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Juurlink DN et al Hyperbaric oxygen for carbon monoxide poisoning Cochrane Database Syst Rev 2005 Jan 25;(1):CD002041 [PMID: 15674890]
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CHEMICAL WARFARE: NERVE AGENTS
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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
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Clinical Findings
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At low carbon monoxide levels (carboxyhemoglobin saturation 10 20%), victims may have headache, dizziness, abdominal pain, and nausea With higher levels, confusion, dyspnea, and syncope may occur Hypotension, coma, and seizures are common with levels greater than 50 60% Survivors of acute severe poisoning may develop permanent obvious or subtle neurologic and neuropsychiatric deficits The fetus and newborn may be more susceptible because of high carbon monoxide affinity for fetal hemoglobin Carbon monoxide poisoning should be suspected in any person with severe headache or acutely altered mental status, especially during cold weather, when improperly vented heating systems may have been used Diagnosis depends on specific measurement of the arterial or venous carboxyhemoglobin saturation, although the level may have declined if high-flow oxygen therapy has already been administered, and levels do not always correlate with clinical symptoms Routine arterial blood gas testing and pulse oximetry are not useful because they give falsely normal PaO2 and oxyhemoglobin saturation determinations, respectively
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Treatment
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A Emergency and Supportive Measures
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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
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B Specific Treatment
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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 United States military personnel in the Iraq invasion were equipped with autoinjectable units containing 2 mg of atropine plus 600 mg of the cholinesterase-reactivating agent pralidoxime
Barthold CL et al Organic phosphorus compounds nerve agents Crit Care Clin 2005 Oct;21(4):673 89 [PMID: 16168308] Bigalke H et al Medical aspects of toxin weapons Toxicology 2005 Oct 30;214(3):210 20 [PMID: 16087285]
Treatment
A Emergency and Supportive Measures
Maintain a patent airway and assist ventilation, if necessary Remove the victim from exposure Treat patients with coma, hypotension, or seizures as described at the beginning of this chapter
B Specific Treatment
The half-life of the carboxyhemoglobin (CoHb) complex is about 4 5 hours in room air but is reduced dramatically by high concentrations of oxygen Administer 100% oxygen by tight-fitting high-flow reservoir face mask or endotracheal tube Hyperbaric oxygen (HBO) can provide 100% oxygen under higher than atmospheric pressures, further shortening the half-life; it may also reduce the incidence of subtle neuropsychiatric sequelae Recent studies disagree about the benefit of HBO, but recommended indications for HBO in patients with carbon monoxide poisoning include a history of loss of consciousness, CoHb greater than 25%, metabolic acidosis, age over 50 years, and cerebellar findings on neurologic examination
Buckley NA et al Hyperbaric oxygen for carbon monoxide poisoning: a systematic review and critical analysis of the evidence Toxicol Rev 2005;24(2):75 92 [PMID: 16180928] Hampson NB et al Storm-related carbon monoxide poisoning: lessons learned from recent epidemics Undersea Hyperb Med 2006 Jul Aug;33(4):257 63 [PMID: 17004412]
CHEMICAL WARFARE: RICIN
Ricin is a naturally occurring toxin found in minute quantities in the castor bean (Ricinus communis) It can cause toxicity if castor beans are thoroughly chewed or blenderized, although the quantity of ricin is small and it is poorly absorbed from the gastrointestinal tract, so symptoms following castor bean ingestion are usually limited to diarrhea and abdominal pain Less commonly, severe gastroenteritis can lead to volume depletion and renal failure On the other hand, purified ricin is extremely toxic if administered parenterally: the LD50 for injected ricin in animals is as low as 01 mcg/kg A fatal case of suspected ricin poisoning by homicidal injection of an estimated 028 mg of ricin was associated with diffuse organ damage and death from cardiac failure after 2 days Inhalation of ricin powder has not been reported in humans, but animal studies suggest it could cause hemorrhagic tracheobronchitis and pneumonia
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