© 2016 northern california ems, inc. all rights reserved ...€¦ · a nor-cal ems webcast the...

A Nor-Cal EMS WebcastThe ChemPack Project

©2016 Northern California EMS, Inc.All Rights Reserved Worldwide.

Presented by Lou Lallo, PharmD, MBA, Dave Lemay, CalFire Chief (ret)for Nor-Cal EMS under HPP Grant.Recorded Live on February 27, 2016.By Patti Garrison.Produced by Engineer Bill Bogenreif. 1

© 2016 Northern California EMS, Inc. All Rights Reserved Worldwide




CHEMPACK PROJECT

Louis Lallo, PharmD, MBA

Dave Lemay, CalFire Chief (ret)

California Department of Public HealthEmergency Preparedness Office




CONFIDENTIALITY:

The information presented here will be kept on a need-to-know basis

The information presented here is not covered under the Freedom of Information Act (FOIA)*

*Protected under 42 USC§ 247d-6b




TOPICS

Overview of CHEMPACK Project

Incident Response

Site Responsibilities

Status of CHEMPACK Project in California

Signs/Symptoms of nerve agent exposure

Types of Agents




TOPICS(continued)

Pathophysiology of Nerve Agents

Treatment of Nerve Agents

Use of Mark-I kit

Sample Protocols for use of Nerve Agent Antidotes

Future Challenges

Conclusion / Questions




“CDC shipping 'chem-packs' to states

Long-awaited antidotes against chemical weapons”

-MSNBC, 8/3/05

“New fears U.S. will be struck again” –Sacramento Bee, 7/31/05

“Fallout over chemical attack risk”-The Guardian, 2/22/05

“Chemical Spill In Dearborn Sends Workers To Hospital” –Detroit.com




THE CHEMPACK PROJECT

An Overview




MISSION STATEMENT

Implement a nationwide project for the “forward” placement of nerve agent antidotes. To provide state and local governments a sustainable resource that increases their capability to respond quicklyto a nerve agent event.




BACKGROUND

SNS Program has a 12-hour response time, too long in the event of a nerve agent attack

Some state and local governments don’t have any nerve agent antidote stocks




BACKGROUND(continued)

Hospitals carry limited or no supplies of treatments for nerve agent exposures

Nerve agent antidotes have variable shelf lives (are not an easily sustainable resource)




SHELF LIFE EXTENSION PROGRAM

(SLEP)

FDA program established with DoD to extend shelf-life of pharmaceuticals

SLEP guidelines provide quality assurance of stored materiel

Environmental monitoring requirements are to ensure product integrity




CHEMPACK EQUIPMENT

CHEMPACK STORAGE CONTAINER




SENSAPHONE 2050

CHEMPACK EQUIPMENT




STANDARD CONTAINERS

The CHEMPACK Project provides two types of containers:

Emergency Medical Service (EMS) Container: Designed for emergency responders

Mostly auto-injectors (allows for rapid administration)

