Recommended Treatment and Management of Chemical Agents Used in Terrorism

AgentToxicityClinical FindingsOnsetDecontaminationaManagement
Nerve agents
    Tabun, sarin, soman, VXAnticholinesterase: muscarinic, nicotinic, and CNS effectsVapor: miosis, rhinorrhea, dyspneaVapor: secondsVapor: fresh air, remove clothes, wash hairAirway, breathing, circulatory support
Liquid: diaphoresis, vomitingLiquid: minutes to hoursLiquid: remove clothes, wash skin and hair copiously with soap and water, irrigate eyesAtropine 0.05–0.1 mg/kg IVb, IMc (min: 0.1 mg; max: 5 mg), repeat every 2–5 min prn for marked secretions, bronchospasm, hypoxia, respiratory compromise, apnea, cardiopulmonary arrest
Both: coma, paralysis, seizures, apneaPralidoxime 25–50 mg/kg IV, IMd (max: 1 g IV; 2 g IM), may repeat within 30–60 min prn, then again every 1 h for 1 or 2 doses prn for persistent weakness, high atropine requirement
Diazepam 0.05–0.3 mg/kg (max: 10 mg) IV, lorazepam 0.1 mg/kg IV or IM (max: 4 mg), midazolam 0.1–0.2 mg/kg (max: 10 mg) IM prn for seizures or severe exposure
    MustardAlkylationSkin: erythema, vesiclesHoursSkin: soap and waterSymptomatic care
Eye: inflammationEyes: irrigation (water)
Respiratory tract: inflammation, respiratory distress, acute respiratory distress syndromeBoth: major impact only if done within minutes of exposure
    LewisiteArsenicalSame as for mustardImmediate painSame as for mustardPossibly British anti–lewisite 3 mg/kg IM every 4–6 h for systemic effects of lewisite in severe cases
Pulmonary agents
    Chlorine, phosgeneLiberate HCl, alkylationEyes, nose, throat: irritation (especially chlorine)MinutesFresh airSymptomatic care
Bronchospasm, pulmonary edema (especially phosgene)Bronchospasm: minutesSkin: water
Pulmonary edema: hours
    CyanideCytochrome oxidase inhibition cellular anoxia, lactic acidosisTachypnea, coma, seizures, apneaSecondsFresh airAirway, breathing, circulatory support; 100% oxygen
Skin: soap and waterSodium bicarbonate prn for metabolic acidosis
Sodium nitrite (3%) dosage (estimated hemoglobin for average child): 0.27 mL/kg (10 g/dL), 0.33 mL/kg (12 g/dL), 0.39 mL/kg (14 g/dL); max: 10 mL
Sodium thiosulfate (25%) 1.65 mL/kg (max: 50 mL)
    CS, CN (Mace),     Capsaicin (pepper spray)Neuropeptide substance P release, alkylationEye: tearing, pain, blepharospasmSecondsFresh airTopical ophthalmics, symptomatic care
Nose and throat: irritationEye: irrigation (water)
Pulmonary failure (rare)
  • CNS indicates central nervous system; IV, intravenous; IM, intramuscular; prn, as needed.

  • a Decontamination, especially for patients with significant exposure to nerve agents or vesicants, should be performed by health care providers dressed in adequate personal protective equipment. For emergency department staff, this consists of a nonencapsulated, chemically resistant body suit, boots, and gloves with a full-face air purifier mask/hood.

  • b Intraosseous route is likely equivalent to intravenous.

  • c Atropine might have some benefit via endotracheal tube or inhalation, as might aerosolized ipratropium.

  • d Pralidoxime is reconstituted to 50 mg/mL (1 g in 20 mL of water) for intravenous administration, and the total dose is infused over 30 minutes, or it may be given by continuous infusion (loading dose: 25 mg/kg over 30 minutes, then 10 mg/kg per hour). For intramuscular use, it might be diluted to a concentration of 300 mg/mL (1 g added to 3 mL of water—by analogy to the Mark 1 autoinjector concentration) to effect a reasonable volume for injection.

  • Reprinted with permission from Markenson D, Redlener I. Pediatric Preparedness for Disaster and Terrorism: A National Consensus ConferenceExecutive Summary. New York, NY: Columbia University Mailman School of Public Health, National Center for Disaster Preparedness; 2003.