1. Module 7 Medical Treatment
As we will see in this section of the course, victims of nerve agent exposure require very different medical treatment than people who have been exposed to a vesicant agent. However, one thing is the same: the number one rule is to protect yourself. Chemical warfare agents are designed to spread and cause multiple injuries. All your skill and training will be useless to the patient if you are exposed to the agent, not to mention the trauma you would face as a patient yourself. You can protect yourself by wearing the appropriate level of PPE and by ensuring that you, the patient, and the treatment environment are decontaminated.

2. Nerve Agent
Immediate medical treatment is essential for people exposed to nerve agent. For severe exposures, seconds can make the difference between life and death.

3. Treatment - No Signs and Symptoms
Reassure
Observe
Vapor: 1 hour
Liquid: Up to 18 hours
At the other extreme, people who think they may have been exposed but are exhibiting no signs and symptoms should be reassured that they are not likely to suffer significant health effects and then placed under medical observation. If vapor exposure is suspected, one hour of observation is sufficient, but for direct contact with liquid agent, the patient should be observed for 18 hours.

4. Basic Nerve Agent Exposure Treatment
Airway/ventilation
High resistance: positive pressure of > cm/H20 or higher is needed
Oxygen
Antidotes
Atropine
Pralidoxime Chloride
(2-PAM Cl)
Diazepam
Once the patient has been decontaminated, treatment of nerve agent exposure consists of two parts: airway management and administration of antidotes. For victims of mild exposure, the antidotes will likely relieve breathing difficulties and no further intervention should be necessary to ensure a patent airway. For patients suffering from larger exposures, however, more aggressive measures may be warranted, including providing oxygen and assisted ventilation. Because of the agent’s effects on the airways, pressures much larger than normal may be required for ventilation. Most respirating devices “pop-off” at a pressure of about 40 to 45 centimeters of water. Pressures of 50 to 70 centimeters or greater may be required to ventilate severe nerve agent exposures.
Antidotes used in treating nerve agent victims include atropine, pralidoxime chloride (or 2-PAM Cl), and diazepam. We’ll talk more about them over the next several minutes.

5. Nerve Agent Effects Nerve agent overstimulates the
nervous system; muscles and
glands over-react and organs
malfunction
Initial treatment involves 2-part antidote
Atropine stops the effect of nerve agent
2-PAM Cl restores normal muscle function by reactivating cholinesterase
Remember from our earlier discussion that nerve agents affect the body by over-stimulating the nervous system causing muscles and glands to over-react and leading critical organs to malfunction. Initial medical treatment consists of administering a two-part antidote to counteract these effects. First, atropine is given to stop the effect of the nerve agent by blocking continued over-stimulation. Then 2-PAM CL is administered to reactive cholinesterase which restores normal control of skeletal muscles.

6. Atropine Atropine blocks effects of over-stimulation
Relieves smooth muscle constriction
Dries up respiratory secretions
Atropine is always given first. By blocking the effects of over-stimulation, the drug relieves the smooth muscle constriction in the lungs and GI tract and dries up respiratory tract secretions. However, atropine cannot relieve paralysis of the respiratory muscles.

7. 2-PAM Cl Effect
Removes organophospate from acetylcholinesterase which can then deactivate acetylchline
Re-establishes normal skeletal muscle contraction
Relieves twitching and paralysis of respiratory muscles
2-PAM CL complements or completes the action of atropine by removing nerve agent from the acetylcholinesterase. This allows the enzyme to resume its usual job of deactivating acetylcholine. As a result, normal skeletal muscle contraction is re-established and muscular twitching and paralysis of respiratory muscles is relieved.

8. Diazepam Administer to patients experiencing convulsions
Consider for patients with severe signs and symptoms
Dosage depends on patient’s age
In addition to the two-drug antidote, the anticonvulsant, diazepam, should be given to patients who are experiencing convulsions and to all patients who display signs of severe exposure. We’ll talk later about the appropriate dosages, which vary depending on the patient’s age.

