# Presentation: 362312

## Use of Auto-Injectorsby Civilian Emergency Medical Personnel to Treat CiviliansExposed to Nerve Agent©

**© 1997 Lockheed Martin Energy Research Corporation**

## Learning Objectives

**Identify the antidotes to be administered in event of nerve agent exposure**
**Identify the conditions under which antidote auto-injectors should be used**
**Demonstrate use of antidote auto-injectors**
**Recognize adverse reactions to use of antidotes**

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**IMPORTANT!**

**Antidotes counter or relieve effects of poisons **
**such as nerve agents.  Use antidotes only when **
**signs and symptoms of exposure are present; **
**they will not protect if given before exposure.**

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## Auto-Injectors

**Simple, compact injection systems **
**Permit rapid injection of required antidotes **
**Prevent needle from being subject to cross-contamination**
**Enable rapid and accurate administration even if care giver or patient is in protective clothing  **

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## Auto-Injectors

**Auto-injectors facilitate timely treatment by providing **
**Simple, accurate, rapid drug administration **
**Pre-measured, controlled dose **
**No vials, ampules or syringes to manipulate **
**Fully automatic operation **
**Rugged construction**

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## Auto-Injectors

**Contain pre-measured doses of nerve agent antidotes atropine and 2-PAM chloride       (2-PAM Cl, pralidoxime chloride or PROTOPAM****®**** CHLORIDE) **
**FDA-approved and commercially available for use by civilian emergency medical personnel in the event of an accidental release of nerve agent or organophosphorus insecticides **

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**States decide if they will use them**
**One U. S.-based manufacturer:  Survival Technology Inc. (STI)**

**Auto-Injectors**

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## Who Can Use Auto-Injectors

**Who Can Use ****Auto-Injectors**

**Concern about administration of inappropriate and harmful doses            during emergency situations**
**Pre-measured doses in auto-injectors safe for civilians meeting profile of military personnel**
**  ****approximate ages of 18–35**
**   ****weight at least 70 kg or 154 pounds **
**  ****healthy with no compromising medical conditions**
**Age, sex, weight and health of all other patients must first be considered when determining amount of atropine and                 2-PAM Cl to administer**

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## Who Can Use Auto-Injectors

**Only qualified civilian emergency responders with adequate training in on-site recognition and treatment of nerve agent intoxication in the event of an accidental release**
**Majority of CSEPP States follow DOT national curriculum for Emergency Medical Technicians**
**Curriculum generally restricts training on use of IVs to Intermediate Emergency Medical Technicians and paramedics**
**Review of each state’s laws and regulations needed to determine appropriate use of auto-injectors**

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## When To Use Auto-Injectors

**Use only after following events have occurred:**
**Emergency medical personnel have donned personal protective equipment subsequent to recognizing existence of chemical agent hazard in area**
**Some or all of symptoms of nerve agent poisoning cited are present**

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## Signs and Symptoms of Nerve Agent Exposure

**                ****MILD ****	**
**headache**
**blurred vision from pinpoint pupils (miosis)**
**tight chest (smooth muscle constrictions)**
**excessive sweating**
**tearing (lacrimation)**
**salivation**
**unexplained runny nose****	****     **

**     ****MODERATELY SEVERE****  **
**  ****severe chest tightness **
**  ****diarrhea (rare)**

**     ****VERY SEVERE **
**  ****bluish discoloration**
**    ****of skin (cyanosis)**
**  ****respiratory failure**
**  ****coma**
**  ****unconscious**
**  ****convulsions****	**

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- Cinetel Productions

## Treatment For Exposure To Nerve Agents 

**Depending on severity of symptoms, immediately administer 1 atropine auto-injector, followed by 1 2-PAM Cl auto-injector **
**Atropine should be given first, followed immediately by   2-PAM Cl   **
**If nerve agent signs and symptoms are still present after 5–10 minutes, repeat injections **

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**If signs and symptoms still exist after additional 10 minutes, repeat injections for third time **
**If signs and symptoms remain after third set of injections, **_**do not**_** give any more antidotes but seek immediate medical help**

**Treatment For Exposure ****To Nerve Agents **

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## Treatment For Exposure To Nerve Agents 

