Emergency Preparedness Conference by fjzhangweiqun

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									Emergency Preparedness Conference
           April 2006

      Dr. Mark Cunningham

  Personal Protective Equipment




                                    1
    Personal Protective Equipment (PPE)

Areas to be covered
Personal Protective equipment for:
•     Blood-borne pathogen protection
•     Airborne respiratory particulates
•     Permeable, semi-permeable and non-permeable
      barrier protections
•     Radiological detectors
•     Nerve Agent Antidotes


                                                    2
                Barrier Protections

1. Barrier protections place a layer of protection between a
   person’s skin and the environment.
2. Barriers can be semi-permeable and non-permeable
3. Barriers may cover specific areas of the body or may
   cover the entire body.
4. Barriers can be single to multiple layers.
5. There is no absolute perfect protection.




                                                               3
                      Airborne protection

1. Airborne protection can be a simple as a mask
   or as complex as a sealed chemical suit system using self
   contained breathing apparatus
2. Masks maybe used to protect others from respiratory
   particulates of the person wearing the mask
3. Masks maybe protective of both the wearer and those
   around them from respiratory particulates.
4. Masks can be simple face covers to complex Powered Air
   Purifier Respirators (PAPRs).




                                                               4
           Blood-Borne Pathogen Protection

1. Equipment and procedures used to protect from blood
   and blood products.
2. Protections may be permeable, semi-permeable and
   non-permeable barriers.




                                                         5
Radiological Detectors

1. Detectors are used during and after decontamination.
2. Detectors are used to look for radioactive particles.
   (Geiger counters)
3. Dosimeters are used to measure personal radiation doses
   from radiation exposure.
   (care givers working in potential radioactive environments
   will need to monitor their radiation exposure levels.)




                                                           6
Nerve Agent Antidotes

1. Types of Nerve Agent Antidote (Auto-injectors)
2. Recognition of symptoms of nerve agent poisoning
3. Administration of nerve agent antidote (Auto-injectors)
4. Indications/contra-indications




                                                             7
Hand protections – stronger barriers
cause loss of dexterity




                                       Butyl rubber gloves – NBC protection


  Simple barrier Latex gloves




                                                  Surgical gloves

                                                                        8
 Nitrile gloves – improved barrier
Hand Protection




                  9
Simple Face Masks




                    10
   Improved Face Mask offering improved
   particulate protection.




Simple cup mask                  N-95 mask




                                             11
Simple Masks with face shields




                                 12
Full Face Shield




                   Offers splash protection for the face




                                                           13
14
Head covers




              Wrap-around head cover




                                       15
                            PAPR Head Covers
                       Offers full head protection




Reusable butyl head cover                       Disposable head cover.



                                                                         16
Foot Covers




   Disposable foot covers




                            17
Foot covers - Chemical protective foot covers




                         Foot covers




      Protective boots


                                                18
Semi-permeable gowns




                       19
Gowns worn with Air-Mate




                           20
            Tychem protective suit




Complete body cover using Breathe Easy PAPR and chemical protective suit




                                                                           21
22
Section One

Regional Air-Mate Bag contents
1. Bag to hold Air-Mate and components
2. Air-Mate Unit
3. Waist Belt
4. Rechargeable battery
5. Black four-foot hose
6. HEPA filter
7. White breathe easy replaceable head cover
8. Air flow indicator
9. Guidelines (inventory list, donning, doffing, maintenance)



                                                           23
Air-Mate power unit – a powered
air purifying respirator (PAPR)
that is a battery-powered system
that uses a small HEPA filter to
clean ambient air before it is
delivered to the wearer.

1. A PAPR system typically
includes a blower/filter unit/battery
pack (base unit), a head piece, and     Air-Mate system
a breathing tube that connects the
base unit to the headpiece.



                                                          24
2. Back of unit is opened by
releasing a four prong system




                                25
3. HEPA Filter is placed
into the unit directly under
the back cover. (Arrows
pointing into the unit)




                               26
4. The battery is gently placed into
the lower half of the unit under the
filter and is attached into a raised
prong system (insure the safety
keeper is slid closed to secure the
battery inside the unit)


                                       Air-Mate with Battery Removed




                                                                       27
  Air-Mate with Battery Inserted
5. Waist belt is attached to Plastic Body of the Air-Mate




                     Belt is adjustable to fit individual



                                                            28
6. Black Hose attachment to Air-Mate Unit




                                            29
7. Black hose attached to head cover




                                       30
8. Charging port and attachment of charging unit




                                                   31
  9. Air Flow Indicator
                                                          Lower band




Performance check using Air Flow Indicator
1. Ensuring the breathing tube is connected to the PAPR unit.
2. Hold the free end of the tube up and drop the black bullet
    shaped air flow indicator (pointed end first) into the hose opening.
3. Switch the Air-Mate PAPR unit on and look at the
    Air Flow Indicator at eye level.
4. The Air Flow Indicator should float on the air coming out and the
    lower band of the Air Flow Indicator should be above the connectors rim.
5. If the Air Flow Indicator fails to rise, air flow is insufficient. DO NOT USE.
6. Remove Air Flow Indicator prior to attaching Black Hose to the head cover.

                                                                            32
Floating air flow indicator

                              33
10. Guidelines will be kept inside the Air-Mate bag for
reference as needed

11. Use of Air-Mate should following 3M recommendations.

Air-Mate 3M User Instruction Manual 520-03-63R01
and 231-01-30.

Hood 3M User Instruction Manual 522-01-11 and 522-02-17.

12. PAPRs (Air-Mate) should be used following OSHA standards
    for respirator use.



                                                           34
                           Section Two
                Donning of Air-Mate HEPA System

1. Inventory Contents of Air-Mate Bag
2. Insure battery is charged and properly inserted in unit
3. New HEPA Filter should be in place (Arrows pointing into unit)
4. Back of unit secured
5. Waist Belt in place
6. Black (four-foot) Hose attaches to unit with a twisting lock
   mechanism to lock the hose (two pins, push in and twist clockwise)
    a. Perform air flow test using Air Flow Indicator.
7. Attach Black Hose to head cover
8. Remove paper shield on head cover
9. Push the On button and check for air flow inside hood.
   (On button has nine raised dots and located on the front of the unit)
                                                                 35
10. Adjust and secure waist belt around wearers waist.
11. Place head cover over head rechecking for air flow
12. Fully charged battery should last eight hours.
13. The Air-Mate unit requires training to use, but does not
require fit testing.
14. Do Not use this unit in oxygen poor environments
or in chemically contaminated environments.




                                                               36
           Indications/Contra-indications for Use

•Air-Mate HEPA system helps provide respiratory protection
against airborne particulate contaminants.
•Do Not use Air-Mate systems in oxygen deficiency and chemical
contaminated environments.
•Do Not enter a contaminated area until the unit has been
properly donned and is working.
•Immediately leave contaminated areas if the air flow in the
hood stops, breathing becomes difficult, you feel dizzy or your
vision is impaired or if you suspect the respiratory unit is
no longer providing adequate protection.



                                                           37
Air-Mate On and Off button



                             38
Donning HEPA filtration (PAPR)
• Select appropriate body cover
• Attach Turbo PAPR Unit to waist and secure waist belt
• Place head cover over head




                                                          39
       Section Three
       Doffing Air-Mate HEPA System


1. With unit running, remove breathe easy head cover
   from wearers head
2. Detach waist belt
3. Turn unit off
4. Remove the back cover of Air-Mate
5. Remove the HEPA Filter and properly dispose of
6. Clean the unit following cleaning procedures
7. Place new filter in the unit
8. Charge the battery by plugging in the charger into Air-Mate unit



                                                             40
Doffing HEPA Filtration (PAPR)
1. With unit running remove breathe easy head cover
2. Detach waist belt
3. Turn unit off
4. Clean following cleaning procedures
5. Place new filters on unit
6. Change battery/charge battery




                                                      41
              Section Four
              Maintenance and Cleaning of Air-Mate HEPA System
1.  Disassemble hood hose and air-mate unit
2.  Open back of unit
3.  Remove filter and battery
    (unit is not water proof - do not submerse unit)
4. Cleaning solvents will weaken and dissolve the plastics
    (clean the unit and parts with a mild cleaning solution of soap and
    water, ensure water doesn’t enter the motor assembly.)
5. Flush the four-foot black hose with mild cleaning solution of soap and
    water inside and out. Flush with clean water and let drain until dripping stops,
    immediately connect the breathing tube to an assembled Air-Mate (PAPR) Unit
    and run system for a minimum of 30 minutes with the breathing tube hanging
    downward.
6. Properly dispose of filter
7. Properly dispose of breathe easy head cover
8. Ensure battery is placed back into unit with a new filter
    (Unit Back is secured)
9. Recharge Battery.
10. Web belt is cleaned with mild cleaning solution of soap and water
11. All parts are placed in Air-Mate Bag                                           42
43
Powered Air Purifier Respirators (PAPR)
             Breathe Easy

  4 Areas to be covered
  1. PAPR bag contents
  2. Donning of PAPR System
  3. Doffing of PAPR System
  4. Maintenance and Cleaning




                                          44
Objectives
1. Familiarization with PAPR system
2. Proper Use of PAPR system
3. Indications/contra-indications
4. Proper Maintenance and Cleaning




                                      45
Indications:
Chemical Protective suit and Breathe Easy PAPR are
indicated for:
     • Decontamination for contaminated patients
     • Working in a contaminated environments (nuclear,
        radiological, chemical, and biological)

Contra-Indications:
Oxygen poor environment.

Warning:
• Breathe Easy PAPRs cannot provide oxygen in an
  oxygen deficient environment.
• Chemical Protective suit can promote heat stress.
                                                          46
Section One
Regional PAPR Bag Inventory/contents
1. Black 3M Carrying Bag to hold PAPR and components
2. 3 each HEPA filters
3. 3 each NBC filters
4. Disposable battery
5. 2 each Breathe Easy replaceable head covers (1-blue, 1-white)
6. 1 each flow meter
7. 1 each black four foot hose
8. 1 each olive colored hose cover (to cover black hose)
9. 1 each breathe easy turbo unit
10. 1 each waist belt
11. 1 each reusable butyl head cover with cape – olive colored
12. 1 each Chemical Protective suit
13. 1 pair butyl rubber gloves
14. 1 pair nitrile gloves
15. 1 pair chemical protective over boots
16. 1 roll duct tape
17. Guidelines (inventory list, donning, doffing, maintenance)
                                                                   47
                      Operator Checklist #1

HEPA Donning Guidelines
1. Inventory black 3M bag
2. Attach 3 each HEPA filters to Turbo Unit
3. Verify waist belt is on Turbo Unit
4. Verify black hose is attached to turbo unit
5. Attach disposable white or blue (proper fitting) head cover to black hose
6. Un-box and attach lithium battery to turbo unit with keyed
    3-prong connector and attach battery clip to waist belt
7. Locate switch on battery, turn unit on
8. You will hear turbo fan unit and feel air flow into hood
9. Do not wear unless you hear fan and feel air flow
10. Wear appropriate body cover for environment
11. Attach turbo PAPR unit to waist and secure waist belt
12. Place head cover over head
13. Maximum use of 12 hours for battery and filters



                                                                           48
                       Operator Checklist #2

NBC Donning Guidelines
1.    Inventory black 3M bag and don chemical protective suit, boots and
      gloves
2.    Attach 3 each NBC filters to Turbo Unit
3.    Verify waist belt is on Turbo Unit
4.    Verify black hose is attached to turbo unit and install butyl hose cover
      over black hose
5.    Attach reusable butyl head cover with cape to black hose
6.    Un-box and attach lithium battery to turbo unit with keyed
      3-prong connector and attach battery clip to waist belt
7.    Locate switch on battery, turn unit on
8.    You will hear turbo fan unit and feel air flow into hood
9.    Do not wear unless you hear fan and feel air flow
10.   Attach turbo PAPR unit to waist over chemical protective suit and secure
      waist belt
11.   Place butyl head cover with cape over head ensure cape lays over butyl
      covered black hose
12.   Maximum use of 12 hours for battery and filters
                                                                             49
            Cleaning and Maintenance
Cleaning of PAPR unit
• 3M has several recommended cleaning solutions, to be
    used as a spray and wiped off to clean unit
2. A water (10) to bleach (1) solution may be used
3. Disposable white and blue head covers maybe worn by a
    single individual and cleaned between uses. Never to be
    shared. If any cracks or tears are noted or the black hose
    does not seat properly, dispose of head cover.
4. Butyl cover for the hose and the butyl head cover with cape
    can be cleaned inside and out and reused as needed.
5. Black hose can be cleaned and reused.
6. Turbo unit should be cleaned with filters attached. Remove
    filters and wipe the threaded filter fittings with cleaning solution.
7. Do not spray cleaning solution directly into turbo unit.




                                                                            50
          Cleaning and Maintenance

Maintenance
1. Battery life should be noted.
2. If rechargeable battery is used, track the usage
3. Filters should be disposed of appropriately after each usage.




                                                            51
                  Indications/Contra-Indications

Indications
1. HEPA filtration is used for respiratory protection
    against airborne particulate contaminants.
2. NBC filtration is used for respiratory protection
    during decontamination of suspected NBC contaminated patients.

Contra-Indications
1. Do Not Use PAPR unit (HEPA/NBC) in oxygen deficient environments.
2. Do Not Use HEPA PAPR filtration in chemical contaminated environments.
3. Do Not Enter a contaminated area until the unit has been properly donned
   and is working with the appropriate filtration and body protection.
4. Immediately leave the contaminated area if the air flow stops, breathing
   become difficult, you feel dizzy or your vision is impaired, or if you suspect
   the respiratory unit is no longer providing adequate protection.


                                                                          52
Breathe Easy Turbo unit – a
powered air purifying respirator
(PAPR) that is a battery-powered
system that uses filters to clean
ambient air before it is delivered to
the wearer.

1. A PAPR system typically
                                        PAPR system with block hose, waist belt
includes a blower/filter unit/battery   and power connection

pack, a head cover, and a breathing
tube that connects the turbo unit to
the head cover.



                                                                                  53
2. Filters for PAPR unit



                             NBC filters in foil packs




                              NBC Filter                 54
    HEPA filters in 3 pack
                   3. Filters are attached to the turbo unit
                   and battery is attached to waist belt


                                             Turbo unit with filters




Turbo unit without filters




                                                                       55
                            Head Covers



            1. Disposable white or blue head cover.
            2. Reusable butyl head cover




Reusable butyl head cover                 Disposable head cover.



                                                                   56
Turbo unit with black hose covered by olive colored cover




                Attaching black hose to head cover
                                                            57
Battery switch - Turning on the PAPR Unit with power cord
attached to battery




                                                            58
Donning HEPA filtration (PAPR)
• Select appropriate body cover
• Attach Turbo PAPR Unit to waist and secure waist belt
• Place head cover over head




                                                          59
Doffing HEPA Filtration (PAPR)
1. With unit running remove breathe easy head cover
2. Detach waist belt
3. Turn unit off
4. Clean following cleaning procedures
5. Place new filters on unit
6. Change battery/charge battery




                                                      60
Donning NBC filtration (PAPR)
1.    Don chemical protective suit, boots,gloves, and
      duct tape all seams
2.   Attach NBC filter to turbo unit
3.   Verify black hose with butyl cover is attached to
      turbo unit and butyl head cover
4.   Attach battery to waist belt
5.   Connect battery to turbo unit
6.   Turn unit On, verify air flow
7.    Attach turbo PAPR unit to waist over chemical suit
8.    Place butyl head cover with cape over head




                                                           61
62
NBC Donning Guidelines
Don chemical protective suit, boots and
    gloves



   Place feet into suit




                                          63
Chemical Protective boots placed over feet of suit.




                                                      64
Alternate boots may be used
                              Tape all seams




                                   Donning Nitrile gloves




       Boots taped                                 65
Donning suit




               66
Tucking the hood in




                      67
                         Suit closed and seams taped (sealed)




             Butyl rubber gloves
             placed over nitrile gloves

(Do Not over-tighten tape at
                                                                68
wrists and boot tops)                     All seams taped
NBC Donning Guidelines
1.   Inventory black 3M bag and don chemical protective suit, boots and gloves
2.   Attach 3 each NBC filters to Turbo Unit
3.   Verify waist belt is on Turbo Unit
4.   Verify black hose is attached to turbo unit and install butyl hose cover over
     black hose
5.   Attach reusable butyl head cover with cape to black hose
6.   Un-box and attach lithium battery to turbo unit with keyed 3-prong connector
     and attach battery clip to waist belt
7.   Locate switch on battery, turn unit on
8.   You will hear turbo fan unit and feel air flow into hood
9.   Do not wear unless you hear fan and feel air flow
10. Attach turbo PAPR unit to waist over chemical protective suit and secure
    waist belt
11. Place butyl head cover with cape over head ensure cape lays over butyl
    covered black hose
12. Maximum use of 12 hours for battery and filters                                  69
                                       Breathe Easy PAPR equipment and bag
                                      Regional PAPR Bag Inventory/contents
                                      1.    Black 3M Carrying Bag to hold PAPR and components
                                      2.    3 each HEPA filters
                                      3.    3 each NBC filters
                                      4.    Disposable battery
                                      5.    2 each Breathe Easy replaceable head covers (1-blue, 1-
                                            white)
                                      6.    1 each flow meter
                                      7.    1 each black four foot hose
Inventory black 3M bag and            8.    1 each olive colored hose cover (to cover black hose)
don chemical protective suit, boots   9.    1 each breathe easy turbo unit
                                      10.   1 each waist belt
and gloves
                                      11.   1 each reusable butyl head cover with cape – olive colored
                                      12.   1 each Chemical Protective suit
                                      13.   1 pair butyl rubber gloves
                                      14.   1 pair nitrile gloves
                                      15.   1 pair chemical protective over boots
                                      16.   1 roll duct tape
                                      17.   Guidelines (inventory list, donning, doffing, maintenance)
                                                                                                 70
Attach 3 each NBC filters to Turbo Unit
Verify waist belt is on Turbo Unit
Verify black hose is attached to turbo
unit and install butyl hose cover over
black hose




                                     71
Un-box and attach lithium battery to turbo unit with keyed 3-prong
connector and attach battery clip to waist belt



                                                                     72
Locate switch on battery, turn unit on
                                         73
Attach reusable butyl head cover with cape to black hose




                                                           74
  Place butyl head cover with cape over head
  ensure cape lays over butyl covered black hose




You will hear turbo fan unit and feel air flow into hood
Do not wear unless you hear fan and feel air flow

                                                           75
Complete suit with Breathe Easy PAPR

                                       76
Doffing NBC filtration PAPR
1.   Decontamination of suit, hood and turbo unit to be completed
     prior to doffing
2. With unit running, remove waist belt.
3. With hood cover on head, remove chemical protective suit
     to below waist level
4. Butyl hood cover is lifted overhead and placed to side for
     proper cleaning
5.   Feet are removed from chemical protective suit
6.   Suit is properly disposed.
7.   Turbo PAPR unit, hose, head cover, and battery cleaned
     following cleaning procedures.
8.   Place new filters in unit
9.   Change or charge battery

                                                                    77
                                                       Doffing
                                       Decontamination of suit, hood and turbo unit to
                                           be completed prior to doffing




Roll cape to expose waist belt

                                                                With unit running,
                                                                remove waist belt.




                                 Unseal the suit center seam

                                                                                     78
Remove arms one at a time from suit and butyl gloves leaving nitrile gloves on
(Place running turbo unit on chair)




                       Lower suit to waist




    Carefully lift cape and hood off the head with eyes closed
                                                                            79
Carefully remove feet one at a time
from the suit as the legs of the suit
are pushed toward the feet




                                        80
Once the feet are out of the suit, remove the nitrile gloves, and
step away and properly dispose of the suit.




                                                                    81
After decontamination and doffing of chemical protective suit
and Breathe Easy PAPR

•    Properly dispose of the chemical protective suit
     and filters (treat as contaminated)
2.   Clean Breathe Easy PAPR following established cleaning
     procedures (Directions included in Breathe Easy Bag)
3.   Reconstitute the Black Bag following the inventory
4.   Recharge the battery
5.   Reseal bag for future need.




                                                                82
83
Indications:
1. To establish the presence or absence of radioactive material
2. To ascertain the level of radioactivity

Contra-indications:
1. None – no contra-indications for monitoring.




                                                           84
Personal Protective Equipment (PPE) - Radiological Monitors


           Areas to be covered
           •   Indication for usage
           •   Types of monitors
           •   Monitor use
           •   Maintenance




                                                              85
Types of Equipment

1. Personal dosimeter film badge

2. Personal reusable dosimeter pen

3. Survey meter (Geiger counter)




                                     86
Personal Dosimeter film badge

1.   It is x-ray sensitive film covered with copper filters.

2.   It is used to monitor exposure to radiation (x-ray and gamma rays)

3.   Personal badges are used to read accumulated exposure over time
     (usually three months)

4.   Badges are one time use – not reusable.

5.   Badges require a lab to process and is used for occupational exposures.

6.   Film badges are not used for emergency exposures.

7.   Film badges should never be used to determine the presence of
     radiation.

                                                                           87
Film Badge
             88
Film badge in use


                    89
Personal reusable dosimeter pen

1.   Personal pocket pen.
2.   Used for short period of time to read on-site exposure to
     radiation (gamma)
3.   It is used in radiological emergencies for accumulated exposure to radiation.
4.   The pen should never be used to determine the presence of radiation.
5.   The pen is recharged and reset between uses (using dosimeter charger)
6.   Dosimeter pen measure accumulated exposure in roentgens (RADS).




