Nerve Agents Part I
 Identify common nerve agents
 Discuss signs and symptoms
 Discuss nursing management and treatment
 Discuss the nurse roles and responsibilities
 Discuss personal safety risk exposure
 Emergency Support Function
 DHH has the role of providing leadership for planning,
 directing and coordinating the overall State efforts to
 provide public health and medical assistance.
 The Secretary of Health and Human Services through
 the Office of Public Health Emergency Preparedness is
 responsible for the federal coordination.
 The command and control of operations are consistent
 with the National Response Framework and compliant
 with National Incident Management System
 Command Chain/ICS
                                    Incident Commander

                            Public Information   Liaison Officer

                              Safety Officer

           Operations               Planning      Logistics        Finance

Public Works      Law Enforcement
  Branch               Branch

         Unified Command
 Enables all agencies with
  responsibility to manage an
  incident together by
  establishing a common set
  of incident objectives and

 Allows Incident Commanders
  to make joint decisions by
  establishing a single
  command structure.

 Maintains unity of command.
  Each employee only reports to
                                              Agency 2    Agency 3
  one supervisor.                 Agency 1
                                              Incident    Incident
                                              Commander   Commander
Disaster Management
        Chemical Disasters
•May result from industrial
accidents, accidental
exposure, or terrorist acts

•Chemical Agents of
  Nerve agents
  Blood agents
  pulmonary agents
Agencies/Partners Involved
 Federal Bureau of Investigation (FBI)
 Military
 US Department of Health and Human
  Services (HHS)-Centers for Disease Control
  and Prevention (CDC)
 Other Federal partners
 Governors Office of Homeland Security and
  Emergency Preparedness
 Fire/Hazmat
Agencies/Partners Involved
 Department of Environmental Quality
 Department of Health and Hospitals
 Law Enforcement: Louisiana State Police
 Louisiana State National Guard
 Department of Public Works
 Department of Wildlife and Fisheries
 Department of Agriculture and Forestry
 Other state agencies
Agencies/Partners Involved
 Local Parish Office of Homeland Security
  and Emergency Preparedness Office
 Louisiana Poison Center
 Healthcare facilities
 Medical Examiners/Coroners
 Animal Control
 Local Partners
 LAVA: Volunteers agencies/volunteers
             Nerve Agents
 Most toxic of chemical warfare agents and inhibit the
  body’s normal functions
 Dangerous to humans and can be utilized as potential
  weapons by terrorist
 Act as acetylcholinesterase inhibitors which produce
  the same signs and symptoms of organophosphate
          Nerve Agents
 Sarin          Odorless

 Soman          Slight camphor odor

 Tabun          Faint fruity odor

 VX             Odorless
 Nerve Agents Exposure
 Inhalation
    Can be dispersed as
     aerosols, vapors, or
    Vapors: absorbed by
     inhalation and vapor
    Immediate onset of
 Nerve Agents Exposure
 Ingestion              Skin/eye
    Readily absorbed       Onset depends on
                             concentration; can be
                             delayed for several
               Safety Risk
 First responders are trained individuals who will
  respond to the event
 Nurses should not be first responders unless you have
  been trained on hazardous materials or part of a fire
  response team
Signs and Symptoms
Signs and Symptoms
 Mild          Severe
                   Muscle weakness
                   Fasciculations
                   Respiratory failure
                   Coma
                   Seizures
                   Permanent damage to
   Miosis          the CNS after high toxic
   Nausea
   Diarrhea
Real Life Incidents
 Sarin incident in Tokyo-1995

 Carbamate insecticide methomyl was added to salt at a
 restaurant in Fresno, California-1999
   Exposure to Healthcare
 Tokyo incident several people were exposed.
  Contaminated individuals may self present to a
 Healthcare workers must wear PPE and use it
 Contaminated individuals must be
Exposure to Healthcare
 Sudden and severe symptoms may occur hours after
  treatment/contamination (through skin)
 You must have appropriate PPE to approach any
  contaminated victim
 Standard
 Airborne
 Droplet
 Contact
          PPE Equipment
 Determined by the type and level of exposure and
  duration of exposure
 Nerve agents are absorbed through intact skin and
  even through the clinical examination gloves
Exposure        Treatment
Skin            Decontaminate using
Inhalation      If severe symptomatic,
                consider antidote use.

