FOURTH GENERATION AGENTS:
MEDICAL MANAGEMENT GUIDELINES

January 2019

FOURTH GENERATION AGENTS
MEDICAL MANAGEMENT GUIDELINES(Information as of January 18, 2019)
Purpose
These guidelines were developed as part of ongoing preparedness for all hazards and areintended to support fire, EMS, and hospital staff in the medical management of patients if an
incident occurs involving a fourth generation agent (FGA, also known as A-series or Novichok
nerve agents), such as the one used in the United Kingdom (U.K.) in 2018. No illicit use or
manufacture of an FGA or other nerve agent is known to have occurred in the United States(U.S.), and there is no known threat of any nerve agent use in the U.S.
This document is divided into two sections: pages 5-7 include recommendations for fire and
EMS responders and pages 8-11 include recommendations for hospital staff, with some
repetition between the two. As part of ongoing standard preparedness, jurisdictions should
update their existing plans with this information and integrate it into in-service training curricula.
Limited experiential and research data specific to FGAs are available. These guidelines
will be updated as additional insights are gained.
If you suspect a nerve agent poisoning incident, ensure emergency services are aware
through 911 and the local FBI Weapons of Mass Destruction (WMD) Coordinator isnotified immediately. Contact your regional poison center (1-800-222-1222) for additional
patient management information.
If FGA presence is suspected or confirmed, the U.S. government can assemble a group of subject
matter experts to provide medical advice to local authorities and providers upon request.
Background
Nerve agents are extremely toxic chemical warfare agents. They are generally categorized aseither volatile or low volatility chemicals. A volatile chemical evaporates readily, forming avapor; exposure would most likely occur from breathing in chemical vapor and symptoms would
appear soon (often within seconds to minutes) after inhalation. Most exposures to low volatility
agents are from dermal contact. Signs and symptoms may be delayed for hours to even days
(latent period). However, under certain circumstances, low volatility agents may be inhaled, inwhich case symptoms would rapidly ensue. Sarin is an example of a volatile nerve agent,
whereas VX is a low volatility agent. Ingestion, eye exposure, and contact with mucous
membranes are additional possible routes of exposure for both volatile and low volatility nerve
agents.
Fourth generation agents are low volatility nerve agents that evaporate even less readily than
VX. FGAs are at least as potent as VX; it takes a lower, or a similar, dose of an FGA compared
to VX to cause adverse health effects or death. All nerve agents inhibit acetylcholinesterase(AChE), an enzyme that normally breaks down the neurotransmitter acetylcholine (ACh). The
1

inhibition of AChE results in an excess of ACh at muscarinic and nicotinic receptors in the brain,in skeletal and smooth muscle, and in exocrine glands (e.g., tear, salivary, bronchial, and sweat
glands). This results in hyperactivity in these target organs, a condition called cholinergic crisis.
Organophosphorus and carbamate pesticides also inhibit AChE and produce similar effects tonerve agents.
Medical providers need to keep in mind that those variables (e.g., the specific agent and dose,
including concentration and duration of exposure; physical states of the agent in theenvironment; routes of exposure; time from exposure to treatment; and underlying medical
conditions) determine toxicity, clinical manifestations, and effectiveness of medical
interventions. Therefore, a spectrum of clinical effects among the nerve agents and amongindividual patients is expected.
What You Should Know about all Nerve Agents
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Nerve agents are extremely toxic and can cause rapid loss of consciousness, convulsions, anddeath from respiratory failure.
Nerve agents are readily absorbed by inhalation, ingestion, and dermal contact. Rapidly fatalsystemic effects may occur.
The time course of health effects depends on the agent, route of exposure, and other factors,
with inhalation causing the most rapid effects and dermal contact associated with a longer(hours to days) latent period.
Patients whose skin, clothing, or personal effects are contaminated with nerve agent can
expose rescuers by direct contact or through evaporation of vapor (“off-gassing”). Patients
whose skin is exposed only to nerve agent vapor pose minimal risk of secondary exposure;
however, clothing can trap vapor.
Along with supportive care and patient decontamination, anticholinergics (e.g., atropine),
oxime AChE reactivators (e.g., pralidoxime chloride (2-PAM)), and anticonvulsants (e.g., thebenzodiazepines - diazepam, midazolam, and lorazepam) are the mainstays of the
management of nerve agent toxicity.

