nerveagents

nerveagents - 3 ER C a s e s Which patient has nerve agent...

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Unformatted text preview: 3 ER C a s e s Which patient has nerve agent poisoning? 9 y e a ro ld with m io s is , a g ita tio n, c o p io us s e c re tio ns , unc o ntro lle d urina tio n. HR 1 2 0 . R R 1 6 /s h a llo w. S a t 8 3 % 1 5 y e a ro ld with g e ne ra lize d s e izure , to ng ue fa s c ic ula tio ns , a b s e nt g a g , a b s e nt re fle xe s 2 y e a ro ld o ld with fus s ine s s /d ia rrh e a p ro g re s s ing to im p a ire d c o ns c io us ne s s , h yp o to nia Joshua Rotenberg MD MMS, Pediatric Neurology Nerve Agents in Children Fellow, Pediatric Neurology Staff Pediatrician, WRAMC & NNMC Assistant Professor of Pediatrics, USUHS Josh Rotenberg MD MMS Joshua Rotenberg MD MMS, Pediatric Neurology Nerve Agents in Children Background: Scope of the Problem Background: The agents Diagnosis Isolation/Decon Treatment Pediatric Issues Joshua Rotenberg MD MMS, Pediatric Neurology Background: Scope of the Problem C WA in US the most important act of terrorism in which CWA was attempted to use a was the World Trade Center bombing in 1993. the explosive used by the terrorists contained sufficient cyanide to contaminate the entire structure. Fortunately, the cyanide was destroyed by the blast Joshua Rotenberg MD MMS, Pediatric Neurology Background: Scope of the Problem Police foil terror plot to use sarin gas in London (Filed: 18/02/2001) Bin Laden British cell planned gas attack on European Parliament (Filed: 16/09/2001) Joshua Rotenberg MD MMS, Pediatric Neurology Background: Scope of the Problem Ira nIra q wa r (1 9 8 4 1 9 8 8 ) UN confirmed that Iraq used Tabun and other organophosphorous nerve agents Sarin and Sulphur mustard used on Kurds in Northern Iraq Iraq has weaponized VX 4 tons GulfWar: large, urban civil popualation threatened for first time since WW1 Joshua Rotenberg MD MMS, Pediatric Neurology Sarin Attacks in Japan Matsumoto Japan, June 1994 7 died, 58 admitted, 600 injured Tokyo Subway March 1995 11 killed, 5,500 injured Sarin released at several points in the Tokyo subway secondary contamination of the house staff in more than 20% Joshua Rotenberg MD MMS, Pediatric Neurology Background: The agents Nerve agents include: Tabun (GA) Sarin (GB) Soman (GD), and VX Joshua Rotenberg MD MMS, Pediatric Neurology Background: The agents O rig ina lly d e ve lo p e d a s ins e c tis id e s m o re p o we rfu l th a n o rg a no p h o s p h a te s T a b un is e a s ie s t a nd c h e a p e s t to m a nufa c ture . S a rin h a s b e e n us e d in te rro ris t a tta c ks VX "o nly e xis ts in m ilita ry s to c kp ile s " De s c rib e d a s a s ta rte r a g e nt fo r C W p ro g ra m . S o m e c o ns id e r m o s t like y to b e us e d a s te rro ris t a g e nt. Joshua Rotenberg MD MMS, Pediatric Neurology Background: The agents Exis t a s a liq uid o r a g a s Liq uid is c o lo rle s s (g typ e ) a m b e rc o lo re d (VX ) G a s c a n b e o d o rle s s , fruity (ta b un) o r s lig h t c a m p h o r o d o r (s o m a n) Va ry in vo la tility s o m e m o re p e rs is te nt th a n o th e rs S a rin a s vo la tile a s wa te r VX ve ry p e rs is te nt Joshua Rotenberg MD MMS, Pediatric