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• Gray EA, Love JW, Arnold JL. CBRNE—Lung-damaging Agents, Phosgene. In: eMedicine: Emergency Medicine (Textbook Online). St. Petersburg, FL: WebMD; June 13, 2006. • Grimaldi JV and Gugliotta G. Chemical plants are feared as targets: views differ on ways to avert catastrophe. The Washington Post. December 16, 2001:A1. • Henretig FM, Cieslak TJ, Madsen JM, et al. The Emergency Department Response to Incidents of Biological and Chemical Terrorism. In: Fleisher GR, Ludwig S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia: Lippincott Williams and Wilkins, 2005. • Noltkamper D, O’Malley GF. CBRNE—Lung-damaging Agents, Chlorine. In: eMedicine: Emergency Medicine. (Textbook Online). St. Petersburg, FL: WebMD. • Organization for the Prohibition of Chemical Weapons. Chemical Weapons Convention. Available at: http://www.opcw.org/html/glance/index.html. • Sidell FR and Franz DR. Overview: Defense Against the Effects of Chemical and Biological Warfare Agents. In: Sidell FR, Takafuji ET, Franz DR, eds. Textbook of Military Medicine. Part 1: Medical Aspects of Chemical and Biological Warfare. Washington DC: Office of the Surgeon General, Walter Reed Army Medical Center; 1997. • Urbanetti JS. Toxic Inhalational Agents. In: Sidell FR, Takafuji ET, Franz DR, eds. Textbook of Military Medicine. Part 1: Medical Aspects of Chemical and Biological Warfare. Washington, DC: Office of the Surgeon General, Walter Reed Army Medical Center; 1997. Riot Control Agents • Billmire DF, Robinson NB, Panitch HB, et al. Pepper-spray induced respiratory failure treated with extracorporeal membrane oxygenation. Pediatrics. 1996;98:961–963. • Park S, Glammons ST. Toxic effects of tear gas on an infant following prolonged exposure. Amer J Dis Child. 1972;123:245–247. • Sidell FR. Riot Control Agents. In: Sidell FR, Takafuji ET, Franz DR, eds. Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare. Washington DC: Office of the Surgeon General, Walter Reed Army Medical Center; 1997. 450–476. • Smith J, Greaves I. The use of chemical incapacitant sprays: a review. J Trauma. 2002;52:595–600. • Weir E. The health impact of crowd-control agents. CMAJ. 2001;164:1889–1890. 131
Table 5.1. Pediatric vulnerabilities to chemical terrorism Realm Potential vulnerability Potential response Physiologic Increased respiratory exposure (higher minute ventilation, live “closer to the ground) Early warning, sheltering* (gas masks not advised because of risk of poor fit, suffocation) Developmental Psychological EMS Increased dermal exposure (thinner, more permeable skin; larger body surface area/mass ratio) Increased risk of dehydration, shock with illness-induced vomiting, diarrhea (decreased fluid reserves, larger body surface area/mass ratio) Increased risk of hypothermia during decontamination (larger body surface area/mass ratio) More fulminant disease; (possible) physiologic detoxification immaturity; more permeable blood-brain barrier Less ability to escape attack site, take appropriate evasive actions (developmental immaturity, normal dependence on adult caregivers who might be injured or dead) Less coping skill of children who suffer injury or witness parental, sibling death (psychological immaturity) Greater anxiety over reported incidents, hoaxes, media coverage, etc Less capacity to cope with influx of critical pediatric patients Loss of routine hospital transfer protocols Limited ability to expand pediatric hospital bed capacity through NDMS * Plausible, but unproved or unstudied, and/or not intuitively obvious † For AAP and AACAP resources for parents and pediatricians, see http://www.aap.org/advocacy/releases/disastercomm.htm and http://www.aacap.org/publications/factsfam/disaster.htm. Protective clothing, early decontamination 1 Recognition, aggressive fluid therapy Warm water decontamination Pediatric-specific research for early diagnosis and treatment of chemical weapons victims 1 ? Child psychiatry involvement, research for preventing pediatric post-traumatic stress disorder 1 Pediatric counseling of parents and children † Community and regional planning with significant pediatric input Source: Adapted from Henretig FM, Cieslak TJ, Eitzen EM Jr. Biological and chemical terrorism. J Pediatr 141:311–326, © 2002, with permission from Elsevier. 132
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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
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Vaccination Large-scale vaccination
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cutaneous lesions; however, previou
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common food source is identified du
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treated people experience some degr
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treatment for plague meningitis. An
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Smallpox is spread most commonly in
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focal, intensely suppurative necros
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Control measures. Some viruses that
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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 124 and 125: Neuromuscular effects. At the neuro
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 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
Page 174 and 175: primitive/progenitor cells and othe
Page 176 and 177: permits bacterial translocation and
Page 178 and 179: To assess radiation dose, a researc
Page 180 and 181: status? 4. Conduct an initial surve
Page 182 and 183: explosion, when it is concentrated
Page 184 and 185: Skin pathway. Although intact skin
Page 186 and 187: personnel should also take a wipe s
Page 188 and 189: • Geiger-Mueller or G-M counters
Page 190 and 191: • 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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