Transcript South Bay Disaster Resource Center at Harbor

South Bay Disaster Resource Center at Harbor-UCLA Medical Center
Nerve Agents &
MARK 1 Antidote Administration
Nerve Agents & MARK 1 Antidote Administration
Objectives
Upon completion of this training, you will be able to:
• Describe why hospitals must prepare for nerve agents.
• Describe nerve agent pathophysiology.
• Describe clinical presentation of nerve agent exposure.
• Describe prioritized Emergency Department response
to nerve agent victims.
• Describe key elements of nerve agent Triage.
• Identify nerve agent antidotes and effects/side-effects.
• Demonstrate competence using MARK1 auto-injectors.
Nerve Agents & MARK 1 Antidote Administration
Why Prepare for Nerve Agent Terrorism
• Small treatment window to decrease morbidity and
mortality:
– Depends upon type of nerve agent, concentration
and duration of exposure.
• After soman gas exposure, the antidote (2-PAM)
must be administered within seconds (practically
rendering the antidote useless).
• After sarin gas exposure, 2-PAM usually is
effective in improving nicotinic symptoms of
weakness and muscle fasciculations, if
administered within 45-60 minutes.
Nerve Agents & MARK 1 Antidote Administration
Why Prepare for Nerve Agent Terrorism
• Potential for mass-casualty exposure:
– 1995 Aum Shinrikyo cult released sarin gas in 5
subway cars in downtown Tokyo
• 5,500 victims sought medical care
• 80% self-transported to medical facilities
Nerve Agents & MARK 1 Antidote Administration
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Most Likely Terrorist Nerve Agents
Tabun (GA)
Sarin (GB)
Soman (GD)
VX
Nerve Agents & MARK 1 Antidote Administration
Nerve Agent Pathophysiology
• Acetylcholine, a neurotransmitter, normally is
secreted at the end-plate of a nerve and “instructs”
nerves, muscles, and glands.
• Acetylcholine normally undergoes enzymatic
degradation by acetylcholinesterase.
• Nerve agents inhibit acetylcholinesterase, and thus
acetylcholine builds up within synapses.
– Results in over-stimulation of the peripheral
and central nervous system.
Nerve Agents & MARK 1 Antidote Administration
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Muscarinic Symptoms of Nerve Agent Exposure
D: Diarrhea
U: urination
M: miosis (pupil constriction)
B: bradycardia, bronchorrhea, & bronchospasm
E: emesis
L: lacrimation
S: salivation, increased secretions, & sweating
Nerve Agents & MARK 1 Antidote Administration
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Nicotinic Symptoms of Nerve Agent Exposure
M: mydriasis (pupillary dilation)
T: tachycardia
W: weakness
tH: hypertension
F: fasciculations (muscle twitching)
Nerve Agents & MARK 1 Antidote Administration
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Prioritized ED Response to Nerve Agent Victims
Safety of staff and protection of ED
Decontamination of victim (if not done in the field)
Airway management
Antidote administration – Atropine and Pralidoxime
Chloride (2-PAM)
Seizure control – Diazepam
Nerve Agents & MARK 1 Antidote Administration
Key Elements of Nerve Agent Triage Assessment
• Signs/symptoms: DUMBELS and/or MTWtHF
• Extent of exposure:
– Mild: Tearing, runny nose, mild chest tightness
– Moderate: Mild symptoms + nausea, vomiting
moderate shortness of breath, wheezing
– Severe: Moderate symptoms + severe shortness
of breath, seizure, cardiovascular collapse
Nerve Agents & MARK 1 Antidote
Administration
Key Elements of Nerve Agent Triage Assessment
• Pre-hospital administration of antidotes.
– How much, when, & what are the signs of
improvement?
• Decision to administer the antidote should be
based upon the initial signs and symptoms and
modified accordingly.
• Onset of signs and symptoms will depend upon
the actual agent.
Nerve Agents & MARK 1 Antidote Administration
Antidote Effects
• Atropine: Blocks acetylcholine at muscarinic
receptor sites and therefore decreases bronchial
secretions.
• 2-PAM: Regenerates acetylcholinesterase and thus
improves nicotinic symptoms (fasciculations, muscle
twitching, weakness).
• Diazepam: Controls seizures.
Nerve Agents & MARK 1 Antidote Administration
Antidote Side Effects
• Atropine: If administered in excess of amount
needed to reverse muscarinic effects, the
anticholinergic syndrome (mydriasis, tachycardia,
hypertension, urinary retention, dry skin) may result.
• 2-PAM: Hypertension that is rapidly responsive to
phentolamine.
Nerve Agents & MARK 1 Antidote Administration
MARK 1 Antidote Kits
• Facilitates rapid administration/self-administration.
• Consists of 2 auto-injector pens:
– Smaller pen: 2 mg Atropine
– Larger pen: 600 mg 2-PAM
Nerve Agents & MARK 1 Antidote Administration
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MARK 1 Administration Techniques
Check injection site – usually lateral thigh – for
objects (i.e., wallets) that may interfere with
administration.
Hold kit in non-dominant hand so larger pen is on
top and both pens are at eye level.
Remove pen; hold like a pencil.
Apply plastic-covered tip like a pencil to injection
site with firm, even motion. Auto-injector will fire.
Hold in place at least 10 seconds.
Nerve Agents & MARK 1 Antidote Administration
Antidote Administration Sequence
1. Atropine
2. 2-PAM
Nerve Agents & MARK 1 Antidote Administration
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References
“Basic Disaster Life Support Provider Manual
Version 2.5.” American Medical Association. 2004
“Domestic Preparedness: Defense Against
Weapons of Mass Destruction; TechnicianHospital Provider Manual”. Booze-Allen &
Hamilton, Inc. 1998.
“Use of MARK I Kits.” New York Department of
Health Policy Statement 03-05.
Desktop: DRC Nerve Agents MARK 1 Antidote Administration