State of Maine

State of Maine
Recommended Curriculum

For
MARK 1 KIT

Introduction
Welcome
EMS WMD Nerve Agent Kits (Mark 1 Kits)

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1994: Matsumoto , Japan
In 1993, the Japanese Oumu religious cult, known to the rest of the world as Aum Shinrikyo, launched a program to produce chemical weapons of mass destruction at a reported cost of US $30 million. After experimenting with VX, tabun, soman, mustard, hydrogen cyanide, and phosgene, the group focused its efforts on the production of sarin, culminating in two notorious attacks.

The first sarin attack occurred on the night of 27 June 1994 in the Kaichi Heights section of Matsumoto in Nagano Prefecture, when cult members released sarin from a delivery truck via a home-made dispersal system, consisting of a heater, fan, and drip system. The intended victims were three judges sleeping in a dormitory, but a shift in the direction of the prevailing wind blew most of the vapor into nearby dwellings, affecting an estimated 600 persons. As a result, seven persons were killed and 58 were hospitalized. In addition, 18 of 52 (35%) rescue workers were injured due to the use of inadequate personal protective equipment (PPE)

1995: Tokyo Subway
The second and most infamous sarin attack took place during the morning rush hour on 20 March 1995, when cult members released sarin vapor in cars of five subway lines of the Tokyo subway system. Five terrorists delivered the sarin as a 30% solution in plastic bags, which they brought onto the trains concealed in lunch bags and soft drink containers. They dispersed the sarin by piercing the bags with the tips of umbrellas, allowing the sarin to evaporate, permeating 15 subway stations with sarin vapor. Ultimately, 5,500 persons were injured (80% of whom had psychological injuries related to anxiety, hysteria, and fear), more than 500 were hospitalized, and 12 persons died. In addition, 135 of 1,364 (10%) emergency medical technicians dispatched to the scene also were injured by sarin.

St. Luke’s International Hospital, which was close to one of the stations, received 640 victims. Of the five victims arriving at St. Luke’s in critical condition, three recovered and two died. One of the survivors arrived at the emergency department in cardiopulmonary arrest. Most of those injured in the attack recovered within a few days, and were discharged, although some have yet to recover fully.

Prerequisite:
None, but “ WMD Awareness Level” training program would be helpful.
(The awareness program must be a national training program or modeled after one of the training programs developed by the Department of Defense (DOD), Department of Justice (DOJ), or Federal Emergency Management Agency (FEMA). An online WMD awareness course is offered through the Domestic Preparedness Campus of Texas A & M University’s web site at:

http://www.teexwmdcampus. com)

Training Outline

Mark 1 Kit – Nerve Agent Antidote

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1. 
   Objectives
   

1. 
   Cognitive Objectives
   

1. Define terrorism.

2. 
   Define what is a Nerve Agent.
   
3. 
   Define what is an Organophosphate Agent.
   
4. 
   Recall signs and symptoms of exposure to a nerve agent using the acronym bubbles.
   
5. 
   List the 4 parts of a Mark 1 Kit.
   
6. 
   List and describe 3 contraindications for administration of the Mark 1 Kits.
   
7. 
   List and describe 2 actions of the medications administered by the Mark 1 Kits.
   
8. 
   List and describe 4 side effects of the medications administered by the Mark 1 Kits.
   
9. 
   Sate that the administration of Mark 1 Kit is for symptomatic relief, and should not delay emergent transport to an emergency department.
   
10. 
    List 3 agencies to notify if a nerve agent incident
    

occurs.

2. 
   Affective Objectives
   

1. Explain the rationale for the administration of the

Mark 1 Kits.

3. 
   Psychomotor Objectives
   

1. Given a Mark 1 training kit, demonstrate self/buddy

management for a nerve agent exposure.

2. Given a Mark 1 training kit, demonstrate the proper use

and disposal of the Mark 1 Kits.

2. 
   Preparation
   

1. 
   Motivation
   

1. 1994: Matsumoto, Japan

a. 7 fatalities

2. 1995: Tokyo Subway

a. 12 fatalities, 1000 ill, 5000 seek treatment.

