# Presentation: 208094

## ACT FAST

** **

**ACT001©**

- Second Edition

## A	gent

**A****	****gent**
**C****	****haracteristics and**
**T****	****oxicology**
**F****	****irst**
**A****	****id and**
**S****	****pecial**
**T****	****reatment**

**ACT002©**

## Purpose of Course

**The intent of this course is to instruct emergency **
**medical personnel on how to care for patients that **
**may have been exposed to chemical warfare agents **
**and assumed to have already been decontaminated. **
** **
**This course is designed primarily for Emergency **
**Medical Technicians with basic life support credentials.  **
**These individuals are referred to in the text as pre-hospital **
**emergency medical personnel.**

**ACT002B©**

## Goal

**To prepare you to recognize signs **
**and symptoms, and provide initial **
**emergency response treatment to **
**patients injured by exposure to nerve **
**and blister agents**

**ACT003©**

## Goal

**To assist in preparing for hazardous **
**materials emergencies**

**ACT004©**

## Instructional Objectives

**•  **** ****Action items**
**•   ****What trainees will be able to **
**    ****do at end of training**
**•   ****Review with trainees**

**ACT005©**

## Required Objectives

**   •   ****DESCRIBE initial first-aid treatment for victims of**
**       ****nerve agent exposure**
**   •   ****DESCRIBE initial first-aid treatment for victims of**
**       ****blister agent exposure**

**ACT006©**

## Supporting Objectives

**•   ****DESCRIBE potential hazards of nerve agents**
**•   ****DESCRIBE potential hazards of blister agents**
**•   ****IDENTIFY signs and symptoms of nerve agent exposure**
**•   ****IDENTIFY signs and symptoms of blister agent exposure**

**ACT007©**

## Student Manual

**•  ****Self-paced review**
**•  ****Self checks included**
**•  ****Additional reference materials such as**
**   ****Material Safety Data Sheets included**

**ACT008©**

## Evaluations

**•   ****Final quiz**

**ACT009A©**

##   BACKGROUND

**ACT010©**

## Purpose

**characteristics**

**ACT011©**

## Chemical Stockpile

**   ****for warfare**
**• ****Primarily nerve agents and blister (vesicant) agents**

**ACT012©**

## Chemical Stockpile Storage Location

**•**

**•**

**•**

**•**

**•**

**•**

**•**

**•**

**Hermiston, OR**
**Tooele, UT**
**Pueblo, CO**

**Aberdeen, MD**
**Newport, IN**
**Richmond, KY**

**Pine Bluff, AR**
**Anniston, AL**

**ACT013©**

## U.S. Army Chemical

**U.S. Army Chemical**
**Stockpile Inventories**

**Storage Location                        Agent Stored**
**                                   ****GA   GB   VX   Mustard   Lewisite**
**  **
**Umatilla                       X       X      X**
**          **
**Tooele                         X       X      X         X               X**
**Pueblo                                                      X**
**  **
**Pine Bluff                             X      X          X**
**Newport                                        X**
**Lexington-**
**  ****Blue Grass                X      X       X**
**Anniston                              X       X         X**
**  **
**Aberdeen                                                  X**

**ACT014©**

##   LOCAL RESPONSE    INFORMATION AND    PROCEDURES  

**ACT015A©**

## Local Response Information and Procedures

**•   ****Specific and unique information requirements **
**    ****to be addressed**
**•   ****Provide you with a framework for **
**    ****site-specific information**

**ACT015B©**

## Your Input is Important

**Community needs and resources vary a great deal **
**from one storage location to the next.  Therefore, **
**YOUR input on how the emergency care elements **
**in your community could best respond to a release **
**with off-post consequences is important to the **
**success of the program. **

**ACT015C©**

## What You Should Know That IS NOT in This Study Guide

**     ****cover everything you need to know in **
**     ****preparation for your role **
**•   ****In short, you need to find out**
**    — ****Who the local players are**
**    — ****The roles and responsibilities of each**
**    — ****The methods of response**
**    — ****What supplies and equipment are on hand**
**    — ****Standard Operating Procedures**
**    — ****Memoranda of Understanding or Agreement**

