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EMS Medicine Live May 2015
Welcome
Fifth EMS Webinar
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EMS Medicine Live May 2015
Vision – Community & Academic EMS Physician
Education • Information Sharing • Board Preparation
– Group involvement • Meet and see our peers • Involve your unique experiences and skills
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EMS Medicine Live Course Directors
Christian Knutsen, MD, MPH
Derek Cooney, MD
Brian Clemency, DO
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EMS Medicine Live May 2015
Webpage http://www.upstate.edu/emergency/education/fellowships/ems-live.php Or google EMS Medicine Live
Facebook https://www.facebook.com/emsmedicinelive
Email [email protected]
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EMS Medicine Live Presentation Info
During presentation • Mute yourself to decrease background noise
Recording • We will record and post conferences on our webpage
and Facebook page • You can record at your site also
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EMS Medicine Live May 2015
Questions –During conference
• Chat questions to EMSMedicineLive to be answered either during or at the end
• Raise hand virtually in chat window
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EMS Medicine Live May 2015
Questions –At the end
• Unmute yourself to ask a question or
• Message EMSMedicineLive if you have a
question and we can ask your question for you.
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EMS Medicine Live May 2015
Zoom Technical Problems? –Message me if you have a suggestion. –If you have a serious problem, email
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EMS Medicine Live May 2015
Presenter Christopher Tanski, MD, MSEd, EMT
– Medical School: SUNY Upstate – EM Residency: Albany Medical Center – EMS Fellowship: U of Buffalo with Brian Clemency
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EMS Medicine Live May 2015
Presenter Christopher Tanski, MD, MSEd, EMT
– Joined SUNY Upstate 2014 – Upstate Physician Response Team – DMAT-4 Physician – Mercy Flight West Command
Physician
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EMS Medicine Live May 2015
Presenter Christopher Tanski, MD, MSEd, EMT
“Nerve Agents 201”
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Nerve Agents 201
Chris Tanski, MD, MSEd, EMT SUNY Upstate Medical University
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Declaration
• I have no financial conflicts of interest.
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Background • Nerve agents are the most toxic substance known to man,
except perhaps for botulinum toxin • Developed in Germany, England and perhaps other
countries • First battlefield use was in 1984, by Iraq
• “Father of Nerve Agents” - Dr. Gerhard Schrader • Dr. Ranajit Ghosh - England
• Newmark, 2004; Newmark, 2007
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Nomenclature
• GA - Tabun - (TAH-bun) • GB - Sarin - (SAH-reen) • GD - Soman - (SO-mahn) • GF - Cyclosarin
• Why no GC or GE?
• Developed by German scientists
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Nomenclature
• VE • VG - Amiton • VM - Edemo • VR – Russian VX, Soviet V-Gas, R-33 • VX – Purple Possum • EA-3148 - Substance 100A
• V stands for . . .
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International Control • Chemical Weapons Convention of 1995
• Destroy all stockpiles of nerve agents by 2007 • U.S. Deadline was April 29, 2012 • U.S. intention is 100% elimination by 2023
• Countries that have not signed the treaty - Angola,
North Korea, Egypt, South Sudan
• The U.S. has three disposal sites
• Cannard, 2006; OPCW, 2015
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Progress? • 98% of GA destroyed • 94% of VX destroyed • 72% of GB destroyed • 57% of GD destroyed • How much total nerve agent is still in
existence? • About 9 million kilograms
• OPCW, 2015
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Pathophysiology • Related to organophosphate insecticides
• All are liquids at STP
• Most are spontaneously volatile
• G-agents are extremely volatile and not persistent; LD50 is
about 1700mg
• V-agents are less volatile and quite persistent; LD50 is about 10mg
• Hoffman et al., 2007; Newmark, 2004
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Pathophysiology • Toxidrome similar to insecticide poisoning but
toxicity increased
• Cholinesterase inhibitors; lead to cholinergic crisis
• The blockade of acetylcholinesterase inhibitors is essentially irreversible, except by oxime compounds (when administered early)
• Better or worse than insecticides? • White et al., 2004
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Muscarinic Receptors
• M1 – found in autonomic ganglia, involved in secretory functions and memory
• M2 – slows heart rate • M3 – secretions, smooth muscle
contractions • M4 – decreased locomotion • M5 – active in CNS
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Pick your acronym • SLUDGEM
• Salivation, lacrimation, urination, defecation/diarrhea, GI complaints, emesis, muscle spasm/miosis
• DUMBELS • Defecation, urination, miosis/muscle cramps, bronchoconstriction, emesis,
