1 module 7 medical treatment. 2 nerve agent 3 treatment - no signs and symptoms reassure observe...
TRANSCRIPT
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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