1	Module I Introduction to Chemical Weapons of Mass Destruction and Mark I Kit Self-Administration First Responders Course
2	COURSE OBJECTIVES The participant should be able to: List examples of Chemical Weapons of Mass Destruction Identify the types of Nerve Agents and their signs, symptoms, and treatments for exposure Demonstrate Proficiency for Mark I Kit Self–Administration Understand Policies, Procedures, & Protocols Complete a written examination with a score of ≥ 70%
3	Chemical Weapons of Mass Destruction
4	Types of Chemical Agents Vesicants / Blister Agent Pulmonary (Choking) Agent Incapacitating (Blood) Agent Nerve Agent
5	Classification of Chemical Agents Persistent Substance can remain on material, equipment and terrain for long periods Non-Persistent Substance dissipates fairly quickly
6	Vesicants / Blister Agent Agent Types: Nitrogen / Sulfur Mustard, Lewisite, Phosgene Oxime Mode of Action: Acid-forming compounds that damages skin and respiratory system, resulting in burns and respiratory problems Rate of Action: Mustard - Vapors 4-6 hours, eyes and lungs affected more rapidly; Skin: 2 to 48 hours. Lewisite – Immediate Physical Properties: Mustard – Oily liquid, clear when pure, brownish when impure, odor of garlic or mustard
7	Vesicants / Blister Agent Signs and Symptoms: Severe skin, eye and mucosal pain irritation Skin erythema with large fluid blisters, slow to heal and may become infected Tearing, conjunctivitis, corneal damage Mild respiratory distress to marked airway damage
8	Vesicants / Blister Agent First Aid Water in large amounts 10:1 concentration of bleach
9	Pulmonary (Choking) Agent Agent Types: Chlorine, Hydrogen Chloride, Nitrogen Oxides, Phosgene Mode of Action: Compounds are acids or acid-forming, action is pronounced in respiratory system, flooding it and resulting in suffocation Rate of Action: Immediate to 3 hours Physical Properties: Chlorine – greenish/yellow gas, odor of bleach Phosgene – colorless gas, odor of new mown hay
10	Pulmonary (Choking) Agent Signs and Symptoms: Airway irritation Eye and skin irritation Dyspnea, cough Sore throat Chest tightness Wheezing Bronchospasm
11	Pulmonary (Choking) Agent First Aid Vapor: fresh air Liquid: copious water irrigation
12	Incapacitating (Blood) Agent Agent Types: Most Arsines, Cyanogen Chloride, Hydrogen Cyanide Mode of Action: Causes intravascular hemolysis that may lead to renal failure. Cyanogen chloride/hydrogen cyanide Cyanide directly prevents cells from utilizing oxygen. The cells then use anaerobic respiration, creating excess lactic acid and metabolic acidosis. Rate of Action: Immediate onset Physical Properties: Colorless gas, odor of bitter almonds
13	Incapacitating (Blood) Agent Signs and Symptoms: Possible cherry – red skin Possible cyanosis Confusion Nausea Gasping for air Seizures prior to death Metabolic acidosis
14	Incapacitating (Blood) Agent First Aid Fresh Air Cyanide Kit
15	Nerve Agents
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17	Nerve Agents Most toxic of the chemical WMD agents Equivalent of pesticides for humans Attacks the nervous system, affecting nerve impulses until the system can no longer control basic body functions A single drop of the most potent types can cause convulsions, loss of consciousness, and death.
18	Types of Nerve Agents Nerve Agents VX GA (tabun) GB (sarin) GD (soman) GF (cyclosarin)
19	Nerve Agents: Physical / Chemical Properties Normally liquid; clear when pure, tan / brown when impure Fruity or sulfur odor
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21	Signs & Symptoms: Low Dose Low Dose / Minor Poisoning Increased saliva Running nose Pressure on the chest Pupil of the eye becomes contracted (night vision, short range vision, & pain) Accompanied by headache Unspecific symptoms: tiredness, slurred speech, hallucinations and nausea
22	Signs & Symptoms: Moderate Higher Dose / Moderate Poisoning Bronchoconstriction Secretion of mucous in the respiratory system (difficulty in breathing and coughing) Gastrointestinal tract (cramp and vomiting) Involuntary discharge of urine and defecation Powerful discharge of saliva, running eyes and sweating Muscular twitching, weakness, local tremors or convulsions
23	Signs & Symptoms: Severe High / Severe Dose Muscular symptoms are more pronounced Convulsions and loss of consciousness Poisoning process rapid Earlier mentioned symptoms may never have time to develop
24	Mnemonic for Nerve Agent Exposure Symptoms S – salivation L – lacrimation U – urination D – defecation G – gastrointestinal pain E – emesis M - miosis D – diarrhea U – urination M – miosis B – bronchorrehea, bronchoconstriction E – emesis L – lacrimation S - salivation
25	Time-Line Symptoms Onset within seconds to minutes (hours) Dependent upon dose Dependent upon route of exposure In general, “for vapor exposure” the longer the time from exposure to development of symptoms, the less severe the effects
26	Types & Treatments for Exposures
27	Types of Exposures Vapor Generally more severe with faster onset of symptoms Liquid Slower onset. Penetrate clothing to be absorbed through skin. (With vapor exposure also consider liquid exposure via skin contact).