lacrimation, salivation/seizures/sweating
• OBSERVE • Others-affected-suddenly, body tremors, salivation, eye tearing, restricted
breathing, vomiting, excessive sweating
• SLUDGEM-RA • Respirations, agitation
• BAD DUMBELS • BAG the PUDDLES
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Signs and Symptoms of Vapor Exposure
• Order of presentation relates to penetrance and access to receptors
• 1st - Miosis (very sensitive), decreased vision • 2nd - Rhinorrhea, salivation • 3rd - Bronchorrhea, bronchoconstriction • 4th - All others - N/V/D, cardiac, musculoskeletal, CNS • MSK effects include fasciculations leading to twitching
and finally flaccid paralysis; similar to seizure presentation
• DEATH IS FROM RESPIRATORY COMPLICATIONS • Newmark, 2004; Hoffman et al., 2007
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Signs and Symptoms of Liquid Exposure
• Order of presentation relates to penetrance and access to receptors
• Presentation can be much more subtle • 1st - Localized sweating • 2nd - Localized fasciculations • 3rd - Everything else • Last - Miosis
• Newmark, 2004
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Differential Diagnosis • Nerve Agent • Miosis • Increased secretions • Normal color skin • No AG acidosis
• Newmark, 2004; Newmark, 2004
• Cyanide • No miosis • Normal secretions • “Cherry-red” skin • AG acidosis
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Prehospital Considerations
• Decontamination is important • Clothing can trap vapors and patient can
continue to offgas • Soap and water decon is appropriate • If time permits, use a commercially
available kit
• Tokuda et al., 2006; Rotenberg & Newmark, 2003
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Treatment
• Patients exposed to vapors either die or recover quickly with appropriate therapy
• 1. Supportive care, especially respiratory • 2. Anticholinergic therapy • 3. Oxime therapy • 4. Anticonvulsant therapy
• Cannard, 2006; Hoffman et al., 2007; Newmark, 2007
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Anticholinergic
• Atropine - anticholinergic agent • Competes with acetylcholine for
muscarinic receptors • Does not interact with nicotinic receptors • Mainly used for its drying effects • Adult starting dose is 2mg • Pediatric starting dose is 0.25-1mg • Cannard, 2006; White et al., 2004; Hoffman et al., 2007
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How much atropine?
• Use as much atropine as needed to “dry” the respiratory system
• The patient should be able to breath easily • Autoinjectors usually start with 2.1mg
atropine • Redose as needed every five minutes • Usually 15-20mg will be the maximum • Newmark, 2004
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Oxime Therapy
• Oximes react with the NA-AChE moiety
• The nerve agent is cleaved and released as two harmless compounds
• The goal is restoration of catalytic activity
• Effective and nicotinic and muscarinic sites
• Hoffman et al., 2007; Newmark, 2004; Rotenberg & Newmark, 2003
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Oxime Therapy • 2-Pralidoxime Chloride (2-PAM or 2-PAMCl) • Autoinjectors available with combined
atropine dosing • Usual starting dose is 600mg • Try to limit dosing to three doses • Time is of the essence • If HTN occurs from 2PAM use, use
phentolamine • Hoffman et al., 2007; Hoffman et al., 2007; Newmark, 2004
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Aging • The NA-AChE moiety loses a side chain in a
process called aging • Once the side chain is lost, oximes are no longer
effective • VX - half-life is 22 days • GA - 13-14 hours • GB - Three to four hours • GD - Two minutes • Regeneration of enzyme can take weeks • Newmark, 2004
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Anticonvulsant • Seizures and status epilepticus can occur
from nerve agents poisoning • Diazepam or lorazepam are approved for
use in SE • Diazepam autoinjectors carry 10mg • May need to repeat doses three or four
times • Midazolam is the best agent but not FDA
approved • Newmark, 2004; White et al., 2004
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DuoDote
• Autoinjector from Meridian Medical Technologies
• Available to the military and first responders
• One needle and one injection provides 2.1mg of atropine and 600mg of 2PAM
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Long-term Outcome
• Most patients who are treated quickly and appropriately recover quickly and fully without any long-term complications
• Hypoxic encephalopathy • Neurobehavioral syndrome - PTSD
• Rotenberg & Newmark, 2003; Newmark, 2004
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Prophylaxis
• Some experts argue that pyridostigmine can be administered prophylactically when nerve agent exposure is expected
• Reversible AChE binding can prevent NA binding
• Available for use by military • 30mg every eight hours
• Tokuda et al., 2006; Newmark, 2004
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Treatment Summary
Minimal symptoms – observation or one DuoDote kit Severe symptoms – Three DuoDote kits, intubate, diazepam
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What if I don’t remember?
