1. State Of Maine Nerve Agent Antidote Kit Training Module Brian Langerman, CCEMT-P, I/C EMS Coordinator – City Of Saco Kevin Bachi – NREMT-P, BS Kennebunk Fire Department

2. Nerve Agent Antidote Kit Training Objectives: Types of Incidents Types of Incidents Signs & Symptoms of Nerve Agent Exposure Signs & Symptoms of Nerve Agent Exposure NAAKs NAAKs Protocols for NAAK Usage Protocols for NAAK Usage Practice Practice Test Test

3. The Threat of Terrorism

4. Potential Probability vs. Impact POTENTIAL IMPACT PROBABILITY/LIKELIHOOD NUCLEAR WEAPON IMPROVISED NUCLEAR DEVICE RADIOACTIVE MATERIAL CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL BIOLOGICAL AGENT

5. Chemical Warfare Agents Historical Perspective Chemicals used in military operations to kill, injure, or incapacitate Chemicals used in military operations to kill, injure, or incapacitate Battlefield use Battlefield use –World War I and Middle East conflicts Terrorist use Terrorist use –Iraq, Matsumoto and Tokyo, Japan

6. Chemical Agent Terrorist Attacks Matsumoto: Matsumoto: –Approximately 280 injured –7 dead Tokyo Tokyo –12 dead –Approximately 1,000 hospitalized –5,500 sought medical care –10% of first responders injured

7. Tabun, Sarin, Soman, VX Mustard, Lewisite Phosgene, Chlorine, Ammonia, Cyanide Mace ®, Pepper Spray Nerve Agents Nerve Agents Vesicants (Blister) Vesicants (Blister) Industrial Chemicals Industrial Chemicals Riot Control Agents Riot Control Agents Chemical Warfare Agents

8. Weapons of Mass Destruction –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) B (Biological hazards) N (Nuclear) N (Nuclear) I (Incendiary) I (Incendiary) C (Chemical Agents, including Toxic Industrial Chemicals) C (Chemical Agents, including Toxic Industrial Chemicals) E (Explosives) E (Explosives) Commonly accepted methods for categorizing WMD are CBRNE and BNICE:

9. Traits of a Terrorist Terrorism IS: 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: Terrorism is NOT: –Senseless or random –One persons terrorist is NOT another’s Freedom fighter –A viable negotiating technique –One to seek compromise

10. Factors of Threat Surprise (relative to time of attack) Surprise (relative to time of attack) Means of attack Means of attack Target of the attack Target of the attack Foreknowledge of the community response Foreknowledge of the community response Significant dates Significant dates

11. Tactics Mass casualties Mass casualties Secondary devices Secondary devices Multiple incidents Multiple incidents Rapid escalation of the hazards Rapid escalation of the hazards

12. Terrorist Weapon Choice Depends on: 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

13. How Nerve Agents Work

14. Normal Nerve Function Nerve, gland or muscle ACh Ach=Acetylcholine stimulates muscle contraction, gland secretion & nerve to nerve conduction

15. Normal Nerve Function ACh Electrical Message continues…

16. Normal Nerve Function ACh AChE To stop further stimulation Ach is broken down by AChE,preventing overstimulation

17. Nerve Agents inhibit AChE AChE ACh GB Ach accumulates and causes over-stimulation of nerves, muscles and glands

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

19. ROUTES OF EXPOSURE Direct Contact Direct Contact Inhalation Inhalation Ingestion Ingestion

20. DIRECT CONTACT Skin or eyes are touched with agent vapor or liquid Skin or eyes are touched with agent vapor or liquid Nerve agents absorbed through skin 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 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 Eyes most sensitive organ for nerve agent vapor effects

21. Nerve agents enter through respiratory system Nerve agents enter through respiratory system Rapidly and effectively enter into blood stream Rapidly and effectively enter into blood stream Respiratory failure chief cause of death after severe exposure INHALATION Nerve agent inhaled into respiratory system

22. INGESTION Ingestion of contaminated food or drink, incidental hand to mouth or eye contact, smoking Ingestion of contaminated food or drink, incidental hand to mouth or eye contact, smoking Unlikely that agent will contaminate food or drink Unlikely that agent will contaminate food or drink Gastrointestinal system