                                                                             90
Dosimeter Pen use

1.   Dosimeter pen is carried usually in a shirt pocket
2.   The pen should be charged (zeroed) before use.
3.   After exposure the pen can be read by looking into the lens
     end (optical viewing end)
4.   The pen should be held up to a light source (to see the internal scale).
5.   The pen scale is zero to 200 (big bad stuff)
6.   Read the indicated exposure by the hairline indicator on the scale.




                                                                                91
                 Viewing lens end




Dosimeter pens




                 Charging end

                                    92
    Dosimeter pen charger

    1. Used to charge (zero) dosimeter pen.

                                              Zero adjuster
Dust cover
over the
charging contact




                                                              93
Dosimeter Pen Charging procedures

1. Remove charging contact dust cover
2. Lightly press pen (charging end) onto charging contact.
3. While holding pen down look into viewing lens end.
4. Turn the zero adjuster until the hairline indicator is zeroed
   (charged)
5. Remove the pen from the charging contact
6. Replace the charging contact dust cover.
7. Verify the pen is zeroed by looking through viewing
   lens at a light source




                                                              94
Survey meter (Geiger counter)

1.   The meter is used to establish the presence or absence of radiation.
     (gamma and beta particle)
2.   The meters measure the strength of radiation.
     (1x milli RADs/hour to 100x milli RADs/hour)
3.   The meter will not measure accumulated radiation exposure.
4.   Meters will give a measurable reading on a gauge and
     may have an audible sound to indicate radiation levels.
     (the clicking sound clicks faster as the radiation level increase)
5.   The meter is battery operated and hand held.
6.   Some meters have a probe unit with a probe cover which can measure
     beta particles. (probe cover closed – gamma, probe cover open – beta)




                                                                             95
Survey meter operation

1.   Insure batteries are in place inside the meter.
     (to check the batteries, open the snap closures and inspect
     the battery compartment)
2.   The unit is stored without batteries and uses 1-4 “D” cell batteries.
3.   To check unit function:
     • Turn the top switch to 10x (10 milli RAD/hour)
     • Hold the probe to the side of the unit at the operational check source.
     • (Probe cover must be open)
     • The top mounted gauge indicator should respond by moving
4.   To survey a suspected area:
     • Turn the top switch to 1x (1 milli RAD/hour)
     • With probe cover open pass the monitor and probe by the suspected area.
     • If the gauge pegs (maxes) set to 10x or 100x if needed.
     • If the gauge moves close the probe cover and resurvey the area.
     • If the survey monitor gauge shows movement then radiation is present.


                                                                        96
                        Survey monitor (Geiger counter)
    Monitor gauge

                                                          Survey monitor
                                                          probe with
                                                          closed cover



Survey monitor switch




 Snap Closure end




                                                                   97
                     Warning:

      LD-50 is 500 RADs accumulated dose
        (LD-50 is a lethal dose for 50%)



If radiation is present follow established guidelines.




                                                98
99
 Nerve Agent Antidote (Auto-injectors)

Areas to be covered

1. Types of Nerve Agent Antidote (Auto-injectors)
2. Recognition of symptoms of nerve agent poisoning
3. Administration of nerve agent antidote (Auto-
   injectors)
4. Indications/contra-indications




                                                      100
Contaminated environments

1.   Recognizing contaminated environments may be very difficult.
2.   If contamination is suspected, initiate treatment as if
     decontamination will be needed.
3.   Law enforcement, local fire department, EMS, and hospital (ER)
     need to be informed of the situation.
4.   EMS may need to back out of the area until decontamination
     is complete.
5.   Chemical personal protection is required. Fire department
     personnel should bring field decontaminated patients to EMS.
     (Assume contamination still exists)
6.   Treat all injured following established guidelines and
     transport to receiving hospitals. (EMS may be directed to a
     decontamination site).
7.   Everyone who enters the contaminated area or handles
     contaminated patients or equipment requires decontamination.
8.   Upon recognition of the onset of symptoms of nerve agent poisoning,
     nerve agent antidote (auto-injectors) should be administered to those
     with symptoms.                                                          101
Symptoms of Nerve Agent Poisoning

1. Pinpoint pupils (miosis)
2. Dim Vision
3. Headache
4. Secretions everywhere (runny nose, mouth salivation)
5. Bradycardia
6. Faciculation of muscles
7. Defecation
8. Convulsions
9. Broncho spasms
10. Respiratory arrest
11. Death

(Onset of symptoms can be seconds to hours and
symptoms can vary by agent and amount of exposure)
                                                      102
SLUDGE




         103
Nerve Agent Antidote: Auto-Injectors
(three types of auto-injectors)

1. Atropine Auto-injector
2. 2-PAM Chloride Auto-injector
3. Convulsion Antidote for Nerve Agent (CANA)
   Auto-injector (Valium)




                                                104
                  Atropine Auto-injector
Atropine helps to speed the heart back up, affects the
muscles of the body and improves the visual problems. It affects
the secretions in the lungs and on the skin. It decreases the
gastrointestinal affects.




