Use of Auto-InjectorsUse of Auto-Injectorsby Civilian Emergency by Civilian Emergency Medical Personnel Medical Personnel to Treat Civiliansto Treat CiviliansExposed to Nerve AgentExposed to Nerve Agent©©

© 1997 Lockheed Martin Energy Research Corporation

Learning ObjectivesLearning Objectives

Identify the antidotes to be administered in Identify the antidotes to be administered in event of nerve agent exposureevent of nerve agent exposure

Identify the conditions under which antidote Identify the conditions under which antidote auto-injectors should be usedauto-injectors should be used

Demonstrate use of antidote auto-injectorsDemonstrate use of antidote auto-injectors Recognize adverse reactions to use of Recognize adverse reactions to use of

antidotesantidotes

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IMPORTANT!IMPORTANT!

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

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Auto-InjectorsAuto-Injectors

Simple, compact injection systems Simple, compact injection systems Permit rapid injection of required antidotes Permit rapid injection of required antidotes Prevent needle from being subject to cross-Prevent needle from being subject to cross-

contaminationcontamination Enable rapid and accurate administration Enable rapid and accurate administration

even if care giver or patient is in protective even if care giver or patient is in protective clothing clothing

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Auto-InjectorsAuto-Injectors

Auto-injectors facilitate timely treatment by Auto-injectors facilitate timely treatment by providing providing

Simple, accurate, rapid drug administration Simple, accurate, rapid drug administration Pre-measured, controlled dose Pre-measured, controlled dose No vials, ampules or syringes to manipulate No vials, ampules or syringes to manipulate Fully automatic operation Fully automatic operation Rugged constructionRugged construction

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Auto-InjectorsAuto-Injectors

Contain pre-measured doses of nerve agent Contain pre-measured doses of nerve agent antidotes atropine and 2-PAM chloride antidotes atropine and 2-PAM chloride (2-PAM Cl, pralidoxime chloride or (2-PAM Cl, pralidoxime chloride or PROTOPAMPROTOPAM®® CHLORIDE) CHLORIDE)

FDA-approved and commercially available FDA-approved and commercially available for use by civilian emergency medical for use by civilian emergency medical personnel in the event of an accidental personnel in the event of an accidental release of nerve agent or organophosphorus release of nerve agent or organophosphorus insecticides insecticides

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States decide if they will use themStates decide if they will use them One U. S.-based manufacturer: Survival One U. S.-based manufacturer: Survival

Technology Inc. (STI)Technology Inc. (STI)

Auto-InjectorsAuto-Injectors

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Who Can Use Who Can Use Auto-InjectorsAuto-Injectors

Concern about administration of Concern about administration of inappropriate and harmful doses inappropriate and harmful doses during emergency situationsduring emergency situations

• Pre-measured doses in auto-injectors safe for civilians Pre-measured doses in auto-injectors safe for civilians meeting profile of military personnelmeeting profile of military personnel

– approximate ages of 18–35approximate ages of 18–35

– weight at least 70 kg or 154 pounds weight at least 70 kg or 154 pounds

– healthy with no compromising medical conditionshealthy with no compromising medical conditions

Age, sex, weight and health of all other Age, sex, weight and health of all other patients must first be considered when patients must first be considered when determining amount of atropine and determining amount of atropine and 2-PAM Cl to administer 2-PAM Cl to administer

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Who Can Use Auto-InjectorsWho Can Use Auto-Injectors

Only qualified civilian emergency responders Only qualified civilian emergency responders with adequate training in on-site recognition with adequate training in on-site recognition and treatment of nerve agent intoxication in and treatment of nerve agent intoxication in the event of an accidental releasethe event of an accidental release

Majority of CSEPP States follow DOT national Majority of CSEPP States follow DOT national curriculum for Emergency Medical Technicianscurriculum for Emergency Medical Technicians

• Curriculum generally restricts training on use of IVs to Curriculum generally restricts training on use of IVs to Intermediate Emergency Medical Technicians and Intermediate Emergency Medical Technicians and paramedicsparamedics

