Module 7 Medical Treatment

1
Module 7Medical Treatment
2
Nerve Agent
3
Treatment - No Signs and Symptoms

• Reassure
• Observe
• Vapor 1 hour
• Liquid Up to 18 hours

4
Basic Nerve Agent Exposure Treatment

• Airway/ventilation
• High resistance positive pressure of gt 50-70
  cm/H20 or higher is needed
• Oxygen
• Antidotes
• Atropine
• Pralidoxime Chloride
• (2-PAM Cl)
• Diazepam

5
Nerve Agent Effects

• Nerve agent overstimulates the
• nervous system muscles and
• glands over-react and organs
• malfunction
• Initial treatment involves 2-part antidote
• Atropine stops the effect of nerve agent
• 2-PAM Cl restores normal muscle function by
  reactivating cholinesterase

6
Atropine

• Atropine blocks effects of over-stimulation
• Relieves smooth muscle constriction
• Dries up respiratory secretions

7
2-PAM Cl Effect

• Removes organophospate from acetylcholinesterase
  which can then deactivate acetylchline
• Re-establishes normal skeletal muscle contraction
• Relieves twitching and paralysis of respiratory
  muscles

8
Diazepam

• Administer to patients experiencing convulsions
• Consider for patients with severe signs and
  symptoms
• Dosage depends on patients age

9
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 Cl until maximum dose per body
  weight is reached

10
Signs of Atropinization

• Secretions dry up
• Less labored breathing

11
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

12
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 Cl as
  recommended in treatment tables until maximum
  total dose is given

13
Potential Problems With Atropine

• Exercise caution in administering atropine
• For non-life-threatening exposures, use extreme
  caution if patient has existing medical problems
• Administer to pregnant woman only if clearly
  needed
• Administer to nursing woman with caution
• Start at low end of dosing range when treating
  elderly

14
Potential Problems with 2-Pam Cl

• Exercise caution in administering 2-PAM Cl
• Reduce dosage if patient has renal insufficiency
• Give to pregnant woman only if clearly needed
• Give to nursing woman with caution

15
Adverse Reactions

• Atropine
• pain at injection site, dry mouth, blurred
  vision, photophobia, confusion, headache,
  dizziness, fast heart beat, palpitations,
  flushing, urinary hesitancy, constipation,
  abdominal distention, nausea, vomiting, loss of
  libido, impotency
• 2 -PAM Cl
• delayed pain at injection site, blurred vision,
  double vision, impaired accommodation, dizziness,
  headache, drowsiness, nausea, rapid heart rate,
  increased blood pressure, hyperventilation,
  muscular weakness

16
Atropine Overdose

• Cause Atropine administered when no prior nerve
  agent exposure has occurred
• Not as serious as underdosing
• Not usually life-threatening

17
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

18
Treatment for Atropine Overdose

• Keep patient cool
• Protect patient from irrational actions
• Transport patient to hospital as soon as possible

19
2-PAM Cl Overdosage

• Symptoms dizziness, blurred vision, double
  vision, headache, impaired ability of eyes to
  change focus, nausea, slightly rapid heart rate
• Treatment artificial respiration and other
  supportive therapy as needed

20
Adult Nerve Agent Treatment

• Starting dose for adults - 2 mg atropine
• Enough must be administered to abate severe
  symptoms if casualty is to survive
• Insecticide poisoning requires more atropine than
  chemical warfare agents per equivalent amount

21
Antidote Administration Methods

• Intramuscular (IM)
• Syringe
• Auto-injector
• Intravascular (IV)

22
Adult Nerve Agent Treatment Mild Exposure

• 2 mg atropine
• IM
• IV
• 2-PAM Cl
• 600 mg IM
• 1 gram IV

23
Adult Nerve Agent Treatment Moderate Exposure

• 2-4 mg atropine initially
• IM
• IV
• 2-PAM Cl
• 600-1200 mg IM initially
• 1 gram IV
• Repeat every 5-10 minutes until atropinized
• 2 mg atropine
• 600 mg 2-PAM Cl

24
Adult Nerve Agent Treatment Severe Exposure

• 6 mg atropine IM initially
• IM
• 2-PAM Cl
• 1800 mg IM initially or
• 1 gram IV
• Repeat 2 mg atropine every 5-10 min. as needed
• Repeat 2-PAM Cl in 1 hour
• Ventilation/Oxygen
• Diazepam 10 mg (2 to 5 mg increments, IV or IM)

25
Atropine Treatment For Children

• Over 10 years 2 mg initially IM
• Between 2 and 10 years 1 mg initially IM
• Less than 2 years 0.5 mg initially
• Alternatively 0.02 mg per kg (2.2 pounds) of body
  weight by IV
• Repeat every 5-10 min. until atropinized

26
2-PAM Cl Treatment For Children

• Less than 22 kg (50 lbs.) 15 mg per kg of body
  weight by IV
• More than 22 kg (50 lbs)
• 600 mg IM, or
• 15 mg per kg of body weight by IV