Some multidose vials for variable dosing with elderly or pediatric patients

Hospital Container: Designed for hospital dispensing

Mostly multidose vials for variable dosing and prolonged treatment

Also contains auto-injectors for rapid use




EMS CONTAINER

EMS CHEMPACK Container for 454 Patients

Item Unit PackCases per Container Units in Container

Mark 1 auto-injector 240 5 1200

Atropine Sulfate 0.4mg/ml 20ml 100 1 100

Pralidoxime 1gm inj 20ml 276 1 276

AtroPen® 0.5 mg 144 1 144

AtroPen® 1.0 mg 144 1 144

Diazepam 5mg/ml auto-injector 150 2 300

Diazepam 5mg/ml vial, 10ml 25 2 50

Sterile water for injection (SWFI) 20cc Vials 100 2 200

Sensaphone® 2050 1 1 1

SATCO B DEA Container 1 1 1

Note: does not contain syringes or supplies




HOSPITAL CONTAINER

Hospital CHEMPACK Container for 1000 Patients

Item Unit PackCases per Container Units in Container

Mark 1 auto-injector 240 2 480

Atropine Sulfate 0.4mg/ml 20ml 100 9 900

Pralidoxime 1gm inj 20ml 276 10 2760

AtroPen® 0.5 mg 144 1 144

AtroPen® 1.0 mg 144 1 144

Diazepam 5mg/ml auto-injector 150 1 150

Diazepam 5mg/ml vial, 10ml 25 26 650

Sterile water for injection (SWFI) 20cc Vials 100 28 2800

Sensaphone® 2050 1 1 1

SATCO B DEA Container 1 1 1

Note: does not contain syringes or supplies




Additional CHEMPACK Ancillary Supplies

•Saline Mini-bag 100cc (0.9% 100ml IV Piggyback mix)

•IV Start Kits

•IV Catheter, 18 or 20 gauge, 1 ¼”

•IV Catheter, 24 Gauge, 1 ¼”

•Safety Glide 10cc 22 gauge X 1 ½” (syringe and needle)

•IV Administration Set, micro Drip 60 GTTS non-vented

Supplies needed to administer CHEMPACK injectable medications

that are not included




Mark IAuto-injector

Diazepam Auto-Injector

Atropine, Pralidoxime, And Diazepam Multi-dose Vials

PHARMACEUTICALS




Pediatric Issues:

Pediatric Atropen - FDA recently approved in various strengths

Pralidoxime (2PAM-Cl) – not FDA approved for children <16, either in multidose vial or auto-injector. High priority for FDA

Some medical protocols describe an off-label use. This is between individual physician and patient

PHARMACEUTICALS




INCIDENT RESPONSE




RESPONSIBILITIES

Pre-Incident

Incident• Manages Design

configuration

• Procures/ships/installs caches

• Transfers materiel and custody (but retains ownership)

• Centrally manages CHEMPACK inventory

• Sustains CHEMPACK inventory

Site

• Retains custody of opened materiel, but material no longer eligible for SLEP

• Returns opened CHEMPACK containers per disposition instructions

• Provides disposition guidance

• Receives and services equipment

• Attempts to obtain funding to restock opened containers

• Provides technical assistance

Site

• Opens CHEMPACK containers

• Dispenses, controls, maintains, and equips users,

SITE

• Selects cache sites• Prepares cache facilities• Assists installation• Assumes custody of

CHEMPACK materiel• Training

CDC

CDC

Post-Incident

CDC




SITERESPONSIBILITIES




Provide name and DEA registrant numbers of personnel signing for CHEMPACK

Provide list of all personnel with access to CHEMPACK

SITE RESPONSIBILITIES




SITE RESPONSIBILITIES(continued)

Assume custody of CHEMPACK materiel

Only Pre-position CHEMPACK materiel with approval from CDHS/EPO and CDC

Agree to break CHEMPACK container seal only when it is determined that an event is beyond local emergency response capabilities




CDC CONDITIONS FOR USING CHEMPACK DRUGS

Threatens the medical security of the community; and

Places multiple lives at risk; and

Is beyond local emergency response capabilities; and

The material is medically necessary to save human life




CALIFORNIAOVERVIEW




California Chempack Coverage




CASE STUDY

Man self-administered Malathion in Sonoma County on 12/31/13 at 1143hrs

Hospital requested 2-PAM from Chempack site in Napa County

CHP picked up via helicopter

2-PAM administered 110 min from time of ingestion and 83 min from time pt arrived at hospital

