Nerve Agent Attacks on Children: Diagnosis and Management

Abstract

Nerve agents (NAs) are the most lethal chemical weapons. We review the pathophysiology and management of NA poisoning of children. NAs cause cholinergic crisis. Children may manifest signs of cholinergic poisoning differently than adults. Children may be less likely to manifest miosis and glandular secretions. They may present with neurologic derangements alone. The goals of treatment should be to limit additional exposure, to provide respiratory support, and to prevent neurologic morbidity. Autoinjectors are optimal delivery vehicles for intramuscular antidotes and are likely to be used in civilian prehospital care. Antidotes include anticholinergics, oximes, and benzodiazepines. Several medications may be available within each class of antidotes. Clinicians will select an antidote based on the status of the individual victim, the accessibility of supportive care, and the availability of the drug. Atropine is well-tolerated and high doses may be required. The oxime pralidoxime chloride has a longer half-life in children. Currently, diazepam is the standard NA anticonvulsant. Midazolam may be the most effective intramuscular anticonvulsant after NA exposure, but, despite its efficacy, it is not an approved agent for seizures. Supportive care and long-term complications are summarized.

Strategies to Enhance Medical Countermeasures After the Use of Chemical Warfare Agents on Civilians

“…These factors will be extremely important when deciding the specific type and dosage of medical countermeasures that can be administered during a civilian chemical emergency. Fortunately, some military countermeasures can be adapted to special populations such as children (Rotenberg and Newmark, 2003;Baker, 2007). However, the development and validation of good animal models to simulate these special segments of the population are still urgently needed.…”

Global Impact of Chemical Warfare Agents Used Before and After 1945

“…Terrorists have expressed an interest in nerve agents and have deployed them in attacks on unprotected civilians (Rotenberg and Newmark, 2003). A Japanese religious cult, Aum Shinrikyo, independently manufactured numerous chemical and biological agents.…”

Chemical-Biological Terrorism and Its Impact on Children

“…12 Both of these antidotes are available in autoinjector form, permitting rapid administration; autoinjectors are particularly important in mass-casualty incidents where there is a need to treat large numbers of victims as quickly and efficiently as possible. Until recently, the rapid administration of atropine and pralidoxime to children was complicated by the absence of pediatric autoinjectors; only the forms approved for adults, containing 2 mg of atropine and 600 mg of pralidoxime, were available.…”

“…12,14 Vesicants Vesicants include sulfur mustard and lewisite, an arsenic-based blistering agent. These chemicals, both of which are released as an aerosol, produce erythema, burning, vesiculation, and then desquamation of the skin.…”