ATP 4-02.11 Reference

CBRN FIRST AID & TACTICAL CONSIDERATIONS

Source: ATP 4-02.11, Chapter 19 — First Aid in a CBRN Environment, 23 March 2026

Key Points

  • Don mask FIRST before administering ATNAA
  • MILD symptoms: 1 ATNAA (self-aid)
  • SEVERE symptoms: 3 ATNAA + 1 CANA or AAS (buddy aid)
  • ATNAA injection site: outer thigh (one hand-width below hip joint)
  • ATNAA contains atropine 2.1mg + pralidoxime chloride 600mg
  • NAPP must be taken within 8 hours prior to expected nerve agent exposure
  • RSDL is preferred decontaminant — neutralizes chemical agents in ~2 minutes
  • Do NOT administer both CANA and AAS for the same exposure series

Critical Warnings

  • Do NOT give NAPP to someone already exposed to nerve agents (pre-treatment only)
  • Do NOT take two NAPP tablets to make up a missed dose
  • Do NOT administer CANA as self-aid — buddy aid only
  • Do NOT use soap + water for nerve agent eye decontamination — use water only
  • Maintain MOPP level when treating casualties in contaminated environment

CBRN Antidote Kit

  • ATNAA × 3 — Antidote Treatment Nerve Agent Auto-Injector (atropine + pralidoxime)
  • CANA × 1 — Convulsant Antidote Nerve Agent (diazepam) — or
  • AAS × 1 — Advanced Anticonvulsant System (midazolam)
  • RSDL — Reactive Skin Decontamination Lotion
  • NAPP — Pyridostigmine bromide (pre-treatment, 30mg tablets, 21/kit)
Critical Sequence in CBRN Environment

In a CBRN environment with nerve agent signs: (1) Don mask immediately. (2) Administer ATNAA if mild symptoms are present. (3) Buddy aid for severe symptoms — 3 ATNAA + 1 CANA/AAS. (4) Decontaminate. Nerve agents are absorbed rapidly and can cause death within minutes. (ATP 4-02.11, para 19-35 to 19-36)

Nerve Agent Pre-Treatment: NAPP

The Nerve Agent Pyridostigmine Pretreatment (NAPP) enhances the efficiency of ATNAA antidotes when taken before exposure. Each tablet contains 30mg pyridostigmine bromide. The kit contains 21 tablets taken over 7 days (one every 8 hours). (ATP 4-02.11, paras 19-25 to 19-26)

NAPP Warning

NAPP is for pre-exposure prophylaxis ONLY. Do NOT give NAPP to any patient who has been exposed to, presents, or has symptoms of organophosphate nerve agent poisoning. Must be taken within 8 hours prior to expected exposure. If a dose is missed, do not double up — continue with one tablet at the next scheduled time.

Nerve Agent Exposure — Signs, Symptoms, and Treatment

Severity Signs and Symptoms Treatment
Mild Unexplained runny nose; unexplained sudden headache; sudden drooling; difficulty seeing (dimness of vision, pinpoint pupils); tightness in the chest; wheezing and coughing; localized sweating and muscular twitching at contaminated skin; stomach cramps; nausea with or without vomiting; altered heart rate Self-aid:
1 × ATNAA
Severe Confused behavior; severe wheezing/dyspnea; stopped breathing; severely pinpoint pupils; red eyes with tearing; vomiting; severe muscular twitching and weakness; involuntary urination and defecation; convulsions; unconsciousness; respiratory failure Buddy aid:
3 × ATNAA
1 × CANA or AAS

Source: ATP 4-02.11, Table 19-2 — Nerve Agent Exposure, Signs and Symptoms, and Medical Countermeasures

ATNAA Auto-Injector Administration

The ATNAA contains atropine 2.1mg and pralidoxime chloride 600mg in separate chambers administered through a single needle. (ATP 4-02.11, para 19-40)

  1. 1

    Don protective mask and hood first — mission permitting.

  2. 2

    Remove ATNAA from carrier. Remove gray safety cap from the green (atropine) end.

  3. 3

    Injection site: outer thigh muscle — approximately one hand-width below the hip joint. Can be injected through clothing. For thin individuals: inject into the buttocks.

  4. 4

    Hold the ATNAA like a hammer and press the green end firmly against the outer thigh until you feel a click — hold for 10 seconds to ensure complete injection.

  5. 5

    Massage the site briefly. Bend the needle back against the injector body to prevent accidental needle stick. Place used injectors in your non-firing hand to count doses given.

  6. 6

    For severe symptoms: administer all 3 ATNAAs. Administer CANA or AAS (not both) to control convulsions — buddy aid only, not self-aid.

Skin Decontamination — RSDL

The Reactive Skin Decontamination Lotion (RSDL) kit is the preferred decontamination method. It removes and neutralizes chemical warfare agents (vesicants and nerve agents) on skin in approximately 2 minutes. (ATP 4-02.11, para 19-42 to 19-43)

  • Tear open the RSDL packet and unfold the decontamination pad
  • Wipe contaminated skin — do not rub vigorously, use a blotting/wiping motion
  • Pay attention to face, neck, and hands (highest exposure areas)
  • For eyes: use water only — RSDL may be irritating to eyes
  • If RSDL unavailable: use soap and large amounts of water (physically removes agents but does not neutralize; may increase absorption of mustard agents)

First Aid in CBRN — General Principles

  • Maintain MOPP level while treating casualties in a contaminated environment
  • Apply TCCC principles (MARCH-PAWS) — hemorrhage control, airway, respiration still take priority
  • Identify contamination type (chemical, biological, radiological) to determine appropriate response
  • Administer appropriate medical CBRN defense material from casualty's own supplies first
  • Decontaminate exposed skin before casualties cross into clean areas
  • For radiological contamination: brush/vacuum dry particles — do not spread with water

ATP 4-02.11 Source

Chapter 19: First Aid in a Chemical, Biological, Radiological, and Nuclear Environment — Army Techniques Publication 4-02.11, Casualty Response, Tactical Combat Casualty Care, and First Aid. Headquarters, Department of the Army, 23 March 2026.

See It in Practice — ESB Tasks

These ESB Medical Lane tasks apply this doctrine directly:

M8: Open Head Wound (CBRN)
Environmental Injuries Back to ATP 4-02.11 Index