Review of each state’s laws and regulations Review of each state’s laws and regulations needed to determine appropriate use of auto-needed to determine appropriate use of auto-injectorsinjectors

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When To Use Auto-InjectorsWhen To Use Auto-Injectors

Use only after following events have occurred:Use only after following events have occurred: Emergency medical personnel have donned Emergency medical personnel have donned

personal protective equipment subsequent to personal protective equipment subsequent to recognizing existence of chemical agent recognizing existence of chemical agent hazard in areahazard in area

Some or all of symptoms of nerve agent Some or all of symptoms of nerve agent poisoning cited are presentpoisoning cited are present

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Signs and Symptoms of Nerve Signs and Symptoms of Nerve Agent ExposureAgent Exposure

MILD MILD headacheheadache blurred vision from pinpoint pupils (miosis)blurred vision from pinpoint pupils (miosis) tight chest (smooth muscle constrictions)tight chest (smooth muscle constrictions) excessive sweatingexcessive sweating tearing (lacrimation)tearing (lacrimation) salivationsalivation unexplained runny noseunexplained runny nose

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

VERY SEVERE VERY SEVERE bluish discolorationbluish discoloration of skin (cyanosis)of skin (cyanosis) respiratory failurerespiratory failure comacoma unconsciousunconscious convulsionsconvulsions

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Cinetel Productions

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

Depending on severity of symptoms, Depending on severity of symptoms, immediately administer 1 atropine auto-immediately administer 1 atropine auto-injector, followed by 1 2-PAM Cl auto-injector injector, followed by 1 2-PAM Cl auto-injector

• Atropine should be given first, followed immediately by Atropine should be given first, followed immediately by 2-PAM Cl 2-PAM Cl

If nerve agent signs and symptoms are still If nerve agent signs and symptoms are still present after 5–10 minutes, repeat injections present after 5–10 minutes, repeat injections

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If signs and symptoms still exist after If signs and symptoms still exist after additional 10 minutes, repeat injections for additional 10 minutes, repeat injections for third time third time

If signs and symptoms remain after third set If signs and symptoms remain after third set of injections, of injections, do notdo not give any more antidotes give any more antidotes but seek immediate medical helpbut seek immediate medical help

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

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If severe signs and symptoms are present:If severe signs and symptoms are present: In case of very severe exposure, all three auto-In case of very severe exposure, all three auto-

injector kits (atropine and 2-PAM Cl) should be injector kits (atropine and 2-PAM Cl) should be administered in rapid succession; then medical help administered in rapid succession; then medical help should be soughtshould be sought

Remove secretions, maintain patient’s airway and, Remove secretions, maintain patient’s airway and,

if necessary, use artificial ventilation if necessary, use artificial ventilation 2-PAM Cl is most effective if administered 2-PAM Cl is most effective if administered

immediately after poisoning. Generally, little is immediately after poisoning. Generally, little is accomplished if drug is given more than 6 hours accomplished if drug is given more than 6 hours after termination of exposureafter termination of exposure

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

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Directions for UseDirections for Use

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1. Remove safety cap (yellow on 1. Remove safety cap (yellow on

atropine; gray on 2-PAM Cl).atropine; gray on 2-PAM Cl).

Mark I kit clip holds the safetyMark I kit clip holds the safety

caps; may not notice if using caps; may not notice if using

Mark I kits. Do not touch coloredMark I kits. Do not touch colored

end of injector after removingend of injector after removing

cap; injector can and will functioncap; injector can and will function

into fingers or hand if any pressure appliedinto fingers or hand if any pressure applied

to this end of injector to this end of injector

Directions for UseDirections for Use

2. Hold injector like a pen. Place 2. Hold injector like a pen. Place

colored end (green on colored end (green on

atropine, black on atropine, black on

2-PAM Cl) on 2-PAM Cl) on

thickest part of thigh and thickest part of thigh and

press hard until injector press hard until injector

functions functions •Pressure automatically activates the Pressure automatically activates the

spring, plunges the needle into the spring, plunges the needle into the

muscle and simultaneously forces muscle and simultaneously forces

fluid through it into the muscle tissuesfluid through it into the muscle tissues AI 16©

