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

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.

This is a preview of subscription content, log in to check access.

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.

    Article  PubMed  CAS  Google 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.

    Article  PubMed  CAS  Google Scholar 

  4. 4.

    Borron SW. Checklists for hazardous materials emergency preparedness. Emerg Med Clin North Am. 2015;33:213–32.

    Article  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  PubMed Central  CAS  Google 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.

    Article  Google 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.

    Article  PubMed  Google 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.

    Article  Google 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.

    Article  CAS  Google 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.

    Article  PubMed  Google Scholar 

Download references

Funding

This statement was funded, in part, by the United States Department of Homeland Security ACMT/DHS Contract number HSHQDC-14-R-00102.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Andrew Stolbach.

Ethics declarations

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.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Stolbach, A., Bebarta, V., Beuhler, M. et al. ACMT Position Statement: Alternative or Contingency Countermeasures for Acetylcholinesterase Inhibiting Agents. J. Med. Toxicol. 14, 261–263 (2018). https://doi.org/10.1007/s13181-018-0658-4

Download citation

Keywords

  • Acetylcholinesterase inhibitors
  • Atropine
  • Pralidoxime
  • Countermeasures
  • Expiration date