Omaha Metropolitan Medical Response System

OMMRS

Administration of Mark I™ Kit, DuoDote™ and AtroPen® Auto-Injectors

Presented by the OMMRS Pharmacy SubcommitteeVersion 2, copyright © 2008

Treatment Disclaimer

This video is intended to provide general guidelines and is This video is intended to provide general guidelines and is not intended for individual patient care. not intended for individual patient care.

Please contact a physician or your regional poison control Please contact a physician or your regional poison control center for patient-specific management advice as needed.center for patient-specific management advice as needed.

Administration of Mark I™ Kit, DuoDote™ and AtroPen® Auto-Injectors Video

Created by the Omaha Metropolitan Medical Response Created by the Omaha Metropolitan Medical Response System Pharmacy SubcommitteeSystem Pharmacy Subcommittee

Provides general information on the use and Provides general information on the use and administration of the Mark I Kit, DuoDote, and administration of the Mark I Kit, DuoDote, and

AtroPen auto-injectors for nerve agent exposuresAtroPen auto-injectors for nerve agent exposures

Please check with your local fire department and Please check with your local fire department and MMRS for specific treatment protocolsMMRS for specific treatment protocols

Nerve Agents

Chemical Warfare Agents Chemical Warfare Agents Tabun (GA)Tabun (GA) Sarin (GB)Sarin (GB) Soman (GD)Soman (GD) VXVX

Organophosphate InsecticidesOrganophosphate Insecticides MalathionMalathion ParathionParathion

Lethal Amount of VX

Mark I Kit Auto-Injector

Contains:Contains: Atropine IM 2 mg in 0.7 millilitersAtropine IM 2 mg in 0.7 milliliters Pralidoxime Chloride (2-PAM or Protopam) IM Pralidoxime Chloride (2-PAM or Protopam) IM

600 mg in 2 milliliters600 mg in 2 milliliters

Duodote Auto-Injector

Contains:Contains: Atropine 2.1 mg in 0.7 milliliters and Pralidoxime Atropine 2.1 mg in 0.7 milliliters and Pralidoxime

Chloride (2-PAM or Protopam) 600 mg in 2 milliliters in Chloride (2-PAM or Protopam) 600 mg in 2 milliliters in two separate internal chambers. When activated, the two separate internal chambers. When activated, the DuoDote administers both drugs IM in a single auto-DuoDote administers both drugs IM in a single auto-injector.injector.

The antidotes should only be used when signs and The antidotes should only be used when signs and symptoms of exposure are presentsymptoms of exposure are present

Self Protection Protect Yourself: Protect Yourself:

Liquid contamination on clothing poses a vapor and dermal contact Liquid contamination on clothing poses a vapor and dermal contact risk to care givers.risk to care givers.

Protection from vapors requires wearing air-supplied respirators Protection from vapors requires wearing air-supplied respirators such as self-contained breathing apparatus until the patient is such as self-contained breathing apparatus until the patient is decontaminated.decontaminated.

Protect yourself by avoiding contact with skin or clothing of victims Protect yourself by avoiding contact with skin or clothing of victims (wear chemical-protective clothing).(wear chemical-protective clothing).

Skin decontamination before patient enters squad or hospitalSkin decontamination before patient enters squad or hospital

Nerve Agents Treatment

Aggressive Respiratory SupportAggressive Respiratory Support SuctionSuction OxygenOxygen IntubationIntubation Assisted VentilationAssisted Ventilation

S-M-I-L-E

S S Self-containedSelf-contained breathing apparatus breathing apparatus MM MaskMask and other PPE and other PPE II InjectInject self or patient AND self or patient AND

InitiateInitiate respiratory support respiratory support LL LeaveLeave area for decontamination area for decontamination E E EvaluationEvaluation by a medical team by a medical team

Nerve AgentsToxicity/Onset of Effects

Nerve Agents and some organophosphate Nerve Agents and some organophosphate insecticides are extremely toxic by inhalation, insecticides are extremely toxic by inhalation, ingestion, and dermal exposureingestion, and dermal exposure

Onset of clinical effects may be rapid following Onset of clinical effects may be rapid following inhalation and ingestion or may be delayed up to 18 inhalation and ingestion or may be delayed up to 18 hours following dermal exposureshours following dermal exposures

