Title: FIELD MEDICAL MANAGEMENT OF THE NBC CONTAMINATED PATIENT 848TH FST
1FIELD MEDICAL MANAGEMENT OF THE NBC CONTAMINATED
PATIENT848TH FST
2Introduction
- PATIENT MANAGEMENT IN THE NBC ENVIRONMENT
3Background Information
- U.S. medical personnel no chemical or biological
patients since World War I
- Saddam Hussein used mustard on the Kurds in
northern Iraq during the 1987-88 campaign
- In March 1988, 5000 Kurds died and 65,000 were
left injured
- Experts say Saddam has launched approx 280
mustard attacks against the people of Iraq
4Background Information
- Greatest nonmilitary use of NBC was in Japan in
March 1995
- 5500 people in subway infected by Saran (nerve
agent)
- 20 or 1100 people hospitalized
- 12 people died
5Military Chemical Agents
- Types persistent vs. nonpersistent
- Persistent agents have a low volatility
(evaporate slowly)
- Stay for days, weeks or months (dependent upon
weather)
- Examples mustard or some nerve agents (nerve
agent VX)
- Nonpersistent agents have a high volatility
(evaporate quickly)
- Stay for minutes to hours
- Ex. phosgene, cyanide, nerve agent G series
6Military Biological Agents
- Types replicating or nonreplicating
- Utility is limited by ease of production,
stability, infectivity or toxicity
- Bacillus Anthracis is considered best bacterial
agent, because stability of spores and ease of
production
- Venezuelan Equine Encephalitis one to 100
organisms will cause full infection in humans
- Staphylococcal Enterotoxins/ Botulism organisms
are 1000x to 10,000x more toxic per unit than
chemical agents
7Detection and Protection
- M8 Paper developed in 1978 to detect presence
of chemical agents
- Paper turns blue for some nerve agents
- Yellow for nerve G-agents
- Red for mustard
8Detection and Protection
- M9 Paper Strips developed in 1980
- Paper turns red with any known liquid chemical
agent
9Detection and Protection
- M40 Chemical Mask Protects against chemical
agents, toxins, smoke and radioactive fallout
particles
10Detection and Protection
- M1 Chemical Agent Monitor (CAM) developed in
1988
- Detects chemical agent vapors
- Must hold over source for 30 seconds to attain an
accurate reading
11Detection and Protection
- Auto Injection Nerve Agent Antidote Kit (Mark I)
- Only used for nerve agent exposure
- Each soldier is issued
- Three Mark 1 injectors
- One 10 mg diazepam (valium) injector
12Detection and Protection
- Mark 1 Contains Atropine and Prolidoxime (2-Pam
Chloride)
- Atropine (2mg) syringe
- Dosage and treatment is based upon assessment of
respiratory symptoms (see case study)
- Usually 4mg or two Mark I kits are adequate, but
up to 280mg has been necessary for the first 24
hour period
- 2-Pam Chloride (600 mg) syringe re-activates
acetyl cholinesterase enzyme
- Renal excretion with a half life of 1.5 hours
- No recommended dosage
- Some studies recommend 20 mg/ kg
- One syringe would provide a 70kg person with
8.9mg/kg
13Diazepam Injector
- After 3 Mark 1 kits are administered during buddy
aid, one 10mg diazepam injector must be
administered
- Any soldier seizing must be administered one 10mg
diazepam injector. If seizures continue,
administer a 2nd and 3rd autoinjector in 5 minute
intervals
14Environmental Effects on Autoinjectors
- Mark 1 autoinjectors freeze at 30 degrees F
- Keep injectors close to body in freezing
temperature environments
15Nerve Agent Pyridostigmine Pretreatment (NAPP)
- Pyridostigmine Bromide is the pretreatment used
with the nerve agent antidote kit (Mark 1)
- Together, these drugs enhance the soldiers
survivability when exposed to nerve agents
- NAPP contains a blister pack of twenty-one 30mg
tablets of pyridostigmine bromide
- Each kit contains 7 days worth of medication
16NAPP Mechanism of Action
- Protects acetylcholinesterase enzyme from binding
with nerve agent
- Binds to acetylcholinesterase in the same manner
as a nerve agent does
- When exposed to a nerve agent, the pre-tx will
not allow the nerve agent to inhibit the bound
enzyme
- If exposed to a nerve agent, the Mark 1 kit will
still work in the presence of NAPP
17When to take NAPP?