Managing Nerve Agent Exposure
ABCDDs: Airway, Breathing, Circulation (supportive care), Decontamination, and Drugs(anticholinergics, reactivators, and anticonvulsants)
Key Clinical Distinguishing Features of FGAs versus other Nerve Agents

FGAs are low volatility nerve agents, like VX, and therefore most likely to be encountered asa liquid.
In general, the latent period between dermal exposure and symptom onset may be longer for
FGAs than for VX and can be up to 3 days. Inhalational, ingestion, or large dermal exposures
will have shorter latent periods.
FGAs are persistent; if not decontaminated, they can remain on environmental surfaces fordays or even many months. Physical surfaces must be decontaminated to prevent additional
exposures.
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Decontamination of skin and hair is crucial and may provide clinical benefit even when
performed hours to days after exposure to liquid agent, although the earlier thedecontamination, the better.
Bronchoconstriction has been a prominent feature of FGA toxicity in animal studies but has
not been observed in the very limited number of human cases. If it occurs,
bronchoconstriction may be difficult to manage clinically.
Seizure activity has been a prominent feature of FGA toxicity in animal studies but has notbeen observed in the very limited number of human cases.
FGAs may cause severe metabolic acidosis with markedly elevated serum lactate.
Patients poisoned by FGAs may need medication and intensive supportive care over an
extended duration. Multiple casualties may strain local resources at the point of care.

Typical Signs and Symptoms (Cholinergic Toxidrome) of Nerve Agent Poisoning
The presentation and timing of symptom onset depends on the agent, dose, and route of
exposure. Potential signs and symptoms may include:
Mouth/Skin: drooling (salivation), foaming at the mouth, excessive sweating
Nose/Eyes: runny nose, watery eyes (lacrimation) with small (often pinpoint) pupils (miosis)
Chest: cough, bronchospasm (severe bronchoconstriction), bronchorrhea (excessive bronchialsecretions), labored breathing, wheezing, respiratory failure
Genitourinary: excessive urination
Abdominal: diarrhea, abdominal (gastrointestinal) cramps, nausea, belching, vomiting (emesis)
Heart Rate: bradycardia
Mental Status: confusion, drowsiness
Musculoskeletal: twitching, fasciculations, cramps, fatigue, weakness
Neurological: tremors, slurred speech, ataxia, absent reflexes, seizures/convulsions,
unconsciousness, coma
Patients may demonstrate some combination of SLUDGE and DUMBBELS.
SLUDGE – Salivation, Lacrimation, Urination, Defecation, Gastrointestinal upset, Emesis
DUMBBELS – Defecation, Urination, Miosis/Muscle weakness, Bronchospasm/Bronchorrhea,
Bradycardia, Emesis, Lacrimation, Salivation/Sweating
Note that: The above are mostly muscarinic effects, with the exception of musculoskeletal effects,
which are mediated by nicotinic receptors; there may be other nicotinic effects.
Nicotinic effects include MTWHF:
MondayMydriasis
Tuesday
Tachycardia
Wednesday
Weakness
THursday
Hypertension
FridayFasciculations3

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Patients may have some but not all of these signs and symptoms. In some cases, miosis(pinpoint pupils) and bronchospasm (severe bronchoconstriction) may not be prominent or
may even be absent.
Exposures to nerve agents, including FGAs, may be difficult to distinguish clinically fromoverdoses of opioids or other street drugs. Polysubstance mixtures and novel preparations ofillicit drugs have become increasingly frequent in street drug intoxications. Some canpresent with unusual physiological profiles and signs and symptoms that could be confusedwith those of chemical warfare agents.

Additional Considerations
The Secretary of Health and Human Services issued a declaration, effective April 11, 2017,
under the Public Readiness and Emergency Preparedness Act (PREP Act) to provide liability
immunity to certain individuals and entities against claim of loss relating to the use of
medical countermeasures against nerve agents, given certain conditions are met:https://www.federalregister.gov/documents/2017/05/10/2017-09455/nerve-agents-andcertain-insecticidesorganophosphorous-andor-carbamate-countermeasures
If standard resources become exhausted, see Contingency Medical Countermeasures for
Treating Nerve Agent Poisoning (https://asprtracie.hhs.gov/technicalresources/resource/6004/contingency-medical-countermeasures-for-treating-nerve-agentpoisoning). The decision to use these contingency measures is at the discretion of the treating
provider.

4PRE-HOSPITAL CARE
FGAs present a significant risk of secondary exposure if responders come into contact withagent on patients, their clothing, personal effects, or contaminated surfaces. Just as
importantly, patient decontamination is a medical intervention because FGAs can deposit on
and in skin and absorption can continue until the patient is fully decontaminated. As long as
FGAs are on or in the skin, they pose a medical risk to the exposed individual even if that
individual does not yet look or feel sick.
To Protect Yourself from Exposure







FGAs are highly potent; contacting small amounts can cause serious health effects.
Avoid any unprotected contact with agent, suspected contaminated surfaces, or potentiallycontaminated people.
Avoid any potential for cross-contamination. Painstaking attention to protective zones,
decontamination protocols, and donning and doffing of personal protective equipment (PPE)
is essential to prevent secondary exposure and spread of agent in the environment.
Report any potential exposure per your employer’s procedures. Symptoms may occur up to 3
days post exposure.
Handle blood and body fluids with extra caution, as though they are contaminated with FGA.
Limited data are available on the risk, but there are concerns that FGAs can persist in body
fluids, posing a potential hazard to personnel.
PPE should be selected based on the employer’s standard operating procedures, the job task,
and the potential for exposure to hazards. For specific PPE recommendations, see Appendix,
pages 17-19.

