General population limits: 0.000003 mg/m3 (all) over an 8-hour workshift)

OSHA PEL: N/A

NIOSH REL: N/A

 ACGIH TLV:

N/ATLV : 0.00001 mg/m3 (U.S. military)

NIOSH IDLH: N/A

1 mg/m3=0.09145ppm

(See Acute Exposure Guideline Levels below.)

If the hazard is from vapor alone, evacuation of the patient upwind from the exposure source may be sufficient.

1. Patients exposed to nerve agent by vapor only should be decontaminated by removing all clothing in a clean air environment and shampooing or rinsing the hair to prevent vapor-off gassing.

2. Patients exposed to liquid nerve agent should be decontaminated by –

1. Washing in warm or hot water at least three times. Use liquid soap (dispose of container after use and replace), large amounts of water, and mild to moderate friction with a single-use sponge or washcloth in the first and second washes. Scrubbing of exposed skin with a brush is discouraged, because skin damage may occur and may increase absorption. The third wash should be to rinse with large amounts of warm or hot water. Shampoo can be used to wash the hair. The rapid physical removal of a chemical agent is essential. If warm or hot water is not available, but cold water is, use cold water. Do not delay decontamination to obtain warm water.

2. Rinsing the eyes, mucous membranes, or open wounds with sterile saline or water.

3. The healthcare provider should –

1. Check the patient after the three washes to verify adequate decontamination before allowing entry to the medical treatment facility. If the washes were inadequate, repeat the entire process.
2. Be prepared to administer antidote and/or to stabilize conventional injuries during the decontamination process.
3. Protect the airway while conducting decontamination and assure appropriate placement of the respirator over the uncontaminated face. The initial assessment of the casualty can best be performed in an agent-free environment where the health care provider is able to "look, listen, and feel" unencumbered by protective clothing. However, careful decontamination can be a time-consuming process. The health care provider may have to enter the contaminated area to treat the casualty during the process. Medical personnel should wear the proper PPE and evaluate the exposed workers.

(For further information see ATSDR medical management guidelines for Nerve Agents, SBCCOM Guidelines for Mass Casualty Decontamination During a Terrorist Chemical Agent Incident (January 2000), and SBCCOM Guidelines for Cold Weather Mass Decontamination During a Terrorist Chemical Agent Incident (January 2002)).

Equipment: N/A

Environment: Large scale procedure (greater than 50g) — use both calcium hypochlorite (HTH) and NaOH. (See Spillage Disposal.)

The small-scale decontamination procedure uses sufficient alcoholic HTH to oxidize.

If alcoholic HTH mixture is not available, then use following in the order of preference: Decontaminating Agent (DS2), Supertropical Bleach Slurry (STB), and Sodium Hypochlorite.

Scoop decontaminated material and place in approved container. After sealing, decontaminate the exterior and label. All leaking containers will be over packed with sorbent (e.g., vermiculite) placed between the interior and exterior containers. Label and dispose according to regulations. Conduct general area monitoring.

UN#: 2810 (Guide 153)

Proper Shipping Name: Toxic liquids, organic, n.o.s.

Hazard Class: 6.1, Packing Group I, Hazard Zone A.

Label: Poison.

Marking: Toxic liquids, organic, n.o.s. (O-ethyl S-(2-diisopropylaminoethyl)methylphosphonothioate) UN 2810, Inhalation Hazard.

Placard: N/A

NFPA 704 Signal:

Health - 4

Flammability - 1

Reactivity - 1

Special - 0

Physical dangers: N/A

Chemical dangers: Relatively stable at room temperature. Unstabilized VX of 95% purity decomposes at a rate of 5% a month at 159.8°F. (71°C.) At pH 12, the toxic by-product has a half-life of about 14 days and in 90 days there is about a 64-fold reduction.

Routes of exposure:The substance can be absorbed into the body by all routes.

Inhalation risk:Usually liquid in normal state. It has low volatility and is about 2000 times less volatile than Sarin (GB); however, it is about 10 times more toxic.

