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

Medical Aspects of Chemical WarfareTable 21-4Management of Severe Nerve Agent Exposure666Antidotes*ManagementBenzodiazepines(if neurological signs)Nerve Agents Severe Symptoms Age Dose Age Dose• Tabun• Sarin• Cyclosarin• Soman• VXIM: intramuscularIO: intraosseousIV: intravenous• ConvulsionsNeonates Atropine 0.1 mg/kg• Loss of consciousness and infants IM/IV/IO or 3 doses• Apneaup to 6 of 0.25mg AtroPen †• Flaccid paralysismonths old (administer in rapid• Cardio-pulmonary arrestsuccession) and• Strange and confused2-PAM 25 mg/kgbehaviorIM or IV slowly, or 1• Severe difficulty breathingMark I † kit (atropine• Involuntary urinationand 2-PAM) if noand defecationother options existYoung Atropine 0.1 mg/kgchildren (6 IV/IM/IO or 3 dosesmonths of 0.5mg AtroPenold–4 yrs (administer in rapidold) succession) and2-PAM 25–50 mg/kgIM or IV slowly, or 1Mark I kit (atropineand 2-PAM) if noother options existOlder Atropine 0.1 mg/kgchildren IV/IM/IO or 3 doses(4–10 yrs of 1mg AtroPenold) (administer in rapidsuccession) and2-PAM 25–50 mg/kg IM or IV slowly, 1Mark I kit (atropineand 2-PAM) up toage 7, 2 Mark I kitsfor ages > 7–10 yrsAdolescents Atropine 6 mg IM or 3(≥ 10 yrs doses of 2 mg AtroPenold) and (administer in rapidadults succession) and2-PAM 1800 mg IV/IM/IO, or 2 MarkI kits (atropine and2-PAM) up to age 14,3 Mark I kits for ages≥ 14 yrsNeonates Diazepam 0.1–0.3mg/kg/dose IV to amax dose of 2 mg, orLorazepam 0.05 mg/kg slow IVYoung Diazepam 0.05–0.3children mg/kg IV to a max(30 days of 5 mg/dose, orold–5 yrsand adultsLorazepam 0.1 mg/kg slow IV not toexceed 4 mgChildren Diazepam 0.05-0.3(≥ 5 yrs old) mg/kg IV to a maxof 10 mg/dose, orLorazepam 0.1 mg/kg slow IV not toexceed 4 mgAdolescentsand adultsDiazepam 5–10 mgup to 30 mg in 8-hrperiod, or Lorazepam0.07 mg/kg slow IV not toexceed 4 mg*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) hasbeen described. Repeat atropine as needed every 5–10 min until pulmonary resistance improves, secretions resolve, or dyspnea decreasesin 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) AtroPen (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.