MARK 1 – Nerve Agent Antidote Kit

1 MARK 1 MARK 1 Nerve Agent Antidote KitNerve Agent Antidote KitLearning ObjectivesLearning ObjectiveszIdentify the antidotes to be administered in event of Nerve Agent exposurezIdentify the conditions under which Antidote auto-injectors should be usedzDemonstrate use of Antidote auto-injectorszRecognize adverse reactions to use of antidotesNerve Agent Antidote Kit Training Cuyahoga County Hazmat Committee, Nov. 2004 For Official Use Only Not for Public ReleaseCuyahoga County Plan Implement Countywide Nerve Agent Exposure Protocol Provide 15 Nerve Agent Antidote Kits (NAAK) for each frontline public safety EMS and Fire Truck in insulated carrying case Provide 5 Valium Auto-Injectors (CANA) to each public safety ALS Unit Equip 10 hospitals with EMS and Hospital CHEMPACKS of Antidote and treatment drugs each capable of treating 1000 patients Nerve Agent Antidote Kit Training Cuyahoga County Hazmat Committee, Nov.

2 2004 For Official Use Only Not for Public ReleaseCuyahoga County Plan -Implementation Drugs can be distributed when the following conditions have been met: Drug license amended to add new drugs Protocol approved and signed by your local medical control Nerve Agent exposure treatment protocol training is completed for all medics Drugs picked up at designated location by paramedic, RN, MD or DO Distribution forms signed AutoAuto--InjectorsInjectorsSimple, compact injection systems zPermit rapid injection of required antidotes zPre-measured, controlled dosezContain pre-measured doses of Nerve Agent antidotes atropine and 2-PAM chloride zEnable rapid and accurate administration even if care giver or patient is clothed AutoAuto--InjectorsInjectorsEach Mark 1 Kit contains two auto-injectors.

3 Z2mg Atropinez600 mg Pralidoxime Chloride (2-PAM) AutoAuto--InjectorsInjectorsEach CANA Kit contains one auto-injector:z10 mg ValiumzCANA = Convulsant Antidote Nerve AgentCan All Patients Receive AutoCan All Patients Receive Auto--Injectors?Injectors?zDosage in Auto-Injectors are based upon healthy adult patientszAge, sex, weight and health of all other patients must first be considered when determining amount of atropine and 2-PAM Cl to administerzProtocol has specific reduced doses for patients under 10 years of ageWho Can Use AutoWho Can Use Auto--Injectors?Injectors?zCurrent Ohio Law and Cuyahoga County Protocol permit only paramedicswho have been trained in recognition and treatment of Nerve Agent intoxication are permitted to use the Mark 1 Kits (NAAK)zMay change in the near future to allow EMT-B and EMT-I to administer, so all EMS responders should be trainedWhen To Use AutoWhen To Use Auto--Injectors?

4 Injectors?zPatient exhibits some or all of symptoms of Nerve Agent poisoningzIf you have protected yourself from exposurezIf YOU have the symptoms of exposure, administer the kit to yourself and seek decontamination and medical careHOW Nerve AGENTS WORKHOW Nerve AGENTS WORKzThey attack the nervous system by Overstimulating nervous system controls body functions through use of chemicals which act as instructions to nerves, muscles and glands zNerve agents interfere with normal chemical instructionsNerve synapseNORMAL NERVOUS SYSTEMNORMAL NERVOUS SYSTEMzAt Nerve ending, acetylcholine is releasedzAcetylcholine crosses synapse between Nerve endings if junction with skeletal muscle, muscles cells contract if junction with smooth muscles, muscles move rhythmically if junction with gland, glandular cells secretezAcetylcholine is inactivated by acetylcholinesteraseNormal activity at Nerve synapseHOW Nerve AGENTS WORKHOW Nerve AGENTS WORKzNerve agents block acetylcholinesterase so it cannot destroy acetylcholine acetylcholine accumulates and continue to stimulate target Nerve muscles twitch uncontrollably and repetitively excess secretions of glandsNerve Agent interferes with normal synapse activityNerve Agent Signs and SymptomsNot all signs and symptoms may , duration, and route of entry Of the Nerve Agent make a differenceNote!

5 Note! Usually liquid in normal state Volatile - many (not all) will generate vapors May be aerosolizedPhysical Properties of Nerve AgentsPhysical Properties of Nerve AgentsNerve AgentsCommon Name Tabun (GA) Sarin (GB) Soman (GD) VXMilitary SymbolVolatility/PersistenceSemi-Persist ent PersistentRate of ActionExtremely rapidRoute of Entry Respiratory SkinOdorFruityCamphor SulfurSymptoms Pinpointing of Pupils Salivation Vomiting/Diarrhea Twitching Difficulty in BreathingProtection Respiratory and SkinFirst Aid Atropine 2-Pam chlorideDecontamination Remove Agent Flush With WaterSigns and Symptoms of Nerve Signs and Symptoms of Nerve Agent ExposureAgent ExposureMILD zexcessive sweatingztight chest (smooth muscle constrictions)zMuscle twitchingMODERATEMODERATE severe chest tightness severe chest tightness diarrhea (rare) diarrhea (rare)