Neurology Background: The agents T o xic e ffe c ts d e p e nd o n th e c o nc e ntra tio n o f th e a g e nt inh a le d a nd th e tim e e xp o s e d to th e a g e nt. No te th e va p o r d e ns ity S a rin 4 .8 6 VX 9 .2 LD5 0 1 0 0 m g /m 3 fo r 1 m inute is e q uiva le nt to 5 0 m g /m 3 fo r 2 m inute s Joshua Rotenberg MD MMS, Pediatric Neurology Joshua Rotenberg MD MMS, Pediatric Neurology Wh e n wo uld y o u la unc h a s a rin a tta c k? Joshua Rotenberg MD MMS, Pediatric Neurology Ho w d o ne rve a g e nts wo rk? Irre ve rs ib le p h o s p h o ryla tio n o f c h o line s te ra s e e nzym e s a t a c e tyc h o line re c e p to rs Nic o tin ic Mus c a rinic C NS Ad re na l Joshua Rotenberg MD MMS, Pediatric Neurology Na ture a nd o ns e t o f s ig ns a nd s y m p to m s va ry b y ro ute o f a b s o rp tio n. Aerosol particles Ne rve Ag e nts Muc o s a l Ab s o rp tio n Gases may be absorbed through any part of the respiratory tract: mucosa of the nose and mouth to the alveoli of the lungs. > than 5 m tend to remain in the upper respiratory tract < than 1 m tend to be breathed in and out again, although some of these smaller particles may be retained. They may also be directly absorbed by the eye/skin/GI tract Joshua Rotenberg MD MMS, Pediatric Neurology Nerve Agents Absorption via Skin Agents which penetrate the skin may form temporary reservoirs so that delayed absorption may occur (less so, that OPP). Even the vapor of some agents can penetrate the intact skin and intoxication may follow. Wounds/abrasions (even minor injuries caused by shaving ) present areas which are more permeable than intact skin. The penetration of agents through the GI tract or abrasions may not neccessarily be accompanied by irritation or damage to the surfaces concerned. Joshua Rotenberg MD MMS, Pediatric Neurology Neuromuscular Effects Twitching Weakness Paralysis Respiratory failure Joshua Rotenberg MD MMS, Pediatric Neurology Autonomic Nervous System Effects Reduced Vision Small pupil size Drooling Sweating Diarrhea Nausea Abdominal pain Vomiting Joshua Rotenberg MD MMS, Pediatric Neurology Eyes Miosis most common finding Matsumoto 134/219 2.5 mm or less Impaired acuity in 124/219 Blurry vision improved with atropine Resolved in a month Visual Darkness Ocular pain Joshua Rotenberg MD MMS, Pediatric Neurology Central Nervous System Effects Headache Convulsions Coma Respiratory arrest Confusion Slurred speech Depression Respiratory depression Joshua Rotenberg MD MMS, Pediatric Neurology Delayed (Chronic) CNS Effects Giddiness, anxiety, jitteriness, restlessness, emotional lability, excessive dreaming, insomnia, nightmares, headaches, tremor, withdrawal and depression, drowsiness difficulty concentrating, slowness on recall, confusion, slurred speech, ataxia. bursts of slow waves of elevated voltage in EEG, especially on hyperventilation, Joshua Rotenberg MD MMS, Pediatric Neurology In the absence of treatment Cause of death Airway obstruction anoxia resulting from airway obstruction, weakness of the muscles of respiration and central depression of respiration. due to pharyngeal muscular collapse, upper airway and bronchial secretions, bronchial constriction and occasionally laryngospasm and paralysis of the respiratory