                If signs/symptoms
                progressing continue antidote

                If breathing has stopped or is
                difficult use artificial
Exposure        Treatment
Eyes            Immediately flush eyes with
                water for 10-15 minutes

Ingestion       Do not induce vomiting
                Consider Mark I kit use
 Adults
    Atropine 2mg
    Pralidoxime (2 Pam)
 Children
    Pediatric atropine
     autoinjector is now
 Supportive therapy and
  assisted ventilation as need
 Benzos for prevention of
       Strategic National
 Managed Inventory
 Antivirals
 Vaccines
 Federal Medical Stations
Pharmacy’s Role
 Hospital/EMS Containers (contents are different)
   Mark 1 Kits
   Atropine Sulfate 0.4mg/mL
   Pralidoxime 1gram vials
   Atropen® 0.5mg auto-injectors
   Atropen® 1mg auto-injectors
   Diazepam 10mg/2mL auto-injectors
   Diazepam 5mg/mL 10mL
   Sterile Water for Injection 20mL single use vials
 Prepositioned across the state. Locations are
 Louisiana Poison Control
   1-800-222-1222
   Will provide consultation on symptoms of nerve agents
    and organophosphate poisoning to first responders and
    health care professionals.
   Will provide assistance regarding dosing questions.
Labeled Containers with

 Duodote eventually will replace Mark I Kits
  Scene Safety Management

 Minimize casualties
 Decontamination
 Triage
 Antidote therapy
 Crisis scene
        Emergency Medical
       Service's (EMS) Role
 EMS has 2 Mark I Kits available on the ambulance
 State Police will pick up EMS container if CHEMPACK
  is needed
 Administer Mark 1 Kit per protocol
 Airway support and ventilation. Perform endotracheal
  intubation if needed.
 Circulatory support: IV therapy and pulse oximetry
 Consultation with Louisiana Poison Control
           Field Treatment
Exposure    Symptoms                Initial Dosing*     Repeat Dosing
                                    (EMS/Field)         (Transport/Hospital)

Mild        DUMBBELS                Observe or MARK 1   Observe

Moderate    DUMBBELS                2 Mark 1**          Atropine 5-10 min
             Agitation                                  2-PAM q 30-60 min
             Respiratory distress

Severe      DUMBBELS                3 MARK 1***         Atropine 5-10 min
             Respiratory distress   Diazepam            2-PAM q 30-60 min
             Seizures                                   Diazepam q 2-5 min
           Hospital’s Role
 Ventilatory support: patients with respiratory failure
  and compromised airways will require immediate
  endotracheal intubation and positive pressure
 Oxygen supplement
 Decontamination before entering the emergency
 Suctioning for removal of bronchial secretions
 Gastric decontamination-activated charcoal
           Hospital’s Role
 Observation
 Treatment-Atropine and Pralidoxime
 Monitoring for seizure activity (administering
  anticonvulsants for prevention)
 Recovery may take several months
 Risk of permanent damage to the Central Nervous
  System (high dose exposure)
 Consult with the Louisiana Poison Center
  Patient       Mild/Moderate Effects1                              Severe Effects2                                      Other Treatment

