**Meticulous attention to standard protocols for personal protection, recognizing toxidromes, and treating patients
continues to be the best way to prepare for and respond to chemical agent exposures**

Purpose
This document provides a quick refresher on standard protocols for recognizing, treating, and protecting yourself from nerve agent exposures. Comprehensive follow-up guidance for Law Enforcement, Fire, EMS, HazMat, and Hospital-Based First Receivers incorporating lessons learned and best practices from the recent United Kingdom incidents will be forthcoming.

Background
Nerve agents are extremely toxic chemical warfare agents. Several nerve agents exist and are generally categorized as either
“high volatility” or “low volatility” chemicals, a measure of how likely they are to disperse in air. A high volatility nerve agent (easily dispersed in air) means that the exposure is likely to occur from breathing in its vapors resulting in the rapid onset of symptoms.
A low volatility nerve agent (not easily dispersed in air) typically gets absorbed through the skin and has a delayed onset of signs
and symptoms. An example of a high volatility nerve agent is sarin, whereas VX is a low volatility agent. In the body, a nerve
agent exerts its effects by inhibiting an enzyme (acetylcholinesterase), resulting in acute illness – specifically, cholinergic crisis.
Organophosphorus or carbamate pesticides produce similar effects to nerve agents.

Signs and Symptoms of Nerve Agent Poisoning
Caveat: Poisoned patients may not demonstrate all of these symptoms
• Mouth/Skin: Drooling (Salivation), foaming at the mouth, and excessive sweating
• Nose/Eyes: Runny nose and watery eyes (Lacrimation) with small (often pinpoint) pupils (Miosis)
• Chest: Cough, chest tightness, difficulty in breathing, wheezing, respiratory failure, “wet” fluid filled lungs
• Abdominal: Urination, Diarrhea, abdominal (Gastrointestinal) cramps, belching, nausea, and/or vomiting (Emesis)
• Mental Status: Confusion, drowsiness, slurred speech, ataxia, unconsciousness, coma
• Muscle/Neurological: Fatigue, weakness, twitching, tremors, cramps, absent reflexes, seizures
Underlined findings = “SLUDGE”- Salivation, Lacrimation, Urination, Diarrhea, Gastrointestinal cramps, Emesis
Other mnemonic used = “DUMBBELS” – Diarrhea, Urination, Miosis/Muscle weakness, Bronchospasm/Bronchorrhea,
Bradycardia, Emesis, Lacrimation, Salivation/Sweating

Clinical Effects of Nerve Agents versus Opioids
Nerve Agent                                                                                                   Opioid
Nose: Runny                                                                                              nose Normal
Airway Secretions/drooling/foaming at the mouth                              Normal
Breathing /Respiratory status:  Increased work of breathing/chest tightness/wheezing/difficulty in breathing/cough/“wet”
fluid filled lungs– more prominent with inhaled exposure; dermal exposure may not cause bronchoconstriction or bronchorrhea
Decreased respiratory rate
Heart rate: Slowed                                                                                         Normal
Mental Status /Neurological: Slow/unconscious/seizures/confusion/slurred speech/ataxia/coma/absent reflexes/ tremors

Slow or unconscious/coma/seizures
Eyes:  Tearing/small pupils-pinpoint                                                   Small pupils-pinpoint
Skin: Wet/sweaty/cyanosis                                                                   Normal/cyanosis
Gastrointestinal: Belching/cramps/vomiting/diarrhea                      Normal
GU: Urination                                                                                                Normal
Muscles: Fatigue/weakness/twitching/ cramps                                    Normal

KEY DISTINCTION BETWEEN NERVE AGENT POISONING AND OPIOID POISONING IS “SLUDGE” OR “DUMBBELS.”

Detection (If you strongly suspect a nerve agent)
•Contact HazMat or special operations teams
•Notify the local FBI Field Office WMD coordinator

Personal Protective Equipment (PPE)
•Emergency responders should have the proper training and education to work with hazardous materials.
•Those providing or assisting with patient care including decontamination should follow institutional policy for a chemical incident, wearing a recommended chemical protective suit, gloves, boots, and respiratory protection to prevent any secondary exposure from patients or objects.
•After patient decontamination is complete, providers should wear a gown and a double layer of nitrile gloves during
patient contact.

Patient Decontamination
•A person potentially exposed to a nerve agent should be decontaminated whether they develop signs of acute illness or not.
•Removal of clothing is a vital step to reduce ongoing and secondary exposure. Responders should pay particular attention to the risk of secondary exposure during clothing removal. Double bagging removed clothing is ideal.
•Wiping skin with a paper towel, dry wipe, or other cloth will also contribute to effective decontamination. This dry decontamination step can be performed by patients themselves and, along with clothing removal, should be done as early as possible.
•If contamination with liquid agent is suspected, patients should be decontaminated with water, ideally with a high-volume, low-pressure shower, including soap if available, gentle rubbing with a soft cloth or sponge, and active drying with a clean towel after the shower.
•If Reactive Skin Decontamination Lotion (RSDL) is available, it is recommended for spot decontamination.