Effects of Nerve Agents

Mild SymptomsMild Symptoms Pinpoint pupils (miosis)Pinpoint pupils (miosis) Excessive sweatingExcessive sweating Tearing (lacrimation)Tearing (lacrimation) Drooling (salivation)Drooling (salivation) Runny noseRunny nose Mild chest tightnessMild chest tightness Mild shortness of breathMild shortness of breath

Effects of Nerve Agents

Moderate SymptomsModerate Symptoms Severe chest tightnessSevere chest tightness WheezingWheezing Profuse airway secretionsProfuse airway secretions Respiratory distressRespiratory distress Vomiting, abdominal crampsVomiting, abdominal cramps DiarrheaDiarrhea Muscle weaknessMuscle weakness

Effects of Nerve Agents

Severe SymptomsSevere Symptoms CyanosisCyanosis SeizuresSeizures ComaComa Flaccid paralysisFlaccid paralysis Respiratory failureRespiratory failure ApneaApnea

S-L-U-D-G-E-M

SS SalivationSalivation AND AND SweatingSweatingLL LacrimationLacrimation (tearing of the eyes) (tearing of the eyes)UU UrinationUrinationDD DefecationDefecation//DiarrheaDiarrheaGG GIGI Upset (abdominal cramping) Upset (abdominal cramping)EE EmesisEmesis AND AND ExcessiveExcessive Airway Secretions Airway SecretionsM M MuscleMuscle Weakness/Paralysis AND Weakness/Paralysis AND MiosisMiosis

Mark I Kit Injection Procedure

1. Remove Mark I Kit from the protective 1. Remove Mark I Kit from the protective pouch.pouch.

2. With the non-dominant hand, hold the 2. With the non-dominant hand, hold the unit by the plastic clip so that the unit by the plastic clip so that the larger one is on top and both are larger one is on top and both are positioned at eye level.positioned at eye level.

3. Remove the AtroPen from slot number 3. Remove the AtroPen from slot number one (1)one (1) of the plastic clip of the plastic clip The The yellowyellow safety cap will remain in the safety cap will remain in the

clip and the AtroPen will now be armed. clip and the AtroPen will now be armed. DO NOTDO NOT hold unit by the hold unit by the greengreen tip the tip the

needle injects from needle injects from greengreen tip. tip.

Mark I Kit Injection Procedure

4. With the other hand, check the injection site 4. With the other hand, check the injection site for buttons or objects in pockets which may for buttons or objects in pockets which may interfere with the injections. interfere with the injections.

5. Grasp the unit and position the 5. Grasp the unit and position the greengreen tip of tip of the AtroPen on victim’s outer thigh or the AtroPen on victim’s outer thigh or buttocks.buttocks.

6. Push firmly until the auto-injector fires.6. Push firmly until the auto-injector fires.

7.7. Hold the injector firmly in place for at least Hold the injector firmly in place for at least 10 10 secondsseconds..

Mark I Kit Injection Procedure

8. Remove the Pralidoxime Chloride Pen from 8. Remove the Pralidoxime Chloride Pen from slot number slot number two (2)two (2) of the plastic clip of the plastic clip The The greygrey safety cap will remain in the clip and safety cap will remain in the clip and

the Pen will now be armedthe Pen will now be armed DO NOTDO NOT hold the unit by the hold the unit by the blackblack tip – the tip – the

needle injects from the needle injects from the blackblack tip. tip.9.9. Grasp the unit and position the Grasp the unit and position the blackblack tip of tip of

the Pen on victim’s alternate outer thigh or the Pen on victim’s alternate outer thigh or buttocks.buttocks.

Mark I Kit Injection Procedure10. Push firmly until the auto-injector fires.10. Push firmly until the auto-injector fires.

11. Hold the injector firmly in place for at least 11. Hold the injector firmly in place for at least 10 seconds10 seconds..

12. Place the auto-injectors in a sharps container.12. Place the auto-injectors in a sharps container.

13. Document the number of auto-injectors administered on 13. Document the number of auto-injectors administered on the patient care report or the triage tag.the patient care report or the triage tag.

