Pediatric Nerve Agent Poisoning

Abstract

Most published recommendations for treatment of pediatric nerve agent poisoning are based on standard resuscitation doses for these agents. However, certain medical and operational concerns suggest that an alternative approach may be warranted for treatment of children by emergency medical personnel after mass chemical events. (1) There is evidence both that suprapharmacological doses may be warranted and that side effects from antidote overdosage can be tolerated. (2) There is concern that many emergency medical personnel will have difficulty determining both the age of the child and the severity of the symptoms. Therefore, the Regional Emergency Medical Advisory Committee of New York City and the Fire Department, City of New York, Bureau of Emergency Medical Services, in collaboration with the Center for Pediatric Emergency Medicine of the New York University School of Medicine and the Bellevue Hospital Center, have developed a pediatric nerve agent antidote dosing schedule that addresses these considerations. These doses are comparable to those being administered to adults with severe symptoms and within limits deemed tolerable after inadvertent nerve agent overdose in children. We conclude that the above approach is likely a safe and effective alternative to weight-based dosing of children, which will be nearly impossible to attain under field conditions.

The use of atropine in a nerve agent response with specific reference to children: are current guidelines too cautious?

“…Many guidelines rely on the ability of the emergency responder, who may have limited paediatric experience, to assess symptom severity and the age or weight of the child accurately. Some have proposed the use of a length-based, colour-coded resuscitation tape to allow estimation of body weight, but the use of such an instrument would delay the delivery of treatment by up to 30 s and the extra time required to administer what may be a more accurate dose is probably not justified 15. Concerns have also been raised that responders may have difficulty deciphering between unexposed crying infants and those in respiratory distress, and faced with this decision treatment may be critically delayed.…”

“…15 The dose should be large enough to achieve a rapid clinical effect both for the benefit of the patient and to assist decisions about future doses. The dose used in symptomatic bradycardia in children (usually 0.02 mg/kg) is also the current paediatric dose recommended by UK sources for use after nerve agent exposure, with the dose repeated every 5–15 minutes until atropinisation is achieved 16 17.…”

“…The use of an autoinjector device is believed to result in broader drug dispersion and increased rate of absorption than would be achieved with a needle and syringe 18. A specific paediatric autoinjector device has recently been introduced, which, in contrast to the adult device, contains only atropine and no pralidoxime 15 19 20. The licensed dose with the device is 0.5 mg for children weighing 15–40 lb and 1.0 mg for those weighing 40–90 lb, with no licence for use in infants and toddlers weighing less than 15 lb.…”

“…The licensed dose with the device is 0.5 mg for children weighing 15–40 lb and 1.0 mg for those weighing 40–90 lb, with no licence for use in infants and toddlers weighing less than 15 lb. Some organisations (eg, the US National Centre for Disaster Preparedness) have reservations over specific paediatric devices as they contain no pralidoxime and are not licensed for use in all children 15 19. It is not clear why pralidoxime has been excluded from this paediatric device as it is believed to play a vital role in adequate antidotal therapy.…”

“…As nerve agents can have a dramatic clinical effect in seconds to minutes, a faster antidotal response would be required than that expected from an intramuscular atropine injection at the lower end of the dose range. Furthermore, most expert resources state repeated doses should be continued at 2–10 minute intervals until the resolution of secretions and bronchorrhoea 2 15 31 32. Such recommendations are generally based on intravenous administration as given the intramuscular time profile illustrated this would run the risk of precipitating delayed atropine toxicity.…”