- What You Should Know That IS NOT in This Study Guide

**ACT015D©**

## Additional Information Resources

** • ****Fire department or other emergency responders**
** • ****Ambulance service or other rescue services**
** • ****Hospital emergency department**
** • ****Local health department**

**ACT015E©**

## Local Community Response Procedures

**     ****expected to come from?**
** •   ****Who, from the facility, is notified?**
** •   ****Who, from the local community, is notified?**
** •   ****Who is likely to be the first on the scene?**

**If an emergency occurs at the installation that could **
**affect the off-post population:**

**ACT015F©**

## Local Community Response Procedures (Continued)

**     ****medical personnel?**
** •   ****What am I expected to do in this situation? **
** •   ****Am I authorized in my state to administer antidotal **
**     ****medications (atropine, 2-PAM chloride)?  Under what **
**     ****circumstances?**

**If an emergency occurs at the installation that could **
**affect the off-post population:**

**ACT015G©**

## CHEMICAL

**AGENTS**

**ACT017©**

## Information will help you in:

**Information will help you in:**
**•  ****Protecting yourself**
**•  ****Treating patients**

**ACT018©**

## Objectives

**• ****DESCRIBE potential hazards of nerve agents**
**• ****DESCRIBE potential hazards of blister agents**
**• ****IDENTIFY most likely route of exposure**

**ACT019©**

** **

** **

**A**

**N**

**D**

**E**

**F**

**F**

**E**

**C**

**T**

**S**

**C**

**H**

**A**

**R**

**A**

**C**

**T**

**E**

**R**

**S**

**T**

**I**

**C**

**S**

**I**

** **

**ACT020©**

## Nerve Agents

**• ****Attack nervous system**
**• ****Scientific classification: Organophosphate**

**© Cinetel Productions**

**ACT021©**

## Specific Names

**Name     Common Name     Referred to As**
**VX                                         VX**
**GB           Sarin                    GB or G-agent**
**GA*          Tabun                  GA or G-agent**

*** Small amount stored at Tooele only**

**ACT022©**

## Physical Properties

**• ****Volatile--generate vapors**
**• ****Potential for release if in vapor form**

**ACT023©**

## How Nerve Agents Work

**   ****through use of chemicals**
**• ****Chemicals act as instructions to nerves, **
**   ****muscles, and glands**
**• ****Two forms of instructions:**
**  ****- stimulate (move or work)**
**  ****- relax (stop or rest)**
**• ****Nerve agent interferes with normal transmission**
**   ****of instructions**

**ACT024©**

## Leads to Destruction of System Control

**   ****central nervous system**
**• ****Causes muscles and certain glands to **
**   ****malfunction**

- Leads to Destruction of System Control

**ACT025©**

## Normal Nervous System Function

**  ****along nerve ****	****	****	****	****cells**

**ACT026A©**

**• ****	****Acetycholine ****	****(a neuro-****	****	****	****transmitter) ****	****is released**

**•****	****Target ****	****	****	****	****cell is ****	****	****	****	****stimulated**

## Normal Nervous System Function

**•****	****Once target cell is stimulated, acetycholine is ****	****deactivated by acetylcholinesterase. **
**•****	****	****Target cell relaxes**

**ACT026B©**

## Nerve Agent Interference

**ACT027©**

**•****	****Excess acytelcholine accumulates**
**• ****	****Muscle action becomes uncontrolled and ****	****	****twitchy**
**•****	****Muscle can tire and collapse**
**•****	****Gland continues to secrete sweat, **
**	****tears, or mucus**

## Routes of Exposure

**• ****Inhalation**
**• ****Ingestion**
**• ****Direct contact**

**© Cinetel Productions**

- Routes of Exposure

**ACT028©**

## Inhalation

**© Cinetel Productions**

**ACT029©**

**Respiratory failure**
**chief cause of death**
**after severe exposure**

## Direct Contact

**Absorption through skin:**
**   ****• ****All agents can be absorbed**
**   • ****VX persists longer**
**   • ****GB evaporates quickly, but still threat**
**   •  ****Scrape or cut in skin allows **
**      ****immediate entry**
**Entry also through eyes**

