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Module 7Medical Treatment

Module 7Medical Treatment

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Nerve AgentNerve Agent

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Treatment - No Signs and Symptoms

• Reassure• Observe

– Vapor: 1 hour– Liquid: Up to

18 hours

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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

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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

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Atropine

• Atropine blocks effects of over-stimulation

• Relieves smooth muscle constriction

• Dries up respiratory secretions

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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

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Diazepam

• Administer to patients experiencing convulsions

• Consider for patients with severe signs and symptoms

• Dosage depends on patient’s age

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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

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Signs of Atropinization

• Secretions dry• Less labored breathing

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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

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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

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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

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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

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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

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Atropine Overdose

• Cause: Atropine administered when no prior nerve agent exposure has occurred

• Not as serious as underdosing• Not usually life-threatening

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Signs and Symptoms Of Atropine Overdose

• Dilated pupils• Dry mouth and skin• Rapid pulse• Flushed skin• Difficulty urinating

• Confusion, delirium• Temperature control

diminished• Intense thirst• Restlessness

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Treatment for Atropine Overdose

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

possible

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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

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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

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Antidote Administration Methods

• Intramuscular (IM)– Syringe– Auto-injector

• Intravascular (IV)

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Adult Nerve Agent Treatment: Mild Exposure

• 2 mg atropine– IM– IV

• 2-PAM Cl– 600 mg IM– 1 gram IV

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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

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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)

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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

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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

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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)

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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

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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

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Advantages of Auto-injectors

• Auto-injectors– permit rapid injection– prevent cross-

contamination– enable rapid, accurate

use even in protective clothing

• Auto-injectors provide– simple, accurate, rapid

drug administration– pre-measured,

controlled dose– no vials/ampules/

syringes– fully automated use– rugged construction

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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

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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

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Who Can Use Auto-Injectors

• FDA approved use – by appropriately trained civilian

emergency medical personnel– in treating victims exposed to

nerve agents or organophosphate insecticides

• State statutes also determine who can use– be aware of your state laws and

local protocols

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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)

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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 remainin kit

– Do not touch the green or black tip

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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.

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Directions for Using Auto-Injectors

• Step 4—Hold auto-injector firmly in place for at least 10 seconds to allow injection to finish

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Directions for Using Auto-Injectors

• Step 5—Carefully remove the auto-injector– Exposed needle will confirm

successful injection

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Directions for Using Auto-Injectors

• Step 6 - Massage injection site for several seconds.

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Directions for UsingAuto-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

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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®

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Ventilation

• If required, insertion of endotracheal tube by a qualified person is recommended

• Requires high “pop off” pressure (50 -70+ cm H2O)

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Vesicant AgentsVesicant Agents

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Sulfur Mustard Agent Treatment

• No antidote available• Ensure immediate and thorough

decontamination• Take precautions for sterile technique• Support airway management as necessary

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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

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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

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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

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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• Un-roof blisters and irrigate• Apply topical antibiotics• Oral or IV analgesics• Assess hydration