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