About
Section 1: General Patient Care
Section 2: Medical Protocols
2.01 - Adrenal Insufficiency / Crisis (Adult & Pediatric)2.02A - Allergic Reaction / Anaphylaxis2.02P - Allergic Reaction / Anaphylaxis2.03A - Altered Mental / Neurological Status / Diabetic Emergencies / Coma - Adult2.03P - Altered Mental / Neurological Status / Diabetic Emergencies / Coma - Pediatric2.04 - Behaviorial Emergencies (Adult & Pediatric)2.05 - Behaviorial Emergencies - Restraints (Adult & Pediatric)2.06A - Bronchospasm / Respiratory Distress (Adult)2.06P - Bronchospasm / Respiratory Distress (Pediatric)2.07 - Hyperthermia (Environmental - Adult & Pediatric)2.08 - Hypothermia (Environmental - Adult & Pediatric)2.09 - Nerve Agent / Organophosphate Poisoning2.10 - Obstetrical Emergencies2.11 - Newly Born Care2.12 - Resuscitation of the Newly born2.13 - Pain and Nausea Management2.14 - Poisoning / Substance Abuse / Overdose2.15A - Seizures2.15P - Seizures2.16A - Shock2.16P - Shock2.17A - Sepsis2.17P - Sepsis2.18 - Stroke2.19 - Hyperkalemia2.20 - Home Hemodialysis Emergency Disconnect
Section 3: Cardiac Emergencies
Section 4: Trauma Protocols
Section 5: Airway Protocols & Procedures
Section 6: Medical Director Options
Section 7: Medical Policies & Procedures
Section 8: Special Operations Principles
Appendices
2.09 - Nerve Agent / Organophosphate Poisoning
First-Responder (Standing Orders)
EMT-Basic (Standing Orders)
EMT-Advanced (Standing Orders)
- 1.0 Routine Patient Care
- Assess for SLUDGEM (Salivation, Lacrimation, Urination, Defecation, Gastric upset, Emesis, Muscle twitching/miosis (constricted pupils) and KILLER Bs (Bradycardia, Bronchorrhea, Bronchospasm).
- Remove to cold zone after decontamination and monitor for symptoms.
- Antidotal therapy should be started as soon as symptoms appear.
- All antidote auto-injections must be administered IM.
- Determine dosing according to the following symptom assessment and guidelines.
EMT-Paramedic (Standing Orders)
- If field conditions permit, initiate cardiac monitoring and consider the administration of IV medications.
- If symptoms persist after the administration of 3 DuoDote kits:
- Atropine 2mg IV/IO; repeat every 5 minutes until secretions clear
- Pralidoxime 1 – 2 gram IV/IO over 30 – 60 minutes
- Diazepam 10mg IM by auto-injector every 10 minutes, as needed. Instead of diazepam, may use :
- Midazolam 2 mg IV/IO/IN every 5 minutes; or 6 mg IM every 10 minutes
EMT-Paramedic (Medical Control)
- Additional doses of above medications.
- Pralidoxime maintenance infusion: up to 500mg per hour (maximum of 12 grams/day).
Caution:
Do not administer an adult dose to a child <50kg.
Caution:
Dermal absorption of nerve agents may lead to delayed symptom onset up to 18 hours after exposure. Initial symptoms/signs may only be local such as localized fasiculations and sweating.
Note:
PROCEDURES FOR SELF-CARE AND CARE OF AUTHORIZED PUBLIC EMPLOYEES OR FIRST RESPONDERS
- Remove self or fellow authorized public employee from area if possible.
- Assess degree of symptoms: Mild, Moderate or Severe.
- Administer 1 to 3 auto-injector kits IM (each kit with atropine 2mg IM and pralidoxime chloride 600mg IM) as guided by degree of symptoms.
- Seek additional medical support for further monitoring and transport of anyone receiving therapy.
- Disrobing will significantly enhance the decontamination process. Perform decontamination, and seek assistance in further decontamination measures.