Patient Decontamination
After FGA exposures, decontaminating patients’ skin and hair is essential. Decontamination is a
medical intervention and should be performed as soon as possible to prevent absorption of agent.
However, even after a delay of hours or days, decontamination may still reduce harm to thepatient and the risk of secondary exposure to other people.
 Removal of clothing and personal effects is a vital step to reduce ongoing and secondary
exposure and can remove significant amounts of chemical contamination. Pay particularattention to how clothing is removed in order to minimize the spread of contamination.
 Containment of suspected or confirmed contaminated clothing in tightly closed plastic bags,
double layered in 6 mil polypropylene bags if possible, is critical. Patient clothing andpersonal effects should be secured for law enforcement purposes.
 Blotting skin with a paper towel, dry wipe, or other dry cloth will also contribute to effective
decontamination. Primary Response Incident Scene Management (PRISM) guidance
recommends 10 seconds of blotting followed by 10 seconds of rubbing the contaminated areaof skin. This dry decontamination step can be performed by patients themselves and, alongwith clothing removal, should be done as early as possible. Disrobing and blotting skin witha paper towel, dry wipe, or other dry cloth can remove significant amounts of chemical
contamination.
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If Reactive Skin Decontamination Lotion (RSDL) is available, it is recommended for spot
decontamination.
Water should be utilized per established decontamination protocols after disrobing, ideallywith a high-volume, low-pressure shower, including soap if available, gentle rubbing with asoft cloth or sponge, and active drying with a clean towel after the shower. Do not delay
decontamination awaiting specialized products such as soap or RSDL.
Avoid using hand sanitizer or other products containing alcohol, as they may enhanceabsorption of FGAs.
Do not use bleach to decontaminate skin.
FGAs are not readily degraded by water; thus, avoid direct contact with runoff.
The U.S. Environmental Protection Agency (EPA) issued a statement in 2000 generally
allowing responders to prioritize actions to save human lives and protect health. After
imminent threats are addressed, responders should immediately take all reasonable steps tocontain contamination (including decontamination runoff) and mitigate environmental
consequences.

Treatment
Meticulous attention to supportive and symptomatic care is the key to patient management. FGA
exposures may be resistant to initial and typically recommended medication doses, requiring
significantly higher doses and a longer duration of repeated dosing than other nerve agent
exposures.
Along with supportive care and decontamination, anticholinergics (e.g., atropine), oxime
AChE reactivators (e.g., 2-PAM), and anticonvulsants (e.g., the benzodiazepines - diazepam,
midazolam, and lorazepam) are the mainstays of the management of nerve agent toxicity. A
simple way to remember this paradigm is the ABCDDs: Airway, Breathing, Circulation(ABC - supportive care), Decontamination, and Drugs (anticholinergics, reactivators, andanticonvulsants).
o Supportive care (the ABCs) ensures preservation of vital functions before and duringdecontamination and administration of medications.
o Decontamination (D) is a medical intervention designed to minimize the conversion of an
external dose (on the skin) to an internal dose (inside the body). It is as important as
supportive care and medication can be lifesaving. Decontamination should be performed
as soon as possible but with FGAs may still be effective even hours or days after
exposure.
o Drugs (D) include the anticholinergic atropine, the oxime AChE reactivator 2-PAM, andanticonvulsants such as the benzodiazepines, diazepam, midazolam, and lorazepam.
Anticholinergics are given until secretions diminish and airway resistance (difficulty
breathing, resistance to ventilation) resolves. 2-PAM is given as long as nicotinic effects
such as muscle weakness (effects not treated by atropine) are present. Anticonvulsants are
given initially in severe cases even in the absence of convulsions because of a positive
interaction (synergism) of anticonvulsants with the other medications; they are also given
to treat convulsions and should be continued until the convulsions resolve.

6

Auto-injectors (AI) have typically been used for administering drugs intramuscularly (IM) totreat nerve agent exposures in a military setting and are available for civilian use. They may
be particularly expedient in the pre-hospital setting. However, if resources permit,
intravenous (IV) or intraosseous (IO) administration would be preferred, especially in
critically ill patients. Lorazepam is also available for intranasal (IN) administration.
o Atropine and 2-PAM are available together in the same AI (DuoDote or Antidote
Treatment Nerve Agent Autoinjector (ATNAA) are interchangeable), as separate AIs
packaged together (Mark 1 kit) and as individual AIs (atropine AIs come in various doses- 2, 1, 0.5, and 0.25 mg; 2-PAM AI contains 600 mg).
o The diazepam AI is called Convulsant Antidote for Nerve Agent (CANA); midazolam andlorazepam are not currently produced in AI form. When given IM, midazolam is absorbed
much more rapidly than diazepam.
For pre-hospital nerve agent treatment regimen, see pages 12-13.



EMS agencies should follow their established treatment protocols.
National Model EMS Clinical Guidelines are also acceptable.
More repeated dosing over a longer duration may be required to treat FGA compared to othernerve agent poisoning.

