ACT001©

A A gent C C haracteristics and T T oxicology F F irst A A id and S S pecial T T reatment ACT002©

Purpose of Course The intent of this course is to instruct emergency medical personnel on how to care for patients that may have been exposed to chemical warfare agents and assumed to have already been decontaminated. This course is designed primarily for Emergency Medical Technicians with basic life support credentials. These individuals are referred to in the text as pre-hospital emergency medical personnel. ACT002B©

To prepare you to recognize signs and symptoms, and provide initial emergency response treatment to patients injured by exposure to nerve and blister agents Goal ACT003©

To assist in preparing for hazardous materials emergencies Goal ACT004©

Action items What trainees will be able to do at end of training Review with trainees Instructional Objectives ACT005©

DESCRIBE initial first-aid treatment for victims of nerve agent exposure DESCRIBE initial first-aid treatment for victims of blister agent exposure Required Objectives ACT006©

DESCRIBE potential hazards of nerve agents DESCRIBE potential hazards of blister agents IDENTIFY signs and symptoms of nerve agent exposure IDENTIFY signs and symptoms of blister agent exposure Supporting Objectives ACT007©

Designed to augment classroom instruction Self-paced review Self checks included Additional reference materials such as Material Safety Data Sheets included Student Manual ACT008©

Self-checks Final quiz Evaluations ACT009A©

BACKGROUND BACKGROUND ACT010©

To familiarize you with chemical agent characteristics Purpose ACT011©

Comprised of chemicals designed and produced for warfare Primarily nerve agents and blister (vesicant) agents Chemical Stockpile ACT012©

Hermiston, OR Tooele, UT Pueblo, CO Aberdeen, MD Newport, IN Richmond, KY Pine Bluff, AR Anniston, AL Chemical Stockpile Storage Location ACT013©

U.S. Army Chemical Stockpile Inventories Storage Location Agent Stored GA GB VX Mustard Lewisite Umatilla X X X Tooele X X X X X Pueblo X Pine Bluff X X X Newport X Lexington- Blue Grass X X X Anniston X X X Aberdeen X ACT014©

LOCAL RESPONSE INFORMATION AND PROCEDURES LOCAL RESPONSE INFORMATION AND PROCEDURES ACT015A©

Specific and unique information requirements to be addressed Provide you with a framework for site-specific information Local Response Information and Procedures ACT015B©

Community needs and resources vary a great deal from one storage location to the next. Therefore, YOUR input on how the emergency care elements in your community could best respond to a release with off-post consequences is important to the success of the program. Your Input is Important ACT015C©

This study guide does not, and cannot, cover everything you need to know in preparation for your role In short, you need to find out — Who the local players are — The roles and responsibilities of each — The methods of response — What supplies and equipment are on hand — Standard Operating Procedures — Memoranda of Understanding or Agreement What You Should Know That IS NOT in This Study Guide ACT015D©

Local emergency services Fire department or other emergency responders Ambulance service or other rescue services Hospital emergency department Local health department Additional Information Resources ACT015E©

Where is the first notification (identification) expected to come from? Who, from the facility, is notified? Who, from the local community, is notified? Who is likely to be the first on the scene? If an emergency occurs at the installation that could affect the off-post population: Local Community Response Procedures ACT015F©

What are the duties of the pre-hospital emergency medical personnel? What am I expected to do in this situation? Am I authorized in my state to administer antidotal medications (atropine, 2-PAM chloride)? Under what circumstances? If an emergency occurs at the installation that could affect the off-post population: Local Community Response Procedures (Continued) ACT015G©

CHEMICAL AGENTS ACT017©

Information will help you in: Protecting yourself Treating patients ACT018©

DESCRIBE potential hazards of nerve agents DESCRIBE potential hazards of blister agents IDENTIFY most likely route of exposure Objectives ACT019©

ANDEFFECTS CHARACTERSTICSI ACT020©

Nerve Agents Attack nervous system Scientific classification: Organophosphate © Cinetel Productions ACT021©

