ATROPINE ONLY

1. ATROPINE ONLY Initial, on scene, treatment by EMS for Nerve Agent or Organophosphate poisoning in the absence of Mark 1 kits

2. Optimal Tx at the scene by EMS Mark 1 Kits • ( 3 Atropens [Atropine] {2mg. Auto-injectors} along with 1 auto-injector pen of 2-PAM [Pralidoxime] {600 mg.}

3. CHEMPACK System • 90+ containers throughout NYS, primarily in hospitals • Can get to emergency scene – or + 1 hour • New formulary as of February 2006 (for reduced number of patients). • Existing stockpiles will be replaced with new formulary

4. CHEMPACK SYSTEM Does your agency know how to implement the system?

5. Hospital Emergency Management Public Health Based on County Plan Notify Dispatch Suspected Nerve Agent Incident Atropine Auto-injectors How it should all fit together

6. CHEMPACK To Emergency Dept. when notified to await your patient To Incident Scene if enough time How does it get to the ED for your Patient?

7. CHEMPACK Formulary Hospital CHEMPACK - Container contains enough auto-injectors and vials of drug to treat 1,000 pts. EMS CHEMPACK - {454 pts.} contains atropine auto-injectors only, (in addition to other drugs), because: • Auto-injectors are generally not used in hospital based treatment and, • Pts. will be transported to hospital/alternate care site for follow up treatment from scene.

8. Plan • NYS has purchased Atropen units. • The expiration date for this batch is April 2009. • BEMS is working on a plan for replacement for expired pens. • The Atropens are to be used by trained EMS providers. • Training to the agency representative to be provided by BEMS personnel in a statewide Train-the-Trainer program. • Agency training officer is to conduct training at agency level, and will notify Medical Director and local REMAC of personnel trained.

9. Study Data • Data on Atropine use alone is necessarily limited • 3 cases studies on <200 patients, during Iran-Iraq war using atropine alone • No untoward effects on military and civilian victims of Nerve Agent exposure with use of atropine alone, (no oximes available) • Patients were mild, moderate and severe exposures

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14. Advantages/Disadvantages(from a terrorist perspective)

16. Participation choices • Agencies can still use and purchase Mark 1 kits • Participation would be voluntary

17. County Emergency Plan for Chempack Who can initiate county emergency Chempack activation: • Emergency Manager/County Executive • Hospital • First responders (must notify MD/Hospital of request) • Local Health Dept. • Others as directed

18. PURPOSE To provide basic life support personnel with the basic knowledge and skills to administer atropine by auto injector in a life-threatening situation.

19. Training • TRAINING PROGRAM OUTLINE FOREMT-B PERSONNELTO ADMINISTER ATROPINE BY AUTO-INJECTORIN LIFE-THREATENING SITUATIONS – (prior to pt. arriving at hospital)

20. Competencies • Upon completion of the training the participants will be able to demonstrate the following competencies: • 1. Identify common causes of nerve agent poisonings; • 2. Identify the signs and symptoms of a severe allergic reaction (anaphylaxis), and how they differ from other medical conditions;

21. Competencies • 3. List the steps for administering atropine by an auto injector; • 4. Describe the methods for safely storing and handling atropine and appropriately disposing of the auto-injector after use;

22. Competencies • 5. List the steps for providing for on-going care of the patient until turned over to definitive care; • 6. Understand the state regulations that allow an agency to possess and use an atropine auto-injector in a life threatening situation. • 7. Activation of County Plan

23. SLUDGEM • SLUDGEM + RESPIRATION and AGITATION • S - salivation (excessive drooling)L - lacrimation (tearing)U - urinationD - defecation / diarrheaG - GI upset ( cramps )E - emesis ( vomiting )M - muscle ( twitching, spasm, "bag of worms" )

24. Signs and symptoms of nerve agent poisoning • MILD SYMPTOMS Blurred vision, miosis Excessive unexplained teary eyes Excessive unexplained runny nose Increased salivation such as sudden unexplained excessive drooling Chest tightness or difficulty breathing Tremors throughout the body or muscular twitching Nausea and/or vomiting Unexplained wheezing or coughing Acute onset of stomach cramps Tachycardia or bradycardia

25. Signs and symptoms of nerve agent poisoning • SEVERE SYMPTOMS Strange or confused behavior Severe difficulty breathing or severe secretions from your lungs/airway Severe muscular twitching and general weakness Involuntary urination and defecation (feces) Convulsions Unconsciousness

26. Effects of Atropine • Atropine will affect the parasympathetic nervous system by lowering its effects on the body. • In nerve agent and organophosphate poisoning, fluids will “leak” from all openings in the body. • Atropine dries up these secretions.

