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Neuromuscular effects. At the neuromuscular junction, initial stimulation of cholinergic synaptic transmission is followed by paralysis. Thus, nicotinic effects include muscle fasciculations and twitching, followed by weakness progressing to flaccid paralysis and respiratory failure. The clinical syndrome of organophosphate toxicity is summarized by various mnemonics, including “bag the puddles,” 1 “sludge” syndrome, and “dumbbels.” B = bronchoconstriction, bronchorrhea A = apnea G = graying/dimming of vision P = pupillary constriction (miosis) U = urination D = diarrhea D = diaphoresis L = lacrimation E = emesis S = salivation, seizures S = salivation, seizures L = lacrimation U = urination D = diarrhea G = graying/dimming of vision E = emesis D = diarrhea U = urination M = miosis B = bronchoconstriction B = bronchorrhea E = emesis L = lacrimation S = salivation Diagnostic Tests The diagnosis of nerve agent toxicity is primarily based on clinical recognition and response to antidotal therapy. Measurements of acetylcholinesterase in plasma or red blood cells (RBCs) may confirm organophosphate poisoning, but correlation between cholinesterase levels and clinical toxicity is poor in some contexts; also, these analyses are rarely available on an emergent basis. RBC cholinesterase levels may help in monitoring recovery or in forensic investigations. In symptomatic patients, treatment is 1 Adapted from Rotenberg JS, Newmark J. Nerve agent attacks on children: diagnosis and management. Pediatrics 2003; 112:648-58. 113
indicated without waiting for cholinesterase levels, while in exposed asymptomatic patients, antidotal therapy is not needed, even if cholinesterase is depressed. Treatment If recognized early, this is a treatable and reversible syndrome. Triage, resuscitation, and decontamination should begin at the scene and at accepting health care facilities (see Chapter 1). Individuals exposed to liquid should be observed for at least 18 hours. Treatment focuses on airway and ventilatory support; aggressive use of antidotes, particularly atropine and pralidoxime (2-PAM); prompt control of seizures; and decontamination as necessary. Antidotal therapy is titrated according to clinical severity (Table 5.4). Atropine, in relatively large doses, is used for its antimuscarinic effects, and pralidoxime chloride serves to reactivate acetylcholinesterase and thus enhance neuromuscular function. Atropine counters bronchospasm and increased bronchial secretions; bradycardia; GI effects of nausea, vomiting, diarrhea, and cramps; and may lessen seizure activity. Severely affected nerve agent casualties in the military have received 20-200 mg of atropine. Atropine should be administered until respiratory status improves, because tachycardia is not an absolute end-point for atropinization. Atropine cannot reverse neuromuscular symptoms, and paralysis may persist without pralidoxime. Pralidoxime cleaves the organophosphate away from the cholinesterase, thus regenerating the intact enzyme if aging has not occurred. This effect is noted most at the neuromuscular junction, with improved muscle strength. Prompt use of pralidoxime is recommended in all serious cases. Both atropine and pralidoxime should be administered IV in severe cases (intraosseous access is likely equivalent to IV). However, animal studies suggest that hypoxia should be corrected, if possible, before IV atropine use, to prevent arrhythmias; otherwise IM use might be preferable initially. Atropine has also been administered by the endotracheal or inhalational route in some contexts, and such use might have a beneficial effect. Experience with organophosphate pesticide poisoning in children suggests that continuous IV infusion of pralidoxime may be optimal. Nevertheless, the IM route is acceptable if IV access is not readily available. This may be of considerable relevance in a mass casualty incident involving children. In fact, most EMS programs in the United States now stock military IM auto-injector kits of atropine and 2-PAM. Similar kits with pediatric doses are currently not available in the United States. However, pediatric autoinjectors of atropine in 0.25 mg, 0.5 mg, and 1.0 mg sizes have recently been approved by the FDA. In dire circumstances, the adult 2-PAM auto-injector (600 mg) might be used in children older than 2–3 years or weighing more than 13 kg. Seizures are primarily controlled with benzodiazepines. Diazepam is principally used by the U.S. military, but other benzodiazepines may be equally efficacious (e.g., midazolam or lorazepam). Midazolam is believed optimal for IM administration in the treatment of status epilepticus in general and so may be especially useful in nerve agent toxicity in 114
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Bioterrorism and Other Public Healt
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Contents Chapter 1. Introduction ..
