1. Maryland State MARK I Training Program Nerve Agents and the MARK I Kits

2. Maryland State MARK I Training Program The MARK I Protocol  This is an Optional Supplemental Protocol which requires your Jurisdictional Medical Director and approval from MIEMSS  Refer to the current version of the MARK I section of the Maryland Medical Protocols for EMS Providers

3. Maryland State MARK I Training Program Objectives  Discuss what nerve agents are and how they affect the body  List signs and symptoms of nerve agent exposure  Name the antidotes that may be administered in the event of nerve agent exposure  Demonstrate the correct use of the MARK I autoinjectors

4. Maryland State MARK I Training Program What are Nerve Agents?  One of the five classifications for chemical weapons  Most toxic of the known chemical agents  Easily dispersed: bombs (non explosive), spray tanks  Enter the body through inhalation, absorption or ingestion  Can cause death within minutes depending upon the length of exposure

5. Maryland State MARK I Training Program  Nerves relay messages to and from the brain  To do this the body produces certain “transmitters” to go from one nerve cell to another  Nerve agents get into the space between nerve cells and causes an unopposed amount of the “transmitter”. The “transmitter is no longer neutralized in the nerve space thus a build up of the transmitter and the nerves continually stimulate muscle or gland cells resulting in pinpointing pupils, excessive gland secretion (drooling, tearing), urination, defecation, GI motility (pain/cramps), vomiting, muscle twitches, and/or convulsions with the death following due usually to respiratory arrest Nerve Agents: How they work

6. Maryland State MARK I Training Program  Two types:  G-type agents are more likely to evaporate and become vapor or may be dispersed as a liquid or vapor. When exposed, effects begin within minutes  V-type agents are oily and evaporate slowly. They persist on the ground, foliage, etc., for long periods of time. When the skin is exposed, effects are seen as soon as 10 minutes but can be delayed up to 18 hours after contact.  Tabun (GA), Sarin (GB), Soman (GD), VX Examples of Nerve Agents

7. Maryland State MARK I Training Program Signs and Symptoms of Nerve Agent Exposure  KEY POINT  S/S will be dependent upon the proximity, concentration of the agent, vapor or liquid, and length of exposure to the agent

8. Maryland State MARK I Training Program Nerve Agents-Signs and Symptoms PSLUDGEMC Vapor Exposure Liquid Exposure P - Pinpointing pupilsxNot seen S - SalivationxNot seen L - Lacrimation (tearing)xNot seen U - Urinationxx D - Defecationxx G - GI; pain/gasxx E - Emesis (vomiting)xx M - Muscle twitching (localized)xx C – Convulsions (generalized)xx

9. Maryland State MARK I Training Program Nerve Agents: TREATMENT NO ONE able to walk and talk is in immediate danger of loss of life with appropriate decontamination

10. Maryland State MARK I Training Program The Antidote: MARK I Kits  What are they?  How do they work?  Who can give them?  Procedure for administration  Any complications/contraindications

11. Maryland State MARK I Training Program Auto-Injectors Simple, compact injection systems  Permit rapid injection of required antidotes  Enable rapid and accurate administration, even if care giver or patient is in protective clothing  Administration is similar to Epi-pen

12. Maryland State MARK I Training Program Auto-Injectors  Contain pre-measured doses of nerve agent antidotes Atropine and 2-PAM Chloride (2-PAM Cl, Pralidoxime Chloride or PROTOPAM ® CHLORIDE)

13. Maryland State MARK I Training Program Auto-Injectors  EMT-B may administer MARK I kits in a “buddy aid” emergency (not for the public) without medical consultation (this is designed for the PPE suited providers or the first wave EMS/Fire response that becomes seriously symptomatic).  In order for an EMTB to administer MARK I kits to the general public who may require assistance, medical consultation and approval must be obtained.