**© Cinetel Productions**

**ACT030©**

## Ingestion

**© Cinetel Productions**

**•  ****Access to bloodstream via digestive system    **
**•  ****Effects similar to inhalation, but at greater doses**

**ACT031©**

## Inhalation Exposure From Atmospheric Transport

**be most concerned with is**

**ACT032©**

***inhalation of agent vapors or aerosols***

## Blister Agents (Vesicants)

**• ****Blisters most noticeable effect**

**© Cinetel Productions**

**ACT033©**

## Specific Names

**Common Name        Referred to as**
**   ****Mustard                H, HD, HT**
**   ****Lewisite*                L**

***Small amount stored at Tooele only**

**ACT034©**

## Physical Properties

**•  ****Form: Liquid or solid**
**• ****Volatile, burns well**

**H**

**HD**

**HT**

**ACT035©**

## How Blister Agents Work

**•****	****Chemical burns to soft membranes**
**  ****- Eyes**
**  ****- Eye ball**
**  ****- Lung tissue**
**  ****- Mouth**
**  ****- Throat**

**ACT036©**

## Mustard Agent Exposure

**• ****Delayed reaction, **
**   ****little or no pain**
**• ****Blisters develop in **
**   ****2 to 36 hours**

**© Cinetel Productions**

**ACT037©**

## Routes of Exposure

**• ****Inhalation**
**• ****Ingestion**
**• ****Direct contact**

**© Cinetel Productions**

- Routes of Exposure

**ACT038©**

## Inhalation

**membrane lining of**
**• ****Nasal passages **
**• ****Throat**
**• ****Bronchial tubes**

**© Cinetel Productions**

**ACT039©**

## Direct contact With Liquid or Vapor

** ****• ****Highly damaging to skin—especially warm, moist areas**
**Mucous Membranes**
** • ****Very susceptible to effects of blister agents**
** • ****Includes:**
**    ****- lining around eyelids**
**    ****- inside mouth and nose**
**Sweat and moisture increase effect**

- Direct contact With Liquid or Vapor

**ACT040©**

## Ingestion

**•  ****If deposited on or in food items, drink, etc.    **
**• ****Injures warm, moist tissues of mouth,**
**    ****throat and esophagus**

**© Cinetel Productions**

**ACT041©**

## Inhalation Exposure From Atmospheric Transport

**be most concerned with is**

**ACT042©**

***inhalation of agent vapors or aerosols***

## Lewisite

**•   ****Different type of blister agent in Chemical Stockpile **
**    ****only at Deseret Chemical Depot**
**•   ****Causes immediate pain upon skin or eye contact**
**     ****(unlike mustards) **
**•   ****Suspected carcinogen**

**ACT043©**

## Key Points—Nerve Agents

**   ****- Stored as liquid (VX oily), generates extremely**
**     ****damaging vapors**
**   ****- Highly damaging by direct contact (touch), inhalation **
**     ****(breathing of contaminated air), and **
**      ****ingestion (eating or drinking)**

**ACT044A©**

## Key Points—Blister Agents

**H**

**HD**

**HT**

**•  ****Blister agent characteristics:**
**    ****- Stored as liquid (oily) or solid, generate**
**      ****damaging vapors**
**    ****- Damaging by direct contact **
**      ****(touch), inhalation (breathing**
**      ****of contaminated air), **
**      ****and ingestion (eating or **
**      ****drinking)**

**ACT044B©**

## Key Points—Exposure

** ****Inhalation of contaminated air**

**ACT045©**

## SIGNS AND

**SIGNS AND**
**SYMPTOMS**

**ACT046©**

## Size up situation based on . . .

**• ****Known information regarding accidental release**
**• ****Recognition of the event based on signs **
**  ****and symptoms**

**ACT047©**

## Objectives

**• ****IDENTIFY signs and symptoms of nerve agent **
**  ****exposure**
**• ****IDENTIFY signs and symptoms of blister agent **
**  ****exposure**

**ACT048©**

## Note!

**Not all signs and symptoms **
**may appear...**
**Dose, duration, and **
**route of entry **
**make a difference**

**ACT049©**

## Specific Signs and Symptoms Of Nerve Agent Exposure

**• ****Miosis (pinpoint pupils)**
**• ****Dim vision**
**• ****Respiratory trouble**
**• ****Localized sweating**
**•  ****Wheezing**

**Constriction**
**  ****(Pinpoint)**

**Expansion**
** ****(Dilation)**

**• ****Runny nose or excess**
**   ****salivation**
**• ****Stomach cramps, vomiting**
**   ****diarrhea**
**•  ****Muscle cramps, twitching**
**• ****Heartbeat irregularities**

- Specific Signs and Symptoms Of Nerve Agent Exposure

**ACT050©**

## Specific Signs and Symptoms Of Nerve Agent Exposure (continued)

**• ****Twitching spasms**
**• ****Convulsions and coma**
**• ****Other symptoms**
** ****- Headache**
** ****- Anxiety**
** ****- Restlessness**
** ****- Giddiness**
** ****- Irritability**

**Mild:**

**ACT051©**

## Factors Affecting Signs and Symptoms

**• ****Reaction time depends on:**
** ****- type of agent involved**
** ****- amount of agent to which patient exposed**
** ****- dose (how much patient absorbed)**
** ****- duration**
** ****- route of exposure**
** ****- sensitivity of patient's system**

**Time Factor (Onset)**

- Factors Affecting Signs and Symptoms

**ACT052©**

## Factors Affecting Signs and Symptoms (Continued)

**• ****Reaction time is immediate if:**
** ****- moderate to large amounts inhaled**
** ****- moderate to large amounts spilled on skin**
**• ****Reaction time is delayed if:**
** ****- small amounts involved**
** ****- absorbed through skin in localized area**

**Time Factor (Onset)**

**ACT053©**

## Exposure Through Inhalation

**• ****Immediate response within seconds**
**• ****Peak effects within 15-20 minutes**

**© Cinetel Productions**

**ACT054©**

## Exposure Through Skin (Absorption)

** • ****Effects can develop up to 18 hours**
**    ****after exposure**
** • ****Absorption can continue and effects **
**    ****worsen for hours, even after decon**
** • ****Later onset, less likely to be lethal**

**© Cinetel Productions**

**ACT055©**

## Toxicity

**  –  ****Equals tiny droplet absorbed into 155-lb person**
**• ****LCt****50**** of VX is 30 milligrams-min/m   (vapor inhalation) **
**  –  ****50 times more toxic than cyanide gas**
**• ****LD****50**** of GB is 1.7 grams/70-kg man (liquid on skin)**
**• ****LCt****50**** of GB is 70 milligrams-min/m   (vapor inhalation) **

**ACT056©**

## Lethality

**Respiratory failure**
**chief cause of death**
**after severe exposures**

**ACT057©**

## Nerve Agent Exposure Levels

**Mild:**
**May also be effects of initial reaction which could lead **
**to more serious effects**
**  ****eyes:  miosis, pain (deep in eye or head), dim or **
**              ****blurred vision**
**  ****nose:  runny**
**  ****lungs:  "tightness in chest”, bronchoconstriction, ****	****      secretions in airways, cough, moderate **
**                 ****difficulty in breathing**

**ACT058A©**

## Nerve Agent Exposure Levels

**Moderate:**
**May also include symptoms under "Mild" **
**  ****eyes:  miosis, pain, dim or blurred vision**
**  ****nose:  runny (severe), nasal congestion**
**  ****lungs:  ”tightness in chest", breathing more difficult,  secretions**
**    ****	****    ****more abundant**
**  ****muscles:  feeling of generalized weakness , twitching of large**
** ****	****      ****muscle groups**
**  ****GI:  nausea, vomiting, diarrhea, cramps**

**ACT058B©**

## Nerve Agent Exposure Levels

**  ****Severe:**
**  ****May develop from symptoms under "Mild" and**
**  ****"Moderate"; or go directly to these symptoms**
**  ****muscles:****	****convulsions, weakness with eventual**
**  ****	****	****flaccid paralysis**
**  ****lungs:****	****cessation of respiration**
**  ****all:****	****	****loss of consciousness, coma, death**

