Nerve Agent Antidote Kit

Nerve Agent Antidote Kit
State of West Virginia Department of Health & Human Resources State Trauma and Emergency Care System Office of EMS Nerve Agent Antidote Kit Training Program

OBJECTIVES This program is intended to assist the EMS provider in:
Identifying the Nerve Agent Antidote Kits, its components, and contents. Recognizing the signs and symptoms of nerve agent exposure. Obtaining the skills needed to safely administer the kits.

Mark I Auto Injectors Through the HRSA Bio-Terrorism Hospital Preparedness Grant, the West Virginia Office of EMS has purchased Nerve Agent Antidote kits for crew protection for each licensed ambulance in the state. Throughout this presentation, the terms Mark I Kits and Nerve Agent Antidote Kits may be used interchangeably.

Nerve Agents Nerve Agents such as Tabun (GA), Sarin (GB), Soman (GD), and VX are the most toxic of the chemical agents. They penetrate skin, eyes, and lungs. Signs and symptoms include loss of consciousness, seizures, apnea, and death after large exposure. Exposure diagnosis made clinically based upon signs and symptoms. NERVE AGENTS The nerve agents are Tabun (GA), Sarin (GB), Soman (GD), and VX. Nerve agents are the most toxic of all the weaponized military agents. These agents can cause sudden loss of consciousness, seizures, apnea, and death. GB, or Sarin, is one of the more commonly stockpiled nerve agents, and it may be inhaled as a vapor, or cause toxic effects by contact with the skin in the liquid form. VX is mainly a liquid skin hazard at normal ambient temperatures. These chemicals are easily absorbed through the skin, eyes, or lungs. The diagnosis of a nerve agent poisoned Responder must be made clinically. There usually is not time for laboratory confirmation. Nerve agents (and similar substances) inhibit cholinesterase, an enzyme present in tissues and blood; there is a laboratory test to determine its activity in blood. Nerve agents are organophosphates (pesticides) that were developed by the Germans (G-agents) in the 1930s and the British (V-agents) in the 1950s during their research into finding more toxic insecticides. . INSTRUCTOR NOTE: To reinforce the fact that nerve agents, while being a weapon of mass destruction, are nevertheless similar in some ways to common pesticides, students might be asked if they have ever used Malathion, Diazinon, or some other common domestic insecticides. Point out that such common substances which are of organophosphate composition are, in fact, household “nerve agents” for insects.

Routes of Exposure Direct contact Inhalation Ingestion

DIRECT CONTACT The agent liquid or vapor comes in direct contact with the victim’s skin or eyes. The agent is then absorbed through skin. Scrapes, cuts and other skin damage offer direct entry points – including freshly shaven skin, sunburn, insect bites, and rashes. VX remains on skin and absorbed more completely. GB evaporates quickly, but still a threat. Eyes most sensitive organ for nerve agent vapor effects.

is the chief cause of death
INHALATION Nerve agents enter through respiratory system. The agent rapidly and effectively enters into blood stream. Respiratory failure is the chief cause of death after severe exposure Nerve agent inhaled into respiratory system

INGESTION The agent enters the body through the ingestion of contaminated food or drink, incidental hand to mouth or eye contact, or smoking. It is unlikely that agent will contaminate food or drink. Gastrointestinal system

How It Works Nerve agents block an enzyme called acetylcholinesterase.
This enzyme is normally responsible for breaking down acetylcholine that has been used as a neurotransmitter to glands and smooth muscle. When it is blocked, the acetylcholine remains in the synapse, causing glands to secrete, and muscle to constrict. Death is from lack of oxygen.