- One tablet should be taken every 8 hours
- The full 21 day supply should be taken, unless
ordered to discontinue
- After 8 hours, the beneficial effect of
pyridostigmine as a pretreatment significantly
diminishes
- It is not recommended taking NAPP longer than 21
consecutive days
18Overdose of NAPP
- Abdominal cramps
- Nausea
- Diarrhea
- Skin rash
19Tx of NAPP Overdose
- Weakness
- Pinpointed pupils
- Overdose resembles a cholinergic crisis
- For an overdose or allergic reaction treat the
patient with 2mg boluses of atropine every 15 to
20 minutes
20Chemical Nerve Agents
- How do they work?
- Acetylcholine is the neurotransmitter between
presynaptic neurons to skeletal muscles,
preganglionic autonomic nervous system and
postganglionic parasympathetic nervous system - Accumulation of Acetylcholine causes excessive
stimulation of muscles (paralysis) and structures
innervated by other neurons
21Chemical Nerve Agents
- Examples Signs Symptoms
- Glands in the mouth are stimulated (salivation)
- Respiratory system (runny nose, bronchospasm,
paralysis of respiratory muscles, pulmonary
edema)
- Gastrointestinal system (n/v)
- Vagus nerve (bradycardia)
- Paralysis of skeletal muscles
- Miosis
- Apnea etc.
22Exposure Routes to Nerve Agents (symptoms almost
immediately)
- Inhalational Exposure
- Low concentrations
- Rhinorrhea
- Miosis (one or both eyes) with or without pain
- Dyspnea
- Moderate concentrations
- All of the above
- Dim vision
- Chest tightness
- Large amount of oral, nasal and bronchial
secretions
- Nausea and vomiting
23Exposure Routes Continued
- Large concentrations
- All of the above
- Loss of consciousness
- Seizures
- Generalized fasciculation
- Apnea
- Paralysis
24Exposure Routes Continued
- Dermal Exposure (symptoms may be delayed up to 18
hours)
- a. symptoms
- Localized sweating at site of contamination
- Underlying fasciculation (may or may not be seen)
- Delayed n/v
- Convulsions (up to 18 hours after exposure)
- All of the symptoms of inhalational exposure (up
to 18 hours from time of exposure)
25Admin of Mark 1 Kit with NO Chemical Exposure
- The following SS will be seen
- Dry skin
- Dry mouth
- Tachycardia
- Dilated pupils
- Urinary retention
- Susceptibility to heat exhaustion/stroke
-
26Medical Treatment for Chemical Nerve Agents
- Vapor exposure to agent initial assessment
(witness initial symptoms)
- Miosis only symptom one Mark I Kit
- Dyspnea and miosis two Mark I Kits
- More severe symptoms three Mark I Kits
- 15 minutes to hours after initial chemical vapor
exposure
- Miosis only symptom no treatment
- Dyspnea (mild) one Mark I Kit
- Severe dyspnea (gasping) two Mark I Kits
- Severe dyspnea, coma, LOC, seizures
- Three Mark I Kits
- Diazepam (valium) for seizures
- No more than two 2-Pam Chloride injectors
initially
27Medical Treatment for Chemical Nerve Agents
- Dermal Exposure (tx is less clear)
- General Rule greater exposure shows quicker
onset of symptoms
- Problem not how to treat, but whether to treat
patient that was exposed and decontaminated.
