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CHEMPAK and the Maine Pharmacy Cache

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  1. CHEMPAK and the Maine Pharmacy Cache Maine CDCOffice of Public Health Emergency Preparedness (OPHEP) & The Northern New England Poison Center

  2. Dan Lambert, MBA, RPh, EMT-IConsultant PharmacistKaren Simone, PharmD, DABATDirectorTamas Peredy, MDMedical Director Northern New England Poison Center

  3. Antidotes Flow Maine Pharmaceutical Cache CMMC, EMMC, MMC, (TAMC) All other ME Hospitals Chempacks Calais, Cary, CMMC, EMMC, Franklin, MMCx2, ME Gen Aug, MDI, SMMC Strategic National Stockpile Regional 1st 2nd 3rd

  4. Antidotes Content Maine Pharmaceutical Cache CMMC, EMMC, MMC, TAMC: BAL, DMPS, cipro, doxy, EDTA, hydoxocobalamin, KI, Prussian blue Others: atropine/2-Pam, Ca gluconate, fomepizole CHEMPACKs Calais, Cary, CMMC, EMMC, Franklin, MMCx2, ME Gen Aug, MDI, SMMC: atropine/2-Pam Strategic National Stockpile Antidotes, other medicine, medical supplies Min-hrs Hrs <12 hrs??

  5. Maine Pharmaceutical Cache • Distributed for the Maine CDC by the Poison Center • Larger supplies at CMMC, EMMC, MMC, & TAMC • Smaller quantities at other hospitals • Antidotes (some only at key 4 hospitals): • Atropine/2-Pam (pralidoxime) • BAL, DMPS, EDTA, Prussian blue • Ciprofoxacin, doxycycline • Fomepizole • Hydoxocobalamin • KI • For first 24 – 48 hours • Until CHEMPACK or federal supplies are available

  6. Maine Pharmaceutical Cache Deployment EMS, ED or other requests deployment Call Northern New England Poison Center (NNEPC) 1-800-222-1222 NNEPC will assist with: Drug indications and dosing Locating and transporting supplies NNEPC notifies Maine CDC Maine CDC contacts Maine Emergency Management Agency (MEMA) MEMA collaborates & coordinates on asset use

  7. CHEMPACK The CDC established CHEMPACK, which is the forward placement of a sustainable resource of Nerve Agent (NA) antidotes throughout the United States Deployment and maintenance of CHEMPACK in Maine is the responsibility of the Maine CDC-Office of Public Health Emergency Preparedness.

  8. CHEMPACK • Nerve Agent (NA) Antidotes • Stored within States • Prior to an incident • Maine Locations: Calais, Cary, CMMC, EMMC, Franklin, MMCx2, ME Gen Aug, MDI,& SMMC

  9. CHEMPAK (EMS & Hospital Containers) • CHEMPACK - EMSContainers: • For emergency responders at the scene • More single-use auto-injectors • Some pediatric • CHEMPACK - HospitalContainers: • For hospital use • More multiuse vials • Both: • Will treat 1,000 casualties • 30% mild exposures • 40% moderate exposures • 30% severe exposures

  10. CHEMPACK Supplies Type: Needles (18-gauge, 1 1/2- and 5/8-inch, ) Syringes (5ml, 20ml) Alcohol wipes How packaged: 1 dose/small zip-lock bag 10 doses/large zip-lock bag Instructions on each zip-lock bag: Drug form and concentration Route of administration Dosing instructions by age and severity

  11. Chempack Deployment EMS, ED or other requests deployment Call Northern New England Poison Center (NNEPC) 1-800-222-1222 Move CHEMPACK and supplies to ED or loading dock May remove drugs boxes from the CHEMPACK container to transport US Centers for Disease Control (CDC) in Atlanta, GA notification Automatic when open container NNEPC notifies Maine CDC Maine CDC contacts Maine Emergency Management Agency (MEMA) MEMA collaborates & coordinates on asset use

  12. Strategic National Stockpile • 1999: Charge to establish a national stockpile • Congressional charge to: • Department of Health and Human Services (DHHS) and • Centers for Disease Control and Prevention (CDC) • Called: • The National Pharmaceutical Stockpile (NPS) • 2003: The NPS becomes the Strategic National Stockpile (SNS). • Large quantities of essential medical materiel • For states and local public health agencies • During an emergency

