New Mexico CHEMPACK Program Mark 1 Kit Training

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New MexicoCHEMPACK Program Mark 1 Kit Training
Ambulance Service and Other First Responder
Training
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CHEMPACK
CHEMPACK is a Federal program. Pre positioned
packages of antidotes for nerve agents are
available across New Mexico for public safety
personnel and emergency department employees.
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CHEMPACK In New Mexico

• There are two variations of the CHEMPACK -- one
  for EMS and one for hospitals.
• The EMS container will treat approximately 454
  victims.
• The hospital container will treat approximately
  1000 victims.

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CHEMPACK In New Mexico

• Hospital Container
• Treats approximately 1000 victims.
• 480 Mark 1 Kits in container.
• Packaged - 2 cases of 240 Mark 1 Kits.
• Each case - 8 boxes with 30 Mark 1 Kits.
• New Mexico has only hospital containers.

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Access to CHEMPACK
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Indications of Nerve Agent Exposure

• Signs symptoms of nerve agent toxicity or
  organophosphate poisoning
• Unexplained multi-casualty incident (MCI).
• Make proper notification to Incident Commander
  (IC) or Dispatch Center
• of suspected nerve agent exposure.

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Nerve Agent Actions

• Causes Central Nervous System problems by
  interrupting the process of chemical signaling at
  the receptor level.
• Physical symptoms are due to excessive
  stimulation of body organs.

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Types of Nerve Agent Exposure

• VAPOR
• Usually more severe with faster onset of
  symptoms.
• LIQUID
• Slower onset of symptoms
• Will penetrate clothing.
• Absorbed through the skin.
• Consider vapor exposure with liquid exposure.

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Nerve Agent Effects

• Pulse
• Slow, normal or fast depending on the nerve
  agent and degree of exposure.
• Blood Pressure
• Low, normal or elevated depending on the
  nerve agent and degree of exposure.

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Nerve Agent Effects

• S Salivation (excessive drooling)
• L Lacrimation (tearing)
• U -Urination
• D Defecation/Diarrhea
• G Gastrointestinal
• E Emesis (vomiting)
• M Miosis (pinpoint pupils)
• R Respiratory (distress)
• A Agitation (CNS symptoms)

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EXPOSURE Signs SymptomsMild to Severe

• Unexplained runny nose
• Tightness in the chest
• Difficulty Breathing
• Bronchospasm
• Pinpoint pupils, blurred vision
• Drooling
• Excessive sweating
• Nausea and/or vomiting
• Abdominal cramps
• Involuntary urination and/or defecation
• Jerking, staggering twitching
• Headache
• Drowsiness
• Coma
• Convulsions
• Apnea

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NERVE AGENT EXPOSURESigns Symptoms

• MILD Rhinorrhea (runny nose) and Miosis
  (pinpoint pupils)
• MODERATE Key finding are respiratory distress,
  excess secretions and pinpoint pupils.
• S-Salivation, L-Lacrimation, U-Urination,
  D-Defecation/Diarrhea,
• G-Gastrointestinal, E-Emesis,
  R-Respirations, A-Agitation
• SEVERE Key findings are respiratory distress,
  excessive secretions, pinpoint pupils, loss of
  consciousness, seizures apnea.
• S-Salivation, L-Lacrimation, U-Urination,
  D-Defecation/Diarrhea,
• G-Gastrointestinal, E-Emesis,
  R-Respirations, A-Agitation

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MARK 1 Kit Use

• Indicated for immediate treatment of moderate to
  severe vapor and/or liquid exposures to nerve
  agents.
• Primarily for self aid or buddy aid. (Treat
  yourself, your crew then treat the victims.)
• Victims should be treated when CHEMPACK cache
  supplies are available responders have been
  treated.