If refractory to standard therapy consider:

Respiratory Distress/Bronchospasm


Repeated doses of atropine 2-6 mg should be titrated to controlling bronchospasm andrespiratory secretions. Cumulative doses may be much higher than used in most clinicalsituations.
If severe bronchoconstriction/airway resistance continues despite repeated doses of atropine,
nebulizer therapy with preferably albuterol/ipratropium or albuterol alone should be used per
protocol.

Seizures

Treat with repeated doses of benzodiazepines (diazepam, midazolam, or lorazepam) until
seizures resolve.
Monitor for the need for mechanical ventilation after administering large doses ofbenzodiazepines.

Waste Management
Used PPE, body fluids, and waste generated in the management of patients should be handledwith extra caution and segregated from other waste, as they may be contaminated with chemical
agent. For more guidance, see waste management section on pages 15-16.

7

IN-HOSPITAL CARE
FGAs present a significant risk of secondary exposure if hospital staff come into contact withagent on patients, their clothing, personal effects, or contaminated surfaces. Just as
importantly, patient decontamination is a medical intervention because FGAs can deposit on
and in skin and absorption can continue until the patient is fully decontaminated. As long as
FGAs are on or in the skin, they pose a medical risk to the exposed individual even if that
individual does not yet look or feel sick.
To Protect Yourself from Exposure







FGAs are highly potent; contacting small amounts can cause serious health effects.
Avoid any unprotected contact with agent, suspected contaminated surfaces, or potentiallycontaminated people.
Avoid any potential for cross-contamination. Painstaking attention to protective zones,
decontamination protocols, and donning and doffing of PPE is essential to prevent secondary
exposure and spread of agent in the environment.
Report any potential exposure per your employer’s procedures. Symptoms may occur up to 3
days post exposure.
Handle blood and body fluids with extra caution, as though they are contaminated with FGA.
Limited data are available on the risk, but there are concerns that FGAs can persist in body
fluids, posing a potential hazard to personnel.
PPE should be selected based on the employer’s standard operating procedures, the job task,
and the potential for exposure to hazards. For specific PPE recommendations, see Appendix,
pages 17-19.

Patient Decontamination
After FGA exposures, decontaminating patients’ skin and hair is essential. Decontamination is a
medical intervention and should be performed as soon as possible to prevent absorption of agent.
However, even after a delay of hours or days, decontamination may still reduce harm to thepatient and the risk of secondary exposure to other people.
 Removal of clothing and personal effects is a vital step to reduce ongoing and secondary
exposure and can remove significant amounts of chemical contamination. Pay particularattention to how clothing is removed in order to minimize the spread of contamination.
 Containment of suspected or confirmed contaminated clothing in tightly closed plastic bags,
double layered in 6 mil polypropylene bags if possible, is critical. Patient clothing andpersonal effects should be secured for law enforcement purposes.
 Blotting skin with a paper towel, dry wipe, or other dry cloth will also contribute to effective
decontamination. PRISM guidance recommends 10 seconds of blotting followed by 10
seconds of rubbing the contaminated area of skin. This dry decontamination step can be
performed by patients themselves and, along with clothing removal, should be done as earlyas possible. Disrobing and blotting skin with a paper towel, dry wipe, or other dry cloth canremove significant amounts of chemical contamination.
 If RSDL is available, it is recommended for spot decontamination.
8

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






Water should be utilized per established decontamination protocols after disrobing, ideallywith a high-volume, low-pressure shower, including soap if available, gentle rubbing with asoft cloth or sponge, and active drying with a clean towel after the shower. Do not delay
decontamination awaiting specialized products such as soap or RSDL.
Avoid using hand sanitizer or other products containing alcohol, as they may enhanceabsorption of FGAs.
Do not use bleach to decontaminate skin.
FGAs are not readily degraded by water; thus, avoid direct contact with runoff.
The EPA issued a statement in 2000 generally allowing responders to prioritize actions tosave human lives and protect health. After imminent threats are addressed, responders should
immediately take all reasonable steps to contain contamination (including decontamination
runoff) and mitigate environmental consequences.
Due to a depot effect, patients’ skin may need repeated decontamination over a course ofdays. Ideally this process would be guided by input from U.S. government subject matter
experts and resources.

Specimen Collection for Laboratory Tests
Nerve agent toxicity results in depression of serum and erythrocyte cholinesterase. However,neither emergent assays for FGAs nor routine laboratory testing to detectorganophosphorus compounds are widely available. Collect blood and urine samples per
Centers for Disease Control and Prevention instructions: https://emergency.cdc.gov/labissues/pdf/Flowchart_ChemEvent_Specimen_collection.pdf
 https://emergency.cdc.gov/labissues/specimens_shipping_instructions.asp
Contact your state public health laboratory for additional guidance for testing by the Laboratory
Response Network for Chemical Threats (LRN-C).
Treatment
Meticulous attention to supportive and symptomatic care is the key to initial patientmanagement. FGA exposures may be resistant to initial and typically recommended treatment
doses, requiring significantly higher doses and a longer duration of repeated dosing than othernerve agent exposures.
Along with supportive care and decontamination, anticholinergics (e.g., atropine), oxime
AChE reactivators (e.g., 2-PAM), and anticonvulsants (e.g., the benzodiazepines - diazepam,
midazolam, and lorazepam) are the mainstays of the management of nerve agent toxicity. A
simple way to remember this paradigm is the ABCDDs: Airway, Breathing, Circulation(ABC - supportive care), Decontamination, and Drugs (anticholinergics, reactivators, andanticonvulsants).
o Supportive care (the ABCs) ensures preservation of vital functions before and duringdecontamination and administration of medications. Airway and ventilator management
may be required depending on the severity of symptoms.
o Decontamination (D) is a medical intervention designed to minimize the conversion of an
external dose (on the skin) to an internal dose (inside the body). It is as important as
supportive care and medication can be lifesaving. Decontamination should be performed9

as soon as possible but with FGAs may still be effective even hours or days after
exposure.
o Drugs (D) include the anticholinergic atropine, the oxime AChE reactivator 2-PAM, andanticonvulsants such as the benzodiazepines, diazepam, midazolam, and lorazepam.
Anticholinergics are given until secretions diminish and airway resistance (difficulty
breathing, resistance to ventilation) resolves. 2-PAM is given as long as nicotinic effects
such as muscle weakness (effects not treated by atropine) are present. Anticonvulsants are
given initially in severe cases even in the absence of convulsions because of a positive
interaction (synergism) of anticonvulsants with the other medications; they are also given
to treat convulsions and should be continued until the convulsions resolve.
Auto-injectors (AI) have typically been used for administering drugs intramuscularly (IM) totreat nerve agent exposures in a military setting and are available for civilian use. However,
if resources permit, intravenous (IV) or intraosseous (IO) administration would be preferred,especially in critically ill patients. Lorazepam is also available for intranasal (IN)administration.
o Atropine and 2-PAM are available together in the same AI (DuoDote or Antidote
Treatment Nerve Agent Autoinjector (ATNAA) are interchangeable), as separate AIs
packaged together (Mark 1 kit) and as individual AIs (atropine AIs come in various doses- 2, 1, 0.5, and 0.25 mg; 2-PAM AI contains 600 mg).
o The diazepam AI is called Convulsant Antidote for Nerve Agent (CANA); midazolam andlorazepam are not currently produced in AI form. When given IM, midazolam is absorbed
from muscle much more rapidly than diazepam.
For hospital nerve agent treatment regimen, see pages 14-15.

More repeated dosing over a longer duration may be required to treat FGA compared to othernerve agent poisoning.

If refractory to standard therapy consider:

Respiratory Distress/Bronchospasm


Repeated doses of atropine 2-6 mg should be titrated to controlling bronchospasm andrespiratory secretions.
Doses of atropine are likely to be significantly higher than for other medical conditions.
Inhaled or nebulized ipratropium (or another antimuscarinic medication) can be combinedwith one of the beta-agonists listed below.
If bronchospasm is still present despite maximal antimuscarinic therapy, consider adjunctive
beta-agonists.
o Short-Acting Beta Agonist (SABA) - Albuterol 2.5 mg/3 ml via INH/Neb; Terbutaline 1
mg/ml.
o Depending on the number of patients and supplies of Long-Acting Beta Agonist (LABA),
consider contingency therapy: formeterol 0.02 mg/2 ml INH/Neb; salmeterol 0.05
mg/INH.
10

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Critically ill patients not responding to antimuscarinic and bronchodilator therapies should betreated according to the standard of care for impending respiratory failure:o Consider systemic corticosteroid dosing similar to the treatment of refractory reactive
airways disease (RAD) (1-2 mg/kg of methylprednisolone)o Magnesium sulfate 2 g IV
For patients who develop acute lung injury (ALI) physiology and are on mechanicalventilation, consider employing standard of care ALI strategies such as the following to
improve ventilation:o Pharmacological neuromuscular blockadeo Extracorporeal Life Support (ECLS)
Etiology of the shortness of breath is due to cholinergic crisis and even thoughneuromuscular blockade is implemented for ventilation, continued anticholinergic therapy
titrated to respiratory secretions is necessary. If neuromuscular blockade is used, electroencephalography (EEG) should be used to monitor seizures.

Seizures
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Repeated doses of benzodiazepines may be needed to gain seizure control.
Barbiturates should also be considered.
Monitor for the need for mechanical ventilation after administering repeated doses ofbenzodiazepines or barbiturates.
Chemically-induced seizures may not be responsive to some common anticonvulsants suchas phenytoin or levetiracetam.
Paralytics for intubation may stop motor activity but seizure activity may be ongoing in thebrain; sedation with general anesthesia or medically induced coma per local capabilities may
be necessary.
EEG monitoring should be initiated if available.
Treat refractory status epilepticus according to established guidelines.

