VX: Nerve Agent

Clear, amber-colored, oily liquid.

VX is one of the nerve agents, which are the most toxic of the known chemical warfare agents. It is tasteless and odorless. Exposure to VX can cause death in minutes. As little as one drop of VX on the skin can be fatal. Nerve agents are chemically similar to organophosphate pesticides and exert their effects by interfering with the normal function of the nervous system.

• Indoor Air: VX can be released into indoor air as a liquid spray (aerosol) or as a vapor when temperatures are high.
• Water: VX can contaminate water; it can break down in water to produce other toxic compounds.
• Food: VX can contaminate food.
• Outdoor Air: VX can be released into outdoor air as a liquid spray (aerosol) or as a vapor when temperatures are high.
• Agricultural: If VX is released into the air as fine particles (aerosol), it has the potential to contaminate agricultural products. If VX is released as a vapor, it is highly unlikely to contaminate agricultural products.

VX can be absorbed into the body by inhalation, ingestion, skin contact, or eye contact. Ingestion is an uncommon route of exposure.

First Responders should use a NIOSH-certified Chemical, Biological, Radiological, Nuclear (CBRN) Self Contained Breathing Apparatus (SCBA) with a Level A protective suit when entering an area with an unknown contaminant or when entering an area where the concentration of the contaminant is unknown. Level A protection should be used until monitoring results confirm the contaminant and the concentration of the contaminant.
NOTE: Safe use of protective clothing and equipment requires specific skills developed through training and experience.

Select when the greatest level of skin, respiratory, and eye protection is required. This is the maximum protection for workers in danger of exposure to unknown chemical hazards or levels above the IDLH or greater than the AEGL-2.

• A NIOSH-certified CBRN full-face-piece SCBA operated in a pressure-demand mode or a pressure-demand supplied air hose respirator with an auxiliary escape bottle.
• A Totally-Encapsulating Chemical Protective (TECP) suit that provides protection against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Coveralls, long underwear, and a hard hat worn under the TECP suit are optional items.

Select when the highest level of respiratory protection is necessary but a lesser level of skin protection is required. This is the minimum protection for workers in danger of exposure to unknown chemical hazards or levels above the IDLH or greater than AEGL-2. It differs from Level A in that it incorporates a non-encapsulating, splash-protective, chemical-resistant splash suit that provides Level A protection against liquids but is not airtight.

• A NIOSH-certified CBRN full-face-piece SCBA operated in a pressure-demand mode or a pressure-demand supplied air hose respirator with an auxiliary escape bottle.
• A hooded chemical-resistant suit that provides protection against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Coveralls, long underwear, a hard hat worn under the chemical-resistant suit, and chemical-resistant disposable boot-covers worn over the chemical-resistant suit are optional items.

Select when the contaminant and concentration of the contaminant are known and the respiratory protection criteria factors for using Air Purifying Respirators (APR) or Powered Air Purifying Respirators (PAPR) are met. This level is appropriate when decontaminating patient/victims.

• A NIOSH-certified CBRN tight-fitting APR with a canister-type gas mask or CBRN PAPR for air levels greater than AEGL-2.
• A NIOSH-certified CBRN PAPR with a loose-fitting face-piece, hood, or helmet and a filter or a combination organic vapor, acid gas, and particulate cartridge/filter combination or a continuous flow respirator for air levels greater than AEGL-1.
• A hooded chemical-resistant suit that provides protection against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Escape mask, face shield, coveralls, long underwear, a hard hat worn under the chemical-resistant suit, and chemical-resistant disposable boot-covers worn over the chemical-resistant suit are optional items.

Select when the contaminant and concentration of the contaminant are known and the concentration is below the appropriate occupational exposure limit or less than AEGL-1 for the stated duration times.

• Limited to coveralls or other work clothes, boots, and gloves.

• VX is on the Superfund Extremely Dangerous Substances list.
• Contact with metals may evolve flammable hydrogen gas.

• When heated, vapors may form explosive mixtures with air, presenting an explosion hazard indoors, outdoors, and in sewers.
• Containers may explode when heated.

• VX is combustible.
• The agent may burn but does not ignite readily.
• Fire may produce irritating, corrosive, and/or toxic gases.
• For small fires, use dry chemical, carbon dioxide, or water spray.
• For large fires, use dry chemical, carbon dioxide, alcohol-resistant foam, or water spray. Move containers from the fire area if it is possible to do so without risk to personnel. Dike fire control water for later disposal; do not scatter the material.
• Avoid methods that will cause splashing or spreading.
• For fire involving tanks or car/trailer loads, fight the fire from maximum distance or use unmanned hose holders or monitor nozzles. Do not get water inside containers. Cool containers with flooding quantities of water until well after the fire is out. Withdraw immediately in case of rising sound from venting safety devices or discoloration of tanks. Always stay away from tanks engulfed in fire.
• Runoff from fire control or dilution water may be corrosive and/or toxic, and it may cause pollution.
• If the situation allows, control and properly dispose of run-off (effluent).

