1. Combat Life Saver LESSON 13 ADMINISTER FIRST AID TO A NERVE AGENT CASUALTY Compiled and edited by, 2LT John C. Miller, PA-C

2. LESSON 13 ADMINISTER FIRST AID TO A NERVE AGENT CASUALTY INTRODUCTION A soldier showing signs of mild nerve agent poisoning will normally be able to take care of himself. A soldier showing signs of moderate to severe nerve agent poisoning, however, will not be able to adequately help himself and must have assistance.

3. ADMINISTER FIRST AID TO A NERVE AGENT CASUALTY TASKTASK Identify the buddy-aid procedures for treating a nerve agent casualty. CONDITIONSCONDITIONS Given multiple-choice examination items pertaining to nerve agent poisoning, buddy-aid treatment, and decontamination. STANDARDSTANDARD Score 70 or more points on the 100-point written examination.

4. TAKE PROTECTIVE MEASURES Anytime you believe you have been or will be exposed to a chemical agent, your first action must be to protect yourself. You cannot continue with your mission or administer aid to casualties if you are overcome by the chemical warfare agent.Anytime you believe you have been or will be exposed to a chemical agent, your first action must be to protect yourself. You cannot continue with your mission or administer aid to casualties if you are overcome by the chemical warfare agent. Put on your protective mask immediately and give the alarm.Put on your protective mask immediately and give the alarm.

5. TAKE PROTECTIVE MEASURES If you have signs and symptoms of mild nerve agent poisoning (unexplained runny nose, sudden headache, dizziness, drooling, tightness in the chest, muscular twitching, stomach cramps, nausea, and/or reduced vision), administer one set of nerve agent autoinjectors to yourself and decontaminate your exposed skin.If you have signs and symptoms of mild nerve agent poisoning (unexplained runny nose, sudden headache, dizziness, drooling, tightness in the chest, muscular twitching, stomach cramps, nausea, and/or reduced vision), administer one set of nerve agent autoinjectors to yourself and decontaminate your exposed skin. Put on the rest of your protective clothing.Put on the rest of your protective clothing.

6. IDENTIFY SIGNS OF SEVERE NERVE AGENT POISONING A casualty may progress from mild to moderate to severe nerve agent poisoning signs. Signs of severe nerve agent poisoning include:A casualty may progress from mild to moderate to severe nerve agent poisoning signs. Signs of severe nerve agent poisoning include: Strange and confused behavior.Strange and confused behavior. Coughing, wheezing, and gurgling sounds while breathing.Coughing, wheezing, and gurgling sounds while breathing. Difficulty in breathing.Difficulty in breathing. Severely pinpointed pupils.Severely pinpointed pupils. Red eyes with tears present.Red eyes with tears present.

7. IDENTIFY SIGNS OF SEVERE NERVE AGENT POISONING Vomiting.Vomiting. Severe muscular twitching and general weakness.Severe muscular twitching and general weakness. Loss of bladder and bowel control.Loss of bladder and bowel control. Decreased pulse rate.Decreased pulse rate. Convulsion.Convulsion. Paralysis.Paralysis. Unconsciousness.Unconsciousness. Respiratory failure (or respiratory arrest) [casualty stops breathing].Respiratory failure (or respiratory arrest) [casualty stops breathing].

8. MASK THE CASUALTY Put the casualty's mask on him immediately if he is not masked. If he is already masked, check the seal.Put the casualty's mask on him immediately if he is not masked. If he is already masked, check the seal. Position the casualty on his back.Position the casualty on his back. 1Squat, do not kneel, in a chemical environment. Pressing your knee against the contaminated ground will reduce the protection time afforded by your protective clothing. Open the casualty's mask carrier and remove his protective mask.Open the casualty's mask carrier and remove his protective mask. Hold the mask with the lenses facing you.Hold the mask with the lenses facing you.

9. MASK THE CASUALTY Put your thumbs on the outside of the cheek pouches of the mask and your fingers on the inside of the cheek pouches.Put your thumbs on the outside of the cheek pouches of the mask and your fingers on the inside of the cheek pouches. Spread the mask open and position it on the casualty's chin.Spread the mask open and position it on the casualty's chin. Put your thumbs through the two bottom straps of the head harness.Put your thumbs through the two bottom straps of the head harness. Cup the casualty's head with the fingers of both hands and lift his head slightly.Cup the casualty's head with the fingers of both hands and lift his head slightly. Slide the head harness over the casualty's head by moving your thumbs toward the back of the casualty's head and down behind his ears.Slide the head harness over the casualty's head by moving your thumbs toward the back of the casualty's head and down behind his ears.