1 kit1 Kit

DuoDote Injection Procedure

1. Remove the DuoDote from the 1. Remove the DuoDote from the plastic pouch.plastic pouch.

2. Place the DuoDote in your 2. Place the DuoDote in your dominant hand. Firmly grasp the dominant hand. Firmly grasp the center of the DuoDote with the center of the DuoDote with the greengreen tip pointing down. Do not tip pointing down. Do not touch the touch the greengreen tip. tip.

3. With your other hand, pull off the 3. With your other hand, pull off the graygray safety release. The DuoDote safety release. The DuoDote is now ready to be administered. is now ready to be administered.

DuoDote Injection Procedure

4. Make sure pockets at the injection site are 4. Make sure pockets at the injection site are empty. empty.

5. Firmly push the 5. Firmly push the greengreen tip straight down tip straight down against the outer thigh. Continue to firmly against the outer thigh. Continue to firmly push until you feel the auto-injector trigger.push until you feel the auto-injector trigger.

6.6. Hold the DuoDote in place for Hold the DuoDote in place for 10 seconds10 seconds..7. Remove the auto-injector from the thigh and 7. Remove the auto-injector from the thigh and

look at the look at the greengreen tip. If the needle is visible, tip. If the needle is visible, the drug has been administered.the drug has been administered.

DuoDote Injection Procedure

8. If the needle is not visible, check to be sure 8. If the needle is not visible, check to be sure the the graygray safety release has been removed safety release has been removed and repeat the procedure. and repeat the procedure.

9. Place the auto-injector in a sharps container.9. Place the auto-injector in a sharps container.10. Document the number of auto-injectors 10. Document the number of auto-injectors

administered on the patient care report or administered on the patient care report or triage tag.triage tag.

Auto-Injector Notes

Auto-injector needle is 8/10 inch long Auto-injector needle is 8/10 inch long Injector needle can go through clothing Injector needle can go through clothing Injector needle may not penetrate bunker gearInjector needle may not penetrate bunker gear Give injections into a large muscle mass area Give injections into a large muscle mass area

such as the outer thigh or buttockssuch as the outer thigh or buttocks

Treatment Guidelines

Mild SymptomsMild SymptomsGive Give OneOne Mark I Kit Mark I Kit OROR OneOne DuoDote DuoDote

2 mg of Atropine & 600 mg of Pralidoxime2 mg of Atropine & 600 mg of Pralidoxime

Treatment Guidelines

Moderate SymptomsModerate SymptomsGive Give TwoTwo MARK I Kits MARK I Kits OR OR TwoTwo DuoDotes DuoDotes

4 mg of atropine & 1200 mg of pralidoxime4 mg of atropine & 1200 mg of pralidoxime

Treatment Guidelines

Severe SymptomsSevere SymptomsGive Give ThreeThree MARK I Kits MARK I Kits OR OR ThreeThree DuoDotes DuoDotes

6 mg of atropine & 1800 mg of pralidoxime6 mg of atropine & 1800 mg of pralidoximeDiazepam (Valium) 5-10 mgDiazepam (Valium) 5-10 mg

Intramuscular or intravenous Intramuscular or intravenous Administer to patients with seizures Administer to patients with seizures Consider for non-convulsing patients with severe Consider for non-convulsing patients with severe

symptomssymptoms

Treatment Guidelines

Continue to give additional 2 mg doses of Continue to give additional 2 mg doses of Atropine at 5 to 10 minutes intervals as Atropine at 5 to 10 minutes intervals as needed to dry excessive secretionsneeded to dry excessive secretions

Atropine

RememberRemember: Patients die a pulmonary death: Patients die a pulmonary death Atropine will dry lung secretions and relax Atropine will dry lung secretions and relax

bronchoconstrictionbronchoconstriction Indicator of sufficient atropine dosing: Indicator of sufficient atropine dosing:

decrease in lung secretions, decreased decrease in lung secretions, decreased airway resistance, drying of nasal and oral airway resistance, drying of nasal and oral secretions and improved respiratory functionsecretions and improved respiratory function

Pupil size should not be used as a guide for Pupil size should not be used as a guide for sufficient atropine dosingsufficient atropine dosing

Atropine

Insufficient atropine can result in fatalitiesInsufficient atropine can result in fatalities Too much atropine can cause dilated pupils, Too much atropine can cause dilated pupils,

dry mouth and skin, rapid heart rate, flushed dry mouth and skin, rapid heart rate, flushed skin, confusion, and urinary retention.skin, confusion, and urinary retention.