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Nerve Agent Antidote KitMark 1 Kit

• Atropine auto injector (2 mg in 0.7 cc)
• Pralidoxime chloride auto injector 2 PAM (600mg
  in 2cc)

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Mark 1 Kits

• The Mark 1 Kit comes in a foam case. The case is
  marked with the expiration date. ALWAYS CHECK
  THE EXPIRATION DATE!!
• The small injector, marked 1 is atropine 2 mg
  and should be given first.
• The larger injector, marked 2, is 2 PAM 600 mg
  and is given after the atropine.

TIP Store at room temperature
approximately 25 C KEEP FROM FREEZING
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Mark 1 Kit Dosing
Mild Exposure Symptoms

• Rhinorrhea (runny nose) and Miosis (pinpoint
  pupils)
• NO Mark 1 Kit administered for mild exposure
  symptoms

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Mark 1 Kit Administration
Moderate Exposure Symptoms

• Respiratory distress, excess secretions, pinpoint
  pupils. (SLUDGEMRA)
• Symptoms related to moderate nerve agent exposure
  should be treated by administering up to 2 Mark 1
  Kits in 5-20 minute intervals.
• Repeat administration at 5-10 minute intervals
  until improvement or signs of atropinization
  (tachycardia dry mouth) are noted.

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Mark 1 Kit Administration
Severe Exposure Symptoms

• Respiratory distress, excess secretions, pinpoint
  pupils, loss of consciousness, seizures apnea.
  (SLUDGEMRA)
• Severe symptoms should be treated by
  administering up to 3 Mark 1 Kits in 3-5 minute
  intervals.
• Repeat administration in 3-5 minute intervals
  until improvement is noted or sign of
  atropinization (tachycardia dry mouth) are
  noted.
• ALS Treat seizures with valium per standing
  orders.
• DO NOT ADMINISTER MORE THAN 3 DOSES OF 2PAM
  (hypertensive effects). ALS titrate atropine
  as needed to alleviate sings symptoms or until
  atropinization is noted.

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• PROCEDURES FOR ADMINISTERING MARK 1 KITS
• NERVE AGENT EXPOSURE

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Mark 1 Kit

• Spring powered injector containing
• Atropine, 2 mg/0.7 ml
• Pralidoxime Chloride, 600 mg/2 ml (2-PAM)

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TREATMENTVapor or Liquid Exposure
Moderate Exposure Symptoms

• Treatment
• (Including mild respiratory distress)
• Self Aid Up to 2 Mark 1 Kits
• Buddy Aid Up to 2 Mark 1 Kits
• Victims When supplies are available, up to 2
  Mark 1 Kits
• If you must administer the Mark 1 Kit to
  yourself, you will be out of commission. You
  must report self administrations to the Incident
  Commander.

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TREATMENTVapor or Liquid Exposure
Severe Exposure

• (Including severe respiratory distress, altered
  mental status, seizure, coma, apnea)
• Self Aid
• Will be unable to help self.
• Buddy Victim Aid
  
• Up to 3 Mark 1 Kits
• ALS 1 Diazepam
• Victim Aid When supplies are available
• TREATMENT MUST BE IMMEDIATE !!!!!

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ADDITIONAL TREATMENTLiquid or Vapor Exposure

• Maintain an open airway and suction as necessary.
• Administer high flow oxygen if available.

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Mark 1 Kit Administration Procedures Atropine 1
Pull small injector out of plastic holder
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GRASPING THE ATROPINE AUTOINJECTOR

• Use Appropriate Body Substance Isolation (BSI)!
• With your dominant hand grasp the Atropine
  auto-injector (the smaller of the two) with the
  thumb and first two fingers.
• DO NOT cover or hold the needle end with your
  hand, thumb, or fingers. You might accidentally
  inject your self.
• An accidental injection into the hand WILL NOT
  deliver an effective dose of the antidote,
  especially if the needle goes through the hand.

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REMOVING THE ATROPINE AUTO INJECTOR

• Pull the injector out of the clip with a smooth
  motion.
• Ensure that the yellow safety cap has been
  removed. (The cap should remain in the clear
  plastic clip see Figure 1.)
• The auto injector is now armed !!!

