1. Nerve agents & Mark 1 Auto injectors
Harbor-UCLA Medical Center
South Bay Disaster Resource Center

2. Objectives At the end of this in-service participants will be able to:
Describe potential chemical agents used as weapons of mass destruction
Discuss the clinical presentation of a patient exposed to a nerve agent
Demonstrate the use of a Mark 1 Nerve Antidote kit

3. Priorities in an “all hazards” response
Life safety
Safety of rescuers
Safety of victims
Appropriate decontamination and treatment of victims
Appropriate protection for staff/rescuers and treatment if necessary
Incident coordination/stability
Property preservation-evidence collection
Protection of the environment

4. Initial treatment for nerve agent exposure
Scene safety
Immediate removal of victim from source of exposure
Direct proportional relationship between absorbed dose and severity of symptoms/morbidity & mortality
Airway management is key
Antidote administration
Seizures

5. Nerve agent triage
Was Mark 1 given in the pre-hospital treatment? How many?
Signs and symptoms upon presentation
Initial symptoms improving?
Is miosis still present
Bronchorhhea present?

6. Minimal Treatment- Nerve agent exposure
Patient exposed to nerve agent
Recovering well from Mark 1 Kit admininstration
Walking and talking indicates respiratory and circulatory status is sufficient to maintain function

7. Expectant patients exposed to nerve agents
Apneic for more than five minutes
Seizures have already begun
No pulse or blood pressure
Patient has minimal to no chance of survival no matter what treatment
Patient is declared expectant (black triage tag)

8. Signs and Symptoms: SLUDGE
Over-stimulation of the nervous system causes muscles and certain glands to over-react
Salivation
Lacrimation
Urination
Defecation
GI Distress
Excrement/Emesis

9. Effects of nerve agent on victim
The nervous system controls body functions by secreting chemical transmitters which act as "instructions" to nerves, muscles and glands.
Nerve agent exposure -interferes with the normal instructions of chemical transmitters that direct the muscle or gland to return to an un-stimulated, relaxed state.
Action of toxic nerve agents is to over-stimulate the nerve endings and central nervous system.

10. Organophosphate poisonings
SLUDGE symptoms
Cases we are familiar with in healthcare due to frequent exposures
Massive doses of Atropine
Common with gardeners in hot house environment
Industrial plants
Migrant farm workers exposed to Malephyon

11. Nerve agent antidote History of the Mark 1 Kit auto injectors
Placement of Mark 1 Kits in CHEMPACK and pharmaceutical caches
Dosaging- Adult and Pediatric
Administration of Mark 1 Kit

12. Mark 1 Autoinjectors
Atropine: administered to block receptor sites of acetylcholine
2-PAM Chloride: restores acetylcholinesterase
Combo Pen/ Mark 1
Package insert- review administration, side effects

13. Mark 1 Kits One chamber has 2mg of Atropine
One chamber has 600 mg of 2 Pam
Other auto injectors contain Valium for seizure control

14. Atropine Dose Monitor Interval 2-Pam Dose
Signs & Symptoms
Atropine Dose Monitor Interval
2-Pam Dose
Severe Respiratory Distress, Agitation SLUDGE
3 Auto-injectors (6 mg) Monitor every 5 minutes
3 Auto-injectors (1.8 gms)
Respiratory Distress, SLUDGE
2 Auto-injectors (4 mg) Monitor every 10 minutes
1 Auto-injector (600 mg)
Asymptomatic None
Monitor for signs & symptoms every 15 minutes
None
Source: New York Department of Health Policy Statement 03-05
Use of "Mark I Kits" (AtroPen Auto-Injector & Pralidoxime Chloride Injector)

15. How to obtain the Mark 1 Kits at Harbor-UCLA Medical Center
Attending physician of ER declares a Code Triage- overhead page for disaster
Notification to pharmacy that pharmaceutical caches are necessary
Delivery of medications to ER
Treatment of staff/victims
Pharmacy notifies CDC that CHEMPACK as been activated via Sensaphone

16. Thank you for your attention
Please sign in on roster
Please take three handouts
For any further questions please notify Dr. Amy Kaji or KathyCrow