1. Omaha Metropolitan Medical Response System OMMRS Mark I Kit Training for Health Care Professionals © Presented by the OMMRS Pharmacy Subcommittee

2. OMMRS Treatment Disclaimer This video is intended to provide general guidelines and is not intended for individual patient care. Please contact a physician or your regional poison control center for patient-specific management advice as needed.

3. OMMRS OMMRS Mark I Kit Training Video © Created by the Omaha Metropolitan Medical Response System Pharmacy Subcommittee Provides general information on the use and administration of the Mark I Kit for nerve agent exposures Please check with your local fire department and MMRS for specific treatment protocols

4. OMMRS Nerve Agents Chemical Warfare Agents Chemical Warfare Agents Tabun (GA) Tabun (GA) Sarin (GB) Sarin (GB) Soman (GD) Soman (GD) VX VX Organophosphate Insecticides Organophosphate Insecticides Malathion Malathion Parathion Parathion Lethal Amount of VX

5. OMMRS Mark I Kit Auto-injector Contains: Atropine IM 2 mg in 0.7 milliliters Atropine IM 2 mg in 0.7 milliliters Pralidoxime Chloride (2-PAM or Protopam) IM 600 mg in 2 milliliters Pralidoxime Chloride (2-PAM or Protopam) IM 600 mg in 2 milliliters The antidotes should only be used when signs and symptoms of exposure are present The antidotes should only be used when signs and symptoms of exposure are present

6. OMMRS Self Protection Protect Yourself: Protect Yourself: Liquid contamination on clothing poses a vapor and dermal contact risk to care givers. Liquid contamination on clothing poses a vapor and dermal contact risk to care givers. Protection from vapors requires wearing air-supplied respirators such as self-contained breathing apparatus until the patient is decontaminated. Protection from vapors requires wearing air-supplied respirators such as self-contained breathing apparatus until the patient is decontaminated. Protect yourself by avoiding contact with skin or clothing of victims (wear chemical-protective clothing). Protect yourself by avoiding contact with skin or clothing of victims (wear chemical-protective clothing). Skin decontamination before patient enters squad or hospital Skin decontamination before patient enters squad or hospital

7. OMMRS Nerve Agents Treatment Aggressive Respiratory Support Aggressive Respiratory Support Suction Suction Oxygen Oxygen Intubation Intubation Assisted Ventilation Assisted Ventilation

8. OMMRS S-M-I-L-E S Self-contained breathing apparatus S Self-contained breathing apparatus MMask and other PPE MMask and other PPE IInject self or patient AND Initiate respiratory support IInject self or patient AND Initiate respiratory support LLeave area for decontamination LLeave area for decontamination E Evaluation by a medical team E Evaluation by a medical team

9. OMMRS Nerve Agents Toxicity/Onset of Effects Nerve Agents and some organophosphate insecticides are extremely toxic by inhalation, ingestion, and dermal exposure Nerve Agents and some organophosphate insecticides are extremely toxic by inhalation, ingestion, and dermal exposure Onset of clinical effects may be rapid following inhalation and ingestion or may be delayed up to 18 hours following dermal exposures Onset of clinical effects may be rapid following inhalation and ingestion or may be delayed up to 18 hours following dermal exposures

10. OMMRS Effects of Nerve Agents Mild Symptoms Mild Symptoms Pinpoint pupils (miosis) Pinpoint pupils (miosis) Excessive sweating Excessive sweating Tearing (lacrimation) Tearing (lacrimation) Drooling (salivation) Drooling (salivation) Runny nose Runny nose Mild chest tightness Mild chest tightness Mild shortness of breath Mild shortness of breath

11. OMMRS Effects of Nerve Agents Moderate Symptoms Moderate Symptoms Severe chest tightness Severe chest tightness Wheezing Wheezing Profuse airway secretions Profuse airway secretions Respiratory distress Respiratory distress Vomiting, abdominal cramps Vomiting, abdominal cramps Diarrhea Diarrhea Muscle weakness Muscle weakness