Patient survived and discharged




California Chempack Coverage




Signs/Symptoms of Nerve Agent

Exposure




SYMPATHETIC NERVOUS SYSTEM




PARASYMPATHETIC NERVOUS SYSTEM




The Autonomic Nervous System

Structure Sympathetic Stimulation Parasympathetic Stimulation

Iris (eye muscle) Pupil dilation Pupil constriction

Salivary Glands Saliva production reduced Saliva production increased

Oral/Nasal MucosaMucus production reduced

Mucus production increased

HeartHeart rate and force increased

Heart rate and force decreased

Lung Bronchial muscle relaxed Bronchial muscle contracted

Stomach Peristalsis reduced Gastric juice secreted; motility increased

Small Intestine Motility reduced Digestion increased

Large Intestine Motility reduced Secretions and motility increased

LiverIncreased conversion ofglycogen to glucose

Kidney Decreased urine secretion Increased urine secretion

Adrenal medullaNorepinephrine andepinephrine secreted

BladderWall relaxedSphincter closed

Wall contractedSphincter relaxed




NERVE AGENT SYMPTOMSMnemonics for Nerve Agent Exposure

“SLUDGEM” S Salivation L Lacrimation U Urination D Defecation G GI distress E Emesis M Miosis (pinpoint pupils)

“DUMBBELS”

D Diarrhea

U Urinary incontinence

M Miosis/Muscle fasciculations

B Bronchorrhea

B Bronchospasm

E Emesis

L Lacrimation

S Salivation




TYPES OFNERVE AGENTS




Nerve Agents

A substance that causes biological effects by inhibiting acetylcholinesterase

Acetylcholine accumulates

Effects are due to excess stimulation of body organs.




Types of Nerve Agents

Organophosphate Pesticides = Nerve Agents

Slow to Act Quick Acting

Longer Duration Short Duration

Less Severe Very Severe





Carbamates Physostigmine (Antilirium) Neostigmine (Prostigmine) Pyridostigmine (Mestinon) Sevin (insecticide)

Organophosphate Pesticide Malathion Diazinon





GA (Tabun)

GB (Sarin)

GD (Soman)

GF (Cyclosarin)

VX




Nerve Agents

Most toxic chemical agents: are liquids, not “gas”

GB (Sarin): vapor or liquid hazard; non-persistent

VX: liquid hazard; persistent

Penetrate skin, eyes, lungs

Loss of consciousness, seizures, apnea, death

Diagnosis made clinically, confirmed by laboratory test




PHYSICAL PROPERTIES

Clear, colorless liquids (until vaporized)

Tasteless, most are odorless

Freeze/melt <0º C

Boil >150º C

Penetrate skin, clothing




TOXICITY & HALF-LIVESOF NERVE AGENTS

AGENT LCt50

(mg-min/m3

LD50

(mg)

Aging Half-

Life

Tabun (GA) 400 1000 46 h

Sarin (GB) 100 1700 5.2 – 12 h

Soman (GD) 50 100 40 sec to 10

min

VX 10 10 50 – 60 h




PATHOPHYSIOLOGYOF

NERVE AGENTS




Normal Nerve Function

ACh





ACh





ACh

AChE




How Nerve Agents Work

AChE

AChGB




Hyperstimulation of organs of cholinergic nervous system

Muscarinic

Smooth muscles

Glands

Nicotinic

Skeletal muscles

Ganglions

Effects of Nerve Agents




Increased secretions

Saliva

Tears

Runny nose (rhinorrhea)

Secretions in airways

Secretions in gastrointestinal tract

Sweating

Effects of Nerve AgentsMuscarinic Sites




Effects of Nerve AgentsMuscarinic Site

Smooth Muscle Contraction:

Eyes: Small pupils - > dim vision

Airways: Narrowing - > shortness of breath

Intestine: Hyperactivity - > nausea, vomiting, diarrhea




Pupil Response




Effects of Nerve AgentsNicotinic Sites

Skeletal muscles Fasciculations

Twitching

Weakness

Flaccid paralysis

Ganglion Tachycardia

Hypertension




Central Nervous System Effects

CNS Acute

Loss of consciousness

Convulsions

Apnea

Prolonged 4 to 6 weeks Psychological effect




Nerve AgentsVapor Exposure

Vapor effects occur within seconds, peak within minutes

Low exposure Miosis (dim vision, eye pain) Runny nose (rhinorrhea) Shortness of breath