Effects of short-term exposure: VX, an organophosphorous compound, is a lethal acetylcholinesterase inhibitor similar in action to Sarin (GB). There is only a slight difference between a fatal dose and a dose that produces little health effects. Death usually occurs within 15 minutes after absorption of a fatal dose. The aging half-life for VX is about 48 hours and is the slowest aging nerve agent.

Effects of long-term effects or repeated exposure:Limited data suggest delayed neuropathy (postural sway, psychomotor performance). Constricted or pin-point pupils (miosis) has been noted up to 62 days.

Melting Point: -58°F(-50°C)

Boiling Point: 568.4°F (298°C)

Vapor Pressure (25°C): 0.00063 mm Hg

Density (25°C): 1.0083 g /ml

Volatility: 8.9-10.5 mg/m3 at 25°C

Vapor density (air=1): 9.2

Aqueous solubility: miscible below 9.4°C; 30 g/L at 25°C

Soluble in organic solvents.

Estimated log Kow: 2.06

log Kbenzene-water: unknown

Flashpoint: 159°F (70.6°C)

Flammability: unknown

10 min             30 min           1hr            4 hr           8 hr

AEGL 1 (discomfort,

non-disabling) - ppm    0.000052   0.000030  0.000016 0.0000091 0.0000065

AEGL 2 (irreversible or

other serious, long-lasting

effects or impaired ability

to escape)- ppm            0.00065      0.00038   0.00027     0.00014   0.000095

AEGL 3 (life-threatening

effects or death) -ppm      0.0027        0.0014  0.00091     0.00048     0.00035

Additional Information

Notes

 Trade Names and Other Synonyms

• Phosphonothioic acid, methyl-,

• O-ethyl S-(2-bis(1-methylethylamino)ethyl)

• 0-ethyl ester

• S-(2-diisopropylaminoethyl) methylphosphonothioate

• S-2-Diisopropylaminoethyl O-ethyl methylphosphonothioate

• S-2((2-Diisopropylamino)ethyl)

• O-ethyl methylphosphonothiolate

• O-ethyl S-(2-diisopropylaminoethyl) methylphosphonothioate

• O-ethyl S-(2-diisopropylaminoethyl) methylthiolphosphonoate·

• S-(2-diisopropylaminoethyl) o-ethyl methyl phosphonothiolate

• Ethyl-S-dimethylaminoethyl methylphosphonothiolate

• TX60

APR - Air-purifying Respirator

CBRN - Chemical, Biological, Radiological, Nuclear

IDLH - Immediately Dangerous to Life and Health

REL - Recommended Exposure Limit

PEL - Permissible Exposure Limit

SCBA - Self-Contained Breathing Apparatus

Additional Information

Notes

   Trade Names and Other Synonyms

• Phosphonothioic acid, methyl-,

• O-ethyl S-(2-bis(1-methylethylamino)ethyl)

• 0-ethyl ester

• S-(2-diisopropylaminoethyl) methylphosphonothioate

• S-2-Diisopropylaminoethyl O-ethyl methylphosphonothioate

• S-2((2-Diisopropylamino)ethyl)

• O-ethyl methylphosphonothiolate

• O-ethyl S-(2-diisopropylaminoethyl) methylphosphonothioate

• O-ethyl S-(2-diisopropylaminoethyl) methylthiolphosphonoate·

• S-(2-diisopropylaminoethyl) o-ethyl methyl phosphonothiolate

• Ethyl-S-dimethylaminoethyl methylphosphonothiolate

• TX60

APR - Air-purifying Respirator

CBRN - Chemical, Biological, Radiological, Nuclear

IDLH - Immediately Dangerous to Life and Health

REL - Recommended Exposure Limit

PEL - Permissible Exposure Limit

SCBA - Self-Contained Breathing Apparatus

Property

Nicotinic effects include skeletal muscle twitching, cramping, and weakness. Nicotinic stimulation can obscure certain muscarinic effects and produce rapid heart rate and high blood pressure. Relatively small to moderate vapor exposure causes pinpoint pupils, rhinorrhea, bronchoconstriction, excessive bronchial secretions, and slight to moderate dyspnea. Mild to moderate dermal exposure results in sweating and muscular fasciculations at the site of contact, nausea, vomiting, diarrhea, and weakness. The onset of these mild to moderate signs and symptoms following dermal exposure may be delayed for as long as 18 hours.