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Q Fever............................
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Basic Principles...................
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Chapter 9. Integrating Terrorism an
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Table 5.4 Nerve agent triage and do
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There are many gaps in knowledge, e
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injured or killed (see also Chapter
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Head injury is common in children.
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In situations of disaster, caregive
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maintaining and securing the airway
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• Schonfeld DJ. In times of crisi
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Types of Disasters Chapter 2. Syste
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problems noted above for flooding,
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Federal Response The United States
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The scope of ESF #8 is broad and in
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• Centers for Disease Control and
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Table 2.1 Types of disasters, hazar
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Medical staffs need to know what wi
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information, health and safety educ
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y private physicians. Approximately
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even required (particularly if a pe
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ICS structure is hierarchical. For
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• Provide community education so
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• Provide for crisis counseling.
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incident command officer is most of
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Figure 3.1 National Response Plan D
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Background History of Bioterrorism
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Epidemiology of a Terrorist Attack
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and may be watery, purulent, or blo
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fluid in these vesicles. A painless
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determined to be due to an agent of
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cared for using standard precaution
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may be providing longer term and mo
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The vaccine has a number of common
Page 74 and 75: Vaccination Large-scale vaccination
Page 76 and 77: cutaneous lesions; however, previou
Page 78 and 79: common food source is identified du
Page 80 and 81: treated people experience some degr
Page 82 and 83: treatment for plague meningitis. An
Page 84 and 85: Smallpox is spread most commonly in
Page 86 and 87: focal, intensely suppurative necros
Page 88 and 89: Control measures. Some viruses that
Page 90 and 91: Control measures. Person-to-person
Page 92 and 93: Signs and symptoms. The incubation
Page 94 and 95: currently used for individuals trav
Page 96 and 97: Accessed July 12, 2006. • Centers
Page 98 and 99: • Roffey R, Tegnell A, Elg HF. Bi
Page 100 and 101: Figure 4.2. Neurological signs, bot
Page 102 and 103: Figure 4.4. Physical distribution o
Page 104 and 105: Figure 4.6. Varicella lesions Note:
Page 106 and 107: Figure 4.8a. Febrile rash illness a
Page 108 and 109: Table 4.1. Early clinical signs and
Page 110 and 111: Table 4.2. Infection control transm
Page 112 and 113: Table 4.3. Diagnostic procedures, i
Page 114 and 115: Table 4.4a. Diagnostic tests for an
Page 116 and 117: Table 4.6. Treatment recommendation
Page 118 and 119: Introduction Chapter 5. Chemical Te
Page 120 and 121: likely manifest as an acute onset o
Page 122 and 123: exposures (Table 5.3). For an in-de
Page 126 and 127: children. Finally, routine administ
Page 128 and 129: Treatment Management of cyanide poi
Page 130 and 131: Sulfur mustard is stockpiled both i
Page 132 and 133: decontamination is therefore extrem
Page 134 and 135: Pulmonary Agents Toxic industrial c
Page 136 and 137: Type I agents, the significance of
Page 138 and 139: After dispersal of riot control age
Page 140 and 141: • Kales SN, Christiani DC. Acute
Page 142 and 143: • Gray EA, Love JW, Arnold JL. CB
Page 144 and 145: Table 5.2. Chemical weapons - Summa
Page 146 and 147: Table 5.3 Representative classes of
Page 148 and 149: Table 5.4. Nerve agent triage and d
Page 150 and 151: Table 5.5. Clinical effects from su
Page 152 and 153: Table 5.7. Medical treatment of rio
Page 154 and 155: Chapter 6. Radiological and Nuclear
Page 156 and 157: from ground zero. For weapons large
Page 158 and 159: (1000 rem), resulting in four fatal
Page 160 and 161: cooling systems at Mayak exploded,
Page 162 and 163: pediatric practices. This put infan
Page 164 and 165: energy, releasing two photons of ex
Page 166 and 167: need to be shielded, although the a
Page 168 and 169: adioactive isotope of potassium. Ba
Page 170 and 171: An integrated, interactive human bo
Page 172 and 173: Biodosimetry and Radiological Terro
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primitive/progenitor cells and othe
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permits bacterial translocation and
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To assess radiation dose, a researc
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status? 4. Conduct an initial surve
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explosion, when it is concentrated
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Skin pathway. Although intact skin
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personnel should also take a wipe s
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• Geiger-Mueller or G-M counters
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• Protective clothing— Disposab
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Decontamination priorities are as f
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These effects can occur anywhere fr
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manifestations of ARS may range fro
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Neutropenia: Viral and Fungal Infec
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The main reason for targeting pregn
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No significant side effects from it
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axilla, groin, and skin folds. Radi
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Followup Care, Including Risk of Ca
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artificial because followup in almo
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adioactive material in an accident.
