mg of atropine) In this setting, atropine is typically delivered IM via an autoinjector However, in severe cases, both atropine and pralidoxime should be administered IV once the patient has been decontaminated and delivered to the ED Animal data suggest that hypoxia should be corrected, if possible, prior to IV atropine use, to prevent arrhythmias; otherwise, IM use might be safer initially Pralidoxime cleaves OP away from the cholinesterase and regenerates the intact enzyme if aging has not yet occurred The beneficial effect is observed predominantly as improved muscle strength Pralidoxime is dosed initially at 25 mg/kg, with maximum doses of g IV or g IM ( Table 132.5 ) Pediatric experience with OP pesticide poisoning suggests that the continuous infusion of pralidoxime may be optimal However, the IM route is acceptable if IV access is not readily available In practice, atropine and pralidoxime are often given concurrently because of the availability of autoinjector kits containing separate vials of mg atropine and 600 mg 2-PAM Recently, combination autoinjectors containing 2.1 mg atropine and 600 mg pralidoxime in a single vial have also become available (Duodote) Additionally, pediatric-sized autoinjectors of pure atropine are now available in 0.25 mg, 0.5 mg, and mg doses Of note, during the Gulf War, 240 Israeli children were evaluated for accidental autoinjection of atropine None had been exposed to nerve agents and systemic anticholinergic effects occurred in many, but seizures, severe dysrhythmias, and deaths were not observed 2-PAM autoinjectors that deliver a proper dose for children are not currently available However, in dire circumstances, the adult autoinjectors with 600 mg pralidoxime might find utility in children older than ages to years or who weigh more than 13 kg (suggested guidelines and weight-based dosing for children of all sizes are detailed in Table 132.5 ) For infants, one might consider using the pediatric-sized atropine autoinjectors, along with conventionally administered IM 2-PAM This can be effected by the discharge of one or several autoinjectors’ contents into an emptied 10 cc sterile saline vial ( Fig 132.7 ) The 300 mg/mL solution may then be withdrawn through a filter needle into one or several syringes suitable for small-volume IM injections Finally, the routine administration of anticonvulsant doses of benzodiazepines is recommended in significant cases, even without observed convulsive activity Diazepam is available in autoinjectors for IM administration, but midazolam absorption from muscle is more rapid than for diazepam Because the latent periods of fourth-generation agents (FGAs) can be up to two days or longer and because it may be difficult to treat FGA-poisoned patients if one simply waits for signs and symptoms to arise, the approach to the