State Of Maine Nerve Agent Antidote Kit Training Module

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State Of MaineNerve Agent Antidote Kit Training
Module

• Brian Langerman, CCEMT-P, I/C
• EMS Coordinator City Of Saco
• Kevin Bachi NREMT-P, BS
• Kennebunk Fire Department

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Nerve Agent Antidote Kit TrainingObjectives

• Types of Incidents
• Signs Symptoms of Nerve Agent Exposure
• NAAKs
• Protocols for NAAK Usage
• Practice
• Test

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The Threat of Terrorism
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Potential Probability vs. Impact
BIOLOGICAL AGENT
NUCLEAR WEAPON
IMPROVISED NUCLEAR DEVICE
POTENTIAL IMPACT
CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL
RADIOACTIVE MATERIAL
PROBABILITY/LIKELIHOOD
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Chemical Warfare AgentsHistorical Perspective

• Chemicals used in military operations to kill,
  injure, or incapacitate
• Battlefield use
• World War I and Middle East conflicts
• Terrorist use
• Iraq, Matsumoto and Tokyo, Japan

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Chemical Agent Terrorist Attacks

• Matsumoto
• Approximately 280 injured
• 7 dead
• Tokyo
• 12 dead
• Approximately 1,000 hospitalized
• 5,500 sought medical care
• 10 of first responders injured

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Chemical Warfare Agents

• Tabun, Sarin, Soman, VX
• Mustard, Lewisite
• Phosgene, Chlorine, Ammonia, Cyanide
• Mace, Pepper Spray

• Nerve Agents
• Vesicants (Blister)
• Industrial Chemicals
• Riot Control Agents

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Weapons of Mass Destruction
Commonly accepted methods for categorizing WMD
are CBRNE and BNICE

• C (Chemical agents, including Toxic Industrial
  Chemicals (TIC) that may be used as WMD)
• B (Biological hazards)
• R (Radiological hazards)
• N (Nuclear hazards)
• E (Explosives)

• B (Biological hazards)
• N (Nuclear)
• I (Incendiary)
• C (Chemical Agents, including Toxic Industrial
  Chemicals)
• E (Explosives)

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Traits of a Terrorist

• Terrorism IS
• Politically motivated violence deliberately
  targeted at civilians
• Instruments of social and political change
• Terrorism seeks to break peoples will so they
  surrender principle to save themselves
• Terrorism is NOT
• Senseless or random
• One persons terrorist is NOT anothers Freedom
  fighter
• A viable negotiating technique
• One to seek compromise

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Factors of Threat

• Surprise (relative to time of attack)
• Means of attack
• Target of the attack
• Foreknowledge of the community response
• Significant dates

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Tactics

• Mass casualties
• Secondary devices
• Multiple incidents
• Rapid escalation of the hazards

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Terrorist Weapon Choice

• Depends on
• Affordability of the weapon
• Ability to move the weapon
• Level of technology (usually low)
• Ability to deny the results if intended objective
  was not achieved

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How Nerve Agents Work
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Normal Nerve Function
Nerve, gland or muscle
ACh
AchAcetylcholine stimulates muscle contraction,
gland secretion nerve to nerve conduction
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Normal Nerve Function
ACh
Electrical Message continues
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Normal Nerve Function
AChE
ACh
To stop further stimulation Ach is broken down by
AChE ,preventing overstimulation
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Nerve Agents inhibit AChE
AChE
GB
ACh
Ach accumulates and causes over-stimulation of
nerves, muscles and glands
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Nerve Agents

• Tabun (GA), Sarin (GB), Soman (GD),VX
• Nerve Agents are the most toxic of the chemical
  agents
• Penetrate skin, eyes, lungs
• Loss of consciousness, seizures, apnea, death
  after large amount
• Diagnosis made clinically confirmed in
  laboratory (Nerve agents inhibit cholinesterase)

