LESSON 4
PERFORM FIRST AID FOR A NERVE AGENT INJURY
(TASK 081-831-1044)

TASK:

Identify procedures for performing self and buddy first aid for a nerve agent injury.

CONDITIONS:

Given multiple-choice questions pertaining to nerve agent poisoning and decontamination.

STANDARD:

Score 70 or more points on a 100-point comprehensive examination.

REFERENCES:

FM 3-4, NBC Protection.
FM 21-11, First Aid for Soldiers
FM 8-285, Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries.

NOTE:   Some of the task titles and information have changed and are not reflected in FM 21-11 and STP 21-1-SMCT. Refer to the Army Training Support Center, Common Core Task internet site at http://www.atsc.army.mil/dld/comcor/comcore.htm for up-to-date task information.

NOTE: The proponent for the following listed tasks is the U.S. Army Chemical School. Tasks: 031-503-1013, Decontaminate Yourself and Individual Equipment Using Chemical Decontamination Kits; 031-503-1015, Protect Yourself from NBC Injury/Contamination with the Appropriate Mission-Oriented Protective Posture (MOPP) Gear; 031-503-1019, React to a Chemical or Biological Hazard or Attack; 031-503-1035, Protect Yourself from Chemical/Biological Contamination Using Your Assigned Protective Mask. The above tasks are referred to throughout this lesson.

SECTION I

ADMINISTER NERVE AGENT ANTIDOTE TO SELF (SELF-AID)

4-1. INTRODUCTION

Chemical agents are intended for use in military operations. They are designed to kill or incapacitate personnel due to the chemical effects of the agent. Chemical agents may be inhaled, ingested when food or water contaminated by the agent is consumed, or absorbed when the agent comes into contact with the skin or eyes. Nerve agents are among the deadliest chemical agents. They can be delivered by artillery shell, mortar shell, rocket, aircraft bomb, spray, or land mine. In general, nerve agents are colorless, odorless, and tasteless.

Your protective mask and protective clothing provide good protection from all chemical agents. The M258A1 or M291 Skin Decontamination Kits are used to remove liquid chemical agents from your exposed skin. The M295 Individual Equipment Decontamination Kit is used to decontaminate your personal equipment. The M259A1 kit can also be used to decontaminate equipment. For more information, refer to task 031-503-1013, Decontaminate Yourself and Individual Equipment Using Chemical Decontamination Kits. Medications contained in the Mark I nerve agent antidote kit help to counteract nerve agent poisoning. The effects of the antidote can be enhanced by taking pyridostigmine bromide tablets at least one hour prior to being exposed to the nerve agent.

4-2. TAKE PYRIDOSTIGMINE BROMIDE PRETREATMENT TABLETS

You will be issued the Nerve Agent Pyridostigmine Pretreatment (NAPP) Tablet Set when the corps/division/wing command determines there is a need. The instructions on the proper use of pyridostigmine will be provided at time of issue. Additionally, instructions are on the tablet set. Although the pyridostigmine itself does not provide protection against nerve agents, it does enhance the efficiency of the medications contained in the Mark I nerve agent antidote set.

The Nerve Agent Pyridostigmine Pretreatment Tablet Set (fig 4-1) contains the pretreatment medication to be taken within 8 hours prior to exposure to nerve agents.

The NAPP consists of a blister pack containing 21 tablets. Each tablet contains 30 mg pyridostigmine bromide. Each blister pack contains enough tablets for 7 days. Take one tablet by mouth, with sufficient water to assist in swallowing the medication, every 8 hours as directed by your commander. If a dose is missed, do not make it up. Do not take two tablets at one time because of a missed dose--merely start again with one tablet every 8 hours. Taking two tablets at one time could result in adverse side effects. Taking more than one tablet at a time DOES NOT provide additional protection--in fact, it may be more hazardous if there is exposure to a nerve agent.