High exposure Immediate loss of consciousness, seizures, apnea,

flaccid paralysis




Nerve AgentsLiquid Skin Exposure

Small amount Localized sweating Fasciculations

Moderate amount (<LD50) Gastrointestinal effects

Large amount (LD50) Sudden loss of consciousness Seizures Apnea




NERVEAGENT

TREATMENT




Nerve AgentsTreatment

Self-protection

Decontamination




Nerve AgentsTreatment

(Continued)

Airway/ventilation

Antidotes

Atropine

2-PAMCl

Diazepam




Nerve Agent AntidotesAtropine

Antagonizes muscarinic effects

Dries secretions; relaxes smooth muscles

Given IV, IM, ET




Nerve Agent AntidotesAtropine

Does not affect fasciculations, muscle strength

When given IV, IM, or ET, will not reverse miosis

May cause cardiac arrhythmias IV in hypoxic patient (v-fib)




Nerve Agent AntidoteAtropine

Starting dose - 2 mg

Maximum cumulative dose - 20 mg

Side effects in normal people

Dilated pupils

Blurred vision

Tachycardia

Decreased sweating




Nerve Agent AntidotesTreatment

Atropine - How much to give?

Until secretions are drying or dry

Until ventilation is “easy”

If conscious, and casualty is comfortable

Don’t rely on heart rate/pupil size




Nerve Agent AntidotesPralidoxime Chloride (2-PAMCl)

Remove nerve agent from AChE in absence of aging (2-PAM “crowbar”)

Does not reverse muscarinic effects on glands and smooth muscles

Helps at nicotinic sites

AChE

2-PAM Cl

Nerve Agent




CLINICAL PHARMACOLOGY2 - PAM

Cholinesterase reactivator

Most critical effect is relieving paralysis of the muscles of respiration

Distributed throughout extracellular water

Is not bound to plasma protein

Rapidly excreted in urine partly unchanged, and partly as a metabolite produced by the liver

Minimum therapeutic concentration in plasma is reached in about 16 minutes after a 600mg injection




CLINICAL PHARMACOLOGY2 – PAM

(continued) Apparent half-life is 74 – 77 minutes Drug interactions:

Barbituates are potentiated by anticholinesterases Morphine, theophylline, aminophylline, succinylcholine, reserpine &

phenothiazine-type tranquilizers should be avoided in patients with organophosphate poisoning

Adverse reactions in normal volunteers: Blurred vision, diplopia, impaired accommodation, dizziness, headache,

drowsiness, nausea, tachycardia, increase systolic and diastolic blood pressure, hyperventilation, muscular weakness

Possible elevations in SGOT and/or SGPT

Acute Toxicity: i.v. – man TDLo: 14mg/kg (toxic effects:CNS)




USE OF MARK-I KIT




TREATMENT PITFALLS

Failure to recognize signs & symptoms of cholinergic excess

Using miosis to interpret severity of exposure or guide atropine therapy

Failure to suspect occult seizures in paralyzed patients

Failure of first responders to adequately protect themselves

Failure to adequately decontaminate victims




TREATMENT PITFALLS(continued)

Failure to recognize the rapidity with which nerve agents act.

Failure to appreciate the time course of liquid nerve agent exposure

Administration of atropine before hypoxemia is treated – may cause ventricular fibrillation

Administration of succinylcholine – may lead to markedly prolonged paralysis

Failure to administer 2-PAM ASAP




FUTURECHALLENGES




FUTURE CHALLENGES

Local and Regional Plan Development

New and Ongoing Training

Security




IN CONCLUSION…

CHEMPACK Project has the potential to save many lives in case of a nerve agent attack or accidental exposure

The effectiveness of the CHEMPACK Project depends on how well we plan and train




THANK YOU!

© 2016 northern california ems, inc. all rights reserved ...€¦ · a nor-cal ems webcast the...

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