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Mark 1 Kit Administration ProceduresInjection
Procedure

• Place green end against your outer thigh and push
  hard until you feel the injector function.
• The needle will penetrate clothing.
• Make sure that pockets are empty or that nothing
  is blocking the injection site.
• Hold firmly for 10 seconds.
• Use the secondary site if primary site is not
  accessible.

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Mark 1 Kit Administration ProceduresInjection
Procedure
Secondary Sites
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Intramuscular Injection Procedure

• Apply firm, even pressure (not jabbing motion) to
  the injector until it pushes the needle onto the
  injection site. Using a jabbing motion may
  result in an improper injection or injury to the
  thigh or buttocks.
• Hold the injector firmly in place for at least 10
  seconds.
• Firm pressure automatically triggers the coiled
  spring mechanism. This plunges the needle
  through clothing into the muscle and at the same
  time injects the antidote into the muscle tissue.
• Carefully remove the auto injector from the
  injection site.

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INTRAMUSCULAR INJECTION SITE ON THE BUTTOCKS
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Used Atropine Injector

• Place the used atropine injector carefully
  between your little finger and the ring finger of
  the hand holding the remaining auto injector and
  clip.
• Watch out for the needle!!

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Mark 1 Kit Administration ProceduresPralidoxim
e Chloride (2PAM)2
Pull the large injector out of the plastic holder.
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Removing the 2-PAM Auto Injector
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Mark 1 Kit Injection Procedure2-PAM

• Use appropriate Body Substance Isolation
  precautions!
• Place black end against outer thigh and push hard
  until you feel the injector function.
• The needle will penetrate clothing.
• Make sure that pockets are empty or that nothing
  is blocking the injection site.
• Hold firmly for at least 10 seconds.
• Use secondary site if primary site in not
  accessible.

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INTRAMUSCULAR INJECTION SITE ON THE BUTTOCKS
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Decontamination

• Consider victim decontamination as soon as
  possible after the initial Mark 1 Kit treatment
  has been administered.
• Decontamination Procedure
• Immediately remove clothing.
• Wash victim using large amounts of water, with
  soap if available.

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Nerve Agent Exposure Overview

• If you, as well as personnel in your immediate
  area, present with signs and symptoms of a
  moderate to severe Nerve Agent Injury,
  immediately administer up to two (2) Mark 1 Kits
  in 5-10 minute intervals (Moderate Symptoms),
  administer up to three (3) Mark 1 Kits in 3-5
  minute intervals (Severe Symptoms).
• The effect of atropine administration on moderate
  or severe cases of nerve agent poisoning may help
  confirm the diagnosis.
• When in doubt, err on the side of caution when
  presented with signs and symptoms of nerve agent
  poisoning.

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Nerve Agent Exposure Overview
Are you seeing any of these signs and symptoms?
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Nerve Agent Exposure Reference Material

• US Army Medical Research Institute of Chemical
  Defensehttp//ccc.apgea.army.mil/courses/distance
  /cbt.htm
• Advanced Topics on Medical Defense against
  Biological and Chemical Agentshttp//www.swankhea
  lth.com
• NBC Med NBC Online Medical Information
  Serverhttp//www.nbc-med.org
• USAMRIID Bio-Treatment HandbookUSAMRIID Medical
  NBC BattlebookNBC Field Handbook - US ArmyNBC
  Protection - US ArmyNBC Decontamination - US
  ArmyNBC Field Training Exercise - US
  ArmyMedical Aspects of NBCEmergency Response to
  TerrorismNerve Agent Overview Recognition /
  Pathophysiology / Treatmenthttp//www.sc-ems.com
• Northeast Hospital Bio-Terrorism Preparedness
  ChemPack Committee
• Minnesota Department of Health Office of
  Emergency Preparedness