Identify the procedures for treating a nerve agent casualty.

Given multiple choice examination items pertaining to nerve agent poisoning, treatment, and decontamination.

Score 70 or more points on the 100-point written examination.

STP 21-1-SMCT, Soldier's Manual of Common Tasks: Skill Level 1.

FM 21-11, First Aid for Soldiers.

FM 8-285, Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries.

Nerve agents are among the deadliest of the chemical agents. Nerve agents can enter the body by inhalation, by ingestion, and through the skin and eyes. Nerve agents are absorbed rapidly and the effects are felt immediately upon entry into the body. A soldier showing signs of mild nerve agent poisoning will normally be able to administer his own Mark I (atropine and 2-PAM chloride). A soldier showing signs of moderate to severe nerve agent poisoning will not be able to help himself and requires assistance. Your first priority, however, is to ensure that you yourself are adequately protected before assisting any nerve agent casualty. You cannot adequately help the casualty if you are also overcome by the nerve agent.

Anytime you believe that you have been exposed to a chemical agent, your first action should be to take adequately protective measures against the agent. Put on your protective mask immediately and give the alarm. If you have signs and symptoms of mild nerve agent poisoning (unexplained runny nose, sudden headache, dizziness, drooling, tightness in the chest, muscular twitching, stomach cramps, nausea, and/or reduced vision), administer one set of nerve agent autoinjectors to yourself and decontaminate exposed skin. Put on the rest of your protective clothing. Now you are prepared to accomplish your mission and to give aid to casualties as your mission allows.

A casualty may progress from mild to moderate to severe nerve agent poisoning rapidly. Signs of severe nerve agent poisoning include:

Strange and confused behavior.

Coughing, wheezing, and gurgling sounds while breathing.

Difficulty in breathing.

Severely pinpointed pupils.

Red eyes with tears present.

Severe difficulty in seeing.

Vomiting.

Severe muscular twitching and general weakness.

Loss of bladder and bowel control.

Decrease in heart rate (pulse).

Convulsions.

Paralysis.

Unconsciousness.

Respiratory arrest (no breathing).

The casualty may have been able 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 immediately 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, 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.

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

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

Hold the mask over the casualty's face so that the lenses are facing up, your thumbs are on the outside of the cheek pouches of the mask, and your fingers are on the inside of the cheek pouches.

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 his head and down behind his ears.

Make sure 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 temple straps should be above his ears.

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

Check the mask to make sure 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 and breathing, cover the mask's inlet valves. If the mask collapses, it is properly fitted and sealed. If it does not collapse, reseat the mask.

CAUTION: If the soldier is not breathing, you cannot be sure that the mask has a good seal.

Make sure the buckles are lying flat and the straps form a straight line with the tabs.

Pull the protective hood over the casualty's head, neck, and shoulders.

After the severe nerve agent poisoning casualty is masked, administer injections of atropine and 2-PAM chloride.

Check the casualty's pocket flaps and the area around the casualty for expended autoinjectors. The casualty may have administered (or attempted to administer) antidote to himself before being overcome by the effects of the nerve agent.

CAUTION: Use the casualty's Mark I kits. Do not use your personal autoinjector kits on the casualty. You may need them for yourself.

Normally, one of the casualty's thighs is used as the injection site. If the casualty is very thin, however, the injection is given in the large muscle of the buttocks.

Thigh. With the casualty laying on his side, position yourself near the casualty's left thigh. (This makes it easier to reach into his mask carrier for additional kits.) The injection site is on the outer part of the casualty's thigh at least the width of one hand below the hip joint and at least the width of one hand above the knee.

Buttocks. Roll the casualty onto his side and position yourself at his hip. The injection site is the upper, outer quadrant of the casualty's buttocks. 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.

After you have positioned yourself, 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 at eye level and the larger 2-PAM chloride autoinjector is on top.

Use your free hand to feel the injection site area and make sure 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 it away from the site.

Grasp the smaller (atropine) autoinjector with the thumb and first two fingers of your dominant hand (Like holding a pen or pencil).

FIGURE 14-3. REMOVING THEATROPINE AUTOINJECTOR

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 press on the green end, you may accidentally inject yourself.

Place the green (needle) end of the autoinjector against and at a 90^o angle (perpendicular) to the injection site.

Apply firm, even pressure to the autoinjector until the needle is triggered (clicks). The needle will penetrate the casualty's clothing and automatically inject the medication into the casualty's muscle.

CAUTION: Do not use a jabbing motion to inject the antidote into the muscle.

Hold the autoinjector in place for at least 10 seconds to make sure that all of the medication has been injected; then pull the autoinjector out of the casualty's body at the same 90^o angle.

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

Grasp the remaining 2-PAM chloride autoinjector with the thumb and first two fingers of your free hand (Like holding a pen or pencil).

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

Place the black end of the autoinjector against the injection site (same thigh or buttocks) at a 90^o angle.

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

Hold the autoinjector in place for at least 10 seconds; then pull out the autoinjector.

Drop the empty plastic clip with out dropping the autoinjectors.

Lay the used autoinjectors on the casualty's side.

Administer the second Mark I kit using the same procedures used with the first kit.

Administer the third Mark I kit using the same procedures.

