State of West Virginia Department of Health & Human Resources State Trauma and Emergency Care System Office of EMS

1. State of West VirginiaDepartment of Health & Human ResourcesState Trauma and Emergency Care SystemOffice of EMS Nerve Agent Antidote Kit Training Program

2. 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.

3. 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.

4. 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.

5. Routes of Exposure • Direct contact • Inhalation • Ingestion

6. 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.

7. 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

8. 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

9. 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.

10. Normal Nerve Function Nerve, gland or muscle ACh ACh=Acetylcholine stimulates muscle contraction, gland secretion and nerve-to-nerve conduction.

11. Normal Nerve Function ACh Electrical message continues…

12. Normal Nerve Function AChE ACh To stop further stimulation, ACh is broken down by AChE, preventing over-stimulation.

13. Nerve Agents Inhibit ACHE AChE GB ACh ACh accumulates and causes over-stimulation of nerves, muscles and glands.

14. 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

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

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

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

18. 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 effectsoccur within seconds and peak within minutes; no late onset.

19. 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.

20. Signs and Symptoms • 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.

21. 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.

22. 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.

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

24. 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.

25. Auto-Injectors

26. 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.

27. 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.

28. MEDICAL TREATMENT Nerve Agent Antidote Kit consists of: autoinjector with 2 mg Atropine and an autoinjector with 600 mg 2-PAM (Pralidoxime)

29. 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.

30. Pralidoxime Chloride aka: 2-PAM or Protopam • Cholinesterase reactivator • Reverses respiratory depression and skeletal muscle paralysis resulting from organophosphate/nerve agent poisonings • 600 mg per dose-not to exceed 1.8 grams total.

31. Pralidoxime (2-PAM) NOTE: THE MAXIMUM DOSE OF PRALIDOXIME IS 1.8 GRAMS. THERE IS NO MAXIMUM DOSE OF ATROPINE.

32. Use of Antidote • Self-Aid • Buddy-Aid

33. 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.

34. 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.

35. 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.

36. Self-Aid

37. 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.

38. 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).

39. Administering the Antidote

40. Administering the Antidote • 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.

41. Administering the Antidote

42. Administering the Antidote • 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.

43. Administering the Antidote • 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.

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

45. Administering the Antidote • 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.

46. Administering the Antidote • 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.

47. Administering the Antidote (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.

48. 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.

49. 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.

50. 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.