27. Dosage • The atropine auto-injector comes in both an adult dose and a pediatric dose. • However, agencies in this program will only be carrying and administering the adult dosage Atropen.

28. Administration of the drug Sit the patient down and try to calm and reassure him/her. If the patient is: • confused, • disoriented, or • unconscious (altered mental state) • with signs of (hypoperfusion) Administer a high concentration of oxygen. If the patient is havingdifficulty breathing, administer the atropine asfollows:

29. Administration of the drug • Step One: Remove the safety cap from the auto-injector. Check to see if the fluid is clear and colorless. Never put yourfingers over the green tip when removing the yellow safetycap or after the safety cap has been removed! • Step Two: Place the tip of the injector against the patient's bare outer thigh. (Halfway between their waist and the knee)

30. Administration of the drug • Step Three: With a quick motion, push the auto-injector firmly against the thigh until the spring-loaded needle is activated. Hold the auto-injector in place for ten (10) seconds. • Step Four: Remove the auto-injector from the thigh and record the time of the injection.

31. Administration of the drug • Step Five: Never put your fingers over thegreen tip after the yellow safety cap has been removed! Dispose of properly using blood borne pathogenic guidelines, into a Sharp’s container. • Step Six: Monitor the patient carefully, and keep them calm. Note if the patient gets any better or worse.

32. System Notification & Activation • Make sure someone notifies dispatch of atropine use by EMS. • Hospital must be notified of treatment with atropine in the field. • As soon as agent is identified, notify dispatch and hospital. • Ascertain whether Chempack should be deployed to the field site.

33. After effects of the drug • The injection itself is relatively painless and the patient may not feel the medication being injected. Soon after the injection the patient should begin to feel the beneficial effects of the drug. • The most common changes the patient may feel are secretions drying up and easing of dyspnea.

34. Turning the pt. over to ALS/Hospital • If the atropine auto-injector is used, make sure the following information is accurately and concisely conveyed to the ALS Provider and/or physician and hospital: • 1. The substance (nerve agent), if known, the patient was exposed to • 2. How long ago the exposure occurred • 3. The signs and symptoms the patient experienced (difficulty breathing, any secretions, any pinpoint pupils, etc.) before the atropine was administered • 4. The time and dose of the atropine administered • 5. Did you notice any change(s) in the patient after the atropine was administered • 6. Other specific information about the patient such as name, age, guardian, physician, medical history, etc.

35. Storage • Keep the atropine auto-injector where you can have quick and easy access to it in an emergency. • Keep it away from children. • It is important to remember that the atropine needs to be kept at room temperature. It should not be refrigerated, nor should you allow it to be exposed to extreme heat, such as the glove compartment of the ambulance during the summer. • Do not expose the atropine auto-injector to direct sunlight; light and heat can cause atropine to degrade.

36. Expiration Date • As with any medication, the atropine auto-injector will have an expiration date, which is printed directly on the unit. It is important to periodically check the expiration date and replace the unit before it expires. When checking the expiration date also check to make sure the fluid is clear and colorless. Replace the unit if the fluid is discolored.

37. SHARPS • The auto-injector unit is generally very safe and easy to use. It is important to remember that the unit does have a sharp needle in it. Do not remove the safety cap until you are ready to use the auto-injector. Never put yourfingers over the green tip when removing the yellow safetycap or after the safety cap has been removed.

38. SHARPS • Dispose of your expired or expended atropine into your Sharp’s container. • Dispose of your Sharp’s container in your usual authorized manner.

39. Authorization • To be authorized to possess and use the atropine auto-injector an agency must have a written notification to the agency Medical Director and also filed with the local Regional Emergency Medical Services Council. • All participating individuals must complete this or an equivalent training program.

40. Distribution • The Atropine Auto-Injector will be distributed to the agencies throughout NYS with the knowledge of the regional medical directors. • All agency personnel participating in the program must attend an approved atropine auto injector training program and documentation of such should be on file at the agency and the local REMSCO.

41. Final Steps for Atropine Use • Bring auto-injectors back to agency. • Notify your agency’s Medical Director that you will be training staff on use and deploying the drug for use. • Train your personnel, (EMT & above). • Put auto-injectors on the rig.

42. Questions?????