ACT FAST Second Edition ACT001©.

ACT FAST Second Edition ACT001©

A gent C haracteristics and T oxicology F irst A id and S pecial
T reatment ACT002©

Purpose of Course The intent of this course is to instruct emergency
medical personnel on how to care for patients that may have been exposed to chemical warfare agents and assumed to have already been decontaminated. This course is designed primarily for Emergency Medical Technicians with basic life support credentials. These individuals are referred to in the text as pre-hospital emergency medical personnel. ACT002B©

Goal To prepare you to recognize signs
and symptoms, and provide initial emergency response treatment to patients injured by exposure to nerve and blister agents ACT003©

Goal To assist in preparing for hazardous materials emergencies
ACT004©

Instructional Objectives
• Action items • What trainees will be able to do at end of training • Review with trainees ACT005©

Required Objectives • DESCRIBE initial first-aid treatment for victims of nerve agent exposure blister agent exposure ACT006©

Supporting Objectives
• DESCRIBE potential hazards of nerve agents • DESCRIBE potential hazards of blister agents • IDENTIFY signs and symptoms of nerve agent exposure • IDENTIFY signs and symptoms of blister agent exposure ACT007©

Student Manual • Designed to augment classroom instruction
• Self-paced review • Self checks included • Additional reference materials such as Material Safety Data Sheets included ACT008©

Evaluations • Self-checks • Final quiz ACT009A©

BACKGROUND ACT010©

Purpose To familiarize you with chemical agent characteristics ACT011©

Chemical Stockpile • Comprised of chemicals designed and produced
for warfare • Primarily nerve agents and blister (vesicant) agents ACT012©

Chemical Stockpile Storage Location
• • • Hermiston, OR Tooele, UT Pueblo, CO • Aberdeen, MD Newport, IN Richmond, KY • • • • Pine Bluff, AR Anniston, AL ACT013©

Stockpile Inventories
U.S. Army Chemical Stockpile Inventories Storage Location Agent Stored GA GB VX Mustard Lewisite Umatilla X X X Tooele X X X X X Pueblo X Pine Bluff X X X Newport X Lexington- Blue Grass X X X Anniston X X X Aberdeen X ACT014©

LOCAL RESPONSE INFORMATION AND PROCEDURES
ACT015A©

Local Response Information and Procedures
• Specific and unique information requirements to be addressed • Provide you with a framework for site-specific information ACT015B©

Your Input is Important
Community needs and resources vary a great deal from one storage location to the next. Therefore, YOUR input on how the emergency care elements in your community could best respond to a release with off-post consequences is important to the success of the program. ACT015C©

What You Should Know That IS NOT in This Study Guide
• This study guide does not, and cannot, cover everything you need to know in preparation for your role • In short, you need to find out — Who the local players are — The roles and responsibilities of each — The methods of response — What supplies and equipment are on hand — Standard Operating Procedures — Memoranda of Understanding or Agreement ACT015D©

Additional Information Resources
• Local emergency services • Fire department or other emergency responders • Ambulance service or other rescue services • Hospital emergency department • Local health department ACT015E©

Local Community Response Procedures
If an emergency occurs at the installation that could affect the off-post population: • Where is the first notification (identification) expected to come from? • Who, from the facility, is notified? • Who, from the local community, is notified? • Who is likely to be the first on the scene? ACT015F©

Local Community Response Procedures (Continued)
If an emergency occurs at the installation that could affect the off-post population: • What are the duties of the pre-hospital emergency medical personnel? • What am I expected to do in this situation? • Am I authorized in my state to administer antidotal medications (atropine, 2-PAM chloride)? Under what circumstances? ACT015G©

CHEMICAL AGENTS ACT017©

Information will help you in: • Protecting yourself
• Treating patients ACT018©

Objectives • DESCRIBE potential hazards of nerve agents
• DESCRIBE potential hazards of blister agents • IDENTIFY most likely route of exposure ACT019©

C H A R A C T E R I S T I C S A N D E F F E C T S ACT020©

Nerve Agents • Attack nervous system
© Cinetel Productions Nerve Agents • Attack nervous system • Scientific classification: Organophosphate ACT021©

