STEPPING UP OUR GAME: THE MICHIGAN CBRNE RESPONSE. Don Edwards, DO, FACEP, FACOEP Jerry Evans, MD, FACEP William Fales, MD, FACEP

Transcription

1 STEPPING UP OUR GAME: THE MICHIGAN CBRNE RESPONSE Don Edwards, DO, FACEP, FACOEP Jerry Evans, MD, FACEP William Fales, MD, FACEP

2 } Dr. Edwards None } Dr. Evans None } Dr. Fales None

3 Don Edwards, DO, FACEP, FACOEP District 1Regional Medical Response Coalition and Region 8 Healthcare Coalition

4 } Rapid acting potentially deadly chemical in different forms 1. Gas Hydrogen Cyanide (HCN) 2. Crystal salt Potassium (KCN) or Sodium Cyanide (NaCN)

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6 } Inhalation symptoms of poisoning within seconds to minutes (especially in closed spaces) } Ingestion rapidly fatal (dose related) } Skin/eyes may be immediate or delayed

7 } Cyanide ion halts cellular respiration by inhibiting enzyme in the mitochondria called cytochrome c oxidase. } Cells become unable to use oxygen, shutting down oxidative phosphorylation and ATP production. } Increases anaerobic glycolysis leading to Lactic Acidosis very quickly. Cells Quickly Die (heart and brain)

8 } Small amount Dizzy, HA, Nausea, vomiting, Rapid RR and HR, weakness } Larger amount Convulsions, LOC, Low BP, Slow HR, Respiratory Failure leading to death

9 } 3 Agents Dispersed by Gas that cause 1.Simultaneous falling/ collapsing 2. Lose Consciousness 3. Seizures Nerve Agent / Cyanide / possibly Hydrogen Sulfide

10 } Most Likely Inhalation or Ingestion Closed spaces make inhalation worse } Must have high index of suspicion

11 } Category S/S Treatment } Immediate conv/apnea O2/ Antidote } Delayed Unconscious breathing Minimal consc + breathing No Antidote Expectant No Cardiac activity no care ** ***** Resources are available for resuscitation

12 Only outside Hot Zone - Why??? Gas, liquids, skin Ambulatory Patients Have them keep walking Gas exposure with no eye irritation do not need decontamination Decontamination simultaneous to antidotes

13 } Antidotes Cyanide Antidote Kits } Cyanokits Sulfanegen

14 } 5g Vial in 0.9 NS or D5W, mix and run over 15 minutes. Hydroxocobalamin rapidly binds to Cyanide forming Cyanocobalamin which is excreted in the urine (the cells can then use Oxygen again)

15 } 911 call for KCN Ingestion } EMS immediate response / Pt apneic but has pulse } Airway placed and transport to ED within minutes

16 } Resuscitation continues } Oxygen, IV Fluids, 2 Cyanokits given quickly and consultation with Poison Control Center } Patient has pulse but no spontaneous CNS activity

17 } Additional patients at scene or is this part of a bigger incident? } Hospital Cyanokits depleted? } PPE for staff? } Secondary contamination?

18 } Ingested KCN is quickly converted to Hydrogen Cyanide gas } This gas can be expelled through ventilation and vomitus. } Cyanide is quickly metabolized.. } How long is the risk?????

19 } PPE } Isolation room/ negative pressure } No aggressive movements (vomit) } Testing for off gassing contamination to facility } 2 hours to 6 hours risk becomes minimal to providers } Some longer term risk for Medical Examiners

20 } MEDDRUN (additional Cyanokits were deployed) State Asset } Technical Support Team (Region 2 South and Local and Regional HAZMAT teams)

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22 Jerry A. Evans, MD, MMM, FACEP Region 6, Medical Director

23 } Most common industrial gases in Michigan Chlorine Ammonia Phosgene Hydrogen Sulfide Natural gas Properties Uses Transportation Preparedness Treatment Resources

24 } Properties Colorless with sharp irritating odor Forms white mist of hydrochloric acid when in contact with moist air Anhydrous HCL combined with water will attack metal and release hydrogen gas which is flammable

25 } Uses Automotive Construction Defense Electronics Food production and handling Healthcare Metal production Water treatment

26 } Transportation 65 million tons manufactured globally annually 13.8 million tons in the US Transported to all states by rail or truck

27 } Preparedness Irritant agent Corrosive due to combining with moist air to make HCl Heavier than air Shelter in place vs. evacuation Turn off ventilation systems

