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PEDIATRICS Vol. 112 No. 3 September 2003, pp. 648-658

REVIEW ARTICLE

Nerve Agent Attacks on Children: Diagnosis and Management

Joshua S. Rotenberg, MD, MMS, FAAP* and Jonathan Newmark, MD, FAAN{ddagger}

* Departments of Child and Adolescent Neurology and Pediatrics, Walter Reed Army Medical Center, Washington, DC, Uniformed Services University of the Health Sciences, Bethesda, MD
{ddagger} Chemical Casualty Care Division, US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland; Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Nerve agents (NAs) are the most lethal chemical weapons. We review the pathophysiology and management of NA poisoning of children. NAs cause cholinergic crisis. Children may manifest signs of cholinergic poisoning differently than adults. Children may be less likely to manifest miosis and glandular secretions. They may present with neurologic derangements alone. The goals of treatment should be to limit additional exposure, to provide respiratory support, and to prevent neurologic morbidity. Autoinjectors are optimal delivery vehicles for intramuscular antidotes and are likely to be used in civilian prehospital care. Antidotes include anticholinergics, oximes, and benzodiazepines. Several medications may be available within each class of antidotes. Clinicians will select an antidote based on the status of the individual victim, the accessibility of supportive care, and the availability of the drug. Atropine is well-tolerated and high doses may be required. The oxime pralidoxime chloride has a longer half-life in children. Currently, diazepam is the standard NA anticonvulsant. Midazolam may be the most effective intramuscular anticonvulsant after NA exposure, but, despite its efficacy, it is not an approved agent for seizures. Supportive care and long-term complications are summarized.

Key Words: chemical warfare agents • terrorism • organophosphorus compounds • sarin • atropine • benzodiazepines • pralidoxime compounds • all children (0–18 years of age)

Abbreviations: NA, nerve agent • OP, organophosphorus • WMD, weapons of mass destruction • AChE, acetylcholinesterase • ACh, acetylcholine • CNS, central nervous system • CN, cyanide • NMDA, N-methyl-D-aspartate • FDA, Food and Drug Administration; AI, autoinjector • IM, intramuscular(ly) • IV, intravenous(ly) • 2-PAM, pralidoxime chloride • CPK, creatine phosphokinase • EEG, electroencephalographic

Received for publication Sep 17, 2002; Accepted May 20, 2003.


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