ATROPINE ONLY
Initial, on scene, treatment by EMS for
Nerve Agent or Organophosphate
poisoning in the absence of Mark 1 kits
Optimal Tx at the scene by EMS
Mark 1 Kits
 ( 3 Atropens [Atropine] {2mg. Auto-injectors}
along with 1 auto-injector pen of 2-PAM
[Pralidoxime] {600 mg.}
CHEMPACK System
 90+ containers throughout NYS, primarily in
hospitals
 Can get to emergency scene – or + 1 hour
 New formulary as of February 2006 (for
reduced number of patients).
 Existing stockpiles will be replaced with new
formulary
CHEMPACK SYSTEM
Does your agency know how to
implement the system?
How it should all fit together
Hospital
Emergency
Management
Public Health
Based on County Plan
Notify Dispatch
Suspected Nerve
Agent Incident
Atropine
Auto-injectors
How does it get to the ED for your Patient?
CHEMPACK
To Emergency Dept.
when notified to
await your patient
To Incident Scene
if enough time
CHEMPACK Formulary
Hospital CHEMPACK - Container contains
enough auto-injectors and vials of drug to
treat 1,000 pts.
EMS CHEMPACK - {454 pts.} contains atropine
auto-injectors only, (in addition to other
drugs), because:
 Auto-injectors are generally not used in
hospital based treatment and,
 Pts. will be transported to hospital/alternate
care site for follow up treatment from scene.
Plan
 NYS has purchased Atropen units.
 The expiration date for this batch is April 2009.
 BEMS is working on a plan for replacement for
expired pens.
 The Atropens are to be used by trained EMS
providers.
 Training to the agency representative to be provided
by BEMS personnel in a statewide Train-the-Trainer
program.
 Agency training officer is to conduct training at
agency level, and will notify Medical Director and
local REMAC of personnel trained.
Study Data
 Data on Atropine use alone is necessarily
limited
 3 cases studies on <200 patients, during IranIraq war using atropine alone
 No untoward effects on military and civilian
victims of Nerve Agent exposure with use of
atropine alone, (no oximes available)
 Patients were mild, moderate and severe
exposures
RAIN
RAIN
RAIN
RAIN
Advantages/Disadvantages
(from a terrorist perspective)
Participation choices
 Agencies can still use and purchase Mark 1
kits
 Participation would be voluntary
County Emergency Plan
for Chempack
Who can initiate county emergency Chempack
activation:
 Emergency Manager/County Executive
 Hospital
 First responders (must notify MD/Hospital of
request)
 Local Health Dept.
 Others as directed
PURPOSE
To provide basic life support personnel with the
basic knowledge and skills to administer atropine
by auto injector in a life-threatening situation.
Training
 TRAINING PROGRAM OUTLINE FOR
EMT-B PERSONNELTO ADMINISTER
ATROPINE BY AUTO-INJECTOR
IN LIFE-THREATENING SITUATIONS –
(prior to pt. arriving at hospital)
Competencies
 Upon completion of the training the
participants will be able to demonstrate the
following competencies:
 1. Identify common causes of nerve agent
poisonings;
 2. Identify the signs and symptoms of a
severe allergic reaction (anaphylaxis), and
how they differ from other medical conditions;
Competencies
 3. List the steps for administering atropine by
an auto injector;

4. Describe the methods for safely storing
and handling atropine and appropriately
disposing of the auto-injector after use;
Competencies
 5. List the steps for providing for on-going
care of the patient until turned over to
definitive care;
 6. Understand the state regulations that allow
an agency to possess and use an atropine
auto-injector in a life threatening situation.
 7. Activation of County Plan
SLUDGEM
 SLUDGEM + RESPIRATION and
AGITATION
 S - salivation (excessive drooling)
L - lacrimation (tearing)
U - urination
D - defecation / diarrhea
G - GI upset ( cramps )
E - emesis ( vomiting )
M - muscle ( twitching, spasm, "bag of
worms" )
Signs and symptoms of nerve agent
poisoning
 MILD SYMPTOMS
Blurred vision, miosis
Excessive unexplained teary eyes
Excessive unexplained runny nose
Increased salivation such as sudden unexplained excessive drooling
Chest tightness or difficulty breathing
Tremors throughout the body or muscular twitching
Nausea and/or vomiting
Unexplained wheezing or coughing
Acute onset of stomach cramps
Tachycardia or bradycardia
Signs and symptoms of nerve agent
poisoning
 SEVERE SYMPTOMS
Strange or confused behavior
Severe difficulty breathing or severe secretions from your lungs/airway
Severe muscular twitching and general weakness
Involuntary urination and defecation (feces)
Convulsions
Unconsciousness
Effects of Atropine
 Atropine will affect the parasympathetic
nervous system by lowering its effects on the
body.
