EMS Protocol of the Week: Weapons of Mass Destruction - Nerve Agents

Hey all,

This week's protocol delves into the world of ⚠weapons of mass destruction⚠ with a focus on biochemical warfare -- specifically nerve agents that cause cholinergic toxicities. And I know you're all just foaming at the mouth waiting to hear about it 👅

This protocol can only be activated via a class order by an FDNY Medical Director from the Office of Medical Affairs. Pre-hospital providers must wear the appropriate chemical protective clothing and operate within the hot, warm, and cold zones as directed by the incident commander (throwback to your Orientation HazMat training).

Patients are tagged and triaged based on signs/symptoms of cholinergic toxicity. All "red" and yellow" patients who exhibit SLUDGEM symptoms (salivation, lacrimation, urination, diarrhea, GI upset, emesis, myosis), respiratory distress, or AMS should receive immediate treatment from the nerve agent antidote kit (see image):

• Atropine 2mg IM auto-injector

• Pralidoxime 600mg IM auto-injector 

Repeat doses of atropine can be given based on secretions and respiratory distress. Don't delay treatment in these patients for decontamination!

Paramedics can also give IM doses of Diazepam or Midazolam for actively seizing patients.

The role of OLMC is to provide additional doses of any of the standing order meds.

Hopefully, we never have to use this one, but if we do -- don't pee your pants -- just stay calm and follow the protocol!

More info at www.nycremsco.org

Best,

Chris Kuhner, MD

PGY-2 Emergency Medicine

Medical Abortions & Misoprostol Toxicity

Medical abortions can be done until 11 weeks of pregnancy and are 98% successful in terminating a pregnancy. They are popular because they are relatively safe and easy to administer. As of 2021, patients can get these medications via mail or pharmacy. 

Contraindications for medical abortions include ectopic pregnancies, pregnancy > 11 weeks, adrenal insufficiency, renal failure, liver failure, cardiac disease, and coagulopathy. 

Medical abortions are typically performed using Mifepristone and Misoprostol. Mifepristone blocks progesterone, preventing the pregnancy from progressing. Misoprostol, a synthetic prostaglandin E1, induces uterine cramping to help expel the pregnancy (think: misoprostol, like prostaglandin). Misoprostol should be taken 24-48 hours after mifepristone and patients should expect to have some bleeding but it should not exceed 2 pads/hr for 2 consecutive hours (think: rule of 2s). Patients are encouraged to take a repeat pregnancy test at 4 weeks or get an US to confirm termination after taking these medications.  

• Mifepristone dose: 200 mg PO

• Misoprostol dose: 800 mcg x1-2 buccally or transvaginally. 

  • If given buccally, the patient will place two 200 mcg pills in each cheek and let them dissolve.

Given the stigma and laws prohibiting safe abortions, many people are now seeking alternative means for abortions, such as medications they find on the internet. Some medications marketed as misoprostol are not regulated and contain other dangerous substances. 

Misoprostol toxicity is very rare, however, due to more limited access to these medications people are at increased risk for harmful side effects. Normal doses of misoprostol in safe abortions are 200-1000 mcg depending on the route. This may cause a slight fever, chills, cramping, nausea, vomiting, or diarrhea, but symptoms typically improve quickly. Toxic doses are in the 3-8 mg range; these patients may have severe GI issues, high fever, chills, severe myalgias with rhabdo, bradycardia, hypoxia, AMS, and hypotension. Doses as high as 12 mg may result in multisystem organ failure and death. Symptoms develop very quickly after ingestion as it is completely absorbed from the stomach in 90 mins. Treatment involves removing any tablets from the vaginal canal, rectum, maybe stomach, and supportive care/symptomatic management until symptoms resolve (usually 12 hours). 

Thanks for reading! 

Ariella

Resources:

https://www.who.int/news-room/fact-sheets/detail/abortion

https://www.emrap.org/episode/emrap2022july1/postabortion

https://www.uptodate.com/contents/first-trimester-pregnancy-termination-medication-abortion?search=medical%20abortion&source=search_result&selectedTitle=1~73&usage_type=default&display_rank=1

https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-01889-6

Graber, D. J., & Meier, K. H. (1991). Acute misoprostol toxicity. Annals of emergency medicine, 20(5), 549-551.

Henriques, A., Lourenço, A. V., Ribeirinho, A., Ferreira, H., & Graça, L. M. (2007). Maternal death related to misoprostol overdose. Obstetrics & Gynecology, 109(2), 489-490.

EMS Protocol of the WEEK!! CO poisoning

Keeping the theme of last weeks cyanide poisoning/smoke inhalation injuries… the EMS protocol of the week is on carbon monoxide poisoning!

What is CO?

A colorless, odorless, tasteless gas produced by burning gasoline, wood, propane, charcoal, or fuels.

Common causes of CO poisoning?

Appliances such as furnaces, heaters, or stoves burning in an enclosed space, as well as smoke inhalation during a fire.

Symptoms?

Headache, dizziness, nausea/vomiting, AMS, weakness.

Initial management is the same as cyanide poisoning (and tbh most other things)... ABCs, supplemental O2, cardiac/vital sign monitoring, IV access.

Treatment

Transport to hyperbaric center if:

-      SpCO > 25% and asymptomatic

-      High index of suspicion of CO poisoning AND headache, AMS, or syncope

-    Pregnant and SpCO > 15%

Key points:

-      Also consider cyanide poisoning if exposed to smoke

-      SpO2 from pulse ox is not accurate and can be falsely elevated

-    Continue giving high concentration O2 even if signs/symptoms have resolved 

See attached protocol; check out https://nycremsco.org/ for more!

Jennifer Wolin, MD

Emergency Medicine PGY-2 Resident Physician

Maimonides Medical Center