Specific Names Name Common Name Referred to As VX VX
GB Sarin GB or G-agent GA* Tabun GA or G-agent * Small amount stored at Tooele only ACT022©

Physical Properties • Usually liquid in normal state
• Volatile--generate vapors • Potential for release if in vapor form ACT023©

How Nerve Agents Work • Nervous system controls normal functions
through use of chemicals • Chemicals act as instructions to nerves, muscles, and glands • Two forms of instructions: - stimulate (move or work) - relax (stop or rest) • Nerve agent interferes with normal transmission of instructions ACT024©

Leads to Destruction of System Control
• Over-stimulates nerve endings and central nervous system • Causes muscles and certain glands to malfunction ACT025©

Normal Nervous System Function
• Nerve impulse transmitted along nerve cells • Acetycholine (a neuro- transmitter) is released • Target cell is stimulated ACT026A©

Normal Nervous System Function
• Once target cell is stimulated, acetycholine is deactivated by acetylcholinesterase. • Target cell relaxes ACT026B©

Nerve Agent Interference
• Nerve agents inactivate acetylcholinesterase • Excess acytelcholine accumulates • Muscle action becomes uncontrolled and twitchy • Muscle can tire and collapse • Gland continues to secrete sweat, tears, or mucus ACT027©

Routes of Exposure • Inhalation • Ingestion • Direct contact
© Cinetel Productions ACT028©

Inhalation Respiratory failure chief cause of death
after severe exposure © Cinetel Productions ACT029©

Direct Contact Absorption through skin: • All agents can be absorbed
• VX persists longer • GB evaporates quickly, but still threat • Scrape or cut in skin allows immediate entry Entry also through eyes © Cinetel Productions ACT030©

Ingestion • Access to bloodstream via digestive system
© Cinetel Productions • Access to bloodstream via digestive system • Effects similar to inhalation, but at greater doses ACT031©

Inhalation Exposure From Atmospheric Transport
The critical route of exposure that you should be most concerned with is *inhalation of agent vapors or aerosols* ACT032©

Blister Agents (Vesicants)
© Cinetel Productions Blister Agents (Vesicants) • Poisons that destroy cells • Blisters most noticeable effect ACT033©

Specific Names Common Name Referred to as Mustard H, HD, HT
Lewisite* L *Small amount stored at Tooele only ACT034©

Physical Properties • Form: Liquid or solid • Volatile, burns well HT
HD • Form: Liquid or solid • Volatile, burns well ACT035©

How Blister Agents Work
• Chemical burns to skin–especially warm, moist surfaces • Chemical burns to soft membranes - Eyes - Eye ball - Lung tissue - Mouth - Throat ACT036©

Mustard Agent Exposure
• Delayed reaction, little or no pain • Blisters develop in 2 to 36 hours © Cinetel Productions ACT037©

Routes of Exposure • Inhalation • Ingestion • Direct contact
© Cinetel Productions ACT038©

Inhalation Can destroy mucous membrane lining of • Nasal passages
• Throat • Bronchial tubes © Cinetel Productions ACT039©

Direct contact With Liquid or Vapor
Skin • Highly damaging to skin—especially warm, moist areas Mucous Membranes • Very susceptible to effects of blister agents • Includes: - lining around eyelids - inside mouth and nose Sweat and moisture increase effect ACT040©

Ingestion • If deposited on or in food items, drink, etc.
© Cinetel Productions • If deposited on or in food items, drink, etc. • Injures warm, moist tissues of mouth, throat and esophagus ACT041©

Inhalation Exposure From Atmospheric Transport
The critical route of exposure that you should be most concerned with is *inhalation of agent vapors or aerosols* ACT042©

Lewisite • Chlorovinyldichloroarsine (organic arsenical)
• Different type of blister agent in Chemical Stockpile only at Deseret Chemical Depot • Causes immediate pain upon skin or eye contact (unlike mustards) • Suspected carcinogen ACT043©

