Nerve Agents Part I

OBJECTIVESIdentify common nerve agentsDiscuss signs and symptomsDiscuss nursing management and treatmentDiscuss the nurse roles and responsibilitiesDiscuss personal safety risk exposure

Emergency Support Function (ESF) 8 OVERVIEW

DHH has the role of providing leadership for planning, directing and coordinating the overall State efforts to provide public health and medical assistance.

The Secretary of Health and Human Services through the Office of Public Health Emergency Preparedness is responsible for the federal coordination.

The command and control of operations are consistent with the National Response Framework and compliant with National Incident Management System requirements.

Command Chain/ICSIncident Commander

Operations Planning Logistics Finance

Public Information Liaison Officer

Safety Officer

Public Works Branch

Law Enforcement Branch

4

Unified Command Enables all agencies with

responsibility to manage an incident together by establishing a common set of incident objectives and strategies.

Allows Incident Commanders to make joint decisions by establishing a single command structure.

Maintains unity of command. Each employee only reports to one supervisor.

Agency 1 Incident Commander

Agency 2 Incident Commander

Agency 3 Incident Commander

Disaster Management Continuum

Chemical Disasters•May result from industrial accidents, accidental exposure, or terrorist acts

•Chemical Agents of Concern

Nerve agentsBlister agents/vesicantsBlood agentsChoking/lung/pulmonary agents

Agencies/Partners InvolvedFederal Bureau of Investigation (FBI)MilitaryUS Department of Health and Human

Services (HHS)-Centers for Disease Control and Prevention (CDC)

Other Federal partnersGovernors Office of Homeland Security

and Emergency PreparednessFire/Hazmat

Agencies/Partners InvolvedDepartment of Environmental QualityDepartment of Health and HospitalsLaw Enforcement: Louisiana State PoliceLouisiana State National GuardDepartment of Public WorksDepartment of Wildlife and FisheriesDepartment of Agriculture and ForestryOther state agencies

Agencies/Partners InvolvedLocal Parish Office of Homeland

Security and Emergency Preparedness Office

Louisiana Poison CenterHealthcare facilitiesMedical Examiners/CoronersAnimal ControlLocal PartnersLAVA: Volunteers agencies/volunteers

Nerve AgentsMost toxic of chemical warfare agents and

inhibit the body’s normal functionsDangerous to humans and can be utilized as

potential weapons by terroristAct as acetylcholinesterase inhibitors which

produce the same signs and symptoms of organophosphate poisioning

Nerve AgentsSarin

Soman

Tabun

VX

Odorless

Slight camphor odor

Faint fruity odor

Odorless

Nerve Agents ExposureInhalation

Can be dispersed as aerosols, vapors, or liquids

Vapors: absorbed by inhalation and vapor contact

Immediate onset of symptoms

Nerve Agents ExposureIngestion

Readily absorbed

Skin/eyeOnset depends on

concentration; can be delayed for several hours

Safety RiskFirst responders are trained individuals who

will respond to the eventNurses should not be first responders unless

you have been trained on hazardous materials or part of a fire response team

Signs and Symptoms

Signs and SymptomsMild

MiosisNauseaDiarrhea

SevereMuscle weaknessFasciculationsRespiratory failureComaSeizuresPermanent damage

to the CNS after high toxic exposure

Real Life IncidentsSarin incident in Tokyo-1995

Carbamate insecticide methomyl was added to salt at a restaurant in Fresno, California-1999

Exposure to Healthcare Workers

Tokyo incident several people were exposed. Contaminated individuals may self present to a facility.

Healthcare workers must wear PPE and use it correctly

Contaminated individuals must be decontaminated

Exposure to Healthcare WorkersSudden and severe symptoms may occur

hours after treatment/contamination (through skin)

You must have appropriate PPE to approach any contaminated victim

PrecautionsStandardAirborneDropletContact

PPE EquipmentDetermined by the type and level of exposure

and duration of exposureNerve agents are absorbed through intact

skin and even through the clinical examination gloves

Treatment/ExposureExposure TreatmentSkin Decontaminate using

soap/water

Inhalation If severe symptomatic, consider antidote use.

If signs/symptoms progressing continue antidote administration.

If breathing has stopped or is difficult use artificial respiration

Treatment/ExposureExposure TreatmentEyes Immediately flush eyes

with water for 10-15 minutes

Ingestion Do not induce vomitingConsider Mark I kit use

TreatmentAdults

Atropine 2mg (antimuscarinic)

Pralidoxime (2 Pam) 600mg

ChildrenPediatric atropine

autoinjector is now available

Supportive therapy and assisted ventilation as need

Benzos for prevention of seizures

STRATEGIC NATIONAL STOCKPILE

Strategic National Stockpile

CHEMPACKManaged InventoryAntiviralsVaccinesFederal Medical Stations

Pharmacy’s Role

CHEMPACKHospital/EMS Containers (contents are

different)Mark 1 Kits Atropine Sulfate 0.4mg/mL Pralidoxime 1gram vials Atropen® 0.5mg auto-injectors Atropen® 1mg auto-injectors Diazepam 10mg/2mL auto-injectors Diazepam 5mg/mL 10mL Sterile Water for Injection 20mL single use

vials

CHEMPACKPrepositioned across the state. Locations are

confidential.Louisiana Poison Control

1-800-222-1222Will provide consultation on symptoms of nerve

agents and organophosphate poisoning to first responders and health care professionals.

