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Nerve agents used in chemical warfare work by cholinesterase inhibition and are most commonly organophosphorus compounds. Agents such as tabun (GA), sarin (GB), soman (GD), and VX are similar to insecticides such as malathion but are vastly more potent. They may be inhaled or absorbed through the skin. Systemic effects due to unopposed action of acetylcholine include miosis, salivation, abdominal cramps, diarrhea, and muscle paralysis producing respiratory arrest. Inhalation also produces severe bronchoconstriction and copious nasal and tracheobronchial secretions.

TREATMENT

A. Emergency and Supportive Measures

Perform thorough decontamination of exposed areas with repeated soap and shampoo washing. Personnel caring for such patients must wear protective clothing and gloves, since cutaneous absorption may occur through normal skin.

B. Specific Treatment

Give atropine in an initial dose of 2 mg intravenously and repeat as needed to reverse signs of acetylcholine excess. (Some victims have required several hundred milligrams.) Treat also with the cholinesterase-reactivating agent pralidoxime, 1–2 g intravenously initially followed by an infusion at a rate of 200–400 mg/h.

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Agency for Toxic Substances and Disease Registry. Toxic Substances Portal: Medical Management Guidelines for Nerve Agents: Tabun (GA); Sarin (GB); Soman (GD); and VX. October 21, 2014. https://www.atsdr.cdc.gov/mmg/mmg.asp?id=523&tid=93
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Candiotti  K. A primer on nerve agents: what the emergency responder, anesthesiologist, and intensivist needs to know. Can J Anaesth. 2017 Oct;64(10):1059–70.
[PubMed: 28766156]
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Iyengar  AR  et al. Organophosphate-hydrolyzing enzymes as first-line of defence against nerve agent-poisoning: perspectives and the road ahead. Protein J. 2016 Dec;35(6):424–39.
[PubMed: 27830420]
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United States Department of Labor. Occupational Safety and Health Administration. Safety and Health Guides/Nerve Agents Guide. https://www.osha.gov/SLTC/emergencypreparedness/guides/nerve.html

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