Key Points—Nerve Agents
• Nerve agent characteristics: - Stored as liquid (VX oily), generates extremely damaging vapors - Highly damaging by direct contact (touch), inhalation (breathing of contaminated air), and ingestion (eating or drinking) ACT044A©

Key Points—Blister Agents
HT H • Blister agent characteristics: - Stored as liquid (oily) or solid, generate damaging vapors - Damaging by direct contact (touch), inhalation (breathing of contaminated air), and ingestion (eating or drinking) HD ACT044B©

Key Points—Exposure Most likely route of exposure:
Inhalation of contaminated air ACT045©

SIGNS AND SYMPTOMS ACT046©

Size up situation based on . . .
• Known information regarding accidental release • Recognition of the event based on signs and symptoms ACT047©

Objectives • IDENTIFY signs and symptoms of nerve agent exposure
• IDENTIFY signs and symptoms of blister agent ACT048©

Note! Not all signs and symptoms may appear... Dose, duration, and
route of entry make a difference ACT049©

Specific Signs and Symptoms Of Nerve Agent Exposure
• Miosis (pinpoint pupils) • Dim vision • Respiratory trouble • Localized sweating • Wheezing • Runny nose or excess salivation • Stomach cramps, vomiting diarrhea • Muscle cramps, twitching • Heartbeat irregularities Constriction (Pinpoint) Expansion (Dilation) ACT050©

Specific Signs and Symptoms Of Nerve Agent Exposure (continued)
Mild: • Generalized weakness • Twitching spasms • Convulsions and coma • Other symptoms - Headache - Anxiety - Restlessness - Giddiness - Irritability ACT051©

Factors Affecting Signs and Symptoms
Time Factor (Onset) • Reaction time depends on: - type of agent involved - amount of agent to which patient exposed - dose (how much patient absorbed) - duration - route of exposure - sensitivity of patient's system ACT052©

Factors Affecting Signs and Symptoms (Continued)
Time Factor (Onset) • Reaction time is immediate if: - moderate to large amounts inhaled - moderate to large amounts spilled on skin • Reaction time is delayed if: - small amounts involved - absorbed through skin in localized area ACT053©

Exposure Through Inhalation
• Effects can occur after single breath • Immediate response within seconds • Peak effects within minutes © Cinetel Productions ACT054©

Exposure Through Skin (Absorption)
• Effects can develop up to 18 hours after exposure • Absorption can continue and effects worsen for hours, even after decon • Later onset, less likely to be lethal © Cinetel Productions ACT055©

Toxicity • LD50 of VX is 10 milligrams/70-kg man (liquid on skin)
– Equals tiny droplet absorbed into 155-lb person • LCt50 of VX is 30 milligrams-min/m (vapor inhalation) – 50 times more toxic than cyanide gas • LD50 of GB is 1.7 grams/70-kg man (liquid on skin) • LCt50 of GB is 70 milligrams-min/m (vapor inhalation) ACT056©

after severe exposures
Lethality Respiratory failure chief cause of death after severe exposures © Cinetel Productions ACT057©

Nerve Agent Exposure Levels
Mild: May also be effects of initial reaction which could lead to more serious effects eyes: miosis, pain (deep in eye or head), dim or blurred vision nose: runny lungs: "tightness in chest”, bronchoconstriction, secretions in airways, cough, moderate difficulty in breathing ACT058A©

Moderate: May also include symptoms under "Mild" eyes: miosis, pain, dim or blurred vision nose: runny (severe), nasal congestion lungs: ”tightness in chest", breathing more difficult, secretions more abundant muscles: feeling of generalized weakness , twitching of large muscle groups GI: nausea, vomiting, diarrhea, cramps ACT058B©

Severe: May develop from symptoms under "Mild" and "Moderate"; or go directly to these symptoms muscles: convulsions, weakness with eventual flaccid paralysis lungs: cessation of respiration all: loss of consciousness, coma, death ACT058C©

Onset time: seconds to several minutes • Symptoms may occur after little more than one breath of vapor • Large amounts may cause reactions within seconds • Effects do not worsen appreciably after 15-20 min following cessation of exposure ACT058D©