Will provide assistance regarding dosing questions.

Labeled Containers with Buffers

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TreatmentDuodote eventually will replace Mark I Kits

PREHOSPITAL MANAGEMENT

Scene Safety Management

Minimize casualtiesDecontaminationTriageAntidote therapyCrisis scene

management

Emergency Medical Service's (EMS) Role

EMS has 2 Mark I Kits available on the ambulance

State Police will pick up EMS container if CHEMPACK is needed

Administer Mark 1 Kit per protocolAirway support and ventilation. Perform

endotracheal intubation if needed.Circulatory support: IV therapy and pulse

oximetry monitoringConsultation with Louisiana Poison Control

Field Treatment Exposure Symptoms Initial Dosing*

(EMS/Field)Repeat Dosing(Transport/Hospital)

Mild DUMBBELS Agitation

Observe or MARK 1 Observe

Moderate DUMBBELS Agitation Respiratory distress

2 Mark 1** Atropine 5-10 min2-PAM q 30-60 min

Severe DUMBBELS Respiratory distress Seizures

3 MARK 1***Diazepam

Atropine 5-10 min2-PAM q 30-60 minDiazepam q 2-5 min

Transport

HOSPITAL MANAGEMENT

Hospital’s RoleVentilatory support: patients with respiratory

failure and compromised airways will require immediate endotracheal intubation and positive pressure ventilation.

Oxygen supplementDecontamination before entering the

emergency departmentSuctioning for removal of bronchial

secretionsGastric decontamination-activated charcoal

Hospital’s RoleObservationTreatment-Atropine and PralidoximeMonitoring for seizure activity (administering

anticonvulsants for prevention)Recovery may take several monthsRisk of permanent damage to the Central

Nervous System (high dose exposure)Consult with the Louisiana Poison Center

Patient Mild/Moderate Effects1

Severe Effects2 Other Treatment

ChildAtropine:0.05mg/kg IM orIV (minimum 0.1mgMaximum 5mg)

AND2-PAM:25mg/kg IM orIV (maximum 2GmIM or 1Gm IV)

Atropine:0.1mg/kg IM orIV (minimum 0.1mg,maximum 5mg)

AND2-PAM:50mg/kg IM orIV (maximum 2Gm IM or 1Gm IV)

Assisted ventilation for severe exposure.Repeat atropine at 2-5 minute intervals untilsecretions have diminished and airway resistance has decreased.Repeat 2-PAM chloride once at 30-60 minutes, then at one-hour intervals for 1-2 doses, as necessary.Diazepam for seizures: Child - 0.05 to 0.3 mg/kg IV(maximum 10 mg);Adult - 5 mg IVOther benzodiazepines (e.g. lorazepam) may provide relief.Phentolamine for 2-PAM chloride-inducedhypertension: 1 mg IV for children; 5 mg IV for adults.

AdultAtropine:2 to 4 mg IM or IV

AND2-PAM3:600mg IM, or

Atropine:6mg IM

AND2-PAM3:

1800 mg IM, or50mg/Kg IV slowly

1. Mild/Moderate effects of nerve agents include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea.2. Severe effects of nerve agents include unconsciousness, seizures, apnea, flaccid paralysis.3. Dose selection of 2-PAM chloride for elderly patients should be cautious (usually starting at 600 mg IM, or 25 mg/kg IV slowly) to account for the

generally decreased organ functions in this population.NOTE: 2-PAM chloride (2-PAM) is pralidoxime chloride, trade name Protopam®.CHEMPACK: CHEMPACK is a federal program to provide nerve agent antidotes (Atropine, 2-PAM, Diazepam) to during an emergency. Additional Assistance: Contact the at 800-222-1222 or 318-813-3317 for additional information regarding dosing.

Hospital’s Role

Employee trainingHospitals are going

to be reserved for your critically ill individuals

Medical SurgeDecontaminationTreatment/

Supportive Measures/Assisted Ventilation

PUBLIC HEALTH

Public Health PreparednessStrategic National Stockpile Exercises, drills, trainings State and local planning effortsParadigm shift to all hazards approach

Public Health’s RolePromote life safety through education,

information and planningGoal is to prevent illness by minimizing

exposure and rapid, effective responseProvide medical intelligence such as

knowledge of antidotes and symptoms of exposure

Procure resources available to the State with forward placement whenever possible

Public Health’s RoleProvide guidance for use of assets under the

direction of the State Health Officer Participate as ESF 8 in Incident Command

and/or Unified CommandAssist in the development of factual

communication for multiple audiences during response

Promote behavioral health

Public Health’s RoleConduct epidemiological investigationsCoordinate laboratory services Participate assessments and actions to

minimize the health and environmental impacts

Office of Public Health Nurse’s Role

Planning, preparedness, and responseAssessmentTriageTreatment/EducationSheltering

Personal SafetyHaving a family emergency planDecontamination of selfPPE Emergency Communication Devices

Vulnerable PopulationsCommunicationEstablish safe shelterFood and waterShelter in place versus Medical Special

Needs Shelters, General Population Shelters, Critical Transportation Needs Shelters

Rely on existing agenciesWill need assistance if decontamination is

neededTime of day when incident happens

EducationIf exposed, remove all clothing immediately

and wash with copious amounts of soap and water.