Treatment*
•Nerve agent toxicity is the result of excessive acetylcholine, causing cholinergic crisis. Therapy focuses on treating the excessive secretions and bronchospasm with anticholinergic medications such as atropine with dosing titrated to respiratory secretions and airway resistance. Pralidoxime chloride (2-PAM Cl), a specific nerve agent antidote, augments the primary therapy of atropine; continuous infusions may be beneficial.
•Seizures should be managed with escalating doses of benzodiazepines (midazolam, lorazepam, or diazepam).
All patients, even without convulsions, who meet the severe criteria should be treated with midazolam, lorazepam,
or diazepam 10 mg IV/IM/IO. A pediatric patient in this setting is defined as an individual less than 18 years old
AND with an ideal body weight (IBW) of ≤ 40 kg. If IBW is > 40 kg, adult medication and dosing are more appropriate. For patients under 40 kg, use midazolam only: 0-13 kg –70 mcg/kg, >13-40 kg – 5 mg.
•Autoinjectors (AI) are a convenient means of rapidly administering drugs to treat nerve agent exposure, which may be especially useful pre-hospital or at a hospital managing a large number of patients. However, only certain drugs in specific doses are available in autoinjectors: DuoDote or Antidote Treatment Nerve Agent Autoinjector (ATNAA) or Mark 1 kit (atropine 2 mg/2-PAM Cl 600 mg); atropine 2 mg, 1 mg, or 0.5 mg; 2-PAM Cl 600 mg; diazepam 10 mg.

*National Model EMS Clinical Guidelines are also acceptable: https://www.nasemso.org/Projects/ModelEMSClinicalGuidelines/

Mild/Moderate symptoms include localized sweating, muscle fasciculations, nausea, vomiting, weakness, dyspnea.

Severe symptoms include unconsciousness, convulsions, apnea, flaccid paralysis.

Mild / Moderate Symptoms                                         Severe Symptoms
Infant (0-2 yrs)       Atropine: 0.05 mg/kg IV/IM/IO                                    Atropine: 0.1 mg/kg IV/IM/IO
2-PAM Cl: 15 mg/kg IV/IM/IO                                      2-PAM Cl: 25 mg/kg IV/IM/IO

Child (2-10 yrs)        Atropine: 1 mg IV/IM/IO                                                Atropine: 2 mg IV/IM/IO
2-PAM Cl: 15 mg/kg IV/IM/IO                                       2-PAM Cl: 25 mg/kg IV/IM/IO

Adolescent (>10 yrs)  Atropine: 2 mg IV/IM/IO/AI;                                   Atropine: 4 mg IV/IM/IO/AI;
2-PAM Cl: 15 mg/kg IV/IM/IO                                 2-PAM Cl: 25 mg/kg IV/IM/IO

Adult                              Atropine: 2 to 4 mg IV/IM/IO/AI;                           Atropine: 6 mg IV/IM/IO/AI;
2-PAM Cl: 600 mg IV/IM/IO/AI                             2-PAM Cl: 1800 mg IV/IM/IO/AI

Elderly, Frail                Atropine: 1 mg IV/IM/IO                                            Atropine: 2 to 4 mg IV/IM/IO
2-PAM Cl: 10 mg/kg IV/IM/IO                                   2-PAM Cl: 25 mg/kg IV/IM/IO

Repeat atropine (2 mg IV/IM) at 5- 10 minute intervals until secretions have diminished and breathing is comfortable or airway resistance has returned to near normal.

Specific Pediatric Considerations
For pediatric patients, existing autoinjectors may provide more than the recommended doses of atropine and
pralidoxime. The reference below provides a strategy to mitigate this issue if time and resources allow. This method allows you to discharge the contents of autoinjectors and dilute the drug to prepare the proper dose. Expert opinion would still recommend that, given the benefit compared to the possible harm in delaying treatment, severe patients should be treated with autoinjectors even if they provide doses above recommendations.
Corvino TF, Nahata MC, Angelos MG, Tschampel MM, Morosco RS, Zerkle J, Nelson RN. Availability, stability, and sterility of pralidoxime for mass casualty use. Ann Emerg Med. 2006 Mar; 47(3):272-7.