2. 
   Prerequisites
   

1. Optional WMD awareness level training program.

3. 
   Materials
   

1. AV equipment

As a result, seven persons were killed and 58 were hospitalized. In addition, 18 of 52 (35%) rescue workers were injured due to the use of inadequate personal protective equipment (PPE).

In addition, 135 of 1364 (10%) emergency medical technicians dispatched to the scene also were injured by sarin.
2. EMS equipment

3. 
   Presentation:
   

1. 
   Medication
   

1. Generic Name

a. Atropine

b. Pralidoxime Chloride (2-PAM)

2. Trade Name

a. Mark One Nerve Agent Antidote Kit

3. Indications

a. Patient with possible or confirmed exposure to a nerve agent/organophosphate agent and is exhibiting signs and symptoms of cholinergic excess.

4. Contraindications

a. There are no known contraindications to the use of Mark 1 Kit if the exposed person has moderate to severe symptoms.

5. Dose

a. 2 mg. Atropine

b. 600 mg. Pralidoxime Chloride (2-PAM)

c. Versed 5mg IM

6. Administration

a. Dual auto injectors-intramuscular injection (similar to epi-pen)

7. Actions

a. Atropine

Blocks the effects of excess acetycholine, dries secretions and decreases wheezing to allow effective ventilation.

b. Pralidoxime Chloride (2-PAM)

Attaches to the nerve agent or pesticide where it poisons the acetylcholinesterase (enzyme that breaks down acetylcholine) and helps to restore normal function in many cases.

c. Versed

Hypnotic, sedative.

8. Side effects

a. Atropine

Palpitations and tachycardia, headache, dizziness, and anxiety, dry mouth, pupillary dilation and blurred vision, urinary retention.

b. Pralidoxime Chloride (2-PAM)

Hypertension, blurred or double vision; difficulty in focusing eyes; difficulty in speaking; rapid breathing; dizziness; fast heartbeat; muscle stiffness

or weakness; pain of injection(after injection into a

muscle).

Signs of Atropinization.

*Blurring of vision

*Delirium

*Urinary retention

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

atropinization subsides.

Do not administer pralidoxime (2PAMCI) to patients with exposure to carbamate pesticide (Sevin).

c. Versed

Drowsines, hypotension, amnesia, respiratory depression, apnea.

9. Dosing

a. Mild symptoms-small pupils, runny nose-

No treatment with Mark 1 Kit

b. Moderate symptoms-(Including mild respiratory distress.)

Administer one (1) Mark 1 Kit, reevaluate in 3-5 minutes

c. Severe symptoms-(Including severe respiratory distress, altered mental status, seizure, coma, etc.)

Administer two (2) Mark 1 Kits in 5-10 minute intervals-(4 shots total).

d. If seizures present 5 mg IM.

10. Assessment of treatment/repeat dosing

a. Goal of treatment-

1. Primary-reduce respiratory secretions to allow effective ventilation/relieve shortness of breath(atropine)

2. Secondary-stop poisoning of the enzyme to begin reversing the nerve agent effects (2-PAM)

b. Assessing treatment-if moderate or severe symptoms are still present 5-10 minutes after initial therapy consider repeating 1 Mark 1 Kit or giving additional atropine alone to improve respiratory symptoms.

4. 
   Application
   

1. 
   Student Activities
   
   1. 
      Auditory
      

1. 
   The student will hear information on the Mark 1 Kit.
   

2. 
   Visual
   
   1. 
      The student will observe a demonstration of assessment and care of the patient requiring care for nerve agent exposure.
      
3. 
   Kinesthetic
   
   1. 
      The student will practice inspecting and reading the label.
      
   2. 
      The student will use the Mark 1 Kit training device to practice
      

Administration of the auto-injector.

5. 
   Evaluation
   

1. 
   Review questions
   

2. 
   Skill Sheets
   

Signs and Symptoms of Nerve Agent (BUBBLES).