12. OMMRS Effects of Nerve Agents Severe Symptoms Severe Symptoms Cyanosis Cyanosis Seizures Seizures Coma Coma Flaccid paralysis Flaccid paralysis Respiratory failure Respiratory failure Apnea Apnea

13. OMMRS S-L-U-D-G-E-M SSalivation AND Sweating LLacrimation (tearing of the eyes) UUrination DDefecation/Diarrhea GGI Upset (abdominal cramping) EEmesis AND Excessive Airway Secretions M Muscle Weakness/Paralysis AND Miosis

14. OMMRS Mark I Kit Injection Procedure 1. Remove Mark I Kit from the protective pouch. 2. With the non-dominant hand, hold the unit by the plastic clip so that the larger one is on top and both are positioned at eye level. 3. Remove the AtroPen from slot number one (1) of the plastic clip The yellow safety cap will remain in the clip and the AtroPen will now be armed. The yellow safety cap will remain in the clip and the AtroPen will now be armed. DO NOT hold unit by the green tip the needle injects from green tip. DO NOT hold unit by the green tip the needle injects from green tip.

15. OMMRS Mark I Kit Injection Procedure 4. With the other hand, check the injection site for buttons or objects in pockets which may interfere with the injections. 5. Grasp the unit and position the green tip of the AtroPen on victim’s outer thigh or buttocks. 6. Push firmly until the auto-injector fires. 7. Hold the injector firmly in place for at least 10 seconds.

16. OMMRS Mark I Kit Injection Procedure 8. Remove the Pralidoxime Chloride Pen from slot number two (2) of the plastic clip The grey safety cap will remain in the clip and the Pen will now be armed The grey safety cap will remain in the clip and the Pen will now be armed DO NOT hold the unit by the black tip – the needle injects from the black tip. DO NOT hold the unit by the black tip – the needle injects from the black tip. 9. Grasp the unit and position the black tip of the Pen on victim’s alternate outer thigh or buttocks.

17. OMMRS Mark I Kit Injection Procedure 10. Push firmly until the auto-injector fires. 11. Hold the injector firmly in place for at least 10 seconds. 12. Place the auto-injectors in a sharps container. 13. Document the number of auto-injectors administered on the patient care report or the triage tag. 1 kit 1 Kit

18. OMMRS Mark I Kit Injection Notes  Auto-injector needle is 8/10 inch long  Injector needle can go through clothing  Injector needle may not penetrate bunker gear  Give injections into a large muscle mass area such as the outer thigh or buttocks

19. OMMRS Treatment Guidelines Mild Symptoms Mild Symptoms Give One Mark I Kit Give One Mark I Kit 2 mg of atropine & 600 mg of pralidoxime 2 mg of atropine & 600 mg of pralidoxime

20. OMMRS Treatment Guidelines Moderate Symptoms Moderate Symptoms Give Two MARK I Kits Give Two MARK I Kits 4 mg of atropine & 1200 mg of pralidoxime 4 mg of atropine & 1200 mg of pralidoxime

21. OMMRS Treatment Guidelines Severe Symptoms Severe Symptoms Give Three MARK I Kits Give Three MARK I Kits 6 mg of atropine & 1800 mg of pralidoxime 6 mg of atropine & 1800 mg of pralidoxime Diazepam (Valium) 5-10 mg Diazepam (Valium) 5-10 mg Intramuscular or intravenous Intramuscular or intravenous Administer to patients with seizures Administer to patients with seizures Consider for non-convulsing patients with severe symptoms Consider for non-convulsing patients with severe symptoms

22. OMMRS Treatment Guidelines Continue to give additional 2 mg doses of Atropine at 5 to 10 minutes intervals as needed to dry excessive secretions Continue to give additional 2 mg doses of Atropine at 5 to 10 minutes intervals as needed to dry excessive secretions

