1. Use of Auto-Injectors by Civilian Emergency Medical Personnel to Treat Civilians Exposed to Nerve Agent © © 1997 Lockheed Martin Energy Research Corporation

2. Learning Objectives Identify the antidotes to be administered in event of nerve agent exposure Identify the antidotes to be administered in event of nerve agent exposure Identify the conditions under which antidote auto-injectors should be used Identify the conditions under which antidote auto-injectors should be used Demonstrate use of antidote auto-injectors Demonstrate use of antidote auto-injectors Recognize adverse reactions to use of antidotes Recognize adverse reactions to use of antidotes AI 2©

3. IMPORTANT! Antidotes counter or relieve effects of poisons such as nerve agents. Use antidotes only when signs and symptoms of exposure are present; they will not protect if given before exposure. AI 3©

4. Auto-Injectors Simple, compact injection systems Permit rapid injection of required antidotes Permit rapid injection of required antidotes Prevent needle from being subject to cross- contamination Prevent needle from being subject to cross- contamination Enable rapid and accurate administration even if care giver or patient is in protective clothing Enable rapid and accurate administration even if care giver or patient is in protective clothing AI 4©

5. Auto-Injectors Auto-injectors facilitate timely treatment by providing Simple, accurate, rapid drug administration Simple, accurate, rapid drug administration Pre-measured, controlled dose Pre-measured, controlled dose No vials, ampules or syringes to manipulate No vials, ampules or syringes to manipulate Fully automatic operation Fully automatic operation Rugged construction Rugged construction AI 5©

6. Auto-Injectors Contain pre-measured doses of nerve agent antidotes atropine and 2-PAM chloride (2-PAM Cl, pralidoxime chloride or PROTOPAM ® CHLORIDE) Contain pre-measured doses of nerve agent antidotes atropine and 2-PAM chloride (2-PAM Cl, pralidoxime chloride or PROTOPAM ® CHLORIDE) FDA-approved and commercially available for use by civilian emergency medical personnel in the event of an accidental release of nerve agent or organophosphorus insecticides FDA-approved and commercially available for use by civilian emergency medical personnel in the event of an accidental release of nerve agent or organophosphorus insecticides AI 6©

7. States decide if they will use them States decide if they will use them One U. S.-based manufacturer: Survival Technology Inc. (STI) One U. S.-based manufacturer: Survival Technology Inc. (STI) Auto-Injectors AI 7©

8. Who Can Use Auto-Injectors Concern about administration of inappropriate and harmful doses during emergency situations Concern about administration of inappropriate and harmful doses during emergency situations Pre-measured doses in auto-injectors safe for civilians meeting profile of military personnelPre-measured doses in auto-injectors safe for civilians meeting profile of military personnel – approximate ages of 18–35 – weight at least 70 kg or 154 pounds – healthy with no compromising medical conditions Age, sex, weight and health of all other patients must first be considered when determining amount of atropine and 2-PAM Cl to administer Age, sex, weight and health of all other patients must first be considered when determining amount of atropine and 2-PAM Cl to administer AI 8©

9. Who Can Use Auto-Injectors Only qualified civilian emergency responders with adequate training in on-site recognition and treatment of nerve agent intoxication in the event of an accidental release Only qualified civilian emergency responders with adequate training in on-site recognition and treatment of nerve agent intoxication in the event of an accidental release Majority of CSEPP States follow DOT national curriculum for Emergency Medical Technicians Majority of CSEPP States follow DOT national curriculum for Emergency Medical Technicians Curriculum generally restricts training on use of IVs to Intermediate Emergency Medical Technicians and paramedicsCurriculum generally restricts training on use of IVs to Intermediate Emergency Medical Technicians and paramedics Review of each states laws and regulations needed to determine appropriate use of auto- injectors Review of each states laws and regulations needed to determine appropriate use of auto- injectors AI 9©

