Protocol Status: PUBLISHED
Protocol:
Version: 2026.01
Effective Date:
Last Reviewed:
Medical Director Approval:
Clinical Note: This content reflects current GCEMS clinical guidelines as of the dates listed above. If content appears inconsistent with current policy, use the most recent approved guideline and notify leadership for correction.

WMD Nerve Agent

 

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
  • Initiate IV
  • 12-Lead EKG
  • Obtain BGL

 

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.