1. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness CHEMICAL AGENTS

2. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness CHEMICAL AGENTS Objectives Identify indicators that may cause the EMS provider to suspect a chemical incident Identify signs, symptoms and management of common chemical agents Ensure adequate protection for EMS providers in a chemical incident

3. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness CHEMICAL AGENTS Terrorism Advantages –Easy to make –Available –Cheap –Immediate effect –Hard to detect –Easily spread –Tie up resources –Psychological impact Disadvantages –Requires large quantities –Production hazardous –Difficult to prepare for

4. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness CHEMICAL AGENTS Considerations Most are liquid and must be aerosolized or vaporized for maximum exposure Small hot zone if no dissemination device Slow steady winds best environment Closed spaces result in higher concentrations Almost all agents most dangerous when inhaled …..Protect lungs first, fast!

5. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness CHEMICAL AGENTS NerveBlisterBloodChokingIrritant

6. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Nerve Agents & Organophosphates Volitile liquid not “Nerve Gas” Examples: –Weapons: Sarin, Soman, VX –Organophosphate pesticides Where were nerve agents used in the past? Exposure: Inhalation and direct skin contact Effects: Over stimulation of nerves –What happens to skin, GI, lungs, pupils, glands?

7. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Symptoms of Nerve Agent/Organophosphate Poisoning S Salivation/Excessive Drooling L Lacrimation/Tearing U Urination/Incontinence D Defecation/Diarrhea G GI Upset/Cramps E Emesis/Vomiting M Muscle Twitching Presence of constricted pupils with SLUDGEM findings indicates nerve agent toxicity

8. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Nerve Agents Treatment Rescue and Decontamination Supportive Care –Ventilatory Support / Frequent Suctioning –High Flow Oxygen –IV / Cardiac Monitoring, as available Antidote Therapy –Mark I Kits –Atropine Benzodiazepam Anti-convulsants

9. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Mark 1 Kits

10. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Contents of Mark 1 Kit The clip numbers indicate order of usage –#1 Atropine –#2 Pralidoxime Chloride (2-PAM CL)

11. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Simple Administration Pull the auto injector straight out from the clip Do not touch the end It’s armed and ready for use Place the colored end against the outer thigh Push and hold pressure for 10 seconds before removing

12. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Injection Site-Lateral Thigh

13. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Remember: Atropine is the first drug used from a Mark 1 Kit Use the same number of 2-PAM CL auto injectors as you did Atropine auto injectors Effects of atropine may include: –Heart rate >90 –Reduced bronchial secretions –Reduced salivation Do not use pupil size as an indicator of atropine effects

14. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Mark 1 Kit Dosages Based on Symptoms SELF-RESCUE Threshold symptoms:  Dim vision  Increased tearing  Runny nose  Nausea/vomiting  Abdominal cramps  Shortness of breath ( Note: many of the above may also be associated with heat related illness ) ThresholdSymptoms-and- Positive evidence of nerve agent or OPP on site 1 Kit

15. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness ADULT PATIENT Mild Symptoms and Signs  Increased tearing  Increased salivation  Dim Vision  Runny nose  Sweating  Nausea/vomiting  Abdominal cramps  Diarrhea Medical Control Order 1 Mark I Kit Moderate Symptoms and Signs  Constricted pupils  Difficulty breathing  Severe vomiting Constricted Pupils 2 Mark I Kits Severe Signs  Constricted pupils  Unconsciousness  Seizures  Severe difficulty breathing Constricted Pupils 3 Mark I Kits (If 3 Mark I Kits are used, administer 1 st dose of available benzodiazepine) Nerve Agent Treatment - Adult

16. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Mark 1 Kit Dosages Based on Symptoms Mild = Threshold symptoms plus constricted pupils, muscle twitching, diaphoresis Moderate = Threshold symptoms plus constricted pupils, urinary incontinence, respiratory distress/wheezing Severe = Threshold symptoms plus constricted pupils, unconsciousness, seizures, severe respiratory distress 1 Kit 2 Kits 3 Kits

17. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness PEDIATRIC Pediatric Patient with Non-Severe Signs/Symptoms Mild or moderate symptoms as above Positive evidence of nerve agent or OPP on site Age >8 years old: As Above Age <8 years old Per Medical Control Pediatric Patient with Severe Signs/Symptoms  Constricted pupils Unconsciousness Seizures Severe difficulty breathing Severe breathing difficulty Weakness Age > 8 years old:  3 Mark I Kits Age < 8 years old:  1 Mark I Kit Contact Medical Control as needed Nerve Agent Treatment - Pediatrics

18. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Pediatric Dosing with Mark 1 Mild Mild Moderate Moderate Severe Severe < Age 8 < Age 8 >Age 8 >Age 8 Contact Medical Control 1 3

19. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Additional Paramedic Pharmacological Intervention Atropine 2-6 mg IV / IM per Mark I Kit Dosing Directive if Mark I Kit is not available –Each Mark I Kit contains 2 mg of atropine Treat seizures per Seizure Protocol –Diazepam: Adult: 2-10 mg IVP Pediatric: –0.2 mg/kg (maximum individual dose 10 mg) via IV route or –0.5 mg/kg (maximum individual dose 10 mg) via rectal route If available, Valium auto-injector for adults –Midazolam (Adult or Pediatric): Midazolam 0.05 mg/kg to max 5 IVP Administer Midazolam 0.1 mg/kg to max 10 mg IM –Treat with initial benzo if 3 Mark I kits administered

20. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Blister Agents Blister agents, also know as vesicants, cause severe burns to eyes, skin, and tissues of the respiratory tract. These agents are also referred to as vesicants. They readily penetrate layers of clothing and quickly damage the skin. Examples of blister agents include: –Lewisite –Mustard Symptoms may be delayed for hours

21. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Blister Agents Symptoms include: –Eye irritation –Skin irritation / chemical burn –Respiratory Distress Cough Routes of Exposure –Inhalation –Skin Absorption –Ingestion

22. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Blister Agents Treatment Thorough decontamination Lots of water Supportive Care Assisted ventilation High flow oxygen IV / cardiac monitor, if available. Symptomatic treatment per protocol.

23. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Blood Agents Mechanism: Interfere with oxygen use at tissue level Routes of Exposure: Inhalation / Ingestion Signs and Symptoms Examples: –Cyanogen chloride (CK) –Hydrogen cyanide (AC) Sources –Smoke –Pharmaceuticals –Electroplating

24. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Blood Agents Treatment Supportive care Assist ventilations High flow oxygen IV / Cardiac monitoring, as available Antidote Therapy –Basic –Advanced

25. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Symptoms of Cyanide Poisoning Respiratory Distress With clear lungs Without cyanosis With normal pulse ox Usually Increased respiratory rate / depth Potential for Rapid Respiratory Arrest Decreased Level of Consciousness –Confusion –ComaSeizuresHeadacheDizziness Pupils dilate (late)

26. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Cyanide Antidotes Basic Amyl Nitrite Inhalants Advanced Sodium Nitrite Injection Sodium Thiosulfate

27. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Basic Antidote Amyl Nitrite Inhalers Requires evidence of exposure Initial treatment Deliver by breaking and –place under the nose –inside O 2 mask –over the intake valve of the BVM Use a new inhalant every 3 minutes if sodium nitrite infusion will be delayed If the patient improves, therapy stops here

28. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Basic Antidote Amyl Nitrite Inhalers Amyl nitrate convert forms methomoglobin. –May be dangerous when cyanide not present Contraindications: Contraindications: –Suspected CO poisoning Adverse Effects: Adverse Effects: –Dizziness, fatigue, dyspnea, nausea, vomiting, hypotension, headache, tachy or bradycardia.

29. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Advanced Antidote Sodium Nitrite Injection When cyanide confirmed, infuse Sodium Nitrite ASAP 10 mL (300mg) Pediatric dose 0.15 mL/kg body weight Infuse over no less than 5 minutes Monitor BP Slow rate of infusion if hypotension develops

30. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Advanced Antidote Sodium Nitrite Injection Indications: –Signs and symptoms present and –Cyanide confirmed on scene Contraindications: –Suspected CO exposure Adverse reactions: –Vomiting, abdominal pain, dizziness, headache, flushing, cyanosis, tachypnea, syncope, hypotension, tachycardia

31. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Choking Agents Choking agents severely stress respiratory system tissues. Common industrial agents, such as chlorine and phosgene, are considered choking agents. Examples of choking agents include: –Chlorine –Perflurorisobutylene –Phosgene –Red phosphorus

32. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Choking Agents Chlorine –Chlorine is a lethal choking agent with a slight bleach odor, and a greenish- yellowish color –High concentrations were lethal enough to create mass casualties during World War I –Heavier than air Many other agents

33. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Choking Agents Signs and Symptoms –Coughing –Choking –Chest tightness –Odors: Chlorine bleach Swimming pools Newly mown grass or hay Routes of Exposure –Inhalation

34. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Treatment of Choking Agents Respiratory chemical PPE Supportive Care –Assist ventilations, as necessary –High flow oxygen –IV / cardiac monitoring, as available Symptomatic treatment per protocol Eye irrigation for Eye Irritation –Remove contact lenses –Flush with 1000cc of NS each eye –Flush from nose-side outward –If available, use Tetracaine hydrochloride 1-2 drops in each eye. Ensure that patient does not rub eyes after administration of Tetracaine as injury may result.

35. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Advanced Treatment for Choking Agents For severe respiratory distress, consider early intubation and aggressive ventilatory support. Evidence of non-cardiogenic pulmonary edema Albuterol if wheezing 2.5mg via nebulizer (repeat x1 PRN) or 2-3 puffs from metered dose inhaler with spacer, (repeat x 1 PRN).

36. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Irritating Agents Riot control agents Considered less lethal Rarely cause severe problems Often used for riot control purposes Examples of irritating agents include: MACE Tear gas Capsicum/pepper spray Symptoms include Burning or irritation in eyes and throat Respiratory distress Coughing /Choking Nausea and vomiting Don’t confuse with nerve agents Treatment: Supportive

37. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness CHEMICAL AGENTS Protection Stage at a safe distance Secure and isolate area Watch for secondary chemical devices Use PPE – Protect your lungs first, fast! Confine contaminated and exposed victims Decontamination before transportation Alert hospitals EARLY

38. August 2005 EMS & Trauma Systems Section Office of Public Health Preparedness Questions