28 } Treatment Decontamination Humidified Oxygen Beta agonists (albuterol) Supportive care

29 } Resources The Chlorine Institute Chemtrec Established by the Chemical industry as a public service hotline for emergency responders. 24/7/365 Community planning resource for hazardous materials

30 } Properties May be anhydrous (100%) or aqua ammonia (19-30%) Colorless Pungent odor, can be detected by humans at 3 to 5 ppm Lighter than air, but can be close to the ground in moist air Strong base, caustic

31 } Uses 80% used in agriculture, primarily fertilizer due to high nitrogen content Refrigeration Power plants for pollution control Heat treatment of metals Methamphetamine labs

32 } Transportation Transported by truck in special pressure containers Nurse tanks used on farms Railcars Pipeline from Gulf of Mexico to midwest

33 } Preparedness Level A suits often needed to deal with leaks High pressure release causes vapor which then turns into dense gas Dense gas cloud may settle to the ground depending on air moisture content If ground cools enough, the ammonia can liquefy and form puddles

34 } Treatment Decontamination Thermal burns (frostbite) Chemical burns (strong base) Respiratory irritant

35 } Properties Heavier than air Poisonous gas at room temperature May be colorless or white to yellow gas Not found naturally

36 } Uses World War I used as a choking agent Used in the production of plastics and pesticides Used in production of many other chemicals

37 } Transportation Transported in cylinders Truck or train may carry the cylinders } Preparedness Know where supplies are kept Decontamination } Treatment Intense Pain due to skin and eye damage Pulmonary edema due to lung damage

38 } Properties Heavier than air Flammable when combined with air Highly toxic at 1000 ppm (one breath leads to death) Colorless Smells like rotten eggs

39 } Uses Byproduct of drilling for or production of natural gas, crude oil and petroleum products Produced when organic material decays and found in pockets during mining Used to produce sulfuric acid and inorganic sulfides

40 } Transportation Pipelines } Preparedness Awareness Respiratory protection Decontamination

41 } Treatment Oxygen Supportive care Sodium Nitrite 3% infusion will produce methemoglobin and may bind Hydrogen Sulfide

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43 } Properties Colorless Odorless } Uses Fuel } Transportation Pipeline Truck and Train

44 } Preparedness Know location of pipelines and storage facilities Respiratory protection Decontamination } Treatment Oxygen Flush eyes and skin with water for 15 minutes Symptomatic

45 } Multiple industrial gases Know your local area Observe gas cloud Begin Decontamination Call Hazmat Team Call Chemtrec Established by the Chemical industry as a public service hotline for emergency responders. 24/7/365 Community planning resource for hazardous materials

46 William Fales, MD, FACEP Western Michigan University School of Medicine and 5 th District Medical Response Coalition

47 Nerve Agents } G Agents Sarin (GB) Soman (GD) Tabun (GA) } V Agent VX Organophosphate Pesticides Malathion Parathion Diazinon Dichlorvos

48 } 1988 Halabja, Iraq } 1995 Tokyo Subway } 2013 Syria

49 To view videos showing the effects of the nerve agent during the 2013 attack in Syria enter Syria sarin attack videos into your search engine of choice. Many of these videos are very disturbing,

50 } Readily available worldwide } 3 million exposures ~300,000 fatalities } Common in suicides ~175,000 deaths in China } 2013 India OPP Incident 22 children deaths Unintentional (?) ingestion } 2012 US Poison Center Data ~2800 exposures 1 Death / 22 serious outcomes } 2000 rural Georgia incident

51 Patient: 40 YO M intentional OD of pesticide concentrate (incl. Phosmet) Arrived 20 min. post-ingestion by POV to rural ED Full SLUDGE Intubated, gastric lavage Received 4 g 2-PAM + 22 mg atropine over 24 hrs. No decontamination / No PPE use by staff Transferred to Psychiatry after 9 days

52 Healthcare Worker 1: 45 YO ED Assistant developed SLUDGE ~1 hr after arrival Close contact with patient s skin, secretions, emesis Intubated x 24 hrs Multiple doses of 2-PAM and atropine over 7 days Discharged after 9 days

53 Healthcare Worker 2: 32 YO ED RN developed SLUDGE No contact with patient s skin, secretions, emesis Shared breathing space Not intubated Received 2-PAM and atropine (10 mg) over 12 hrs Improved

54 Healthcare Worker 3: 56 YO ED RN developed dyspnea, confusion, headache No contact with patient s skin, secretions, emesis Shared breathing space Received atropine (6 mg) without improvement Developed (atropine-related?) hallucinations Improved after IV lorazepam

55 Key Points HCWs are at risk for nosocomial poisoning Need patient decon and PPE Incident occurred from single patient & in rural ED Extreme toxicity from OPPs What if?