9. Administration of Antidotes
Dosage varies depending on age and weight of patient and severity of signs and symptoms
Dosages may need to be repeated at specified intervals
repeat atropine until patient is “atropinized”
repeat 2-PAM Cl until maximum dose per body weight is reached
The appropriate dosages of atropine and 2-PAM CL to administer after an exposure to nerve agent are determined by the age and weight of the patient and by the severity of the signs and symptoms.
The initial doses of these drugs may need to be repeated at specific intervals based on the patient’s response to treatment. Additional doses of atropine should be given until the patient is “atropinized.” (We’ll discuss what this means in a minute.) Doses of 2-PAM CL may be repeated to relieve signs and symptoms, but the total amount given should not exceed the maximum allowed for the patient’s body weight.

10. Signs of Atropinization
Secretions dry
Less labored breathing
“Atropinization” is the term used to describe noticeable signs that the patient has received enough atropine to decrease respiratory impairment and relieve other signs and symptoms of exposure. Recognition of “atropinization” helps the health care provider ensure the patient is not under-dosed. Sufficient atropine has been given when the patient’s secretions are dry—this means tearing, runny nose, and production of excess saliva and phlegm have stopped—and breathing is less labored.

11. Two Common Problems Underdosage
administering too little antidote to relieve agent effects
most serious problem: failing to administer atropine when needed
Administering antidote to patients not exposed to nerve agent
The most common mistake in administering atropine is giving too little of the drug to relieve the effects of the nerve agent. The most extreme and serious example of under-dosing would be failing to administer atropine to a victim of nerve agent exposure.
The second most common problem is administering antidote to patients who have not been exposed to nerve agent. Atropine can produce adverse effects when given to someone who has not been exposed to an organophosphate

12. Guideline for Administering Antidotes
Make sure atropine warranted
Administer dosages of antidotes as recommended in treatment tables
Continue administering atropine as recommended in treatment tables until atropinization is achieved
If needed, repeat dosage of 2-PAM Cl as recommended in treatment tables until maximum total dose is given
Follow these guidelines to be sure patients receive the appropriate amounts of nerve agent antidotes.
First, make sure that atropine is warranted before it is given. To receive the drug, a patient should exhibit at least two signs and symptoms of mild or moderate exposure. Atropine should be given immediately to a victim who exhibits any sign of severe exposure.
Once you’re sure that exposure did occur, administer the dosages of the antidotes recommended in the treatment tables we will discuss in a few minutes.
Observe the patient and repeat the recommended dosages of atropine until atropinization is achieved.
If needed, repeat the recommended dosages of 2-PAM Cl until the patient has received the maximum total dose listed in the treatment tables.

13. Potential Problems With Atropine
Exercise caution in administering atropine:
For non-life-threatening exposures, use extreme caution if patient has existing medical problems
Administer to pregnant woman only if clearly needed
Administer to nursing woman with caution
Start at low end of dosing range when treating elderly
While atropine should not be withheld from anyone who has received a life-threatening exposure to nerve agent, certain cautions should be observed when administering the drug to people with certain health conditions. If the exposure is not life-threatening, extreme care should be observed in giving atropine to people with heart rhythm disorder, severe narrow angle glaucoma, pyloric stenosis, enlarged prostrate, significant renal insufficiency, recent myocardial infarction, or chronic lung disease. Pregnant women should receive the drug only if it is clearly needed, and caution should be used in giving the drug to women who are nursing infants. When treating elderly patients, start at the low end of the recommended dosing range.

14. Potential Problems with 2-Pam Cl
Exercise caution in administering 2-PAM Cl:
Reduce dosage if patient has renal insufficiency
Give to pregnant woman only if clearly needed
Give to nursing woman with caution
Dosages of 2-PAM Cl should be reduced for patient’s who have defective kidney function. As with atropine, 2-PAM Cl should be give to pregnant women only if clearly needed and to nursing mothers with caution.