Name Common Name Referred to As VX GB Sarin GB or G-agent GA* Tabun GA or G-agent * Small amount stored at Tooele only Specific Names ACT022©

Usually liquid in normal state Volatile--generate vapors Potential for release if in vapor form Physical Properties ACT023©

Nervous system controls normal functions through use of chemicals Chemicals act as instructions to nerves, muscles, and glands Two forms of instructions: - stimulate (move or work) - relax (stop or rest) Nerve agent interferes with normal transmission of instructions How Nerve Agents Work ACT024©

Over-stimulates nerve endings and central nervous system Causes muscles and certain glands to malfunction Leads to Destruction of System Control ACT025©

Nerve impulse transmitted along nerve cells Normal Nervous System Function ACT026A© Acetycholine (a neuro- transmitter) is released Target cell is stimulated

Normal Nervous System Function Once target cell is stimulated, acetycholine is deactivated by acetylcholinesterase. Target cell relaxes ACT026B©

Nerve agents inactivate acetylcholinesterase Nerve Agent Interference ACT027© Excess acytelcholine accumulates Muscle action becomes uncontrolled and twitchy Muscle can tire and collapse Gland continues to secrete sweat, tears, or mucus

Inhalation Ingestion Direct contact © Cinetel Productions Routes of Exposure ACT028©

© Cinetel Productions Inhalation ACT029© Respiratory failure chief cause of death after severe exposure

Absorption through skin: All agents can be absorbed VX persists longer GB evaporates quickly, but still threat Scrape or cut in skin allows immediate entry Entry also through eyes © Cinetel Productions Direct Contact ACT030©

© Cinetel Productions Access to bloodstream via digestive system Effects similar to inhalation, but at greater doses Ingestion ACT031©

The critical route of exposure that you should be most concerned with is Inhalation Exposure From Atmospheric Transport ACT032© *inhalation of agent vapors or aerosols*

Poisons that destroy cells Blisters most noticeable effect © Cinetel Productions Blister Agents (Vesicants) ACT033©

Common Name Referred to as Mustard H, HD, HT Lewisite* L *Small amount stored at Tooele only Specific Names ACT034©

Form: Liquid or solid Volatile, burns well H HD HT Physical Properties ACT035©

Chemical burns to skin–especially warm, moist surfaces Chemical burns to soft membranes - Eyes - Eye ball - Lung tissue - Mouth - Throat How Blister Agents Work ACT036©

Delayed reaction, little or no pain Blisters develop in 2 to 36 hours © Cinetel Productions Mustard Agent Exposure ACT037©

Inhalation Ingestion Direct contact © Cinetel Productions Routes of Exposure ACT038©

Can destroy mucous membrane lining of Nasal passages Throat Bronchial tubes © Cinetel Productions Inhalation ACT039©

Skin Highly damaging to skin—especially warm, moist areas Mucous Membranes Very susceptible to effects of blister agents Includes: - lining around eyelids - inside mouth and nose Sweat and moisture increase effect Direct contact With Liquid or Vapor ACT040©

If deposited on or in food items, drink, etc. Injures warm, moist tissues of mouth, throat and esophagus © Cinetel Productions Ingestion ACT041©

The critical route of exposure that you should be most concerned with is Inhalation Exposure From Atmospheric Transport ACT042© *inhalation of agent vapors or aerosols*

Chlorovinyldichloroarsine (organic arsenical) Different type of blister agent in Chemical Stockpile only at Deseret Chemical Depot Causes immediate pain upon skin or eye contact (unlike mustards) Suspected carcinogen Lewisite ACT043©

Nerve agent characteristics: - Stored as liquid (VX oily), generates extremely damaging vapors - Highly damaging by direct contact (touch), inhalation (breathing of contaminated air), and ingestion (eating or drinking) Key Points—Nerve Agents ACT044A©

H HD HT Blister agent characteristics: - Stored as liquid (oily) or solid, generate damaging vapors - Damaging by direct contact (touch), inhalation (breathing of contaminated air), and ingestion (eating or drinking) Key Points—Blister Agents ACT044B©