You are initially issued one NAPP when the chemical protective ensemble is expected to be opened for use. You are responsible for carrying the NAPP and safeguarding it against loss. Service members will secure the blister pack in the sleeve or breast pocket of the chemical protective ensemble (or in another part of the ensemble, as directed by local standing operating procedure (SOP)).

When the order to take pyridostigmine pretreatment has been given, it should be taken as directed even though the protective mask is worn.

Signs and Symptoms of Pyridostigmine Bromide Overdose, Adverse Reactions, and Contraindications

Although no detrimental effects are expected at the recommended dosage, depending on the length of time and the amount of medication taken as well as individual physiologic variations, some individuals may have contraindications for taking pyridostigmine bromide while others may experience adverse reactions.

Signs and symptoms of overdose, adverse reactions, or side effects are:

• Abdominal cramps.
• Nausea and vomiting.
• Diarrhea.
• Blurring of vision, miosis.
• Increased bronchial secretions.
• Cardiac arrhythmia's, hypertension.
• Weakness, muscle cramps, and muscular twitching.
• Skin rash.

Since pyridostigmine bromide may increase bronchial secretions and aggravate bronchiolar constriction, caution should be used in its administration to personnel with bronchial asthma.

If you have any of the above signs/symptoms, consult unit medical personnel as soon as possible.

4-3. IDENTIFY WHEN PROTECTIVE MEASURES ARE TO BE INITIATED

Your best protection against nerve agents and other chemical agents is your protective mask. You should immediately mask when:

• Your are commanded to mask.
• Someone gives a chemical agent warning either by yelling, "Gas!" or by giving hand and arm signals.

FIGURE 4-2. CHEMICAL AGENT WARNING SIGNAL

• You detect the presence of a chemical agent using M8 paper, M9 paper, or other device.
• Your position is hit by a concentration of artillery, mortar, or rocket fire, or by aircraft bombs.
• Your position is under attack by aircraft spray.
• Smoke or mist of an unknown source is present or approaching.
• A suspicious liquid is present.
• You are entering an area known to be or suspected of being contaminated with a toxic chemical.
• You notice signs and symptoms of nerve agent poisoning in yourself or in others.
• You note inappropriate laughter, unusual behavior, slurred speech, unusual restlessness, dizziness, stumbling, or sudden feelings of depression in yourself or in others. (These signs and symptoms may be caused by an incapacitating agent. Incapacitating agents may be combined with a chemical agent in order to interfere with a soldier's ability to take protective actions against the chemical agent.)
• Soldiers suddenly collapse without evident cause.

4-4. IDENTIFY EARLY SIGNS AND SYMPTOMS OF NERVE AGENT POISONING

Nerve agents are absorbed rapidly and the effects are felt immediately. Signs and symptoms of nerve agent poisoning are divided into two groups--early and severe. A person with early (mild) symptoms is capable of administering first aid to himself (self-aid). A person with severe symptoms is not capable of helping himself and must rely on others to administer first aid (buddy-aid). The number and severity of symptoms that are caused by nerve agent poisoning depend upon the amount of nerve agent absorbed by the body. Early signs and symptoms of nerve agent poisoning include:

• An unexplained runny nose.
• A sudden headache.
• Sudden drooling.
• Tightness in the chest or difficulty in breathing.
• Muscular twitching around exposed skin.
• Stomach cramps.
• Nausea.
• Vision difficulties (reduced vision).

4-5. PUT ON YOUR PROTECTIVE MASK

In case of chemical attack, your first action should be to hold your breath and put on your protective mask immediately. If you are having signs or symptoms of nerve agent poisoning and are not masked, put on your protective mask before injecting yourself with nerve agent antidote.

Put on your protective mask (see task 031-503-1035, Protect Yourself from Chemical/Biological Contamination Using Your Assigned Protective Mask).

Give the alarm by yelling, "Gas!" or by using hand signals (see task 031-503-1019, React to Chemical or Biological Hazard or Attack).

4-6. SELECT INJECTION SITE

The nerve agent antidotes need to be injected into a large muscle. In most individuals, the thigh muscle is used. If a person is very thin, however, the injection should be given in the buttocks.

