Day 1:

Introduction and Toxicological Thinking

1. Describe the context and need for advanced training in medical management of chemical, biological, radiological and nuclear (CBRN) casualties.
2. Apply the CRESS (consciousness, respirations, eyes, secretions, skin) algorithm into the identification of toxidromes.
3. Outline the LADMER (liberation, absorption, distribution, metabolism, elimination, response) approach to the treatment of chemical, biological, radiological, and nuclear (CBRN) casualties.
4. Identify useful reference materials for the management of CBRN casualties.

Advanced Pharmacological Management of Nerve Agent Casualties

1. Analyze the pathophysiology of nerve agent exposure.
2. Differentiate the clinical effects of nerve agent exposure based on the specific agent, dose, and route of exposure to predict patient outcomes.
3. Manage nerve agent casualties at the Role 3/4, and intensive care settings.
4. Critique the standard treatment protocols for nerve agent-induced seizures and propose alternative, evidence-based polytherapy regimens for refractory cases.
5. Design a flexible pharmaceutical strategy for a mass-casualty incident based on standard U.S. medical countermeasures with contingency options and NATO-ally formularies.
6. Assess the complex challenges of managing CBRN casualties,868 comparing and contrasting historical events, such as the Iran-Iraq War and the Tokyo subway attack.
7. Justify continuous dosing of anticholinergics, oximes, and anticonvulsants for a severely poisoned patient, adapting the regimen based on the patient's evolving clinical status and response to therapy.

Metabolic Intoxications Overview

1. Evaluate the fundamental principles for identifying and treating a casualty with a metabolic agent intoxication.
2. Consider a differential diagnosis for a patient presenting with undifferentiated cellular hypoxia, evaluating the clinical toxidromes of various metabolic poisons, including cyanide, hydrogen sulfide, and phosphine.
3. Justify the administration of specific, and sometimes unconventional, antidotes for intoxications from agents like hydrogen sulfide and hydrogen selenide, based on an understanding of their complex toxicological mechanisms.

Day 2:

Advanced Management of Pulmonary and Vesicant Agent Casualties

1. Compare & contrast the distinct timelines of centrally-acting agents with peripherally-acting agents, predicting the onset of delayed pulmonary edema and justifying appropriate disposition for exposed casualties.
2. Analyze a treatment plan for a casualty with combined vesicant and pulmonary injuries.
3. Evaluate the indications and risks of topical, intradermal, intra-arterial, and nebulized calcium for a patient with severe hydrofluoric acid burns and inhalation injury.

Management of Opioids, Anticholenergics, and Miscellaneous Agent

1. Appraise the pharmacokinetic properties of naloxone, including its absorption, distribution, metabolism, and elimination.
2. Consider an appropriate antidote for a person poisoned with thallium or arsenic describing its mechanism of action and administration protocol.
3. Evaluate the appropriate pharmacological agent to manage agitation, autonomic activity, and prevent or treat seizures, given a case involving a patient exposed to anticholinergic agents.

Simulation Exercise 1: Chemical Antidote Infusions: Medication Preparation

1. Calculate appropriate infusion rates for atropine, pralidoxime, and naloxone.
2. Evaluate commonly used infusion equipment options within the context of this scenario.
3. Prepare a Cyanokit™ infusion.
4. Consider alternative solutions to standard nerve agent antidote formulations.
5. Prepare standardized pralidoxime and atropine infusions.

Joint Program Executive Office Chemical, Biological, Radiological and Nuclear Defense (JPEO-CBRND): CBRN Medical Advanced Development & Countering Emerging Threats - Rapid Acquisition and Investigation of Drugs for Repurposing

1. Analyze the DoDs multi-layered medical countermeasure (MCM) acquisition strategy, differentiating between the development of novel produces and the rapid repurposing of existing products.
2. Evaluate the strategic advantages of the Countering Emerging Threats – Rapid Acquisition and Investigation of Drugs for Repurposing (CET-RAIDR) program by justifying its use of FDA-approved drugs to rapidly inform Clinical Practice Guidelines (CPGs) for novel threats.
3. Synthesize information from the Joint Program Manager (JPM) CBRN Medical product pipeline with the stated goals of the Chemical Biological Defense Program (CBDP) to predict future shifts in military medical readiness and formulate potential integration points for these new capabilities into existing clinical and operational workflows.

Advanced Pharmacy Management of Biological Casualties

1. Differentiate between likely CBRN threat agents, using the Clinical Practice Guideline’s syndromic algorithms.
2. Appreciate an integrated management plan for a suspected bio incident in a prolonged casualty care or mass casualty (MASCAL) operational environment.
3. Appraise the supporting evidence, regulatory status, and population-specific factors while evaluating competing medical countermeasures and prophylaxis strategies for a presented biological casualty.

Day 3:

Simulation Exercise II: WAVE

1. Identify and treat severe nerve agent seizures and inhalational chemical injury.
2. Practice preparation of medication infusions.
3. Distinguish endemic vs intentional disease in potentially weaponized biological agent scenarios.
4. Describe radiation injury patterns to allow for appropriate triage and treatment.
5. Utilize the Chemical Patient Protective Wrap to safely transport a patient through a contaminated environment.

Envenomation and Marine Toxins & Tropical Threats

1. Explain the patterns of signs and symptoms of various tropical poisonous and venomous hazards.
2. Associate various tropical hazards with appropriate management strategies and targeted treatments.
3. Describe anticipated illness and risks during evacuation and care.
4. Identify limitations, complications, and adverse events of various treatment modalities.

Day 4:

Classified Sessions and Operational Security

1. Identify emerging chemical and biological threats across the globe.
2. Assess the efficacy of existing antidotes and countermeasures against emerging threats.
3. Describe the role for novel antidotes and countermeasures against emerging threats.
4. Discuss relevant medical management of human cases exposed to non-traditional agents.