Nerve agents: Lessons from the Iranian experiences

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 of 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 of nerve agents like tabun sarin and GF. We witnessed two different clinical pictures of 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 of death in nerve gas victims. In severe cases the treatment was as following: Ventilation and administration of oxygen (resuscitation). Injection of enough atropine (see below). Application of 250 mg of obidoxime IV (our oxime of choice at that time). Administration of 10 mg of Diazepam IM. Successful administration of" high dosed atropine"had an important role on recovery of thousands nerve gas victims. Method of rapid and effective atropinization: 1- Injection of a test dose of 4 mg of atropine IV in 1-2 minutes. Examination of the patient's reaction after two minutes. Further atropinization is indicated if there are no signs of atropine intoxication. 2- 25 mg of atropine IV within five minutes accompanied by continuous monitoring of 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 of atropinization (dry moth and/or tongue) the „third dose“ was given. 3. The administration of atropine (step2) was repeated until the mouth and tongue were dry.The administration of atropine was also discontinued when miosis became absent or mydriasis appeared regardless of 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.