Case Presentation

1
Case Presentation 17

• Jim Pointer, MD
• Alameda County EMS
• Medical Director

2
The Call

• You respond to a 9-1-1 call to the City Center
  BART Station. The complaint is chemical
  exposure
• You don the appropriate protective gear. You and
  several other medics descend the stairs to the
  station

3
Havoc Reigns

• Hundreds of people are running and screaming
  help or Im dying
• As you reach the platform, you notice that your
  boots stick to the concrete. Many patrons stop
  to take off their shoes so they can escape

4
The Scene

• A train sits in the station, doors open, alarm
  sounding. A car is littered with 20-30 bodies.
• A number of individuals are choking, gasping for
  air.
• Others are vomiting, unconscious, or seizing

5
The Scene (cont.)

• Because you are wearing SCBA gear, you cannot
  perceive smells, but a victim runs by and yells
  Its cyanide it smells like sulfur!
• Several unprotected civilian rescuers fall to the
  ground

6
The Patients

• Decontaminated viable patients are relocated to a
  secure location.

7
Typical Patient

• START is performed.
• This patient is a typical red victim
• 40-ish male in a business suit, short of breath,
  vomiting, and profusely sweating
• Vital signs B/P - 152/94, RR 42, HR 124
• Airway open, breathing labored with profuse
  airway secretions

8
Secondary Exam

• HEENT pupils pinpoint, rhinorrhea, increased
  saliva pharyngeal secretions, slight sulfur
  smell on breath
• Lungs shallow, tight respirations with wheezes
• Abdomen Mild tenderness throughout, vomiting
  present
• Extremities weakness, fasciculations and
  intermittent twitching
• Neuro GCS - 12

9
What is it?

• What type of agent is involved?
• Specifically, what is the agent?
• What is the treatment?

Nerve Gas
VX
Atropine and 2-PAM
10
Nerve Agent Exposure

• Tokyo subway incident March 1995
• 12 dead
• 1000 hospitalized
• 5500 sought medical care
• 132 first responders injured
• Hours passed before a diagnosis was made

11
Nerve Agents
12
Nerve AgentsAging Times and Lethalities
13
Pretreatment

• Pyridostigmine bromide
• Pretreatement for Soman (GD) exposure only
• One 30 mg tablet q 8 hrs x 7 days
• Mark I therapy must also be given
• Ineffective for GB or VX
• Not enough data for GA or GF

14
Iraq Denies Nerve Gas SaleWASHINGTON, Dec. 12,
2002 (CBS) A senior Iraqi general Thursday
dismissed as "ridiculous" a published report that
Iraq may have provided nerve gas to Islamic
extremists affiliated with al Qaeda. "This is
really a ridiculous assumption from the American
administration," Lt. Gen. Hossam Mohammed Amin
told a press conference. "They know very well we
have no prohibited substances." Administration
officials also tried to play down the report in
The Washington Post that U.S. intelligence had
received credible reports of a transfer of
chemical weapons possibly VX nerve gas to an
extremist group in the past month. A senior
administration official, commenting on the Post
report, told The Associated Press that U.S.
intelligence had uncorroborated information that
Islamic extremists with ties to al Qaeda may have
received a poisonous substance. The official,
speaking on condition of anonymity, said the U.S.
does not know whether the material was nerve gas
nor whether the extremists are linked to Saddam's
government.
Administration officials told The Post the
source of the material was still unknown, and
that it was uncertain the deal involved nerve
gas. One official told the newspaper the report
could be a mere hypothesis.
But Defense Secretary Donald Rumsfeld said the
possibility of such a sale "should come as no
surprise to anybody."
15
VX

• Developed by a British scientist in the 1950s
• May have been used by Hussein in the Iran -
  Iraq war (1980-88) and in
  attack on Kurdish town of
  Halabja
• Popularized in the movie,
  The Rock

