Transcript Document

Nerve Agent Antidote Kit Training
Objectives:
Types of CBRNE Incidents
 Signs & Symptoms of Nerve Agent
Exposure
 NAAKs
 Escape Hoods
 Protocols for NAAK Usage
 Practice
 Test

The Threat of NBC
Terrorism
Potential Probability vs. Impact
BIOLOGICAL
AGENT
NUCLEAR
WEAPON
POTENTIAL
IMPACT
IMPROVISED
NUCLEAR
DEVICE
RADIOACTIVE
MATERIAL
PROBABILITY/LIKELIHOOD
CHEMICAL AGENT
OR TOXIC
INDUSTRIAL
CHEMICAL
Chemical Warfare Agents
Historical Perspective

Chemicals used in military operations
to kill, injure, or incapacitate

Battlefield use


World War I and Middle East conflicts
Terrorist use

Iraq, Matsumoto and Tokyo, Japan
Chemical Agent Terrorist
Attacks

Matsumoto:



Approximately
280 injured
7 dead
Tokyo




12 dead
Approximately 1,000
hospitalized
5,500 sought medical
care
10% of first responders
injured
Chemical Warfare Agents

Nerve Agents
Tabun, Sarin, Soman, VX

Vesicants (Blister)
Mustard, Lewisite

Industrial Chemicals
Phosgene, Chlorine,
Ammonia, Cyanide

Riot Control Agents
Mace®, Pepper Spray
Nerve Agents





Tabun(GA), Sarin(GB), Soman(GD),VX
Most toxic of the chemical agents
Penetrate skin, eyes, lungs
Loss of consciousness, seizures, apnea,
death after large amount
Diagnosis made clinically; confirmed in
laboratory (Nerve agents inhibit
cholinesterase)
Normal Nerve Function
Nerve, gland or muscle
ACh
Ach=Acetylcholine stimulates muscle contraction, gland secretion & nerve to nerve conduction
Normal Nerve Function
ACh
Electrical Message continues…
Normal Nerve Function
AChE
ACh
To stop further stimulation Ach is broken down by AChE ,preventing overstimulation
Nerve Agents inhibit AChE
AChE
ACh
GB
Ach accumulates and causes over-stimulation of nerves, muscles and glands
Nicotinic & Muscarinic
Ach & Glandular Response
Ach on Skeletal Muscle
Ach on Smooth Muscle
Atropine Working
Atropine on Gland
Atropine on Smooth Muscle
AchE and how Oxime works
NA at Nerve Synapse
NA on Gland
NA on Skeletal Muscle
NA on Smooth Muscle
Normal AchE Response
Effects of Nerve Agents
Organs with cholinergic receptors

Muscarinic (Atropine works)



Smooth muscles
Exocrine glands
Nicotinic (Atropine ineffective)


Skeletal muscles
Ganglia (Sympathetic/Parasympathetic)
SLUDGEM
Salivation
 Lacrimation (Tears)
 Urination
 Defecation
 GI Upset
 Emesis (Vomiting)
 Miosis (Pinpoint pupils)

Signs and Symptoms of Nerve Agents
Muscarinic Sites

Increased secretions

Saliva

Tears

Runny nose

Secretions in airways

Secretions in gastrointestinal tract

Sweating
Signs and Symptoms of Nerve Agents
Muscarinic Sites

Smooth muscle contraction



Eyes: miosis
Airways: bronchoconstriction
(shortness of breath)
Gastrointestinal:
hyperactivity (nausea,
vomiting, and diarrhea)
*Dark room for 2 min 3,6,13,20,41, and 62days after exposure
Signs and Symptoms of Nerve Agents
Nicotinic Sites


Skeletal muscles

Fasciculations

Twitching

Weakness

Flaccid paralysis
(Over-stimulation of Ach)
ACh
Other (ganglionic)

Tachycardia

Hypertension
GB
*Myosis and fasciculations is the most reliable evidence of OPP*
Nerve Agents
Other Signs and Symptoms

Cardiovascular




Tachycardia, bradycardia
Heart block, ventricular arrhythmias
*Most disappear once antidote is given
Central Nervous System

Acute

Prolonged (4-6 weeks)
• Loss of consciousness
• Seizures
• Apnea
• Psychological effects
Signs and Symptoms of Nerve Agents
Vapor Exposure