Thigh

If you are right-handed, select a site on your right thigh. If you are left-handed, select a site on your left thigh. The injection site should be in the outer part of the thigh. It is important that the injections be given into a large muscle area. The site should be at least one hand's width below the hip joint and at least one hand's width above the knee. Choose a site that is away from buttons, zippers, and objects being carried in your pockets.

FIGURE 4-3. INJECTION SITES

Buttocks

If you are right-handed, select a site on the upper, outer quadrant of your right buttocks. If you are left-handed, select a site on the upper, outer quadrant of your left buttocks. The upper, outer part of the buttocks is used to avoid hitting a major nerve or artery. Hitting the nerve could result in paralyzing the leg. The site should be free of objects in your pocket which could be hit by the needle.

4-7. ADMINISTER ONE NERVE AGENT ANTIDOTE KIT

Administer a Mark I nerve agent antidote kit (NAAK) only after you mask and only if you are having signs and symptoms of nerve agent poisoning. You should have three Mark I kits in the inside pocket of your M17 mask carrier. In the case of the M40 series carrier, there is no room for the Mark I kits and SOP dictates the storage location, usually in the battle dress uniform (BDU). In freezing temperatures, carry the kits where they will be protected from the cold. The Mark I kit has two automatic injectors (autoinjectors). The large autoinjector contains pralidoxime chloride (2-PAM chloride). The smaller autoinjector contains atropine. Procedures for administering the antidotes follow.

FIGURE 4-4. MARK I NERVE AGENT ANTIDOTE KIT

Administer Atropine

Remove one Mark I kit from your mask carrier (or other location as specified by local SOP).

Hold the kit with your nondominant hand by the plastic clip with the larger (2-PAM chloride) autoinjector on top. Hold the set at eye level in front of you so that you can see the autoinjectors.

Grasp the body of the smaller (atropine) autoinjector with the thumb and first two fingers.of your dominant hand. Do not cover the green (needle) end of the autoinjector with your fingers or hand. Touching the green end may cause the autoinjector to function when you remove it from the clip.

Pull the autoinjector out of the clip with a smooth motion (upon removal the injector is automatically armed.) If the autoinjector accidentally functions, obtain another Mark I kit. Nerve agent antidote must be administered into a large muscle in order to be effective quickly. Administering antidote into a finger or hand is not adequate.

Hold the autoinjector with your thumb and two fingers (pencil writing position).

FIGURE 4-5. REMOVING THE ATROPINE AUTOINJECTOR

The autoinjector should be held at a 90° angle to your body. Place the green (needle) end of the autoinjector against the thigh (or buttocks) muscle. Make sure that the needle will not hit anything in your pocket when it functions. If your jacket is covering the injection site, lift the bottom of the jacket before giving yourself the injection.

Press the green end of the autoinjector against the injection site using firm, even pressure until it functions (needle is activated). The needle will penetrate through your clothing and into the muscle. The antidote will be injected automatically. Do not use a jabbing motion to activate the needle. A jabbing motion is not necessary and may cause the autoinjector to function improperly.

FIGURE 4-6. ADMINISTERING AN INJECTION

Hold the autoinjector in place for at least ten seconds after the needle has functioned. The seconds can be estimated by counting "one thousand and one, one thousand and two, one thousand and three, one thousand and four, one thousand and five, one thousand and six, one thousand seven, one thousand and eight, one thousand and nine, one thousand and ten." This time is needed to ensure that all of the antidote has been injected.

Carefully remove the atropine autoinjector by pulling it straight out.

Place the used autoinjector between two fingers of the hand holding the remaining autoinjector and clip. The green (needle) end should point away from your hand.

Administer 2-PAM Chloride

Grasp the body of the 2-PAM chloride autoinjector (the large autoinjector remaining in the clip) with the thumb and two fingers of your right hand. Do not cover the black (needle) end of the autoinjector with your fingers or hand.

Pull the autoinjector out of the clip with a smooth motion. If you accidentally activate the needle while removing the autoinjector, obtain another Mark I kit and administer the new 2-PAM chloride autoinjector.