• If a tank, rail car, or tank truck is involved in a fire, isolate it for 0.5 mi (800 m) in all directions; also, consider initial evacuation for 0.5 mi (800 m) in all directions.
• Small spills (involving the release of approximately 52.83 gallons (200 liters) or less), when VX is used as a weapon
• First isolate in all directions: 100 ft (30 m).
• Then protect persons downwind during the day: 0.1 mi (0.2 km).
• Then protect persons downwind during the night: 0.1 mi (0.2 km).
• Large spills (involving quantities greater than 52.83 gallons (200 liters)), when VX is used as a weapon
• First isolate in all directions: 200 ft (60 m).
• Then protect persons downwind during the day: 0.4 mi (0.7 km).
• Then protect persons downwind during the night: 0.6 mi (1.0 km).

• VX is persistent in the environment.
• Vapors are heavier than air. They will spread along the ground and collect and stay in poorly-ventilated, low-lying, or confined areas (e.g., sewers, basements, and tanks).
• Hazardous concentrations may develop quickly in enclosed, poorly-ventilated, or low-lying areas. Keep out of these areas. Stay upwind.

• OSHA: Not established/determined
• NIOSH: Not established/determined

• AIR MATRIX
  Frishman G, Amirav A [2000]. Fast GC-PFPD system for field analysis of chemical warfare agents. Field Anal Chem Technol 4(4):170-194.Rohrbaugh DK [2000]. Methanol chemical ionization quadrupole ion trap mass spectrometry of O-ethyl S-[2-(diisopropylamino)ethyl] methylphosphonothiolate (VX) and its degradation products. J Chromatogr A 893(2):393-400.
• OTHER
  No references were identified for this sampling matrix for this agent.
• SOIL MATRIX
  Groenewold GS, Appelhans AD, Gresham GL, Olson JE, Jeffery M, Wright JB [1999]. Analysis of VX on soil particles using ion trap secondary ion mass spectrometry. Anal Chem 71(13):2318-2323.
• SURFACES
  Groenewold GS, Williams JM, Appelhans AD, Gresham GL, Olsbn JE, Jeffery MT, Rowland B [2002]. Hydrolysis of VX on concrete: rate of degradation by direct surface interrogation using an ion trap secondary ion mass spectrometer. Environ Sci Technol 36(22):4790-4794.
• WATER
  Creasy WR, Brickhouse MD, Morrissey KM, Stuff JR, Cheicante RL, Ruth J, Mays J, Williams BR, O’Connor R, Durst HD [1999]. Analysis of chemical weapons decontamination waste from old ton containers from Johnston Atoll using multiple analytical methods. Environ Sci Technol 33(13):2157-2162.Creasy WR, Stuff JR, Williams B, Morrissey K, Mays J, Duevel R, Durst HD [1997]. Identification of chemical-weapons-related compounds in decontamination solutions and other matrices by multiple chromatographic techniques. J Chromatogr A 774(1-2):253-263.Crenshaw MD, Hayes TL, Miller TL, Shannon CM [2001]. Comparison of the hydrolytic stability of S-(N,N-diethylaminoethyl) isobutyl methylphosphonothiolate with VX in dilute solution. J Appl Toxicol 21: (Suppl.):S3-S6.
  D’Agostino PA, Hancock JR, Provost LR [1999]. Analysis of O-ethyl S-[2-(diisopropylamino)ethyl] methylphosphonothiolate (VX) and its degradation products by packed capillary liquid chromatography–electrospray mass spectrometry. J Chromatogr A 837(1-2):93-105.
  D’Agostino PA, Provost LR, Visentini J [1987]. Analysis of O-ethyl S-[2-(diisopropylamino)ethyl] methylphosphonothiolate (VX) by capillary column gas chromatography-mass spectrometry. J Chromatogr A 402:221-232.Degenhardt-Langelaan CEAM, Kientz CE [1996]. Capillary gas chromatographic analysis of nerve agents using large volume injections. J Chromatogr A 723(1, 2):210-214.Rohrbaugh DK [1998]. Characterization of equimolar VX–water reaction product by gas chromatography—mass spectrometry. J Chromatogr A 809(1-2):131-139.Sega GA, Tomkins BA, Griest WH [1997]. Analysis of methylphosphonic acid, ethyl methylphosphonic acid and isopropyl methylphosphonic acid at low microgram per liter levels in groundwater. J Chromatogr A 790(1-2):143-152.Wils ERJ, Hulst AG [1990]. Determination of O-ethyl S-2-diisopropylaminoethyl methylphosphonothioate (VX) by thermospray liquid chromatography––mass spectrometry. J Chromatogr A 523:151-161.

