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CHEMICAL AGENTS August 2005 EMS & Trauma Systems Section

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Presentation on theme: "CHEMICAL AGENTS August 2005 EMS & Trauma Systems Section"— Presentation transcript:

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


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