maryland state mark i training program nerve agents and the mark i kits

Maryland State MARK I Training Program

Nerve Agents and the MARK I Kits


The MARK I Protocol

This is an Optional Supplemental Protocol which requires your Jurisdictional Medical Director and approval from MIEMSS

Refer to the current version of the MARK I section of the Maryland Medical Protocols for EMS Providers


Objectives Discuss what nerve agents are and how

they affect the body List signs and symptoms of nerve agent

exposure Name the antidotes that may be

administered in the event of nerve agent exposure

Demonstrate the correct use of the MARK I autoinjectors


What are Nerve Agents? One of the five classifications for chemical

weapons Most toxic of the known chemical agents Easily dispersed: bombs (non explosive),

spray tanks Enter the body through inhalation, absorption

or ingestion Can cause death within minutes depending

upon the length of exposure


Nerves relay messages to and from the brain To do this the body produces certain “transmitters” to

go from one nerve cell to another Nerve agents get into the space between nerve cells

and causes an unopposed amount of the “transmitter”. The “transmitter is no longer neutralized in the nerve space thus a build up of the transmitter and the nerves continually stimulate muscle or gland cells resulting in pinpointing pupils, excessive gland secretion (drooling, tearing), urination, defecation, GI motility (pain/cramps), vomiting, muscle twitches, and/or convulsions with the death following due usually to respiratory arrest

Nerve Agents: How they work


Two types: G-type agents are more likely to evaporate and

become vapor or may be dispersed as a liquid or vapor. When exposed, effects begin within minutes

V-type agents are oily and evaporate slowly. They persist on the ground, foliage, etc., for long periods of time. When the skin is exposed, effects are seen as soon as 10 minutes but can be delayed up to 18 hours after contact.

Tabun (GA), Sarin (GB), Soman (GD), VX

Examples of Nerve Agents


Signs and Symptoms of Nerve Agent Exposure

KEY POINT S/S will be dependent

upon the proximity, concentration of the agent, vapor or liquid, and length of exposure to the agent


Nerve Agents-Signs and Symptoms

PSLUDGEMCVapor

ExposureLiquid Exposure

P - Pinpointing pupils x Not seen

S - Salivation x Not seen

L - Lacrimation (tearing) x Not seen

U - Urination x x

D - Defecation x x

G - GI; pain/gas x x

E - Emesis (vomiting) x x

M - Muscle twitching (localized) x x

C – Convulsions (generalized) x x


Nerve Agents: TREATMENT

NO ONE able to

walk and talk is in immediate

danger of loss of life with

appropriate decontamination


The Antidote: MARK I Kits

What are they? How do they work? Who can give them? Procedure for administration Any complications/contraindications


Auto-InjectorsSimple, compact injection systems Permit rapid injection of required

antidotes Enable rapid and accurate

administration, even if care giver or patient is in protective clothing

Administration is similar to Epi-pen


Auto-Injectors Contain pre-measured doses

of nerve agent antidotes Atropine and 2-PAM Chloride (2-PAM Cl, Pralidoxime Chloride or PROTOPAM® CHLORIDE)


Auto-Injectors EMT-B may administer MARK I kits in a

“buddy aid” emergency (not for the public) without medical consultation (this is designed for the PPE suited providers or the first wave EMS/Fire response that becomes seriously symptomatic).

In order for an EMTB to administer MARK I kits to the general public who may require assistance, medical consultation and approval must be obtained.


Atropine - Blocks the action of the excess amounts

“transmitter” and reduces the PSLUDGEMC signs and symptoms

2-PAM-Cl (Pralidoxime) Acts as a ”crowbar” and takes the nerve agent off of the enzyme so that the “transmitters” in the nerve space can be neutralized, thus allowing the relaxation of the gland or muscle

Nerve Agents: Antidote

2-PAMCl2-PAMCl

Nerve Agent

Enzyme


Antidote (ALS level only)

Valium call CANA in

autoinjector form (follow System protocol)

Used to control seizures


Dosing Schedule NOT ALL VICTIMS

EXPOSED NEED TREATMENT

Dose of antidote will be dependent upon the signs and symptoms that the victim is demonstrating