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ROUTES OF EXPOSURE

• Direct Contact
• Inhalation
• Ingestion

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DIRECT CONTACT

• Skin or eyes are touched with agent vapor or
  liquid
• Nerve agents absorbed through skin
• VX remains on skin and absorbed more completely
• GB evaporates quickly, but still a threat
• Scrapes, cuts or other skin damage offer direct
  entry points
• freshly shaven skin, sunburn, insect bites,
  rashes
• Eyes most sensitive organ for nerve agent vapor
  effects

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INHALATION

• Nerve agents enter through respiratory system
• Rapidly and effectively enter into blood stream

Respiratory failure chief cause of death after
severe exposure
Nerve agent inhaled into respiratory system
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INGESTION

• Ingestion of contaminated food or drink,
  incidental hand to mouth or eye contact, smoking
• Unlikely that agent will contaminate food or drink

Gastrointestinal system
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Potential Exposure

• No signs or symptoms
• Reassure
• Segregate in cold zone
• Observe
• Arrange transport to ED by bus or vans

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Mild Exposure

• Miosis, rhinorrhea - observation only
• IV or IM atropine will not reverse miosis
• Localized fasciculations and sweating
• Exclusion (Hot) Zone No immediate treatment
• Contamination Reduction (Warm) Zone
• One MARK I Kit
• Atropine 2 mg IM
• 2-PAM 600 mg IM (Adult only)

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Moderate Exposure

• Miosis, rhinorrhea, SOB, wheezing, secretions,
  muscle weakness, GI effects
• Exclusion (Hot) Zone No immediate treatment
• Contamination Reduction (Warm) Zone
• One to two MARK I kits (repeat every 5-10 min)
• Atropine 2-4 mg IM (repeat every 5-10 min)
• 2-PAM 600-1200 mg IM

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Severe Exposure

• Unconscious, seizing, flaccid, apnea
• Exclusion (Hot) Zone
• 3 MARK I kits IM as soon as possible
• Contamination Reduction (Warm) Zone
• 3 MARK I kits IM as soon as possible
• Atropine 2-6 mg IM
• 2PAM 600-1800 mg IM

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Severe Exposure (cont.)

• For seizures
• Paramedics may administer
• Midazolam (Versed) IM
• Adult 5 mg IM

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SLUDGEM / DUMBELS

• Salivation
• Lacrimation (Tears)
• Urination
• Defecation
• GI Upset
• Emesis (Vomiting)
• Miosis (Pinpoint pupils)

• Diarrhea
• Urination
• Miosis
• Bronchospasm/bradycardia
• Emesis
• Lacrimation
• Salivation

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Effects of Nerve Agents

• Organs with cholinergic receptors
• Muscarinic (Atropine works)
• Smooth muscles
• Exocrine glands
• Nicotinic (Atropine ineffective)
• Skeletal muscles
• Ganglia (Sympathetic/Parasympathetic)

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Signs and Symptoms of Nerve AgentsMuscarinic
Sites

• Increased secretions
• Saliva
• Tears
• Runny nose
• Secretions in airways
• Secretions in gastrointestinal tract
• Sweating

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Signs and Symptoms of Nerve AgentsMuscarinic
Sites

• Smooth muscle contraction
• Eyes miosis
• Airways bronchoconstriction (shortness of
  breath)
• Gastrointestinal hyperactivity (nausea,
  vomiting, and diarrhea)

Dark room for 2 min 3,6,13,20,41, and 62days
after exposure
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Signs and Symptoms of Nerve AgentsNicotinic
Sites (Over-stimulation of Ach)

• Skeletal muscles
• Fasciculations
• Twitching
• Weakness
• Flaccid paralysis
• Other (ganglionic)
• Tachycardia
• Hypertension

Miosis and fasciculations are the most reliable
evidence of OPP
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Nerve AgentsOther Signs and Symptoms

