South Bay Disaster Resource Center at Harbor-UCLA Medical Center

1. South Bay Disaster Resource Center at Harbor-UCLA Medical Center Nerve Agents & MARK 1 Antidote Administration

2. Nerve Agents & MARK 1 Antidote Administration Objectives Upon completion of this training, you will be able to: • Describe why hospitals must prepare for nerve agents. • Describe nerve agent pathophysiology. • Describe clinical presentation of nerve agent exposure. • Describe prioritized Emergency Department response to nerve agent victims. • Describe key elements of nerve agent Triage. • Identify nerve agent antidotes and effects/side-effects. • Demonstrate competence using MARK1 auto-injectors.

3. Nerve Agents & MARK 1 Antidote Administration Why Prepare for Nerve Agent Terrorism • Small treatment window to decrease morbidity and mortality: • Depends upon type of nerve agent, concentration and duration of exposure. • After soman gas exposure, the antidote (2-PAM) must be administered within seconds (practically rendering the antidote useless). • After sarin gas exposure, 2-PAM usually is effective in improving nicotinic symptoms of weakness and muscle fasciculations, if administered within 45-60 minutes.

4. Nerve Agents & MARK 1 Antidote Administration Why Prepare for Nerve Agent Terrorism • Potential for mass-casualty exposure: • 1995 Aum Shinrikyo cult released sarin gas in 5 subway cars in downtown Tokyo • 5,500 victims sought medical care • 80% self-transported to medical facilities

5. Nerve Agents & MARK 1 Antidote Administration Most Likely Terrorist Nerve Agents • Tabun (GA) • Sarin (GB) • Soman (GD) • VX

6. Nerve Agents & MARK 1 Antidote Administration Nerve Agent Pathophysiology • Acetylcholine, a neurotransmitter, normally is secreted at the end-plate of a nerve and “instructs” nerves, muscles, and glands. • Acetylcholine normally undergoes enzymatic degradation by acetylcholinesterase. • Nerve agents inhibit acetylcholinesterase, and thus acetylcholine builds up within synapses. • Results in over-stimulation of the peripheral and central nervous system.

7. Nerve Agents & MARK 1 Antidote Administration Muscarinic Symptoms of Nerve Agent Exposure • D: Diarrhea • U: urination • M: miosis (pupil constriction) • B: bradycardia, bronchorrhea, & bronchospasm • E: emesis • L: lacrimation • S: salivation, increased secretions, & sweating

8. Nerve Agents & MARK 1 Antidote Administration Nicotinic Symptoms of Nerve Agent Exposure • M: mydriasis (pupillary dilation) • T: tachycardia • W: weakness • tH: hypertension • F: fasciculations (muscle twitching)

9. Nerve Agents & MARK 1 Antidote Administration Prioritized ED Response to Nerve Agent Victims • Safety of staff and protection of ED • Decontamination of victim (if not done in the field) • Airway management • Antidote administration – Atropine and Pralidoxime Chloride (2-PAM) • Seizure control – Diazepam

10. Nerve Agents & MARK 1 Antidote Administration Key Elements of Nerve Agent Triage Assessment • Signs/symptoms: DUMBELS and/or MTWtHF • Extent of exposure: • Mild: Tearing, runny nose, mild chest tightness • Moderate: Mild symptoms + nausea, vomiting moderate shortness of breath, wheezing • Severe: Moderate symptoms + severe shortness of breath, seizure, cardiovascular collapse

11. Nerve Agents & MARK 1 Antidote Administration Key Elements of Nerve Agent Triage Assessment • Pre-hospital administration of antidotes. • How much, when, & what are the signs of improvement? • Decision to administer the antidote should be based upon the initial signs and symptoms and modified accordingly. • Onset of signs and symptoms will depend upon the actual agent.

12. Nerve Agents & MARK 1 Antidote Administration Antidote Effects • Atropine: Blocks acetylcholine at muscarinic receptor sites and therefore decreases bronchial secretions. • 2-PAM: Regenerates acetylcholinesterase and thus improves nicotinic symptoms (fasciculations, muscle twitching, weakness). • Diazepam: Controls seizures.

13. Nerve Agents & MARK 1 Antidote Administration Antidote Side Effects • Atropine: If administered in excess of amount needed to reverse muscarinic effects, the anticholinergic syndrome (mydriasis, tachycardia, hypertension, urinary retention, dry skin) may result. • 2-PAM: Hypertension that is rapidly responsive to phentolamine.

14. Nerve Agents & MARK 1 Antidote Administration MARK 1 Antidote Kits • Facilitates rapid administration/self-administration. • Consists of 2 auto-injector pens: • Smaller pen: 2 mg Atropine • Larger pen: 600 mg 2-PAM

15. Nerve Agents & MARK 1 Antidote Administration MARK 1 Administration Techniques • Check injection site – usually lateral thigh – for objects (i.e., wallets) that may interfere with administration. • Hold kit in non-dominant hand so larger pen is on top and both pens are at eye level. • Remove pen; hold like a pencil. • Apply plastic-covered tip like a pencil to injection site with firm, even motion. Auto-injector will fire. • Hold in place at least 10 seconds.

16. Nerve Agents & MARK 1 Antidote Administration Antidote Administration Sequence • Atropine • 2-PAM

17. Nerve Agents & MARK 1 Antidote Administration References • “Basic Disaster Life Support Provider Manual Version 2.5.” American Medical Association. 2004 • “Domestic Preparedness: Defense Against Weapons of Mass Destruction; Technician-Hospital Provider Manual”. Booze-Allen & Hamilton, Inc. 1998. • “Use of MARK I Kits.” New York Department of Health Policy Statement 03-05. Desktop: DRC Nerve Agents MARK 1 Antidote Administration