MARK I Kit Dosing ScheduleExposure Clinical Treatment

Mild

Unexplained runny nose, sudden headache, sudden drooling, difficulty seeing, tightness in the chest with mild difficulty breathing, wheezing and coughing, localized sweating and localized muscular twitching in the contaminated skin, stomach cramps, nausea without vomiting

VAPOR (small exposure): If only symptoms are pinpoint pupils and/or runny nose, DO NOT TREAT; otherwise, treatment should begin with one dose of the MARK I kit initially. This may be repeated in 10 minutes if patient is still symptomatic; LIQUID (small exposure): The onset of symptoms may be from minutes to hours after exposure; Treatment should begin with one dose of MARK I kit and may be repeated in 10 minutes if the patient is still symptomatic

Moderate

All of the above, but also include more severe effects such as diarrhea, moderate to severe difficulty breathing, and some skeletal-muscular twitching/fasciculations.

VAPOR or LIQUID: administer 2 MARK I kits; an additional Atropine auto-injector (2.0 mg) may be repeated in 10 minutes if the patient is still symptomatic

Severe

Providers with severe symptoms will not be able to treat themselves and will need buddy aid. Symptoms are all of the mild/moderate symptoms plus: impaired thinking, increasing wheezing and increased difficulty breathing, severe pinpoint pupils (if vapor), red eyes with tearing (if vapor), vomiting, severe muscular twitching and general weakness, involuntary defecation, convulsions, respiratory failure, bradycardia

VAPOR or LIQUID: administer 3 MARK I kits; an additional Atropine auto-injector (2.0 mg) may be repeated until symptoms decrease or cease.

Objective of Treatment:Get ALSTreat the patient with additional atropine until patient’s secretions start to dry, airway resistance decreases and breathing improves.


Who can give them? EMT-B may administer MARK I kits in a

“buddy aid” emergency (not for the public) without medical consultation.

In order for an EMTB to administer MARK I kits to the general public who may require assistance, medical consultation and approval must be obtained.

CRT, CRT(I) and EMT-P can administer to public who has signs and symptoms indicating need for antidote.


How do you know when the MARK I kits are working???

Evidence of response to treatment includes improvement in initial symptoms and drying of secretions. If neither occurs after initial MARK I administration, then administer additional atropine until these endpoints are reached.


Directions for Use

1. Remove safety cap (yellow on

atropine; gray on 2-PAM Cl).

MARK I kit clip holds the safety

caps; may not notice if using

MARK I kits. Do not touch colored

end of injector after removing

cap; injector can and will

activate/ inject into fingers or hand

if any pressure applied to this end of autoinjector


Directions for Use

2. Hold injector like a pen. Place colored end (green on atropine, black on2-PAM Cl) on thickest part of thigh and press hard until injector functions Pressure automatically activates the

spring, plunges the needle into the muscle and simultaneously forces fluid through it into the muscle tissues


3. Hold firmly in place for a VERBAL COUNT of ten seconds, then remove

4. Massage the area of injection

Directions for Use


Directions for Use

5. Dispose of the used injector in sharps container after use

6. Document the dosage on the triage tag or place one MARK I band per administration/ dose supplied in the kit (three kits = three bands)


Concerns about MARK I Kits Precautions

Contraindications

Adverse Reactions


PRECAUTIONS

ALL PATIENTS TREATED ARE TO BE TRANSPORTED


CONTRAINDICATIONS

Patients not manifesting signs or symptoms shall NOT be treated with a MARK I kit

Patients with only constricted pupils and/or runny nose should NOT be treated with a MARK I kit


2 PAM Adverse Effects 2 to 5 minutes after

intramuscular injection of 2-PAM Cl, mild to moderate pain may be experienced at site of injection

2-PAM Cl may generate hypertension


Atropine Adverse Effects

Flushed and hot skin Restlessness Dry mucous

membranes Blurred vision Dizziness Headache Nausea


Questions

maryland state mark i training program nerve agents and the mark i kits

Documents

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