Higher exposures (any route) cause loss of consciousness, seizures, muscle fasciculations, flaccid paralysis, copious secretions, apnea, and death.

Children do not always respond to chemicals in the same way that adults do. Different protocols for managing their care may be needed.

Respiratory protection: Pressure-demand, self-contained breathing apparatus (SCBA) is recommended in response situations that involve exposure to any nerve agent vapor or liquid

Skin protection : Chemical-protective clothing and butyl rubber gloves are recommended when skin contact is possible because nerve agent liquid is rapidly absorbed through the skin and may cause systemic toxicity.

Before transport, all casualties must be decontaminated. If needed, consult with the base station physician or the regional poison control center for advice concerning management of multiple casualties.

1. Check triage tag/card for any previous treatment or triage.

2. Survey for evidence of associated traumatic/blast injuries.

3. Observe for sweating, labored breathing, coughing/vomiting, secretions.

4. Severe casualty triaged as immediate if assisted breathing is required.

5. Blast injuries or other trauma, where there is question whether there is chemical exposure, victims must be tagged as immediate in most cases. Blast victims evidence delayed effects such as ARDS, etc.

6. Mild/moderate casualty: self/buddy aid, triaged as delayed or minimal and release is based on strict follow up and instructions.

7. If there are chemical exposure situations which may cause delayed but serious signs and symptoms, then overtriage is considered appropriate to the proper facilities that can observe and manage any delayed onset symptoms.

8. Expectant categories in multi-casualty events are those victims who have experienced a cardiac arrest, respiratory arrest, or continued seizures immediately. Resources should not be expended on these casualties if there are large numbers of casualties requiring care and transport with minimal or scant resources available.

1. Immediate: casualties who require lifesaving care within a short time, when that care is available and of short duration. This care may be a procedure that can be done within minutes at an emergency treatment station (e.g., relief of an airway obstruction, administering antidotes) or may be acute lifesaving surgery.

2. Delayed: casualties with severe injuries who are in need of major or prolonged surgery or other care and who will require hospitalization, but delay of this care will not adversely affect the outcome of the injury (e.g., fixation of a stable fracture).

3. Minimal: casualties who have minor injuries, can be helped by nonphysician medical personnel, and will not require hospitalization.

4. Expectant: casualties with severe life-threatening injuries who would not survive with optimal medical care, or casualties whose injuries are so severe that their chance of survival does not justify expenditure of limited resources. As circumstances permit, casualties in this category may be reexamined and possibly be retriaged to a higher category

Patient         Mild/Moderate                     Severe                                   Other

 Age                Symptoms²                     Symptoms³                             Treatment

Infant       Atropine: 0.05 mg/kg IM;    Atropine: 0.1 mg/kg IM;

(0-2 yrs) 2-PAM Cl: 15 mg/kg IM    2-PAM Cl: 25 mg/kg IM

Assisted ventilation should be started after administration of antidotes for severe exposures.

Repeat atropine at (2 mg IM) 5-10 min. intervals until secretions have diminished and breathing is comfortable or airway resistence has returned to near normal.

Child          Atropine: 1 mg IM;            Atropine: 2 mg IM;

(2-10 yrs) 2-PAM Cl: 15 mg/kg IM    2-PAM Cl: 25 mg/kg IM

Adolescent   Atropine: 2 mg IM;          Atropine: 4 mg IM;

(>10 yrs)  2-PAM Cl: 15 mg/kg IM   2-PAM Cl: 25 mg/kg IM

Adult          Atropine: 2 to 4 mg IM;       Atropine: 6 mg IM;

2-PAM         Cl: 600 mg IM                 2-PAM  Cl: 1800 mg IM

Elderly,       Atropine: 1 mg IM;            Atropine: 2 to 4 mg IM;

frail           2-PAM Cl: 10 mg/kg IM     2- PAM Cl: 25 mg/kg IM

1. 2-PAMCl solution needs to be prepared from the ampule containing 1 gram of desiccated 2-PAMCl: inject 3 ml of saline, 5% distilled or sterile water into ampule and shake well. Resulting solution is 3.3 ml of 300 mg/ml.

