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exposed but not critically injured will be taken by parents to hospitals and pediatricians’
offices without prior on-scene decontamination—thus posing similar challenges for and
possibly personal risk to pediatric care providers themselves.
Specific Pediatric Vulnerabilities to Chemical Agents
Children have inherent physiologic, developmental, and psychological differences from
adults that may enhance susceptibility and worsen prognosis after a chemical agent
exposure (see also Chapter 1, Children Are Not Small Adults). Briefly, such physiologic
differences include higher minute ventilation, increased skin permeability, relatively
larger body surface area, less intravascular volume reserve in defense of hypovolemic
shock, and shorter stature (which places children nearer to the greatest gas vapor density
at ground level). Children who are pre-ambulatory or pre-verbal and those who have
special needs are less able to evade danger or seek attention effectively. A chaotic
atmosphere compounded by rescuers wearing unfamiliar garb may frighten children of all
ages and potentially increase the posttraumatic response to stress. Those providing care
for children are faced with additional complexities posed by developmental, age, and
weight considerations beyond the general scope of the already enormous challenge.
Pediatric vulnerabilities become particularly significant when weapons of mass
destruction are involved. A chemical agent will most likely be dispersed via an aerosol
route or in combination with traditional warfare. Chemical exposures warrant expedient
and thorough decontamination to limit continued primary and secondary exposures.
Children’s relatively large body surface area plays a key role in degree of contamination
and in their ability to maintain thermal homeostasis after decontamination. Table 5.1
summarizes pediatric-specific vulnerabilities to chemical agents.
Chemical Injuries and Approach to the Unknown Chemical
Attack
A listing of many of the most notable chemical agents of concern has been compiled by
the CDC (see http://www.bt.cdc.gov/agent/agentlistchem.asp). Toxic effects from
chemical agents usually follow dermal or inhalational exposure and may develop via
injury to the skin, eyes, and respiratory epithelium, as well as via systemic absorption.
The intensity and route of exposure to chemical agents affect both the rapidity of onset
(seconds to hours) and the severity of symptoms. For example, a mild exposure to sarin
vapor results in lacrimation, rhinorrhea, miosis, and slightly blurry vision; an intense
exposure leads to seizures, apnea, and rapid death within minutes.
Clinical syndromes and management after exposure to various chemical agents (nerve
agents, vesicants, pulmonary agents, cyanide, and riot-control agents) are summarized in
Table 5.2 and detailed in the following sections. For in-depth discussions of general
principles of supportive care for victims of chemical warfare agents, see Osterhoudt, et al,
2005, and Erickson, 2004.
Understanding the epidemiology of acute mass exposure to a toxin is helpful in
recognizing a covert chemical attack with unknown agents. Mass exposure to a toxin will
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