2. OBJECTIVES
Identify common nerve agents
Discuss signs and symptoms
Discuss nursing management and treatment
Discuss the nurse roles and responsibilities
Discuss personal safety risk exposure
3. Emergency Support Function (ESF) 8
OVERVIEW
DHH has the role of providing leadership for planning,
directing and coordinating the overall State efforts to
provide public health and medical assistance.
The Secretary of Health and Human Services through
the Office of Public Health Emergency Preparedness is
responsible for the federal coordination.
The command and control of operations are consistent
with the National Response Framework and compliant
with National Incident Management System
requirements.
5. Unified Command
Enables all agencies with
responsibility to manage an
incident together by
establishing a common set
of incident objectives and
strategies.
Allows Incident Commanders
to make joint decisions by
establishing a single
command structure.
Maintains unity of command.
Each employee only reports to
one supervisor. Agency 1
Incident
Commander
Agency 2
Incident
Commander
Agency 3
Incident
Commander
7. Chemical Disasters
•May result from industrial
accidents, accidental
exposure, or terrorist acts
•Chemical Agents of
Concern
Nerve agents
Blister
agents/vesicants
Blood agents
Choking/lung/
pulmonary agents
8. Agencies/Partners Involved
Federal Bureau of Investigation (FBI)
Military
US Department of Health and Human
Services (HHS)-Centers for Disease Control
and Prevention (CDC)
Other Federal partners
Governors Office of Homeland Security and
Emergency Preparedness
Fire/Hazmat
9. Agencies/Partners Involved
Department of Environmental Quality
Department of Health and Hospitals
Law Enforcement: Louisiana State Police
Louisiana State National Guard
Department of Public Works
Department of Wildlife and Fisheries
Department of Agriculture and Forestry
Other state agencies
10. Agencies/Partners Involved
Local Parish Office of Homeland Security
and Emergency Preparedness Office
Louisiana Poison Center
Healthcare facilities
Medical Examiners/Coroners
Animal Control
Local Partners
LAVA: Volunteers agencies/volunteers
11. Nerve Agents
Most toxic of chemical warfare agents and inhibit the
body’s normal functions
Dangerous to humans and can be utilized as potential
weapons by terrorist
Act as acetylcholinesterase inhibitors which produce
the same signs and symptoms of organophosphate
poisioning
13. Nerve Agents Exposure
Inhalation
Can be dispersed as
aerosols, vapors, or
liquids
Vapors: absorbed by
inhalation and vapor
contact
Immediate onset of
symptoms
14. Nerve Agents Exposure
Ingestion
Readily absorbed
Skin/eye
Onset depends on
concentration; can be
delayed for several
hours
15. Safety Risk
First responders are trained individuals who will
respond to the event
Nurses should not be first responders unless you have
been trained on hazardous materials or part of a fire
response team
17. Signs and Symptoms
Mild
Miosis
Nausea
Diarrhea
Severe
Muscle weakness
Fasciculations
Respiratory failure
Coma
Seizures
Permanent damage to
the CNS after high toxic
exposure
18. Real Life Incidents
Sarin incident in Tokyo-1995
Carbamate insecticide methomyl was added to salt at a
restaurant in Fresno, California-1999
19. Exposure to Healthcare Workers
Tokyo incident several people were exposed.
Contaminated individuals may self present to a
facility.
Healthcare workers must wear PPE and use it
correctly
Contaminated individuals must be
decontaminated
20. Exposure to Healthcare Workers
Sudden and severe symptoms may occur hours after
treatment/contamination (through skin)
You must have appropriate PPE to approach any
contaminated victim
22. PPE Equipment
Determined by the type and level of exposure and
duration of exposure
Nerve agents are absorbed through intact skin and
even through the clinical examination gloves
23. Treatment/Exposure
Exposure Treatment
Skin Decontaminate using
soap/water
Inhalation If severe symptomatic,
consider antidote use.
If signs/symptoms
progressing continue antidote
administration.
If breathing has stopped or is
difficult use artificial
respiration
25. Treatment
Adults
Atropine 2mg
(antimuscarinic)
Pralidoxime (2 Pam)
600mg
Children
Pediatric atropine
autoinjector is now
available
Supportive therapy and
assisted ventilation as need
Benzos for prevention of
seizures
29. CHEMPACK
Hospital/EMS Containers (contents are different)
Mark 1 Kits
Atropine Sulfate 0.4mg/mL
Pralidoxime 1gram vials
Atropen® 0.5mg auto-injectors
Atropen® 1mg auto-injectors
Diazepam 10mg/2mL auto-injectors
Diazepam 5mg/mL 10mL
Sterile Water for Injection 20mL single use vials
30. CHEMPACK
Prepositioned across the state. Locations are
confidential.