6 Headache blurred vision from pinpoint pupils (miosis) tearing (lacrimation) salivation unexplained runny noseVERY SEVERE VERY SEVERE bluish discolorationbluish discolorationof skin (cyanosis)of skin (cyanosis) respiratory failurerespiratory failure comacoma unconsciousunconscious convulsionsconvulsions Reaction time depends on:- type of Agent involved- dose (how much patient absorbed)-duration- route of exposure- sensitivity of patient's systemTime Factor (Onset)Factors Affecting Factors Affecting Signs and SymptomsSigns and Symptoms Reaction time is immediate if:- moderate to large amounts inhaled- moderate to large amounts spilled on skin Reaction time is delayed if:- small amounts involved- absorbed through skin in localized areaTime Factor (Onset)Factors Affecting Signs and Factors Affecting Signs and Symptoms (Continued)Symptoms (Continued) Effects can occur after single breath Immediate response within seconds Peak effects within 15-20 minutes Cinetel ProductionsExposure Through InhalationExposure Through Inhalation Effects can develop up to 18 hoursafter exposure Absorption can continue and effects worsen for hours, even after decon Later onset, less likely to be lethal Cinetel ProductionsExposure Through Skin Exposure Through Skin (Absorption)(Absorption)Absorption through skin.

7 All agents can be absorbed VX persists longer Sarin (GB) evaporates quickly, but still a threat Scrape or cut in skin allows immediate entry Cinetel ProductionsDirect ContactDirect ContactComparative ToxicitiesChlorineCyanogen ChloridePhosgeneHydrogen CyanideMustardSarinVX0100200300400500600 ChlorineCyanogen ChloridePhosgeneHydrogen CyanideMustardSarinVXSigns and symptoms could also apply to: Epilepsy Gastroenteritis Exposure to agriculturalinsecticides Carbon Monoxide Poisoning Heat illnesses Emphysema Stroke Head trauma Drug overdoseOther Possible Causes of Other Possible Causes of SymptomsSymptomsNerve Agent Antidote Kit Training Cuyahoga County Hazmat Committee, Nov. 2004 For Official Use Only Not for Public ReleaseAdult - Symptoms and Treatment of Nerve Agents3 Mark 1 Kits and repeat atropine every 5-10 minutes until secretions stop AND1 Valium Auto-injector for seizures, if present1-2 Mark 1 Kits and repeat atropine every 5-10 minutes until secretions stop1 Mark 1 KitDecontamination and Observation OnlyUnconsciousnessApneaSeizuresFlaccidP inpoint pupils Runny Nose Headache WheezingNausea Diarrhea CrampingSweatingMuscle TwitchingChest TightnessNoneSevere ExposureModerate ExposureMild ExposureNo SymptomsNerve Agent Antidote Kit Training Cuyahoga County Hazmat Committee, Nov.

8 2004 For Official Use Only Not for Public ReleasePeds - Symptoms and Treatment of Nerve Agents<10 yrs or < 40 kgAtropine and 2-PAM as shown. Valium to mg/kg IV or IM may also be given if seizures are present Atropine mg/kg IV or IM, repeated every 5-10 minutes until respirations improve2-PAM 25-50 mg/kg IV or IM may repeat at 1 hour Decontamination and Observation OnlyDecontamination and Observation OnlyUnconsciousnessApneaSeizuresFlaccidM iosis and ANY Other Symptom of ExposureMiosisMild RhinorrheaNoneSevere ExposureModerate ExposureMild ExposureNo SymptomsTreatment For Exposure Treatment For Exposure To Nerve Agents To Nerve Agents zDepending on severity of symptoms, immediately administer 1 atropine auto-injector, followed by 1 2-PAM Cl auto-injector Atropine should be given first.

9 Followed immediately by 2-PAM ClzIf Nerve Agent signs and symptoms are still present after 5 10 minutes, repeat injections zIf signs and symptoms still exist after additional 10 minutes, repeat injections for third time zIf signs and symptoms remain after third set of injections, do notgive any more antidotes but seek immediate definitive medical careTreatment For Exposure Treatment For Exposure To Nerve Agents To Nerve Agents If severe signs and symptoms are present:If severe signs and symptoms are present: In case of very severe exposure, all three autoIn case of very severe exposure, all three auto--injector kits (atropine and 2injector kits (atropine and 2--PAM PAM ClCl) may be ) may be administered in rapid succession; then medical administered in rapid succession; then medical help should be soughthelp should be sought Note: If self administering, if you are able to Note: If self administering, if you are able to administer kits to yourself, you don t have severe administer kits to yourself, you don t have severe symptomssymptoms ABC s still apply.

10 Remove secretions, maintain ABC s still apply. Remove secretions, maintain patient s airway and, if necessary, use artificial patient s airway and, if necessary, use artificial ventilation by BVM ventilation by BVM Treatment For Exposure Treatment For Exposure To Nerve Agents To Nerve Agents What does the Atropine do?What does the Atropine do? Atropine blocks effects of over-stimulation Relieves smooth muscle constriction Dries up respiratory secretionsWhat does 2 What does 2--PAM Chloride do?PAM Chloride do? Removes organophospate from acetylcholinesterase which can then deactivate acetylchline Re-establishes normal skeletal muscle contraction Relieves twitching and paralysis of respiratory musclesDirections for UseDirections for Use Remove safety cap (yellow on Remove safety cap (yellow on atropine; gray on 2atropine; gray on 2--PAM PAM ClCl)) Mark I kit clip holds the safetyMark I kit clip holds the safetycaps; may not notice if using caps; may not notice if using Mark I kits.