Mild exposure


Moderate exposure


Pronounced dyspnea, nausea, vomiting, diarrhea, weakness
Severe exposure


Miosis (dim vision, eye pain), rhinorrhea, dyspnea
Immediate loss of consciousness, seizures, apnea, and
flaccid paralysis
Vapor effects occur within seconds, peak within 5
minutes; if no effects within 20 minutes probably
safe to assume there has not been an exposure.
Signs and Symptoms of Nerve Agents
Liquid Exposure

Mild exposure (to 18 hours)




Moderate exposure (<LD50) (to 18 hours)



Localized sweating
Fasciculations
No miosis
Gastrointestinal effects
Miosis uncommon
Severe exposure (LD50) (<30 minutes)





Sudden loss of consciousness
Seizures
Apnea
Flaccid paralysis
Death
10mg of VX
LD50=lethal dose for 50% of the exposed population while the other 50% would suffer lesser effects
Diagnosis of Nerve Agent Exposure

Symptomatic
May be systemic or organ-specific
 Combination of symptoms is more
definitive


Situational
Multiple casualties with similar
symptoms
 Time or location factors in common

Nerve Agent Treatment




Escape the Area* / Notify Dispatch
Decontaminate (strip down / H2O)
DO NOT ENTER ONCE SUSPICION EXISTS
IF Symptomatic use the NAAK Kits:


Atropine
2-PAMCl
* Use Escape Hood if needed
Nerve Agent
Treatment

Atropine
Antagonizes muscarinic effects
(Blocks the effect of Ach)
 Dries secretions; relaxes smooth
muscles


Dose

2 mg in each autoinjector
Nerve Agent
Treatment

Atropine

Side effects in normal people
• Mydriasis (Pupil Dilation)
• Blurred vision
• Tachycardia
• Decreased secretions and sweating
Nerve Agent
Treatment

Pralidoxime Chloride
(2PAM-Cl)




Remove nerve agent from
AChE in absence of aging (ie
enzyme and agent can
become bound irreversiblyhas to be given in 4-6 hrs
(Sarin) 60hrs (VX) and 2 min
for Soman
Nerve Agent
200 mg in each autoinjector
No effects at muscarinic sites
Helps at nicotinic sites
AChE
2-PAMCl
This antidote breaks the bond between the nerve
Agent and AChE and removes the agent
Nerve Agent
Treatment - Autoinjectors
MARK I Injections - Dispersal
Nerve Agent Treatment
 Treatment regimen

No signs/symptoms
• Reassure
• Observe
• Vapor: 1 hour
• Liquid: Up to 18 hours
Nerve Agent Treatment


Mild vapor exposure
 Miosis, rhinorrhea
- observation only
 Increasing SOB –
treat
Mild liquid exposure
 Localized
fasiculations &
sweating - treat

One MARK I kit (2
mg atropine/ 600
mg 2 -PAMCl)
Parenteral atropine
will not reverse
miosis
Nerve Agent
Treatment

Moderate vapor or liquid
exposure

One or two MARK I kits
Nerve Agent
Treatment
 Severe

- vapor or liquid
Give 3 MARK I kits
• Airway
• Ventilation/O2
• Consider diazepam 10 mg IM (2 to
5 mg IV)
• Repeat atropine every 5 to10
minutes as needed
• Repeat 2-PAMCl in one hour
Nerve Agent Summary

Vapor exposure
 Symptoms develop
suddenly
 Most ambulatory
victims require
minimal intervention
 Risk of secondary
contamination,
which is minimized
by removing the
victim’s clothing
 Requires immediate
access to antidotes
• Liquid exposure
– Symptoms delayed
minutes to hours
– Greater need for
decontamination
– High risk of secondary
contamination; victims
require decontamination
(clothing removal &
washdown)
– Requires immediate
access to antidotes
Riot Control Agents

Irritating agents, lacrimators,
“tear gas”

Cause reaction in




Eyes: burning, tearing, eyelid
spasm, redness
Airways: burning, coughing,
dyspnea
Skin: burning, erythema
Eye irrigation and supportive
care
Chemical Agent Summary

Vapor exposure




Nerve agent symptoms develop suddenly,
mustard and phosgene symptoms are
delayed
Most ambulatory victims require minimal
intervention
Risk of secondary contamination
Requires airway management; antidotes
for nerve agents and Lewisite
Chemical Agent Summary

Liquid exposure




Symptoms delayed minutes to hours
Greater need for decontamination
Risk of secondary contamination, victims
require clothing removal & decontamination
Requires immediate access to antidotes
Escape Hood Video