10. When To Use Auto-Injectors Use only after following events have occurred: Emergency medical personnel have donned personal protective equipment subsequent to recognizing existence of chemical agent hazard in area Emergency medical personnel have donned personal protective equipment subsequent to recognizing existence of chemical agent hazard in area Some or all of symptoms of nerve agent poisoning cited are present Some or all of symptoms of nerve agent poisoning cited are present AI 10©

11. Signs and Symptoms of Nerve Agent Exposure MILD MILD headache headache blurred vision from pinpoint pupils (miosis) blurred vision from pinpoint pupils (miosis) tight chest (smooth muscle constrictions) tight chest (smooth muscle constrictions) excessive sweating excessive sweating tearing (lacrimation) tearing (lacrimation) salivation salivation unexplained runny nose unexplained runny nose MODERATELY SEVERE MODERATELY SEVERE severe chest tightness severe chest tightness diarrhea (rare) diarrhea (rare) VERY SEVERE VERY SEVERE bluish discoloration bluish discoloration of skin (cyanosis) of skin (cyanosis) respiratory failure respiratory failure coma coma unconscious unconscious convulsions convulsions AI 11© Cinetel Productions

12. Treatment For Exposure To Nerve Agents Depending on severity of symptoms, immediately administer 1 atropine auto- injector, followed by 1 2-PAM Cl auto-injector Depending on severity of symptoms, immediately administer 1 atropine auto- injector, followed by 1 2-PAM Cl auto-injector Atropine should be given first, followed immediately by 2-PAM ClAtropine should be given first, followed immediately by 2-PAM Cl If nerve agent signs and symptoms are still present after 5–10 minutes, repeat injections If nerve agent signs and symptoms are still present after 5–10 minutes, repeat injections AI 12©

13. If signs and symptoms still exist after additional 10 minutes, repeat injections for third time If signs and symptoms still exist after additional 10 minutes, repeat injections for third time If signs and symptoms remain after third set of injections, do not give any more antidotes but seek immediate medical help If signs and symptoms remain after third set of injections, do not give any more antidotes but seek immediate medical help Treatment For Exposure To Nerve Agents AI 13©

14. If severe signs and symptoms are present: In case of very severe exposure, all three auto- injector kits (atropine and 2-PAM Cl) should be administered in rapid succession; then medical help should be sought In case of very severe exposure, all three auto- injector kits (atropine and 2-PAM Cl) should be administered in rapid succession; then medical help should be sought Remove secretions, maintain patients airway and, Remove secretions, maintain patients airway and, if necessary, use artificial ventilation if necessary, use artificial ventilation 2-PAM Cl is most effective if administered immediately after poisoning. Generally, little is accomplished if drug is given more than 6 hours after termination of exposure 2-PAM Cl is most effective if administered immediately after poisoning. Generally, little is accomplished if drug is given more than 6 hours after termination of exposure Treatment For Exposure To Nerve Agents AI 14©

15. Directions for Use AI 15© 1. Remove safety cap (yellow on atropine; gray on 2-PAM Cl). atropine; gray on 2-PAM Cl). Mark I kit clip holds the safety Mark I kit clip holds the safety caps; may not notice if using caps; may not notice if using Mark I kits. Do not touch colored Mark I kits. Do not touch colored end of injector after removing cap; injector can and will function into fingers or hand if any pressure applied to this end of injector

16. Directions for Use 2. Hold injector like a pen. Place colored end (green on colored end (green on atropine, black on atropine, black on 2-PAM Cl) on 2-PAM Cl) on thickest part of thigh and thickest part of thigh and press hard until injector press hard until injector functions functions Pressure automatically activates thePressure automatically activates the spring, plunges the needle into the spring, plunges the needle into the muscle and simultaneously forces muscle and simultaneously forces fluid through it into the muscle tissues fluid through it into the muscle tissues AI 16©

17. 3. Hold firmly in place for ten seconds, then remove. Massage the area of injection Directions for Use AI 17©