Normal Nerve Function ACh Nerve, gland or muscle
Nerves communicate with muscles, organs, and other nerves by releasing chemicals or neurotransmitters at their connection site (synapse). One of the most common neurotransmitters is acetylcholine (ACh), which is released and collects at the receptor site stimulating the end organ to respond and produce a variety of effects: muscle contractions, gland secretion, and nerve-to-nerve conduction. ACh ACh=Acetylcholine stimulates muscle contraction, gland secretion and nerve-to-nerve conduction. NOTE: In this graphic, the receptor target to the right of the synapse could be the continuing nerve, a gland, or a muscle. NOTE: At instructor’s discretion, an optional video describing nerve agent physiological effects may be used.

Electrical message continues…
Normal Nerve Function ACh When a nerve impulse reaches the synapse, ACh is released from the nerve ending and diffuses across the synaptic cleft to combine with receptor sites on the next nerve, and the electrical message continues. NOTE: Emphasize that the effect of unwanted electrical message propagation depends on the receiving end organ. A gland will continue to secrete, a muscle will continue to contract, a nerve will continue to generate additional electrical impulses. Electrical message continues…

Normal Nerve Function AChE ACh
To stop further stimulation of the nerve, ACh is rapidly broken down by acetylcholinesterase (AChE), producing choline, acetic acid, and the regenerated enzyme. Thus, a “check and balance” system prevents the accumulation of ACh and the resultant over-stimulation of nerves, muscles, and glands. ACh NOTE: This slide is an artist’s depiction of AChE metabolism of the neurotransmitter. The actual location of AChE is on the post-synaptic membrane, not in the synaptic cleft. Consider re-emphasizing that inhibition of the AChE allows accumulated ACh to continue stimulating muscle contraction, gland secretion, and nerve propagation of unwanted impulses. This mechanism relates directly to the signs and symptoms resulting from nerve agent exposure, and relating this process of effects to patients with apparently bizarre and varied symptoms could be extremely important in making a correct diagnosis in the aftermath of a terrorist attack. To stop further stimulation, ACh is broken down by AChE, preventing over-stimulation.

Nerve Agents Inhibit ACHE
HOW NERVE AGENTS WORK The term “nerve agents” refers to chemicals that produce biological effects by inhibiting the enzyme AChE, thus allowing the neurotransmitter ACh to accumulate. Included among the “nerve agents” are some drugs (such as physostigmine and pyridostigmine) and some insecticides (Sevin®, malathion, and related insecticides). These compounds cause the same biological effects as the nerve agents developed for military use, but the latter are more than a hundred-fold more potent. As a result of inhibition of AChE, the neurotransmitter ACh accumulates to over-stimulate the organs it normally stimulates in the portion of the nervous system. This causes hyperactivity in these organs. These are all innervated by the cholinergic portion of the nervous system and have muscarinic receptors, nicotinic receptors, or a combination (central nervous system and cardiovascular system). ACh GB ACh accumulates and causes over-stimulation of nerves, muscles and glands.

Effects Acetylcholine is a transmitter in two kinds of synapses, meaning nerve agents function in two ways. Muscarinic receptors: Smooth muscle Glands Nicotinic receptors: Skeletal Muscles Ganglion

Effects: Muscarinic Smooth muscle contraction: Eyes: miosis
Airway: dyspnea due to severe bronchoconstriction. GI: vomiting & diarrhea. Secretions: Saliva, tears Runny nose Bronchorrhea Sweating

Effects: Nicotinic Skeletal muscle: Fasiculations Localized twitching
Leads to flaccidity Ganglion: Tachycardia Hypertension

Overall Effects Heart rate: fast or slow – may develop other arrhythmias. Central nervous system: Acute: Loss of consciousness Seizures Apnea Prolonged: Psychological effects

Signs and Symptoms of Vapor Exposure
Mild exposure: Miosis (dim vision, eye pain), rhinorrhea, dyspnea. Moderate exposure: Pronounced dyspnea, nausea, vomiting, diarrhea, weakness. Severe exposure: Immediate loss of consciousness, seizures, apnea, and flaccid paralysis. Vapor effects occur within seconds and peak within minutes; no late onset.

