Abstract

Sarin is now a weapon of the terrorist. Its acute effects are primarily due to unrestricted cholinergic activity at both muscarinic and nicotinic receptors. Treatment is based on the use of large doses of atropine and pralidoxime which may lead to practical problems of sufficient drug supplies for the average hospital. Ventilation may be necessary and present problems. Victim decontamination involves use of bleach, soap and water. Staff handling casualties need protection with respirators and butyl rubber boots and gloves.

Diagnosis
Nerve agent poisoning is diagnosed clinically, based on exposure to an agent with resulting meiosis and blurred vision with bronchospasm
and salivation. More severe cases may lead to respiratory failure secondary to pulmonary oedema and respiratory muscle paralysis.
Muscle fasciculation with abdominal cramps and urinary and faecal incontinence may also be a feature. With the organophosphate insecticides, it is typical to find bradycardia and excess salivation as presenting features. In the reports of the Tokyo poisonings, tachycardia and
hypertension, a nicotinic, presynaptic effect, was common and excess secretions were only seen in the most severely poisoned patients.

General management
In the military situation, at risk personnel are issued with nuclear, chemical and biological warfare (NCB) suits. Oral pyridostigmine is
taken prophylactically if a real risk of attack is perceived and "combo pens" of atropine (2 mg) and pralidoxime (4 g) are issued for self
treatment on exposure to a nerve agent. Soldiers are trained in symptom recognition and agent identification as well as safe procedures
in the presence of such agents. In civilian life this level of preparedness is unlikely.

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