Atropine overdose is rarely life-threateningAtropine overdose is rarely life-threatening

PralidoximeAdverse Effects

Mild to moderate pain at injection siteMild to moderate pain at injection site Other Side Effects:Other Side Effects:

Blurred visionBlurred vision HeadacheHeadache Increased blood pressureIncreased blood pressure Double visionDouble vision DizzinessDizziness DrowsinessDrowsiness TachycardiaTachycardia HyperventilationHyperventilation

Pediatric Use

In a mass terrorist attack, proportionately In a mass terrorist attack, proportionately more children than adults may be affectedmore children than adults may be affected

Pediatric patients may be more seriously ill Pediatric patients may be more seriously ill than adults following the same exposurethan adults following the same exposure

Best option is to dose atropine and Best option is to dose atropine and pralidoxime based on the child’s weightpralidoxime based on the child’s weight

Pediatric Dosing AtropineAtropine

Children: 0.05 mg/kg IV or IM every 5 to10 minutes as needed for Children: 0.05 mg/kg IV or IM every 5 to10 minutes as needed for bronchospasm and secretionsbronchospasm and secretions

PralidoximePralidoxime Children: 25-50 mg/kg (max 1 gram/dose) IV or IM; repeat in one Children: 25-50 mg/kg (max 1 gram/dose) IV or IM; repeat in one

hour as needed hour as needed

DiazepamDiazepam Children: 0.2-0.5 mg/kg IV or IM; may repeat every 5 to10 Children: 0.2-0.5 mg/kg IV or IM; may repeat every 5 to10

minutes as needed to control seizuresminutes as needed to control seizures

Pediatric Use

Atropine is most needed initially in the field and ideally Atropine is most needed initially in the field and ideally should be given from pre-filled syringes, pediatric auto-should be given from pre-filled syringes, pediatric auto-injectors, or multi-dose vialsinjectors, or multi-dose vials

The Mark I Kit auto-injector may be discharged into a The Mark I Kit auto-injector may be discharged into a sterile container, such as a vial, and the amount needed sterile container, such as a vial, and the amount needed drawn up and given IMdrawn up and given IM

Do not give IV due to the preservativeDo not give IV due to the preservative There is potential for injury from the injector needle when There is potential for injury from the injector needle when

administered to small childrenadministered to small children In the absence of any other option, one Mark I Kit In the absence of any other option, one Mark I Kit OROR

one DuoDote may be given to children weighing 12 kg or one DuoDote may be given to children weighing 12 kg or greatergreater

For the child For the child in extremisin extremis, one Mark I Kit , one Mark I Kit OROR one one DuoDote may be given, regardless of sizeDuoDote may be given, regardless of size

Pediatric Use

AtroPen is an atropine auto-injector available in AtroPen is an atropine auto-injector available in various doses (0.25 mg, 0.5 mg, 1 mg, 2 mg)various doses (0.25 mg, 0.5 mg, 1 mg, 2 mg)

Use of a pediatric-strength AtroPen, facilitates Use of a pediatric-strength AtroPen, facilitates the rapid administration of atropine doses to the rapid administration of atropine doses to childrenchildren

AtroPen 0.5 mg contains atropine 0.5 mg/0.7 mlAtroPen 0.5 mg contains atropine 0.5 mg/0.7 ml Dosing is based on child’s weight and severity of Dosing is based on child’s weight and severity of

symptomssymptoms

Pediatric Use

Children weighing 13 to 40 pounds: Give One AtroPen 0.5mg Children weighing 13 to 40 pounds: Give One AtroPen 0.5mg auto-injector; repeat dose every 5-10 minutes as neededauto-injector; repeat dose every 5-10 minutes as needed

Children weighing 41 to 62 pounds: Give Two AtroPen 0.5mg Children weighing 41 to 62 pounds: Give Two AtroPen 0.5mg auto-injectors; repeat entire dose every 5-10 minutes as neededauto-injectors; repeat entire dose every 5-10 minutes as needed