muscles. Joshua Rotenberg MD MMS, Pediatric Neurology Cause of death With adequate pulmonary support/toilet and atropine, the individual may survive several lethal doses of a nerve agent. However, if the exposure has been many times the lethal dose, death may occur despite treatment as a result of respiratory arrest and cardiac arrhythmia. When overwhelming doses of the agent are absorbed quickly, death occurs rapidly without orderly progression of symptoms. Joshua Rotenberg MD MMS, Pediatric Neurology Other symptoms Headache cough sore throat Can persist for weeks Joshua Rotenberg MD MMS, Pediatric Neurology Differential Diagnosis Sudden Mass casualties no sign of trauma Suspect airborne toxin Hy p o xe m ic , m io s is , p ro fus e s e c re tio ns Anti C h o line s te ra s e a g e nt Unc o ns c io us , no nh yp o xe m ic C y a nid e Less acute causes of respiratory problems venous blood gasses arterialized Bo-tox p a ra lys is , a b s e nt re fle xe s AR DS like p ic tu re anthrax,plague,phosgene Joshua Rotenberg MD MMS, Pediatric Neurology T re a tm e nt: ins titu te ra p id ly b a s e d o n c lin ic a l jud g m e nt C a n m e a s ure R BC le ve ls o f a c e tyc h o line s te ra s e Assess treatment and recovery. Insensitive as a screen Matsumoto: ChE decreased in 43% of severely affected Tokyo: decreased in 74% of admiitted 4% have genetic low levels Have genetic high levels, lose 50%, still be nl One call to lab, 3 send outstime is critical Diagnosis: Clinical presentation is likely to vary in children. Joshua Rotenberg MD MMS, Pediatric Neurology Joshua Rotenberg MD MMS, Pediatric Neurology Isolation/Decon De c o nta m ina tio n is ne c e s s a ry Do g m a T ruth : Us e wh a t is a va ila b le 0 .0 5 % b le a c h p e o p le 0 .5 % h o u s e h o ld b le a c h e q uip m e nt G o o d re s ults c a n b e o b ta ine d with s uc h wid e ly d iffe ring m e a ns a s ta lc um p o wd e r, flo ur, s o a p a nd wa te r, o r s p e c ia l d e c o nta m ina nts . Joshua Rotenberg MD MMS, Pediatric Neurology Isolation/Decon Is o la tio n a n d De c o n a re ne c e s s a ry in th e fie ld Tokyo: Most casualties arrive in POV First responders may also be early casualties Rotate health care workers in "hot zone" Hot, Warm, Cold Zone Triage in hot and cold zones 23 % health care workers had some sort of physical disorder, though mild. symptoms included ocular pain, headache, sore throat, dyspnea, nausea, dizziness, and nose pain none was seriously affected Joshua Rotenberg MD MMS, Pediatric Neurology Triage: Tokyo Subway, St. Lukes Mild severity miosis, rhinorrhea, and mild headache victims were immobile or complained of moderate degree dyspnea, vomiting, severe headache or with neurologic complication like fasciculation victims had cardiac or respiratory arrest. Joshua Rotenberg MD MMS, Pediatric Neurology Moderate severity Critical severity Treatment Atro p ine , re s p ira to ry s up p o rt (s e c re tio n m a na g e m e nt) Antid o te s m us t b e g ive n q uic kly But m a y s till b e e ffe c tive if g ive n la te , e ve n in e xtre m is Joshua Rotenberg MD MMS, Pediatric Neurology Treatment Atro p ine g ive lib e ra lly to d ry s e c re tio ns P ra lid o xim e 1 g o ve r 5 1 0 m in Fa s c ic ula tio ns , S e izure