Skin Exposure to Nerve Agent
Mild: May also be effects of initial reaction which could lead to more serious effects skin: sweating at exposure site muscle: localized, unorganized twitching at exposure site (fasciculation) ACT058E©

Moderate: May also include symptoms under “Mild” muscle: generalized (at random, all over) fasciculation and twitching; generalized weakness that increases with any form of activity GI: nausea, vomiting, diarrhea ACT058F©

Severe: May develop from symptoms under "Mild" and "Moderate"; or go directly to these symptoms muscle: extremely weak; convulsions (seizures) with eventual flaccid paralysis lung: cessation of respiration all: sudden loss of consciousness and collapse, death ACT058G©

Skin Exposure to Nerve Agent Time Course
Onset time: minutes to several hours • The larger the exposure the shorter the onset time • After large exposure, effects within minutes • After asymptomatic period, first effect may be loss of consciousness • Onset time may be as long as 18 hrs after exposure; in such cases effects usually not lethal ACT058H©

Differential diagnosis . . .
... refers to distinguishing one disease from another when they produce similar effects ACT059©

Other Possible Causes of Symptoms
Signs and symptoms could also apply to: • Heat illnesses • Emphysema • Stroke • Head trauma • Drug overdose • Epilepsy • Gastroenteritis • Exposure to agricultural insecticides (organophosphates and carbanates) ACT060©

Blister Agent Release Potential
While liquid deposition of mustard agent or high concentrations of vapor are not expected, it is important to recognize the signs and symptoms of more severe exposures ACT061A©

Specific Signs and Symptoms of Mustard Agent Exposure
• Eye irritation and inflammation • Photophobia • Erythema • Blisters • Inflammation of respiratory tract ACT061B©

How Mustard Blisters Skin
© Cinetel Productions Normal skin Reddened skin Blistered skin ACT061C©

Factors Affecting Signs and Symptoms
Time Factor (Onset) • Reaction time depends on: - type of agent - amount of agent to which patient exposed - dose (how much patient absorbed) - duration of exposure - route of exposure - sensitivity of patient's system ACT062©

Peak Effect Inhalation • Effects occur after few hours latency
• Sneezing, coughing, bronchitis Skin Absorption • Effects delayed and absorption can continue for hours © Cinetel Productions ACT063©

Peak Effect (Continued)
Toxicity • LD50 is 7 grams/70-kg man (liquid on skin) • Between 4 and 32 micrograms/70-kg man can cause blistering • Vapor form 3 times more toxic than cyanide Lethality • Low (~3% in World War I) • Chief cause of death: - Respiratory failure - Infections © Cinetel Productions ACT064©

Mustard Agent Exposure Levels
Mild: skin: no immediate clinical effects (no burning, stinging, or redness); becomes "fixed" to the tissue within minutes, blisters appear about 2 to 36 hours later eyes: within 4 to 12 hours after exposure, itching, tearing, conjunctivitis (reddening of tissues surrounding the eyeball), sensation of grit in the eye, burning and photophobia (sensitivity to light), some swelling of eyelids ACT065A©

Moderate: skin: no immediate clinical effects; blisters appear sooner and are more severe than in cases of "mild" dose eyes: in 3 to 6 hours; increased intensity from "Mild" symptoms; swelling of lids to the point of near closure; spasms of the muscles surrounding the eye; increased photophobia; blurred vision; possible discharge; miosis; severe inflammation of conjuctiva and cornea ACT065B©

Severe: skin: no immediate clinical effects blisters appear sooner and are large necrosis skin charring (delayed) eyes: severe pain increased swelling of lids to point of closure, discharge possible damage to cornea Muscles: large amounts may affect nerve endings ACT065C©

Mustard Agent Exposure Through Inhalation/Ingestion
Mild: nose, throat and windpipe: burning sensation, sinus pain, cough GI: nausea and vomiting ACT065D©

Moderate: nose, throat and windpipe: burning sensation lungs: chest tightness, severe cough GI: nausea and vomiting, stomach pains ACT065E©

