Abstract
Nerve agents (NA) are simple and cheap to produce but can produce casualties on a
massive scale. They have already been employed by terrorist organizations and rogue
states on civilians and armed forces alike. By inhibiting the enzyme acetylcholine
esterase, NAs prevent the breakdown of the neurotransmitter acetylcholine. This results
in over-stimulation of muscarinic and nicotinic receptors in the autonomic and central
nervous systems and at the neuromuscular junction. Increased parasympathetic stimulation
produces miosis, sialorrhea, bronchospasm and bronchorrhea. Effects at the neuromuscular
junction cause weakness, fasciculations, and eventually paralysis. Central effects
include altered behavior and mental status, loss of consciousness, seizures, or apnea.
Most deaths are due to respiratory failure. Treatment with atropine competitively
blocks the parasympathetic effects. Oximes like pralidoxime salvage acetylcholine
esterase by “prying off” NA, provided the attachment has not “aged” to an irreversible
bond. This reverses weakness. Benzodiazepines like diazepam are effective against
NA induced seizures. Mortality has been surprisingly low. If victims can survive the
first 15 to 20 min of a vapor attack, they will likely live. The low mortality rate
to date underscores that attacks are survivable and research reveals even simple barriers
such as clothing offer substantial protection. This article reviews the properties
of NAs and how to recognize the clinical features of NA intoxication, employ the needed
drugs properly, and screen out anxious patients who mistakenly believe they have been
exposed.
Keywords
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References
- The road to Ypres: the beginnings of gas warfare in World War I.J Mod Hist. 1975; 47: 460-468
- Medical aspects of chemical and biological warfare.Office of the Surgeon General United States Army at TMM Publications, Washington, D.C.1997
- Study proves Iraq used nerve gas.Nature. 1993; 363: 3
- The birth of nerve agent warfare: lessons from Syed Abbas Foroutan.Neurology. 2004; 62: 1590-1596
- Treatment of chemical and biological warfare injuries: insights derived from the 1984 Iraqi attack on Majnoon Island.Mil Med. 1991; 156: 171-177
- Report of the mission dispatched by the Secretary-General to investigate allegations of the use of chemical weapons in the conflict between the Islamic Republic of Iran and Iraq.United Nations, New York1984 (March 26)
- Sarin poisoning in Matsumoto, Japan.Lancet. 1995; 346: 290-293
- Sarin poisoning on Tokyo subway.South Med J. 1997; 90: 587-593
- Clinical features on nerve gas terrorism in Matsumoto.J Clin Neurosci. 2002; 9: 17-21
- Report on 640 victims of the Tokyo subway sarin attack.Ann Emerg Med. 1996; 28: 129-135
- Centre for Disarmament Affairs. Disarmament: the chemical weapons convention with selective index.United Nations, New York1994
- Chemical warfare agents: emergency medical and emergency public health issues.Ann Emerg Med. 1999; 34: 191-204
- Environmental temperature and the percutaneous absorption of a cholinesterase inhibitor, VX.J Invest Dermatol. 1977; 68: 357-361
- The biochemical basis of neuropharmacology.8th ed. Oxford University Press, Oxford2003
- The reactivatibility of cholinesterase inhibited by VX and sarin in man.Toxicol Appl Pharmacol. 1974; 27: 241-252
- Relationship between pupil size and acetylcholinesterase activity in patients exposed to sarin vapor.Intensive Care Med. 1997; 23: 1005-1007
- A severe organophosphate poisoning requiring the use of an atropine drip.J Toxicol Clin Toxicol. 1986; 24: 69-76
- Goodman and Gilman's the pharmacological basis of therapeutics.10th/ed. McGraw-Hill, New York2001
- Nerve agents.in: Medical management of chemical casualties handbook. Third ed. USAMRICD, Chemical Casualty Care Division, Aberdeen Proving Ground, MD2000
- Psycho-physiological effects of the terrorist sarin attack on the Tokyo subway system.Mil Med. 2001; 166: 23-26
- A review of nerve agent exposure for the critical care physician.Crit Care Med. 2002; 30: 2346-2354
- Soman and sarin: clinical manifestations and treatment of accidental poisoning by organophosphates.Clin Toxicol. 1974; 7: 1-17
Agency for Toxic Substances and Disease Registry A. Medical Management Guidelines (MMGs) for Nerve Agents: Tabun (GA; Sarin (GB); Soman; and VX. In: U.S. Dept. of Health and Human Services; 2006.
- Chemical warfare agents: toxicology and treatment.Wiley, Chichester1996
- Secondary exposure of medical staff to sarin vapor in the emergency room.Intensive Care Med. 1995; 21: 1032-1035
- Tokyo subway gas attack.Lancet. 1997; 350: 296
- Nerve agent attacks on children: diagnosis and management.Pediatrics. 2003; 112: 648-658
- Position paper: single-dose activated charcoal.Clin Toxicol. 2005; 43: 61-87
- High dose atropine in organophosphorus poisoning.Postgrad Med J. 1990; 66: 878
- Chemical warfare. Nerve agent poisoning.Crit Care Clin. 1997; 13: 923-942
- Atropine poisoning in children during the Persian Gulf crisis. A national survey in Israel.JAMA. 1992; 268: 630-632
- Pralidoxime continuous infusion in the treatment of organophosphate poisoning.Ann Pharmacother. 1997; 31: 441-444
- Pralidoxime chloride continuous infusions.Ann Emerg Med. 1987; 16: 831-832
- Review of oximes in the antidotal treatment of poisoning by organophosphorus nerve agents.J Toxicol Clin Toxicol. 2002; 40: 803-816
- Anticonvulsant treatment of nerve agent seizures: anticholinergics versus diazepam in soman-intoxicated guinea pigs.Epilepsy Res. 2000; 38: 1-14
- Effects of sarin on the nervous system in rescue team staff members and police officers 3 years after the Tokyo subway sarin attack.Environ Health Perspect. 2001; 109: 1169-1173
- Chronic neurobehavioral effects of Tokyo subway sarin poisoning in relation to posttraumatic stress disorder.Arch Environ Health. 1998; 53: 249-256
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