18. 4. After auto-injector has been activated, empty container should be disposed of empty container should be disposed of properly properly It cannot be refilled nor can the protrudingIt cannot be refilled nor can the protruding needle be retracted needle be retracted It should be disposed of in a sharps containerIt should be disposed of in a sharps container per rules for handling medical wastes and possible per rules for handling medical wastes and possible blood-borne pathogens blood-borne pathogens Note dosage on triage tag or write on Note dosage on triage tag or write on chest or forehead of patient chest or forehead of patient Directions for Use AI 18©

19. IMPORTANT: Medical personnel assisting evacuated victims of nerve agent exposure should avoid exposing themselves to cross- contamination by ensuring that they do not come in contact with patients clothing Directions for Use AI 19©

20. Precautions Place any patient receiving atropine under medical observation for at least 24 hours Place any patient receiving atropine under medical observation for at least 24 hours If atropine is used to treat infants, smaller amounts should be given If atropine is used to treat infants, smaller amounts should be given AI 20©

21. Adverse Reactions 2 to 5 minutes after intramuscular injection of 2-PAM Cl, mild to moderate pain may be experienced at site of injection 2 to 5 minutes after intramuscular injection of 2-PAM Cl, mild to moderate pain may be experienced at site of injection AI 21©

22. 2-PAM Cl in a normal person may cause: blurred vision double vision (diplopia)blurred vision double vision (diplopia) impaired accommodation dizzinessimpaired accommodation dizziness headache drowsinessheadache drowsiness nausea rapid heart rate (tachycardia)nausea rapid heart rate (tachycardia) increased systolic and hyperventilationincreased systolic and hyperventilation diastolic blood pressure diastolic blood pressure Adverse Reactions These are relatively non-toxic responses when compared to effects of nerve agent or organophorus insecticide exposures AI 22©

23. Overdosage If excessive atropine is administered to a normal person: Signs of atropinization will become even more severe and patient may also develop Signs of atropinization will become even more severe and patient may also develop blurring of visionblurring of vision deliriumdelirium urinary retentionurinary retention When signs and symptoms of atropinization develop, no more atropine should be injected until atropinization subsides When signs and symptoms of atropinization develop, no more atropine should be injected until atropinization subsides AI 23©

24. In case of 2-PAM Cl: Observed in normal subjects only Observed in normal subjects only dizziness dizziness blurred vision blurred vision double vision (diplopia) double vision (diplopia) headache headache impaired accommodation impaired accommodation nausea nausea slightly rapid heart rate (tachycardia) slightly rapid heart rate (tachycardia) Artificial respiration and other supportive therapy should be administered as needed Artificial respiration and other supportive therapy should be administered as needed Overdosage AI 24©

25. Caring For Auto-Injector Supplies Auto-injectors have a five-year shelf life, making them suitable for storage in emergency stockpiles Auto-injectors have a five-year shelf life, making them suitable for storage in emergency stockpiles Store auto-injectors at room temperature (approximately 25°C, 77°F) Store auto-injectors at room temperature (approximately 25°C, 77°F) Keep them from freezing Keep them from freezing May AI 25©

26. Caring For Auto-Injector Supplies Antidotes will freeze at temperatures below 29F Antidotes will freeze at temperatures below 29F Do not carry auto-injectors in external pocket of BDO when temperature below freezing. Place in inner pocket where body heat will keep them warm Do not carry auto-injectors in external pocket of BDO when temperature below freezing. Place in inner pocket where body heat will keep them warm Tie string to auto-injector and thread through outer layers of clothing to outside pocket or belt. Extract auto-injector by pulling the string when needed Tie string to auto-injector and thread through outer layers of clothing to outside pocket or belt. Extract auto-injector by pulling the string when needed Frozen auto-injectors still usable after being thawed if they do not appear broken or cracked Frozen auto-injectors still usable after being thawed if they do not appear broken or cracked AI 26©