                                                            105
            2-PAM Chloride Auto-injector

2-PAM Chloride affects nerve endings reversing the over-
stimulation of the nerves that lead to convulsions and death.




                                                          106
          CANA (Valium) Auto-injector


Valium auto-injector is used to treat the convulsions,
which is the major indicator of a lethal dose of nerve agent.




                                                           107
Atropen   (Meridian)
     AtroPen®    2 mg, 1 mg, 0.5 mg
     Auto-Injectors
     (atropine injection)
     NDC 11704-106-01 (2mg)
     NDC 11704-105-01 (1mg)
     NDC 11704-104-01 (0.5mg)
     DELIVERS: Available       in three dosage strengths, 0.5mg, 1mg and, 2 mg atropine sulfate
     equivalent in 0.7 mL
     INDICATIONS: Antidote       for organophosphorous (nerve agent/ insecticide) poisoning
     SHELF     LIFE: 3 years from the date of formulation
     STORAGE    REQUIREMENTS: Controlled room temperature 77°F (25°C) [see USP
     Controlled Room Temperature]
     NEEDLE     GAUGE: 22 gauge
     NEEDLE     LENGTH: 0.8" (2.2 cm)
     LENGTH      OF UNIT: 3.9" (10 cm)
     DIAMETER      OF UNIT: 0.6" (1.4 cm)
     PACKAGING         FOR SHIPPING: 12 units per 6 3/4" x 6 1/2" x 4 1/2" box, weighing 1
     pound
     PACKAGED:         12 auto-injectors/box
     PRESCRIPTION         REQUIRED: Yes
     DEA    REGISTRATION CERTIFICATE: Not required
     END    USER CERTIFICATE: Required

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Mark      I
Nerve Agent Antidote Kit
(atropine injection and pralidoxime chloride injection)
Known by the U. S. Armed Services as NAAK
National Stock Number: 6505-01-174-9919
CONSISTS     OF: AtroPen® (2 mg atropine sulfate equivalent in 0.7 mL) and
Pralidoxime Chloride 600 mg Auto-Injector (600 mg pralidoxime chloride in 2 mL)
linked by a plastic holder and housed in a foam pouch
INDICATIONS:   Antidote for organophosphorous (nerve agent/insecticide)
poisoning. Use AtroPen® first followed by Pralidoxime Chloride 600 mg Auto-
Injector
SHELF   LIFE: 5 years from the date of formulation
STORAGE    REQUIREMENTS: Controlled room temperature 77°F (25°C) [see
USP Controlled Room Temperature] Keep from freezing
PACKAGING      FOR SHIPPING: 30 units per 9 3/16" x 6 1/4" x 5 7/8" box, weighing
5 pounds, 8 interior boxes (240 units) per 19 1/16" x 13 1/4" x 13" shipper box,
weighing 40 pounds
PACKAGED:      30 auto-injector kits/box
PRESCRIPTION      REQUIRED: Yes
DEA   REGISTRATION CERTIFICATE: Not required
END   USER CERTIFICATE: Required


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Treatment guidelines

1.   Upon recognition of the onset of symptoms. Administer set number 1:
      1 Atropine auto-injector
      1 2-PAM chloride auto-injector
     (Injector in upper outer thigh muscle without removing clothing)
2.   If symptoms persist after 10 minutes, Administer set number 2:
     1 Atropine auto-injector
     1 2-PAM chloride auto-injector
     (Injector in upper outer thigh muscle without removing clothing)
3.   If symptoms persist after 10 more minutes, administer set number 3:
     1 Atropine auto-injector
     1 2-PAM chloride auto-injector
     (Injector in upper outer thigh muscle without removing clothing)
4.   If victim is having convulsions, administer
     1 CANA (Valium) auto-injector
     (Injector in upper outer thigh muscle without removing clothing)
5.   Save all administered auto-injectors and transport with patient
     (Annotate time and body area auto-injectors administered on run sheet)
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                            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 protective
clothing. Kneeling on a contaminated area will greatly reduce the
protection time afforded by your protective clothing.Place yourself
near the casualty's head, face his feet, and squat behind his left
shoulder.