23. Potential Exposure No signs or symptoms No signs or symptoms –Reassure –Segregate in cold zone –Observe –Arrange transport to ED by bus or vans

24. Mild Exposure Miosis, rhinorrhea - observation only Miosis, rhinorrhea - observation only –IV or IM atropine will not reverse miosis Localized fasciculations and sweating 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)

25. Moderate Exposure Miosis, rhinorrhea, SOB, wheezing, secretions, muscle weakness, GI effects 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

26. Severe Exposure Unconscious, seizing, flaccid, apnea Unconscious, seizing, flaccid, apnea Exclusion (Hot) Zone: Exclusion (Hot) Zone: –3 MARK I kits IM as soon as possible Contamination Reduction (Warm) Zone: Contamination Reduction (Warm) Zone: –3 MARK I kits IM as soon as possible  Atropine 2-6 mg IM  2PAM 600-1800 mg IM

27. Severe Exposure (cont.) –For seizures: –Paramedics may administer  Midazolam (Versed) IM –Adult: 5 mg IM

28. SLUDGEM / DUMBELS Salivation Salivation Lacrimation (Tears) Lacrimation (Tears) Urination Urination Defecation Defecation GI Upset GI Upset Emesis (Vomiting) Emesis (Vomiting) Miosis (Pinpoint pupils) Miosis (Pinpoint pupils) Diarrhea Diarrhea Urination Urination Miosis Miosis Bronchospasm/bradycardia Bronchospasm/bradycardia Emesis Emesis Lacrimation Lacrimation Salivation Salivation

29. Effects of Nerve Agents Organs with cholinergic receptors Muscarinic (Atropine works) Muscarinic (Atropine works) – Smooth muscles – Exocrine glands Nicotinic (Atropine ineffective) Nicotinic (Atropine ineffective) – Skeletal muscles – Ganglia (Sympathetic/Parasympathetic)

30. Signs and Symptoms of Nerve Agents Muscarinic Sites Increased secretions Increased secretions –Saliva –Tears –Runny nose –Secretions in airways –Secretions in gastrointestinal tract –Sweating

31. Signs and Symptoms of Nerve Agents Muscarinic Sites Smooth muscle contraction 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

32. Signs and Symptoms of Nerve Agents Nicotinic Sites (Over-stimulation of Ach) Skeletal muscles Skeletal muscles –Fasciculations –Twitching –Weakness –Flaccid paralysis Other (ganglionic) Other (ganglionic) –Tachycardia –Hypertension GB ACh *Miosis and fasciculations are the most reliable evidence of OPP*

33. Nerve Agents Other Signs and Symptoms Cardiovascular Cardiovascular –Tachycardia, bradycardia –Heart block, ventricular arrhythmias –*Most disappear once antidote is given Central Nervous System Central Nervous System –Acute  Loss of consciousness  Seizures  Apnea –Prolonged (4-6 weeks)  Psychological effects

34. Signs and Symptoms of Nerve Agents Vapor Exposure Mild exposure Mild exposure –Miosis (dim vision, eye pain), rhinorrhea, dyspnea Moderate exposure Moderate exposure –Pronounced dyspnea, nausea, vomiting, diarrhea, weakness Severe exposure 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. 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.

35. Signs and Symptoms of Nerve Agents Liquid Exposure Mild exposure (to 18 hours) Mild exposure (to 18 hours) –Localized sweating –Fasciculations –No miosis Moderate exposure (<LD 50 ) (to 18 hours) Moderate exposure (<LD 50 ) (to 18 hours) –Gastrointestinal effects –Miosis uncommon Severe exposure (LD 50 ) (<30 minutes) Severe exposure (LD 50 ) (<30 minutes) –Sudden loss of consciousness –Seizures –Apnea –Flaccid paralysis –Death 10mg of VX LD50=lethal dose for 50% of the exposed population while the other 50% would suffer lesser effects

36. Diagnosis of Nerve Agent Exposure Symptomatic Symptomatic –May be systemic or organ-specific –Combination of symptoms is more definitive Situational Situational –Multiple casualties with similar symptoms –Time or location factors in common