15. Adverse Reactions Atropine 2 -PAM Cl
pain at injection site, dry mouth, blurred vision, photophobia, confusion, headache, dizziness, fast heart beat, palpitations, flushing, urinary hesitancy, constipation, abdominal distention, nausea, vomiting, loss of libido, impotency
2 -PAM Cl
delayed pain at injection site, blurred vision, double vision, impaired accommodation, dizziness, headache, drowsiness, nausea, rapid heart rate, increased blood pressure, hyperventilation, muscular weakness
Following the injection of atropine, the patient may experience mild to moderate pain at the site of the injection. Other side effects may include dryness of mouth, blurred vision, sensitivity to light, confusion, headache, dizziness, rapid and pounding heart beat, flushing, difficulty urinating, constipation, swollen abdomen, nausea, vomiting, loss of libido, and impotency.
An intramuscular injection of 2-PAM CL may be followed in forty to sixty minutes by mild to moderate pain at the site of the injection. Side effects may include blurred vision, double vision and inability to focus, dizziness, headache, drowsiness, nausea, rapid heart beat, increased blood pressure, hyperventilation, and muscular weakness.

16. Atropine Overdose
Cause: Atropine administered when no prior nerve agent exposure has occurred
Not as serious as underdosing
Not usually life-threatening
The most common cause of atropine overdose is administering the drug when exposure to nerve agent did not actually occur. Aside from that situation, it is more common for patients to be under-dosed than over-dosed, and underdosage is a more serious problem. Atropine overdose is seldom life-threatening.
During the First Gulf War, children in Israel who had not been exposed to nerve agent were accidentally given atropine at doses 17 times higher than appropriate for their ages. No seizures or life-threatening complications were reported as a result.

17. Signs and Symptoms Of Atropine Overdose
Dilated pupils
Dry mouth and skin
Rapid pulse
Flushed skin
Difficulty urinating
Confusion, delirium
Temperature control diminished
Intense thirst
Restlessness
Atropine overdose should be suspected if the patient exhibits the signs and symptoms listed on the screen. These effects may last 48 hours or longer.

18. Treatment for Atropine Overdose
Keep patient cool
Protect patient from irrational actions
Transport patient to hospital as soon as possible
If an atropine overdose occurs, the patient should be kept cool and protected from taking irrational actions. Transport to a hospital should be arranged as soon as possible.

19. 2-PAM Cl Overdosage
Symptoms: dizziness, blurred vision, double vision, headache, impaired ability of eyes to change focus, nausea, slightly rapid heart rate
Treatment: artificial respiration and other supportive therapy as needed
Patients who have received an overdose of 2-PAM Cl may exhibit the signs and symptoms shown here. They should be provided with artificial respiration and other supportive therapy as needed.

20. Adult Nerve Agent Treatment
Starting dose for adults - 2 mg atropine
Enough must be administered to abate severe symptoms if casualty is to survive
Insecticide poisoning requires more atropine than chemical warfare agents per equivalent amount
For adults who have been exposed to nerve agent, antidote treatment begins by administering 2 milligrams of atropine. Depending on the severity of symptoms, additional doses may be needed. Patients suffering from a severe exposure will probably not survive unless they receive enough atropine to relieve their critical signs and symptoms, particularly those involving respiration.
Organophosphate insecticides belong to the same chemical family as nerve agents, but they act somewhat differently in the body. They continue to disrupt the transmission of nerve impulses for much longer than nerve agents. Consequently, more atropine may be required when treating cases of insecticide poisoning.

21. Antidote Administration Methods
Intramuscular (IM)
Syringe
Auto-injector
Intravascular (IV)
Nerve agent antidotes can be given in two basic ways: by intramuscular injection or intravenously. Two different types of devices are available for giving IM injections. The most familiar of these is the standard syringe, where the appropriate dose is carefully measured out of a vial or ampule then carefully injected into the patient.
The second type of device is the auto-injector. These devices have a number of attributes that make them desirable for emergency use in the field. As a result, CSEPP communities have decided to use auto-injectors as the main method for administering nerve agent antidotes.