• Cardiovascular
• Tachycardia, bradycardia
• Heart block, ventricular arrhythmias
• Most disappear once antidote is given
• Central Nervous System
• Acute
• Loss of consciousness
• Seizures
• Apnea
• Prolonged (4-6 weeks)
• Psychological effects

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Signs and Symptoms of Nerve Agents Vapor Exposure

• Mild exposure
• Miosis (dim vision, eye pain), rhinorrhea,
  dyspnea
• Moderate exposure
• Pronounced dyspnea, nausea, vomiting, diarrhea,
  weakness
• Severe exposure
• Immediate loss of consciousness, seizures, apnea,
  and flaccid paralysis
• Vapor effects occur within seconds, peak within 5
  minutes if no effects within 20 minutes probably
  safe to assume there has not been an exposure.

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Signs and Symptoms of Nerve Agents Liquid
Exposure

• Mild exposure (to 18 hours)
• Localized sweating
• Fasciculations
• No miosis
• Moderate exposure (ltLD50) (to 18 hours)
• Gastrointestinal effects
• Miosis uncommon
• Severe exposure (LD50) (lt30 minutes)
• Sudden loss of consciousness
• Seizures
• Apnea
• Flaccid paralysis
• Death

10mg of VX
LD50lethal dose for 50 of the exposed
population while the other 50 would suffer
lesser effects
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Diagnosis of Nerve Agent Exposure

• Symptomatic
• May be systemic or organ-specific
• Combination of symptoms is more definitive
• Situational
• Multiple casualties with similar symptoms
• Time or location factors in common

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Treatment

• Self-protection
• Decontamination

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Who Can Administer Mark 1 kits

• In the State of Maine, an emergency responder can
  only administer the Mark 1 kits to themselves, or
  another emergency responder
• If you and your partner have an exposure, and
  your partner becomes symptomatic, treat yourself
  first and then treat your partner

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Nerve Agent Treatment

• Escape the Area / Notify Dispatch
• Decontaminate (strip down / H2O)
• DO NOT ENTER ONCE SUSPICION EXISTS
• IF Symptomatic use the NAAK Kits
• Atropine
• 2-PAMCl

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Nerve AgentTreatment

• Atropine
• Side effects in normal people
• Mydriasis (Pupil Dilation)
• Blurred vision
• Tachycardia
• Decreased secretions and sweating

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Nerve AgentTreatment

• Pralidoxime Chloride (2PAM-Cl)
• Remove nerve agent from AChE in absence of aging
  (ie enzyme and agent can become bound
  irreversibly- has to be given in 4-6 hrs (Sarin)
  60hrs (VX) and 2 min for Soman
• 200 mg in each autoinjector
• No effects at muscarinic sites
• Helps at nicotinic sites

This antidote breaks the bond between the nerve
Agent and AChE and removes the agent
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MARK I Injections - Dispersal
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Nerve Agent Treatment

• Treatment regimen
• No signs/symptoms
• Reassure
• Observe
• Vapor 1 hour
• Liquid Up to 18 hours

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Nerve Agent Treatment

• One MARK I kit (2 mg atropine/ 600 mg 2 -PAMCl)
• Parenteral atropine will not reverse miosis

• Mild vapor exposure
• Miosis, rhinorrhea - observation only
• Increasing SOB treat
• Mild liquid exposure
• Localized fasiculations sweating - treat

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Nerve AgentTreatment

• Moderate vapor or liquid exposure
• One or two MARK I kits

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Nerve AgentTreatment

• Severe - vapor or liquid
• Give 3 MARK I kits
• Airway
• Ventilation/O2
• Consider Midazolam 5 mg IM and repeat the
  atropine every 5 to10 minutes as needed
• Repeat 2-PAMCl