Signs and Symptoms of Liquid Exposure
Mild exposure (to 18 hours): Localized sweating. Fasciculations. No miosis. Moderate exposure (<LD50) (to 18 hours): Gastrointestinal effects. Miosis uncommon. Severe exposure (LD50) (<30 minutes): Sudden loss of consciousness. Seizures, apnea. Flaccid paralysis. Death.

Signs and Symptoms Treated with one (1) Nerve Agent Antidote Kit.
Mild: Eyes - small pupils (miosis). Dim vision. Headache. Runny nose (rhinnorhea). Salivation. Tightness in the chest. Time of onset: seconds to minutes after exposure. Treated with one (1) Nerve Agent Antidote Kit.

Signs and Symptoms Severe:
All of the mild, plus. Severe breathing difficulty or cessation of respiration. Generalized muscular twitching, weakness, or paralysis. Convulsions. Loss of consciousness. Loss of bladder and bowel control. Time of onset: seconds to minutes after exposure. Treated with two (2) – three (3) Nerve Agent Antidote Kits.

Nerve Agents Other Signs and Symptoms
Cardiovascular: Tachycardia, bradycardia Heart block, ventricular arrhythmias Most disappear once antidote is given Central nervous system Acute: Loss of consciousness. Seizures. Apnea. Prolonged (4-6 weeks): Psychological effects. OTHER SIGNS AND SYMPTOMS OF NERVE AGENTS Cardiovascular. Bradyarrhythmias, heart block, tachyarrhythmias (sinus tachycardia), and ventricular arrhythmias (ventricular tachycardia and ventricular fibrillation) may occur, but most disappear once the antidote is given. Central nervous system. Acute severe effects include loss of consciousness, seizures, and apnea. Effects from a mild exposure include nervousness, fatigue, minor memory disturbances, irritability, and other minor psychological symptoms. The latter, whether caused by a severe or mild exposure, might linger for 4 to 6 weeks after exposure before resolving. NOTE: An optional sequence from the Chemical Stockpile Emergency Preparedness Project (CSEPP) video showing the effects of ACh and AChE may be shown.

SLUDGEM S – Saliva L – Lacrimation (tearing) U – Urination
D – Defecation/Diarrhea G – Gastrointestinal Effects (cramping) E – Emesis M – Miosis (pinpoint pupils)/Muscle twitching

Antidote Uses The Nerve Agent Antidote Kits provided by the West Virginia Office of EMS are intended for use in the treatment of public safety personnel in cases involving nerve agent poisoning. Antidote kits for the general public will be provided by the ChemPack program.

Auto-Injectors

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.

Nerve Agent Treatment Escape the Area.
DO NOT ENTER ONCE SUSPICION EXISTS! Decontaminate – gross emergency decon (strip down/flush with copious amounts of water). IF symptomatic, use the Nerve Agent Antidote Kits. TREATMENT OF NERVE AGENT EXPOSURE - AIRWAY AND VENTILATION Establishment of a patent airway is essential for the survival of the severely exposed patient. Severely intoxicated patients will die if aggressive airway management is not quickly available. With large numbers of victims, rapid scene and resource assessment will influence triage decisions regarding interventional therapy. Because of the intense bronchoconstriction and secretions associated with nerve agent exposure, effective ventilation may not be initially possible due to high airway resistance (50 to 70 cm H2O). Adequate atropinization will reverse these muscarininc effects; therefore, atropine should be administered before other measures are attempted. Endotracheal intubation, followed by positive pressure ventilation with a bag-valve mask, should be performed as quickly as possible. Periodic suctioning of secretions will help to improve ventilation and air exchange. Patients with seizures and respiratory failure can be saved with immediate and adequate intervention. Antidote administration. Three medications are used to treat the signs and symptoms of nerve agent intoxication: atropine sulfate, pralidoxime chloride, and diazepam. The general indications for use of these antidotes will be presented first, followed by a discussion of their use in the treatment of mild, moderate, or severe nerve agent intoxication. NOTE: It is important to stress that attempts to ventilate the rigid airways of a nerve agent patient before treatment with atropine will be very difficult or totally unsuccessful.