22. Adult Nerve Agent Treatment: Mild Exposure
2 mg atropine IM IV
2-PAM Cl
600 mg IM
1 gram IV
Adults suffering from a mild exposure should first receive 2 milligrams of atropine, administered either IM or IV. This drug should be followed by 2-PAM Cl, either 600 milligrams given IM or 1 gram IV. One Mark I kit contains the appropriate dosages of the two drugs for IM administration.
A patient suffering from exposure only to agent vapor, should receive this treatment only if having some difficulty in breathing due to shortness of breath, chest tightness, or airways congested with phlegm. If the only effects of vapor exposure are miosis and a runny nose, the patient should be observed to see if the effects diminish without antidote treatment.
2-PAM Cl can cause a dramatic increase in blood pressure when administered intravenously. Therefore, when given by this route, the recommended dosage of the drug should be administered over a 20- to 30-minute period in 250 ml of normal saline.

23. Adult Nerve Agent Treatment: Moderate Exposure
2-4 mg atropine initially IM IV
2-PAM Cl
mg IM initially
1 gram IV
Repeat every 5-10 minutes until atropinized
2 mg atropine
600 mg 2-PAM Cl
Adults displaying symptoms of a moderate exposure to nerve agent should be treated a bit more aggressively. Treatment should begin with 2 to 4 milligrams of atropine delivered either IM or IV. 2-PAM Cl should follow with either 600 to 1200 milligrams administered IM or 1 gram given by slow IV. For IM administration, these dosages are equivalent to 1 or 2 Mark I kits.
If the patient was exposed to liquid nerve agent, the appropriate initial dosages of antidotes depend on how much time has passed since the exposure began. If less than about an hour has passed, 4 milligrams of atropine and 1200 milligrams of 2-PAM Cl should be given. If several hours have elapsed, these dosages should be halved.
Following the initial treatment, the patient should be observed. Additional 2-mg doses of atropine and 600-mg doses of 2-PAM Cl should be given at intervals of 5 to 10 minutes until signs and symptoms are relieved. The patient should receive no more than 3 total doses of 2-PAM Cl, but atropine therapy can continue as needed.

24. Adult Nerve Agent Treatment: Severe Exposure
6 mg atropine IM initially IM
2-PAM Cl
1800 mg IM initially; or
1 gram IV
Repeat 2 mg atropine every 5-10 min. as needed
Repeat 2-PAM Cl in 1 hour
Ventilation/Oxygen
Diazepam: 10 mg (2 to 5 mg increments, IV or IM)
By the time medical responders arrive, a severely exposed victim will likely be unconscious and will have suffered convulsions. The patient may be flaccidly paralyzed and either not breathing or experiencing severe breathing difficulty.
These patients should immediately be given 6 milligrams of atropine, and 2-PAM Cl therapy should be started, either with 1800 milligrams IM or 1 gram via slow IV. The IM doses of the 2 antidotes are equivalent to 3 Mark I kits.
Additional 2-milligram doses of atropine should be given at 5- to 10-minute intervals until the patient is getting adequate oxygen. If needed, additional 2-PAM Cl can be given after one hour.
Severely exposed patients will require assisted ventilation with oxygen. However, until the patient begins to respond to the atropine, these measures will probably not be effective because of airway constriction and heavy secretions. Therefore, atropine should be given before beginning other efforts to restore the airway. Suctioning of secretions may also be needed to relieve severe breathing difficulty.
In addition to the two-drug antidote, the anti-convulsant diazepam should be administered to patients who are experiencing convulsions or who display signs of severe exposure. For adults, 10 milligrams of diazepam should be administered, either IV or IM, after the initial doses of atropine and 2-PAM Cl have been given. Up to two additional doses can be given at 10-minute intervals if convulsions continue.