Most likely route of exposure: Inhalation of contaminated air Key Points—Exposure ACT045©

SIGNS AND SYMPTOMS ACT046©

Known information regarding accidental release Recognition of the event based on signs and symptoms Size up situation based on... ACT047©

IDENTIFY signs and symptoms of nerve agent exposure IDENTIFY signs and symptoms of blister agent exposure Objectives ACT048©

Not all signs and symptoms may appear... Dose, duration, and route of entry make a difference Note! ACT049©

Miosis (pinpoint pupils) Dim vision Respiratory trouble Localized sweating Wheezing Constriction (Pinpoint) Expansion (Dilation) Runny nose or excess salivation Stomach cramps, vomiting diarrhea Muscle cramps, twitching Heartbeat irregularities Specific Signs and Symptoms Of Nerve Agent Exposure ACT050©

Generalized weakness Twitching spasms Convulsions and coma Other symptoms - Headache - Anxiety - Restlessness - Giddiness - Irritability Mild: Specific Signs and Symptoms Of Nerve Agent Exposure (continued) ACT051©

Reaction time depends on: - type of agent involved - amount of agent to which patient exposed - dose (how much patient absorbed) - duration - route of exposure - sensitivity of patient's system Time Factor (Onset) Factors Affecting Signs and Symptoms ACT052©

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 area Time Factor (Onset) Factors Affecting Signs and Symptoms (Continued) ACT053©

Effects can occur after single breath Immediate response within seconds Peak effects within minutes © Cinetel Productions Exposure Through Inhalation ACT054©

Effects can develop up to 18 hours after exposure Absorption can continue and effects worsen for hours, even after decon Later onset, less likely to be lethal © Cinetel Productions Exposure Through Skin (Absorption) ACT055©

LD 50 of VX is 10 milligrams/70-kg man (liquid on skin) – Equals tiny droplet absorbed into 155-lb person LCt 50 of VX is 30 milligrams-min/m (vapor inhalation) – 50 times more toxic than cyanide gas LD 50 of GB is 1.7 grams/70-kg man (liquid on skin) LCt 50 of GB is 70 milligrams-min/m (vapor inhalation) Toxicity ACT056©

© Cinetel Productions Respiratory failure chief cause of death after severe exposures Lethality ACT057©

Nerve Agent Exposure Levels Mild: May also be effects of initial reaction which could lead to more serious effects eyes: miosis, pain (deep in eye or head), dim or blurred vision nose: runny lungs: "tightness in chest”, bronchoconstriction, secretions in airways, cough, moderate difficulty in breathing ACT058A©

Nerve Agent Exposure Levels Moderate: May also include symptoms under "Mild" eyes: miosis, pain, dim or blurred vision nose: runny (severe), nasal congestion lungs: ”tightness in chest", breathing more difficult, secretions more abundant muscles: feeling of generalized weakness, twitching of large muscle groups GI: nausea, vomiting, diarrhea, cramps ACT058B©

Severe: May develop from symptoms under "Mild" and "Moderate"; or go directly to these symptoms muscles:convulsions, weakness with eventual flaccid paralysis lungs:cessation of respiration all:loss of consciousness, coma, death Nerve Agent Exposure Levels ACT058C©

Nerve Agent Exposure Levels Onset time: seconds to several minutes Symptoms may occur after little more than one breath of vapor Large amounts may cause reactions within seconds Effects do not worsen appreciably after min following cessation of exposure ACT058D©

Skin Exposure to Nerve Agent Mild: May also be effects of initial reaction which could lead to more serious effects skin: sweating at exposure site muscle: localized, unorganized twitching at exposure site (fasciculation) ACT058E©

Skin Exposure to Nerve Agent Moderate: May also include symptoms under “Mild” muscle: generalized (at random, all over) fasciculation and twitching; generalized weakness that increases with any form of activity GI: nausea, vomiting, diarrhea ACT058F©