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57 SLUDGE-B 3 } Salivation } Lacrimation } Urination } Defecation } Gastric Emesis } Bronchorrhea } Bronchospasm } Bradycardia DUMB 3 ELS } Defecation } Urination } Miosis } Bronchorrhea } Bronchospasm } Bradycardia } Emesis } Lacrimation } Salivation

58 Intermediate (Neurologic) Syndrome } hours postexposure } 10-40% occurrence } Features neck flexion weakness cranial nerve abnormalities proximal muscle weakness respiratory insufficiency } Supportive Care Prolonged ventilation } Usually self-limited Delayed Neurotoxicity } 1-3 weeks post-exposure } Limited to few specific OPs } Features transient, painful "stockingglove" paresthesias symmetrical motor polyneuropathy Flacid LE weakness Ascends to UE weakness Distal > proximal muscles } Usually gradual improvement Sometimes permanent disability

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60 } Rescue using PPE } DECON Possibly with concurrent treatment } Autoinjectors (+ Benzo) } Supportive Care } Additional Meds Atropine Pralidoxime Chloride (2-PAM) Benzodiazepine

61 } Pre-Hospital Hot Zone Level A preferred Firefighter gear + SCBA For brief recon and rescue of live victims 3-30 Rule Per department policy } Warm Zone & 1st Receivers Chemical suit (e.g., Tychem) (Powered) Air Purifying Respirator Gloves and boots

62 DECON Considerations } Prehospital Decon Systems (tents) Mass Field Decontamination Dry Decon Limited pre-decon treatment } Hospital Assume limited pre-arrival DECON First Receiver doctrine and IDLH Fixed unit vs tents No notice preparedness Unannounced drills

63 } Simple, affordable handheld device for hospital DECON } Identifies volatile organic compounds (VOC) Doesn t ID chemical } Helps identify who Is more heavily contaminated Is not contaminated

64 } Mark I 2 autoinjector system Atropine 2 mg + 2-PAM 600 mg No longer manufactured Still available in Chempack } Duodote Single autoinjector system Atropine 2 mg + 2-PAM 600 mg Replaced Mark I } CANA Convulsant Antidote for Nerve Agent Diazepam (Valium) 10 mg autoinjector Not readily available in Michigan Except for CHEMPACK and military

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66 } Competes with ACh at muscarinic receptors Prevents ACh activation } Initial dosing: 2-6 mg IM/IV/IO Autoinjectors likely fastest way for initial dose Peds: 0.05 mg/kg IV/IO } Goal: Decrease secretions and bronchospasm Repeat every 5 minutes as needed Do NOT base treatment on pupillary response } Patients may require 100 s mg / infusion over several days

67 } Pralidoxime reactivates acetylcholinesterase 2-PAM Pry Bar } Initial Dosing: mg via autoinjector 1-2 g IV/IO (SLOW over 30 minutes) May repeat in 1 hr then q 12 hrs } Consider IV infusion of ~8 mg/kg/hr Check cholinesterase levels if able } Consult Poison Control

68 } 2009 British study } Randomized, double blind, placebo controlled trial } 235 patients } No difference in Mortality Trend towards worse outcomes with 2-PAM Intubation rates Organophosphate

69 } All critically ill patients should receive a receive a benzodiazepine All seizing patients Beware of subclinical status All unresponsive patients All patients receiving >3 autoinjectors } Midazolam may be better than diazepam Midazolam 10 mg IM Midazolam autoinjector coming soon? Any benzo will do } No evidence that non-benzodiazepine anticonvulsants (e.g., phenytoin) are effective

70 } MEDDRUN MI specific - Highly mobile Air >>> Ground EMS Rapid response (<15 min out of shoot) Nerve agent & other counter measures and supplies } CHEMPACK CDC Operated Fixed locations Exclusively nerve agent focused } One central activation number

71 } Nerve agents and OPPs present real threats } Know (and practice) DECON and PPE } Know the Cholinergic Toxidrome SLUDGE+B 3 or DUMB 3 BELS } Know the antidotes Duodotes Atropine, 2-PAM, Benzos Remember MEDDRUN and CHEMPACK

72 Thanks! Dr. Edwards: Dr. Evans: Dr. Fales: