HomeMy WebLinkAbout202.012 - Nerve Agent Response
STANDARD OPERATING PROCEDURES MANUAL
TACTICAL OPERATIONS
202.012 NERVE AGENT RESPONSE
EFFECTIVE: OCTOBER 2007
Current Revision Date: 3/1/2 2 Next Revision Date: 3/1/2 5
Author’s Name/Rank: Kevin Reynolds, Captain Review Level: 1
Administrative Support:
Evelyn Yin-Zepeda,
Management Analyst II ADA
PURPOSE
The purpose of this policy is to establish standards for Fresno Fire Department (FFD
or Department) members and other public safety personnel in treating nerve agent
exposures for self-administration.
APPLICATION
This policy applies to procedures for treatment in the event Department members
become exposed to a nerve agent or agents. Examples of nerve agents include
Tabun (GA), Sarin (GB), Soman (GD), Cyclosarin (GF), and VX. This includes
exposures to organophosphate compounds which produce the clinical triad of
salivation, lacrimation, and rhinorrhea, ONLY during the event of a nerve-agent
exposure.
OPERATIONAL POLICY
DuoDote kits will be carried on USAR units only to meet the state’s typing
requirements. DuoDote kits are to be inspected weekly and results will be noted on
Administrative Manual, Section 106.029, Emergency Equipment Weekly Inspection
Report (FD-11).
Nerve agent antidote medications are administered only if the person is showing signs
and symptoms of nerve agent poisoning. THEY ARE NOT TO BE GIVEN
PROPHYLACTICALLY.
All providers are to ensure personal safety by using appropriate personal protective
equipment and ensuring adequate decontamination of victims. Medical procedures
within the exclusion zone are only to be performed by personnel who have specific
training, which allows them to operate in that area.
Public safety personnel who have been trained and equipped may self-administer
DuoDote auto-injectors on themselves per EMS Policy and Procedures. Under no
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circumstances are public safety personnel to administer any medications to patients
other than themselves or other public safety personnel under this policy. The Atropine
(2.1mg) and 2-PAM (Pralidoxime Chloride – 600mg) auto-injectors included in the
DuoDote nerve agent antidote auto-injector are only to be used by trained and
equipped public safety personnel.
OPERATIONAL GUIDELINE
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PROCESS
1. Indications:
Public safety personnel exhibiting multiple symptoms of nerve agent
organophosphate exposure as follows:
A -Altered mental status.
B -Bronchorrhea, breathing difficulty or wheezing, bradycardia.
S -Salivation, sweating, seizures.
L -Lacrimation (tearing).
U – Urination.
D -Defecation or diarrhea, gastro-intestinal upset (abdominal cramps).
E - Emesis (vomiting).
M -Miosis (abnormal contraction of pupils, muscle activity [twitching]).
Note: Multiple patients with multiple symptoms make diagnosis more
likely.
2. Contraindications:
a. Use of DuoDote auto-injector in persons who in fact do not have
nerve agent or organophosphate exposure.
b. As prophylaxis against suspected nerve agents or organophosphate.
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3. Complications:
a. Over-Atropination can cause cardiac arrhythmia, tachycardia,
myocardial ischemia, or death.
b. Accidental injection.
c. Localized trauma at injection site from injection.
4. Self Administration:
a. With non-dominant hand, hold the auto-injector in front of body at
eye level.
b. With dominant hand, check the injection site (thigh or buttocks) for
buttons or objects in pockets, which may interfere with the injections.
c. With dominant hand, grasp the auto-injector with the thumb and first
two fingers. DO NOT cover or hold the needle end with hand, thumb,
or finger, as this may lead to accidental injection.
d. Remove the auto-injectors gray safety release when ready to use.
The auto-injector is now armed. DO NOT touch the needle end.
e. Hold the auto-injector with thumb and two fingers (pencil writing
position). DO NOT touch the needle end.
f. Position the green (needle) end of the auto-injector against the
injection site (thigh or buttocks). DO NOT inject into areas near the
hip, knee, or femur.
g. Apply firm even pressure (not a jabbing motion) to the auto-injector
until it pushes the needle into your thigh (or buttocks). Take care not
to hit any objects in pockets. Using a jabbing motion may result in an
improper injection or injury.
h. Hold the auto-injector firmly in place for at least ten seconds.
i. Carefully remove the auto-injector from the injection site.
j. If time permits, massage the injection sites.
k. After administering one set of injections, initiate decontamination
procedures as necessary.
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l. Administer the appropriate number of DuoDote nerve agent antidote
related to the signs and symptoms (mild, moderate, or severe).
m. After the administration of the nerve agent antidote, pin the used
auto-injector on the clothing at the torso.
5. Buddy System Administration:
a. Position your buddy on his/her side (recovery position).
