ATPM Slides

8/11/2019 ATPM Slides

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Required when distributed (EMR, EMT, AEMT)



ObjectivesAt the completion of this educationmodule, the provider will have:

An understanding of scene safety and assuring

responder safety.An understanding of the physiological effectsof nerve agents.Will demonstrate with 100% accuracy the

procedure to auto-injection administration.



Why Now?Increased concern for

terrorismAvailable in old munitionsin US and elsewhere

Have been successfullymanufactured byother countries

Very lethal



How it worksNerve agents block an enzyme calledacetylcholinesterase.This enzyme is normally responsible for

breaking down acetylcholine that hasbeen used as a neurotransmitter to glandsand smooth muscle.When it is blocked, the acetylcholine

remains in the synapse, causing glands tosecrete, and muscles to constrict.Death is due from lack of oxygen.



Normal Nerve Function

ACh




ACh




ACh

AChE



How Nerve Agents WorkAChE

AChGB



EffectsAcetylcholine is a transmitter in two kinds of

synapses, meaning nerve agents function in twowaysMuscarinic Receptors

Smooth muscleGlands

Nicotinic ReceptorsSkeletal musclesAutonomic ganglion



How it works cont.The interruption in communication causesoverstimulation of these organs or musclescausing hyperactivity

Effects are seen in the skeletal muscles andsmooth muscles (GI tract)





How it works cont.If the agent is inhaled, bronchoconstrictionoccursSudden loss of consciousness and convulsions

may follow



Effects: NicotinicSkeletal muscle

FasiculationsLocalizedtwitchingLeads to

flaccidityGanglion

TachycardiaHypertension



Effects: MuscarinicSmooth muscle contraction

Eyes: miosis-constriction

Airway: SOBSevere bronchoconstrictionGI: vomiting & diarrhea

SecretionsSaliva, TearsRunny nose (rhinorrhea)BronchorrheaSweating



Overall EffectsHeart Rate: tachy or bradyCan get arrhythmiasCentral Nervous System

AcuteLoss of consciousnessSeizuresApnea



Remember SLUDGEM

SalivationLacrimation

UrinationDefecationG astric upsetEmesisMiosis (pupil constriction), muscle twitching



Symptoms[4,5]

Mild Moderate

Blurred vision, miosis(excessive constriction of

the pupils)Excessive, unexplainedteary eyesExcessive, unexplainedrunny nose

Increased salivation, suchas sudden drooling

Chest tightness ordifficulty breathing

Tremors throughout thebody or musculartwitchingNausea and/or vomitingUnexplained wheezing,coughing, or increased

airway secretionsAcute onset of stomachcrampsTachycardia orbradycardia (abnormallyfast or slow heartbeat)



Severe Symptoms [4,5] Strange or confused behaviorSevere difficulty breathing or copioussecretions from lungs/airway

Severe muscular twitching and generalweaknessInvoluntary urination and defecationConvulsions

Loss of consciousnessRespiratory arrest (possibly leading to death)



No amount of atropine will stopseizures.

Treatment endpoint is airwayimprovement with decreased salivation

and rhinorrhea



Signs and Symptoms of Vapor ExposureMild exposure

Miosis (dim vision, eye pain), rhinorrhea, slightdyspnea

Moderate exposurePronounced dyspnea, nausea, vomiting,diarrhea, weakness

Severe exposure

Immediate loss of consciousness, seizures,apnea, and flaccid paralysis

Vapor effects occur within seconds,peak within minutes; no late onset



Signs and Symptoms of Liquid Exposure

Mild exposure (up to 18 hours)Localized sweatingFasciculationsNo miosis

Moderate exposure ( to 18 hours)Gastrointestinal effectsMiosis uncommon

Severe exposure (<30 minutes)Sudden loss of consciousnessSeizures, apneaFlaccid paralysisDeath





Types of Nerve AgentsSarin (GB)Soman (GD)

Tabun (GA)V agent (VX)



Physical PropertiesGas vs. liquid4-6x denser than air

soluble in waterG agents disperse within several hoursVX will persist for weeksVX>GD>GB>GA lethality



PersistencyTerm used to describe how long the agent willstay on a surface before it evaporatesPersistent agents remain on a surface usuallylonger than 24 hours.