  13. A single “push package” weighs 94,424 pounds and fills either one wide-body aircraft or seven tractor trailers.

  14. SNS Deployment • Maine CDC asks governor to request SNS deployment. • Partial or complete Push Packages arrive within twelve (12) hours of the federal decision to deploy. • Push Package contents are constantly updated but contain in general: • Antibiotics - IV administration supplies • Nerve agent antidotes - Airway maintenance supplies • Antitoxins - Medical/surge items. • Life-support medications • Technical Advisory Response Unit (TARU) is sent. • TARU staff coordinate with state and local officials. • SNS assets are efficiently received and distributed.

  15. Vendor Managed Inventory • Additional supplies • Pharmaceuticals and/or medical • After 12-hour push packages (if needed) • Within 24 to 36 hours • First option • If 12-hour turnaround not needed • If need is specific to certain known items OR

  16. Other Supplies • US Postal service: • Ciprofloxacin and doxycycline • At MMC and EMMC • Maine EMS: • Atropine/2-PAM autoinjectors • In ambulances • Training requirements

  17. Antidotes • CHEMPACK • Nerve agent antidotes • Maine Pharmaceutical Cache • Nerve agent antidotes • Chelating agents (heavy metals/radiation) • Antibiotics • Toxic alcohol antidote • Cyanide antidote • Radiation (power plant-related)

  18. Nerve Agents Antidotes in: CHEMPACK Maine Pharmaceutical Cache Strategic National Stockpile

  19. Nerve Agents Pharmacology

  20. Effects of Nerve Agents • Muscarinic (Atropine works) • Smooth muscles • Exocrine glands • Nicotinic (Atropine ineffective, 2-PAM works) • Skeletal muscles • Ganglia (Sympathetic/Parasympathetic) • Central Nervous System (Diazepam works)

  21. Muscarinic Effects Increased secretions • Saliva • Tears • Runny nose • Secretions in airways • Secretions in gastrointestinal tract • Sweating Smooth muscle contraction • Eyes: miosis (Can use Lidocaine 2%) • Airways: bronchoconstriction (shortness of breath) • Gastrointestinal: hyperactivity (nausea, vomiting, and diarrhea)

  22. Nicotinic Effects • Skeletal muscles • Fasciculations • Twitching • Weakness • Flaccid paralysis • Other (ganglionic) • Tachycardia • Hypertension

  23. Other Signs & Symptoms • Cardiovascular • Bradycardia (muscarinic, late nicotinic) • Tachycardia (nicotinic) • Heart block, ventricular arrhythmias • Central Nervous System • Loss of consciousness • Seizures • Apnea

  24. ATROPINE Antagonize muscarinic effects Dry secretions Relax smooth muscles Give IV,IM,ET Starting dose 2mg, cumulative dose 20mg (insecticides may require much larger doses – grams or more in severe cases) PRALIDOXIME Cl (2PAM-Cl) Remove nerve agent from AChE in absence of aging 1-2 g IV over 15-30min 5 minutes is possible/not ideal Rapid IV = hypertension Helps at nicotinic sites Nerve Agents Treatment • DIAZEPAM • Treats seizures (Other less-understood beneficial effects)

  25. Mark I Autoinjector DuoDoteAtropine 2mg, 2-PAM 600mg

  26. Nerve Agent Treatment-EMS State of Maine (Mark 1 kits = NAAK): EMTs can only administer to EMTs (self or other EMTs) Treat yourself first and then others Escape the Area/ Notify Dispatch Decontaminate (strip down / H2O) DO NOT ENTER ONCE SUSPICION EXISTS IF Symptomatic use the NAAK Kits: Atropine 2-PAMCl NAAK = Nerve Agent Antidote Kit Mark I = a brand name for NAAK