25. Atropine Treatment For Children
Over 10 years: 2 mg initially IM
Between 2 and 10 years: 1 mg initially IM
Less than 2 years: 0.5 mg initially
Alternatively 0.02 mg per kg (2.2 pounds) of body weight by IV
Repeat every 5-10 min. until atropinized
A different antidote treatment regimen is followed for children. Here, the appropriate dosages depend on the patient’s age. For exposed children, a single dose of atropine—as listed on the screen—should be administered initially. The patient should then be observed and additional doses given at 5- to 10-minute intervals until the symptoms are relieved.
As was the case with adults, severely exposed children will likely require ventilation support with oxygen and removal of secretions.

26. 2-PAM Cl Treatment For Children
Less than 22 kg (50 lbs.): 15 mg per kg of body weight by IV
More than 22 kg (50 lbs):
600 mg IM, or
15 mg per kg of body weight by IV
After receiving an initial dose of atropine, exposed children should be given 2-PAM Cl. If given IV, a dose of 15 milligrams per kilogram of body weight should be given. (Remember that 2-PAM Cl should be given by IV slowly over 20 to 30 minutes in 250 milliliters of normal saline.) If needed, this dose can be repeated twice at intervals of one hour.
Children who weigh more than 50 pounds can receive the 600 milligram adult dose of 2-PAM Cl delivered IM. This dose can be repeated twice at 5 to 10 minute intervals if needed.

27. Diazepam Treatment For Children
Children > 30 days old to 5 years
mg/kg IV every 2 to 5 min (max 5 mg)
Children > 5 years
1 mg IV every 2 to 5 min (max 10 mg)
Children who are convulsing or suffering from severe exposure should be given diazepam. Those between 30 days and 5 years of age, should initially be given 0.2 to 0.5 milligrams per kilogram of body weight by IV. This dosage can be repeated every 2 to 5 minutes as needed until a maximum total dose of 5 milligrams has been given.
For children over 5 years of age, the appropriate dose of diazepam is 1 milligram by IV, repeated as needed every 2 to 5 minutes until a maximum total dose of 10 milligrams is reached.

28. Administering Antidote
Three sequential steps for administering antidote:
1. Determine correct dosage for the patient
2. Assess severity of signs and symptoms
3. Administer treatment appropriate for patient’s weight/age and symptoms
Three sequential steps should be followed in administering antidotes to victims of nerve agent exposure. First, determine the correct dosage of each antidote based on the patient’s weight and age. Second, assess the severity of the patient’s signs and symptoms. Third, administer the doses of antidote appropriate for the patient’s weight or age and the signs and symptoms being experienced.
We have just talked about the antidote dosages, and we covered signs and symptoms in an earlier section, so now let’s consider how the antidotes are administered.

29. Auto-Injectors Alternative means of IM injection
Simple, compact injection systems
Contain pre-measured amount of antidote
Needle revealed only when injector pressed against patient’s skin
Cannot be refilled or reused
The auto-injector is a simple, compact device containing a pre-measured dose of antidote. The needle of the auto-injector is concealed and is only exposed when the device is automatically activated by pressing the end firmly against the patient’s skin. After use, the needle cannot be retracted and the auto-injector cannot be refilled or reused. It should be disposed of in a sharps disposal container.

30. Advantages of Auto-injectors
permit rapid injection
prevent cross-contamination
enable rapid, accurate use even in protective clothing
Auto-injectors provide
simple, accurate, rapid drug administration
pre-measured, controlled dose
no vials/ampules/ syringes
fully automated use
rugged construction
Auto-injectors permit rapid injection of the required antidotes. Some studies suggest that the force of the injection produces quicker results than injections administered with a standard syringe. Using the auto-injectors also prevents cross-contamination that could result from re-use of antidote deliver systems, and allows rapid and accurate administration even if the health care provider or patient is wearing protective clothing, including gloves.
As we talked about earlier, victims of nerve agent exposure require rapid treatment. Auto-injectors facilitate this by providing simple, accurate, rapid administration of antidotes in a pre-measured, controlled dose. There are no vials, ampules, or syringes to manipulate, and operation is fully automatic. Since the auto-injectors were originally designed for use by the military in combat situations, they are ruggedly constructed.