23. OMMRS Atropine Remember : Patients die a pulmonary death Remember : Patients die a pulmonary death Atropine will dry lung secretions and relax bronchoconstriction Atropine will dry lung secretions and relax bronchoconstriction Indicator of sufficient atropine dosing: decrease in lung secretions, decreased airway resistance, drying of nasal and oral secretions and improved respiratory function Indicator of sufficient atropine dosing: decrease in lung secretions, decreased airway resistance, drying of nasal and oral secretions and improved respiratory function Pupil size should not be used as a guide for sufficient atropine dosing Pupil size should not be used as a guide for sufficient atropine dosing

24. OMMRS Atropine Insufficient atropine can result in fatalities Insufficient atropine can result in fatalities Too much atropine can cause dilated pupils, dry mouth and skin, rapid heart rate, flushed skin, confusion, and urinary retention. Too much atropine can cause dilated pupils, dry mouth and skin, rapid heart rate, flushed skin, confusion, and urinary retention. Atropine overdose is rarely life-threatening Atropine overdose is rarely life-threatening

25. OMMRS Pralidoxime Adverse Effects Mild to moderate pain at injection site Mild to moderate pain at injection site Other Side Effects: Other Side Effects: Blurred vision Blurred vision Headache Headache Increased blood pressure Increased blood pressure Double vision Double vision Dizziness Dizziness Drowsiness Drowsiness Tachycardia Tachycardia Hyperventilation Hyperventilation

26. OMMRS Pediatric Use In a mass terrorist attack, proportionately more children than adults may be affected In a mass terrorist attack, proportionately more children than adults may be affected Pediatric patients may be more seriously ill than adults following the same exposure Pediatric patients may be more seriously ill than adults following the same exposure Best option is to dose atropine and pralidoxime based on the child’s weight Best option is to dose atropine and pralidoxime based on the child’s weight

27. OMMRS Pediatric Dosing Atropine Atropine Children: 0.05 mg/kg IV or IM every 5 to10 minutes as needed for bronchospasm and secretions Children: 0.05 mg/kg IV or IM every 5 to10 minutes as needed for bronchospasm and secretions Pralidoxime Pralidoxime Children: 25-50 mg/kg (max 1 gram/dose) IV or IM; repeat in one hour as needed Children: 25-50 mg/kg (max 1 gram/dose) IV or IM; repeat in one hour as needed Diazepam Diazepam Children: 0.2-0.5 mg/kg IV or IM; may repeat every 5 to10 minutes as needed to control seizures Children: 0.2-0.5 mg/kg IV or IM; may repeat every 5 to10 minutes as needed to control seizures

28. OMMRS Pediatric Use Atropine is most needed initially in the field and ideally should be given from pre-filled syringes, pediatric auto- injectors, or multi-dose vials Atropine is most needed initially in the field and ideally should be given from pre-filled syringes, pediatric auto- injectors, or multi-dose vials The auto-injector may be discharged into a sterile container, such as a vial, and the amount needed drawn up and given IM The auto-injector may be discharged into a sterile container, such as a vial, and the amount needed drawn up and given IM Do not give IV due to the preservative Do not give IV due to the preservative There is potential for injury from the injector needle when administered to small children There is potential for injury from the injector needle when administered to small children In the absence of any other option, one Mark I Kit may be given to children weighing 12 kg or greater In the absence of any other option, one Mark I Kit may be given to children weighing 12 kg or greater For the child in extremis, one Mark I Kit may be given, regardless of size For the child in extremis, one Mark I Kit may be given, regardless of size

29. OMMRS Pediatric Use AtroPen is an atropine auto-injector available in various doses (0.25 mg, 0.5 mg, 1 mg, 2 mg) AtroPen is an atropine auto-injector available in various doses (0.25 mg, 0.5 mg, 1 mg, 2 mg) Use of a pediatric-strength AtroPen, facilitates the rapid administration of atropine doses to children Use of a pediatric-strength AtroPen, facilitates the rapid administration of atropine doses to children AtroPen 0.5 mg contains atropine 0.5 mg/0.7 ml AtroPen 0.5 mg contains atropine 0.5 mg/0.7 ml Dosing is based on child’s weight and severity of symptoms Dosing is based on child’s weight and severity of symptoms

