Omaha Metropolitan Medical Response System
OMMRS
Administration of Mark I™ Kit, DuoDote™ and
AtroPen® Auto-Injectors
Presented by the OMMRS Pharmacy Subcommittee
Version 2, copyright © 2008
Treatment Disclaimer
This video is intended to provide general guidelines
and is not intended for individual patient care.
Please contact a physician or your regional poison
control center for patient-specific management
advice as needed.
Administration of Mark I™ Kit, DuoDote™ and
AtroPen® Auto-Injectors Video
Created by the Omaha Metropolitan Medical Response
System Pharmacy Subcommittee
Provides general information on the use and
administration of the Mark I Kit, DuoDote, and
AtroPen auto-injectors for nerve agent exposures
Please check with your local fire department and
MMRS for specific treatment protocols
Nerve Agents

Chemical Warfare Agents





Tabun (GA)
Sarin (GB)
Soman (GD)
VX
Organophosphate Insecticides


Malathion
Parathion
Lethal Amount of VX
Mark I Kit Auto-Injector
Contains:
 Atropine IM 2 mg in 0.7 milliliters
 Pralidoxime Chloride (2-PAM or Protopam) IM
600 mg in 2 milliliters
Duodote Auto-Injector
Contains:
 Atropine 2.1 mg in 0.7 milliliters and Pralidoxime
Chloride (2-PAM or Protopam) 600 mg in 2 milliliters in
two separate internal chambers. When activated, the
DuoDote administers both drugs IM in a single autoinjector.

The antidotes should only be used when signs and
symptoms of exposure are present
Self Protection

Protect Yourself:

Liquid contamination on clothing poses a vapor and
dermal contact risk to care givers.

Protection from vapors requires wearing air-supplied
respirators such as self-contained breathing apparatus
until the patient is decontaminated.

Protect yourself by avoiding contact with skin or clothing
of victims (wear chemical-protective clothing).

Skin decontamination before patient enters squad or
hospital
Nerve Agents
Treatment

Aggressive Respiratory Support
Suction
 Oxygen
 Intubation
 Assisted Ventilation

S-M-I-L-E
S Self-contained breathing apparatus
 M Mask and other PPE
 I Inject self or patient AND
Initiate respiratory support
 L Leave area for decontamination
 E Evaluation by a medical team

Nerve Agents
Toxicity/Onset of Effects


Nerve Agents and some organophosphate
insecticides are extremely toxic by inhalation,
ingestion, and dermal exposure
Onset of clinical effects may be rapid following
inhalation and ingestion or may be delayed up to 18
hours following dermal exposures
Effects of Nerve Agents

Mild Symptoms

Pinpoint pupils (miosis)

Excessive sweating

Tearing (lacrimation)
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Drooling (salivation)
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Runny nose

Mild chest tightness

Mild shortness of breath
Effects of Nerve Agents

Moderate Symptoms

Severe chest tightness

Wheezing

Profuse airway secretions

Respiratory distress

Vomiting, abdominal cramps

Diarrhea

Muscle weakness
Effects of Nerve Agents

Severe Symptoms

Cyanosis

Seizures

Coma

Flaccid paralysis

Respiratory failure

Apnea
S-L-U-D-G-E-M
S Salivation AND Sweating
L Lacrimation (tearing of the eyes)
U Urination
D Defecation/Diarrhea
G GI Upset (abdominal cramping)
E Emesis AND Excessive Airway Secretions
M Muscle Weakness/Paralysis AND Miosis
Mark I Kit Injection Procedure
1. Remove Mark I Kit from the
protective pouch.
2. With the non-dominant hand, hold
the unit by the plastic clip so that
the larger one is on top and both
are positioned at eye level.
3. Remove the AtroPen from slot
number one (1) of the plastic clip