FIGURE 4-7. REMOVING THE 2-PAM AUTOINJECTOR

Place the black (needle) end of the autoinjector against your thigh (or buttocks) muscle.

Using firm, even pressure, press the black end of the autoinjector against the injection site until the needle functions. Use the same procedure as used with the atropine autoinjector.

Hold the autoinjector in place for at least ten seconds, then carefully remove the 2-PAM chloride autoinjector by pulling it straight out.

Secure Used Autoinjectors

Drop the plastic clip. Do not drop the autoinjectors.

Lift a pocket flap on your protective jacket and push the needle of the used 2-PAM chloride autoinjector through the flap. (The flap is penetrated from the back so that the needle will be away from your body.)

Bend the needle down to form a hook.

FIGURE 4-8. USED AUTOINJECTORS (ONE SET) ATTACHED TO POCKET FLAP

Repeat the penetration and bending process with the expended atropine autoinjector.

(NOTE: The expended autoinjectors are secured to your clothing in case you require medical help. Attaching both used autoinjectors to your outer clothing will inform medical personnel that nerve agent antidote has been administered and the amount that has been administered.)

4-8. DECONTAMINATE YOUR SKIN

Refer to task 031-503-1013, "Decontaminate Yourself and Individual Equipment Using Chemical Decontamination Kits."

FIGURE 4-9. M258A1 DECONTAMINATION KIT

FIGURE 4-10. M291 DECONTAMINATION KIT

4-9. UPGRADE MOPP AND SEEK AID

After administering the first Mark I and decontaminating your skin, up-grade MOPP.

If you can walk and are not confused (you know who you are and where you are), you will probably not need additional antidote.

Seek buddy-aid or medical aid for additional injections.

SECTION II

ADMINISTER FIRST AID TO A NERVE AGENT CASUALTY (BUDDY-AID)

4-10. INTRODUCTION

A soldier showing signs of severe nerve agent poisoning will not be able to help himself. Unless he receives help, he will probably die. However, you should put on your own protective mask and perform needed self-aid procedures before giving buddy-aid. You cannot help the casualty if you are also overcome by the nerve agent.

Buddy-aid will be required when a soldier is totally and immediately incapacitated prior to being able to apply self-aid. All three sets of nerve agent antidote and the CANA need to be given by a buddy.

Buddy-aid may also be required for a soldier who attempts to counter the nerve agent by self-aid but becomes incapacitated after administering one set of the antidote. Before initiating buddy-aid, a buddy should determine if one set of injectors has already been used so that no more than three sets of the antidote are administered.

4-11. IDENTIFY SIGNS OF SEVERE NERVE AGENT POISONING

A casualty may or may not have signs and symptoms of mild nerve agent poisoning prior to the appearance of the signs of severe nerve agent poisoning. Signs of severe nerve agent poisoning include:

• Strange and confused behavior.
• Gurgling sounds while breathing.
• Severely pinpointed pupils.
• Red eyes with tears present.
• Vomiting.
• Severe muscular twitching.
• Loss of bladder and bowel control.
• Convulsions.
• Unconsciousness.

4-12. MASK THE CASUALTY

The casualty may have been unable to put on his protective mask before he was overcome by the nerve agent. If so, check his mask to make sure that it is on properly. If the casualty has not masked himself, then you must mask him using the following procedures.

Approach the casualty. If the casualty is moving or flailing about on the ground, approach him from the area of his head and left shoulder. This will help to protect you from accidental injury.

If the casualty is not lying on his back, you must roll the casualty onto his back with his face up. Do this by squatting next to the casualty, grasping the casualty's clothing at the far shoulder and hip, and rolling him toward you in a gentle, even manner.

Place yourself near the casualty's head, face his feet, and squat behind his left shoulder.

Open the casualty's protective mask carrier and remove his protective mask.

Hold the mask so that the lenses are facing you, your thumbs are on the outside of the cheek pouches of the mask, and your fingers are on the inside of the cheek pouches.

