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.
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.
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.
et al. Organophosphorus nerve agent poisoning: managing the poisoned patient. Br J Anaesth. 2019;123:457.
et al. Neurotoxicity of pesticides. Acta Neuropathol. 2019;138:343.
et al. Advice on assistance and protection from the Scientific Advisory Board of the Organisation for the Prohibition of Chemical Weapons: Part 2. On preventing and treating health effects from acute, prolonged, and repeated nerve agent exposure, and the identification of medical countermeasures able to reduce or eliminate the longer-term health effects of nerve agents. Toxicology. 2019;413:13.