2. Mild/Moderate symptoms include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea.

3. Severe symptoms include unconsciousness, convulsions, apnea, flaccid paralysis.

Decontaminable gurneys are made of a monofilament polypropylene fabric that allows drainage of liquids, does not absorb chemical agents, and is easily decontaminated. Fiberglass back boards have been developed specifically for use in HAZMAT incidents. These are nonpermeable and readily decontaminated. The Chemical Resuscitation Device is a bag-valve mask equipped with a chemical agent cannister that can be used to ventilate casualties in a contaminated environment.

If exposure to liquid agent is suspected, cut and remove all clothing and wash skin immediately with soap and water. If shower areas are available, a thorough shower with soap and water should be used. However, if water supplies are limited, and showers are not available, an alternative form of decontamination is to use 0.5% sodium hypochlorite solution, or absorbent powders such as flour, talcum powder, or Fuller’s earth. If exposure to vapor only is certain, remove outer clothing and wash exposed skin with soap and water or 0.5% sodium hypochlorite. Place contaminated clothes and personal belongings in a sealed double bag.

In cases of ingestion, do not induce emesis. If the victim is alert and able to swallow, immediately administer a slurry of activated charcoal.

Patients who are comatose, hypotensive, or seizing or have cardiac dysrhythmias should be treated according to advanced life support (ALS) protocols. Diazepam (5 to 10 mg in adults and 0.2 to 0.5 mg/kg in children) should be used to control convulsions. Lorazepam or other benzodiazepines may be used but barbiturates, phenytoin, and other anticonvulsants are not effective.

Patients who are seriously symptomatic (as in cases of chest tightness or wheezing), patients who have histories or evidence of significant exposure, and all patients who have ingested acrolein should be transported to a medical facility for evaluation. Others may be discharged at the scene after their names, addresses, and telephone numbers are recorded. Those discharged should be advised to seek medical care promptly if symptoms develop (see Patient Information Sheet below).

For patients exposed to nerve agent vapor only, remove outer clothing and wash exposed areas including the head and hair with soap and water. For patients exposed to liquid agent, remove all clothing and wash entire body and hair with soap and water or 0.5% hypochlorite followed by a water rinse.

Irrigate exposed eyes with plain water or saline for about 5 to 10 minutes (see Basic Decontamination under Decontamination Zone, above). Remove contact lenses if present and easily removable without additional trauma to the eye.

In cases of ingestion, do not induce emesis. If the patient is able to swallow, immediately administer a slurry of activated charcoal if not given previously. (More information is provided in Ingestion Exposure above.)

Patients with a history of possible exposure to vapor only (with no possibility of liquid exposure) who have no signs of exposure by the time they reach the medical facility have not been exposed (because these effects occur within seconds to minutes after exposure). They can be discharged.

Antidotes

Assisted ventilation as needed.

Repeat atropine (2mg IM or 1mg IM for infants) at 5-10 min. intervals until secretions have diminished and breathing is comfortable or airway resistence has returned to near normal.

Phentolamine for 2-PAM induced hypertension: 5 mg IV for adults; 1 mg IV for children)

Diazepam for convulsions:(0.2 to 0.5 mg IV for infants #5 years; 1 mg IV for children >5 years; 5 mg IV for adults)

1. Mild/Moderate symptoms include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea.

2. Severe symptoms include unconsciousness, convulsions, apnea, flaccid paralysis.

Formaldehyde poisoning can cause permanent alterations of nervous system function, including problems with memory, learning, thinking, sleeping, personality changes, depression, headache, and sensory and perceptual changes.