CHEMICAL
AGENTS
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
CHEMICAL AGENTS
Objectives
Identify indicators that may cause the
EMS provider to suspect a chemical
incident
Identify signs, symptoms and
management of common chemical
agents
Ensure adequate protection for EMS
providers in a chemical incident
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
CHEMICAL AGENTS
Terrorism
Advantages
–
–
–
–
–
–
–
–
Disadvantages
Easy to make
Available
Cheap
Immediate effect
Hard to detect
Easily spread
Tie up resources
Psychological impact
August 2005
– Requires large
quantities
– Production hazardous
– Difficult to prepare for
EMS & Trauma Systems Section
Office of Public Health Preparedness
CHEMICAL AGENTS
Considerations
Most are liquid and must be aerosolized or
vaporized for maximum exposure
Small hot zone if no dissemination device
Slow steady winds best environment
Closed spaces result in higher
concentrations
Almost all agents most dangerous when
inhaled …..Protect lungs first, fast!
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
CHEMICAL AGENTS
Nerve
Blister
Blood
Choking
Irritant
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Nerve Agents &
Organophosphates
Volitile liquid not “Nerve Gas”
Examples:
– Weapons: Sarin, Soman, VX
– Organophosphate pesticides
Where were nerve agents used in the past?
Exposure: Inhalation and direct skin contact
Effects: Over stimulation of nerves
– What happens to skin, GI, lungs, pupils, glands?
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Symptoms of
Nerve Agent/Organophosphate
Poisoning
S
L
U
D
G
E
M
August 2005
Salivation/Excessive Drooling
Lacrimation/Tearing
Urination/Incontinence
Defecation/Diarrhea
GI Upset/Cramps
Emesis/Vomiting
Presence of
constricted pupils
with SLUDGEM
findings indicates
nerve agent toxicity
Muscle Twitching
EMS & Trauma Systems Section
Office of Public Health Preparedness
Nerve Agents
Treatment
Rescue and Decontamination
Supportive Care
– Ventilatory Support / Frequent Suctioning
– High Flow Oxygen
– IV / Cardiac Monitoring, as available
Antidote Therapy
– Mark I Kits
– Atropine
Benzodiazepam Anti-convulsants
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Mark 1 Kits
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Contents of Mark 1 Kit
The clip
numbers
indicate order of
usage
– #1 Atropine
– #2 Pralidoxime
Chloride
(2-PAM CL)
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Simple Administration
Pull the auto injector
straight out from the clip
Place the colored end against
the outer thigh
Do not touch the end
Push and hold pressure for
10 seconds before removing
It’s armed and ready for
use
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Injection Site-Lateral Thigh
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Remember:
Atropine is the first drug used from a
Mark 1 Kit
Use the same number of 2-PAM CL
auto injectors as you did Atropine auto
injectors
Effects of atropine may include: Do not use pupil
– Heart rate >90
– Reduced bronchial secretions
– Reduced salivation
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
size as an
indicator of
atropine effects
Mark 1 Kit Dosages
Based on Symptoms
SELF-RESCUE
Threshold symptoms:






Dim vision
Increased tearing
Runny nose
Nausea/vomiting
Abdominal cramps
Shortness of breath
Threshold
Symptoms
-andPositive evidence
of nerve agent or
OPP on site
(Note: many of the above may
also be associated with heat
related illness)
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
1 Kit
Nerve Agent Treatment - Adult
ADULT PATIENT
Mild Symptoms
and Signs
Moderate
Symptoms and
Signs
Severe Signs
August 2005
Increased tearing
Increased salivation
Dim Vision
Runny nose
Sweating
Nausea/vomiting
Abdominal cramps
Diarrhea
Medical Control
Order
1 Mark I Kit
Constricted pupils
Difficulty breathing
Severe vomiting
Constricted
Pupils
2 Mark I Kits
Constricted
Pupils
3 Mark I Kits
(If 3 Mark I Kits are
used, administer 1st
dose of available
benzodiazepine)
Constricted pupils
Unconsciousness
Seizures
Severe difficulty
breathing
EMS & Trauma Systems Section
Office of Public Health Preparedness
Mark 1 Kit Dosages