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

Directions for UseDirections for Use

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4. After auto-injector has been activated, 4. After auto-injector has been activated,

empty container should be disposed ofempty container should be disposed of

properly properly •It cannot be refilled nor can the protruding It cannot be refilled nor can the protruding

needle be retracted needle be retracted

•It should be disposed of in a “sharps” container It should be disposed of in a “sharps” container

per rules for handling medical wastes and possible per rules for handling medical wastes and possible

blood-borne pathogens blood-borne pathogens

Note dosage on triage tag or write on Note dosage on triage tag or write on

chest or forehead of patientchest or forehead of patient

Directions for UseDirections for Use

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

Directions for UseDirections for Use

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PrecautionsPrecautions

Place any patient receiving atropine under Place any patient receiving atropine under medical observation for at least 24 hours medical observation for at least 24 hours

If atropine is used to treat infants, smaller If atropine is used to treat infants, smaller amounts should be givenamounts should be given

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Adverse ReactionsAdverse Reactions

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

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2-PAM Cl in a normal person may cause: 2-PAM Cl in a normal person may cause: • blurred vision • double vision (diplopia) blurred vision • double vision (diplopia)

• impaired accommodation • dizzinessimpaired accommodation • dizziness

• headache • drowsiness headache • drowsiness

• nausea • rapid heart rate (tachycardia) nausea • rapid heart rate (tachycardia)

• increased systolic and • hyperventilationincreased systolic and • hyperventilation

diastolic blood pressure diastolic blood pressure

Adverse ReactionsAdverse Reactions

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

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OverdosageOverdosage

If excessive atropine is administered to a If excessive atropine is administered to a normal person: normal person:

Signs of atropinization will become even Signs of atropinization will become even more severe and patient may also developmore severe and patient may also develop

• blurring of visionblurring of vision

• deliriumdelirium

• urinary retentionurinary retention

When signs and symptoms of atropinization When signs and symptoms of atropinization develop, no more atropine should be injected develop, no more atropine should be injected until atropinization subsides until atropinization subsides

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In case of 2-PAM Cl:In case of 2-PAM Cl: Observed in normal subjects only Observed in normal subjects only

• dizzinessdizziness

• blurred visionblurred vision

• double vision (diplopia)double vision (diplopia)

• headacheheadache

• impaired accommodation impaired accommodation

• nauseanausea

• slightly rapid heart rate (tachycardia) slightly rapid heart rate (tachycardia)

Artificial respiration and other supportive Artificial respiration and other supportive therapy should be administered as neededtherapy should be administered as needed

OverdosageOverdosage

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Caring For Auto-Injector SuppliesCaring For Auto-Injector Supplies

Auto-injectors have a five-year shelf life, Auto-injectors have a five-year shelf life, making them suitable for storage in making them suitable for storage in emergency stockpiles emergency stockpiles

Store auto-injectors at room temperature Store auto-injectors at room temperature (approximately 25°C, 77°F)(approximately 25°C, 77°F)

Keep them from freezingKeep them from freezing May

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Caring For Auto-Injector SuppliesCaring For Auto-Injector Supplies

Antidotes will freeze at temperatures below Antidotes will freeze at temperatures below 29F29F

Do not carry auto-injectors in external pocket Do not carry auto-injectors in external pocket of BDO when temperature below freezing. of BDO when temperature below freezing. Place in inner pocket where body heat will Place in inner pocket where body heat will keep them warmkeep them warm

Tie string to auto-injector and thread through Tie string to auto-injector and thread through outer layers of clothing to outside pocket or outer layers of clothing to outside pocket or belt. Extract auto-injector by pulling the belt. Extract auto-injector by pulling the string when neededstring when needed

Frozen auto-injectors still usable after being Frozen auto-injectors still usable after being thawed if they do not appear broken or thawed if they do not appear broken or crackedcracked

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