FIGURE 4-11. MASKING A CASUALTY

Spread the mask open and position it on the casualty's chin.

Put your thumbs through the two bottom straps of the head harness.

Cup the casualty's head with the fingers of both hands and lift his head slightly.

Slide the head harness over the casualty's head by moving your thumbs toward the back of the casualty's head and down behind his ears.

Make sure that the two bottom straps of the head harness are placed below the casualty's ears and the head pad is centered in the middle of the back of his head.

The head harness should not need to be adjusted. If the straps do need to be tightened, tighten them using short, firm jerks.

Check the mask to ensure that it is completely sealed on the casualty's face. If the casualty is conscious and can follow instructions, have him clear his mask (cover the outlet valve and voicemitter and blow hard, then cover the inlet valves and inhale). If the casualty is unconscious, cover the mask's inlet valves. The mask will collapse if it is properly fitted and sealed. If it does not collapse, reseat the mask. (NOTE: If the soldier is unconscious and not breathing, you cannot be sure that the mask has a good seal.)

Pull the protective hood over the casualty's head, neck, and shoulders. Information on masking is contained in task 031-503-1035, "Protect Yourself from Chemical/Biological Contamination Using Your Assigned Protective Mask."

4-13. ADMINISTER NERVE AGENT ANTIDOTE KITS

After the casualty is masked, position the casualty on his/her right side (similar to the swimmer position) with the head slanted down so that the casualty will not roll back over. If vomiting occurs, the matter will be caught in the mask. Determine if the soldier has self-administered any antidote. Begin administering injections of atropine and 2-PAM chloride. The casualty may be administered a total of three Mark I antidote kits without medical attention.

Select Injection Site

If the casualty's thigh muscle is large enough, give the injections in his thigh. If the casualty is very thin, give the injection in the large muscle of his buttocks.

Thigh. If the injections are to be given in the casualty's thigh, position yourself near the casualty's thigh. The injection site should be on the outer part of the casualty's upper thigh. The injection site should be at least one hand's width below the hip joint and at least one-hand's width above the knee.

FIGURE 4-12. INJECTING A CASUALTY'S THIGH

Buttocks. If the injection is to be given in the casualty's buttocks, roll the casualty onto his side and position yourself at his hip. The injection site should be in the upper, outer quadrant of the casualty's upper buttocks when casualty is on his side. The upper, outer quadrant is used to avoid hitting the major nerve in the buttocks. If the casualty's jacket is covering the injection site, lift the bottom of the jacket.

FIGURE 4-13. INJECTING THE CASUALTY'S BUTTOCKS

Administering Atropine

Remove one Mark I nerve agent antidote kit from the inside pocket of the casualty's mask carrier. (NOTE: If the temperature is near or below freezing, the casualty may be carrying the autoinjectors in another location.)

Hold the kit by the clip in your nondominant hand so that it is in front of your body and at eye level. The larger 2-PAM chloride autoinjector should be on top.

Use your free hand to ensure that the injection site is free from buttons or other obstructions that could be hit by the needle. If the mask carrier or any other equipment is covering the injection site, move the equipment away from the site.

FIGURE 4-14. REMOVING THE ATROPINE AUTOINJECTOR

Grasp the smaller (atropine) autoinjector with the thumb and two fingers of your dominant hand.

Pull the atropine autoinjector out of the clip with a smooth motion. Do not cover or hold the green (needle) end of the autoinjector. If you do, the needle may function.

Hold the autoinjector with the thumb and two fingers of your dominant hand and place the green (needle) end of the autoinjector against and at a 90° angle to the injection site.

Apply firm even pressure to the autoinjector until the needle functions, penetrates the casualty's clothing, and injects the medication into the casualty's muscle. Do not use a jabbing motion to inject the antidote into the muscle.

Hold the autoinjector in place for at least ten seconds; then pull the autoinjector out of the casualty's body.