Bradycardia

Urination

Bronchial constriction

Bronchospasm

Lacrimation

Emesis

Seizures

Nerve Agent Kits___________________________

OUTLINE

I. Terrorism

A. FBI Definition:

1. The unlawful use of force against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof in furtherance of political or social goals.

II. What is a Nerve Agent?

1. 
   Nerve Agent:
   

1. Nerve agents are chemical warfare agents, similar to

but much more potent than organophosphate insecticides. They are colorless to amber-colored, tasteless liquids that may evaporate to create a gas. GB and VX are odorless, while GA has a slight fruity odor, and GD has a slight camphor odor.

III. What is an Organophosphate Agent?

A. Organophosphate Agent:

1. Some commonly used pesticides (for example, the

organophosphate (OP) Malathion and the carbamate

(Sevin) and some common therapeutic drugs (the

carbamates pyridostigmine (Mestinon) and physostigmine (Antilirium) also inhibit acetylcholinesterase and can be considered “nerve agents.” However, while the OP pesticides cause the same biological effects as nerve agents, there

are some important differences in the duration of biological activity and response to therapy.
IV. Signs and Symptoms of a Nerve Agent (BUBBLES)

A. Bradycardia

B. Urination

C. Bronchial constriction

D. Bronchospasm

E. Lacrimation

F. Emesis

G. Seizures

V. Parts of a Mark 1 Kit

A. Has two (2) auto injectors.

1. Auto injector containing 2mg Atropine

2. Auto injector containing 600mg 2PAMCI

3. Small foam case.
VI. Contraindications for administration of Mark 1 Kits

1. 
   NOTES___G-Agents'>Prophylactic use
   
   1. 
      Relative contraindication
      

a. Children under 3 years old

NOTES

G-Agents: The American name for the gas three nerve agents:

Sarin, Tabun, Suman

V-Agents: Second generation post Second World War nerve agents include VX-gas. They are all organophosphates significantly more potent than Sarin and the first generation nerve gasses.


Organo-phosphate

An organic compound containing Phosphorous Oxygen double bond.

Special Note:Auto-injector should be stored at a controlled room temperature of 25°C(77°F). Short exposures to temperatures of 15-30° C (59-86°F) are permitted (see USP guidelines on Controlled Room Temperature). These products should be kept from freezing and protected from light.

VII. Actions of the medications administered by the Mark 1 Kits

1. 
   Atropine
   

1. Blocks the effects of excess acetylcholine, dries secretions and decreases wheezing to allow effective ventilation.

2. 
   Pralidoxime Chloride(2-PAM)
   

1 .Attaches to the nerve agent or pesticide where

it poisons the acetylcholinesterase (enzyme that

breaks down acetylcholine) and helps to restore

normal function in many cases.

VIII. Side effects of the medications administered by the Mark 1 Kits

1. 
   Atropine
   

1. Tachycardia

2. Palpitations

2. 
   Pralidoxime Chloride (2-PAM)
   

1. Hypertension

2. Dizziness

IX. Indications for use of a Mark 1 Kit

1. 
   Known agent exposure
   

B. Symptomatic Relief

C. Three or more signs and symptoms of a Nerve

Agent
X. Self Administration of the Mark 1 Kit

A. The NAAK contains 2 auto injectors:

One 2mg Atropine Auto-injector and

one 600mg 2 PAM Chloride Auto-injector.

B. Remove the NAAK from its storage location.

C. With your non-dominate hand, hold the auto

injector at eye level so that the larger auto injector

is on top.

D. With your other and, check the clothing over the

lateral thigh muscle for buttons or objects in the

pockets that may interfere with the injection.

E. Grasp the atropine auto-injector (Green Tip)

with the thumb & first two fingers of your dominate

hand and pull out of the holder.

F. Atropine should be administered first.

G. Hold the auto-injector like a pen or pencil between

the thumb and first two fingers.

H. Remove the end cap.

I. The auto-injector should be administered through

your pants into the lateral thigh muscle.

J. Position the green tip of the auto-injector against

the injection site.

K. Apply firm even pressure to the injector until it

pushes the needle in the lateral thigh muscle.