14. Maryland State MARK I Training Program  Atropine - Blocks the action of the excess amounts “transmitter” and reduces the PSLUDGEMC signs and symptoms  2-PAM-Cl (Pralidoxime) Acts as a ”crowbar” and takes the nerve agent off of the enzyme so that the “transmitters” in the nerve space can be neutralized, thus allowing the relaxation of the gland or muscle Nerve Agents : Antidote 2-PAMCl Nerve Agent Enzyme

15. Maryland State MARK I Training Program Antidote (ALS level only)  Valium call CANA in autoinjector form (follow System protocol)  Used to control seizures

16. Maryland State MARK I Training Program Dosing Schedule  NOT ALL VICTIMS EXPOSED NEED TREATMENT  Dose of antidote will be dependent upon the signs and symptoms that the victim is demonstrating

17. Maryland State MARK I Training Program MARK I Kit Dosing Schedule ExposureClinicalTreatment Mild Unexplained runny nose, sudden headache, sudden drooling, difficulty seeing, tightness in the chest with mild difficulty breathing, wheezing and coughing, localized sweating and localized muscular twitching in the contaminated skin, stomach cramps, nausea without vomiting VAPOR (small exposure): If only symptoms are pinpoint pupils and/or runny nose, DO NOT TREAT; otherwise, treatment should begin with one dose of the MARK I kit initially. This may be repeated in 10 minutes if patient is still symptomatic; LIQUID (small exposure): The onset of symptoms may be from minutes to hours after exposure; Treatment should begin with one dose of MARK I kit and may be repeated in 10 minutes if the patient is still symptomatic Moderate All of the above, but also include more severe effects such as diarrhea, moderate to severe difficulty breathing, and some skeletal-muscular twitching/fasciculations. VAPOR or LIQUID: administer 2 MARK I kits; an additional Atropine auto-injector (2.0 mg) may be repeated in 10 minutes if the patient is still symptomatic Severe Providers with severe symptoms will not be able to treat themselves and will need buddy aid. Symptoms are all of the mild/moderate symptoms plus: impaired thinking, increasing wheezing and increased difficulty breathing, severe pinpoint pupils (if vapor), red eyes with tearing (if vapor), vomiting, severe muscular twitching and general weakness, involuntary defecation, convulsions, respiratory failure, bradycardia VAPOR or LIQUID: administer 3 MARK I kits; an additional Atropine auto-injector (2.0 mg) may be repeated until symptoms decrease or cease. Objective of Treatment: Get ALS Treat the patient with additional atropine until patient’s secretions start to dry, airway resistance decreases and breathing improves.

18. Maryland State MARK I Training Program Who can give them?  EMT-B may administer MARK I kits in a “buddy aid” emergency (not for the public) without medical consultation.  In order for an EMTB to administer MARK I kits to the general public who may require assistance, medical consultation and approval must be obtained.  CRT, CRT(I) and EMT-P can administer to public who has signs and symptoms indicating need for antidote.

19. Maryland State MARK I Training Program How do you know when the MARK I kits are working???  Evidence of response to treatment includes improvement in initial symptoms and drying of secretions. If neither occurs after initial MARK I administration, then administer additional atropine until these endpoints are reached.

20. Maryland State MARK I Training Program 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 activate/ inject into fingers or hand if any pressure applied to this end of autoinjector

21. Maryland State MARK I Training Program Directions for Use 2. Hold injector like a pen. Place colored end (green on atropine, black on2-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

22. Maryland State MARK I Training Program 3.Hold firmly in place for a VERBAL COUNT of ten seconds, then remove 4.Massage the area of injection Directions for Use

23. Maryland State MARK I Training Program Directions for Use 5.Dispose of the used injector in sharps container after use 6.Document the dosage on the triage tag or place one MARK I band per administration/ dose supplied in the kit (three kits = three bands)

24. Maryland State MARK I Training Program Concerns about MARK I Kits  Precautions  Contraindications  Adverse Reactions

25. Maryland State MARK I Training Program PRECAUTIONS  ALL PATIENTS TREATED ARE TO BE TRANSPORTED

26. Maryland State MARK I Training Program CONTRAINDICATIONS  Patients not manifesting signs or symptoms shall NOT be treated with a MARK I kit  Patients with only constricted pupils and/or runny nose should NOT be treated with a MARK I kit

27. Maryland State MARK I Training Program 2 PAM Adverse Effects  2 to 5 minutes after intramuscular injection of 2-PAM Cl, mild to moderate pain may be experienced at site of injection  2-PAM Cl may generate hypertension

28. Maryland State MARK I Training Program Atropine Adverse Effects  Flushed and hot skin  Restlessness  Dry mucous membranes  Blurred vision  Dizziness  Headache  Nausea

29. Maryland State MARK I Training Program Questions