31. Auto-Injectors FDA-approved
Mark I kit combines one atropine injector and one 2-PAM Cl injector (adult dosages only)
Diazepam auto-injector available in adult dosage only
Atropine auto-injectors (AtroPen®) also commercially available in four dosage levels
Auto-injectors containing nerve agent antidotes are manufactured and marketed by Meridian Medical Technologies, Inc, on approval from the U.S. Food and Drug Administration.
The Mark I Nerve Agent Antidote Kit, which is used by the U.S. Army and CSEPP communities, contains one 2-mg atropine injector and one 600-mg 2-PAM Cl injector. This kit is useful in treating people over 10 years of age. 2-PAM Cl injectors are not available for children weighing less than 50 pounds. Auto-injectors containing adult dosages of diazepam are also available.
The manufacturer also offers a line of atropine auto-injectors—called Atropen®—for civilian use. These devices come in four dosage levels for treating patients of various weights and ages, from infants to adults. Since the Mark I kit is used in CSEPP, we’ll talk mostly about this device. But you may want to consider looking into the Atropen® injectors for your community.

32. Content of Auto-Injectors
The 2-mg atropine auto-injector contains glycerin, phenol, citrate buffer, and water
The 600-mg 2-PAM Cl auto-injector contains benzyl alcohol, glycine, and water
Do not administer to patient with hypersensitivity to any component of injector solution
The 2-mg atropine auto-injector contains, in addition to atropine, glycerin, phenol, citrate buffer, and water. The 600-mg 2-PAM Cl injector contains benzyl alcohol, glycine, and water. Neither of the antidotes should be administered to any patient who is known to be hypersensitive to any component of its injection solution.

33. Who Can Use Auto-Injectors
FDA approved use
by appropriately trained civilian emergency medical personnel
in treating victims exposed to nerve agents or organophosphate insecticides
State statutes also determine who can use
be aware of your state laws and local protocols
The FDA has approved these auto-injectors for use by appropriately trained civilian emergency medical personnel in treating victims exposed to nerve agents or organophosphorus insecticides. The FDA specifically limits the use of auto-injectors to people who have been trained to recognize exposure symptoms and provide appropriate treatment.
State statutes also determine who is authorized to use the auto-injectors. Some sates require that controlled drugs (such as atropine, 2-PAM Cl, and diazepam) be administered only under the direction of a physician. Other states allow emergency personnel to administer these medicines. You should be aware of the state laws and any local protocols applicable to your community.

34. Directions for Using Auto-Injectors
Step 1—Remove Mark I kit from its protective pouch
Hold unit by the plastic holder (the end with the numbers)
There are 7 steps to follow in using auto-injectors in the Mark I Kit to administer antidote to a patient.
The first step is to remove the Mark I Kit from its protective pouch. Grasp the plastic holder exposed at the open end of the pouch and pull the kit out.

36. Directions for Using Auto-Injectors
Step 2—Remove the appropriate auto-injector from the kit’s holder
Administer atropine first, then 2-PAM Cl
Safety release will remain in kit
Do not touch the green or black tip
Next, remove the appropriate auto-injector from the Mark I Kit’s plastic holder. The atropine injector is labeled “1” and should be administered first. Once all the steps have been completed to administer the atropine, they should be repeated using the 2-PAM Cl injector.
When each auto-injector is removed from the kit, its safety release remains in the holder. (The safety release is yellow on the atropine injector and gray on the 2-PAM Cl injector.) The injector is now ready for activation. Be very careful not to touch the green or black tip. Any pressure on this tip can cause the device to activate, injecting antidote into your fingers or hand. (The activation tip is green on the atropine injector and black on the 2-PAM Cl injector.)