Exposure to nerve agents may be rapidly fatal. Eye exposure: Liquid VX produces health effects within seconds to minutes; larger exposures may cause death within 1 to 10 minutes. Ingestion exposure: No information is available on the time course of effects following ingestion of VX. Inhalation exposure: Inhaled VX produces health effects within seconds to minutes; larger exposures may cause death within 1 to 10 minutes. Skin exposure: Liquid VX may produce health effects within minutes. Health effects from mild to moderate exposure may be delayed up to 18 hours; larger exposures may cause death within minutes to hours.

Nerve agents cause the same health effects regardless of the route of exposure. Initial effects depend on the dose and route of exposure. Nerve agents interfere with the normal functioning of the nervous system. Skeletal muscles, certain organs of the body, and the central nervous system (CNS) may all be affected by exposure to the nerve agent.

• Contracted or pinpoint pupils (miosis), redness of the membranes (conjunctiva), pain in and around the eye, dim and/or blurred vision, a sensation of pressure with heaviness, and reflex nausea and vomiting (emesis).
• Effects are usually local, occurring from direct contact with nerve agent vapor, aerosol, or liquid; but exposure by other routes can also affect the eyes.

• Nausea, vomiting (emesis), diarrhea, abdominal pain, and cramping.

• Mild to moderate: Contracted or pinpoint pupils (miosis), runny nose (rhinorrhea), narrowing of the large airways (bronchoconstriction), fluid build up within the airways of the lungs, and slight to moderate difficulty breathing or shortness of breath (dyspnea).
• Severe: In addition to the symptoms described above, there can be loss of consciousness; seizures; muscular twitching (fasciculations); floppy (flaccid) paralysis; increased fluid build up within the airways and within the digestive tract, resulting in secretions from the nose and mouth; cessation of breathing (apnea); and death.

• Mild to moderate: Health effects may be immediate or may be delayed up to 18 hours. Profuse sweating (diaphoresis) and muscular twitching (fasciculations) at the site of contact, nausea, vomiting (emesis), diarrhea, and weakness (malaise).
• Severe: Health effects may appear quickly; 2 to 30 minutes post-exposure. In addition to the symptoms described above, there can be loss of consciousness; seizures; muscular twitching (fasciculations); floppy (flaccid) paralysis; increased fluid build up within the airways and within the digestive tract, resulting in secretions from the nose and mouth; cessation of breathing (apnea), and death.

The purpose of decontamination is to make an individual and/or their equipment safe by physically removing toxic substances quickly and effectively. Care should be taken during decontamination, because absorbed agent can be released from clothing and skin as a gas. Your Incident Commander will provide you with decontaminants specific for the agent released or the agent believed to have been released.

The following are recommendations to protect the first responders from the release area:

• Position the decontamination corridor upwind and uphill of the hot zone.
• The warm zone should include two decontamination corridors. One decontamination corridor is used to enter the warm zone and the other for exiting the warm zone into the cold zone. The decontamination zone for exiting should be upwind and uphill from the zone used to enter.
• Decontamination area workers should wear appropriate PPE. See the PPE section of this card for detailed information.
• A solution of detergent and water (which should have a pH value of at least 8 but should not exceed a pH value of 10.5) should be available for use in decontamination procedures. Soft brushes should be available to remove contamination from the PPE.
• Labeled, durable 6-mil polyethylene bags should be available for disposal of contaminated PPE.

The following methods can be used to decontaminate an individual:

• Decontamination of First Responder:
  • Begin washing PPE of the first responder using soap and water solution and a soft brush. Always move in a downward motion (from head to toe). Make sure to get into all areas, especially folds in the clothing. Wash and rinse (using cold or warm water) until the contaminant is thoroughly removed.
  • Remove PPE by rolling downward (from head to toe) and avoid pulling PPE off over the head. Remove the SCBA after other PPE has been removed.
  • Place all PPE in labeled durable 6-mil polyethylene bags.
• Decontamination of Patient/Victim:
  • Remove the patient/victim from the contaminated area and into the decontamination corridor.
  • Remove all clothing (at least down to their undergarments) and place the clothing in a labeled durable 6-mil polyethylene bag.
  • Thoroughly wash and rinse (using cold or warm water) the contaminated skin of the patient/victim using a soap and water solution. Be careful not to break the patient/victim’s skin during the decontamination process, and cover all open wounds.
  • Cover the patient/victim to prevent shock and loss of body heat.
  • Move the patient/victim to an area where emergency medical treatment can be provided.