28	Mechanism of Action Absorption (any body surface) Skin Eyes Respiratory Tract
29	Treatment of Mild Exposure Symptoms Constricted pupils, headache, mild runny nose, salivation, localized sweating, nausea, vomiting, localized muscle twitching, feeling of weakness Onset: seconds to minutes for vapor 30 min to hours for liquids Treatment Observation only If shortness of breath is increasing 1 MARK I Kit
30	Treatment of Moderate Exposure Symptoms Constricted pupils, runny nose, SOB, wheezing, secretions, muscle weakness, vomiting, diarrhea onset within 10 minutes Treatment 1 to 2 MARK I Kits
31	Treatment of Severe Exposure Symptoms Unconscious, seizures, flaccid paralysis, apnea Onset of symptoms immediate (1-30 minutes) Treatment Immediately give 3 MARK I Kits
32	Mark I Kit: Self-Administration
33	MARK I Kits Prepackaged unit / 1 Mark I Kit Atropine 2 mg autoinjector (1) 2-PAM 600 mg autoinjector (1) IM administration (only) Single patient use
34	MARK I Kits: Auto-injectors
35	Antidote Actions Atropine Dries up secretions Doesn’t reverse skeletal muscle weakness Especially respiratory muscle weakness 2-PAM (Pralidoxime, Protopam) Reverses muscle weakness Restores normal skeletal muscle function Makes Atropine work better
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37	Your Turn.
38	Removing Auto-injector
39	IM Site Selection Inject into large muscle mass Anterolateral thigh preferred site Upper outer quadrant of buttocks optional site Check for objects in pockets!
40	Mark One Kit Use – Atropine # 1 Place green end against outer thigh and push hard until you feel the injector function. Hold firmly in place for 10 seconds.
41	Pralidoxime Chloride # 2 Pull the large injector out of the plastic holder.
42	Pralidoxime Chloride # 2 Place the black end against the outer thigh and push hard until you feel the injector function. Hold firmly in place for 10 seconds
43	Disposal of Auto-injector In a safe manner
44	Review: Using Auto-Injectors Select site for injection Remove smaller autoinjector first (Atropine) Position needle end of injector against injection site Apply firm, even pressure, and hold in place for 10 seconds Repeat for larger autoinjector (2-PAM) Dispose of safely Massage injection sites
45	Antidotes: Effects If Given Without An Exposure to Nerve Agents Atropine Decreased sweating Blurred vision Confusion Dry mouth Flushing Tachycardia Urinary retention 2-PAM, (Pralidoxime) Visual disturbances Dizziness Headache Hypertension Hyperventilation Nausea Muscular weakness
46	Mark I Kit Contraindications In the face of life-threatening poisoning by organophosphorous nerve agents and insecticides, there are no absolute contraindications for the use of atropine.
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48	Policies, Procedures, & Protocol (PPP)
49	PPP Eligible Agencies: Fire Departments Department of Environmental Resources (HazMat) Police Agencies (SWAT & Bomb Squad) Emergency Medical Services (Ambulance)
50	PPP Each agency will maintain a minimum cache of 12 Mark 1 kits on 1^st arriving apparatus; Minimum cache will be supplied/stored in orange 1200 Pelican Box (Optional cache of 24 kits may be substituted and supplied/stored in orange 1300 Pelican Box; Pelican Boxes must be secured w/seal.
51	PPP Records & Reporting Completed “Location of Storage” form must be submitted to Public Health upon placement.
52	PPP
53	PPP Records & Reporting (cont): A weekly “Seal Log” will be maintained and made available upon request to PHS.
54	PPP
55	PPP Records & Reporting (cont): Any use or loss of a Mark 1 kit will be reported via fax within 24 hours to PHS per the “Notification of Usage” form.
56	PPP
57	PPP TRAINING: AGENCY will send representative(s) to the “Train-the-Trainer” course. Upon completion, the agency will be issued a box of Mark I Trainers and allocated Mark I Kits. AGENCY will provide WMD & Mark I Kit training to all their first responder personnel and maintain training on an annual basis (EXCEPTION: EMT recertify every six months).
58	PPP PERSONNEL USAGE: Mark I kits will be used ONLY by current employees or volunteers of an approved Mark I Kit Provider Agency Mark I kits will be used only by personnel that have been trained in their use and have them available
59	PPP Mark I Kits are issued for first responders and intended for self-administration. They are NOT to be used for general public. Nerve agent antidote medications are only given if a first responder is showing symptoms of nerve agent poisoning.
60	Questions?