                 Atropine:                         Atropine:                                              Assisted ventilation for severe exposure.
Child            0.05mg/kg IM or                   0.1mg/kg IM or                                         Repeat atropine at 2-5 minute intervals until
                 IV (minimum 0.1mg                 IV (minimum 0.1mg,                                     secretions have diminished and airway resistance
                 Maximum 5mg)                      maximum 5mg)                                           has decreased.
                                                                                                          Repeat 2-PAM chloride once at 30-60 minutes,
                           AND                                            AND
                                                                                                          then at one-hour intervals for 1-2 doses, as
                 2-PAM:                            2-PAM:
                 25mg/kg IM or                     50mg/kg IM or                                          Diazepam for seizures:
                 IV (maximum 2Gm                   IV (maximum 2Gm IM or 1Gm IV)                          Child - 0.05 to 0.3 mg/kg IV
                 IM or 1Gm IV)                                                                            (maximum 10 mg);
                                                                                                          Adult - 5 mg IV
                                                                                                          Other benzodiazepines (e.g. lorazepam) may
                                                                                                          provide relief.
                                                                                                          Phentolamine for 2-PAM chloride-induced
                                                                                                          1 mg IV for children; 5 mg IV for adults.
                 Atropine:                         Atropine:
Adult            2 to 4 mg IM or IV                6mg IM
                            AND                                           AND
                 2-PAM3:                           2-PAM3:
                 600mg IM, or                      1800 mg IM, or
                                                   50mg/Kg IV slowly

1.   Mild/Moderate effects of nerve agents include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea.
2.   Severe effects of nerve agents include unconsciousness, seizures, apnea, flaccid paralysis.
3.   Dose selection of 2-PAM chloride for elderly patients should be cautious (usually starting at 600 mg IM, or 25 mg/kg IV slowly) to account for the
     generally decreased organ functions in this population.
NOTE: 2-PAM chloride (2-PAM) is pralidoxime chloride, trade name Protopam®.
CHEMPACK: CHEMPACK is a federal program to provide nerve agent antidotes (Atropine, 2-PAM, Diazepam) to during an emergency.
Additional Assistance: Contact the at 800-222-1222 or 318-813-3317 for additional information regarding dosing.
            Hospital’s Role
 Employee training
 Hospitals are going to be
  reserved for your
  critically ill individuals
 Medical Surge
 Decontamination
 Treatment/Supportive
Public Health Preparedness
 Strategic National Stockpile
 Exercises, drills, trainings
 State and local planning efforts
 Paradigm shift to all hazards approach
Public Health’s Role
 Promote life safety through education, information
  and planning
 Goal is to prevent illness by minimizing exposure and
  rapid, effective response
 Provide medical intelligence such as knowledge of
  antidotes and symptoms of exposure
 Procure resources available to the State with forward
  placement whenever possible
     Public Health’s Role
 Provide guidance for use of assets under the direction
  of the State Health Officer
 Participate as ESF 8 in Incident Command and/or
  Unified Command
 Assist in the development of factual communication
  for multiple audiences during response
 Promote behavioral health
     Public Health’s Role
 Conduct epidemiological investigations
 Coordinate laboratory services
 Participate assessments and actions to minimize the
 health and environmental impacts
     Office of Public Health
          Nurse’s Role
 Planning, preparedness, and response
 Assessment
 Triage
 Treatment/Education
 Sheltering
          Personal Safety
 Having a family emergency plan
 Decontamination of self
 Emergency Communication Devices
 Vulnerable Populations
 Communication
 Establish safe shelter
 Food and water
 Shelter in place versus Medical Special Needs Shelters,
  General Population Shelters, Critical Transportation
  Needs Shelters
 Rely on existing agencies
 Will need assistance if decontamination is needed
 Time of day when incident happens
 If exposed, remove all clothing immediately and wash
  with copious amounts of soap and water.
 Shelter in place: Go indoors, close all windows, doors,
  and close up the building. Turn off fans, air
  conditioners, and heaters. Move to a lower, inner
  room vs. higher room for floods
 Listen to the local news and radio for further
 Contaminated clothing should be double bagged.
 Food and water
      CHEMPACK Response
      Operation Overview
 Step 1: Event- a suspected chemical or biological
  incident occurs. 911 is notified of the situation and the
  need for security considerations or medical attention
  for/by the public. At this time, 911 operators also
  notify the parish Office of Homeland Security and
  Emergency Preparedness of the event.
 Step 2: Isolation- security and medical responders
  will follow local parish protocol for isolation and triage
  for treatment.
     CHEMPACK Response
     Operation Overview
 Step 3: CHEMPACK Standby/Alert- the Louisiana Poison
 Center will be notified by either the field Incident
 Commander or the 911 Operations Center that there is a
 suspected nerve or organophosphate incident. Triaging
 assistance is provided to the Incident Commander an on-
 scene first responders. Since positive identification of the
 substance involved is nearly impossible in the initial
 response, symptoms consistent with a nerve agent or
 organophosphate exposure will be sufficient for
 recommending appropriate treatment and release of the
         Louisiana Poison Center: 1-800-222-1222
     CHEMPACK Response
     Operation Overview
 Step 4: CHEMPACK Activation- If the Tier I assets
 are insufficient to meet the need, then the Louisiana
 Poison Center activates this CHEMPACK plan. The
 Louisiana Poison Center will notify appropriate Host
 Sites with a request for Tier II countermeasures via the
 CHEMPACK assets. The Louisiana Poison Center
 considers such factors as wind trajectory, volume of
 patients, and treatment needs when selecting Host
 Site(s) and Receiving Site (s) for CHEMPACK supplies.
 Louisiana Poison Center will notify Host Sites to open
 containers and prepare appropriate “allocations” for
      CHEMPACK Response
      Operation Overview
distribution. Further, Louisiana Poison Center
  coordinates transportation with Louisiana State Police.
 Step 5: Countermeasures- Tier II CHEMPACK assets
  will be dispensed as per the plan and appropriate
  Regional plan(s).
 Step 6: Collection/Transportation of a Specimen-
  A request may be made to transport a sample of the
  substance/agent to the State Lab for analysis.
           Scenario Facts
 XYZ Plant located in       It’s Friday, January 14
  Somewhere, Louisiana in     something has been
  Region 10                   dispersed into the
 Has a population of         ventilation system at the
  approximately 300           XYZ Plant and no one is
  employees on duty           aware.
Labeled Containers with