s tre a te d with b e nzo d ia ze p ine s IM no t o p tim a l b ut a c c e p ta b le a ve ra g e to ta l d o s e in a d ult 5 0 m g Joshua Rotenberg MD MMS, Pediatric Neurology Ma rk 1 US A/US AF Atro p ine 2 m g (0 .7 m l) 2 P AM C l a uto inje c to r d is p e ns e s 6 0 0 m g /2 m l Joshua Rotenberg MD MMS, Pediatric Neurology P ro p h y la xis P y rid o s tig m ine Milita ry us e o nly Joshua Rotenberg MD MMS, Pediatric Neurology S up p o rtive th e ra p y fo r C WA e xp o s ure inc lud e P ulm o na ry tre a tm e nt/to ile t Fluid s , e lc tro ly te s , nutritio n Hy p o th e rm ia Ey e c a re Atte ntio n to s kin le s io ns , T re a tm e nt o f c o m p lic a ting infe c tio ns Joshua Rotenberg MD MMS, Pediatric Neurology s up p le m e nta ry o xyg e n b ro nc h o d ila to rs Pediatric considerations/guidance Antid o te s Do s a g e s O rg a n S y s te m S p e c ific T o ky o S ub wa y, 1 9 9 5 Matsumoto, 1994 age 389 mean 33 y.o. Joshua Rotenberg MD MMS, Pediatric Neurology 16 children 5 pregnant women Treatments: Pediatric Dosage Atropine AC LS p ro to c o l 0 .0 2 to 0 .0 5 m g /kg to a m a xim um o f 2 m g . Ma y re p e a t q 1 0 m in ute s to re ve rs e c h o line rg ic s ym p to m s . Min d o s e 0 .1 m g Ma x d o s e 0 .5 m g c h ild ; 1 m g a d o le s c e nt S h o uld we b e lib e ra l with a tro p ine ? AC LS d o s ing m a y no t b e s uffic ie nt Joshua Rotenberg MD MMS, Pediatric Neurology n=2 6 8 , 9 2 % o f p e d ia tric ER 's Mo s t c a s e s a c c id e nta l; 7 .5 % inte ntio na l b y p a re nts e xp e c ting e xp o s ure d o s e s o f 0 .0 1 to 0 .1 7 m g /kg no fa ta litie s ,s e izure s 0 .0 4 5 to 0 .1 7 m g /kg m ild e ffe c ts Atro p ine P o is o ning in Is ra e li C h ild re n Joshua Rotenberg MD MMS, Pediatric Neurology T re a tm e nts : P e d ia tric Do s a g e Pralidoxime (US ) 2 P AM, P ro to p a m 2 0 5 0 m g /kg x 1 im /iv/s c . Ma y re p e a t in 1 h o ur to re lie ve m us c le we a kne s s (nic o tinic ) Wa tc h fo r m us c le rig id ity , la ryng o s p a s m , ta c h yc a rd ia n.b . o th e rs us e d in Euro p e a nd Is ra e l S o m e s tud ie s s ug g e s t c o ntinu o us infus io n m a y b e b e tte r no d a ta in kid s Joshua Rotenberg MD MMS, Pediatric Neurology T re a tm e nts : P e d ia tric Do s a g e Diazepam Fo r s e ve re s e izure s /s ta tus e p ile p tic us 3 0 d to 5 y 0 .0 5 to 0 .3 m g /kg IV to a m a x o f 5 m g /d o s e . Ma y re p e a t q 1 5 3 0 m inute s 5 y .o . 0 .0 5 to 0 .3 m g /kg IV to a m a x o f 1 0 m g /d o s e . Joshua Rotenberg MD MMS, Pediatric Neurology C a rb a m a te a nd O rg a no p h o s p h a te p o is o ning in yo ung c h ild re n P e d ia tric Em e rg C a re , Ap ril 1 9 9 9 S tup o r/C o m a 1 0 0 % Hyp o to n ia 1 0 0 % Mio s is 5 6 % Dia rrh e a ,, Bra d yc a rd ia , S a liva tio n 2 5 3 7 % P u lm o n a ry e d e m a 3 7 % a g e 2 8 , Me d ia n 2 .8 CNS P re d o m ina nc e o f C NS find ing s in c h ild re n? Im m a turity o f b lo o d b ra in vs . d e ve lo p m e nta l e ffe c t o n C NS c h o line s te ra s e Joshua Rotenberg MD MMS, Pediatric Neurology Pulmonary Inc re a s e d m inute vo lum e a nd va p o r d e ns ity inc re a s e s d o s e o f va p o r to c h ild re n S m a lle r a irwa y will b e m o re e a s ily o b s truc