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          Patient Administration Questions




1. If you (the patient) can walk and are not confused
(you know who you are and where you are), you will
probably not need additional antidote.


2. If your heart is beating very fast and your mouth
is very dry about five to ten minutes after
administering the antidotes, you have enough
antidote.



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Indications:

Signs and symptoms of nerve agent poisoning

Contra-indications:

If no signs of nerve agent poisoning is present do not
administer auto-injectors.




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                       Caution

•Whether you are using an auto-injector always hold it
like a pencil.
•Never hold your thumb over either end.
•An auto-injector will go right through your thumb, out
the nail and squirt the medication all over the ceiling!




                                                           114
Administration procedures

1. Observe universal precautions
2. Perform initial assessment
3. If nerve agent poisoning is suspected, administer one set
    1 Atropine auto-injector
    1 2-PAM chloride auto-injector
    (Injector in upper outer thigh muscle without removing clothing)

Identify the atropine and 2-PAM chloride auto-injectors. Check the expiration date.
Remove the activation cap from the back end of the auto-injector. Sweep target
area with hand to check for wallets or keys.
Place the auto-injector black tip on the thigh at right angle to the leg using a
quick motion, press hard into the thigh until auto-injector functions, hold in
place for several seconds, before removing auto-injector. Massage the injection
area for 10 seconds.

                                                                           115
4. If symptoms persist for 10 minutes, administer set number 2
    1 Atropine auto-injector
    1 2-PAM chloride auto-injector
    (Injector in upper outer thigh muscle without removing clothing)

Identify the atropine and 2-PAM chloride auto-injectors. Check the expiration date.
Remove the activation cap from the back end of the auto-injector. Sweep target
area with hand to check for wallets or keys.

Place the auto-injector black tip on the thigh at right angle to the leg using a
quick motion, press hard into the thigh until auto-injector functions, hold in
place for several seconds, before removing auto-injector. Massage the injection
area for 10 seconds.




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5. If symptoms persist for 10 more minutes, administer set number 3
     1 Atropine auto-injector
     1 2-PAM chloride auto-injector
     (Injector in upper outer thigh muscle without removing clothing)

Identify the atropine and 2-PAM chloride auto-injectors. Check the expiration date.
Remove the activation cap from the back end of the auto-injector. Sweep target
area with hand to check for wallets or keys.
Place the auto-injector black tip on the thigh at right angle to the leg using a
quick motion, press hard into the thigh until auto-injector functions, hold in
place for several seconds, before removing auto-injector. Massage the injection
area for 10 seconds.

6. If symptoms of convulsions, administer CANA (Valium) as above
Identify CANA (Valium) auto-injector. Check the expiration date.
Remove the activation cap from the back end of the auto-injector. Sweep target
area with hand to check for wallets or keys.
Place the auto-injector black tip on the thigh at right angle to the leg using a
quick motion, press hard into the thigh until auto-injector functions, hold in
place for several seconds, before removing auto-injector. Massage the injection
area for 10 seconds.
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It is recommended that (3) Three Atropen auto-
injectors be available for each person at risk for
nerve agent or organophosphate insecticide
poisoning
   (1)   one for mild symptoms
   (2)   two more for severe symptoms

No more than 3 Atropen auto-injectors should
be given, unless the patient is under the
supervision of trained medical provider


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    Pediatric and Elderly Antidote
    Recommended Dosage
         dose strengths are available depending on the patients
Different
age and weight.

    Adults   and Children over 90 lbs.- (Generally over 10 years of Age
              Atropen   2 mg (Green)


    Children   weighing 40-90 lbs.- Generally between 4-10 Years of Age
              Atropen   1 mg (Dark Red)


    Children   weighing 15-40 lbs.- Generally 6 months to 4 years of age
              Atropen   0.5 mg (Blue)




    NOTE!    Children weighing <15 lbs. should ordinarily not be treated with
    Atropen auto-injectors. Atropine doses for these children should be
    individualized at doses of 0.05 mg/kg
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        Emergency Care
Emergency Care of the Severely poisoned
individuals should include-
  Removal       of the oral and bronchial secretions
  Maintenance       of a patent airway
  Supplemental       oxygen
  Artificial   ventilation (If Necessary)

NOTE! Atropine should not be used until
cyanosis has been overcome since atropine
may produce ventricular fibrillation and possible
seizures in the presence of hypoxia
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