Atropine Use in Children After Nerve Gas Exposure

Following the FDA’s approval of a pediatric dosage Atropen®, the Pediatric Expert Advisory Panel was asked to review the existing guidelines and recommendations regarding the treatment of children exposed to nerve agents and the Mark-1 Kit; review the new literature on pediatric nerve agent exposure; and to develop recommendations and guidelines for this new device including modifications to the existing recommendations and guidelines if warranted. In May 2003, the first nationally accepted pediatric disaster and terrorism preparedness recommendations and treatment guidelines were issued by the Program for Pediatric Preparedness of the National Center for Disaster Preparedness (NCDP). These guidelines were based on a National Consensus Conference sponsored by the Program for Pediatric Preparedness and funded by the Agency for Healthcare Research and Quality and the EMS for Children Program of the Health Resources and Services Administration. At that time, the only available treatment for certain types of nerve gas exposure (predominantly those with anticholinesterase properties) was the Mark 1 kit. The recommendations were based on established usage of antidotes for cholinergic toxicity and were felt to be both safe and supported by the literature. It was stated that the Mark 1 Autoinjector kits (although not approved for pediatric use) should be used as initial treatment for children with severe, life-threatening nerve agent toxicity for whom IV treatment is not possible or available, or for whom more precise IM (mg/kg) dosing would be logistically impossible. It was further felt that while not within the published dosage range for cholinergic toxicity, if a Mark 1 kit was the only source of atropine and pralidoxime available after a bona fide exposure it should be used to treat all children, even those younger than 3 years old. Furthermore, it was felt to be imperative to expedite approval of the pediatric autoinjector kit (which contains both atropine and an oxime and is designed for children) that is currently produced and marketed abroad but not available in the United States.