27
Diazepam Treatment For Children

• Children gt 30 days old to 5 years
• 0.2 - 0.5 mg/kg IV every 2 to 5 min (max 5 mg)
• Children gt 5 years
• 1 mg IV every 2 to 5 min (max 10 mg)

28
Administering Antidote

• Three sequential steps for administering
  antidote
• 1. Determine correct dosage for the patient
• 2. Assess severity of signs and symptoms
• 3. Administer treatment appropriate for
  patients weight/age and symptoms

29
Auto-Injectors

• Alternative means of IM injection
• Simple, compact injection systems
• Contain pre-measured amount of antidote
• Needle revealed only when injector pressed
  against patients skin
• Cannot be refilled or reused

30
Advantages of Auto-injectors

• Auto-injectors
• permit rapid injection
• prevent cross-contamination
• enable rapid, accurate use even in protective
  clothing

• Auto-injectors provide
• simple, accurate, rapid drug administration
• pre-measured, controlled dose
• no vials/ampules/ syringes
• fully automated use
• rugged construction

31
Auto-Injectors

• FDA-approved
• Mark I kit combines one atropine injector and one
  2-PAM Cl injector (adult dosages only)
• Diazepam auto-injector available in adult dosage
  only
• Atropine auto-injectors (AtroPen) also
  commercially available in four dosage levels

32
Content of Auto-Injectors

• The 2-mg atropine auto-injector contains
  glycerin, phenol, citrate buffer, and water
• The 600-mg 2-PAM Cl auto-injector contains benzyl
  alcohol, glycine, and water
• Do not administer to patient with
  hypersensitivity to any component of injector
  solution

33
Who Can Use Auto-Injectors

• FDA approved use
• by appropriately trained civilian emergency
  medical personnel
• in treating victims exposed to nerve agents or
  organophosphorus insecticides
• State statutes also determine who can use
• be aware of your state laws and local protocols

34
Directions for Using Auto-Injectors

• Step 1Remove Mark I kit from its protective
  pouch
• Hold unit by the plastic holder (the end with the
  numbers)

35
(No Transcript)
36
Directions for Using Auto-Injectors

• Step 2Remove the appropriate auto-injector
• from the kits holder
• Administer atropine first,
• then 2-PAM Cl
• Safety release will remain in kit
• Do not touch the green or black tip

37
(No Transcript)
38
Directions for Using Auto-Injectors

• Step 3Place green or black tip against patients
  thigh and push hard until the injector functions
• Its OK to inject through clothing if pockets are
  empty
• For very thin people. Bunch up thigh to provide
  thicker area for injection.

39
(No Transcript)
40
Directions for Using Auto-Injectors

• Step 4Hold auto-injector firmly in place for at
  least 10 seconds to allow injection to finish

41
(No Transcript)
42
Directions for Using Auto-Injectors

• Step 5Carefully remove the auto-injector
• Exposed needle will confirm successful injection

43
(No Transcript)
44
Directions for Using Auto-Injectors

• Step 6Massage injection site for several
  seconds.

45
(No Transcript)
46
Directions for UsingAuto-Injectors

• Step 7Dispose of empty auto-injector in a sharps
  disposal container.
• Bend needle
• Note dosages on a triage tag or write on
  patients chest or forehead
• Move yourself and victim away from contaminated
  area
• Seek medical help

47
(No Transcript)
48
Manufacturers Recommended AtroPen
Auto-InjectorAtropine Dosages
49
Ventilation

• If required, insertion of endotracheal tube by a
  qualified person is recommended
• Requires high pop off pressure (50 -70 cm H2O)

50
Vesicant Agents
51
Sulfur Mustard Agent Treatment

• No antidote available
• Ensure immediate and thorough decontamination
• Take precautions for sterile technique
• Support airway management as necessary

52
Decontamination

• Part of supportive treatment
• Physical removal of agent
• remove clothing
• flush skin with soap and water
• flush eyes with sterile saline, sterile water, or
  water
• Must be done within 2 minutes to prevent damage
• Delays in decontamination will not prevent
  illness, but will prevent cross-contamination

53
Eye Contact

• Flush eyes immediately
• tilt head to the side
• pull eyelids apart with fingers
• pour water slowly into eyes
• Do not cover eyes with bandages
• Dark or opaque glasses provide relief from
  photophobia

54
Sulfur Mustard Treatment

• Humidified air
• Oxygen and cough suppressants
• Antibiotics not helpful immediately
• Oxygen assisted ventilation
• Intubation before it becomes difficult
• Bronchodilators
• Steroids may be administered
• Flushing eyes becomes less effective with time

55
Sulfur Mustard Treatment (cont.)

• Apply pupil dilators (mydriatics) topically
• Oral analgesics preferred to topical
  administration
• Antibiotics applied topically
• Vaseline on eyelids
• Soothing creams for skin irritations
• Unroof blisters and irrigate
• Apply topical antibiotics
• Oral or IV analgesics
• Assess hydration