Note: If necessary, initiate decontamination procedures so as not
to become a victim prior to assisting your buddy.
b. Determine number of previous DuoDotes administered to your
buddy.
c. Determine injection site.
i. Thigh injection area. The thigh injection site is the area of about
one hand’s width above the knee to one hand’s width below the
hip joint, into a large muscle, and away from any bone.
ii. Buttocks. If your buddy is slightly built, then the injections should
be administered into the upper outer quadrant of the buttocks to
avoid injury to the vascular or nervous system.
d. Position yourself near the injection site.
e. With non-dominant hand, hold the auto-injector in front of you at eye
level.
f. With dominant hand, check the injection site (thigh or buttocks) for
buttons or objects in pockets, which may interfere with the injections.
g. With dominant hand, grasp the auto-injector with the thumb and first
two fingers. DO NOT cover or hold the needle end with hand, thumb,
or finger, as this may lead to accidental injection.
h. Pull the auto-injectors gray safety release when ready to use. The
auto-injector is now armed. DO NOT touch the needle end.
i. Hold the auto-injector with thumb and two fingers (pencil writing
position). DO NOT touch the needle end.
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j. Position the green (needle) end of the auto-injector against the
injection site (thigh or buttocks). DO NOT inject into areas near the
hip, knee, or femur.
k. Apply firm even pressure (not a jabbing motion) to the auto-injector
until pushes the needle into your buddy’s thigh (or buttocks). Take
care not to hit any objects in buddy’s pockets. Using a jabbing motion
may result in an improper injection or injury.
l. Hold the auto-injector firmly in place for at least ten (10) seconds.
m. Carefully remove the auto-injector from the injection site.
n. Carefully attach the used auto-injectors to your buddy’s clothing.
o. Repeat the above steps using the second and third sets of DuoDote,
as necessary.
p. As time permits, document doses given as appropriate to the
situation (on the triage tag and/or the pre-hospital care report).
q. If time permits, massage the injection site.
DRUG DOSAGE AND ADMINISTRATION
1. Nerve Agent Exposure:
a. Mild Exposure: administer one (1) DuoDote auto-injector.
b. Moderate Exposure: administer two (2) DuoDote auto-injectors.
c. Severe Exposure: administer three (3) DuoDote auto-injectors.
2. Special Considerations:
It is important the injections be administered into a large muscle area. If
you or your buddy are slightly built and have insufficient muscle mass in
the outer thigh area, the injections should be administered into the upper
outer quadrant of the buttocks. The outer quadrant of the buttocks
should be used to avoid potential nerve damage.
Accidental injections into the hand WILL NOT deliver an effective dose
of the antidote, especially if the needle goes through the hand.
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Squat (DO NOT kneel) when administering nerve agent antidotes to
your buddy. Kneeling may force the chemical agent to enter through the
protective clothing.
3. DuoDote Service Providers:
a. Skills Proficiency:
Training will be provided by a trainee who has attended the local
EMS Agency Nerve Agent Exposure class, passing the skills and
written tests. After the training has been provided, skills testing
sheets will be placed on file with the provider agency and made
available for audit by the local EMS Agency.
b. DuoDote Tracking:
Public safety personnel who administer a DuoDote nerve agent
antidote used for an exposure must file a Quality Improvement
Report within 72 hours (refer to Central California Emergency
Medical Service Agency (CCEMSA) Policy No.704, Quality
Improvement). Patients with nerve agent exposure do not require
reporting the incident on a Quality Improvement Report. Patients
assessed and treated for nerve agent exposure must be documented
on Administrative Manual, Section 106.004, Fresno County First
Responders Pre-Hospital Care Report Worksheet (EMS-13).
INFORMATION
These procedures have been written in accordance with Fresno County Emergency
Medical Services (EMS) Administrative Policies and Procedures, Policy No. 568, as
well as California Health and Safety Code Division 2.5, and California Code of
Regulations Title 22, Division 9.
DEFINITIONS
1. Vapor Exposures:
a. Mild: Miosis, dim vision, headache, rhinorrhea, salivation, dyspnea.
Time of onset: seconds to minutes after exposure.
b. Severe: All the above, plus severe breathing difficulty or cessation
of respirations, generalized muscular twitching, weakness or
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paralysis, convulsions, loss of consciousness, loss of bladder, and
bowel control. Time of onset is seconds to minutes after exposure.
2. Liquid on Skin:
a. Mild/Moderate: Muscle twitching at the site of exposure, sweating at
the site of exposure, nausea, vomiting, feeling of weakness. Time of
onset: 10 minutes to 18 hours after exposure.
b. Severe: All the above, plus severe breathing difficulty or cessation
of breathing, generalized muscular twitching, weakness or paralysis,
convulsions, loss of consciousness, loss of bladder and bowel
control. Time of onset: minutes to an hour after exposure.
CROSS-REFERENCES
Administrative Manual
Section 106.029, Emergency Equipment Weekly Inspection Report
(FD-11)
Section 106.004, Fresno County First Responders Pre-Hospital Care
Report Worksheet (EMS-13)
Central California Emergency Medical Service Agency (CCEMSA)
Policy 568, Nerve Agent Exposure
Policy 811, First Responder Prehospital Care Report – BLS
Policy 704, Quality Improvement
California Health and Safety Code Division 2.5, and California Code of
Regulations Title 22, Division 9
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