Nerve Agent Antidote Kit consists of: autoinjector with 2 mg Atropine
MEDICAL TREATMENT Nerve Agent Antidote Kit consists of: autoinjector with 2 mg Atropine and an autoinjector with 600 mg 2-PAM (Pralidoxime) There are two specific antidotes for nerve agent exposure, Atropine and 2 Pam. Atropine is an acetylcholine blocking agent; it takes the place of the acetylcholine at the receptor sites. This corrects the bradycardia and dries out secretions produced by over stimulation of organs. Atropine does not correct respiratory muscle weakness so the victim will likely need respiratory support. The second medication, 2Pam (Pralidoxime chloride), disengages the agent from the enzyme, thereby returning normal function to the acetylcholinesterase. These two drugs are both included in a Mark I Nerve Agent Antidote Kit. As shown here, each Mark I kit is a 2 part auto-injector that contains 2mg atropine and 600 mg 2-Pam. Note to Instructor: A video demonstration and skills checklist for the Mark I Antidote Kit are included on the CD.

ATROPINE Potent parasympatholytic, blocks acetylcholine receptors. Treats SLUDGEM. There are no contraindications to atropine when used in the management of severe chemical or organophosphate poisoning. 2 mg doses with no maximum total dose. Atropine is a potent Parasympathetic drug that blocks the acetylcholine receptors and treats the effects of SLUDGEM. There are no contraindications to atropine when used in the management of severe chemical or organophosphate poisoning. The adult dosage is 2 mg doses, with no maximum total dose as long as it is tolerated by the patient.

Pralidoxime Chloride Cholinesterase reactivator aka: 2-PAM or Protopam
Reverses respiratory depression and skeletal muscle paralysis resulting from organophosphate/nerve agent poisonings 600 mg per dose-not to exceed 1.8 grams total. Pralidoxime Chloride or 2 PAM is a Cholinesterase reactivator. It reverses respiratory depression and skeletal muscle paralysis resulting from organophosphate/nerve agent poisonings. Remember! 3x 600 mg. or 1.8 grams is the maximum dosage!

Pralidoxime (2-PAM) NOTE:
THE MAXIMUM DOSE OF PRALIDOXIME IS GRAMS. THERE IS NO MAXIMUM DOSE OF ATROPINE. Remember, the most important point of the dosages in the administration of Mark I kits is: The maximum dose of pralidoxime is 1.8 grams. There is no maximum dose of atropine.

Use of Antidote Self-Aid Buddy-Aid

Self-Aid The nerve agent antidotes need to be injected into a large muscle. In most individuals, the thigh muscle is used. If a person is very thin, however, the injection should be given in the buttocks. Note: If you are exhibiting signs and symptoms of severe nerve agent poisoning, you will probably be unable to conduct self-aid technique.

Self-Aid Thigh: If you are right-handed, select a site on your right thigh. If you are left-handed, select a site on your left thigh. The injection site should be in the outer part of the thigh. It is important that the injections be given into a large muscle area. The site should be at least one hand's width below the hip joint and at least one hand's width above the knee. Choose a site that is away from buttons, zippers, and objects being carried in your pockets.

Self-Aid Buttocks: If you are right-handed, select a site on the upper, outer quadrant of your right buttocks. If you are left-handed, select a site on the upper, outer quadrant of your left buttocks. The upper, outer part of the buttocks is used to avoid hitting a major nerve or artery. Hitting the nerve could result in paralyzing the leg. The site should be free of objects in your pocket which could be hit by the needle.

