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Pediatric 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

Conditions

Atropine
Age <18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other

Suspected cholinergic crisis 

Any one of the following:
vomiting, diarrhea, bronchospasm or bronchial secretions,
shortness of breath, decreased LOC, paralysis, seizure, apnea or any known liquid exposure

Pralidoxime
Age <18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other

Suspected cholinergic crisis 

Any one of the following:
vomiting, diarrhea, bronchospasm or bronchial secretions,
shortness of breath, decreased LOC, paralysis, seizure, apnea or any known liquid exposure

Obidoxime
Age <18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other

Suspected cholinergic crisis 

Any one of the following:
vomiting, diarrhea, bronchospasm or bronchial secretions,
shortness of breath, decreased LOC, paralysis, seizure, apnea or any known liquid exposure

Diazepam
Age <18 years
LOA N/A
HR N/A
RR N/A
SBP N/A
Other

Suspected cholinergic crisis 

Any one of the following:
vomiting, diarrhea, bronchospasm or bronchial secretions,
shortness of breath, decreased LOC, paralysis, seizure, apnea or any known liquid exposure

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
  Weight
< 10 kg < 10 kg ≥10 kg to <40 kg ≥10 kg to <40 kg
Route
IV (ACP only) IM IV (ACP only) IM
Initial Dose 0.5 mg 0.5 mg 1 mg 1 mg
Subsequent doses 0.5 mg 0.5 mg 1 mg 1 mg
Dosing interval 5 min 5 min 5 min 5 min
Max # of doses N/A N/A N/A N/A
Consider Diazepam
  Weight
< 10 kg < 10 kg ≥10 kg to <40 kg ≥10 kg to <40 kg
Route
IV (ACP only) IM IV (ACP only) IM
Initial Dose 2 mg 2 mg 0.2 mg/kg 0.2 mg/kg
Subsequent doses 2 mg  2 mg 8 mg 8 mg
Dosing interval N/A N/A N/A N/A
Max # of doses 1 1 1 1
Consider Pralidoxime
  Weight
< 10 kg < 10 kg ≥10 kg to <40 kg ≥10 kg to <40 kg
Route
IV (ACP only) IM IV (ACP only) IM
Initial Dose 15 mg/kg 15 mg/kg 15 mg/kg 15 mg/kg
Max. single dose 150 mg 150 mg 600 mg 600mg
Dosing interval 60 min 60 min 60 min 60 min
Max # of doses 2 2 2 2
Consider Obidoxime (if not using pralidoxime)
  Weight
< 10 kg < 10 kg ≥10 kg to <40 kg ≥10 kg to <40 kg
Route
IV (ACP only) IM IV (ACP only) IM
Initial Dose 8 mg/kg 8 mg/kg 8 mg/kg 8 mg/kg
Max. single dose 80 mg 80 mg 320 mg 320 mg
Dosing interval N/A N/A N/A N/A
Max # of doses 1 1 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

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