  27. Chelating Agents Antidotes in: Maine Pharmaceutical Cache

  28. Chelation & Heavy Metal Poisoning • BAL (British anti-Lewisite, dimercaprol): • Lewisite gas (systemic toxicity) • DMPS (Unithiol): • Arsenic, bismuth?, lead, mercury • EDTA, calcium disodium & Succimer: • Lead (Zinc) • Prussian Blue: • Poisoning: thallium

  29. Dimercaprol & DMPS (Unithiol) BAL (British anti-Lewisite) or Dimercaprol: Developed to treat Lewisite An arsenic based poison gas Injection in peanut oil given IM every 4 hours initially Maine has supply in largest hospitals DMPS (Unithiol): Water soluble analog of BAL Injection initially, then orally Maine has supply in largest hospitals

  30. EDTA, calcium disodium • Lead: • Mostly replaced by DMPS, except in severe cases • Important not to give BAL 1st in severe overdoses • Then should be given together (BAL and EDTA) for early doses • Confusion with sodium EDTA can lead to life-threatening hypocalcemia • Maine has supply in largest hospitals • Other possible uses: • Zinc • Manganese • Certain types of radiation exposure

  31. Action: Block GI absorption, enterohepatic recirculation Dose: Up to 10 g daily for acute thallium poisoning 1 gm with 4oz water p.o. t.i.d. Duration: Possibly several days or more Maine has supply of powder to be used until commercial supplies obtained Prussian Blue (Ferric hexacyanoferrate)

  32. Anthrax Threat • USSR accidental release (1979): • Aerosolized anthrax spores • From military microbiology lab • At least 79 cases ofanthrax and 68 deaths • Potential for harm in US: • 3,000,000 deaths from 100 kg spores Upwind of Washington, DC • Lethality matching or exceeding hydrogen bomb

  33. Anthrax • Spore-forming Bacillus anthracis • Inhalation, cutaneous & intestinal • Not contagious

  34. Acute Treatment Inhalation or oral exposure: IV Ciprofloxacin OR Doxycycline AND 1 or 2 additional IV antimicrobials (rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, clindamycin, clarythromycin) Dermal exposure: Oral ciprofoxacin OR doxycyclin Iv as above if: systemic effects, significant edema, swelling of head/neck region Post-exposure Oral Ciprofloxacin OR Doxycycline Anthrax Treatment

  35. Fomepizole(Antizol®) • Antidote for: • Ethylene glycol (antifreeze) • Methanol (windshield wiper fluid) • Inhibits alcohol dehydrogenase • Prevents metabolism of ethylene glycol and methanol to toxic metabolites

  36. Cyanide

  37. The Tylenol Crisis • Chicago, 1982 • Extra Strength Tylenol • Laced with potassium cyanide • 8 bottles • 7 people died • 31 million bottles recalled • Worth $100,000 were • $100,000 reward offered • Has never been claimed

  38. Availability of Cyanide (sources) • Laboratory analysis • Solvent for gold and silver • Mining, electroplating, metallurgy, jewelry and photography • Sodium nitroprusside • Antihypertensive • Products of combustion • Fires • Exhaust • Tobacco smoke • Acetonitrile-based products • Artificial nail glue remover

  39. Cyanide (chemistry, mechanism and form) • Cyanide chemistry/mechanism • Carbon atom triple bonded to a nitrogen atom • Irreversible inhibitor of cytochrome c oxidase • Disrupts ATP energy production in cell mitochondria • Cells unable to use oxygen • Hydrogen cyanide (HCN) • Colorless gas • Faint bitter almond -like odor • Not all can smell hydrogen cyanide • Sodium cyanide and potassium cyanide • White powders

  40. Cyanide Antidote Kit (old) • Amyl nitrite (for inhalation) • Until IV established • Limited usefulness • Sodium nitrite (for injection) • Causes methemoglobinemia (in sub-toxic amounts) • Methemoglobin binds cyanide • Pulls cyanide away from cytochrome oxidase • Cells able to utilize oxygen again • Not recommended for those with compromised hemoglobin • House fire victims (smoke, carbon monoxide) • Sodium thiosulfate (for injection) • Sometimes sufficient alone

  41. Cyanide Antidote Kit (new)

  42. Hydroxocobalamin Hydroxocobalamin = antidote Cyanocobalamin = B12