing)
- Irritation of eyes, nose, and throat
- Irritative laryngospasm
| Fresh air Skin: Irrigate with water | - Strict bed rest
- High flow nasal cannula†, nasal CPAP†, or positive pressure ventilation, as needed to support breathing
- Admit to a pulmonary ICU
- For upper airway symptoms:
- Provide humidified oxygen
- Pulmonary toilet
- Inhaled racemic epinephrine for stridor upper airway obstruction
- Bronchoscopy for severe upper airway obstruction
- Give antibiotics only after identification and testing of causative organism
|
Crowd-control agents:
- CS (o-chlorobenzylidene malononitrile)
- CN (mace)
- OC (oleoresin capsicum, pepper spray)
| Alkylation Release of substance P (OC) | Eye: Tearing, pain, blepharospasm Nose and throat irritation Type I pulmonary effects if very concentrated exposure Bronchospasm | Fresh air Skin: Flush with water or soapy water Eye: Water or normal saline irrigation Avoid bleach | - If no sign of an open globe, apply topical ophthalmic anesthetic drops (eg, proparacaine 0.5 percent one drop to each eye) and evaluate for corneal abrasions and other ocular injuries
- Symptomatic support of bronchospasm (eg, oxygen, inhaled short-acting beta-2 agonists [eg, albuterol], and corticosteroids)
- If severe exposure with signs of upper airway compromise, as above for type I pulmonary agents
|
| Mustard compounds (eg, sulfur mustard [H]) | Alkylation | Skin: Erythema, vesicles Eye: Inflammation Respiratory tract: Inflammation | Skin: Soap and water Eyes: Water (only effective if done within minutes of exposure) | Symptomatic and supportive care for partial thickness burns, corneal toxicity, and bone marrow suppression |
| Lewisite (L) | | Skin: Erythema, vesicles Eye: Inflammation Respiratory tract: Inflammation | Skin: Soap and water Eyes: Water (only effective if done within minutes of exposure) | - Symptomatic and supportive care as for partial thickness burns
- Dimercaprol [BAL] 3 to 4 mg/kg IM every four to six hours for systemic effects in severe cases
|
| BZ (3-quinuclidinyl benzilate) | Competitive antagonism of acetylcholine at muscarinic receptors | Anticholinergic effects:
- Peripheral:
- Dilated pupils
- Dry mouth
- Flushed skin
- Tachycardia
- Hypertension
- Absent bowel sounds
- Urinary retention
| Irrigate skin with water or soapy water | - Benzodiazepines as needed for agitation
- Physostigmine for patients with peripheral and moderate to severe central effects (eg, delirium with danger to self or others or seizures) by providers familiar with its use
For specific indications and dosing, refer to UpToDate topics on chemical terrorism and anticholinergic poisoning |
