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

2. 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
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

3. 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
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

4. 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!
[slight modification]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

5. CHEMICAL AGENTS Nerve Blister Blood Choking Irritant August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

6. 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?
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

7. 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
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

8. 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
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

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

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

11. 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
[made font larger]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

12. Injection Site-Lateral Thigh
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness 6

13. 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
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

14. Mark 1 Kit Dosages Based on Symptoms SELF-RESCUE
Threshold
Symptoms
-and-
Positive evidence
of nerve agent or
OPP on site
1 Kit
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)
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

15. Nerve Agent Treatment - Adult Moderate Symptoms and Signs
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
Unconsciousness
Seizures
Severe difficulty breathing
3 Mark I Kits
(If 3 Mark I Kits are used, administer 1st dose of available benzodiazepine)
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

16. 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
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

17. Nerve Agent Treatment - Pediatrics
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
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

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

19. 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
[Some revisions to slide, mainly rearranged by drug class vs. adult/ped. Changed midazolam to what state protocols are supposed to be.
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

20. 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
[Changed “may also be referred to as ‘mustard agents’ to ‘vesicants’. Deleted phosgene oxime as it is more of a corrosive than a vesicant. It can cause severe skin irritation but doesn’t form blisters like vesicants. Also dropped use of “sulfur” and “nitrogen” mustard as this as first responders don’t need to know the difference. Also added comment about delayed symptoms with mustard]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

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

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

23. 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
[Simplified slides, added seizures as a sign, moved routes from next slide, changed vertigo to dizziness.
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

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

25. 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
Coma
Seizures
Headache
Dizziness
Pupils dilate (late)
[moved from later in presentation, reorganized]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

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

27. Basic Antidote Amyl Nitrite Inhalers
Requires evidence of exposure
Initial treatment
Deliver by breaking and
place under the nose
inside O2 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
[Moved from later in presentation, deled inhale x30” per protocol
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

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

29. 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
[Moved from later in presentation, slightly modified]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

30. 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
[Moved from later in section]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

31. 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
[Deleted cyanide as it is a blood agent, not choking agent]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

32. Choking Agents Chlorine Many other agents
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
Deleted reference to being “least lethal”. EMS should consider this as lethal as anything else. Added reference to being heavier than air.
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

33. Choking Agents Signs and Symptoms Routes of Exposure Coughing Choking
Chest tightness
Odors:
Chlorine bleach
Swimming pools
Newly mown grass or hay
Routes of Exposure
Inhalation
[deleted absorption as likely route of exposure, considered very unlikely)
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

34. 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.
[Slightly simplified slide]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

35. 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).
[Slightly simplified slide]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

36. 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
[Simplified and combined with next several slides]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

37. CHEMICAL AGENTS Protection Alert hospitals EARLY
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
[Added last bullet, slight modifications]
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness

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