38. Directions for Using Auto-Injectors
Step 3—Place green or black tip against patient’s thigh and push hard until the injector functions
It’s OK to inject through clothing if pockets are empty
For very thin people. Bunch up thigh to provide thicker area for injection.
The third step is to place the green or black tip of the auto-injector against the patient’s outer thigh and push hard until the injector functions. The auto-injector will extend its needle and deliver the medicine.
It’s okay to inject through clothing, but make sure pockets at the injection site are empty.
Very thin people should also be injected in the thigh, but before giving the injection, bunch up the thigh muscle to provide a thicker area for injection.

40. Directions for Using Auto-Injectors
Step 4—Hold auto-injector firmly in place for at least 10 seconds to allow injection to finish
Hold the auto-injector firmly in place for at least 10 seconds to allow the full dose of antidote to be injected.

42. Directions for Using Auto-Injectors
Step 5—Carefully remove the auto-injector
Exposed needle will confirm successful injection
Next, carefully remove the auto-injector. If the needle is not protruding from the end of the injector, repeat Steps 3 and 4, but press harder.

44. Directions for Using Auto-Injectors
Step 6 - Massage injection site for several seconds.
Massage the injection site for several seconds to help disperse the antidote..

46. Directions for Using Auto-Injectors
Step 7—Dispose of empty auto-injector in a sharps disposal container.
Bend needle
Note dosages on a triage tag or write on patient’s chest or forehead
Move yourself and victim away from contaminated area
Seek medical help
The final step is to dispose of the empty auto-injector in a sharps disposal container in accordance with rules for handling medical wastes and possible blood-borne pathogens. Dosages should be noted on a triage tag or written on the chest or forehead of the patient.
Move yourself and the exposed individual away from the contaminated areas right away, and seek medical help.

48. Manufacturers Recommended AtroPen® Auto-Injector Atropine Dosages
Patient weight/age
AtroPen® auto-injector
> 90 lbs (10+ yrs)
2 mg AtroPen®
lbs (4 - 10yrs)
1 mg AtroPen®
lbs (6 mos - 4 yrs)
0.5 mg AtroPen®
< 15 lbs (< 6 mos)
0.25 mg AtroPen®
The process we have just talked about is based on the auto-injectors in the Mark I Nerve Agent Antidote Kit. The process for administering the individual AtroPen® auto-injectors that we mentioned earlier, is very similar. One of the key differences is that the AtroPen® injectors come in four dosage levels to treat patients of different ages and weights. For the AtroPen® injectors, the manufacturer has simplified the process of selecting the correct dosage by color-coding the injector labels. The label of the 2-mg auto-injector is green, the 1-mg is dark red, the 0.5-mg is blue, and the 0.25-mg is yellow.

49. Ventilation
If required, insertion of endotracheal tube by a qualified person is recommended
Requires high “pop off” pressure ( cm H2O)
It is essential that the airway of a severely exposed patient be re-established as quickly as possible. Otherwise, the patient will likely die.
After administering atropine to a severely exposed patients, endotracheal intubation, followed by positive-pressure ventilation with a bag-valve mask may be required. Because of the intense airway constriction and copious secretions caused by nerve agent intoxication, much higher than normal pressures may be required for effective ventilation. “Pop-off” pressures of 50 to 70 centimeters of water or higher may be required to ventilate an un-atropinized patient. Many respirating devices, including some used on ambulances, “pop off” at about 40 to 45 centimeters of water.

50. Vesicant Agents
A dramatically different treatment regimen is followed to treat victims of exposure to a vesicant agent.

51. Sulfur Mustard Agent Treatment
No antidote available
Ensure immediate and thorough decontamination
Take precautions for sterile technique
Support airway management as necessary
Treatment of people exposed to sulfur mustard is largely supportive because no antidote is available to counteract the effects of the agent. Immediate and thorough decontamination offers the best hope for reducing the severity of signs and symptoms.
If the patient is suffering from severe blistering, sterile techniques must be observed to avoid introducing infection into the blister wounds. In addition to damaging skin tissue, sulfur mustard suppresses the immune system, thus reducing the patient’s ability to fight infection.
Respiratory support may be required if the patient has inhaled significant amounts of mustard agent. If blisters have formed in the respiratory tract, breathing may be difficult. Oxygen should be administered as needed.