 In nerve agent and organophosphate
poisoning, fluids will “leak” from all openings
in the body.
 Atropine dries up these secretions.
Dosage
 The atropine auto-injector comes in both an
adult dose and a pediatric dose.
 However, agencies in this program will only
be carrying and administering the adult
dosage Atropen.
Administration of the drug
Sit the patient down and try to calm and
reassure him/her. If the patient is:
 confused,
 disoriented, or
 unconscious (altered mental state)
 with signs of (hypoperfusion)
Administer a high concentration of oxygen.
If the patient is having difficulty breathing,
administer the atropine as follows:
Administration of the drug
 Step One: Remove the safety cap from the
auto-injector. Check to see if the fluid is clear
and colorless. Never put your fingers over
the green tip when removing the yellow
safety cap or after the safety cap has been
removed!
 Step Two: Place the tip of the injector against
the patient's bare outer thigh. (Halfway
between their waist and the knee)
Administration of the drug
 Step Three: With a quick motion, push the
auto-injector firmly against the thigh until the
spring-loaded needle is activated. Hold the
auto-injector in place for ten (10) seconds.
 Step Four: Remove the auto-injector from the
thigh and record the time of the injection.
Administration of the drug
 Step Five: Never put your fingers over the
green tip after the yellow safety cap has
been removed! Dispose of properly using
blood borne pathogenic guidelines, into a
Sharp’s container.
 Step Six: Monitor the patient carefully, and
keep them calm. Note if the patient gets any
better or worse.
System Notification & Activation
 Make sure someone notifies dispatch of
atropine use by EMS.
 Hospital must be notified of treatment with
atropine in the field.
 As soon as agent is identified, notify dispatch
and hospital.
 Ascertain whether Chempack should be
deployed to the field site.
After effects of the drug
 The injection itself is relatively painless and
the patient may not feel the medication being
injected. Soon after the injection the patient
should begin to feel the beneficial effects of
the drug.
 The most common changes the patient may
feel are secretions drying up and easing of
dyspnea.
Turning the pt. over to ALS/Hospital
 If the atropine auto-injector is used, make sure the following






information is accurately and concisely conveyed to the ALS
Provider and/or physician and hospital:
1. The substance (nerve agent), if known, the patient was
exposed to
2. How long ago the exposure occurred
3. The signs and symptoms the patient experienced (difficulty
breathing, any secretions, any pinpoint pupils, etc.) before the
atropine was administered
4. The time and dose of the atropine administered
5. Did you notice any change(s) in the patient after the atropine
was administered
6. Other specific information about the patient such as name,
age, guardian, physician, medical history, etc.
Storage
 Keep the atropine auto-injector where you can have
quick and easy access to it in an emergency.
 Keep it away from children.
 It is important to remember that the atropine needs to
be kept at room temperature. It should not be
refrigerated, nor should you allow it to be exposed to
extreme heat, such as the glove compartment of the
ambulance during the summer.
 Do not expose the atropine auto-injector to direct
sunlight; light and heat can cause atropine to
degrade.
Expiration Date
 As with any medication, the atropine auto-
injector will have an expiration date, which is
printed directly on the unit. It is important to
periodically check the expiration date and
replace the unit before it expires. When
checking the expiration date also check to
make sure the fluid is clear and colorless.
Replace the unit if the fluid is discolored.
SHARPS
 The auto-injector unit is generally very safe
and easy to use. It is important to remember
that the unit does have a sharp needle in it.
Do not remove the safety cap until you are
ready to use the auto-injector. Never put
your fingers over the green tip when
removing the yellow safety cap or after the
safety cap has been removed.
SHARPS
 Dispose of your expired or expended atropine
into your Sharp’s container.
 Dispose of your Sharp’s container in your
usual authorized manner.
Authorization
 To be authorized to possess and use the
atropine auto-injector an agency must have a
written notification to the agency Medical
Director and also filed with the local Regional
Emergency Medical Services Council.
 All participating individuals must complete
this or an equivalent training program.
Distribution
 The Atropine Auto-Injector will be distributed
to the agencies throughout NYS with the
knowledge of the regional medical directors.
 All agency personnel participating in the
program must attend an approved atropine
auto injector training program and
documentation of such should be on file at
the agency and the local REMSCO.
Final Steps for Atropine Use
 Bring auto-injectors back to agency.
 Notify your agency’s Medical Director that you
will be training staff on use and deploying the
drug for use.
 Train your personnel, (EMT & above).
 Put auto-injectors on the rig.
Questions?????