Additional ConsiderationsIn the cases of FGA poisoning in the U.K., clinicians felt the oxime 2-PAM was helpful inmaintaining blood pressure and renal perfusion for reasons which remain unclear.
In a critically ill patient who is hemodynamically unstable and refractory to standard
therapies, treating providers can consider additional measures that may be of theoreticalbenefit, e.g., intravenous lipid emulsion.

Waste Management
Used PPE, body fluids, and waste generated in the management of patients should be handledwith extra caution and segregated from other waste, as they may be contaminated with chemical
agent. For more guidance, see waste management section on pages 15-16.

11

Pre-Hospital Treatment Recommendations (Autoinjector-Based)
Nerve Agent Poisoning
Antidotes
Patient Age
Infant (0-2yrs)

Child (3-7yrs; 13–25
kg)

Child (8-14yrs; 26-50
kg)

Mild/Moderate
Symptoms
Atropine 0.05 mg/kg IM
or Atropine AI 0.25 mg
or 0.5 mg
AND
2-PAM 15-30 mg/kg IM

1 Atropine AI 1 mg
AND
1 2-PAM AI or 2-PAM
15-30 mg/kg IM

1 DuoDote; OR 1
Atropine AI 2 mg
AND
1 2-PAM AI or 2-PAM
15-30 mg/kg IM

Additional Treatment
Severe Symptoms
Atropine 0.1 mg/kg IM or
Atropine AI 0.25 mg or 0.5mg
AND
2-PAM 45 mg/kg IM;ANDMidazolam 0.15 mg/kg IM
OR
Lorazepam 4 mg IM
OR
Lorazepam 0.1 mg/kg IN
OR
Diazepam 0.2-0.5 mg/kg
IM
1 DuoDote; OR 1 Atropine
AI 2 mg
AND 1 2-PAM AI or 2PAM 45 mg/kg IM;ANDMidazolam 5 mg IM
OR
Lorazepam 4 mg IM OR
Lorazepam 0.1 mg/kg IN
OR
1 CANA
2 DuoDote; OR 2 Atropine
AI 2 mg AND 2 2-PAM AI
or 2-PAM 45 mg/kg IM;ANDMidazolam 5 mg IM
OR
Lorazepam 4 mg IM OR
Lorazepam 0.1 mg/kg IN
OR
1 CANAFor mild/moderate,
repeat atropine (2 mg)(for child 3-7 yrs, 1 mg;
for infant, 0.25-0.5 mg)
at 5-10 minute intervals
until secretions havediminished andbreathing is
comfortable or airway
resistance has returned
to near normal.
For severe, repeat
atropine as above but at
2-5 minute intervals.
Anticonvulsant should
be administered insevere cases whether
seizures are apparent ornot.
If convulsions arepresent, repeat
benzodiazepine until
convulsions resolve.
Assisted ventilation
should be started asneeded afteradministration ofantidotes.

12Adolescent(>14
years)/Adult

1 to 2 DuoDote; OR
1 to 2 Atropine AI 2 mg
AND
1 2-PAM AI

3 DuoDote;AND
1 CANAOR
Midazolam 10 mg IM
OR
Lorazepam 6 mg IM/IN

Elderly,frail

1 DuoDote

2 to 3 DuoDote; OR
1 to 2 Atropine AI 2 mg
AND
2 to 3 2-PAM AI;
AND
1 CANAOR
Midazolam 10 mg IM
OR
Lorazepam 6 mg IM/IN

Autoinjector Products:
DuoDote = ATNAA = Mark 1 kit = Atropine 2 mg + 2-PAM 600 mg AI
Atropine AI = various doses, two different manufacturers*
2-PAM AI = 2-PAM 600 mg AI
CANA = Diazepam 10 mg AI* Please see the following webpage for more information on FDA approved atropine AI products
and current nerve agent emergency use authorization information:
https://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm063
809.htm13

Hospital Treatment Recommendations (Weight-Based)
Nerve Agent Poisoning
Antidotes
Patient Age
Infant (0-2yrs)

Child (3-7yrs; 13–25
kg)

Child (8-14yrs; 26-50
kg)

Mild/Moderate
Symptoms
Atropine 0.05 mg/kg
IV/IO/IMAND
2-PAM 15-30 mg/kg
IV/IO/IM

Additional Treatment
Severe Symptoms
Atropine 0.1 mg/kg
IV/IO/IMAND
2-PAM 45 mg/kg
IV/IO/IM;AND
Midazolam 0.15 mg/kg
IV/IO/IMOR
Lorazepam 4 mg IV/IO/IM
OR
Lorazepam 0.1 mg/kg IN
OR
Diazepam 0.2-0.5 mg/kg
IV/IO/IMFor mild/moderate,
repeat atropine (2 mg)(for child 3-7 yrs, 1 mg;
for infant, 0.25-0.5 mg)
at 5-10 minute intervals
until secretions havediminished andbreathing is
comfortable or airway
resistance has returned
to near normal.

