Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Management of Chemical Toxicity in PediatricsTable 21-3Management of Mild to Moderate Nerve Agent ExposuresManagementAntidotes*Benzodiazepines (if neurological signs)Nerve Agents Symptoms Age Dose Age Dose• Tabun• Sarin• Cyclosarin• Soman• VX• Localized sweating• Muscle fasciculations• Nausea• Vomiting• Weakness/floppiness• Dyspnea• Constricted pupils andblurred vision• Rhinorrhea• Excessive tears• Excessive salivation• Chest tightness• Stomach cramps• Tachycardia orbradycardiaNeonates and Atropine 0.05 mg/kginfants up to IM/IV/IO to max6 months old 4 mg or 0.25 mgatroPen † and 2-PAM15 mg/kg IM or IVslowly to max 2 g/hrYoung children Atropine 0.05 mg/kg(6 months IM/IV/IO to maxold–4 yrs old) 4 mg or 0.5 mgatroPen and 2-PAM25 mg/kg IM or IVslowly to max 2 g/hrOlder children Atropine 0.05 mg/kg(4–10 yrs old) IV/IM/IO to max4 mg or 1 mgatroPen and 2-PAM25–50 mg/kg IM oriV slowly to max2 g/hrAdolescents Atropine 0.05 mg/kg(≥ 10 yrs IV/IM/IO to max 4old) and mg or 2 mg AtroPenadults and 2-PAM 25–50mg/kg IM or IV slowlyto max 2 g/hrNeonatesDiazepam 0.1–0.3 mg/kg/dose IV to a maxdose of 2 mg, or Lorazepam0.05 mg/kgslow IVYoung Diazepam 0.05–0.3children (30 mg/kg IV to a max ofdays old–5 5 mg/dose or Lorazeyrsold) pam 0.1 mg/kg slowiV not to exceed 4 mgChildren (≥ 5 Diazepam 0.05–0.3yrs old)mg/kg IV to a max of10 mg/dose or Lorazepam0.1 mg/kg slowiV not to exceed 4 mgAdolescents Diazepam 5–10 mg upand adultsto 30 mg in 8 hr periodor Lorazepam 0.07mg/kg slow IV not toexceed 4 mg2-PAM: 2-pralidoximeIM: intramuscularIO: intraosseousIV: intraveneousPDH: Pediatrics Dosage Handbook*In general, pralidoxime should be administered as soon as possible, no longer than 36 hours after the termination of exposure. Pralidoximecan be diluted to 300 mg/mL for ease of intramuscular administration. Maintenance infusion of 2-PAM at 10–20 mg/kg/hr (max 2 g/hr)has been described. Repeat atropine as needed every 5–10 minutes until pulmonary resistance improves, secretions resolve, or dyspneadecreases in a conscious patient. Hypoxia must be corrected as soon as possible.† Meridian Medical Technologies Inc, Bristol, Tenn.Data sources: (1) Rotenberg JS, Newmark J. Nerve agent attacks on children: diagnosis and management. Pediatrics. 2003;112:648–658. (2)Pralidoxime [package insert]. Bristol, Tenn: Meridian Medical Technologies, Inc; 2002. (3) AtropPen (atropine autoinjector) [package insert].Bristol, Tenn: Meridian Medical Technologies, Inc; 2004. (4) Henretig FM, Cieslak TJ, Eitzen Jr EM. Medical progress: biological and chemicalterrorism. J Pediatr. 2002;141(3):311–326. (5) Taketomo CK, Hodding JH, Kraus DM. American Pharmacists Association: Pediatric DosageHandbook. 13th ed. Hudson, Ohio; Lexi-Comp Inc: 2006.Perioperative Care of Children with Nerve AgentIntoxicationChemical exposures and trauma often occur simultaneously,and surgical intervention is sometimesrequired. However, many drugs used for perioperativemanagement can exacerbate the side effects of nerveagent exposure. For example, nerve agents can interactwith medications typically used for resuscitativeefforts. 74 Anesthetics, such as sodium pentothal andpropofol, cause cardiac depression, which is intensifiedby the excessive muscarinic activity induced by nerveagents. Doses of these drugs may need to be reduced.Volatile anesthetics may be preferable because they665