The yellow safety cap will remain in
the clip and the AtroPen will now be
armed.
DO NOT hold unit by the green tip
the needle injects from green tip.
Mark I Kit Injection Procedure
4. With the other hand, check the injection site
for buttons or objects in pockets which may
interfere with the injections.
5. Grasp the unit and position the green tip of
the AtroPen on victim’s outer thigh or
buttocks.
6. Push firmly until the auto-injector fires.
7. Hold the injector firmly in place for at least 10
seconds.
Mark I Kit Injection Procedure
8. Remove the Pralidoxime Chloride Pen from
slot number two (2) of the plastic clip


The grey safety cap will remain in the clip and
the Pen will now be armed
DO NOT hold the unit by the black tip – the
needle injects from the black tip.
9. Grasp the unit and position the black tip of
the Pen on victim’s alternate outer thigh or
buttocks.
Mark I Kit Injection Procedure
10. Push firmly until the auto-injector fires.
11. Hold the injector firmly in place for at least 10 seconds.
12. Place the auto-injectors in a sharps container.
13. Document the number of auto-injectors administered
on the patient care report or the triage tag.
1 Kit
DuoDote Injection Procedure
1. Remove the DuoDote from the
plastic pouch.
2. Place the DuoDote in your
dominant hand. Firmly grasp the
center of the DuoDote with the
green tip pointing down. Do not
touch the green tip.
3. With your other hand, pull off the
gray safety release. The DuoDote
is now ready to be administered.
DuoDote Injection Procedure
4. Make sure pockets at the injection site are
empty.
5. Firmly push the green tip straight down
against the outer thigh. Continue to firmly
push until you feel the auto-injector trigger.
6. Hold the DuoDote in place for 10 seconds.
7. Remove the auto-injector from the thigh and
look at the green tip. If the needle is visible,
the drug has been administered.
DuoDote Injection Procedure
8. If the needle is not visible, check to be sure
the gray safety release has been removed
and repeat the procedure.
9. Place the auto-injector in a sharps container.
10. Document the number of auto-injectors
administered on the patient care report or
triage tag.
Auto-Injector Notes




Auto-injector needle is 8/10 inch long
Injector needle can go through clothing
Injector needle may not penetrate bunker gear
Give injections into a large muscle mass area
such as the outer thigh or buttocks
Treatment Guidelines
 Mild
Symptoms
Give
One Mark I Kit OR One DuoDote
2
mg of Atropine & 600 mg of Pralidoxime
Treatment Guidelines
 Moderate
Give
Symptoms
Two MARK I Kits OR Two DuoDotes
4
mg of atropine & 1200 mg of pralidoxime
Treatment Guidelines
 Severe
Symptoms
Give
Three MARK I Kits OR Three DuoDotes
6
mg of atropine & 1800 mg of pralidoxime
Diazepam
(Valium) 5-10 mg
 Intramuscular
or intravenous
 Administer to patients with seizures
 Consider for non-convulsing patients with severe
symptoms
Treatment Guidelines
 Continue
to give additional 2 mg doses of
Atropine at 5 to 10 minutes intervals as
needed to dry excessive secretions
Atropine
Remember: Patients die a pulmonary death
 Atropine will dry lung secretions and relax
bronchoconstriction
 Indicator of sufficient atropine dosing:
decrease in lung secretions, decreased airway
resistance, drying of nasal and oral secretions
and improved respiratory function
 Pupil size should not be used as a guide for
sufficient atropine dosing

Atropine
Insufficient atropine can result in fatalities
 Too much atropine can cause dilated pupils,
dry mouth and skin, rapid heart rate, flushed
skin, confusion, and urinary retention.
 Atropine overdose is rarely life-threatening

Pralidoxime
Adverse Effects


Mild to moderate pain at injection site
Other Side Effects:
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Blurred vision
Headache
Increased blood pressure
Double vision
Dizziness
Drowsiness
Tachycardia
Hyperventilation
Pediatric Use
In a mass terrorist attack, proportionately
more children than adults may be affected
 Pediatric patients may be more seriously ill
than adults following the same exposure
 Best option is to dose atropine and
pralidoxime based on the child’s weight