Severity
Signs & Symptoms
Adult Treatment
Mild
Runny Nose
Cough
Pupils may be pinpoint
Eye Pain
Lacrimation
Decontaminate
Administer 100% Oxygen
Administer One kit IM OR
2mg atropine IM only & either:
600mg IM pralidoximine OR
1g IV pralidoximine
Moderate
Runny Nose
Cough
Sweating, twitching
Nausea, abdominal cramping
Weakness
Localized sweating (seen with dermal exposure)
Eye pain, trouble seeing
Wheezing, shortness of breath
Decontaminate
Administer 100% Oxygen
Administer Two to Three kits IM
OR
4mg atropine IM only & either:
600-1200mg IM pralidoxime OR
1gm IV pralidoxime
Severe
All the above, plus:
- Vomiting
- Diarrhea
- Drooling, copious respiratory secretions
- Significant weakness
- Seizures
- Decreased level of consciousness
- Apnea
Decontaminate
Administer 100% Oxygen
Administer Three kits IM
OR
6mg atropine IM only & either:
1200-1800mg IM pralidoxime OR
1gm IV pralidoxime
&
Diazepam 10mg IM Autoinjector (CANA Kit)
OR
Midazolam 6-10mg IV/IO/IM
Pediatric Dosing for Nerve Agent Exposures
Kg
Age
Atropine
Pralidoxime
Midazolam
0
0
0.02-0.05mg/kg
20-40 mg/kg
0.1mg/kg
1
Preemie
0.1mg
20-40mg
0.05-0.1mg
2
Newborn
0.1mg
40-80mg
0.1-0.2mg
5
3mos
0.1mg-0.25mg
100-200mg
0.25-0.5mg
10
12mos
0.2-0.5mg
200-400mg
0.5-1mg
15
2-3yrs
0.3-0.75mg
300-600mg
2mg
20
4-7yrs
0.4-1mg
400-800mg
2.5mg
25
6-9yrs
0.5-1.25mg
500mg-1g
3mg
30
7-11yrs
0.6-1.5mg
600mg-1g
3.5mg
35
8-13yrs
0.7-1.75mg
700mg-1g
4mg
40
9-14yrs
0.8-2mg
800mg-1g
4.5mg
45
10-16yrs
0.9-2mg
900mg-1g
5mg
50
11-18yrs
1-2mg
1g
5mg
55
12-18yrs
1.25-2mg
1g
5mg
60
13-18yrs
1.5-2mg
1g
5mg
65
14-18yrs
2mg
1g
5mg
70
16-18yrs
2mg
1g
5mg
Pediatric Atropens
Weight
Mild
Moderate
Severe
15-40lbs (7-18kg)
1 x 0.5mg Atropen
1 x 1mg Atropen
3 x 0.5mg Atropen
40-90lbs (18-41kg)
1 x 1mg Atropen
1 x 2mg Atropen
3 x 1mg Atropen
>90lbs (41kg)
1 x 2mg Atropen
2 x 2mg Atropen
3 x 2mg Atropen
Note: Pralidoxime reduced dose pediatric autoinjectors are not available
Adult AutoInjectors
Pediatric Dosing for SEVERE Nerve Agent Toxicity Using Adult Autoinjectors (i.e. seizures, hypotension, coma, cardiac arrest).
Use only if Pediatric Atropen or when Atropine/Pralidoxime vials are not available
Approximate Age
Approximate Weight
Number of Autoinjectors (each type)
Atropine dosing range (mg/kg)
Pralidoxime dosing range (mg/kg)
3-7yrs
13-25kg
1
0.08-0.13
24-46
8-14yrs
25-50kg
2
0.08-0.13
24-46
>14yrs
>51kg
3
0.11 or less
35 or less
Note:
Mark I kits and Duodote are not approved for pediatric use, however, they should be used as initial therapy in circumstances for children with severe life-threatening nerve agent toxicity when IV therapy is not available. This assumes 0.8 inch needle insertion depth.
Potential high dose of atropine and pralidoxime for age/weight. However, these numbers are within the general guidelines recommended for the first 60-90 minutes of therapy after a severe exposure.
Administer injection in large muscle mass. Avoid deltoid. Suggest using thigh.
Potential high dose of atropine and pralidoxime for age/weight. However, these numbers are within the general guidelines recommended for the first 60-90 minutes of therapy after a severe exposure.
Administer injection in large muscle mass. Avoid deltoid. Suggest using thigh.