Based on Symptoms
Mild = Threshold symptoms
plus constricted pupils,
muscle twitching,
diaphoresis
1 Kit
Moderate = Threshold
symptoms plus constricted
pupils, urinary incontinence,
respiratory
distress/wheezing
2 Kits
Severe = Threshold
symptoms plus constricted
pupils, unconsciousness,
seizures, severe respiratory
distress
August 2005
3 Kits
EMS & Trauma Systems Section
Office of Public Health Preparedness
Nerve Agent Treatment - Pediatrics
PEDIATRIC
Pediatric Patient with
Non-Severe
Signs/Symptoms
Pediatric Patient with
Severe Signs/Symptoms
August 2005
Mild or moderate
symptoms as above
Constricted pupils
Unconsciousness
Seizures
Severe difficulty
breathing
Positive evidence
of nerve agent or
OPP on site
Severe breathing
difficulty
Weakness
EMS & Trauma Systems Section
Office of Public Health Preparedness
Age >8 years
old:
As Above
Age <8 years
old
Per Medical
Control
Age > 8 years
old:
3 Mark I Kits
Age < 8 years
old:
1 Mark I Kit
Contact Medical
Control
as needed
Pediatric Dosing with Mark 1
Mild
Contact Medical Control
Moderate
Contact Medical Control
Severe
< Age 8
1
>Age 8
3
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Additional Paramedic
Pharmacological Intervention
Atropine 2-6 mg IV / IM per Mark I Kit Dosing Directive if
Mark I Kit is not available
– Each Mark I Kit contains 2 mg of atropine
Treat seizures per Seizure Protocol
– Diazepam:
Adult: 2-10 mg IVP
Pediatric:
– 0.2 mg/kg (maximum individual dose 10 mg) via IV route or
– 0.5 mg/kg (maximum individual dose 10 mg) via rectal route
If available, Valium auto-injector for adults
– Midazolam (Adult or Pediatric):
Midazolam 0.05 mg/kg to max 5 IVP
Administer Midazolam 0.1 mg/kg to max 10 mg IM
– Treat with initial benzo if 3 Mark I kits administered
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Blister Agents
Blister agents, also know as vesicants, cause
severe burns to eyes, skin, and tissues of the
respiratory tract. These agents are also referred
to as vesicants. They readily penetrate layers of
clothing and quickly damage the skin.
Examples of blister agents include:
– Lewisite
– Mustard
Symptoms may be delayed for hours
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Blister Agents
Symptoms include:
– Eye irritation
– Skin irritation /
chemical burn
– Respiratory Distress
Cough
Routes of Exposure
– Inhalation
– Skin Absorption
– Ingestion
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Blister Agents
Treatment
Thorough decontamination
Lots of water
Supportive Care
Assisted ventilation
High flow oxygen
IV / cardiac monitor, if available.
Symptomatic treatment per
protocol.
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Blood Agents
Mechanism: Interfere with
oxygen use at tissue level
Routes of Exposure:
Inhalation / Ingestion
Signs and Symptoms
Examples:
– Cyanogen chloride (CK)
– Hydrogen cyanide (AC)
Sources
– Smoke
– Pharmaceuticals
– Electroplating
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Blood Agents
Treatment
Supportive care
Assist ventilations
High flow oxygen
IV / Cardiac monitoring, as available
Antidote Therapy
– Basic
– Advanced
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Symptoms of Cyanide Poisoning
Respiratory Distress
With clear lungs
Without cyanosis
With normal pulse ox
Usually Increased
respiratory rate / depth
Potential for Rapid
Respiratory Arrest
August 2005
Decreased Level of
Consciousness
– Confusion
– Coma
Seizures
Headache
Dizziness
Pupils dilate (late)
EMS & Trauma Systems Section
Office of Public Health Preparedness
Cyanide Antidotes
Basic
Amyl Nitrite Inhalants
Advanced
Sodium Nitrite Injection
Sodium Thiosulfate
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Basic Antidote
Amyl Nitrite Inhalers
Requires evidence of
exposure
Initial treatment
Deliver by breaking and
– place under the nose
– inside O2 mask
– over the intake valve of the
BVM
Use a new inhalant every
3 minutes if sodium nitrite
infusion will be delayed
If the patient improves,
therapy stops here
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Basic Antidote
Amyl Nitrite Inhalers
Amyl nitrate convert forms
methomoglobin.