The autoinjectors are administered one kit after the other until all three kits have been administered. There is no waiting period between kits. The casualty may have already given himself injections. Any kit administered by the casualty to himself must be counted as part of the three-kit maximum.

Administer the CANA (convulsant antidote for nerve agent) autoinjector after the third Mark I to prevent convulsions.

NOTE: CANA is NOT for use as self-aid. If you know whom you are, where you are, and what you are doing, you do not need CANA.

NOTE: DO NOT use your own CANA on the casualty. If you do, you may not have any antidote for your own treatment, if needed.

Remove the CANA autoinjector from the casualty's mask carrier and remove the packaging.

Grasp the CANA autoinjector with your dominant hand with the needle end extending beyond your thumb and two fingers (Like holding a pen or pencil).

With your other hand, pull the safety cap from the autoinjector base. The injector is now armed.

DO NOT touch the black (needle) end because you may accidentally inject yourself.

Position the black (needle) end of the autoinjector against the casualty's injection site (thigh or buttocks) at a 90^o angle.

Apply firm, even pressure (not a jabbing motion) to the autoinjector until it pushes the needle into the casualty's thigh (or buttocks). Make sure you do not hit the casualty's mask carrier or any objects in the casualty's pockets.

Hold the autoinjector firmly in place for at least 10 seconds.

Carefully pull the CANA autoinjector from the casualty's injection site. Drop the safety cap.

FIGURE 14-6. THREE SETS OF USED AUTOINJECTORS AND A USED CANA

Attach used autoinjectors (atropine, 2-PAM chloride, and CANA) to the casualty's outer clothing, usually the left pocket flap of his outer garment. Push the needle of the autoinjector through the pocket flap, penetrating the flap from the back. Then bend the needle down to form a hook. Repeat the procedure with the other 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

SPECIAL NOTE: The combat lifesaver can administer additional atropine and CANA carried in his aid bag. Additional information is contained in Subcourse IS0825.

Obtain the M291 Skin Decontamination Kit from the casualty's mask carrier.

The M291 Skin Decontaminating Kit is provided to service members for skin decontamination. This kit may also be used to decontaminate selected individual equipment, such as load bearing equipment, protective gloves, mask, hood, and weapon.

NOTE: The M291 kit is for external use only. Keep decontaminating powder out of the eyes; it may be slightly irritating to the eyes. Use water to wash toxic agent out of eyes. You may also use a 0.5 percent chlorine solution to wash toxic agent out of cuts or wounds.

Remove one skin decontaminating packet from the carrying pouch. Tear the packet open quickly at the notch. Although any notch may be used to open the packet, opening at the TEAR LINE will place applicator pad in a position that is easier to use.

Remove the applicator pad from packet and discard the empty packet.

Unfold the applicator pad and slip your finger(s) into the handle.

Thoroughly scrub the exposed skin on the casualty's hands (back of hand, palm, and fingers) until they are completely covered with black powder from the applicator pad.

NOTE: If the casualty needs to breathe before you finish, reseal the mask, clear and check it, and tell the casualty to take a breath; then resume the decontaminating procedure.

Thoroughly scrub the exposed skin of the casualty's face until the exposed skin is completely covered with black powder from the applicator pad.

Have the casualty hold his breath and close his eyes. Grasp his mask beneath his chin and pull the hood and mask away from chin enough to allow one hand between the mask and the face. Hold mask in this position until you discard the applicator pad.

Scrub up and down across the face, beginning at front of one ear to the nose and then to the other ear.

Scrub across the face to the corner of the nose.

Scrub an extra stroke at the corner of the nose.

Scrub across the nose and tip of the nose to the other corner of the nose.

Scrub an extra stroke at the corner of the nose.

Scrub across the face to the other ear.

Next, scrub up and down across the face to the mouth and then to the other end of jawbone.

Scrub across the cheek to the corner of the mouth.

Scrub an extra stroke at the corner of the mouth.

Scrub across the closed mouth to the center of the upper lip.

Scrub an extra stroke above the upper lip.

Scrub across the closed mouth to the other corner of the mouth.

Scrub an extra stroke at the corner of the mouth.

Scrub across the cheek to the end of the jawbone.

Next, scrub up and down across the face to the chin and then to the other end of the jawbone.

Scrub across the under jaw to the chin, cupping.

Scrub an extra stroke at the center of the chin.

Scrub across the under jaw to the end of the jawbone.

Turn your hand out and quickly wipe the inside of the mask that touches the face.

Discard the applicator pad.

Immediately seal the mask, then clear and check it.

Remove a second skin decontaminating packet from the carrying pouch.

Tear the packet open quickly at the notch.

Remove the applicator pad from packet and discard the empty packet.

Without breaking the seal between the face and mask, thoroughly scrub the skin of the neck and ears until they are completely covered with black powder.

e. Redo Hands

Redo the casualty's hands until they are completely covered with black powder.

Discard the applicator pad.

Put protective gloves on the casualty.

Fasten the casualty's hood.

Bury the used pads and packets if circumstances permit.

NOTE: Remove the powder with soap and water when operational conditions permit. It does not matter how long the powder stays on the skin.

NOTE: The M291 kit is replacing the M258A1 kit. For U.S. Army personnel, replaced by the M291, the M258A1 kit will be used for decontamination of individual equipment only.