• There’s an app for that • http://disaster.nlm.nih.gov/ • http://www.start.umd.edu/gtd/
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Summary
• Nerve agents are extraordinarily dangerous
• There is still a substantial stockpile in various parts of the world
• Immediate therapy is crucial and can mean the difference between life and death
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References • Cannard, K. (2006). The acute treatment of nerve agent exposure. Journal of the neurological sciences, 249(1),
86-94. • Hoffman, R. S., Nelson, L. S., Howland, M. A., Lewin, N. A., Flomenbaum, N. E., & Goldfrank, L. R. (2007).
Chapter 109. Insecticides: Organic phosphorous compounds and carbamates. In R. S. Hoffman, L. S. Nelson, M. A. Howland, N. A. Lewin, N. E. Flomenbaum, & L. R. Goldfrank (Eds.), Goldfrank’s manual of toxicologic emergencies. Columbus, OH: McGraw-Hill.
• Hoffman, R. S., Nelson, L. S., Howland, M. A., Lewin, N. A., Flomenbaum, N. E., & Goldfrank, L. R. (2007). Chapter 126. Chemical weapons. In R. S. Hoffman, L. S. Nelson, M. A. Howland, N. A. Lewin, N. E. Flomenbaum, & L. R. Goldfrank (Eds.), Goldfrank’s manual of toxicologic emergencies. Columbus, OH: McGraw-Hill.
• Newmark, J. (2004). Nerve agents: pathophysiology and treatment of poisoning. Seminars in neurology, 24(2), 185-196.
• Newmark, J. (2004). Therapy for nerve agent poisoning. Archives of neurology, 61(5), 649-652. • Newmark, J. (2007). Nerve agents. The Neurologist, 13(1), 20-32. • Organisation for the Prohibition of Chemical Weapons. (2015, May). Report of the OPCW on the
implementation of the convention on the prohibition of the development, production, stockpiling, and use of chemical weapons and on their destruction (C-14/4). The Hague, Netherlands: Author.
• Rotenberg, J. S., & Newmark, J. (2003). Nerve agent attacks on children: diagnosis and management. Pediatrics, 112(3), 648-658.
• Tokuda, Y., Kikuchi, M., Takahashi, O., & Stein, G. D. (2006). Prehospital management of sarin nerve gas terrorism in urban settings: 10 years of progress after the tokyo subway sarin attack. Resuscitation, 68(2), 193-202.
• White, S. R., Eitzen, E. M., & Klein, K. R. (2004). Chapter 185. Toxicology of hazardous chemicals. In J. E. Tintinalli, G. D. Kelen, J. S. Stapczynski, O. J. Ma, & D. M. Cline (Eds.), Emergency medicine: a comprehensive study guide, 6e. Columbus, OH: McGraw-Hill.
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EMS Medicine Live May 2015
Questions?
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EMS Medicine Live May 2015
Next Conference June 30th, 1 PM Eastern Christian Martin-Gill, MD
UPMC EMS Physician Assistant Professor of Emergency Medicine Associate Program Director of EMS Fellowship Associate Medical Director, UPMC Prehospital Care Associate Medical Director, STAT MedEvac Flight Physiology