1. Use of Auto-Injectors by Civilian Emergency Medical Personnel to Treat Civilians Exposed to Nerve Agent©
© 1997 Lockheed Martin Energy Research Corporation

2. Learning Objectives
Identify the antidotes to be administered in event of nerve agent exposure
Identify the conditions under which antidote auto-injectors should be used
Demonstrate use of antidote auto-injectors
Recognize adverse reactions to use of antidotes
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3. IMPORTANT! Antidotes counter or relieve effects of poisons
such as nerve agents. Use antidotes only when
signs and symptoms of exposure are present;
they will not protect if given before exposure.
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4. Auto-Injectors Simple, compact injection systems
Permit rapid injection of required antidotes
Prevent needle from being subject to cross-contamination
Enable rapid and accurate administration even if care giver or patient is in protective clothing
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5. Auto-Injectors Auto-injectors facilitate timely treatment by providing
Simple, accurate, rapid drug administration
Pre-measured, controlled dose
No vials, ampules or syringes to manipulate
Fully automatic operation
Rugged construction
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6. Auto-Injectors
Contain pre-measured doses of nerve agent antidotes atropine and 2-PAM chloride (2-PAM Cl, pralidoxime chloride or PROTOPAM® CHLORIDE)
FDA-approved and commercially available for use by civilian emergency medical personnel in the event of an accidental release of nerve agent or organophosphorus insecticides
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7. Auto-Injectors States decide if they will use them
One U. S.-based manufacturer: Survival Technology Inc. (STI)
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8. Who Can Use Auto-Injectors
Concern about administration of inappropriate and harmful doses during emergency situations
Pre-measured doses in auto-injectors safe for civilians meeting profile of military personnel
approximate ages of 18–35
weight at least 70 kg or 154 pounds
healthy with no compromising medical conditions
Age, sex, weight and health of all other patients must first be considered when determining amount of atropine and PAM Cl to administer
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9. Who Can Use Auto-Injectors
Only qualified civilian emergency responders with adequate training in on-site recognition and treatment of nerve agent intoxication in the event of an accidental release
Majority of CSEPP States follow DOT national curriculum for Emergency Medical Technicians
Curriculum generally restricts training on use of IVs to Intermediate Emergency Medical Technicians and paramedics
Review of each state’s laws and regulations needed to determine appropriate use of auto-injectors
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10. When To Use Auto-Injectors
Use only after following events have occurred:
Emergency medical personnel have donned personal protective equipment subsequent to recognizing existence of chemical agent hazard in area
Some or all of symptoms of nerve agent poisoning cited are present
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11. Signs and Symptoms of Nerve Agent Exposure
MILD
headache
blurred vision from pinpoint pupils (miosis)
tight chest (smooth muscle constrictions)
excessive sweating
tearing (lacrimation)
salivation
unexplained runny nose
Cinetel Productions
VERY SEVERE
bluish discoloration
of skin (cyanosis)
respiratory failure
coma
unconscious
convulsions
MODERATELY SEVERE
severe chest tightness
diarrhea (rare)
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12. Treatment For Exposure To Nerve Agents
Depending on severity of symptoms, immediately administer 1 atropine auto-injector, followed by 1 2-PAM Cl auto-injector
Atropine should be given first, followed immediately by 2-PAM Cl
If nerve agent signs and symptoms are still present after 5–10 minutes, repeat injections
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13. Treatment For Exposure To Nerve Agents
If signs and symptoms still exist after additional 10 minutes, repeat injections for third time
If signs and symptoms remain after third set of injections, do not give any more antidotes but seek immediate medical help
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14. Treatment For Exposure To Nerve Agents
If severe signs and symptoms are present:
In case of very severe exposure, all three auto-injector kits (atropine and 2-PAM Cl) should be administered in rapid succession; then medical help should be sought
Remove secretions, maintain patient’s airway and,
if necessary, use artificial ventilation
2-PAM Cl is most effective if administered immediately after poisoning. Generally, little is accomplished if drug is given more than 6 hours after termination of exposure
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15. Directions for Use 1. Remove safety cap (yellow on
atropine; gray on 2-PAM Cl).
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 can and will function
into fingers or hand if any pressure applied
to this end of injector
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16. Directions for Use 2. Hold injector like a pen. Place
colored end (green on
atropine, black on
2-PAM Cl) on
thickest part of thigh and
press hard until injector
functions
Pressure automatically activates the
spring, plunges the needle into the
muscle and simultaneously forces
fluid through it into the muscle tissues
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17. Directions for Use
3. Hold firmly in place for ten seconds, then remove Massage the area of injection
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18. Directions for Use 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
It should be disposed of in a “sharps” container
per rules for handling medical wastes and possible
blood-borne pathogens
Note dosage on triage tag or write on
chest or forehead of patient
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19. Directions for Use
IMPORTANT: Medical personnel assisting evacuated victims of nerve agent exposure should avoid exposing themselves to cross-contamination by ensuring that they do not come in contact with patients’ clothing
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20. Precautions
Place any patient receiving atropine under medical observation for at least 24 hours
If atropine is used to treat infants, smaller amounts should be given
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21. Adverse Reactions
2 to 5 minutes after intramuscular injection of 2-PAM Cl, mild to moderate pain may be experienced at site of injection
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22. Adverse Reactions 2-PAM Cl in a normal person may cause:
blurred vision • double vision (diplopia)
impaired accommodation • dizziness
headache • drowsiness
nausea • rapid heart rate (tachycardia)
increased systolic and • hyperventilation
diastolic blood pressure
These are relatively non-toxic responses when
compared to effects of nerve agent or
organophorus insecticide exposures
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23. Overdosage If excessive atropine is administered to a normal person:
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
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24. Overdosage In case of 2-PAM Cl: Observed in normal subjects only
dizziness
blurred vision
double vision (diplopia)
headache
impaired accommodation
nausea
slightly rapid heart rate (tachycardia)
Artificial respiration and other supportive therapy should be administered as needed
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25. Caring For Auto-Injector Supplies
Auto-injectors have a five-year shelf life, making them suitable for storage in emergency stockpiles
Store auto-injectors at room temperature (approximately 25°C, 77°F)
Keep them from freezing
May
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26. Caring For Auto-Injector Supplies
Antidotes will freeze at temperatures below 29F
Do not carry auto-injectors in external pocket of BDO when temperature below freezing. Place in inner pocket where body heat will keep them warm
Tie string to auto-injector and thread through outer layers of clothing to outside pocket or belt. Extract auto-injector by pulling the string when needed
Frozen auto-injectors still usable after being thawed if they do not appear broken or cracked
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