Self-Aid

Self-Aid ADMINISTER ONE (1) NERVE AGENT ANTIDOTE KIT Administer a Nerve Agent Antidote Kit (NAAK) only if you are having signs and symptoms of nerve agent poisoning. In freezing temperatures, carry the kits where they will be protected from the cold. The kit has two automatic injectors (autoinjectors). The large autoinjector contains pralidoxime chloride (2-PAM chloride). The smaller autoinjector contains atropine. Procedures for administering the antidotes follow.

Administering the Antidote
Remove one Mark I kit. Hold the kit with your non-dominant hand by the plastic clip with the larger (2-PAM Chloride) autoinjector on top. Hold the set at eye level in front of you so that you can see the autoinjectors. Grasp the body of the smaller (atropine) autoinjector with the thumb and first two fingers of your dominant hand. Do not cover the green (needle) end of the autoinjector with your fingers or hand. Touching the green end may cause the autoinjector to function when you remove it from the clip. Pull the autoinjector out of the clip with a smooth motion (upon removal the injector is automatically armed). If the autoinjector accidentally functions, obtain another kit. Nerve agent antidote must be administered into a large muscle in order to be effective quickly. Administering antidote into a finger or hand is not adequate. Hold the autoinjector with your thumb and two fingers (pencil writing position).

The auto injector should be held at a 90° angle to your body. Place the green (needle) end of the autoinjector against the thigh (or buttocks) muscle. Make sure that the needle will not hit anything in your pocket when it functions. If your jacket is covering the injection site, lift the bottom of the jacket before giving yourself the injection. Press the green end of the autoinjector against the injection site using firm even pressure until it functions (needle is activated). The needle will penetrate through your clothing and into the muscle. The antidote will be injected automatically. Do not use a jabbing motion to activate the needle as it may cause the auto injector to function improperly.

Hold the autoinjector in place for at least ten (10) seconds after the needle has functioned. This time is needed to ensure that all of the antidote has been injected. Carefully remove the atropine autoinjector by pulling it straight out. Place the used autoinjector between two fingers of the hand holding the remaining autoinjector and clip. The green (needle) end should point away from your hand.

Administer 2-PAM Chloride Grasp the body of the 2-PAM chloride autoinjector (the large autoinjector remaining in the clip) with the thumb and two fingers of your right hand. Do not cover the black (needle) end of the autoinjector with your fingers or hand. Pull the autoinjector out of the clip with a smooth motion. If you accidentally activate the needle while removing the autoinjector, obtain another kit and administer the new 2-PAM chloride autoinjector.

Note: The used Atropine injector is between the pinky and ring finger of the non-dominant hand

Place the black (needle) end of the autoinjector against your thigh (or buttocks) muscle. Using firm, even pressure, press the black end of the autoinjector against the injection site until the needle functions. Use the same procedure as used with the atropine autoinjector. Hold the autoinjector in place for at least ten (10) seconds, then carefully remove the 2-PAM chloride autoinjector by pulling it straight out.

Secure used autoinjectors: Drop the plastic clip. Do not drop the autoinjectors. Lift a pocket flap on your protective jacket or location designated by local SOP and push the needle of the used 2-PAM chloride autoinjector through the flap. (The flap is penetrated from the back so that the needle will be away from your body.) Bend the needle down to form a hook.

(NOTE: The expended autoinjectors are secured to your clothing in case you require medical help. Attaching both used autoinjectors to your outer clothing will inform medical personnel that nerve agent antidote has been administered and the amount that has been administered.) NOTE: PPE issued to EMS Personnel may not have exterior pockets. Local SOP will have to establish where to secure used injectors so they are visible by medical personnel at the hospital.

Notes! If you can walk and are not confused (you know who you are and where you are), you will probably not need additional antidote. WARNING If your heart is beating very fast and your mouth is very dry about five (5) to ten (10) minutes after administering the antidotes, you have already given yourself enough antidote.