30. OMMRS Pediatric Use Children weighing 13 to 40 pounds: Give One AtroPen 0.5mg auto-injector; repeat dose every 5-10 minutes as needed Children weighing 13 to 40 pounds: Give One AtroPen 0.5mg auto-injector; repeat dose every 5-10 minutes as needed Children weighing 41 to 62 pounds: Give Two AtroPen 0.5mg auto-injectors; repeat entire dose every 5-10 minutes as needed Children weighing 41 to 62 pounds: Give Two AtroPen 0.5mg auto-injectors; repeat entire dose every 5-10 minutes as needed Children weighing 63 to 84 pounds: Give Three AtroPen 0.5mg auto-injectors; repeat entire dose every 5-10 minutes as needed Children weighing 63 to 84 pounds: Give Three AtroPen 0.5mg auto-injectors; repeat entire dose every 5-10 minutes as needed Children weighing greater than 84 pounds: Give One Mark I Kit ; repeat dose every 5-10 minutes as needed Children weighing greater than 84 pounds: Give One Mark I Kit ; repeat dose every 5-10 minutes as needed

31. OMMRS AtroPen Injection Procedure 1. Snap the grooved end of the plastic sleeve down and over the yellow safety cap. Remove the AtroPen from the plastic sleeve. 2. Firmly grasp the AtroPen with the green tip pointed down. 3. Pull off the yellow safety cap with your other hand. DO NOT touch the green tip the needle injects from green tip. 4. The auto-injector will go through clothing, but make sure that pockets near the injection site are empty.

32. OMMRS AtroPen Injection Procedure 5. Aim and firmly push the green tip against the outer thigh. 6. Small children should also be injected in the thigh, but the thigh should be gently pinched to provide a thicker area for injection. 7. Hold the auto-injector firmly in place for ten seconds. 8. Remove the AtroPen and massage the injection site. 9. Place the auto-injector in a sharps container.

33. OMMRS For additional information and guidance on the use of Mark I Kits contact your poison control center at 1-800-222-1222

34. OMMRS Resources The Nebraska Regional Poison Center website www.nebraskapoison.com contains: www.nebraskapoison.com OMMRS Mark I Kit Training Video and Handout OMMRS Mark I Kit Training Video and Handout OMMRS Reference Cards OMMRS Reference Cards NBC Agents Overview/Quick Reference Guide NBC Agents Overview/Quick Reference Guide EMS Immediate Response NBC Reference Card EMS Immediate Response NBC Reference Card Psychiatric Medication Resources in Emergencies Psychiatric Medication Resources in Emergencies

35. OMMRS References CDC Website: www.bt.cdc.gov CDC Website: www.bt.cdc.govwww.bt.cdc.gov Chemical Warfare Involving Kids Response Project Syllabus: CWIKresponse.com Chemical Warfare Involving Kids Response Project Syllabus: CWIKresponse.com Domestic Preparedness Training Program Instructor Guide. U.S. Army Edgewood Research, Development and Engineering Center. 1998, Booz- Allen and Hamilton Inc. and Science Applications International Corporation Domestic Preparedness Training Program Instructor Guide. U.S. Army Edgewood Research, Development and Engineering Center. 1998, Booz- Allen and Hamilton Inc. and Science Applications International Corporation Henretig F, Mechem C, Jew R. “Potential use of autoinjector-packaged antidotes for treatment of pediatric nerve agent toxicity”, Ann of Emerg Med, 40:4, October 2002 Henretig F, Mechem C, Jew R. “Potential use of autoinjector-packaged antidotes for treatment of pediatric nerve agent toxicity”, Ann of Emerg Med, 40:4, October 2002 MICROMEDEX® Healthcare Series Vol. 124, expires 6/2005