Severe: nose, throat and windpipe: severe burning lungs: difficulty breathing due to airway damage GI: nausea, vomiting, bloody diarrhea, stomach pains muscles: large amounts may affect nerve endings ACT065F©

Mustard Agent Exposure Time Course
• Onset of symptoms may be delayed initial signs/symptoms: 2 to 36 hrs, acute tracheobronchitis • Approximate for moderate exposure: to 4 hrs—chest tightness, hacking cough, hoarseness, sneezing to 16 hrs—sinus pain, increased respiration rate to 48 hrs—severe cough, unable to speak, very rapid breathing to 48 hrs—severe dyspnea, lung tissue hemorrhage, bronchopneumonia ACT066©

Lewisite Signs and Symptoms
In spite of its chemical differences from mustard agents, Lewisite produces similar damage in body tissues. ACT067A©

Inhalation of Lewisite Vapor
• When inhaled, vapor may produce mild to moderate irritation of upper respiratory tract • May also cause sneezing • Similar to mustard effects — Except, in most severe cases, fluid may accumulate in lungs and ooze into lining of the chest cavity ACT067B©

Direct Contact with Liquid Lewisite
• Immediate severe pain upon contact with eyes and skin (unlike mustard) • Eyes can be severely damaged resulting in permanent injury of blindness • More severe skin lesions than mustard — Erythema followed by blistering over entire area of erythema — Deeper injury to connective tissue and muscle — Greater vascular damage — More inflammation ACT067C©

Other Effects • Systemic poison (liver and kidneys)
at sufficiently large doses • Has induced Bowen’s disease (slow-growing, usually nonfatal skin cancer) ACT067D©

Lewisite Exposure eye: prompt redness, swelling, irritation,
immediate burning sensation, may cause inflammation of iris, corneal injury nose: prompt irritation respiratory tract: rapid irritation, hoarseness, loss of voice, cough; pneumonia, fever, accumulation of fluid in lungs, fluid between membranes lining chest cavity ACT067E©

Lewisite Exposure (Continued)
skin: prompt burning redness within 30 min, blisters on 1st or 2nd day; pain more severe and necrosis deeper than mustard GI tract: diarrhea, nausea, vomiting, liver failure cardiovascular system: shock after severe symptoms, anemia, concentration of blood ACT067F©

Lewisite Exposure (Continued)
bladder: kidney failure central nervous system: malaise, prostration, depression after severe symptoms ACT067G©

Other Possible Causes Of Signs and Symptoms
Blister agent signs and symptoms could also apply to: • Hay fever • Chemical or thermal burns • Heavy tear gas exposure • Poison ivy, poison oak, and other contact allergies ACT068©

Nerve Agent Summary • Specific signs and symptoms of nerve agent exposure - Miosis - Increased secretions - Respiratory difficulty • Not all signs and symptoms may appear • Dose, duration, and route of entry can make difference ACT069A©

Blister Agent Summary • Specific signs and symptoms of blister agent exposure — Eye irritation and inflammation — Erythema (skin reddening) — Blisters — Respiratory irritation and distress • Not all signs and symptoms may appear • Dosage, duration, and route of entry can make difference ACT069B©

Objectives • DESCRIBE need for self protection when
providing treatment for nerve or blister agent exposure • DESCRIBE initial first aid treatment for victims of nerve agents of blister agents ACT072©

You Can Protect Yourself By:
• Recognizing area with exposure potential and the zone set up to operate safely during the emergency • Ensuring that the exposed person is completely decontaminated ACT074A©

Emergency Time Line Once chemical plume expected to cross borders of post: • Initial hazard prediction given, identifying pattern and path of off-post exposure • Emergency response and treatment teams established ACT074B©

• It is assumed that patients will have been
decontaminated before being brought to EMS personnel in the cold zone • Information regarding decontamination or removal from contaminated areas should not be interpreted as encouraging EMS personnel to go into the hot zone • PPE may be required. The CSEPP training course, Personal Protective Equipment, describes the approved equipment and associated requirements ACT074C©

