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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.

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south bay disaster resource center at harbor ucla medical center
South Bay Disaster Resource Center at Harbor-UCLA Medical Center

Nerve Agents &

MARK 1 Antidote Administration

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 administration3
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 administration4
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 administration5
Nerve Agents & MARK 1 Antidote Administration

Most Likely Terrorist Nerve Agents

  • Tabun (GA)
  • Sarin (GB)
  • Soman (GD)
  • VX
nerve agents mark 1 antidote administration6
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.
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Nerve Agents & MARK 1 Antidote Administration

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 administration8
Nerve Agents & MARK 1 Antidote Administration

Nicotinic Symptoms of Nerve Agent Exposure

  • M: mydriasis (pupillary dilation)
  • T: tachycardia
  • W: weakness
  • tH: hypertension
  • F: fasciculations (muscle twitching)
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Nerve Agents & MARK 1 Antidote Administration

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 administration10
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
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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.
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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.
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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.
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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
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Nerve Agents & MARK 1 Antidote Administration

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.
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Nerve Agents & MARK 1 Antidote Administration

Antidote Administration Sequence

  • Atropine
  • 2-PAM
nerve agents mark 1 antidote administration17
Nerve Agents & MARK 1 Antidote Administration

References

  • “Basic Disaster Life Support Provider Manual Version 2.5.” American Medical Association. 2004
  • “Domestic Preparedness: Defense Against Weapons of Mass Destruction; Technician-Hospital 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