Volatilitythe ease with which a chemical changes from aliquid to a gas; the tendency of a chemicalagent to evaporate.

Name Code Odor Features Onset of Volatility Route of



Name CodeName

Odor Features Onset ofSymptoms

Volatility Route ofExposure

Tabun GA Fruity Easy tomanufacture

Immediate Low Contact;vapor

Sarin GB None Will off-gaswhile onvictim'sclothing

Immediate High Primarilyresp vaporhazard;

extremelylethal ifskincontact

Soman GD Fruity Ages rapidly,making itdifficult to treat

Immediate Moderate Contactwith skin;minimalvaporhazard

V agent VX None Most lethalchemical agent;difficulty todecon

Immediate Very Low Contactwith skin;no vaporhazard



Transporting Contaminated PatientsEMS personnel must be wearing PPE.If necessary, different triage categories of

contaminated patients may betransported together.Helicopters do not transportcontaminated patients.

Once an ambulance has been used tomove contaminated patients, it may onlybe used for contaminated patients untildecontamination is verified.



• Request specific staging information.• Maintain safe location upwind and uphill.• Pay strict attention to hot, warm and coldzones.• Activate ICS.



TriageImmediate : 2 or more body systems involved-airway, convulsing, decreased consciousness, nospontaneous respirationsDelayed : no immediate life threat, patientwithout symptoms OR has been given >4mgAtropine and is recovering… observe at least 18hours

Minimal: walking and talking, may only have dimvision, pinpoint pupils… observe 18 hours Expectant : inadequate resources, completearrest



Treatment

Airway supportAntidotes

Atropine2-PamChloride(pralidoxime Chloride)Diazepam (valium)

DuoDote ™ Has one auto-injector2mg Atropine and600mg 2-PamCl



AtropineWorks on muscarinic effectsDose until airway sx resolve, and secretions aredryingDo not rely on heart rate or pupil size



Pralidoxime (2PAM)Works like a “crowbar” byremoving nerve agent from

acetylcholinesteraseMore effective if given early, assome of the nerve agents bond“ages” to permanent in under 2minutes

AChE 2-PAMCl

Nerve Agent



What is DuoDote™? Developed by Meridian Medical Technologies as astreamlined, easy-to-use replacement for the Mark IKitFDA-approved for emergency medical services (EMS)use in the treatment of organophosphorus nerveagent and organophosphorus insecticide poisoning

Contains 2 antidotes in 1 auto-injector:2.1 mg of atropine in a 0.7-mL solution600 mg of pralidoxime chloride in a 2-mL solution

Features next-generation BinaJect™

delivery technology2 antidotes delivered sequentiallyinto separate areas of the muscleEasy to use: only 1 injection

with 1 needle



Where Does DuoDote

Work? Effects of organophosphoruspoisoning:

Chemical nerve agentsand organophosphorus

insecticides cause an excessbuildup of acetylcholine (ACh), aneurotransmitterThis buildup occurs when theactivity of an enzyme calledacetylcholinesterase (AChE) isblocked by the nerve agent 4

Blocking AChE results inoverstimulation of cholinergicnervous pathways

There are 2 types of AChreceptors: muscarinic receptorsaffect breathing andgastrointestinal functions, whilenicotinic receptors affect vascular

function and muscle movement4



How Does DuoDote Work? Complementary actions:

Atropine blocks AChon the postsynaptic(downstream) side ofsynapses at muscariniccholinergic receptors inmultiple organ systems,thereby reducingcholinergicoverstimulation

Pralidoxime chloridereactivates the AChEenzyme, allowing it toresume its function ofmoderating the activityof ACh once again 1



How Quickly Does DuoDoteWork?

After injection,atropine andpralidoxime chloridebegin counteractingthe effects oforganophosphoruspoisoning withinabout 10 minutes

Both antidotesreach their peakconcentrations inthe bloodstreamwithin about 30minutes 1

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00 60 120 180 240 300 360 420 480 540 600 660 720

A t r o p

i n e

P l a s m a

L e v e

l s ( n g / m

L )

Time (minutes)

Time to maximumconcentration = 31 min

1

6

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1

0 P r a

l i d o x

i m e

P l a s m a

L e v e

l s ( μ g

/ m L )

0 60 120 180 240 300 360 420 480 540 600 660 720

Time (minutes)

Time to maximumconcentration = 28 min

1



What Happened toMARK-1?