Pediatric Dosing

Atropine


Pralidoxime


Children: 0.05 mg/kg IV or IM every 5 to10 minutes
as needed for bronchospasm and secretions
Children: 25-50 mg/kg (max 1 gram/dose) IV or IM;
repeat in one hour as needed
Diazepam

Children: 0.2-0.5 mg/kg IV or IM; may repeat every 5
to10 minutes as needed to control seizures
Pediatric Use
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Atropine is most needed initially in the field and ideally
should be given from pre-filled syringes, pediatric autoinjectors, or multi-dose vials
The Mark I Kit auto-injector may be discharged into a
sterile container, such as a vial, and the amount needed
drawn up and given IM
Do not give IV due to the preservative
There is potential for injury from the injector needle
when administered to small children
In the absence of any other option, one Mark I Kit OR
one DuoDote may be given to children weighing 12 kg or
greater
For the child in extremis, one Mark I Kit OR one
DuoDote may be given, regardless of size
Pediatric Use


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
AtroPen is an atropine auto-injector available in
various doses (0.25 mg, 0.5 mg, 1 mg, 2 mg)
Use of a pediatric-strength AtroPen, facilitates the
rapid administration of atropine doses to children
AtroPen 0.5 mg contains atropine 0.5 mg/0.7 ml
Dosing is based on child’s weight and severity of
symptoms
Pediatric Use



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Children weighing 13 to 40 pounds: Give One AtroPen 0.5mg
auto-injector; repeat dose every 5-10 minutes as needed
Children weighing 41 to 62 pounds: Give Two AtroPen 0.5mg
auto-injectors; repeat entire dose every 5-10 minutes as needed
Children weighing 63 to 84 pounds: Give Three AtroPen 0.5mg
auto-injectors; repeat entire dose every 5-10 minutes as needed
Children weighing greater than 84 pounds: Give One Mark I Kit
OR one DuoDote; repeat dose every 5-10 minutes as needed
AtroPen Injection Procedure
1.
2.
3.
4.
Snap the grooved end of the plastic sleeve
down and over the yellow safety cap. Remove
the AtroPen from the plastic sleeve.
Firmly grasp the AtroPen with the green tip
pointed down.
Pull off the yellow safety cap with your other
hand. DO NOT touch the green tip - the needle
injects from green tip.
The auto-injector will go through clothing, but
make sure that pockets near the injection site
are empty.
AtroPen Injection Procedure
5.
6.
7.
8.
9.
Aim and firmly push the green tip against the
outer thigh.
Small children should also be injected in the
thigh, but the thigh should be gently pinched to
provide a thicker area for injection.
Hold the auto-injector firmly in place for ten
seconds.
Remove the AtroPen and massage the
injection site.
Place the auto-injector in a sharps container.
For additional information and guidance on the
treatment of nerve agent and insecticide
exposures, please contact your poison control
center at 1-800-222-1222
Resources
The Nebraska Regional Poison Center website
www.nebraskapoison.com contains:


OMMRS Administration of Mark I™ Kit, DuoDote™ and
AtroPen® Auto-Injectors Video and Handout
OMMRS Reference Cards
 NBC Agents Overview/Quick Reference Guide
 EMS Immediate Response NBC Reference Card
 Psychiatric Medication Resources in Emergencies
References

CDC Website: www.bt.cdc.gov

Chemical Warfare Involving Kids Response Project Syllabus:
CWIKresponse.com

Domestic Preparedness Training Program Instructor Guide. U.S. Army
Edgewood Research, Development and Engineering Center. 1998, BoozAllen and Hamilton Inc. and Science Applications International Corporation

Henretig F, Mechem C, Jew R. “Potential use of autoinjector-packaged
antidotes for treatment of pediatric nerve agent toxicity”, Ann of Emerg Med,
40:4, October 2002

MICROMEDEX® Healthcare Series Vol. 124, expires 12/2008