Nerve Agent Exposure Author: Elliot Rodriguez, MD, FACEP; Christine M. Stork, PharmD, DABAT
Editorial changes - 2009-10-30
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Drug Therapy
  • Administer iv or im atropine in patients with signs of muscarinic cholinergic excess.
  • Consider iv or im 2-pralidoxime in all patients requiring atropine and in those with or at risk for nicotinic cholinergic excess.
  • Consider iv diazepam or another benzodiazepine in patients with severe signs of toxicity or in patients who have had a seizure.
Drug Treatment for Nerve Agent Exposure (table)

Administer iv or im atropine in patients with signs of muscarinic cholinergic excess. C

  • Administer iv or im atropine, 1 to 2 mg (up to 6 mg in patients presenting in extremis), and titrate the dose every 5 to 10 minutes to a total dose of 20 mg if needed until bronchial secretions are clear in patients with:
    • Bronchorrhea and bronchospasm
    • Excessive diarrhea, vomiting, and diaphoresis
  • In children under age 2, administer atropine, 0.3 to 0.5 mg iv.
  • In children aged 2 to 10, administer atropine, 1 mg iv, as the initial dose.
  • Correct hypoxemia concurrent with atropine administration.
  • See table Drug Treatment for Nerve Agent Exposure.
Background | Back to top


Consider iv or im 2-pralidoxime in all patients requiring atropine and in those with or at risk for nicotinic cholinergic excess. C

  • Give iv or im 2-pralidoxime in patients with:
    • Muscle fasciculations or weakness
    • Bronchorrhea and bronchospasm
    • Excessive diarrhea, vomiting, and diaphoresis
  • Administer to a maximum single dose in adults of 30 mg/kg or 2 g and consider higher doses or continuous infusion of 500 to 2000 mg/kg·h in severe cases.
  • In children, consider 15 to 30 mg/kg by slow iv infusion.
  • See table Drug Treatment for Nerve Agent Exposure.
Background | Back to top


Consider iv diazepam or another benzodiazepine in patients with severe signs of toxicity or in patients who have had a seizure. C

  • Administer diazepam, 5 to 10 mg iv, or another benzodiazepine and repeat as needed in patients with:
    • Current seizure activity
    • Severe nicotinic and muscarinic signs in two or more organ systems and who are receiving atropine and 2-pralidoxime
    • Loss of consciousness
  • See table Drug Treatment for Nerve Agent Exposure.
Background | Back to top

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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