Treatment

• The most important care the casualty receives is the care given within the first few minutes after exposure.
• Removal of the victim from the environment and decontamination should occur first.
• Support ventilation and providing an open airway are the first steps in treatment of nerve agent patients.
• High-flow oxygen should be administered to avoid an abnormal cardiac rhythm.
• Atropine, preferably through IV administration, and pralidoxime chloride may be given when advanced treatment is warranted.
• Valium may be considered for the treatment of seizures and muscle twitches. Diazepam, an anticonvulsant, may also be used.

WARNING! The antidotes - atropine and diazepam - are not available to non-medical civilians. Intramuscular administration of these drugs in large doses by untrained personnel may cause serious injury or death.

Every first responder must understand the effects of nerve agents, the time period in which symptoms occur, and the correct steps required to save the exposed casualty.

Timely and accurate determination of the type of agent, and route of entry responsible for the signs or symptoms, is critical if the poisoned casualty is to survive long enough to reach adequate medical care.

After a terrorist attack nerve agents may be encountered in either vapor or liquid forms.

When more than one organ system is affected, exposure moves rapidly from mild to severe.

Treatment of Nerve Agent Poisoning

The first responder must rapidly determine the following:

• Extent of the poisoning
• What, if any, medications have been administered
• Complications induced by the poisoning and/or resulting from conventional wounds

Self-Protection

First, protect yourself from contamination. If you have reason to believe or have been alerted to the presence of nerve agents in an area, LEAVE THE AREA — do not return. There's nothing you can do to help a nerve agent casualty unless you have full protective gear.

Mild and Improving Symptoms

Observation is all that is needed for the casualty with mild symptoms such as rhinorrhea, slight or recovering breathing diffi culty, or excessive salivation that is decreasing. The casualty with mild and diminishing symptoms should, however, remain under observation, since residual effects of chemicals may cause symptoms to suddenly increase. This may require atropine followed by observation for several hours.

Pain in the eyes, twitching of the eyelids, redness, and miosis cannot be treated in the fi eld setting by the fi rst responder. However, eye pain can be controlled with atropine eye drops at a medical facility. These conditions, although annoying, are not life threatening.

Severe Symptoms

If the casualty has severe symptoms involving two or more major organ systems (gastrointestinal, skeletal muscle, respiratory, etc.), the first step is to administer both atropine and diazepam via autoinjector. Additionally, more atropine (2 mg, Atropine) should be given every fi ve minutes until secretions decrease or the casualty is breathing easier (or it is easier to ventilate him). A total of 15 to 20 mg of atropine may be required in the fi rst 3 hours after the onset of symptoms.

Antidote

WARNING! The antidotes - atropine and diazepam - are not available to non-medical civilians. Intramuscular administration of these drugs in large doses by untrained personnel may cause serious injury or death.

If the casualty is unconscious and in respiratory difficulty, atropine and diazepam (Valium) should be given immediately, followed by additional atropine as described above. Over the next 5 to 15 minutes, 10 to 15 mg of atropine may be needed. Atropine administered with the autoinjector will show some effectiveness in three to fi ve minutes. During the time the atropine takes to reach maximum effect, the constriction and secretions in the airway and feeling of "tightness in the chest" will begin to decrease. Atropine will have a drying effect on salivation and mucus serections.

Atropine (2 mg) should be administered at three to five-minute intervals until the casualty can tell the first responder that it is easier to breathe or manual ventilation becomes easier. Observe the casualty for indications that the atropine can be discontinued. Discontinue atropine when:

• Secretions of the mouth, nose, and lungs are minimized.
• The casualty tells you that breathing is easier, or it is easier to administer assisted ventilation.

Pralidoxime Chloride (2-PAMCl) in the autoinjector (600 mg, 2 ml) is the second drug for use in nerve agent poisoning cases. The 2-PAMCl removes nerve agent from the enzyme acetyl cholinesterase. The 2-PAMCl must be used as early as possible. If symptoms are severe, involving two or more organ systems (for example, the lungs and gastrointestinal tract) diazepam should be given immediately. Additional 2-PAMCl autoinjectors are not administered until an hour later.

WARNING! 2-PAMCl can dangerously increase blood pressure. Do not exceed specified dosage levels.

Discontinue the use of 2-PAMCl after symptoms of respiratory distress have eased. Diazepam via 10-mg autoinjector is used by the U.S. military for controlling convulsing casualties.

Diazepam should be given only to severe casualties, and severe casualties cannot self-administer it. The key to increasing the effectiveness of the diazepam is administering it before convulsions begin.

When two or more organ systems become involved, one diazepam autoinjector should be administered along with the three atropine autoinjections to lessen the convulsive activity the casualty may experience. The first responder may administer a second and third diazepam autoinjector using the guidelines below.

After the first injection:

• Observe the casualty for about ten minutes
• Turn the casualty on his/her side to facilitate breathing
• Pad areas to prevent other injuries
• Restrain if necessary

If still convulsing after ten minutes, give the second diazepam autoinjector.

Following the second injection (medical aid):

• Observe the casualty for five to ten minutes
• If still convulsing after five to ten minutes, administer a third diazepam autoinjector

Ventilation

Aggressive airway maintenance and the use of assisted ventilation will greatly increase the casualty's chances for survival. Without this aggressive, far-forward resuscitation, the casualty will not survive.