Nerve agents: Lessons from the Iranian experiences

Abstract

On September 22, 1980 Iraqis attacked Iran's air bases and simultaneously entered Iran with six army divisions on three fronts and occupied a vast part Iranian territories. At that time, Iraqis did not have chemical warfare. But in time, they began to develop an intensive research program to produce and store chemical weapons and used the war fields to test and perfect their chemical warfare. They began with mustard and then added different kinds nerve agents like tabun sarin and GF. We witnessed two different clinical pictures nerve gas poisoning; fulminant and classic (severe, moderate and mild). Treatment was based on 4 steps: 1- Restoring respiration. 2- Atropine. 3- Oxime. 4- Diazepam (and other drugs).Respiratory arrest was the main factor death in nerve gas victims. In severe cases the treatment was as following: Ventilation and administration oxygen (resuscitation). Injection enough atropine (see below). Application 250 mg obidoxime IV (our oxime choice at that time). Administration 10 mg Diazepam IM. Successful administration of high dosed atropinehad an important role on recovery thousands nerve gas victims. Method rapid and effective atropinization: 1- Injection a test dose 4 mg atropine IV in 1-2 minutes. Examination the patient's reaction after two minutes. Further atropinization is indicated if there are no signs atropine intoxication. 2- 25 mg atropine IV within five minutes accompanied by continuous monitoring the pulse rate. The injection rate was reduced when the pulse was 20 to 30 beats above the initial value. The injection rate was increased while bradycardia was still present. If there was no sign atropinization (dry moth and/or tongue) the „third dose“ was given. 3. The administration atropine (step2) was repeated until the mouth and tongue were dry.The administration atropine was also discontinued when miosis became absent or mydriasis appeared regardless whether the mouth was completely dry or not. This method allowed the treatment with atropine to be completed within 10 to 15 minutes on average. In many instances we needed 100-200 mg atropine (for initial atropinization ) to overcome life threatening cholinergic crisis.