– May be dangerous when
cyanide not present
Contraindications:
– Suspected CO poisoning
Adverse Effects:
– Dizziness, fatigue, dyspnea,
nausea, vomiting,
hypotension, headache, tachy
or bradycardia.
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Advanced Antidote
Sodium Nitrite Injection
When cyanide confirmed,
infuse Sodium Nitrite ASAP
10 mL (300mg)
Pediatric dose 0.15 mL/kg body
weight
Infuse over no less than 5
minutes
Monitor BP
Slow rate of infusion if
hypotension develops
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Advanced Antidote
Sodium Nitrite Injection
Indications:
– Signs and symptoms present
and
– Cyanide confirmed on scene
Contraindications:
– Suspected CO exposure
Adverse reactions:
– Vomiting, abdominal pain,
dizziness, headache, flushing,
cyanosis, tachypnea, syncope,
hypotension, tachycardia
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Choking Agents
Choking agents severely stress respiratory
system tissues. Common industrial agents,
such as chlorine and phosgene, are considered
choking agents.
Examples of choking agents include:
–
–
–
–
Chlorine
Perflurorisobutylene
Phosgene
Red phosphorus
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Choking Agents
Chlorine
– Chlorine is a lethal choking
agent with a slight bleach
odor, and a greenishyellowish color
– High concentrations were
lethal enough to create mass
casualties during World War I
– Heavier than air
Many other agents
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Choking Agents
Signs and Symptoms
–
–
–
–
Coughing
Choking
Chest tightness
Odors:
Routes of Exposure
– Inhalation
Chlorine bleach
Swimming pools
Newly mown grass or
hay
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Treatment of Choking Agents
Respiratory chemical PPE
Supportive Care
–
–
–
Assist ventilations, as necessary
High flow oxygen
IV / cardiac monitoring, as available
Symptomatic treatment per protocol
Eye irrigation for Eye Irritation
–
–
–
–
Remove contact lenses
Flush with 1000cc of NS each eye
Flush from nose-side outward
If available, use Tetracaine hydrochloride 1-2 drops in each
eye.
Ensure that patient does not rub eyes after administration of
Tetracaine as injury may result.
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Advanced Treatment for
Choking Agents
For severe respiratory distress, consider
early intubation and aggressive
ventilatory support.
Evidence of non-cardiogenic pulmonary edema
Albuterol if wheezing
2.5mg via nebulizer (repeat x1 PRN) or
2-3 puffs from metered dose inhaler with spacer,
(repeat x 1 PRN).
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Irritating Agents
Riot control agents
Considered less lethal
Rarely cause severe problems
Often used for riot control purposes
Examples of irritating agents include:
MACE
Tear gas
Capsicum/pepper spray
Symptoms include
Burning or irritation in eyes and throat
Respiratory distress
Coughing /Choking
Nausea and vomiting
Don’t confuse with nerve agents
Treatment: Supportive
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
CHEMICAL AGENTS
Protection
Stage at a safe distance
Secure and isolate area
Watch for secondary chemical devices
Use PPE – Protect your lungs first, fast!
Confine contaminated and exposed victims
Decontamination before transportation
Alert hospitals EARLY
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness
Questions
August 2005
EMS & Trauma Systems Section
Office of Public Health Preparedness