**In case of very severe exposure, all three auto-injector kits (atropine and 2-PAM Cl) should be administered in rapid succession; then medical help should be sought**
**Remove secretions, maintain patient’s airway and, **
**    ****if necessary, use artificial ventilation  **
**2-PAM Cl is most effective if administered immediately after poisoning.  Generally, little is accomplished if drug is given more than 6 hours after termination of exposure**

**Treatment For Exposure ****To Nerve Agents **

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## Directions for Use

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**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 function**
**into fingers or hand if any pressure applied**
**to this end of injector **

**Directions for Use**

**2.  Hold injector like a pen. Place **
**                    ****colored end (green on **
**                    ****atropine, black on **
**                    ****2-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**

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## 3.  Hold firmly in place for ten       seconds, then  remove.                                Massage the area of injection

**3.  Hold firmly in place for ten       seconds, then  remove.                                Massage the area of injection**

**Directions for Use**

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**4.  After auto-injector has been activated, **
**     ****empty container should be disposed of**
**     ****properly  **
**It cannot be refilled nor can the protruding **
** ****needle be retracted  **
**It should be disposed of in a “sharps” container **
** ****per rules for handling medical wastes and possible **
** ****blood-borne pathogens **
**     ****Note dosage on triage tag or write on **
**     ****chest or forehead of patient**

**Directions for Use**

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## IMPORTANT: Medical personnel assisting evacuated victims of nerve agent exposure should avoid exposing themselves to cross-contamination by ensuring that they do not come in contact with patients’ clothing

**IMPORTANT: Medical personnel assisting evacuated victims of nerve agent exposure should avoid exposing themselves to cross-contamination by ensuring that they do not come in contact with patients’ clothing**

**Directions for Use**

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## Precautions

**Place any patient receiving atropine under medical observation for at least 24 hours **
**If atropine is used to treat infants, smaller amounts should be given**

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## Adverse Reactions

**2 to 5 minutes after intramuscular injection of 2-PAM Cl, mild to moderate pain may be experienced at site of injection**

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## 2-PAM Cl in a normal person may cause: 
blurred vision                        •   double vision (diplopia) 
impaired accommodation    •   dizziness
headache                               •   drowsiness 
nausea                                   •    rapid heart rate (tachycardia) 
increased systolic and         •    hyperventilation
    diastolic blood pressure       

**2-PAM Cl in a normal person may cause: **
**blurred vision                        •   double vision (diplopia) **
**impaired accommodation    •   dizziness**
**headache                               •   drowsiness **
**nausea                                   •    rapid heart rate (tachycardia) **
**increased systolic and         •    hyperventilation**
**    ****diastolic blood pressure       **

**Adverse Reactions**

**These are relatively non-toxic responses when **
**compared to effects of nerve agent or **
**organophorus insecticide exposures**

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## Overdosage

**If excessive atropine is administered to a normal person: **
**Signs of atropinization will become even more severe and patient may also develop**
**blurring of vision**
**delirium**
**urinary retention**
**When signs and symptoms of atropinization develop, no more atropine should be injected until atropinization subsides **

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## In case of 2-PAM Cl:
Observed in normal subjects only 
  dizziness
  blurred vision
  double vision (diplopia)
  headache
  impaired accommodation 
  nausea
  slightly rapid heart rate (tachycardia)  
Artificial respiration and other supportive     therapy should be administered as needed

**In case of 2-PAM Cl:**
**Observed in normal subjects only **
**  ****dizziness**
**  ****blurred vision**
**  ****double vision (diplopia)**
**  ****headache**
**  ****impaired accommodation **
**  ****nausea**
**  ****slightly rapid heart rate (tachycardia)  **
**Artificial respiration and other supportive     therapy should be administered as needed**

***Overdosage***

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## Caring For Auto-Injector Supplies

**Auto-injectors have a five-year shelf life, making them suitable for storage in emergency stockpiles  **
**Store auto-injectors at room temperature (approximately 25°C, 77°F)**
**Keep them from freezing**

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## Caring For Auto-Injector Supplies

**Antidotes will freeze at temperatures below 29F**
**Do not carry auto-injectors in external pocket of BDO when temperature below freezing.  Place in inner pocket where body heat will keep them warm**
**Tie string to auto-injector and thread through outer layers of clothing to outside pocket or belt.  Extract auto-injector by pulling the string when needed**
**Frozen auto-injectors still usable after being thawed if they do not appear broken or cracked**

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