Initial treatment consists of repeated administration of antidotes and supportive measures.

Atropine and pralidoxime chloride (2-PAM Cl) are antidotes for nerve agent toxicity; however, 2-PAM Cl must be administered within minutes to a few hours (depending on the agent) following exposure to be effective. There is also generally no benefit in giving more than three injections of 2-PAM Cl. Atropine should be administered every 5 to 10 minutes until secretions begin to dry up. If the military Mark I kits containing autoinjectors are available, they provide the best way to administer the antidotes to healthy adults. One autoinjector automatically delivers 2 mg atropine and the other automatically delivers 600 mg 2-PAM Cl. If the Mark I kit is unavailable, or the patient/victim is not an otherwise healthy adult, administer antidotes as described below:
Infant (0 – 2 yrs), for mild to moderate physical findings, including localized sweating, muscular twitching (fasciculations), nausea, vomiting, weakness, and shortness of breath (dyspnea); administer Atropine at 0.05 mg/kg IM; 2-PAM Cl at 15 mg/kg IM.
Infant (0 – 2 yrs), for severe physical findings, including unconsciousness, convulsions, cessation of breathing (apnea), and floppy (flaccid) paralysis; administer Atropine at 0.1 mg/kg IM; 2-PAM Cl at 25 mg/kg IM.
Child (2 – 10 yrs), for mild to moderate physical findings, including localized sweating, muscular twitching (fasciculations), nausea, vomiting, weakness, and shortness of breath (dyspnea); administer Atropine at 1 mg IM; 2-PAM Cl at 15 mg/kg IM.
Child (2 – 10 yrs), for severe physical findings, including unconsciousness, convulsions, cessation of breathing (apnea), and floppy (flaccid) paralysis; administer Atropine at 2 mg IM; 2-PAM Cl at 25 mg/kg IM.
Adolescent (> 10 yrs), for mild to moderate physical findings, including localized sweating, muscular twitching (fasciculations), nausea, vomiting, weakness, and shortness of breath (dyspnea); administer Atropine at 2 mg IM; 2-PAM Cl at 15 mg/kg IM.
Adolescent (> 10 yrs), for severe physical findings, including unconsciousness, convulsions, cessation of breathing (apnea), and floppy (flaccid) paralysis; administer Atropine at 4 mg IM; 2-PAM Cl at 25 mg/kg IM.
Adult, for mild to moderate physical findings, including localized sweating, muscular twitching (fasciculations), nausea, vomiting, weakness, and shortness of breath (dyspnea); administer Atropine at 2 to 4 mg IM; 2-PAM Cl at 600 mg IM.
Adult, for severe physical findings, including unconsciousness, convulsions, cessation of breathing (apnea), and floppy (flaccid) paralysis; administer Atropine at 6 mg IM; 2-PAM Cl at 1800 mg IM.
Elderly, frail for mild to moderate physical findings, including localized sweating, muscular twitching (fasciculations), nausea, vomiting, weakness, and shortness of breath (dyspnea); administer Atropine at 1 mg IM; 2-PAM Cl at 10 mg/kg IM.
Elderly, frail for severe physical findings, including unconsciousness, convulsions, cessation of breathing (apnea), and floppy (flaccid) paralysis; administer Atropine at 2 to 4 mg IM; 2-PAM Cl at 25 mg/kg IM.
Assisted ventilation should be started after administration of antidotes for severe exposures.
Repeat atropine (2 mg IM for adults or 0.05 to 0.1 mg/kg for children) at 5 to 10 minute intervals until secretions have diminished and breathing is comfortable, or airway resistance has returned to near normal.