 Decontamination on Scene
Decontamination of
Vehicle              Decontamination Tent
Mass Casualty Incident
               Phone Calls
 You are the nurse
 working in the triage line.  What symptoms should
                               the PHN tell her to
                               watch for?
 Contact the Louisiana Poison Control Center
  1-800-222-1222 for questions/concerns
 Nerve agents exposure serious medical emergency
 For life saving measures rapid administration of
 Remember DUMBBELS
 Always wear appropriate PPE before taking care of any
 Most toxic of chemical agents
 Triage
 Treatment: Decontamination, Rapid antidote therapy,
 supportive therapy, and ventilator assistance,
 Anticonvulsants for prevention of seizures
            Future Topics
 Chemicals Agents
    Blistering agents/vesicants
    Tissue/Blood agents
    choking/lung/pulmonary agents
 Biological Agents
 Radiological Agents
             Future Topics
 Disaster triage
 Decontamination
 Centers for Disease Control and Prevention
   Veenema, Tener Goodwin., Ready RN: Handbook for
    Disaster Nursing and Emergency Preparedness, 2009.
   Agency for Toxic Substances and Disease Registry
   American Academy of Pediatrics
   Louisiana Emergency Operations Plan
   State/Regional CHEMPACK Response Plan
      Password for
SurveyMonkey Participant
       (all uppercase)
            Contact Us
Louisiana Department of Health and Hospitals
            Office of Public Health
     Center for Community Preparedness
          8919 World Ministry, Ste. B
            Baton Rouge, LA 70810
         Sherhonda Harper, RN, MHA
 Statewide Nurse Consultant, Nursing Services
           Emergency Preparedness
            (225) 763-5740-OFFICE
              (225) 763-5727-FAX

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