Additional Considerations
•If faced with a mass casualty incident and if pharmaceutical therapies become exhausted, consider contingency medical countermeasures at your discretion.
•Poison Control Centers provide 24-hour-a-day patient care support at 1-800-222-1222.
•The Secretary of Health and Human Services issued a declaration, effective April 11, 2017, under the Public Readiness and Emergency Preparedness Act (PREP Act) to provide liability immunity to certain individuals and entities against any claim of loss relating to the use of medical countermeasures against nerve agents, given certain conditions are met:
https://www.federalregister.gov/documents/2017/05/10/2017-09455/nerve-agents-and-certain-insecticides-organophosphorous-andor-carbamate-countermeasures
Other Resources
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention /
Agency for Toxic Substances and Disease Registry
https://emergency.cdc.gov/agent/nerve/index.asp
https://www.atsdr.cdc.gov/mmg/mmg.asp?id=523&tid=93
Office of the Assistant Secretary for Preparedness and Response
https://chemm.nlm.nih.gov/na_hospital_mmg.htm
Personal Protective Equipment
U.S. Department of Labor
Occupational Safety and Health Administration
https://www.osha.gov/Publications/OSHA3370-protecting-EMS-respondersSM.pdf
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=9765
Patient Decontamination
U.S. Departments of Health and Human Services and Homeland Security
https://www.phe.gov/Preparedness/responders/Pages/patientdecon.aspx
General
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Preparedness and Response
https://asprtracie.hhs.gov/
National Fire Protection Association
https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=473

History Channel

History Channel

CDC

CDC Health Alert Network (HAN) Health Advisory: Hurricane Florence—Clinical Guidance for Carbon Monoxide (CO) Poisoning

Centers for Disease Control and Prevention (CDC) sent this bulletin at 09/16/2018 02:56 PM EDT

CDC issued the following Health Alert Network (HAN) Health Advisory on September 16, 2018. You are receiving this information because you subscribe to COCA email updates. If a colleague forwarded this email to you, yet you would like to receive future updates directly from COCA, click here. If you have any questions about this or other clinical issues, please e-mail coca@cdc.gov On behalf of the Clinician Outreach and Communication Activity (COCA) Centers for Disease Control and Prevention (CDC) Join us on Facebook

Distributed via the CDC Health Alert Network September 16, 2018 1345 ET (1:45 PM ET) CDC HAN-00415 Hurricane Florence—Clinical Guidance for Carbon Monoxide (CO) Poisoning Summary The Centers for Disease Control and Prevention (CDC) is reminding clinicians seeing patients from the areas affected by Hurricane Florence to maintain a high index of suspicion for CO poisoning. Other people who may be exposed to the same CO source may need to be identified and assessed. The signs and symptoms of CO exposure are variable and nonspecific. A tension-type headache is the most common symptom of mild CO poisoning. Other symptoms may include dizziness, flu-like symptoms without a fever, drowsiness, chest pain, and altered mental status. Clinical manifestations of severe CO poisoning include tachycardia, tachypnea, hypotension, metabolic acidosis, dysrhythmias, myocardial ischemia or infarction, noncardiogenic pulmonary edema, neurologic findings including irritability, impaired memory, cognitive and sensory disturbances, ataxia, altered or loss of consciousness, seizures, coma, and death, although any organ system might be involved. Although CO poisoning can be fatal to anyone, children, pregnant women, the unborn, persons with sickle cell disease, older adults, and persons with chronic illness (e.g., heart or lung disease) are particularly vulnerable. Background High winds and heavy rain from Hurricane Florence began affecting the southeastern U.S. around September 12, 2018. Impact on the southeast coast and inland led to thousands of people without power.  Those without power may turn to alternate power sources such as gasoline generators and may use propane or charcoal grills for cooking. If used or placed improperly, these sources can lead to CO build up inside buildings, garages, or campers and poison the people and animals inside. With a focused history of patient activities and health symptoms, exposure to a CO source may become apparent. Appropriate and prompt diagnostic testing and treatment are crucial to reduce morbidity and prevent mortality from CO poisoning. Identifying and mitigating the CO source is critical in preventing other poisoning cases. Recommendations for Clinicians Consider CO poisoning in patients affected by Hurricane Florence, particularly those in areas currently without power. Assess symptoms and recent patient activities that point to likely CO exposure. Evaluation should also include examination for other conditions, including smoke inhalation, trauma, medical illness, or intoxication. Administer 100% oxygen until the patient is symptom-free or until a diagnosis of CO poisoning has been ruled out. Perform COHgb testing when CO poisoning is suspected. Venous or arterial blood may be used for testing. A fingertip pulse multiple wavelength spectrophotometer, or CO-oximeter, can be used to measure heart rate, oxygen saturation, and COHgb levels in the field, but any suspicion of CO poisoning should be confirmed with a COHgb level by multiple wavelength spectrophotometer (CO-oximeter). A conventional two-wavelength pulse oximeter is not accurate when COHgb is present. For more information, see https://www.cdc.gov/disasters/co_guidance.html. An elevated carboxyhemoglobin (COHgb) level of 2% or higher for non-smokers and 9% or higher COHgb level for smokers strongly supports a diagnosis of CO poisoning. The COHgb level must be interpreted in light of the patient’s exposure history and length of time away from CO exposure, as levels gradually fall once the patient is removed from the exposure. In addition, carbon monoxide can be produced endogenously as a by-product of heme metabolism. Patients with sickle cell disease can have an elevated COHgb level as a result of hemolytic anemia or hemolysis. For additional information about interpretation of COHgb levels, visit https://www.cdc.gov/disasters/co_guidance.html or call Poison Control at (800) 222-1222. Hyperbaric oxygen therapy (HBO) should be considered in consultation with a toxicologist, hyperbaric oxygen facility, or Poison Control Center (800) 222-1222. For additional management considerations, consult a toxicologist, Poison Control at (800) 222-1222, or a hyperbaric oxygen facility. Be aware that CO exposure may be ongoing for others spending time in or near the same environment as the patient. These individuals should be evaluated and tested as described in this advisory. Clinicians treating people for CO poisoning should notify emergency medical services (EMS), the fire department, or law enforcement to investigate and mitigate the source and advise people when it is safe to return. Advise patients about safe practices related to generators, grills, camp stoves, or other gasoline, propane, natural gas, or charcoal-burning devices. Stress that that these devices should never be used inside an enclosed space, home, basement, garage, or camper — or even outside near an open window or window air conditioner. Please see https://www.cdc.gov/co/pdfs/generators.pdf. For More Information Clinical Guidance for Carbon Monoxide (CO) Poisoning After a Disaster https://www.cdc.gov/disasters/co_guidance.html

