EMS Protocol of the Week - Weapons of Mass Destruction Nerve Agent Exposure (Adult and Pediatric)

Timed up perfectly to coincide with our annual hazmat days is the REMAC’s WMD protocol, specifically with regards to weaponized nerve agents (think sarin gas). Obviously, incidents such as these, should they occur, would trigger all sorts of MCI operations, but the point of this protocol specifically is to highlight how the use of antidotes (in this case, DuoDote – the atropine/pralidoxime combo autoinjector) is operationalized. In these cases, one of the FDNY EMS medical directors would issue a Class Order instructing agencies to start utilizing this specialized intervention, an order which may wind up disseminated to OLMC facilities like ours to further disseminate to EMS crews. Use this protocol as a reference tool in the specific dosing of DuoDotes; note that there are separate tables for initial treatment, subsequent management, and pediatrics specifically. Also note that these tables all fall under a CFR header, meaning CFRs, EMTs, and paramedics can all administer these autoinjectors.

Of course, this protocol will hopefully never need to be utilized, but having these sort of strategies set ahead of time goes a long way in disaster preparedness and protection of life in what is hopefully a never-event.

Thanks for reading! www.nycremsco.org and the protocol binder for more!

Dave

PODT: Urushiol-Producing Plants

In North America, contact dermatitis from plant exposure is most commonly caused by poison ivy, oak, and sumac.

These plants secrete urushiol oil, which causes a type IV hypersensitivity reaction (cell-mediated, delayed) when in contact with the skin, GI tract, or respiratory tract (through smoke).

Patients often present days to weeks post-exposure, as the oil can stay on clothes, equipment, pets, etc. for up to years. As such, it is important to advise patients to thoroughly wash everything that may have been exposed ASAP. After exposure, it takes approximately 20-30 minutes for urushiol to penetrate the skin, so washing skin as soon as possible after a possible exposure can prevent reaction.

Rash is vesicular, pruritic, and linear. Appears 1-2 days post-exposure (possibly shorter if patient has prior exposure, longer if naïve).

The vesicles seen above contain clear fluid that is not contagious. Patients may say the rash is “spreading,” but they likely have just not fully decontaminated and still transferring oil to other parts of their body.

Treatment is generally supportive. Symptoms can be treated with oral antihistamines, calamine lotion, oatmeal baths, cool compresses, topical astringents under occlusion dressings to dry weeping lesions.

For severe reactions, 15-20 day steroid taper can be prescribed. Low-dose steroid bursts are not recommended, as rebound dermatitis is seen.

Not indicated are topical antihistamines, anesthetics containing benzocaine, antibiotics containing neomycin or bacitracin.