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Sarin Poisoning

Poisoning by Sarin

Sarin poisoning stems from either inhalation or direct contact with sarin, an extremely dangerous neurotoxin that acts as an acetylcholinesterase inhibitor. The clinical presentation depends on the severity of exposure, but an immediate appearance of hypothermia, convulsions, hypersecretion of glands, tremors, and weakness is observed. Death may ensue due to respiratory failure and severe airway obstruction. The diagnosis is difficult to attain and is based on clinical criteria and epidemiologic information.


Presentation

Initially synthesized by humans as a weapon for chemical warfare, sarin (also known as O-isopropyl methylphosphonofluoridate) is a colorless and clear liquid that belongs to a group of highly toxic and life-threatening nerve agents [1] [2]. Similar to organophosphates, sarin behaves as an inhibitor of acetylcholinesterase (Ach); thus it produces symptoms by promoting cholinergic effects at both muscarinic (M) and nicotinic (N) receptors of the parasympathetic part of the autonomic nervous system [2] [3] [4] [5]. Sarin poisoning has been described in very few reports, mainly during the terrorist attacks in Japan during the 90's [1] [3] [6]. In addition to direct contact with its liquid form, individuals can inhale sarin as a gas and it is equally potent in both forms [2]. The clinical presentation depends on the route of exposure - dermal absorption may delay first signs for up to 18 hours, with local sweating and glandular hypersecretion, together with weakness and fasciculations being the main symptoms [2] [4]. On the other hand, instantaneous development of life-threatening symptoms such as airway obstruction, weakness and failure of respiratory muscles leading to anoxia, and convulsions is seen in the case of inhalation [2] [4]. Additional findings include miosis, hypothermia, muscle twitching, tremors, ataxia, visual deficits, cardiac abnormalities (including cardiac arrest) and coma [1] [3] [7].

Asymptomatic
  • These findings suggest that asymptomatic sequelae to sarin exposure, rather than PTSD, persist in the higher and visual nervous systems beyond the turnover period of ChE; sarin may have neurotoxic actions in addition to the inhibitory action on brain[ncbi.nlm.nih.gov]
Hypothermia
  • Additional findings include miosis, hypothermia, muscle twitching, tremors, ataxia, visual deficits, cardiac abnormalities (including cardiac arrest) and coma.[symptoma.com]
Bronchorrhea
  • Intubation may be necessary in cases of respiratory distress due to laryngospasm, bronchospasm, bronchorrhea, or seizures. Immediate aggressive use of atropine may eliminate the need for intubation.[openanesthesia.org]
Abdominal Cramps
  • Symptoms include: Dilated pupils Headache Sense of pressure Salivation Runny nose or congestion Nausea Vomiting Tightness in chest Anxiety Mental confusion Nightmares Weakness Tremors or twitches Involuntary defecation or urination Abdominal cramps Diarrhea[thoughtco.com]
Drooling
  • The nose runs, the eyes cry, the mouth drools and vomits, and bowels and bladder evacuate themselves. It is not a dignified state. Since sarin has no smell or taste, the person may very well have no idea what's going on.[theatlantic.com]
  • Our mouths drool and our noses drip uncontrollably, and our eyes tear and leak – not that we can see ourselves doing this in the mirror, because our vision blurs as our pupils contract.[haaretz.com]
  • These include: Chest tightness Cough Runny nose Watery eyes Nausea Vomiting Blurred vision Headache Abdominal Pain Drooling Diarrhea INcreased urination Fatigue Difficulty breathing Confusion Low Blood Pressure Muscle twitching Seizure Loss of Consciousness[gcnlive.com]
  • Symptoms may include a runny nose, eye pain, drooling, excessive sweating, rapid breathing, coughing, increased urination and nausea, according to the CDC.[time.com]
  • Symptoms of nerve agent poisoning include: Neuromuscular Effects Autonomic Nervous System Effects Central Nervous System Effects Twitching Weakness Paralysis Respiratory failure Reduced Vision Small pupil size Drooling Sweating Diarrhea Nausea Abdominal[faculty.washington.edu]
Foaming at the Mouth
  • According to the Syrian Observatory for Human Rights (SOHR), victims were having difficulty breathing, foaming at the mouth, seizures, bleeding from the nose and mouth, fainting, and some progressed to losing consciousness and dying.[gcnlive.com]
  • Excessive acetylcholine corroborates what has been reported and seen in the videos taken just after the attack, including uncontrolled salivation that will cause "foaming at the mouth," vomiting, tearing, involuntary defecation and urination, tiny pinpoint[tonic.vice.com]
  • Symptoms included bleeding from the nose and mouth, coma, convulsions, difficulty breathing, extreme sensitivity to light, flulike symptoms, foaming at the mouth, fevers, loss of consciousness, loss of memory, loss of vision, nausea, vomiting, paralysis[wired.com]
  • “For example, if it’s a secretion in the mouth, it will make the person foam at the mouth,” he said. If it’s tear ducts, it will make you cry. if its muscles in the leg, it will make the muscles twitch.”[pbs.org]
  • Those on the periphery of that zone were the ones being rushed to hospitals, gasping for breath and foaming at the mouth, in the hopes of being saved.[foxnews.com]
Suggestibility
  • The results suggested delayed effects on psychomotor performance, the higher and visual nervous system and the vestibulo-cerebellar system with psychiatric symptoms resulting from PTSD.[ncbi.nlm.nih.gov]
  • It is suggested that a delayed effect on the vestibulo-cerebellar system was induced by acute sarin poisoning; females might be more sensitive than males.[ncbi.nlm.nih.gov]
  • In sarin cases, a variety effects were observed 6-8 months after exposure, suggesting delayed neurological effects.[ncbi.nlm.nih.gov]
  • These findings suggest that asymptomatic sequelae to sarin exposure, rather than PTSD, persist in the higher and visual nervous systems beyond the turnover period of ChE; sarin may have neurotoxic actions in addition to the inhibitory action on brain[ncbi.nlm.nih.gov]
  • “Many of the victims have individual signs suggestive of exposure to an organophosphate agent.[newscientist.com]
Ataxia
  • Additional findings include miosis, hypothermia, muscle twitching, tremors, ataxia, visual deficits, cardiac abnormalities (including cardiac arrest) and coma.[symptoma.com]