Mark-1 kits are no longer available for use.DuoDote has replaced themHere is a slide that compares them side by side



D D t I j ti



DuoDote InjectionInstructions

Select site and inject:The injection site is themid-outer thigh area.You can inject throughclothing, but make sure

that pockets are emptySwing and firmly pushGreen Tip straight down(at a 90º angle) againstmid-outer thigh, continuing

to push firmly until you feelthe auto-injector trigger

After the DuoDote Auto-Injector triggers, hold it firmly inplace against the injection sitefor10 seconds







Self TreatmentDo not place finger

over either end!Upper outerquadrant ofbuttocks is best spotHold in place for 10seconds



Alternate locationCan also use lower,outer quadrant ofthighNeedle will go right

through clothes,turnout, or PPEwithout problems



Basic/Advanced Standing OrdersRoutine patient care: Assess for SLUDGEM(salivation, lacrimation, urination,defecation, gastric upset, emesis,miosis/muscle twitching)

Remove to cold zone afterdecontamination and monitor forsymptomsTreatment using DuoDote ™ autoinjectors

self and peer onlyTreatment using DuoDote ™ autoinjectorsto public in emergency stockpile releaseonly



Basic Standing OrdersAntidotal therapy should be started as soon assymptoms appear.

All injections must be given IMTreatment using DuoDote ™ autoinjectors selfand peer onlyTreatment using DuoDote ™ autoinjectors topublic in emergency stockpile release only



Adolescent/Adult Basic

Standing Orders2 or more minor symptoms

One DuoDote ™ kit Reassess: if more severe symptoms appear within10 minutes administerTwo additional DuoDote ™ kits

Initial Moderate SymptomsTwo DuoDote ™ kits

Initial Severe SymptomsGive Three DuoDote kits ANDOne autoinjector of Diazepam 10 mg

May repeat DuoDote ™ kit every hour for threehours

Basic Standing Orders:



Basic Standing Orders:PEDIATRIC

DuoDote ™ may be used for pedi patientsin life threatening situation w/ exposuresymptomsChild 13-25kg (29 - 55lb) – One DuoDoteChild 26-50kg (56 - 110lb) – Up to TwoDuoDote kits based on progression ofsymptomsChild over 51kg (>110lb) – Up to ThreeDuoDote kits based on progression andseverity of symptoms



Paramedic Standing Orders:PEDIATRIC

Children <12 kg (26 lbs):Use of DuoDote kit is not recommendedIf no other source available after 90 min mayconsider using one DuoDote kit.

If child is seizing and >26 (> 57lbs)kgMay use one Adult Diazepam injector



Provider ProtectionIf a first responder display symptoms:Notify dispatch immediatelyEvacuate areaDo not reenter until cleared by HazmatRemove clothing and decontaminateTreatment basic and paramedic same as formass casualty



Provider TreatmentUse only if nerve agent symptoms are present.DuoDote ™ kits offer no prophylactic protectionand use prior to appearance of symptoms maybe harmful. All injections must be given IM.



Accidental ODIf First Responder accidentally gives Mark 1 kit tothemselves without being exposed to nerveagent

HotRedUnable to sweat (dry)

ConfusionNeed to be kept in cool, controlled environmentuntil wears off



References[1] Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 AnnualReport of the American Association of Poison Control CentersToxic Exposure Surveillance System. Am J Emerg Med.2004;22:335-404

[2]Department of Health and Human Services. Centers for DiseaseControl and Prevention. Third National Report on HumanExposure to Environmental Chemicals . Atlanta, GA: NationalCenter for Environmental Health; 2005 NCEH Pub. No. 05-0570.[3]Olson KB. Aum Shinrikyo: once and future threat? Emerg InfectDis. 1999;5:512-516.[4]Cannard K. The acute treatment of nerve agent exposure. JNeurol Sci , 2006;249:86-94[5]Department of Health and Human Services. Centers forDisease Control and Prevention. Third National Report on HumanExposure to Environmental Chemicals . Atlanta, GA: National

Center for Environmental Health; 2005;NCEH Pub No. 05-0570



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ATPM Slides