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131, canned milk or other milk prod
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home immediately after the incident
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• National Council on Radiation P
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• U.S. Nuclear Regulatory Commiss
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Radiation Detection, PPE, Monitorin
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• National Council on Radiation P
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• Peter RU, Gottlober P. Manageme
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Recommendations for State and Local
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Figure 6.2. Environmental exposure
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Figure 6.4. Bone marrow irradiated
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Figure 6.6. Classic Andrews diagram
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Figure 6.8. Examples of radiation s
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Figure 6.10. Localized radiation ef
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Table 6.2. Biodosimetry based on ac
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Table 6.4. Diagnostic steps in acut
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Table 6.6. Dose assessment summary
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Table 6.8. Antibiotics for treatmen
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Table 6.10. Radionuclide specific t
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Introduction Chapter 7. Blast Terro
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Spalling effect. When a blast wave
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Clinical findings and diagnosis. Cl
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highest position. Because of the pr
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perilymph in the membranous labyrin
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• Hemoptysis. • Subcutaneous em
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management and immediately involve
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considered (see Chapter 4, Biologic
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• Circumstances (weather conditio
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Bibliography Explosives, Incendiary
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Trauma Systems and Planning/Mitigat
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Table 7.2 Spectrum of primary blast
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Table 7.3 Principles of Advanced Tr
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Determine the severity of the burn
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Chapter 8. Mental Health Issues Men
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• Amnesia for important parts of
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Treatment. Treatment should be guid
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• Before notifying the family, br
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• Be conscious of nonverbal commu
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sadness, anger, guilt, or a sense o
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was mean to my father yesterday and
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these roles, they should work close
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• Lack of availability of trauma-
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The structure provided by a preexis
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necessarily meet the children’s n
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Make Psychological Contact Tune in
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A communications goal of “educati
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• Schonfeld D. Crisis interventio
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Chapter 9. Integrating Terrorism an
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Chain of command. A chain of comman
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The chain of command established by
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Advice for families of children wit
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Quarantine procedures. Quarantine p
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Chapter 10. Working with Government
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need under the 12 Emergency Service
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ecognizes that community clinicians
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Chapter 11. Conclusion This report
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Planning for special medical needs
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Table 11.1 Environmental constraint
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Table 11.2 Pediatric medical compla
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• The post-storm environment is h
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Acronyms AAP American Academy of Pe
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RIA RTG SCIWORA SEB SI SNS SSRI STA
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Appendix A. Pediatric Terrorism and
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1. List which biological agents (mi
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19. Identify chemical terrorism tox
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39. Provide followup care, being mi
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Learning Objectives: At the end of
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Lead Editors Appendix B. List of Co
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James Tsung, MD, FAAP Attending Phy
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Gerald S. Braley, PhD Major, United
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Kobi Peleg, PhD Michael Stein, MD J
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Lou E. Romig MD, FAAP, FACEP Childr
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Maternal & Child Health Bureau Dan
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