16
VX (cont.)

• Most toxic of the nerve agents. LD50 is as
  little as 10 mg.
• Normally in liquid state with a slight sulfur
  small with the consistency of motor oil
• Special, adhesive form has been developed
• Gas form is available

17
VX (cont.)

• Characteristics
• Boiling point 298? C
• Specific Gravity 1.0113
• Freezing point - 50? C
• Density 1.0083 g/ml
• Persistent (does not evaporate)

18
VX (cont.)

• U.S., France, and Russia have admitted to
  stockpiles
• (British destroyed its supply)
• Accidental release killed thousands of sheep in
  Utah (1968)
• Syria and Iraq probably have the agent

19
VX (cont.)

• Could be deployed by detonating a container of
  gas over a target area
• Synthesis is extremely complicated and dangerous
• A VX attack would probably precipitate a nuclear
  retaliation.

20
Normal Nerve Function
ACh
21
Normal Nerve Function
ACh
22
Normal Nerve Function
AChE
ACh
23
How Nerve Agents Work
AChE
GB
ACh
24
Effects of Nerve Agents

• Hyperstimulation of organs of the cholinergic
  nervous system
• Muscarinic
• Smooth muscles
• Glands
• Nicotinic
• Skeletal muscles
• Ganglions

25
Muscarinic Sites

• Increase secretions
• Saliva
• Tears
• Runny nose (rhinorrhea)
• Secretions in airways and gastrointestinal tract
• Sweating

26
Muscarinic Sites (cont.)

• Smooth Muscle Contraction
• Eyes
• small pupils ? dim vision
• Airway
• narrowing ? shortness of breath
• Intestines
• Hyperactivity ? nausea, vomiting, diarrhea

27
Pupil Response
28
Nicotinic Site

• Skeletal muscles
• Fasciculations
• Twitching
• Weakness
• Flaccid paralysis
• Ganglion
• Tachycardia
• Hypertension

29
Central Nervous System Effects

• Acute
• Loss of consciousness
• Convulsions
• Apnea
• Prolonged 4 to 6 weeks
• Psychological effects

30
Mneumonic forNerve Agent Exposure
31
and another
S alivation
32
Vapor Exposure

• Vapor effects occur within seconds, peak within
  minutes
• Low Exposure
• Miosis (dim vision, eye pain)
• Rhinorrhea
• Shortness of breath
• High Exposure
• Immediate loss of consciousness, seizures, apnea,
  flaccid paralysis

33
Treatment

• Self-protection
• Decontamination
• Airway/ventilation
• Antidotes
• Atropine
• 2-PAM
• Diazepam

34
Atropine

• Antagonizes muscarinic effects
• Dries secretion, relaxes smooth muscles
• May give IV, IM, ET
• Does not effect fasciculations, muscle strength
• Will not reverse miosis
• May cause cardiac arrhythmias (v-fib) if
  given IV in hypoxic patient

35
Atropine (cont.)

• How much to give?
• Until secretions are drying or dry
• Until ventilation is easy
• If conscious and victim is comfortable
• Dont rely on heart rate or pupil size.

36
Pralidoxime Chloride (2-PAM)

• Removes nerve agent from AChE in absence of aging
  
• 2-PAM crowbar
• Does not reverse muscarinic effects on glands or
  smooth muscles
• Helps at nicotinic sites

37
Personal Protective Equipment

• Respiratory protective equipment
• NIOSH, MSUA approved pressure demand, full-face
  piece SCBA with protective ensemble
• Gloves
• Butyl rubber gloves MS M4 Nortan Protective set
• Eye Protection
• Chemical goggles minimum
• Goggles and face shield for splash hazard

38
Auto Injectors
Mark-1 Auto-injector Contains Atropine 2mg and
2-PAM 600 mg given IM
39
Potential Exposure (no signs or symptoms)

• Reassure
• Segregate in cold zone
• Observe
• Arrange transport by bus or vans

40
Dosing with Autoinjector
41
Policy 7150

• Dosing for
• Atropine,
• 2-PAM
• Diazepam