History:
- Exposure to chemical/biological/ radiological/nuclear hazard
- Potential exposure to unknown substance/hazard
Significant Findings:
- Visual disturbances
- Headache
- Nausea/vomiting
- Salivation
- Lacrimation
- Respiratory distress
- Diaphoresis
- Seizure activity
- Respiratory arrest
Differential:
- Nerve agent exposure (e.g., VX, sarin, soman, etc.)
- Organophosphate exposure (pesticide)
- Vesicant exposure (e.g., mustard gas, etc.)
- Respiratory irritant exposure (e.g., hydrogen sulfide, ammonia, chlorine, etc.)
Treatment:
- Oxygen
- Initiate triage and/or decontamination as indicated; avoid inhalation and skin contact
Minor Symptoms:
- Salivation
- Lacrimation
- Visual disturbances
-
- Atropine 2 mg IV/IM every 5 min until symptoms resolve
Major Symptoms:
- Altered mental status
- Seizures
- Respiratory distress
-
- Nerve agent kit IM x 3 rapidly (see pediatric doses below)
-
- if unconscious, seizing and/or fasciculating:
-
- Lorazepam (Ativan) 1-2 mg IV/IM (may be repeated once after 5 min) or Midazolam (Versed) 10 mg/2 mL slow IV push
-
- Atropine 2 mg IV/IM every 5 min until symptoms resolve
- Notify receiving facility or contact Medical Control
PEARLS:
- In the face of a bona fide attack, begin with 1 nerve agent kit for patients less than 7 years of age, 2 nerve agent kits from 8 to 14 years of age, and 3 nerve agent kits for patients 15 years of age and over.
- If triage/MCI issues exhaust supply of nerve agent kits, use pediatric atropens (if available). Use the 0.5 mg dose if patient is less than 40 pounds (18 kg), 1 mg dose if patient weighs between 40 to 90 pounds (18 to 40 kg), and 2 mg dose for patients greater than 90 pounds (greater than 40 kg).
- Follow local HAZMAT protocols for decontamination and use of personal protective equipment.
- Carefully evaluate patients to ensure they are not reacting from exposure to another agent (e.g. narcotics, vesicants, etc.).
- The main symptom that the Atropine addresses is excessive secretions so Atropine should be given until salivation improves.