Nerve Agent

							   Module 7
Medical Treatment




                    1
Nerve Agent




              2
Treatment - No Signs and Symptoms
• Reassure
• Observe
  – Vapor: 1 hour
  – Liquid: Up to 18 hours




                                3
      Basic Nerve Agent Exposure
              Treatment
• Airway/ventilation
   – High resistance: positive pressure of > 50-70 cm/H20 or
     higher is needed
   – Oxygen
• Antidotes
   – Atropine
   – Pralidoxime Chloride
     (2-PAM Cl)
   – Diazepam



                                                               4
             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

                                          5
Atropine
     • Atropine blocks
       effects of over-
       stimulation
     • Relieves smooth
       muscle constriction
     • Dries up respiratory
       secretions




                              6
                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


                                                               7
                Diazepam
• Administer to patients experiencing
  convulsions
• Consider for patients with severe signs
  and symptoms
• Dosage depends on patient’s age




                                            8
     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



                                                     9
        Signs of Atropinization
• Secretions dry up
• Less labored
  breathing




                                  10
       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



                                            11
            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


                                              12
 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

                                                  13
 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




                                                14
              Adverse Reactions
• Atropine
  – 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

                                                             15
          Atropine Overdose

• Cause: Atropine administered when no
  prior nerve agent exposure has occurred
• Not as serious as underdosing
• Not usually life-threatening




                                            16
    Signs and Symptoms Of Atropine
               Overdose

•   Dilated pupils         • Confusion, delirium
•   Dry mouth and skin     • Temperature control
•   Rapid pulse              diminished
•   Flushed skin           • Intense thirst
•   Difficulty urinating   • Restlessness




                                                   17
   Treatment for Atropine Overdose

• Keep patient cool
• Protect patient from irrational actions
• Transport patient to hospital as soon as
  possible




                                             18
        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



                                                19
    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


                                          20
  Antidote Administration Methods
• Intramuscular (IM)
   – Syringe
   – Auto-injector
• Intravascular (IV)




                                    21
Adult Nerve Agent Treatment: Mild
            Exposure

• 2 mg atropine
   – IM
   – IV
• 2-PAM Cl
   – 600 mg IM
   – 1 gram IV

                                22
    Adult Nerve Agent Treatment:
         Moderate Exposure
• 2-4 mg atropine initially
   – IM
   – IV
• 2-PAM Cl
   – 600-1200 mg IM initially
   – 1 gram IV
• Repeat every 5-10 minutes until atropinized
   – 2 mg atropine
   – 600 mg 2-PAM Cl
                                                23
      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)


                                                   24
    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


                                              25
 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



                                               26
  Diazepam Treatment For Children

• Children > 30 days old to 5 years
  – 0.2 - 0.5 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)



                                               27
       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

                                          28
            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



                                        29
    Advantages of Auto-injectors
• Auto-injectors        • Auto-injectors
  – permit rapid          provide
    injection             – simple, accurate,
                            rapid drug
  – prevent cross-
                            administration
    contamination
                          – pre-measured,
  – enable rapid,           controlled dose
    accurate use even     – no vials/ampules/
    in protective           syringes
    clothing              – fully automated use
                          – rugged
                            construction
                                             30
             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

                                              31
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
                                     32
    Who Can Use Auto-Injectors

• FDA approved use
  – by appropriately trained civilian
    emergency medical personnel
  – in treating victims exposed to
    nerve agents or
    organophosphorus insecticides
• State statutes also
  determine who can use
  – be aware of your state laws and
    local protocols

                                        33
            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)




                                                         34
35
              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

                                     36
37
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.


                                     38
39
           Directions for Using
              Auto-Injectors
• Step 4—Hold auto-
  injector firmly in
  place for at least 10
  seconds to allow
  injection to finish




                                  40
41
Directions for Using
   Auto-Injectors
          • Step 5—Carefully
            remove the auto-
            injector
             – Exposed needle will
               confirm successful
               injection




                                42
43
           Directions for Using
              Auto-Injectors
• Step 6—
  Massage
  injection site
  for
  several
  seconds.




                                  44
45
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

                                   46
47
Manufacturers Recommended AtroPen®
            Auto-Injector
         Atropine Dosages

   Patient weight/age           AtroPen® auto-injector
      > 90 lbs (10+ yrs)            2 mg AtroPen®

    40 - 90 lbs (4 - 10yrs)         1 mg AtroPen®

  15 - 40 lbs (6 mos - 4 yrs)      0.5 mg AtroPen®

     < 15 lbs (< 6 mos)           0.25 mg AtroPen®


                                                         48
                  Ventilation
• If required, insertion of endotracheal tube by a
  qualified person is recommended
• Requires high “pop off” pressure (50 -70+ cm
  H2O)




                                                     49
Vesicant Agents




                  50
  Sulfur Mustard Agent Treatment

• No antidote available
• Ensure immediate and thorough
  decontamination
• Take precautions for sterile technique
• Support airway management as necessary




                                       51
                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



                                                               52
                 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



                                          53
         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


                                                     54
  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
• Unroof blisters and irrigate
• Apply topical antibiotics
• Oral or IV analgesics
• Assess hydration

                                                55