ACMT Position Statement: Alternative or Contingency Countermeasures for Acetylcholinesterase Inhibiting Agents

  • Andrew Stolbach
  • Vikhyat Bebarta
  • Michael Beuhler
  • Shaun Carstairs
  • Lewis Nelson
  • Michael Wahl
  • Paul M. Wax
  • Charles McKay
Position Statement

Abstract

First responders and health care providers must prepare to provide care for patients poisoned by acetylcholinesterase (AchE) inhibitor chemical warfare agents or pesticides. However, pre-deployed medical countermeasures (MCMs) may not be sufficient due to production and delivery interruption, rapid depletion of contents during a response, expiration of MCM components, or lack of local availability of approved MCMs. To augment supplies of community-based and forward-deployed nerve agent countermeasures, the American College of Medical Toxicology (ACMT) supports several strategies: (1) The use of expired atropine, diazepam, and pralidoxime auto-injectors and vials if non-expired drugs are unavailable; and (2) Investigation, development, and identification of alternative countermeasures—commonly stocked drugs that are not approved for nerve agent poisoning but are in the same therapeutic class as approved drugs.

Keywords

Acetylcholinesterase inhibitors Atropine Pralidoxime Countermeasures Expiration date 

Notes

Compliance with Ethical Standards

Conflicts of Interest

None.

Disclaimer

While individual practices may differ, this is the position of the American College of Medical Toxicology (ACMT) at the time written, after a review of the issue and pertinent literature.

References

  1. 1.
    United States Department of Health and Human Services. Chemical Hazards. Emergency Medical Management. https://chemm.nlm.nih.gov/chempack.htm. Accessed 19 Jan 2018.
  2. 2.
    Arendse R, Irusen E. An atropine and glycopyrrolate combination reduces mortality in organophosphate poisoning. Hum Exp Toxicol. 2009;28(11):715–20.CrossRefPubMedGoogle Scholar
  3. 3.
    Jain P, Sharma S, Dua T, Barbui C, Das RR, Aneja S. Efficacy and safety of anti-epileptic drugs in patients with active convulsive seizures when no IV access is available: systematic review and meta-analysis. Epilepsy Res. 2016;122:47–55.CrossRefPubMedGoogle Scholar
  4. 4.
    Borron SW. Checklists for hazardous materials emergency preparedness. Emerg Med Clin North Am. 2015;33:213–32.CrossRefPubMedGoogle Scholar
  5. 5.
    United States Department of Health and Human Services (Food and Drug Administration). Expiration Dating Extension. https://www.fda.gov/EmergencyPreparedness/Counterterrorism/MedicalCountermeasures/MCMLegalRegulatoryandPolicyFramework/ucm411446.htm. Accessed 19 Jan 2018.
  6. 6.
    United States Department of Health and Human Services (Food and Drug Administration). Memorandum Expiry Dating Extension Update for AtroPen (atropine), CANA (diazepam), Morphine Sulfate, and Pralidoxime Chloride. Auto-Injectors. https://www.fda.gov/downloads/Drugs/DrugSafety/UCM496442.pdf. March 2, 2016. Accessed 19 Jan 2018.
  7. 7.
    Schier JG, Ravikumar PR, Nelson LS, Heller MB, Howland MA, Hoffman RS. Preparing for chemical terrorism: stability of injectable atropine sulfate. Acad Emerg Med. 2004;11:329–34.CrossRefPubMedGoogle Scholar
  8. 8.
    Schwirtz A, Seeger H. Comparison of the robustness and functionality of three adrenaline auto-injectors. J Asthma Allergy. 2012;5:39–49.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    American College of Medical Toxicology, American Academy of Clinical Toxicology. Antidote shortages in the USA: impact and response. J Med Toxicol. 2015;11:144–6.CrossRefGoogle Scholar
  10. 10.
    Murray DB, Eddleston M, Jefferson TS, Thompson A, Dunn M, Vidler DS, et al. Rapid and complete bioavailability of antidotes for organophosphorus nerve agent in cyanide poisoning in minipigs after intraosseous administration. Ann Emerg Med. 2012;60:424–30.CrossRefPubMedGoogle Scholar
  11. 11.
    Raipal S, Ali R, Bhatnagar A, Bhandari SK, Mittal G. Clinical and bioavailability studies of sublingually administered atropine sulfate. Am J Emerg Med. 2010;28:143–50.CrossRefGoogle Scholar
  12. 12.
    Raipal S, Mittal G, Sachdeva R, Chhillar M, Ali R, Agrawal SS, et al. Development of atropine sulphate nasal drops and its pharmacokinetic safety evaluation in healthy human volunteers. Environ Toxicol Pharmacol. 2009;27:206–11.CrossRefGoogle Scholar
  13. 13.
    Perrone J, Henretig F, Sims M, Beers M, Grippi MA. A role for ipratropium in chemical terrorism preparedness. Acad Emerg Med. 2003;10:290.CrossRefPubMedGoogle Scholar

Copyright information

© American College of Medical Toxicology 2018

Authors and Affiliations

  • Andrew Stolbach
    • 1
  • Vikhyat Bebarta
    • 2
  • Michael Beuhler
    • 3
  • Shaun Carstairs
    • 4
  • Lewis Nelson
    • 5
  • Michael Wahl
    • 6
  • Paul M. Wax
    • 7
  • Charles McKay
    • 8
  1. 1.Johns Hopkins UniversityBaltimoreUSA
  2. 2.University of Colorado School of MedicineDenverUSA
  3. 3.Carolinas Poison CenterCharlotteUSA
  4. 4.University of CaliforniaSan DiegoUSA
  5. 5.Rutgers New Jersey Medical SchoolNewarkUSA
  6. 6.Illinois Poison CenterChicagoUSA
  7. 7.University of Texas Southwestern Medical SchoolDallasUSA
  8. 8.University of Connecticut School of MedicineFarmingtonUSA

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