**ACT058C©**

## Nerve Agent Exposure Levels

**Onset time: seconds to several minutes**
** **
**• ****Symptoms may occur after little more**
**  ****than one breath of vapor**
** **
**• ****Large amounts may cause reactions**
**  ****within seconds**
**• ****Effects do not worsen appreciably after**
**  ****15-20 min following cessation of exposure**
**  **

**ACT058D©**

## Skin Exposure to Nerve Agent

**Mild:**
**May also be effects of initial reaction which could lead **
**to more serious effects**
**  ****skin:       sweating at exposure site**
**  **
**  ****muscle:  localized, unorganized twitching **
**                 ****at exposure site (fasciculation) **

**ACT058E©**

## Skin Exposure to Nerve Agent

**Moderate:**
**May also include symptoms under “Mild”**
**  **
**  ****muscle:  generalized (at random, all over) fasciculation**
**	****       ****and twitching; generalized weakness that**
**	****       ****increases with any form of activity **
** **
**  ****GI:****	****         nausea, vomiting, diarrhea**

**ACT058F©**

## Skin Exposure to Nerve Agent

**Severe:**
**May develop from symptoms under "Mild" and "Moderate"; **
**or go directly to these symptoms**
**  ****muscle: extremely weak; convulsions (seizures) **
**                   ****with eventual flaccid paralysis**
**  ****lung:  cessation of respiration**
**  ****all:  sudden loss of consciousness and collapse, death**

**ACT058G©**

## Skin Exposure to Nerve Agent Time Course

**Onset time: minutes to several hours **
** **
**• ****The larger the exposure the shorter the onset time **
** **
**• ****After large exposure, effects within minutes**
**• ****After asymptomatic period, first effect may be **
**   ****loss of consciousness**
**  **
**• ****Onset time may be as long as 18 hrs after exposure;**
**   ****in such cases effects usually not lethal**

**ACT058H©**

## Differential diagnosis . . .

**... refers to distinguishing one disease from **
**    ****another when they produce similar effects**

**ACT059©**

## Other Possible Causes of Symptoms

**Signs and symptoms could also apply to:**

**• ****Epilepsy**
**• ****Gastroenteritis**
**• ****Exposure to**
**  ****agricultural**
**  ****insecticides **
**  ****(organophosphates and**
**  ****carbanates)**

**•  ****Heat illnesses**
**• ****Emphysema**
**• ****Stroke**
**• ****Head trauma**
**• ****Drug overdose**

**ACT060©**

## Blister Agent Release Potential

**agent or high concentrations of vapor **
**are not expected, it is important to **
**recognize the signs and symptoms of **
**more severe exposures**

**ACT061A©**

## Specific Signs and Symptoms of Mustard Agent Exposure

**• ****Eye irritation and inflammation**
**• ****Photophobia**
**• ****Erythema**
**• ****Blisters**
**• ****Inflammation of respiratory tract**

**ACT061B©**

## How Mustard Blisters Skin

**Normal skin**

**Reddened skin**

**Blistered skin**

**© Cinetel Productions**

**ACT061C©**

## Factors Affecting Signs and Symptoms

**Time Factor (Onset)**
**• ****Reaction time depends on:**
** ****-  type of agent**
** ****- amount of agent to which patient exposed**
** ****- dose (how much patient absorbed)**
** ****- duration of exposure**
** ****- route of exposure**
** ****- sensitivity of patient's system**

- Factors Affecting Signs and Symptoms

**ACT062©**

## Peak Effect

**• ****Effects occur after **
**  ****few hours latency**
**• ****Sneezing, coughing, **
**   ****bronchitis**
**Skin Absorption**
**• ****Effects delayed and absorption **
**  ****can continue for hours**

**© Cinetel Productions**

**ACT063©**

## Peak Effect (Continued)

**© Cinetel Productions**

**Toxicity**
**• ****LD****50**** is 7 grams/70-kg man (liquid on skin)**
**• ****Between 4 and 32 micrograms/70-kg **
**  ****man can cause blistering**
**• ****Vapor form 3 times more toxic than **
**  ****cyanide**
**Lethality**
** • ****Low (~3% in World War I)**
**• ****Chief cause of death:**
**   ****- Respiratory failure**
**   ****- Infections**

**ACT064©**

## Mustard Agent Exposure Levels

**skin:  no immediate clinical effects (no burning, **
**           ****stinging, or redness); **
**           ****becomes "fixed" to the tissue within minutes, **
**           ****blisters appear about 2 to 36 hours later**
**eyes:  within 4 to 12 hours after exposure, itching,**
**	****tearing, conjunctivitis (reddening of tissues**
**	****surrounding the eyeball), sensation of grit in**
**	****the eye, burning and photophobia (sensitivity**
**	****to light), some swelling of eyelids**

**Mild:**

**ACT065A©**

## Mustard Agent Exposure Levels

**Moderate:**

**    ****skin:  no immediate clinical effects; blisters appear**
**              ****sooner and are more severe than in cases of "mild"**
**              ****dose**
**    ****eyes:****	****in 3 to 6 hours; increased intensity from "Mild" symptoms;**
**	****swelling of lids to the point of near closure; spasms of the**
**	****muscles surrounding the eye;  increased photophobia; **
**	****blurred vision; possible discharge; miosis; severe ****	****	****inflammation of conjuctiva and cornea **
**     **

**ACT065B©**

## Mustard Agent Exposure Levels

**skin:****	****  no immediate clinical effects**
**	****  ****blisters appear sooner and are large**
**	****  ****necrosis**
**	****  ****skin charring (delayed)**
**	**
**eyes:****	****  severe pain**
**	****  ****increased swelling of lids to point **
**	****    ****of closure, discharge**
**	****  ****possible damage to cornea**
**Muscles:  large amounts may affect nerve endings**

**Severe:**

**ACT065C©**

## Mustard Agent Exposure Through Inhalation/Ingestion

**Mild:**
**  **
**  ****nose, throat**
**  ****and windpipe:  burning sensation, **
**  ****sinus pain, cough**
**  **
**  ****GI:  nausea and vomiting**

**ACT065D©**

## Mustard Agent Exposure Through Inhalation/Ingestion

**Moderate:**
**  **
**  ****nose, throat**
**  ****and windpipe: burning sensation**
**  ****lungs:  chest tightness, severe cough**
**  **
**  ****GI:  nausea and vomiting, stomach pains**

**ACT065E©**

## Mustard Agent Exposure Through Inhalation/Ingestion

**Severe:**
** **
**  ****nose, throat**
**  ****and windpipe:  severe burning**
**  ****lungs:  difficulty breathing due to airway damage**
**  **
**  ****GI:  nausea, vomiting, bloody diarrhea,**
**         ****stomach pains**
**  ****muscles:  large amounts may affect nerve endings**

**ACT065F©**

## Mustard Agent Exposure Time Course

- Mustard Agent Exposure Time Course

**ACT066©**

## Lewisite Signs and Symptoms

**agents, Lewisite produces similar damage in body**
**tissues.**

**ACT067A©**

## Inhalation of Lewisite Vapor

**    ****moderate irritation of upper respiratory tract**
**•   ****May also cause sneezing**
**•   ****Similar to mustard effects**
**     —****	****Except, in most severe cases, fluid may **
**	****accumulate in lungs and ooze into lining of the **
**	****chest cavity  **
**         **

**ACT067B©**

## Direct Contact with Liquid Lewisite

**    ****with eyes and skin (unlike mustard)  **
**•  ****Eyes can be severely damaged resulting in permanent **
**   ****injury of blindness**
**•  ****More severe skin lesions than mustard**
**	****—****	****Erythema followed by blistering over entire area of **
**	****     ****erythema**
**	****—****	****Deeper injury to connective tissue and muscle**
**	****—****	****Greater vascular damage**
**	****—****	****More inflammation**

- Direct Contact with Liquid Lewisite

**ACT067C©**

## Other Effects

**    ****at sufficiently large doses **
**•   ****Has induced Bowen’s disease (slow-growing, **
**	****usually nonfatal skin cancer)**
**    **