37. Treatment Self-protection Self-protection Decontamination Decontamination

38. 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 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 If you and your partner have an exposure, and your partner becomes symptomatic, treat yourself first and then treat your partner

39. Nerve Agent Treatment Escape the Area* / Notify Dispatch Escape the Area* / Notify Dispatch Decontaminate (strip down / H 2 O) Decontaminate (strip down / H 2 O) DO NOT ENTER ONCE SUSPICION EXISTS DO NOT ENTER ONCE SUSPICION EXISTS IF Symptomatic use the NAAK Kits: IF Symptomatic use the NAAK Kits: –Atropine –2-PAMCl

40. Nerve Agent Treatment Atropine Atropine –Side effects in normal people  Mydriasis (Pupil Dilation)  Blurred vision  Tachycardia  Decreased secretions and sweating

41. Nerve Agent Treatment Pralidoxime Chloride (2PAM-Cl) 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 AChE 2-PAMCl Nerve Agent This antidote breaks the bond between the nerve Agent and AChE and removes the agent

42. MARK I Injections - Dispersal

43. Nerve Agent Treatment Treatment regimen Treatment regimen –No signs/symptoms  Reassure  Observe –Vapor: 1 hour –Liquid: Up to 18 hours

44. Nerve Agent Treatment Mild vapor exposure Mild vapor exposure –Miosis, rhinorrhea - observation only –Increasing SOB – treat Mild liquid exposure Mild liquid exposure –Localized fasiculations & sweating - treat One MARK I kit (2 mg atropine/ 600 mg 2 - PAMCl) One MARK I kit (2 mg atropine/ 600 mg 2 - PAMCl) Parenteral atropine will not reverse miosis

45. Nerve Agent Treatment Moderate vapor or liquid exposure Moderate vapor or liquid exposure –One or two MARK I kits

46. Nerve Agent Treatment Severe - vapor or liquid Severe - vapor or liquid –Give 3 MARK I kits  Airway  Ventilation/O 2  Consider Midazolam 5 mg IM and repeat the atropine every 5 to10 minutes as needed  Repeat 2-PAMCl

47. Treatment Airway/ventilation Airway/ventilation Antidotes Antidotes –Atropine –Pralidoxime (2-PAM) –Midazolam

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

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

50. Atropine Atropine - How much to give? Atropine - How much to give? –Until secretions are drying or dry –Until ventilation is “easy”  If conscious, and victim is comfortable –Don’t rely on heart rate/pupil size

51. Atropine Overdose If excessive atropine is administered: Signs of atropinization will become even more severe and patient may also develop 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 When signs and symptoms of atropinization develop, no more atropine should be injected until atropinization subsides

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

53. 2-PAM may cause: 2-PAM may cause: –blurred vision –diplopia –impaired accommodation –headache –nausea 2-PAM Adverse Reactions These are relatively mild when compared to effects of nerve agents – dizziness – drowsiness – tachycardia –hyperventilation – hypertension

54. Midazolam Decreases seizure activity Decreases seizure activity Reduces seizure-induced brain injury Reduces seizure-induced brain injury Must observe carefully for respiratory depression Must observe carefully for respiratory depression

55. Autoinjectors

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

57. Directions for Use 1. Remove safety cap Yellow on atropine Yellow on atropine Gray on 2-PAM Gray on 2-PAM Mark I kit clip holds the safety caps 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 Do not touch colored end of injector after removing cap - injector will inject into fingers or hand

58. 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 medicationPressure automatically activates the spring, inserts the needle into the muscle and injects the medication

59. 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 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 Directions for Use

60. Riot Control Agents Summary Irritating agents, lacrimators, “tear gas” Irritating agents, lacrimators, “tear gas” Cause reaction in Cause reaction in –Eyes: burning, tearing, eyelid spasm, redness –Airways: burning, coughing, dyspnea –Skin: burning, erythema Eye irrigation and supportive care Eye irrigation and supportive care

61. Nerve Agent Summary Vapor exposure Vapor exposure –Symptoms develop suddenly –Most ambulatory victims require minimal intervention –Risk of secondary contamination, which is minimized by removing the victim’s 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

62. Chemical Agent Summary Vapor exposure 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

63. Chemical Agent Summary Liquid exposure 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

64. ANY QUESTIONS ???