52. Decontamination Part of supportive treatment Physical removal of agent
remove clothing
flush skin with soap and water
flush eyes with sterile saline, sterile water, or water
Must be done within 2 minutes to prevent damage
Delays in decontamination will not prevent illness, but will prevent cross-contamination
Decontamination is an important part of the supportive treatment. The intent is to physically remove the blister agent from the patient. First, all clothing, jewelry, wigs, etc., should be removed from the patient. Then, the skin should be washed with soap and water, and the eyes should be flushed with sterile saline, sterile water, or, if necessary, plain water. When decontaminating skin areas, pay special attention to skin creases, such as the groin, armpits, behind the ears, between fingers, etc.) These are the areas where the agent is most likely to cause severe blistering.
Decontamination must be performed within 2 minutes of exposure to prevent damage. If performed 30 minutes later, decontamination will not reduce injury to the patient, but it will prevent the spread of contamination to others, including health care providers.

53. Eye Contact Flush eyes immediately tilt head to the side
pull eyelids apart with fingers
pour water slowly into eyes
Do not cover eyes with bandages
Dark or opaque glasses provide relief from photophobia
If sulfur mustard has gotten into the eyes, speed in decontamination is especially critical. Irreversible damage will be done very quickly even though the effects of the damage may not begin to appear for several hours. Decontaminate the eyes immediately by tilting head to one side, pulling the eyelids apart with the fingers, and pouring water slowly into the eyes. Make sure that hands and fingers used in this procedure are not contaminated with agent. Do not cover the eyes with bandages. If exposure to light causes eye pain or discomfort, the patient can be provided with dark or opaque glasses.

54. Sulfur Mustard Treatment
Humidified air
Oxygen and cough suppressants
Antibiotics not helpful immediately
Oxygen assisted ventilation
Intubation before it becomes difficult
Bronchodilators
Steroids may be administered
Flushing eyes becomes less effective with time
Symptoms in the upper airway (such as sore throat, hoarseness, or nonproductive cough) may be relieved by providing humidified air or oxygen and cough suppressants. Antibiotics are not helpful initially, but may be needed if injuries become infected.
Intubation may be needed if airway injury is severe. In this case it should be performed before it is made difficult by constriction of the larynx and swelling of affected tissues. Bronchodilators may help relieve the constriction of the air passages of the lungs, and, if these are not effective steroids may be given.
Decontamination of the eyes becomes less effective with the passage of time as the agent rapidly affixes itself to the tissue. Once signs and symptoms begin to appear in the eye, not much benefit will be gained by painfully prying swollen eyelids apart to flush with water.

55. Sulfur Mustard Treatment (cont.)
Apply pupil dilators (mydriatics) topically
Oral analgesics preferred to topical administration
Antibiotics applied topically
Vaseline on eyelids
Soothing creams for skin irritations
Un-roof blisters and irrigate
Apply topical antibiotics
Oral or IV analgesics
Assess hydration
If eye injuries are severe, homatropine or other pupil dilators should be applied topically to prevent scarring. Eye pain should be relieved using oral analgesics as topical analgesics may delay healing and allow damage to the cornea. Topical antibiotics should be topically several times a day, and vaseline applied to the lid edges will prevent them from sticking together.
Skin irritations and itching may be reduced by application of soothing creams or lotions. To prevent additional infection, large blisters should be unroofed and, several times a day, irrigated and treated with a topical antibiotic. Pain medication will likely be required administered either orally or by IV.
Additional intravenous fluids may be needed, but fluid replacement is not as serious a problem as it would be for thermal burns affecting the same area. The patient should not be overloaded with fluids.