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Treatment

• Airway/ventilation
• Antidotes
• Atropine
• Pralidoxime
• (2-PAM)
• Midazolam

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Atropine

• Given IV, IM, ET
• Antagonizes muscarinic effects
• Dries secretions relaxes smooth muscles
• Does not affect miosis, fasciculations, muscle
  strength (nicotinic)
• May cause cardiac arrhythmias IV in hypoxic
  patient (v-fib)

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Atropine

• Starting dose - 2 mg
• Maximum cumulative dose - 20 mg
• Side effects in normal people
• Dilated pupils
• Blurred vision
• Tachycardia
• Decreased sweating

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Atropine

• Atropine - How much to give?
• Until secretions are drying or dry
• Until ventilation is easy
• If conscious, and victim is comfortable
• Dont rely on heart rate/pupil size

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Atropine Overdose

• If excessive atropine is administered
• Signs of atropinization will become even more
  severe and patient may also develop
• blurring of vision
• delirium
• urinary retention
• When signs and symptoms of atropinization
  develop, no more atropine should be injected
  until atropinization subsides

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Pralidoxime Chloride (2-PAM)

• Remove nerve agent from AChE in absence of aging
  (2-PAM crowbar)
• Does not reverse muscarinic effects on glands and
  smooth muscles
• Helps at nicotinic sites

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2-PAM Adverse Reactions

• 2-PAM may cause
• blurred vision
• diplopia
• impaired accommodation
• headache
• nausea

• dizziness
• drowsiness
• tachycardia
• hyperventilation
• hypertension

These are relatively mild when compared to
effects of nerve agents
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Midazolam

• Decreases seizure activity
• Reduces seizure-induced brain injury
• Must observe carefully for respiratory depression

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Autoinjectors
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Auto-Injectors

• Simple, compact injection systems
• Permit rapid injection of required antidotes
• Prevent needle from being subject to
  cross-contamination
• Enable rapid and accurate administration even if
  care giver or patient is in protective clothing

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Directions for Use

• 1. Remove safety cap
• Yellow on atropine
• Gray on 2-PAM
• Mark I kit clip holds the safety caps
• May not notice if using Mark I kits
• Do not touch colored end of injector after
  removing cap - injector will inject
• into fingers or hand

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Directions for Use

• 2. Hold injector - either like a pen or in fist.
  
• 3. Place colored end (Green on atropine, black
  on 2-PAM) on thickest part of thigh and press
  hard until injector functions.
• Pressure automatically activates the spring,
  inserts the needle into the muscle and injects
  the medication

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Directions for Use

• 4. After auto-injector has been activated, empty
  container should be disposed of properly
• It cannot be refilled nor can the protruding
• needle be retracted
• It should be disposed of in a sharps
  container
• 5. Note dosage on triage tag or write on chest
  or forehead of patient

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Riot Control Agents Summary

• Irritating agents, lacrimators, tear gas
• Cause reaction in
• Eyes burning, tearing, eyelid spasm, redness
• Airways burning, coughing, dyspnea
• Skin burning, erythema
• Eye irrigation and supportive care

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Nerve Agent Summary

• Vapor exposure
• Symptoms develop suddenly
• Most ambulatory victims require minimal
  intervention
• Risk of secondary contamination, which is
  minimized by removing the victims clothing
• Requires immediate access to antidotes

• Liquid exposure
• Symptoms delayed minutes to hours
• Greater need for decontamination
• High risk of secondary contamination victims
  require decontamination (clothing removal
  washdown)
• Requires immediate access to antidotes

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Chemical Agent Summary

• Vapor exposure
• Nerve agent symptoms develop suddenly, mustard
  and phosgene symptoms are delayed
• Most ambulatory victims require minimal
  intervention
• Risk of secondary contamination
• Requires airway management antidotes for nerve
  agents and Lewisite

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Chemical Agent Summary

• Liquid exposure
• Symptoms delayed minutes to hours
• Greater need for decontamination
• Risk of secondary contamination, victims require
  clothing removal decontamination
• Requires immediate access to antidotes

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ANY QUESTIONS ???