te d b ro nc h o c o ns tric tio n a nd s e c re tio ns Joshua Rotenberg MD MMS, Pediatric Neurology Dermatologic S kin a b s o rp tio n o f liq uid m a y b e s ig nific a nt c o ns id e ra tio n in infa nts . La rg e s urfa c e to vo lum e ra tio in c h ild re n c o m p a re d to a d ults Fa t s o lub le a g e nts (le s s th a n O P P ) Bre a ks in s kin m a y p e rm it e a s ie r p e ne tra tio n o f a g e nt. Inc id e nc e o f a to p y is a p p ro x 4 % . Joshua Rotenberg MD MMS, Pediatric Neurology Dermatologic Decontamination Ble a c h is a m ild to m o d e ra te m uc o s a l irrita nt. 0 .5 % b le a c h m a y c a us e c o nta c t d e rm a tittis In c h ild re n c a n p re s e nt like "p ric kly h e a t", e ry th e m a , e d e m a , b lis te ring . Joshua Rotenberg MD MMS, Pediatric Neurology Environmental Exposure/ Temperature Regulation: Hy p o th e rm ia P a tie nts will b e fully d is ro b e d b e fo re d e c o nta m ina tio n Ad e q ua te c o ve r, c lo th ing , d ia p e rs s h o uld b e a va ila b le fo r p a re nts a nd c h ild re n. Wa tc h fo r d e la y e d e ffe c ts with wa rm ing c o ld wa te r/b le a c h s o lutio n. Joshua Rotenberg MD MMS, Pediatric Neurology Feeding No info rm a tio n is a va ila b le re g a rd ing b re a s t fe e d ing . Bre a s t fe e d ing m o th e rs s h o uld b e e nc o ura g e d to p um p a nd d is c a rd . Until wh e n? No re s e a rc h d o ne Ho we ve r, ne rve a g e nts a re le s s lip id s o lub le th a n O P P . Institutions s h o uld b e re a d y to s up p o rt infa nt fe e d ing s Joshua Rotenberg MD MMS, Pediatric Neurology Developmental-Triage and care Mild a nd e a rly s ym p to m s m a y b e m is s e d d ue to a c h ild 's in a b ility to c o m m unic a te s ym p to m s o f p a in a nd p re s s ure . Alte rna tive ly, a p h ys ic ia n m ig h t d is m is s s ig ns s ym p to m s s uc h a s s le e p ine s s , h yp o to nia , c ra m p s , rh inno rh e a a s ty p ic a l o f o th e r c h ild h o o d illne s s e s a nd b e h a vio r. Wh a t will we d o with th e m o th e r/infa nt p a irs in d e c o n? Une s c o rte d c h ild re n? Joshua Rotenberg MD MMS, Pediatric Neurology Long-Term Effects: C NS : O rg a no p h o s p a te p o is o ning lite ra ture s ug g e s ts c h ro nic C NS (ne uro c o g nitive /c e re b e lla r) a nd P NS im p a irm e nt C a rc ino g e nic ity: Lim ite d d a ta in a nim a ls s ug g e s ts no e ffe c t. O ne s tud y s ug g e s ts g e no to xic ity in h um a n lym p h o c y te s R e p ro d uc tive Effe c ts : Lim ite d d a ta in a nim a ls s ug g e s ts no e ffe c t. Tokyo well babies Joshua Rotenberg MD MMS, Pediatric Neurology Take Home Goodies Mass cas + no trauma=Inhalant Presentation varies with: agent, state, absorption, temperature Autonomic, CNS, muscular symptoms Start treatment based on suspicion atropine, respiratory support Consider diazepam, pralidoxime Pediatric Issues: acute and chronic Joshua Rotenberg MD MMS, Pediatric Neurology AAP Guidelines Joshua Rotenberg MD MMS, Pediatric Neurology ...
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This note was uploaded on 01/31/2012 for the course PDBIO 305 taught by Professor Woods,a during the Fall '08 term at BYU.

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