10. MASK THE CASUALTY Make sure the two bottom straps of the head harness are below the casualty's ears, the temple straps are above his ears, and the head pad is centered in the middle of the back of his head.Make sure the two bottom straps of the head harness are below the casualty's ears, the temple straps are above his ears, and the head pad is centered in the middle of the back of his head. 1The head harness should not need to be adjusted. If the straps do need to be tightened, tighten them using short, firm, jerks. Check the seal of the mask against the casualty's face.Check the seal of the mask against the casualty's face. 1If the casualty can follow instructions, have him clear his mask by covering the outlet valve and voicemitter and exhaling forcefully, then covering the inlet valves and inhaling.

11. MASK THE CASUALTY 1If the casualty cannot follow instructions, cover the mask's inlet valves. If the mask collapses when the casualty inhales, it is properly sealed. If it does not collapse, reseat the mask. If the soldier is not breathing, you cannot determine whether the mask is properly sealed. Make sure the buckles are lying flat and the straps form a straight line with the tabs.Make sure the buckles are lying flat and the straps form a straight line with the tabs. Pull the protective hood over the casualty's head, neck, and shoulders.Pull the protective hood over the casualty's head, neck, and shoulders.

12. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Select Injection SiteSelect Injection Site The normal injection site is the outer part of the casualty's thigh at least the width of one hand below the hip joint and at least the width of one hand above the knee.The normal injection site is the outer part of the casualty's thigh at least the width of one hand below the hip joint and at least the width of one hand above the knee. If the casualty is very thin, roll the casualty onto his stomach or side and select a site on the upper, outer quadrant of the casualty's buttocks. Lift his jacket if it is covering the site.If the casualty is very thin, roll the casualty onto his stomach or side and select a site on the upper, outer quadrant of the casualty's buttocks. Lift his jacket if it is covering the site.

15. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Administer AtropineAdminister Atropine Remove one Mark I nerve agent antidote kit from the inside pocket of the casualty's mask carrier.Remove one Mark I nerve agent antidote kit from the inside pocket of the casualty's mask carrier. 1If the temperature is near or below freezing, the autoinjectors may be carried next to the casualty's body. Hold the kit by the clip in your nondominant hand at eye level with the larger (2-PAM chloride) autoinjector on top.Hold the kit by the clip in your nondominant hand at eye level with the larger (2-PAM chloride) autoinjector on top. Feel the injection site with your free hand to make sure the site is free from buttons or other obstructions which could damage the needle.Feel the injection site with your free hand to make sure the site is free from buttons or other obstructions which could damage the needle.

17. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Grasp the body of the lower (smaller) autoinjector with the thumb and two fingers of your dominant hand.Grasp the body of the lower (smaller) autoinjector with the thumb and two fingers of your dominant hand. 1Do not touch the green (needle) end of the autoinjector since the pressure could cause the needle to function. Pull the atropine autoinjector out of the clip with a smooth motion.Pull the atropine autoinjector out of the clip with a smooth motion. Form a fist around the autoinjector and place the green end of the autoinjector against the injection site (thigh or buttocks) at a 90 degree angle to the surface of the site.Form a fist around the autoinjector and place the green end of the autoinjector against the injection site (thigh or buttocks) at a 90 degree angle to the surface of the site.

19. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Apply firm even pressure to the autoinjector until the needle functions (clicks), penetrates the clothing, and automatically injects the medication into the casualty's muscle.Apply firm even pressure to the autoinjector until the needle functions (clicks), penetrates the clothing, and automatically injects the medication into the casualty's muscle. 1Do not use a jabbing motion to inject the antidote into the muscle. Hold the autoinjector in place for at least 10 seconds.Hold the autoinjector in place for at least 10 seconds. Pull the autoinjector out of the casualty's body at the same 90 degree angle.Pull the autoinjector out of the casualty's body at the same 90 degree angle. Place the used atropine autoinjector between two fingers of the hand holding the kit with the needle pointing away from your hand.Place the used atropine autoinjector between two fingers of the hand holding the kit with the needle pointing away from your hand.

21. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Administer 2-PAM ChlorideAdminister 2-PAM Chloride Grasp the body of the remaining (2-PAM chloride) autoinjector with the thumb and two fingers of your free hand.Grasp the body of the remaining (2-PAM chloride) autoinjector with the thumb and two fingers of your free hand. Pull the autoinjector out of the clip in a smooth motion.Pull the autoinjector out of the clip in a smooth motion. 1Do not touch the black (needle) end of the autoinjector. Form a fist around the autoinjector and place the black end of the autoinjector against the injection site at a 90 degree angle.Form a fist around the autoinjector and place the black end of the autoinjector against the injection site at a 90 degree angle. Apply firm, even pressure until the needle functions.Apply firm, even pressure until the needle functions. 1Do not use a jabbing motion.

25. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Hold the autoinjector in place for at least 10 seconds.Hold the autoinjector in place for at least 10 seconds. Pull the autoinjector out of the casualty's body at the same 90 degree angle.Pull the autoinjector out of the casualty's body at the same 90 degree angle. Drop the empty plastic clip without dropping the autoinjectors.Drop the empty plastic clip without dropping the autoinjectors. Lay the used autoinjectors on the casualty's chest or back.Lay the used autoinjectors on the casualty's chest or back. Administer Second and Third KitsAdminister Second and Third Kits Administer the second Mark I kit using the same procedures as for the first kit.Administer the second Mark I kit using the same procedures as for the first kit.

26. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Administer the third kit of autoinjectors.Administer the third kit of autoinjectors. There is no waiting period between kits.There is no waiting period between kits. 1If the casualty already administered one set of injectors to himself (used autoinjectors attached to pocket flap), you will only administer the two additional Mark I kits. The CANA is NOT for use as self-aid. If you know who you are, where you are, and what you are doing, you do not need CANA.The CANA is NOT for use as self-aid. If you know who you are, where you are, and what you are doing, you do not need CANA. Administer the CANA immediately after the third MARK I to prevent convulsions.Administer the CANA immediately after the third MARK I to prevent convulsions.

27. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Grasp the CANA autoinjector with your dominant hand with the needle end extending beyond your thumb and two fingers.Grasp the CANA autoinjector with your dominant hand with the needle end extending beyond your thumb and two fingers. With your other hand, pull the safety cap off the autoinjector base.With your other hand, pull the safety cap off the autoinjector base. The injector is now armed.The injector is now armed. DO NOT touch the black (needle) end because you may accidently inject yourself.DO NOT touch the black (needle) end because you may accidently inject yourself. Position the black (needle) end of the autoinjector against the casualty's injection site (thigh or buttocks).Position the black (needle) end of the autoinjector against the casualty's injection site (thigh or buttocks).

29. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Apply firm, even pressure (not a jabbing motion) to the injector until it pushes the needle into the casualty's thigh (or buttocks). Make sure you do not hit the casualty's mask carrier or any objects in the individual's pockets.Apply firm, even pressure (not a jabbing motion) to the injector until it pushes the needle into the casualty's thigh (or buttocks). Make sure you do not hit the casualty's mask carrier or any objects in the individual's pockets. Hold the injector firmly in place for at least 10 seconds.Hold the injector firmly in place for at least 10 seconds. Carefully remove the CANA autoinjector from the casualty's injection site.Carefully remove the CANA autoinjector from the casualty's injection site. Drop the safety cap. (The cap can be disposed of earlier.)Drop the safety cap. (The cap can be disposed of earlier.)

30. ADMINISTER THREE NERVE AGENT ANTIDOTE KITS AND CANA Secure Used AutoinjectorsSecure Used Autoinjectors Attach used autoinjectors, atropine, PAM chloride, and CANA to the casualty's clothing, usually the left pocket flap.Attach used autoinjectors, atropine, PAM chloride, and CANA to the casualty's clothing, usually the left pocket flap.