Symptoms could arrive within 18 hours if
decontamination was not complete - Hair, clothing or a NBC contaminated foreign body
in wound or body cavity could precipitate
symptoms up to 18 hours after initial
decontamination - If symptoms are observed follow inhalational
protocol
- If no symptoms are observed, watch patient for 18
hours for symptoms to develop
28Medical Tx Facility Management of Nerve Agent
- Decontamination precedes medical tx of injuries
- Main principles of therapy for contamination tx
are
- Assisted ventilation (hours or days)
- Cholinergic blockade (atropine) 2mg q 2hrs for at
least 24 hours
- Enzyme reactivation (2 Pam Chloride)
- Anticonvulsant (valium)
- Supportive care (iv fluids, electrolyte
restoration, tx for shock)
29Case Study of a NBC Patient Exposed to SARAN
(nerve agent)
- 52 year old male working in a DOD plant was
exposed to Saran. Patient was in MOPP Level 4,
later found to have a cracked voice meter
diaphragm. He presented in ER with increased
oral and nasal secretions and difficulty
breathing ten minutes after symptoms developed - EKG changes occurred immediately upon
admission. T wave inversion in V4-6 and ST
depression in all leads. ST depression remained
for 2 days post admission. T wave inversion
remained for 2 weeks post admission
30Vesicants Blister Agents
- Mustard
- Introduced in 1917. It has caused more chemical
battlefield injuries than any other agent
- No antidote
- Persistent oily liquid
- At high temperatures (100-120F) mustard will
vaporize and persist for 7 hours
- At cool temperatures (up to 100 hours (4 days)
- Freezing point is 57 degrees Fahrenheit. Cannot
be dispersed by aircraft or in winter conditions
31Vesicants Continued
- Clinical Effects of Exposure
- Eyes
- Tearing
- Burning
- Reddening
- Lid edema
- Corneal damage
- Airway
- Rhinorrhea
- Sneezing
- Epistaxis
- Hoarseness
- Cough (may be productive)
- Dyspnea
32Vesicants Continued
- Skin
- Blisters (1 to 2 hours post exposure)
- Yellow in color
- Severe exposure may resemble 2nd or 3rd degree
burn
- Mustard is absorbed by the skin within 1 to 2
minutes of exposure. It is thought that the
mustard causes direct DNA damage. After blisters
develop the patient is no longer able to transfer
mustard to others
33Vesicants Continued
- Patient management of Mustard contamination
- Decontamination within 1 to 2 minutes of exposure
- Done by buddy aid or by patient
- After 2 minutes post exposure, decontamination of
skin will not prevent blister formation
- Equipment, clothing, hair, etc. will still be
dangerous after 2 minutes
- Treatment
- Goal keep patient comfortable, lesion clean and
prevent infection
- Itching relieved by cortisone cream
- Small lesions (
- Surrounding area should be cleaned once daily
- Topical antibiotic Q8 hrs
- Only bandage if patient is returning to duty
34Vesicants Continued
- Large lesions (1 cm)
- Un-roof the blisters
- Irrigate underlying area with saline Q8h
- Cover area with topical antibiotic ointment
- Eye injury
- Goal prevent infection and scarring
- Irrigate eyes 3-4 times daily with saline
topical antibiotic 4 times daily
- Topical atropine (dilates pupils) Q8h
- Vaseline applied to eyelid edges to prevent
adhesions
- Steroids? Systemic analgesics
35Vesicants Continued
- Airway injury
- Maintain airway/oxygenation
- Hypoxia due to toxic bronchitis
- Treatment with broncho dilators may be necessary
- Underlying airway irritability may be exaggerated
(asthma/ smoker)
- Steroids may be necessary
- Severe pulmonary compromised patients should be
intubated immediately b/c high occurrence of
vocal cord spasm
- 87 of patients requiring intubation died of
further complications
36Small Pox
- 30 fatality rate for unvaccinated people
- Spreads person to person by aerosolization
- Incubation of 12 to 14 days
- Rash first appears on face and arms, then to
trunk and legs
- No antiviral tx for infection
- Vaccination titers last 30 years
- 1 million doses given show 250 people demonstrate
infection
37Small Pox
- Three types of viral infection
- Pustule (90) 30 fatal
- Hemorrhagic (presents as acute leukemia) 100
fatal
- Malignant (presents as severe abdominal pain)
100 fatal
38Triage Treatment of the NBC Patient (Overview)
- Any medical treatment facility in Echelon I or II
should expect chemical contaminated patients who
have been through some form of decontamination
- Entry point is where ambulances enter area
- Triage station
- Immediate medical procedure within one hour or
patient will loose life or limb
- Delayed delay will not affect outcome
- Minimal minimal care is needed and patient is
