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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

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Table 5.4. Nerve Agent Triage and Dosing

Symptoms Triage Level: Disposition Anticholinergics Oxime-Pralidoxime Chloride (2-PAM) Benzodiazepinesa
Asymptomatic Delayed: observe. None None None
Miosis, mild rhinnorhea Delayed: admit or observe. None None None
Miosis and any other symptom Immediate: admit.

Atropine.
0.05 mg/kg IV, IM, IO, to max 4 mg; repeat as needed q 5-10 min until pulmonary resistance improves or secretions resolve; correct hypoxia before IV use; increased risk of ventricular fibrillation.
Alternatives:
Consider scopolamine for nervous system and peripheral effects; glycopyrrolate for peripheral effects only.

2-PAM.
25-50 mg/kg IV, IM, to max 1,800 mg; repeat q 1 hr prn; watch for muscle rigidity, laryngospasm, tachycardia, hypertension.

If neurologic symptoms or rapid progression:
Midazolam.
0.15-0.2 mg/kg, IM, IV, repeat as necessary or start continuous IV drip; less likely to cause apnea by IM route
Diazepam IV, prn (see below)
Lorazepam
IV at 0.05-0.1 mg/kg (IM absorption variable).
If IV or IM is not available, consider midazolam given sublingual or intranasal at 0.2 mg/kg or diazepam prn or lorazepam prn.

Apnea, convulsions, cardiopulmonary arrest Immediate: admit, intensive-care status.

Atropine
0.05-0.10 mg/kg IV, IM, IO
Repeat q 5-10 min as above (no max).
Endotracheal tube: increase dose 2-3 times, mix with 3-5 mL normal saline and introduce via suction catheter, flush 3-5 mL normal saline.

2-PAM
25-50 mg/kg IV, IM, as above.

Midazolam, as above.
Diazepam.
30 days to 5 yr old: 0.05-0.3 mg/kg, IV, max 5 mg/dose.
≥5 yr old: 0.05-0.3 mg/kg, IV, max 10 mg/dose.
Repeat q 15-30 min, prn.
Lorazepam IV, IM.

Autoinjector  

Atropine
2 mg for ≥40 kg
1 mg for ≥20 kg
0.5 mg for ≥10 kg
(0.05 mg/kg/dose).

2-PAM
600 mg for ≥12 kg
(50 mg/kg/dose).

Diazepam
10 mg for ≥30 kg
(0.3 mg/kg/dose).

Notes: IV = intravenous; IM = intramuscular.

a Monitor respiratory status and blood pressure.

Note: Remember airway, breathing, circulation, decontamination/drugs. Consider oxygen, bronchodilators, nasogastric tube/drainage, ophthalmic analgesia, mydriatics, temperature control. If prolonged impairment of consciousness, electroencephalogram (EEG) (to rule out nonconvulsive status epilepticus) and imaging.

Source: Adapted from Rotenberg JS, Newmark J. Pediatrics 2003;112:648-58.

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