(Attachment 9 of HOT Area Chempack SOG) Subject:
Nerve Agent / Organophosphate Antidote Administration Recommendations Purpose:
Provide medical guidance to physicians providing delegated authority for any local jurisdiction receiving the
CHEMPACK. The treatments outlined within this document are considered the standards for administration of these medications and are based on best practice recommendations from the United States Army Medical Research Institute for Chemical Defense.
Authority:
This document does not constitute or represent any authorization for distribution or administration of any medication or medical procedure. It is the responsibility of the local medical authority to determine and authorize the appropriate application, dosing, and management for patients exposed to nerve agents / organophosphates.
Definitions:
The nerve agents – Tabun (GA), Sarin (GB), Soman (GD), GF, and VX – are considered primary agents of threat because of their high toxicity and effectiveness through multiple routes of entry. Routes of exposure include the gastrointestinal tract, eyes, respiratory tract, and skin. Nerve agents are chemically similar to organophosphate pesticides, but are intended to be much more potent.
Organophosphates – insecticides/pesticides – pose equal threat through both common use (accessibility) and ease of accidental exposure through the multiple routes of exposure, as described above.
The main principles of therapy for nerve agent poisoning are early treatment, assisted ventilation, bronchial suction, muscarinic cholinergic blockade (atropine), enzyme reactivation (pralidoxime chloride), anticonvulsants (diazepam), and bronchodilation (albuterol/atrovent – not included in the CHEMPACK).
Medications are delivered in various forms including Auto-injectors (automatic, spring activated syringes containing a predetermined medication) for expedient intramuscular (IM) administration and multi-dose vials for less expedient administration intramuscularly (IM) or intravenously (IV).
The terms, “Nerve Agent Antidote Kit”, “NAAK” and “Mark I" are used interchangeably and contain adult dosing of atropine and pralidoxime (2-PAM).
The terms “pralidoxime chloride” and “2-PAM” are used interchangeably.
Indications:
The most effective care that patients can receive is that care given within the first few minutes following their exposure to nerve agent or organophosphate pesticide.
The CHEMPACK can be used by medical personnel as additional antidote in the case of exposure to nerve agent or organophosphate pesticide.
Reference:
U.S. Army Medical Research Institute of Chemical Defense (2000) Medical Management of Chemical Casualties Handbook. Third Ed. Chemical Casualty Care Division: Aberdeen Proving Grounds.
Procedure:
Upon recognition that nerve agent or organophosphate pesticide exposure has occurred and symptoms of exposure are present, personnel should administer antidotes using the following weight based recommended guidelines.
5. Patients >90 lbs.
6. Mild Exposure for Patients >90 lbs. – Pinpoint Pupils (Dim Vision) No antidote administration
Advise patient to monitor for progression of other obvious signs and symptoms
7. Moderate Exposure for Patients >90 lbs. – Pinpoint Pupils (Dim of Vision), Nasal Discharge, Mild SOB, Nausea or Vomiting, or Tremors
2mg Atropine IM or IV and 600mg Pralidoxime Chloride IM or IV
Atropine 2mg IM (Syringe or AtroPen auto-injector) or IV (Syringe), immediately followed by Pralidoxime Chloride 600mg IM (Syringe or ComboPen auto injector) or IV (Syringe)
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
8. Severe Exposure for Patients >90 lbs. – Severe SOB, Apneic, Unconscious, or Convulsions 6mg Atropine IM or IV, 1800mg Pralidoxime Chloride IM or IV, and 10mg Diazepam IM or IV EITHER:
Atropine 6mg IM or IV (Syringe), immediately followed by Pralidoxime Chloride 1800mg IM or IV (Syringe)
OR 3 NAAKs:
Atropine 2mg IM by AtroPen auto-injector, immediately followed by
Pralidoxime Chloride 600mg IM by ComboPen auto injector, immediately followed by;
Atropine 2mg IM by AtroPen auto-injector, immediately followed by
Pralidoxime Chloride 600mg IM by ComboPen auto injector, immediately followed by;
Atropine 2mg IM by AtroPen auto-injector, immediately followed by Pralidoxime Chloride 600mg IM by ComboPen auto injector
AND:
Diazepam 2-10mg IM (Syringe or 10mg auto injector) or IV (Syringe)
Repeat Atropine 2mg IM (Syringe or AtroPen auto-injector) or IV (Syringe) PRN until SOB relieved and drying of secretions.
Repeat Prolidoxime Chloride is not necessary until approximately 1 hour after initial dosing. The same dosing regimen is appropriate. Re-dosing should not occur until atropinization has occurred.
Repeat Diazepam 2-10mg IM (Syringe or 10mg auto-injector) or IV (Syringe) PRN until convulsions cease.