expected to return to duty
- Expectant treatment will not improve outcome
39Triage Treatment
- Regardless of method used to DECON a patient,
certification of chemical decon is accomplished
by any of the following
- Processing through a decon facility
- M8 paper
- M9 tape
- M256 test kit
- CAM
- Possibility of admitting a chemically
contaminated patient to a field medical treatment
facility(MTF) is extremely low
40Triage Treatment
- Risk of contamination of MTF personnel is as
follows
- Foreign material in wounds of mustard or nerve
agents. Removal of material eliminates risk
- Check wounds with CAM for 30 seconds for chemical
contamination
- Dilution of 0.5 Hypochlorite solution for
surgical decontamination of patient's skin
- Do not irrigate eyes- corneal injury will result
- Irrigation of abdomen will result in severe
adhesion formation
- Irrigation of thoracic cavity is not recommended
- OR personnel should wear 2 pairs of latex gloves
- Gloves are safe for 25 minutes of NBC exposure
- Gloves should be changed at least every 20
minutes
41Triage Treatment
- Wound exploration of chemically contaminated
patient
- Debridement excision of wound should maintain a
"no touch technique"
- Fragments of debris should be discarded
immediately in a container of 5.0 (five)
Hypochlorite
- Check wound for at least 30 seconds with CAM
after debridement for the presence of NBC
contamination
- Bulky tissue (amputations or large amounts of
tissue) should be placed in a chemical proof bag
with 5.0 Hypochlorite solution and sealed
42Triage Treatment
- Suspected non-cavity contaminated wounds should
be irrigated with 0.5 Hypochlorite and then
suctioned. The suctioned liquid will be safe
from NBC contamination after 5 minutes.
Subsequent irrigation with saline - Penetrating abdominal wounds should be irrigated
with saline and then suctioned. The irrigation
should not be swabbed-out of abdomen with
surgical sponges, due to risk of aerosolizing or
splashing contaminated liquids/materials
43Triage Treatment
- Biologically contaminated patient
- Decontamination of biologically contaminated
patients is of lesser concern
- Biological agents are not dermally active
- Decon prevents the secondary infection spread
from potential aerosolization
- Dermal exposure to suspected biological agents
should be treated with soap and water. A brush
should be used to loosen skin surface particles
- The suspected contaminated area should be
irrigated with a 0.5 Hypochlorite solution, with
a contact time of 15 minutes
- Clothing and equipment contaminated with
suspected biological agents should be soaked in
5 Hypochlorite solution for 30 minutes prior to
regular cleaning
44Triage Treatment
- Hypochlorite
- 0.5 solution
- One six ounce container of Calcium Hypochlorite
granules in 5 gallons of water
- 5.0 solution
- eight six ounce containers of Calcium
Hypochlorite granules in 5 gallons of water
45(No Transcript)
46 MOPP
- Mission Oriented Protective Posture (MOPP)
- Flexible use of protective clothing and equipment
that balances protection with performance
degradation
47What determines MOPP Level?
- What is the mission
- Type, importance and risk
- Activity level
- Time required for mission
- Enemy capabilities
- Warning time to potential exposure
- Weather
- Any additional protection available
- What is the training and physical level of
troops
- Is it day or night
48MOPP Levels
49Operational Considerations for MOPP
- Can be worn for 24 hours when in contact with
chemical agents
- Must exchange be 24 hours has elapsed
- Can be worn for 22 days without exposure
- Commander can authorize wearing for up to 30
days
- MOPP suit cannot be decontaminated
- MOPP 4 raises body temp 10 degrees F
50Operational Considerations Continued
- Overboots and gloves can be worn for 12 hours in
a chemical environment
- Recommended only wearing boots and gloves for 14
days in clean environment
51Command, Control and Communication in MOPP
- Leaders become heat casualties first b/c higher
activity levels
- Soldiers exhibit behavior changes
- Disorientation
- Confusion during multi-input situations
- Increased frustration levels
- Increased irritability
- Radio transmission time increases 47
- Number of radio transmissions increases 100
- Casualties increase 75
52NBC Reports
- NBC one reports are at the unit level
- Informs higher headquarters of a witnessed
attack
- All NBC one reports are used by higher
headquarters to develop and issue a downwind
warning to all units
- Units use downwind warning to plot advancement of
chemical attack, and take necessary protective
posture
53Questions
CPT Dave Reed