Children weighing 63 to 84 pounds: Give Three AtroPen 0.5mg Children weighing 63 to 84 pounds: Give Three AtroPen 0.5mg auto-injectors; repeat entire dose every 5-10 minutes as neededauto-injectors; repeat entire dose every 5-10 minutes as needed

Children weighing greater than 84 pounds: Give One Mark I Kit Children weighing greater than 84 pounds: Give One Mark I Kit OROR one DuoDote; repeat dose every 5-10 minutes as needed one DuoDote; repeat dose every 5-10 minutes as needed

AtroPen Injection Procedure

1.1. Snap the grooved end of the plastic sleeve down Snap the grooved end of the plastic sleeve down and over the and over the yellowyellow safety cap. Remove the safety cap. Remove the AtroPen from the plastic sleeve.AtroPen from the plastic sleeve.

2.2. Firmly grasp the AtroPen with the Firmly grasp the AtroPen with the greengreen tip pointed tip pointed down.down.

3.3. Pull off the Pull off the yellowyellow safety cap with your other hand. safety cap with your other hand. DO NOTDO NOT touch the touch the greengreen tip - the needle injects tip - the needle injects from from greengreen tip. tip.

4.4. The auto-injector will go through clothing, but make The auto-injector will go through clothing, but make sure that pockets near the injection site are empty.sure that pockets near the injection site are empty.

AtroPen Injection Procedure

5.5. Aim and firmly push the Aim and firmly push the greengreen tip against the outer tip against the outer thigh.thigh.

6.6. Small children should also be injected in the thigh, Small children should also be injected in the thigh, but the thigh should be gently pinched to provide a but the thigh should be gently pinched to provide a thicker area for injection.thicker area for injection.

7.7. Hold the auto-injector firmly in place for ten Hold the auto-injector firmly in place for ten seconds. seconds.

8.8. Remove the AtroPen and massage the injection Remove the AtroPen and massage the injection site.site.

9.9. Place the auto-injector in a sharps container.Place the auto-injector in a sharps container.

For additional information and guidance on the For additional information and guidance on the treatment of nerve agent and insecticide treatment of nerve agent and insecticide exposures, please contact your poison exposures, please contact your poison

control center at control center at 1-800-222-1222 1-800-222-1222

Resources

The Nebraska Regional Poison Center website The Nebraska Regional Poison Center website www.nebraskapoison.comwww.nebraskapoison.com contains: contains:

OMMRSOMMRS Administration of Mark I™ Kit, DuoDote™ and Administration of Mark I™ Kit, DuoDote™ and AtroPen® Auto-Injectors Video and HandoutAtroPen® Auto-Injectors Video and Handout

OMMRSOMMRS Reference Cards Reference Cards NBC Agents Overview/Quick Reference GuideNBC Agents Overview/Quick Reference Guide EMS Immediate Response NBC Reference CardEMS Immediate Response NBC Reference Card Psychiatric Medication Resources in EmergenciesPsychiatric Medication Resources in Emergencies

References

CDC Website: CDC Website: www.bt.cdc.govwww.bt.cdc.gov

Chemical Warfare Involving Kids Response Project Syllabus: Chemical Warfare Involving Kids Response Project Syllabus: CWIKresponse.comCWIKresponse.com

Domestic Preparedness Training Program Instructor Guide. U.S. Army Domestic Preparedness Training Program Instructor Guide. U.S. Army Edgewood Research, Development and Engineering Center. 1998, Booz-Edgewood Research, Development and Engineering Center. 1998, Booz-Allen and Hamilton Inc. and Science Applications International CorporationAllen and Hamilton Inc. and Science Applications International Corporation

Henretig F, Mechem C, Jew R. “Potential use of autoinjector-packaged Henretig F, Mechem C, Jew R. “Potential use of autoinjector-packaged antidotes for treatment of pediatric nerve agent toxicity”, antidotes for treatment of pediatric nerve agent toxicity”, Ann of Emerg MedAnn of Emerg Med, , 40:4, October 200240:4, October 2002

MICROMEDEX® Healthcare Series Vol. 124, expires 12/2008