Public - Nerve Agent Exposure

Nerve Agent Exposure

Author: Elliot Rodriguez, MD, FACEP; Christine M. Stork, PharmD, DABAT
Editorial changes - 2009-10-30
Author information and module status



		Prevention
		Screening
		Diagnosis
		Consultation for Diagnosis
		Hospitalization
		Non-drug Therapy
		Drug Therapy
		Patient Education
		Consultation for Management
		Follow-up

	Tables
	References
	Glossary
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Diagnosis
Assess for the presence of both muscarinic and nicotinic signs and symptoms consistent with cholinergic crisis. Obtain information about the route of exposure (mucous membrane or dermal) and type of exposure (liquid or vapor). Consider obtaining cholinesterase levels to confirm the diagnosis and to assess for complications after severe exposures. Base additional testing on clinical presentation and the presence of complications and concomitant injuries. Consider the broad differential diagnosis of nerve agent exposure.
History and Physical Examination Elements for Nerve Agent Exposure (table)
Laboratory and Other Studies for Nerve Agent Exposure (table)
Differential Diagnosis of Nerve Agent Exposure (table)


Assess for the presence of both muscarinic and nicotinic signs and symptoms consistent with cholinergic crisis.
Perform a thorough history and physical exam, using the mnemonic DUMBBELS to look for specific signs and symptoms: Diaphoresis, diarrhea Urination Miosis Bradycardia Bronchospasm and bronchorrhea Emesis Lacrimation, rhinorrhea, and salivation Seizures, muscle fasciculation, weakness In addition, look for an altered level of consciousness and cognitive deficits. See table History and Physical Examination Elements for Nerve Agent Exposure. See table Nerve Agents and Their Chemical Properties.
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Obtain information about the route of exposure (mucous membrane or dermal) and type of exposure (liquid or vapor).
After mucous membrane or vapor exposure, assess carefully for miosis, dim vision, rhinorrhea, and pulmonary symptoms. After dermal exposure, assess carefully for localized sweating and muscle fasciculations and nausea and vomiting, noting that severe systemic symptoms may not be present initially after dermal exposure. See table History and Physical Examination Elements for Nerve Agent Exposure. See table Nerve Agents and Their Chemical Properties.
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Consider obtaining cholinesterase levels to confirm the diagnosis and to assess for complications after severe exposures.
Consider measuring erythrocyte and plasma cholinesterase activity levels to confirm acute nerve agent exposure and to establish a postexposure baseline level for follow-up. Do not delay treatment while waiting for laboratory studies if clinical evaluation suggests nerve agent exposure. See table Laboratory and Other Studies for Nerve Agent Exposure.
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Base additional testing on clinical presentation and the presence of complications and concomitant injuries.
Consider obtaining: Pulse oximetry or ABG to assess for hypoxemia An ECG and continuous cardiac monitoring to assess and monitor for myocardial infarction or ischemia and dysrhythmias A chest radiograph See table Laboratory and Other Studies for Nerve Agent Exposure.
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Consider the broad differential diagnosis of nerve agent exposure.
Obtain a thorough history, assessing for systemic symptoms not seen with nerve agent toxicity. In patients who do not have the classic signs and symptoms of nerve agent exposure, carefully assess for other conditions that can present similarly. See table Differential Diagnosis of Nerve Agent Exposure.
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FAQs

Christine M. Stork, PharmD, DABAT has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Elliot Rodriguez, MD, FACEP has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Jerrold B. Leikin, MD, editorial consultant, received royalties from McGraw-Hill, Taylor and Francis; editor of Toxicoterrorism (McGraw-Hill).
Steven E. Weinberger, MD, FACP, Acting Editor, PIER, has stock holdings in Glaxosmithkline and Abbott.

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