Antidotes for nerve agent poisoning: should we differentiate children from adults?

Chemical terrorism presents a threat to the civilian population, including children. Nerve agent antidotes are available in prepackaged autoinjectors that can be delivered rapidly following an exposure. The published evidence on the use of nerve agent antidotes consists of case reports, extrapolation from pediatric organophosphate poisonings, and expert opinion. This review examines the evidence supporting the use of nerve agent antidotes in children.

The use of adult formulated atropine and pralidoxime autoinjectors will deliver doses above current recommendations for infants and children. Data demonstrate, however, that atropine overdose is generally well tolerated in young children. Children symptomatic of nerve agent poisoning will likely need both supraphysiologic doses and frequent re-dosing of atropine.

Based on limited data, the Mark 1 autoinjector kit (Meridian Medical Technologies, Columbia, Maryland, USA) appears to be the most efficacious antidote delivery system following a nerve agent attack. Symptomatic children under 1 year of age should be given a full atropine dose from the Atropen (Meridian Medical Technologies) (0.5 mg) or Mark 1 kits (2 mg), while children over 1 year of age should be given a full dose of both atropine and pralidoxime from the Mark 1 kit when more accurate weight-based dosing of antidotes is impossible.