Atropine 1 mg IV/IO/IM Atropine 2 mg IV/IO/IM orAND
Atropine 0.1 mg/kg
2-PAM 15 -30 mg/kg
IV/IO/IM;
IV/IO/IM
AND 2-PAM 45 mg/kg
IV/IO/IM;AND
Midazolam 5 mg IV/IO/IM
OR
Lorazepam 4 mg IV/IO/IM
OR
Lorazepam 0.1 mg/kg IN
OR
Diazepam 0.2-0.5 mg/kg
IV/IO/IM

Anticonvulsant should
be administered insevere cases whether
seizures are apparent ornot.

Atropine 2 mg IV/IO/IM
AND
2-PAM 15-30 mg/kg
IV/IO/IM

Atropine 4 mg IV/IO/IM
AND 2-PAM 45 mg/kg
IV/IO/IM;AND
Midazolam 5 mg IV/IO/IM
OR
Lorazepam 4 mg IV/IO/IM
OR

For severe, repeat
atropine as above but at
2-5 minute intervals.

If convulsions arepresent, repeat
benzodiazepine until
convulsions resolve.
Assisted ventilation
should be started asneeded afteradministration ofantidotes.

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Lorazepam 0.1 mg/kg IN
OR
Diazepam 0.2-0.5 mg/kg
IV/IO/IM
Adolescent(>14
years)/Adult

Atropine 2-4 mg
IV/IO/IMAND
2-PAM 600 mg IV/IO/IM

Atropine 6 mg IV/IO/IM
AND 2-PAM 1800 mg
IV/IO/IM;AND
Diazepam 10 mg IV/IO/IM
OR
Midazolam 10 mg
IV/IO/IMOR
Lorazepam 6 mg
IV/IO/IM/IN

Elderly,
frail

Atropine 2 mg IV/IO/IM
AND
2-PAM 10 mg/kg
IV/IO/IM

Atropine 2-4 mg IV/IO/IM
AND
2-PAM 25 mg/kg
IV/IO/IM;AND
Diazepam 10 mg IV/IO/IM
OR
Midazolam 10 mg
IV/IO/IMOR
Lorazepam 6 mg
IV/IO/IM/IN

Waste Management
Once lifesaving efforts are under control, the incident command should develop a comprehensive
waste management plan along with a site-specific health and safety plan. The incident-specificcomprehensive waste management plan should address the following: Consideration must be given early on, in an exposure or suspected exposure event, of theneed to preserve certain materials and samples as required for investigation and chain ofcustody purposes. Consultation with the local FBI WMD Coordinator or other law
enforcement may be necessary to ensure proper materials (and quantities) are preserved.
 Materials and samples needed for investigation and chain of custody should be secured andisolated from the waste collection activities. Once designated as “evidence” the materials are
no longer treated as “waste.” FGAs can persist for extremely long periods of time on materials and effluent liquids such as
water (e.g., from patient and responder decontamination processes). Personnel handling thesematerials and liquids must be made aware of the potential hazard they present and provided
with appropriate PPE.
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




The plan must identify specific collection and decontamination methods and personnel.
Personnel must be knowledgeable of the FGA hazards, effective decontamination methods,
and have appropriate PPE.
Waste must be decontaminated before it is handled by the facility’s regular waste
management staff.
Incineration may be identified in the Comprehensive Waste Management Plan as the best
decontamination method for some of the contaminated materials. Local permit modifications
and requirements may vary per state regulation.
Consult with experts for disposal recommendations.

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APPENDIX - PERSONAL PROTECTIVE EQUIPMENT
Painstaking attention to protective zones, decontamination protocols, and donning and doffingof personal protective equipment (PPE) is essential to prevent secondary exposure and spreadof agent in the environment.
Employers must comply with Occupational Safety and Health Administration (OSHA) standards
on PPE (29 CFR 1910.132): https://www.osha.gov/lawsregs/regulations/standardnumber/1910/1910.132, Respiratory Protection (29 CFR 1910.134):https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134, Hazardous Waste
Operations and Emergency Response (29 CFR 1910.120): https://www.osha.gov/lawsregs/regulations/standardnumber/1910/1910.120, and other requirements, including state
regulations, whenever such requirements apply.
The Occupational Safety and Health Administration (OSHA) provides general guidance for EMS
and hospitals that receive and treat victims of hazardous substance releases in the following
documents:
 Best Practices for Protecting EMS Responders during Treatment and Transport of Victims ofHazardous Substance Releases and Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents
Involving the Release of Hazardous Substances.
Key Safe Work Practices include:

Ensure that personnel take sufficient time to don and doff PPE carefully and correctly
without distraction.
Avoid using hand sanitizer or other products containing alcohol, as they may enhanceabsorption of agent and spread it over a larger area of skin. Do not use bleach todecontaminate skin.
Establish an exposure management plan that addresses decontamination and monitoring of
personnel in the case of any exposure. Training and follow-up should be part of thepersonnel training.
At the hospital, minimize the number of personnel entering the patient’s room and takeprecautions to avoid cross-contamination.