Buddy-Aid A victim showing signs of severe nerve agent poisoning will not be able to help himself. Unless he receives help, he will probably die. However, your self-protection must be first and foremost. You cannot help the casualty if you are also overcome by the nerve agent. Buddy-aid will be required when a victim is totally and immediately incapacitated prior to being able to apply self-aid. All three(3) sets of nerve agent antidote need to be given by a buddy. Buddy-aid may also be required for a victim who attempts to counter the nerve agent by self-aid but becomes incapacitated after administering one(1) set of the antidote. Before initiating buddy-aid, a buddy should determine if one (1) set of injectors has already been used so that no more than three (3) sets of the antidote are administered.

Buddy-Aid WARNING Do not kneel when administering aid to a chemical agent casualty. If you press your knee against the contaminated ground, you may force the chemical agent into or through your clothing. Kneeling on a contaminated area will greatly reduce the protection time afforded by your clothing. Place yourself near the casualty's head, face his feet, and squat behind his left shoulder.

ADMINISTER NERVE AGENT ANTIDOTE KITS
Position the casualty on his/her left side with the head slanted down so that the casualty will not roll back over. Determine if the victim has self-administered any antidote. Begin administering injections of atropine and 2-PAM chloride. The victim may be administered a total of three(3) Nerve Agent Antidote Kits. Select Injection Site If the victim’s thigh muscle is large enough, give the injections in his thigh. If the casualty is very thin, give the injection in the large muscle of his buttocks. Thigh. If the injections are to be given in the victim's thigh, position yourself near the casualty's thigh. The injection site should be on the outer part of the victim upper thigh. The injection site should be at least one hand's width below the hip joint and at least one-hand's width above the knee.

Buttocks. If the injection is to be given in the victim's buttocks, roll the victim onto his side and position yourself at his hip. The injection site should be in the upper, outer quadrant of the victim's upper buttocks when victim is on his side. The upper, outer quadrant is used to avoid hitting the major nerve in the buttocks. If the victim's jacket is covering the injection site, lift the bottom of the jacket.

Apply firm, even pressure until the needle functions. Do not use a jabbing motion. Hold the autoinjector in place for at least ten (10) seconds; then pull out the autoinjector. Drop the empty plastic clip without dropping the autoinjectors. Lay the used injectors on the victim's side.

Administer Additional Antidote CAUTION: If the victim has already administered one (1) kit to himself, only administer two (2) additional kits. The victim should not receive more than three (3) sets of injections without being seen by medical personnel.

Additional Antidote Victims with signs and symptoms of severe exposure must be re-evaluated every five minutes. If SLUDGEM remains present, administer additional kits-up to a total of three (3). Atropine can be continued at 2 mg doses as long as SLUDGEM remains present.

Secure Used Autoinjectors Attach all used autoinjectors (one at a time) to the victim’s outer clothing or a location designated in your local SOP. Push the needle of the autoinjector through the pocket flap and bend the needle to form a hook. Repeat the procedure with all remaining autoinjectors. Be careful not to puncture your gloves with the needles. (The used autoinjectors will tell medical personnel how much medication the victim has received. This information will help them determine what additional care is needed.)

Once antidote has been administered, send victim to decon and transport to definitive health care as directed by medical command.

Questions? EMS providers and other public safety responders have never faced a greater threat to personal safety than responding to a terrorist chemical attack involving nerve agents. This program provides an overview of the dangers to First Responders exposed to a nerve agent during a chemical attack. It also describes actions First Responders should take – including utilizing pre-incident planning, on scene size-up procedures, and self decontamination methods - to minimize these dangers. This program will also prepare first responders to recognize the signs and symptoms of exposure to nerve agents, understand their adverse health effects, and be able to self-administer a Mark I antidote kit if exposed to a nerve agent.

For additional information
West Virginia Office of EMS 350 Capitol Street, Room 425 Charleston, WV

Nerve Agent Antidote Kit

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