• Calculator Online

Adult Nerve Agent Exposure Medical Directive

A Primary Care Paramedic or an Advanced Care Paramedic may provide the treatment prescribed in this Medical Directive if authorized.

Indications

Exposure to a known or suspected nerve agent;
AND
Signs and symptoms of a cholinergic crisis.

Conditions

Atropine
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic crisis
Moderate Exposure
Any one of the following:
vomiting, diarrhea, bronchospasm or bronchial secretions, shortness of breath or any known liquid exposure
Severe Exposure
Signs and symptoms of a moderate exposure and any one of the following:
decreased LOA, paralysis, seizure or apnea
Pralidoxime
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic crisis
Moderate Exposure
Any one of the following:
vomiting, diarrhea, bronchospasm or bronchial secretions, shortness of breath or any known liquid exposure
Severe Exposure
Signs and symptoms of a moderate exposure and any one of the following:
decreased LOA, paralysis, seizure or apnea
Obidoxime
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic crisis
Moderate Exposure
Any one of the following:
vomiting, diarrhea, bronchospasm or bronchial secretions, shortness of breath or any known liquid exposure
Severe Exposure
Signs and symptoms of a moderate exposure and any one of the following:
decreased LOA, paralysis, seizure or apnea
Diazepam
Age ≥18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other Suspected cholinergic crisis
Moderate Exposure
Any one of the following:
vomiting, diarrhea, bronchospasm or bronchial secretions, shortness of breath or any known liquid exposure
Severe Exposure
Signs and symptoms of a moderate exposure and any one of the following:
decreased LOA, paralysis, seizure or apnea

Contraindications

Atropine
Allergy or sensitivity to Atropine
Pralidoxime
Allergy or sensitivity to Pralidoxime
Obidoxime
Allergy or sensitivity to Obidoxime
Diazepam
Allergy or sensitivity to Diazepam

Treatment

Consider Atropine
  Moderate Exposure Severe Exposure
Route Route
IM Auto-injector IV (ACP only) IM Auto-injector IV (ACP only)
Initial Dose 2 mg 2.1 mg 2 mg 6.3 mg 2 mg 6 mg
Subsequent doses 2 mg 2.1 mg 2 mg 2.2 mg 2 mg 2 mg
Dosing interval 5 min 5 min 5 min 5 min 5 min 5 min
Max # of doses N/A N/A N/A N/A N/A N/A
Consider Pralidoxime
  Moderate Exposure Severe Exposure
  Route Route
  IM Auto-injector IM Auto-injector
Dose 600 mg 600 mg 1800 mg 1800 mg
Max. single dose 600 mg 600 mg 1800 mg 1800 mg
Dosing interval N/A N/A N/A N/A
Max. # of doses 1 1 1 1
Consider Obidoxime (if not using pralidoxime)
  Moderate Exposure Severe Exposure
  Route Route
  IM Auto-injector IM Auto-injector
Dose 150 mg 150 mg 450 mg 450 mg
Max. single dose 150 mg 150 mg 450 mg 450 mg
Dosing interval N/A N/A N/A N/A
Max. # of doses 1 1 1 1
Consider Diazepam
  Moderate Exposure Severe Exposure
  Route Route
  IM Auto-injector
Dose 10 mg 10 mg
Max. single dose 10 mg 10 mg
Dosing interval N/A N/A
Max. # of doses 1 1

Clinical Considerations

Only one of pralidoxime or obidoxime should be administered.

Administration of IV medications applies to ACPs only.

Do not delay IM administration if IV access is not already established.

Atropine should be administered prior to airway interventions if secretions are copious.

Subsequent doses of atropine are intended for patients showing signs of bronchial secretions and may be repeated as indicated until airway secretions are controlled.

Decontamination procedures must be integrated with antidote administration.

Contact

Ministry of Health and Long-Term Care
5700 Yonge Street, 6th Floor
Toronto, ON M2M 4K5

416-327-7900

Social