Seizures in the absence of other muscarinic and/or nicotinic effects of nerve agents / organophosphates require further investigation for cause.
Monitor patient for return of signs and symptoms. Always assure the safety of the medical team and the patient by consideration of routes of exposures and potential for missed agent / substance in decontamination.
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
Patients ≥40 and ≤90 lbs.
9. Mild Exposure for Patients ≥40 and ≤90 lbs. – Pinpoint Pupils (Dim Vision) No antidote administration.
Advise patient to monitor for progression of obvious signs & symptoms
10. Moderate Exposure for Patients ≥40 and ≤90 lbs. – Pinpoint Pupils (Dim of Vision), Nasal Discharge, Mild SOB, Nausea or Vomiting, or Tremors
Dose with 1mg Atropine IM or IV
Atropine 1mg IM (Syringe or 1mg AtroPen auto-injector) or 1mg IV (Syringe)
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
HOTRAC Regional Healthcare System Plan
September 2013 Page 136
Patients ≥40 and ≤90 lbs. (Continued)
11. Severe Exposure for Patients ≥40 and ≤90 lbs. – Severe SOB, Apneic, Unconscious, or Convulsions Dose with 3mg Atropine IM or IV and 2-10mg Diazepam IM or IV
EITHER:
Atropine 3mg IM or IV (Syringe) OR 3 Atropen 1mg IM Injections:
Atropine 1mg IM by AtroPen auto-injector, immediately followed by Atropine 1mg IM by AtroPen auto-injector, immediately followed by Atropine 1mg IM by AtroPen auto-injector
AND:
Diazepam 2-10mg IM (Syringe or 10mg auto injector) or IV (Syringe) Pralidoxime Chloride is not recommended in pediatric patients.
Repeat Atropine 2mg IM (Syringe or AtroPen auto-injector) or IV (Syringe) PRN until SOB relieved and drying of secretions.
Repeat Diazepam 2-10mg IM (Syringe or 10mg auto-injector) or IV (Syringe) PRN until convulsions cease.
Seizures in the absence of other muscarinic and/or nicotinic effects of nerve agents / organophosphates require further investigation for cause.
Monitor patient for return of signs and symptoms. Always assure the safety of the medical team and the patient by consideration of routes of exposures and potential for missed agent / substance in decontamination.
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
12. Patients <40 lbs.
13. Mild Exposure for Patients <40 lbs. – Pinpoint Pupils (Dim Vision) No antidote administration
Advise patient to monitor for progression of other obvious signs and symptoms
14. Moderate Exposure for Patients <40 lbs. – Pinpoint Pupils (Dim of Vision), Nasal Discharge, Mild SOB, Nausea or Vomiting, or Tremors
Dose with 0.5mg Atropine IM or IV
Atropine 2mg IM (1 AtroPen auto-injector)
Pinpoint pupils (dim vision) may be persistent after other symptoms have been resolved.
15. Severe Exposure for Patients <40 lbs. – Severe SOB, Apneic, Unconscious, or Convulsions Dose with 1.5mg Atropine IM or IV and 2-10mg Diazepam IM or IV
EITHER:
Atropine 1.5mg IM or IV (Syringe) OR 3 Atropen 0.5mg IM injections:
Atropine 0.5mg IM by AtroPen auto-injector, immediately followed by Atropine 0.5mg IM by AtroPen auto-injector, immediately followed by Atropine 0.5mg IM by AtroPen auto-injector
AND:
Diazepam 0.5-10mg IM (Syringe or 10mg auto injector) or IV (Syringe) Pralidoxime Chloride is not recommended in pediatric patients.
Auto-injectors are not recommended for patients under 15 lbs.
16. Patients <40 lbs. (Continued)
Repeat Atropine 0.5mg IM (Syringe or AtroPen auto-injector) or IV (Syringe) PRN until SOB relieved and drying of secretions.
Repeat Diazepam 0.5-10mg IM (Syringe or 10mg auto-injector) or IV (Syringe) PRN until convulsions cease.
Seizures in the absence of other muscarinic and/or nicotinic effects of nerve agents / organophosphates require further investigation for cause.
Monitor patient for return of signs and symptoms. Always assure the safety of the medical team and the patient by consideration of routes of exposures and potential for missed agent / substance in decontamination.
Pinpoint pupils (dim vision) may be persistent after life-threatening conditions have been resolved.
In children with cholinergic poisoning, a loading dose of pralidoxime (20-40 mg/kg IV over 30-60 min) followed by an infusion of 10-20 mg/kg/h is often recommended (Goldfrank's Toxicologic Emergencies 8th ed 2006, p. 1515).