**ACT067D©**

## Lewisite Exposure

**eye:      prompt redness, swelling, irritation, **
**              ****immediate burning sensation, may cause**
**              ****inflammation of iris, corneal injury**
**nose:    prompt irritation**
**respiratory tract:****	****rapid irritation, hoarseness, **
**	****	****	****loss of voice, cough;  pneumonia, **
**	****	****	****fever, accumulation of fluid in lungs, ****	****	****	****fluid between membranes lining**
**	****	****	****chest cavity**

**ACT067E©**

## Lewisite Exposure (Continued)

**skin:****	****  prompt burning redness within 30 min,**
**	****  ****blisters on 1st or 2nd day;  pain more **
**	****  ****severe and necrosis deeper than mustard**
**GI tract:  diarrhea, nausea, vomiting, liver failure**
**cardiovascular system:****	****shock after severe symptoms, **
**	****	****	****	****anemia, concentration **
**	****	****	****	****of blood**

**ACT067F©**

## Lewisite Exposure (Continued)

**bladder:                               kidney failure**
**central nervous system:   malaise, prostration, **
**                                            ****depression after **
**                                            ****severe symptoms**

**ACT067G©**

## Other Possible Causes Of Signs and Symptoms

**• ****Chemical or thermal burns**
**• ****Heavy tear gas exposure**
**•  ****Poison ivy, poison oak, and**
**   ****other contact allergies**

**Blister agent signs and symptoms could also apply to:**

**ACT068©**

## Nerve Agent Summary

**   ****- Miosis**
**   ****- Increased secretions**
**   ****- Respiratory difficulty**
**• ****Not all signs and symptoms may appear**
**• ****Dose, duration, and route of entry can make difference**

**ACT069A©**

## Blister Agent Summary

**   — ****Eye irritation and inflammation**
**   — ****Erythema (skin reddening)**
**   — ****Blisters**
**   — ****Respiratory irritation and distress**
**•  ****Not all signs and symptoms may appear**
**•  ****Dosage, duration, and route of entry can make difference**

**ACT069B©**

## FIRST AID AND 

**FIRST AID AND **
**SPECIAL **
**TREATMENT**

**ACT070©**

## A   Airway 

**A****   Airway **
**B****   Breathing**
** **
**C****   Circulation**

- ABC’s OF Emergency Care

**ACT071©**

## Objectives

**•  ****DESCRIBE need for self protection when **
**   ****providing treatment for nerve or blister **
**   ****agent exposure**
**• ****DESCRIBE initial first aid treatment for victims **
**   ****of nerve agents**
**• ****DESCRIBE initial first aid treatment for victims **
**   ****of blister agents**

**ACT072©**

## Protect yourself

- rule number one:

**Protect yourself**

**ACT073©**

## You Can Protect Yourself By:

**     ****and the zone set up to operate safely**
**     ****during the emergency**
**  •  ****Ensuring that the exposed person is **
**     ****completely decontaminated  **

**ACT074A©**

## Emergency Time Line

**•  ****Initial hazard prediction given, identifying pattern**
**   ****and path of off-post exposure**
**•  ****Emergency response and treatment teams established**
**   **

**ACT074B©**

## •  It is assumed that patients will have been 

**•  ****It is assumed that patients will have been **
**   ****decontaminated before being brought to EMS **
**   ****personnel in the cold zone**
**•  ****Information regarding decontamination or removal **
**   ****from contaminated areas should not be interpreted **
**   ****as encouraging EMS personnel to go into the hot zone**
**•  ****PPE may be required.  The CSEPP training course, Personal**
**   ****Protective Equipment, describes the approved equipment**
**   ****and associated requirements**