Antidotes-in-ER_AEM-2017

NPR

NY Times

“……In attacks on Jan. 13, Jan. 22 and Feb. 1, the draft said, government forces fired chemical agents, “most probably chlorine,” into a residential part of eastern Ghouta’s Douma neighborhood, near a sports stadium, roughly 800 yards from the front lines, between 5 a.m. and 6:30 a.m.

Some witnesses described a “slow-acting agent” that smelled like chlorine, the draft said, and they had sufficient time “to rouse the victims, obtain wet cloths to serve as makeshift face masks, and evacuate the affected areas.”……..Thirty-one people, including 11 children, were sickened in the first three attacks, but none died. Two other episodes of possible chlorine use, on Feb. 25 and March 7, caused more extensive casualties, killing two children, including an infant, and injuring 18 civilians...…..”

BBC

“…..Dr Stephen Jukes, an intensive care consultant at the hospital, said: “When we first were aware this was a nerve agent, we were expecting them not to survive.

“We would try all our therapies. We would ensure the best clinical care. But all the evidence was there that they would not survive.”

Both Skripals were heavily sedated which allowed them to tolerate the intrusive medical equipment they were connected to, but also helped to protect them from brain damage, a possible consequence of nerve agent poisoning.

Over time, the sedation was reduced and the ventilation switched from the mouth to the trachea, as shown by the vivid scar seen on Yulia Skripal’s neck in the TV statement she gave after she was released.

Once the patients became more conscious, staff had to carefully consider what they could tell them without prejudicing the police investigation, and decide on the right moment to allow questioning by detectives.

Medical director Dr Christine Blanshard explained: “Those are very difficult decisions, because on the one hand you want to provide reassurance to the patients that they are safe and they are being looked after, and on the other hand you don’t want to give them information that might cause difficulties with subsequent police interviews.”

It was the doctors and nurses that, out of concern for their patients, insisted that international inspectors obtain a court order before they would be allowed to take blood samples from the Skripals.

Dr Jukes explained: “These are vulnerable patients, they needed some form of advocate and without a court order we could not allow things to happen to them without their consent.”

Once the Skripals were stable and able to speak, the key concern for medical staff was how their production of the key enzyme acetylcholinesterase – needed to re-establish their normal body functions – could be stimulated.

The body will do this naturally after nerve agent poisoning, but the process can take many months.

In trying combinations of drugs, Dr Murray says the hospital received input from “international experts”, some of them from Porton Down.

The laboratory, internationally known for its chemical weapons expertise, processed tests and offered advice on the best therapies.

New approaches to well-known treatments were tried. Dr Jukes said that the speed of the Skripals’ recovery came as a very pleasant surprise that he cannot entirely explain……”

Washington Post

“…..The dead included at least seven children under the age of 18, among them a 15-year-old girl, the ministry said. The baby was eight months old and died after inhaling tear gas at the main protest area east of Gaza City…..”