Decontamination • Essential part of treatment
• Prevents agent from doing further harm • Prevents agent from spreading Note: Should be accomplished before patient is brought to the treatment area ACT075©

Atropine Effect Atropine blocks effects of over-stimulation
Relieves smooth muscle constriction Dries up respiratory secretions ACT078©

2-PAM Chloride Effect Removes organophospate from acetylcholinesterase which can then deactivate acetylchline Re-establishes normal skeletal muscle contraction Relieves twitching and paralysis of respiratory muscles ACT079©

Administration of Antidotes
Dosage varies depending on age and weight of patient and severity of signs and symptoms Dosages may need to be repeated at specified intervals repeat atropine until patient is “atropinized” repeat 2-PAM Chloride until maximum dose per body weight is reached ACT080©

Two Common Problems Underdosage
administering too little antidote to relieve agent effects most serious problem: failing to administer atropine when needed Administering antidote to patients not exposed to nerve agent ACT081©

Additional Drug Therapy— Diazepam
Administer to patients experiencing convulsions Consider for patients with severe signs and symptoms Dosage depends on patient’s age ACT082©

Guideline For Administering Antidotes
• Make sure atropine warranted • Administer dosages of antidotes as recommended in treatment tables • Continue administering atropine as recommended in treatment tables until atropinization is achieved • If needed, repeat dosage of 2-PAM Chloride as recommended in treatment tables until maximum total dose is given ACT083©

Atropine Overdose Cause: Atropine administered when no prior nerve agent exposure has occurred Not as serious as underdosing Not usually life-threatening ACT085©

Signs and Symptoms Of Atropine Overdose
• Dilated pupils • Dry mouth and skin • Rapid pulse • Flushed skin • Difficulty urinating • Confusion, delirium • Temperature control diminished • Intense thirst • Restlessness ACT086©

Other Possible Causes of Symptoms Similar To Atropine Overdose
• Heat stroke • Locoweed • Atropine-like medicines ACT087A©

Treatment for Atropine Overdose
• Keep cool • Protect from irrational actions • Transport to hospital as soon as possible ACT087B©

Alternate Method of Administration of Antidote
Auto-injectors approved for civilians by Food and Drug Administration - Simple, compact, injection systems equipped with pre- measured amount (dose) of antidote - Atropine auto-injectors approved for adults and children, but not infants - 2-PAM chloride auto-injectors approved for adults only ACT088©

Respiratory Support • Required only if exposure is severe
• Range from administering oxygen (if breathing is difficult) to providing ventilation, airway management and suction as needed ACT089©

Ventilation • If required, insertion of endotracheal tube by
a qualified person is recommended • Requires higher “pop off” pressure (70+ cm H2O) ACT090© Source: DOT Emergency Medical Care--Paramedic

Treatment For Exposure To Blister Agent
After protecting yourself, immediately • Ensure patient is thoroughly decontaminated • Take precautions for sterile technique • Support airway management as necessary ACT091©

Eye Contact SPEED CRITICAL! • Flush eyes immediately
• Do not cover eyes with bandages • Dark or opaque glasses provide relief from photophobia - Tilt head to the side - Pull eyelids apart with fingers - Pour water slowly into eyes ACT092©

Skin Contact Pay special attention to Around ears Eyelids Inside nose
Inside mouth Neck creases Pay special attention to Arm pits Groin Behind knees Between toes ACT093©

Inhalation Supply respiratory support if needed for significant inhalation exposure Administer oxygen as needed If breathing has stopped, resuscitate the person Give intravenous fluids if needed, but do not overload ACT094©

Treatment For Exposure to Lewisite
• Decontaminate exposed person immediately to avoid deep burns • Antidote has been developed but is no longer manufactured ACT095©

Key Points • PROTECT SELF • Initial first aid for nerve agent exposure
- Give atropine, follow up with 2-PAM chloride - Support airway management as necessary - Atropine overdose possible if given when no nerve agent exposure occurred • Initial first aid for blister agent exposure - Ensure that patient is decontaminated - Take precautions for sterile technique ACT096©

ACT FAST Second Edition ACT001©.

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