Managing Patients Before they are Decontaminated:
Responders and hospital personnel providing or assisting with patient care before and duringdecontamination should select PPE based on the employer’s standard operating procedures, thejob task, and the potential for exposure to hazards. The PPE section of the FGA Reference Guide(https://chemm.nlm.nih.gov/nerveagents/FGA.htm) outlines recommendations for PPE selection.
Managing Patients After they are Decontaminated:
Limited data are available on the risk of post-decontamination handling of patients who havebeen exposed to FGAs, but there are concerns that FGAs can persist in body fluids, posing a17

potential hazard to personnel. Due to a depot effect in the skin, repeated decontamination over a
course of days may be beneficial. For these reasons, the following specific PPE
recommendations provide a precautionary approach to worker protection measures. This
guidance will be updated as more evidence becomes available.
Because of the concerns that FGAs can persist in body fluids, the following guidance provides aprecautionary approach to protect EMS and hospital personnel from exposure when treating apatient, following decontamination, who was suspected or confirmed to have been exposed to
FGAs:

Two pairs of single-use (disposable) nitrile examination gloves with extended cuffs. Outer
gloves should be a minimum of 7 mil thickness at the palm and inner gloves should be aminimum of 5 mil thickness at the palm. Gloves should be changed every 15 minutes orwhen they become soiled.
or
One pair of single-use (disposable) 15 mil nitrile or 14 mil butyl rubber gloves. Gloves
should be changed every 2 hours or when soiled.

Single-use (disposable) surgical or isolation gown; a single-use (disposable) apron thatcovers the torso to the level of the mid-calf; and single-use (disposable) sleeves. Gown
should pass ANSI/AAMI PB70 Level 3 or 4 requirements and apron and sleeves should beconstructed of fabric that provides protection against VX (such as TyChem® F, Microchem®
4000, or Zytron® 300 fabric).
orSingle-use (disposable) coverall. Coverall should be constructed of fabric and seams thatprovides protection against VX (such as TyChem® F, Microchem® 4000, Zytron® 300
fabric with taped seams).

Single-use (disposable) full-face shield.

When it is not possible to implement the precautionary approach above, EMS and hospital
personnel at a minimum should wear appropriate PPE and take blood and body fluid precautions,
including: Two pairs of nitrile medical exam gloves, Gown, Eye or face protection, and Take all measures to prevent direct contact with secretions and body fluids as they may
contain chemical agent.
It should be recognized that this level of PPE may not provide sufficient exposure reduction.
Therefore, gloves should be changed every 15 minutes, or when they become soiled, or between
patients if possible, whichever occurs soonest, and gowns should be changed when they become18soiled. Limited real world experience in the U.K. demonstrated this approach was adequate toprotect workers given the specifics associated with the March and June 2018 incidents.
Responders and hospital personnel should report any potential exposure and be medicallyevaluated immediately per your department or agency’s procedures. Symptoms may occur up to
3 days post exposure.
In order to determine when it is appropriate to downgrade PPE, employers are encouraged
to perform a risk and hazard assessment, taking into account patient status. See the FGA
Reference Guide (https://chemm.nlm.nih.gov/nerveagents/FGA.htm) for information necessary
to conduct the risk and hazard assessment.
General recommendations for handling PPE include: PPE should be inspected prior to donning for any defects and those that are punctured, torn,or otherwise damaged should be discarded and replaced.
 PPE should be taken off in a dedicated area when exiting the patient room to prevent crosscontamination.
 PPE, linens, and other waste that have come into contact with the patient should besegregated from other waste and disposed of properly. Consult with experts for disposal
recommendations.

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References
Best Practices for Protecting EMS Responders during Treatment and Transport of Victims ofHazardous Substance Releases (DOL/OSHA)Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents
Involving the Release of Hazardous Substances (DOL/OSHA)
Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance forCommunities (HHS & DHS)
Primary Response Incident Scene Management (PRISM) Decontamination Guidance for
Chemical Incidents (HHS/ASPR/BARDA)
First Responders’ Environmental Liability Due to Mass Decontamination Runoff (EPA)
Contingency Medical Countermeasures
Schwartz MD, Sutter ME, Eisnor D, Kirk MA. Contingency Medical Countermeasures for Mass
Nerve-Agent Exposure: Use of Pharmaceutical Alternatives to Community Stockpiled Antidotes.
Disaster Medicine and Public Health Preparedness. 2018 Oct; 15:1-8.
ARDS
Thompson BT, Chambers RC, Liu KD. Acute Respiratory Distress Syndrome. N Engl J Med.
2017 Aug 10; 377(6):562-572.
Global Recommendations for Reactive Airway Disease Management
Albertson TE, Sutter ME, Chan AL. The Acute Management of Asthma. Clin Rev Allergy
Immunol. 2015 Feb; 48(1):114-25.
Lipid Emulsion Therapy as Heroic Measure
Hoegberg LCG, Gosselin S. Lipid Resuscitation In Acute Poisoning: After a Decade of
Publications, What Have We Really Learned? Curr Opin Anaesthesiol. 2017 Aug; 30(4):474479.

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