Shelter in place: Go indoors, close all windows, doors, and close up the building. Turn off fans, air conditioners, and heaters. Move to a lower, inner room vs. higher room for floods

Listen to the local news and radio for further instructions

EducationContaminated clothing should be double

bagged.Food and water

CHEMPACK Response Operation Overview

Step 1: Event- a suspected chemical or biological incident occurs. 911 is notified of the situation and the need for security considerations or medical attention for/by the public. At this time, 911 operators also notify the parish Office of Homeland Security and Emergency Preparedness of the event.

Step 2: Isolation- security and medical responders will follow local parish protocol for isolation and triage for treatment.

CHEMPACK Response Operation Overview

Step 3: CHEMPACK Standby/Alert- the Louisiana Poison Center will be notified by either the field Incident Commander or the 911 Operations Center that there is a suspected nerve or organophosphate incident. Triaging assistance is provided to the Incident Commander an on-scene first responders. Since positive identification of the substance involved is nearly impossible in the initial response, symptoms consistent with a nerve agent or organophosphate exposure will be sufficient for recommending appropriate treatment and release of the assets.

Louisiana Poison Center: 1-800-222-1222

CHEMPACK Response Operation Overview

Step 4: CHEMPACK Activation- If the Tier I assets are insufficient to meet the need, then the Louisiana Poison Center activates this CHEMPACK plan. The Louisiana Poison Center will notify appropriate Host Sites with a request for Tier II countermeasures via the CHEMPACK assets. The Louisiana Poison Center considers such factors as wind trajectory, volume of patients, and treatment needs when selecting Host Site(s) and Receiving Site (s) for CHEMPACK supplies. Louisiana Poison Center will notify Host Sites to open containers and prepare appropriate “allocations” for

CHEMPACK Response Operation Overview

distribution. Further, Louisiana Poison Center coordinates transportation with Louisiana State Police.

Step 5: Countermeasures- Tier II CHEMPACK assets will be dispensed as per the plan and appropriate Regional plan(s).

Step 6: Collection/Transportation of a Specimen- A request may be made to transport a sample of the substance/agent to the State Lab for analysis.

Scenario FactsXYZ Plant located in

Somewhere, Louisiana in Region 10

Has a population of approximately 300 employees on duty

It’s Friday, January 14 something has been dispersed into the ventilation system at the XYZ Plant and no one is aware.

Labeled Containers with Buffers

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Decontamination on Scene Decontamination of Vehicle Decontamination Tent

Treatment

Transport

Mass Casualty Incident

Phone CallsYou are the nurse

working in the triage line.

What symptoms should the PHN tell her to watch for?

SummaryContact the Louisiana Poison Control

Center 1-800-222-1222 for questions/concerns

Nerve agents exposure serious medical emergency

For life saving measures rapid administration of antidotes

Remember DUMBBELSAlways wear appropriate PPE before taking

care of any victim

SummaryMost toxic of chemical agentsTriageTreatment: Decontamination, Rapid antidote

therapy, supportive therapy, and ventilator assistance, Anticonvulsants for prevention of seizures

Future TopicsChemicals Agents

Blistering agents/vesicants Tissue/Blood agentschoking/lung/pulmonary agents

Biological AgentsRadiological Agents

Future TopicsDisaster triageDecontaminationPPE JUMPSTART/START

ReferencesCenters for Disease Control and Prevention

www.bt.cdc.govVeenema, Tener Goodwin., Ready RN:

Handbook for Disaster Nursing and Emergency Preparedness, 2009.

Agency for Toxic Substances and Disease Registry

American Academy of PediatricsLouisiana Emergency Operations PlanState/Regional CHEMPACK Response Plan

Password for SurveyMonkey

Participant Evaluation

NERVE (all uppercase)

QUESTIONS

Contact UsContact UsLouisiana Department of Health and Louisiana Department of Health and

HospitalsHospitals

Office of Public HealthOffice of Public Health

Center for Community PreparednessCenter for Community Preparedness

8919 World Ministry, Ste. B8919 World Ministry, Ste. B

Baton Rouge, LA 70810Baton Rouge, LA 70810

225-763-3503225-763-3503

http://www.dhh.louisiana.govhttp://www.dhh.louisiana.gov

CONTACT INFORMATION

Sherhonda Harper, RN, MHASherhonda Harper, RN, MHA

Statewide Nurse Consultant, Nursing Statewide Nurse Consultant, Nursing ServicesServices

Emergency PreparednessEmergency Preparedness

DHH/OPHDHH/OPH

(225) 763-5740-OFFICE(225) 763-5740-OFFICE

(225) 763-5727-FAX(225) 763-5727-FAX