Workup

Except for terrorist attack-related incidents, the diagnosis of sarin poisoning has virtually never been made in general practice. Nevertheless, nerve agents such as sarin must be considered in the differential diagnosis of sudden and life-threatening respiratory and gastrointestinal tract complaints in a cluster of patients who were in the same surroundings shortly before symptoms occurred. For this reason, history taking that reveals many individuals affected by the same symptoms might be crucial in raising suspicion. Physicians must perform a quick physical examination during which cholinergic effects of sarin poisoning must be observed - miosis, sweating, hypothermia, muscle weakness, spasms, etc. In addition, some studies have identified leukocytosis, elevated serum creatine kinase levels, hyperglycemia, hypokalemia, and hypotriglyceridemia in the laboratory workup [3].

Treatment

  • We examined clinical and laboratory findings of 264 people who sought treatment and the results of health examinations on 155 residents done 3 weeks after the poisoning.[ncbi.nlm.nih.gov]
  • Initial treatment for these critically ill patients included CPR, 2 mg of intravenous atropine sulfate, and 5 mg to 20 mg of intravenous diazepam for convulsive disorders.[nointervention.com]
  • These are lower-toxicity pesticides used variously for home and garden pest control, veterinary treatments, agricultural pest control, and even treatment of head lice.[poison.org]
  • Treatment of these symptoms varies by the nature of the chemical and the severity of the symptoms.[sharecare.com]
  • Treatment Termination of the exposure including removing all soiled clothing. Gently cleanse with soap and water to hydrolyze organophosphate solutions. Airway control and adequate oxygenation.[openanesthesia.org]

Prognosis

  • Once the patient survives for a few hours, the prognosis is equally as good as that of unexposed people. Psychologic complications cannot be disregarded; almost 60% of victims suffered from PTSD that persisted longer than 6 months.[nointervention.com]
  • This prognosis is based on decades of research on rats and mice, and the fate of veterans of the 1990-1991 Gulf War who were exposed to low-levels of sarin gas and who continue to suffer serious health effects 26 years later.[blogs.scientificamerican.com]

Epidemiology

  • The diagnosis is difficult to attain and is based on clinical criteria and epidemiologic information.[symptoma.com]
  • The epidemiological pattern of occurrence such as the mass influx of patients in a short time suggests exposure to sarin, a nerve agent in Syria’s arsenal.[undispatch.com]
  • Biden: Syrian gov't responsible for "heinous use" of chem. weapons Syrian state news agency: Kerry lying about chemical weapons attack "The reported symptoms of the patients, in addition to the epidemiological pattern of the events -- characterized by[cbsnews.com]
Sex distribution
Age distribution

Prevention

  • CONCLUSIONS: Rescuers should protect themselves with appropriate clothing, gloves, and a mask to prevent a secondary disaster for at least 24 hours after a similar accident.[ncbi.nlm.nih.gov]
  • However, do not administer antidotes preventatively; there is no benefit to doing so.[emedicine.medscape.com]
  • Preventing Sarin Poisoning An option pursued by chemists and medical professionals is a vaccine–an approach is to release scavenger molecules into the blood stream.[decodedscience.org]
  • Decontamination may be followed by the administration of antidotes such as diazepam, atropine, and oximes to prevent initial and/or continued physical effects. 1 Answer A You may not be able to prevent nerve gas poisoning, but in the unlikely event that[sharecare.com]

References

Article

  1. Abu-Qare AW, Abou-Donia MB. Sarin: health effects, metabolism, and methods of analysis. Food Chem Toxicol. 2002;40(10):1327-1333.
  2. Lee EC. Clinical manifestations of sarin nerve gas exposure. JAMA. 2003;290(5):659-662.
  3. Yanagisawa N, Morita H, Nakajima T. Sarin experiences in Japan: acute toxicity and long-term effects. J Neurol Sci. 2006;249(1):76-85.
  4. Miyaki K, Nishiwaki Y, Maekawa K, et al. Effects of sarin on the nervous system of subway workers seven years after the Tokyo subway sarin attack. J Occup Health. 2005;47(4):299-304.
  5. Smythies J, Golomb B. Nerve gas antidotes. J R Soc Med. 2004;97(1):32.
  6. Shewale SV, Anstadt MP, Horenziak M, et al. Sarin causes autonomic imbalance and cardiomyopathy: an important issue for military and civilian health. J Cardiovasc Pharmacol. 2012;60(1):76-87.
  7. Tokuda Y, Kikuchi M, Takahashi O, Stein GH. Prehospital management of sarin nerve gas terrorism in urban settings: 10 years of progress after the Tokyo subway sarin attack. Resuscitation. 2006;68(2):193-202.

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Last updated: 2018-06-22 09:28