32. DECONTAMINATE EXPOSED SKIN Obtain M291 KitObtain M291 Kit Obtain the M291 decontamination kit from the casualty's mask carrier.Obtain the M291 decontamination kit from the casualty's mask carrier. The M291 Skin Decontaminating Kit is provided to service members for skin decontamination. This kit may also be used to decontaminate selected individual equipment, such as load bearing equipment, protective gloves, mask, hood, and weapon.The M291 Skin Decontaminating Kit is provided to service members for skin decontamination. This kit may also be used to decontaminate selected individual equipment, such as load bearing equipment, protective gloves, mask, hood, and weapon. Seek overhead cover or use a poncho for protection against further contamination.Seek overhead cover or use a poncho for protection against further contamination.

33. DECONTAMINATE EXPOSED SKIN Decontaminate HandsDecontaminate Hands Remove one skin decontaminating packet from the carrying pouch.Remove one skin decontaminating packet from the carrying pouch. Tear open quickly at notch. Although any notch may be used to open the packet, opening at the TEAR LINE will place applicator pad in a position that is easier to use.Tear open quickly at notch. Although any notch may be used to open the packet, opening at the TEAR LINE will place applicator pad in a position that is easier to use. Remove applicator pad from packet and discard empty packet.Remove applicator pad from packet and discard empty packet. Unfold applicator pad and slip finger(s) into handle.Unfold applicator pad and slip finger(s) into handle.

34. DECONTAMINATE EXPOSED SKIN Thoroughly scrub exposed skin on the casualty's hands (back of hand, palm, and fingers) until completely covered with black powder from the applicator pad.Thoroughly scrub exposed skin on the casualty's hands (back of hand, palm, and fingers) until completely covered with black powder from the applicator pad. Decontaminate FaceDecontaminate Face Thoroughly scrub exposed skin of the casualty's face until completely covered with black powder from the applicator pad.Thoroughly scrub exposed skin of the casualty's face until completely covered with black powder from the applicator pad. 1Have casualty hold his breath, close his eyes. Grasp his mask beneath chin, and pull hood and mask away from chin enough to allow one hand between the mask and the face. Hold mask in this position until you discard the applicator pad.

35. DECONTAMINATE EXPOSED SKIN 1Scrub up and down across face beginning at from of one ear to nose to other ear. 1Scrub across face to corner of nose. 1Scrub extra stroke at corner of nose. 1Scrub across nose and tip of nose to other corner of nose. 1Scrub extra stroke at corner of nose. 1Scrub across face to other ear.

36. DECONTAMINATE EXPOSED SKIN 1Next scrub up and down across face to mouth to other end of jawbone. 1Scrub across cheek to corner of mouth. 1Scrub extra stroke at corner of mouth. 1Scrub across closed mouth to center of upper lip. 1Scrub extra stroke above upper lip. 1Scrub across closed mouth to other corner of mouth. 1Scrub extra stroke at corner of mouth. 1Scrub across cheek to end of jawbone.

37. DECONTAMINATE EXPOSED SKIN 1Next, scrub up and down across face to chin and to other end of jawbone. 1Scrub across the under jaw to chin, cupping. 1Scrub extra stroke at center of chin. 1Scrub across the under jaw to the end of the jawbone. 1Turn your hand out, and quickly wipe the inside of the mask that touches the face. 1Discard applicator pad. 1Immediately seal mask, clear, and check it. 1Remove second skin decontaminating packet from carrying pouch. 1Tear open quickly at notch. 1Remove applicator pad from packet and discard empty packet.

38. DECONTAMINATE EXPOSED SKIN Decontaminate NeckDecontaminate Neck 1If the casualty was already masked when becoming contaminated, without breaking the seal between the face and mask, thoroughly scrub skin of neck and ears until completely covered with black powder. 1Redo hands until completely covered with black powder. 1Discard applicator pad. 1Put the protective gloves on the casualty. 1Fasten casualty's hood. 1Remove powder with soap and water when operational conditions permit. It does not matter how long the powder stays on your skin. 1Bury the used pads and packets if circumstances permit.

39. ADMINISTER FIRST AID TO A NERVE AGENT CASUALTY CLOSING Masking the casualty, administering three Mark 1 kits and CANA, and decontaminating exposed skin are initial treatment measures for a nerve agent casualty. The medical phase of the combat lifesaver course presents additional treatment procedures for severe nerve agent casualties and treatment for victims of other types of chemical agents. This lesson is tested on the written examination.

40. Questions