Louisiana Poison Control
1-800-222-1222
Will provide consultation on symptoms of nerve agents
and organophosphate poisoning to first responders and
health care professionals.
Will provide assistance regarding dosing questions.
34. Scene Safety Management
Minimize casualties
Decontamination
Triage
Antidote therapy
Crisis scene
management
35. Emergency Medical Service's
(EMS) Role
EMS has 2 Mark I Kits available on the ambulance
State Police will pick up EMS container if CHEMPACK
is needed
Administer Mark 1 Kit per protocol
Airway support and ventilation. Perform endotracheal
intubation if needed.
Circulatory support: IV therapy and pulse oximetry
monitoring
Consultation with Louisiana Poison Control
36. Field Treatment
Exposure Symptoms Initial Dosing*
(EMS/Field)
Repeat Dosing
(Transport/Hospital)
Mild DUMBBELS
Agitation
Observe or MARK 1 Observe
Moderate DUMBBELS
Agitation
Respiratory distress
2 Mark 1** Atropine 5-10 min
2-PAM q 30-60 min
Severe DUMBBELS
Respiratory distress
Seizures
3 MARK 1***
Diazepam
Atropine 5-10 min
2-PAM q 30-60 min
Diazepam q 2-5 min
39. Hospital’s Role
Ventilatory support: patients with respiratory failure
and compromised airways will require immediate
endotracheal intubation and positive pressure
ventilation.
Oxygen supplement
Decontamination before entering the emergency
department
Suctioning for removal of bronchial secretions
Gastric decontamination-activated charcoal
40. Hospital’s Role
Observation
Treatment-Atropine and Pralidoxime
Monitoring for seizure activity (administering
anticonvulsants for prevention)
Recovery may take several months
Risk of permanent damage to the Central Nervous
System (high dose exposure)
Consult with the Louisiana Poison Center
41. Patient Mild/Moderate Effects1 Severe Effects2 Other Treatment
Child
Atropine:
0.05mg/kg IM or
IV (minimum 0.1mg
Maximum 5mg)
AND
2-PAM:
25mg/kg IM or
IV (maximum 2Gm
IM or 1Gm IV)
Atropine:
0.1mg/kg IM or
IV (minimum 0.1mg,
maximum 5mg)
AND
2-PAM:
50mg/kg IM or
IV (maximum 2Gm IM or 1Gm IV)
Assisted ventilation for severe exposure.
Repeat atropine at 2-5 minute intervals until
secretions have diminished and airway resistance
has decreased.
Repeat 2-PAM chloride once at 30-60 minutes,
then at one-hour intervals for 1-2 doses, as
necessary.
Diazepam for seizures:
Child - 0.05 to 0.3 mg/kg IV
(maximum 10 mg);
Adult - 5 mg IV
Other benzodiazepines (e.g. lorazepam) may
provide relief.
Phentolamine for 2-PAM chloride-induced
hypertension:
1 mg IV for children; 5 mg IV for adults.
Adult
Atropine:
2 to 4 mg IM or IV
AND
2-PAM3:
600mg IM, or
Atropine:
6mg IM
AND
2-PAM3:
1800 mg IM, or
50mg/Kg IV slowly
1. Mild/Moderate effects of nerve agents include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea.
2. Severe effects of nerve agents include unconsciousness, seizures, apnea, flaccid paralysis.
3. Dose selection of 2-PAM chloride for elderly patients should be cautious (usually starting at 600 mg IM, or 25 mg/kg IV slowly) to account for the
generally decreased organ functions in this population.
NOTE: 2-PAM chloride (2-PAM) is pralidoxime chloride, trade name Protopam®.
CHEMPACK: CHEMPACK is a federal program to provide nerve agent antidotes (Atropine, 2-PAM, Diazepam) to during an emergency.
Additional Assistance: Contact the at 800-222-1222 or 318-813-3317 for additional information regarding dosing.