**ACT074C©**

## Decontamination

**• ****Prevents agent from doing further harm**
**• ****Prevents agent from spreading**

**Note:  Should be accomplished before patient**
**           ****is brought to the treatment area**

**ACT075©**

## Administering Drugs

**• ****Laws vary from state to state**
**• ****Be familiar with YOUR local and**
**  ****state laws**

**ACT076©**

## Nerve Agent Antidotes

**• ****2-PAM chloride**

**ACT077©**

## Atropine Effect

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

**ACT078©**

## 2-PAM Chloride Effect

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

**ACT079©**

## 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 Chloride until maximum dose per body weight is reached**

**ACT080©**

## 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**

**ACT081©**

## Additional Drug Therapy— Diazepam

**Administer to patients experiencing convulsions**
**Consider for patients with severe signs and symptoms**
**Dosage depends on patient’s age**

**ACT082©**

## Guideline For Administering Antidotes

**• ****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 Chloride as **
**  ****recommended in treatment tables until maximum total **
**  ****dose is given**

- Guideline For Administering Antidotes

**ACT083©**

## Signs of Atropinization

**• ****Breathing easy**

**ACT084©**

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

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

**ACT085©**

## Signs and Symptoms Of Atropine Overdose

**• ****Dry mouth and skin**
**• ****Rapid pulse**
**• ****Flushed skin**
**• ****Difficulty urinating**

**• ****Confusion, delirium**
**• ****Temperature control diminished**
**•  ****Intense thirst**
**•  ****Restlessness**

**ACT086©**

## Other Possible Causes of Symptoms Similar To Atropine Overdose

**• ****Locoweed**
**• ****Atropine-like medicines**

**ACT087A©**

## Treatment for Atropine Overdose

**•  ****Protect from irrational actions**
**•  ****Transport to hospital as soon as possible**

**ACT087B©**

## Alternate Method of Administration of Antidote

** ****- Simple, compact, injection ****	****	****systems equipped with  pre-****	****	****measured amount (dose) of ****	****	****antidote**
** ****- Atropine auto-injectors approved ****	****for adults and children, but not ****	****	****infants**
** ****- 2-PAM chloride auto-injectors ****	****	****approved for adults only**

**ACT088©**

## Respiratory Support

**•  ****Range from administering oxygen **
**   ****(if breathing is difficult) to providing **
**   ****ventilation, airway management**
**   ****and suction as needed**

**ACT089©**

## Ventilation

**  ****a qualified person is recommended**
**• ****Requires higher “pop off” pressure (70+ cm H****2****O)**

**Source:  DOT Emergency Medical Care--Paramedic**

**ACT090©**

## Treatment For Exposure To Blister Agent

**• ****Take precautions for sterile technique**
**• ****Support airway management as necessary**

**After protecting yourself, immediately**

- Treatment For Exposure To Blister Agent

**ACT091©**

## Eye Contact

**• ****Flush eyes immediately**
** **
**• ****Do not cover eyes with bandages**
**• ****Dark or opaque glasses provide **
**   ****relief from photophobia**

** ****SPEED CRITICAL!**

**- Tilt head to the side**
**- Pull eyelids apart with fingers**
**- Pour water slowly into eyes**

**ACT092©**

## Skin Contact

**Arm pits**
**Groin**
**Behind knees**
**Between toes**

** ****Pay special attention to**

**Around ears**
**Eyelids**
**Inside nose**
**Inside mouth**
**Neck creases**

**ACT093©**

## Supply respiratory support if needed for significant inhalation exposure
Administer oxygen as needed
If breathing has stopped, resuscitate the person
Give intravenous fluids if needed, but do not overload

**Supply respiratory support if needed for significant inhalation exposure**
**Administer oxygen as needed**
**If breathing has stopped, resuscitate the person**
**Give intravenous fluids if needed, but do not overload**

**ACT094©**

## Treatment For Exposure to Lewisite

**    ****to avoid deep burns**
**•   ****Antidote has been developed but is no **
**    ****longer manufactured**

**ACT095©**

## Key Points

**• ****Initial first aid for nerve agent exposure**
** ****- Give atropine, follow up with 2-PAM chloride**
** ****- Support airway management as necessary**
** ****- Atropine overdose possible if given when no **
**   ****nerve agent exposure occurred**
**• ****Initial first aid for blister agent exposure**
** ****- Ensure that patient is decontaminated**
** ****- Take precautions for sterile technique **
** ****- Support airway management as necessary**** **

**ACT096©**