Skin Exposure to Nerve Agent Severe: May develop from symptoms under "Mild" and "Moderate"; or go directly to these symptoms muscle: extremely weak; convulsions (seizures) with eventual flaccid paralysis lung: cessation of respiration all: sudden loss of consciousness and collapse, death ACT058G©

Skin Exposure to Nerve Agent Time Course Onset time: minutes to several hours The larger the exposure the shorter the onset time After large exposure, effects within minutes After asymptomatic period, first effect may be loss of consciousness Onset time may be as long as 18 hrs after exposure; in such cases effects usually not lethal ACT058H©

... refers to distinguishing one disease from another when they produce similar effects Differential diagnosis... ACT059©

Signs and symptoms could also apply to: Epilepsy Gastroenteritis Exposure to agricultural insecticides (organophosphates and carbanates) Heat illnesses Emphysema Stroke Head trauma Drug overdose Other Possible Causes of Symptoms ACT060©

While liquid deposition of mustard agent or high concentrations of vapor are not expected, it is important to recognize the signs and symptoms of more severe exposures Blister Agent Release Potential ACT061A©

Eye irritation and inflammation Photophobia Erythema Blisters Inflammation of respiratory tract Specific Signs and Symptoms of Mustard Agent Exposure ACT061B©

Normal skin Reddened skin Blistered skin © Cinetel Productions How Mustard Blisters Skin ACT061C©

Time Factor (Onset) Reaction time depends on: - type of agent - amount of agent to which patient exposed - dose (how much patient absorbed) - duration of exposure - route of exposure - sensitivity of patient's system Factors Affecting Signs and Symptoms ACT062©

Inhalation Effects occur after few hours latency Sneezing, coughing, bronchitis Skin Absorption Effects delayed and absorption can continue for hours Peak Effect © Cinetel Productions ACT063©

© Cinetel Productions Peak Effect (Continued) Toxicity LD 50 is 7 grams/70-kg man (liquid on skin) Between 4 and 32 micrograms/70-kg man can cause blistering Vapor form 3 times more toxic than cyanide Lethality Low (~3% in World War I) Chief cause of death: - Respiratory failure - Infections ACT064©

skin: no immediate clinical effects (no burning, stinging, or redness); becomes "fixed" to the tissue within minutes, blisters appear about 2 to 36 hours later eyes: within 4 to 12 hours after exposure, itching, tearing, conjunctivitis (reddening of tissues surrounding the eyeball), sensation of grit in the eye, burning and photophobia (sensitivity to light), some swelling of eyelids Mild: Mustard Agent Exposure Levels ACT065A©

Moderate: Mustard Agent Exposure Levels skin: no immediate clinical effects; blisters appear sooner and are more severe than in cases of "mild" dose eyes:in 3 to 6 hours; increased intensity from "Mild" symptoms; swelling of lids to the point of near closure; spasms of the muscles surrounding the eye; increased photophobia; blurred vision; possible discharge; miosis; severe inflammation of conjuctiva and cornea ACT065B©

skin: no immediate clinical effects blisters appear sooner and are large necrosis skin charring (delayed) eyes: severe pain increased swelling of lids to point of closure, discharge possible damage to cornea Muscles: large amounts may affect nerve endings Severe: Mustard Agent Exposure Levels ACT065C©

Mild: nose, throat and windpipe: burning sensation, sinus pain, cough GI: nausea and vomiting Mustard Agent Exposure Through Inhalation/Ingestion ACT065D©

Moderate: nose, throat and windpipe: burning sensation lungs: chest tightness, severe cough GI: nausea and vomiting, stomach pains Mustard Agent Exposure Through Inhalation/Ingestion ACT065E©

Severe: nose, throat and windpipe: severe burning lungs: difficulty breathing due to airway damage GI: nausea, vomiting, bloody diarrhea, stomach pains muscles: large amounts may affect nerve endings Mustard Agent Exposure Through Inhalation/Ingestion ACT065F©

