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- Chemical Treatment Guide: GREEN

Chemical Treatment Guide: GREEN

• Carbamates: insecticide poisoning
• Organophosphates: insecticide poisoning and nerve agents (GA, GB, GD, GF, VX)


The muscarinic effects are described as the classic SLUDGE syndrome (excessive Salivation,
Lacrimation, Urination, Diarrhea, Gastrointestinal distress, and Emesis). Additional muscarinic
effects include bronchorrhea, bronchospasm, and bradycardia. The patient will have constricted
pupils (miosis, which may last as long as 2 months despite appropriate treatment) with inhalation
or skin exposure. Ingestion may or may not cause miosis. Stimulation of nicotinic receptors will
produce tachycardia, muscle paralysis (apnea), muscle twitching/fasiculations, and seizures.

Supportive Care

• Remove the patient from the hazardous area.
• Avoid exposure to the patient’s sweat, vomit, stool, and vapors emitting from soaked clothes.
• Administer high-flow O2.
• If the patient was exposed externally, remove his/her clothing and decontaminate as
appropriate (place the patient’s clothes in sealed bag).
• Contact the Poison Information Center (1-800-222-1222).


If treating 1-4 patients:
• If the patient is bradycardic (patient is usually tachycardic) or has excessive pulmonary
secretions, adult dose administer atropine 0.03 mg/kg IV (2 mg/70 kg),
pediatric dose 0.05mg/kg maximum dose is 3mg. Repeat every 5 minutes until secretions are inhibited.
• In case of organophosphate poisoning, adult and pediatric dose consider pralidoxime
(Protopam ®, 2-PAM®) 1-2 g mixed in 100 mL NS IV drip over 30 minutes. In severe cases, 2-
PAM® may be given via IV at a maximum rate of 200 mg/min or 1 g/5 min (used when
nicotinic effects are present, as evidenced by fasciculation of large muscles). Observe patient
for hypertension. (May be needed with high exposure to carbamates.)
• If seizures continue for 3 minutes, Administer benzodiazepines:
- Midazolam (Versed) Adult dose 2 mg increments IV, IO, IM, or IN,
Pediatric dose 0.1mg/kg, maximum single dose 4 mg IV, IO, IM. For IN administration use 0.2
mg/kg/dose (use 10 mg/2mL concentration), maximum single dose 5 mg; may repeat once
if necessary. Maximum total dose of 10 mg

If treating 5 or more patients older than 5 years of age or treating self-exposure (with pinpoint
pupils): Adult and pediatric.

• Administer DuoDote(s) (combined Atropine and Pralidoxime) or Mark I Kit(s) (two autoinjectors
containing Atropine 2 mg in one and pralidoxime 600 mg in the other.
-For early symptoms (severe rhinorrhea or mild to moderate dyspnea): administer one
DuoDote or Mark I auto-injector kit. If no improvement in patient’s status in 10 minutes,
administer another DuoDote or Mark I auto-injector kit.
- For severe respiratory distress, coma, or seizures: administer three DuoDotes or Mark I
auto-injectors and one CANA/Valium auto-injector (diazepam 10 mg IM).

For all patients meeting the preceding criteria:
• Alert the emergency department to prepare for a contaminated patient.
• Do not induce vomiting or give Furosemide (Lasix®) or Morphine.
• If the patient is experiencing eye pain and/or blepharospasm, administer Scopolamine 1 drop
in each eye.

- If risk of exposure from fumes is high, call for a hazardous materials team. PPE (usually
Level A) with SCBA must be worn in the hazardous area. PPE with a minimum of Level C
protection must be worn for treatment outside the hazardous area.
- If advised by the Poison Information Center, every other dose of Atropine can be increased
to 0.06 mg/kg IV.
- The endpoint for treatment is manifested by patient improvement with clear lung sounds.
- When possible, establish an IV and administer Atropine, Diazepam, Lorazepam, and
Midazolam IV and Pralidoxime IV drip.
- For IN administration, administer 1ml per nare, give half the volume in one nostril and the
other half of the volume in the other nare.

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