Place the used atropine autoinjector between two fingers of the hand holding the clip. Point the needle away from your hand. Make sure that the needle does not puncture or tear your protective gloves.

Administer 2-PAM Chloride

Grasp the remaining 2-PAM chloride autoinjector with the thumb and two fingers of your free hand.

Pull the autoinjector out of the clip in a smooth motion. Do not touch or cover the black (needle) end of the autoinjector.

Hold the autoinjector with the thumb and two fingers of your dominant hand and place the black end of the autoinjector against the casualty's thigh (or buttocks) at a 90° angle.

FIGURE 4-15. REMOVING THE 2-PAM CHLORIDE AUTOINJECTOR

Apply firm, even pressure until the needle functions. Do not use a jabbing motion.

Hold the autoinjector in place for at least ten seconds; then pull out the autoinjector.

Drop the empty plastic clip without dropping the autoinjectors.

Lay the used injectors on the casualty's side.

Administer Additional Antidote

Administer the second and third Mark I kits using the same procedures as for the first kit. After the administering of the third kit of autoinjectors, a CANA injection should be given (para. 4-14).

The autoinjectors are administered one kit after the other until all three kits have been administered. There is no waiting period between kits.

If the casualty does not have three Mark I kits, search the immediate area for used and unused autoinjectors. The casualty may have already given himself injections or have been trying to give himself an injection and dropped the autoinjectors. Be sure to check the casualty's pocket flap for the presence of used autoinjectors.

4-14 ADMINISTER CANA INJECTION

CANA is a convulsant antidote for nerve agents. CANA is NOT for use as self-aid.

FIGURE 4-16. CANA INJECTOR

Preparing to administer the CANA injection consists of the following steps:

Administer the CANA injection following the same procedure used for the atropine and 2-PAM Cl injections.

• The injector is now armed.
• Do not touch the black (needle) end.
• Holding or covering the black (needle) end may result in accidentally injecting yourself.

  (1) Position the black end of the CANA injection against the injection site (thigh or buttocks)--

  • On the casualty's outer thigh muscle or--
  • On the upper, outer portion of the casualty's buttocks.

  (2) Apply firm, even pressure (not a jabbing motion) on the injector to activate the needle. This causes the needle to penetrate both the casualty's clothing and muscle. Using a jabbing motion may result in an improper injection or injury to the thigh or buttocks.

  (3) Hold the injector firmly in place for at least 10 seconds. The 10 seconds can be estimated by counting "one thousand and one, one thousand and two," and so forth.

Secure Used Autoinjectors

Attach all used autoinjectors (one at a time) to the casualty's outer clothing, usually the left pocket flap of his protective outer garment. Push the needle of the autoinjector through the pocket flap and bend the needle to form a hook. Repeat the procedure with all remaining autoinjectors. Be careful not to puncture your gloves with the needles. (The used autoinjectors will tell medical personnel how much medication the soldier has received. This information will help them determine what additional care is needed.)

FIGURE 4-17. SECURED USED INJECTORS

4-15. DECONTAMINATE THE CASUALTY'S EXPOSED SKIN

After the casualty has been administered a total of three Mark I kits and the CANA, use the casualty's M258A1 or M291 skin decontamination kit to decontaminate the casualty's skin that was exposed to the nerve agent.

Refer to task 031-503-1013, "Decontaminate Yourself and Individual Equipment Using Chemical Decontaminat Kits" for more information on the various kit procedures. The procedures you follow for your personal decontamination generally apply to a casualty's decontamination. Procedures are a little more complicated when it involves the area under the casualty's mask and whether the casualty is conscious or not.

Have the casualty hold his breath.

Lift the casualty's mask to expose the lower part of his face.

Quickly wipe the exposed area of his face and the interior surface of the mask that comes into contact with his face.

Replace the mask.

Tell the casualty to resume breathing.

Seek help (usually a combat medic) for the casualty. If your mission allows, evacuate the casualty to an aid post or collection point where he can receive additional care and be evacuated to a field medical treatment facility (aid station). Evacuation procedures are discussed in Lesson 16.