Onset of symptoms may be delayed - initial signs/symptoms: 2 to 36 hrs, acute tracheobronchitis Approximate for moderate exposure: - 2 to 4 hrs—chest tightness, hacking cough, hoarseness, sneezing - 4 to 16 hrs—sinus pain, increased respiration rate - 16 to 48 hrs—severe cough, unable to speak, very rapid breathing - 24 to 48 hrs—severe dyspnea, lung tissue hemorrhage, bronchopneumonia Mustard Agent Exposure Time Course ACT066©

In spite of its chemical differences from mustard agents, Lewisite produces similar damage in body tissues. Lewisite Signs and Symptoms ACT067A©

When inhaled, vapor may produce mild to moderate irritation of upper respiratory tract May also cause sneezing Similar to mustard effects —Except, in most severe cases, fluid may accumulate in lungs and ooze into lining of the chest cavity Inhalation of Lewisite Vapor ACT067B©

Immediate severe pain upon contact with eyes and skin (unlike mustard) Eyes can be severely damaged resulting in permanent injury of blindness More severe skin lesions than mustard —Erythema followed by blistering over entire area of erythema —Deeper injury to connective tissue and muscle —Greater vascular damage —More inflammation Direct Contact with Liquid Lewisite ACT067C©

Systemic poison (liver and kidneys) at sufficiently large doses Has induced Bowen’s disease (slow-growing, usually nonfatal skin cancer) Other Effects ACT067D©

eye: prompt redness, swelling, irritation, immediate burning sensation, may cause inflammation of iris, corneal injury nose: prompt irritation respiratory tract:rapid irritation, hoarseness, loss of voice, cough; pneumonia, fever, accumulation of fluid in lungs, fluid between membranes lining chest cavity Lewisite Exposure ACT067E©

skin: prompt burning redness within 30 min, blisters on 1st or 2nd day; pain more severe and necrosis deeper than mustard GI tract: diarrhea, nausea, vomiting, liver failure cardiovascular system:shock after severe symptoms, anemia, concentration of blood Lewisite Exposure (Continued) ACT067F©

bladder: kidney failure central nervous system: malaise, prostration, depression after severe symptoms Lewisite Exposure (Continued) ACT067G©

Hay fever Chemical or thermal burns Heavy tear gas exposure Poison ivy, poison oak, and other contact allergies Blister agent signs and symptoms could also apply to: Other Possible Causes Of Signs and Symptoms ACT068©

Specific signs and symptoms of nerve agent exposure - Miosis - Increased secretions - Respiratory difficulty Not all signs and symptoms may appear Dose, duration, and route of entry can make difference Nerve Agent Summary ACT069A©

Specific signs and symptoms of blister agent exposure — Eye irritation and inflammation — Erythema (skin reddening) — Blisters — Respiratory irritation and distress Not all signs and symptoms may appear Dosage, duration, and route of entry can make difference Blister Agent Summary ACT069B©

FIRST AID AND SPECIAL TREATMENT ACT070©

A Airway B Breathing C Circulation ABC’s OF Emergency Care ACT071©

DESCRIBE need for self protection when providing treatment for nerve or blister agent exposure DESCRIBE initial first aid treatment for victims of nerve agents DESCRIBE initial first aid treatment for victims of blister agents Objectives ACT072©

rule number one: Protect yourself ACT073©

Recognizing area with exposure potential and the zone set up to operate safely during the emergency Ensuring that the exposed person is completely decontaminated You Can Protect Yourself By: ACT074A©

Once chemical plume expected to cross borders of post: Initial hazard prediction given, identifying pattern and path of off-post exposure Emergency response and treatment teams established Emergency Time Line ACT074B©

It is assumed that patients will have been decontaminated before being brought to EMS personnel in the cold zone Information regarding decontamination or removal from contaminated areas should not be interpreted as encouraging EMS personnel to go into the hot zone PPE may be required. The CSEPP training course, Personal Protective Equipment, describes the approved equipment and associated requirements ACT074C©

Essential part of treatment Prevents agent from doing further harm Prevents agent from spreading Note: Should be accomplished before patient is brought to the treatment area Decontamination ACT075©