• Immediately remove the patient/victim from the source of exposure.
• Often the first physical finding of minimal symptomatic exposure to nerve agent vapor is markedly constricted pupils (miosis); however, if this is the only physical finding of nerve agent exposure, do not administer antidotes but follow the instructions below.
• When exposed to liquid nerve agent, immediately flush the eyes with water for about 5 to 10 minutes by tilting the head to the side, pulling the eyelids apart with fingers, and pouring water slowly into the eyes.
• When exposed to nerve agent vapor, there is no need to flush the eyes.
• Do not cover eyes with bandages.
• Changes in the eye can lead to nausea and vomiting without necessarily being a sign of systemic exposure. However, if eye pain, nausea, or vomiting are seen in combination with any other physical findings of nerve agent poisoning, administer antidotes atropine and 2-PAM Cl as directed.
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• Ensure that the patient/victim has an unobstructed airway.
• Do not induce vomiting (emesis).
• Administer nothing by mouth (NPO).
• If the patient/victim’s condition can be evaluated within 30 minutes after ingestion, in a hospital setting, consider gastric lavage. Gastric contents should be considered potentially hazardous and should be quickly isolated.
• Be alert to physical findings of systemic exposure, and administer antidotes as required.
• Maintain records of all injections given.
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• In cases of moderate to severe exposure, antidotes alone will not provide effective treatment, and ventilatory support is essential.
• Evaluate respiratory function and pulse.
• Ensure that the patient/victim has an unobstructed airway.
• Assist with ventilation as required. Do not provide mouth-to-mouth resuscitation. Contact with off-gassed vapor or with liquid agent may occur.
• If shortness of breath occurs or breathing is difficult (dyspnea), administer oxygen.
• Suction secretions from the nose, mouth, and respiratory tract.
• Marked resistance to ventilation is expected due to bronchial constriction and spasm. Resistance lessens after administration of atropine.
• Ventilatory distress is a physical finding of systemic exposure and requires antidote administration.
• Maintain records of all injections given.
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• Some nerve agents may remain in the hair or clothing and should be decontaminated if that was not previously done. See the decontamination section of this card.
• Skin exposure to liquid nerve agents will not necessarily result in systemic exposure if the site of exposure is decontaminated promptly. Before administering nerve agent antidotes, observe the site of exposure for localized sweating and muscular twitching. If these physical findings appear, administer antidotes, otherwise careful observation is all that is needed.
• Maintain records of all injections given.
• Seek medical attention immediately.

Electrocardiogram (ECG), and adequacy of respiration and ventilation, should be monitored. Supplemental oxygenation, frequent suctioning of secretions, insertion of a tube into the trachea (endotracheal intubation), and assisted ventilation may be required. Diazepam (5 to 10 mg in adults and 0.2 to 0.5 mg/kg in children) may be used to control convulsions. Lorazepam or other benzodiazepines may be used, but barbiturates, phenytoin, and other anticonvulsants are not effective. Administration of atropine (if not already given) should precede the administration of benzodiazepines in order to best control seizures. Patients/victims who have inhalation exposure and who complain of chest pain, chest tightness, or cough should be observed and examined periodically for 6 to 12 hours to detect delayed-onset inflammation of the large airways (bronchitis), inflammatory lung disease (pneumonia), accumulation of fluid in the lungs (pulmonary edema), or respiratory failure.

Patients/victims who have severe exposure should be evaluated for persistent central nervous system (CNS) effects.

Limited data are available on long-term exposures of humans to VX. The available data do not suggest that VX is a human carcinogen, reproductive toxin or developmental toxin. Chronic or repeated exposure to VX may result in characteristic nervous, digestive, locomotory, visual and cardiovascular symptoms.

• Consult with the Incident Commander regarding the agent dispersed, dissemination method, level of PPE required, location, geographic complications (if any), and the approximate number of remains.
• Coordinate responsibilities and prepare to enter the scene as part of the evaluation team along with the FBI HazMat Technician, local law enforcement evidence technician, and other relevant personnel.
• Begin tracking remains using waterproof tags.

• Wear PPE until all remains are deemed free of contamination.
• Establish a preliminary (holding) morgue.
• Gather evidence, and place it in a clearly labeled impervious container. Hand any evidence over to the FBI.
• Remove and tag personal effects.
• Perform a thorough external evaluation and a preliminary identification check.
• See the Decontamination section for decontamination procedures.
• Decontaminate remains before they are removed from the incident site.

The following methods can be used to decontaminate the environment/spillage disposal:

• Do not touch or walk through the spilled agent if at all possible. However, if you must, personnel should wear the appropriate PPE during environmental decontamination. See the PPE section of this card for detailed information.
• Keep combustibles (e.g., wood, paper, and oil) away from the spilled agent.
• Use water spray to reduce vapors or divert vapor cloud drift. Avoid allowing water runoff to contact the spilled agent.
• Do not direct water at the spill or the source of the leak.
• Stop the leak if it is possible to do so without risk to personnel, and turn leaking containers so that gas rather than liquid escapes.
• Prevent entry into waterways, sewers, basements, or confined areas.
• Isolate the area until gas has dispersed.
• Ventilate the area.

Agents can seep into the crevices of equipment making it dangerous to handle. The following methods can be used to decontaminate equipment:

• Not established/determined