42. Hospital’s Role
Employee training
Hospitals are going to be
reserved for your
critically ill individuals
Medical Surge
Decontamination
Treatment/Supportive
Measures/Assisted
Ventilation
44. Public Health Preparedness
Strategic National Stockpile
Exercises, drills, trainings
State and local planning efforts
Paradigm shift to all hazards approach
45. Public Health’s Role
Promote life safety through education, information
and planning
Goal is to prevent illness by minimizing exposure and
rapid, effective response
Provide medical intelligence such as knowledge of
antidotes and symptoms of exposure
Procure resources available to the State with forward
placement whenever possible
46. Public Health’s Role
Provide guidance for use of assets under the direction
of the State Health Officer
Participate as ESF 8 in Incident Command and/or
Unified Command
Assist in the development of factual communication
for multiple audiences during response
Promote behavioral health
47. Public Health’s Role
Conduct epidemiological investigations
Coordinate laboratory services
Participate assessments and actions to minimize the
health and environmental impacts
48. Office of Public Health Nurse’s
Role
Planning, preparedness, and response
Assessment
Triage
Treatment/Education
Sheltering
49. Personal Safety
Having a family emergency plan
Decontamination of self
PPE
Emergency Communication Devices
50. Vulnerable Populations
Communication
Establish safe shelter
Food and water
Shelter in place versus Medical Special Needs Shelters,
General Population Shelters, Critical Transportation
Needs Shelters
Rely on existing agencies
Will need assistance if decontamination is needed
Time of day when incident happens
51. Education
If exposed, remove all clothing immediately and wash
with copious amounts of soap and water.
Shelter in place: Go indoors, close all windows, doors,
and close up the building. Turn off fans, air
conditioners, and heaters. Move to a lower, inner
room vs. higher room for floods
Listen to the local news and radio for further
instructions
53. CHEMPACK Response Operation
Overview
Step 1: Event- a suspected chemical or biological
incident occurs. 911 is notified of the situation and the
need for security considerations or medical attention
for/by the public. At this time, 911 operators also
notify the parish Office of Homeland Security and
Emergency Preparedness of the event.
Step 2: Isolation- security and medical responders
will follow local parish protocol for isolation and triage
for treatment.
54. CHEMPACK Response Operation
Overview
Step 3: CHEMPACK Standby/Alert- the Louisiana Poison
Center will be notified by either the field Incident
Commander or the 911 Operations Center that there is a
suspected nerve or organophosphate incident. Triaging
assistance is provided to the Incident Commander an on-
scene first responders. Since positive identification of the
substance involved is nearly impossible in the initial
response, symptoms consistent with a nerve agent or
organophosphate exposure will be sufficient for
recommending appropriate treatment and release of the
assets.
Louisiana Poison Center: 1-800-222-1222
55. CHEMPACK Response Operation
Overview
Step 4: CHEMPACK Activation- If the Tier I assets
are insufficient to meet the need, then the Louisiana
Poison Center activates this CHEMPACK plan. The
Louisiana Poison Center will notify appropriate Host
Sites with a request for Tier II countermeasures via the
CHEMPACK assets. The Louisiana Poison Center
considers such factors as wind trajectory, volume of
patients, and treatment needs when selecting Host
Site(s) and Receiving Site (s) for CHEMPACK supplies.
Louisiana Poison Center will notify Host Sites to open
containers and prepare appropriate “allocations” for
56. CHEMPACK Response Operation
Overview
distribution. Further, Louisiana Poison Center
coordinates transportation with Louisiana State Police.
Step 5: Countermeasures- Tier II CHEMPACK assets
will be dispensed as per the plan and appropriate
Regional plan(s).
Step 6: Collection/Transportation of a Specimen-
A request may be made to transport a sample of the
substance/agent to the State Lab for analysis.
57.
58.
59. Scenario Facts
XYZ Plant located in
Somewhere, Louisiana in
Region 10
Has a population of
approximately 300
employees on duty
It’s Friday, January 14
something has been
dispersed into the
ventilation system at the
XYZ Plant and no one is
aware.
65. Phone Calls
You are the nurse
working in the triage line. What symptoms should
the PHN tell her to
watch for?
66.
67. Summary
Contact the Louisiana Poison Control Center
1-800-222-1222 for questions/concerns
Nerve agents exposure serious medical emergency
For life saving measures rapid administration of
antidotes
Remember DUMBBELS
Always wear appropriate PPE before taking care of any
victim
68. Summary
Most toxic of chemical agents
Triage
Treatment: Decontamination, Rapid antidote therapy,
supportive therapy, and ventilator assistance,
Anticonvulsants for prevention of seizures
71. References
Centers for Disease Control and Prevention
www.bt.cdc.gov
Veenema, Tener Goodwin., Ready RN: Handbook for
Disaster Nursing and Emergency Preparedness, 2009.
Agency for Toxic Substances and Disease Registry
American Academy of Pediatrics
Louisiana Emergency Operations Plan
State/Regional CHEMPACK Response Plan
74. Contact Us
Louisiana Department of Health and Hospitals
Office of Public Health
Center for Community Preparedness
8919 World Ministry, Ste. B
Baton Rouge, LA 70810
225-763-3503
http://www.dhh.louisiana.gov