L. Hold the injector in place for 10 seconds and then

carefully remove it.

NOTES

Warning: Do not kneel at any time while providing aid to the casualty, contact with the ground could force the chemical into or through clothing.


Warning: Do not hold the unit by the green tip. The needle ejects from the green tip.

Warning: If you are thinly-built, inject yourself into the upper outer quadrant of the buttock.

There is a nerve that crosses the buttocks; hitting this nerve can cause paralysis.

Caution: Do not hold the unit by the black tip. The needle ejects from the black tip.
After you have given yourself the first set of injections. You most likely will not need additional antidote if you are ambulatory and know who you are. If needed, second and third sets of injections will be given only by a buddy or by medical personnel.

M. Place the used auto-injector into a sharps container

if available.

N. Complete the same sequence of events for

administration of the 2 PAM Chloride.

O. Document the number of auto-injectors administered.

P. Assure proper disposal of sharps.
XI. Emergency Agencies to Notify:

A. Local Fire Department/Haz-Mat Teams

B. State Police

C. EMA

NOTES

Description of Action Required	Correct
Remove kit from protective pouch
Hold MARK-1 trainer by plastic clip
Remove AtroPen trainer from slot number 1 of the
plastic clip. The yellow safety cap will remain in the clip
Grasp the trainer and position the green tip of the
AtroPen trainer on self/victim's outer thigh.
Push firmly until red prod ejects from unit
Remove ComboPen trainer from slot number 2 of the
plastic clip. The gray safety cap will remain in the clip
Grasp the trainer and position the black tip of the
ComboPen trainer on self/victim's outer thigh
Push firmly until white prod ejects from unit
Dispose of the sharps correctly(secure safely to
individual)

Adminstration of the Nerve Agent Antidote Kit	Correct
The NAAK contains 2 auto injectors: One 2mg Atropine
Auto-injector and one 600mg 2 Pam Chloride Auto-injector
Remove the NAAK from its storage location
With your non-dominate hand, hold the auto injector at
eye level so that the larger auto injector is on top
With your other hand, check the clothing over the lateral
thigh muscle for buttons or objects in the pockets that may
interfere with the injection.
Grasp the atropine auto-injector (GREEN TIP) with the thumb
& first two fingers of your dominant hand and pull out of the
holder.
Atropine should be administered first
Hold the auto-injector like a pen or pencil between the thumb
and first two fingers
Remove the end cap
The auto injector should be administered through your pants
into the lateral thigh muscle
Position the green tip of the auto-injector against the injection site
Apply firm even pressure to the injector until it pushes the needle
in the lateral thigh muscle
Hold the injector in place for 10 seconds and then carefully remove it
Place the used auto injector into a sharps container if available
Complete the same sequence of events for administration of the
2 Pam Chloride
Document the number of auto injectors administered

Glossary:
Acetyl-cholinesterase:

The enzyme that Sarin inhibits, normally breaks down acetylcholine into acetic acid and choline.

Aerosols:

A fine suspension of liquid particles in the air.

Amiton:

One of the second generation nerve agents similar to VX-gas 10 times more toxic than Sarin.

Aum Shinrikyo:

The name of the Japanese cult responsible for the Sarin bombing.

Binary munitions:

A two part shell which allows the two chemicals necessary in the final stage of Sarin synthesis allows the reaction to occur shortly before explosion.

Choline:

One of the products from the hydrolysis of acetylcholine.

G-Agents:

The American name for the first three nerve agents Sarin, Tabun and Soman.

Isopropyl Methylphosphanoflouridate:

Alternative name for Sarin gas.

Organo-Phosphates:

An Organic compound containing a Phosphorus Oxygen double bond.

Miosis:

Scientific name for the reproduction of gametes.

Soman:

One of the first generation of organophosphate nerve agents.

Tabun:

The first purpose made nerve agent.

V-Agents:

Second generation post second world war nerve agents includes VX-gas. They are all organophosphates significantly more potent than Sarin and the first generation nerve gasses.

VX-Gas:

One of the V-agents (discovered in 1949) far more persistent than the first generation nerve agents.