Nerve Agent Antidote Kit Training Objectives: Types of CBRNE Incidents Signs & Symptoms of Nerve Agent Exposure NAAKs Escape Hoods Protocols for NAAK.
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Nerve Agent Antidote Kit TrainingObjectives:
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
POTENTIALIMPACT
PROBABILITY/LIKELIHOOD
NUCLEARWEAPON
IMPROVISEDNUCLEAR
DEVICE
RADIOACTIVEMATERIAL
CHEMICAL AGENTOR TOXIC
INDUSTRIALCHEMICAL
BIOLOGICALAGENT
Chemical Warfare AgentsHistorical 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
Tabun, Sarin, Soman, VX
Mustard, Lewisite
Phosgene, Chlorine, Ammonia, Cyanide
Mace®, Pepper Spray
Nerve Agents
Vesicants (Blister)
Industrial Chemicals
Riot Control Agents
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
AChAChAch=Acetylcholine stimulates muscle contraction, gland secretion & nerve to nerve conduction
Normal Nerve Function
AChACh
Electrical Message continues…
Normal Nerve Function
AChACh
AChEAChE
To stop further stimulation Ach is broken down by AChE ,preventing overstimulation
Nerve Agents inhibit AChE
AChEAChE
AChACh GBGB
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 AgentsMuscarinic Sites
Increased secretions Saliva Tears Runny nose Secretions in airways Secretions in gastrointestinal tract Sweating
Signs and Symptoms of Nerve AgentsMuscarinic 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 AgentsNicotinic Sites (Over-stimulation of Ach)
Skeletal muscles Fasciculations Twitching Weakness Flaccid paralysis
Other (ganglionic) Tachycardia Hypertension
GBGB
AChACh
*Myosis and fasciculations is the most reliable evidence of OPP*
Nerve AgentsOther Signs and Symptoms
Cardiovascular Tachycardia, bradycardia Heart block, ventricular arrhythmias *Most disappear once antidote is given
Central Nervous System Acute
• Loss of consciousness• Seizures• Apnea
Prolonged (4-6 weeks)• Psychological effects
Signs and Symptoms of Nerve Agents Vapor Exposure
Mild exposure Miosis (dim vision, eye pain), rhinorrhea, dyspnea
Moderate exposure Pronounced dyspnea, nausea, vomiting, diarrhea, weakness
Severe exposure 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) Localized sweating Fasciculations No miosis
Moderate exposure (<LD50) (to 18 hours) 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 AgentTreatment
Atropine
Side effects in normal people
• Mydriasis (Pupil Dilation)
• Blurred vision
• Tachycardia
• Decreased secretions and sweating
Nerve AgentTreatment
Pralidoxime Chloride (2PAM-Cl) Remove nerve agent from
AChE in absence of aging (ie enzyme and agent can become bound irreversibly- has to be given in 4-6 hrs (Sarin) 60hrs (VX) and 2 min for Soman
200 mg in each autoinjector
No effects at muscarinic sites
Helps at nicotinic sites
AChEAChE 2-PAMCl
Nerve AgentNerve Agent
This antidote breaks the bond between the nerve Agent and AChE and removes the agent
Nerve AgentTreatment - 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 AgentTreatment
Moderate vapor or liquid
exposure One or two MARK I kits
Nerve AgentTreatment
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
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