Laws vary from state to state Be familiar with YOUR local and state laws Administering Drugs ACT076©

Atropine 2-PAM chloride Nerve Agent Antidotes ACT077©

Atropine Effect Atropine blocks effects of over- stimulation Relieves smooth muscle constriction Dries up respiratory secretions ACT078©

2-PAM Chloride Effect Removes organophospate from acetylcholinesterase which can then deactivate acetylchline Re-establishes normal skeletal muscle contraction Relieves twitching and paralysis of respiratory muscles ACT079©

Administration of Antidotes l Dosage varies depending on age and weight of patient and severity of signs and symptoms l Dosages may need to be repeated at specified intervals – repeat atropine until patient is “atropinized” – repeat 2-PAM Chloride until maximum dose per body weight is reached ACT080©

Two Common Problems l Underdosage – administering too little antidote to relieve agent effects – most serious problem: failing to administer atropine when needed l Administering antidote to patients not exposed to nerve agent ACT081©

Additional Drug Therapy— Diazepam l Administer to patients experiencing convulsions l Consider for patients with severe signs and symptoms l Dosage depends on patient’s age ACT082©

Make sure atropine warranted Administer dosages of antidotes as recommended in treatment tables Continue administering atropine as recommended in treatment tables until atropinization is achieved If needed, repeat dosage of 2-PAM Chloride as recommended in treatment tables until maximum total dose is given Guideline For Administering Antidotes ACT083©

Secretions dry Breathing easy Signs of Atropinization ACT084©

Atropine Overdose l Cause: Atropine administered when no prior nerve agent exposure has occurred l Not as serious as underdosing l Not usually life-threatening ACT085©

Dilated pupils Dry mouth and skin Rapid pulse Flushed skin Difficulty urinating Confusion, delirium Temperature control diminished Intense thirst Restlessness Signs and Symptoms Of Atropine Overdose ACT086©

Heat stroke Locoweed Atropine-like medicines Other Possible Causes of Symptoms Similar To Atropine Overdose ACT087A©

Keep cool Protect from irrational actions Transport to hospital as soon as possible Treatment for Atropine Overdose ACT087B©

l Auto-injectors approved for civilians by Food and Drug Administration - Simple, compact, injection systems equipped with pre- measured amount (dose) of antidote - Atropine auto-injectors approved for adults and children, but not infants - 2-PAM chloride auto-injectors approved for adults only Alternate Method of Administration of Antidote ACT088©

Required only if exposure is severe Range from administering oxygen (if breathing is difficult) to providing ventilation, airway management and suction as needed Respiratory Support ACT089©

If required, insertion of endotracheal tube by a qualified person is recommended Requires higher “pop off” pressure (70+ cm H 2 O) Source: DOT Emergency Medical Care--Paramedic Ventilation ACT090©

Ensure patient is thoroughly decontaminated Take precautions for sterile technique Support airway management as necessary After protecting yourself, immediately Treatment For Exposure To Blister Agent ACT091©

Flush eyes immediately Do not cover eyes with bandages Dark or opaque glasses provide relief from photophobia SPEED CRITICAL! - Tilt head to the side - Pull eyelids apart with fingers - Pour water slowly into eyes Eye Contact ACT092©

Arm pits Groin Behind knees Between toes Pay special attention to Around ears Eyelids Inside nose Inside mouth Neck creases Skin Contact ACT093©

Inhalation l Supply respiratory support if needed for significant inhalation exposure l Administer oxygen as needed l If breathing has stopped, resuscitate the person l Give intravenous fluids if needed, but do not overload ACT094©

Decontaminate exposed person immediately to avoid deep burns Antidote has been developed but is no longer manufactured Treatment For Exposure to Lewisite ACT095©

PROTECT SELF Initial first aid for nerve agent exposure - Give atropine, follow up with 2-PAM chloride - Support airway management as necessary - Atropine overdose possible if given when no nerve agent exposure occurred Initial first aid for blister agent exposure - Ensure that patient is decontaminated - Take precautions for sterile technique - Support airway management as necessary Key Points ACT096©