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Table 5.2. Chemical weapons – Summary of pediatric management considerations Agent Toxicity Clinical findings Onset Decontamination * Management Nerve Agents Tabun Sarin Soman VX Anticholinesteras e: muscarinic, nicotinic, and CNS effects Vapor: seconds Liquid: minuteshours Vapor: miosis, rhinorrhea, dyspnea Liquid: diaphoresis, vomiting Both: coma, paralysis, seizures, apnea Vapor: fresh air, remove clothes, wash hair Liquid: remove clothes, copious washing of skin and hair with soap and water, ocular irrigation Vesicants Mustard Alkylation Skin erythema, Hours Wash skin with soap Symptomatic care Lewisite Arsenical vesicles, ocular inflammation, respiratory tract inflammation Immediate pain and water, ocular irrigation (major impact only if done within min of exposure) Pulmonary Agents Chlorine Phosgene Liberate HCL, alkylation Eyes, nose, throat irritation (especially chlorine); bronchospasm, pulmonary edema (especially phosgene) Minutes: eyes, nose, throat irritation; bronchospasm Hours: pulmonary edema Fresh air, wash skin with water ABCs Atropine: 0.05 mg/kg IV † , IM ‡ (min 0.1 mg, max 5 mg), repeat q2–5 min prn for marked secretions, bronchospasm Pralidoxime: 25 mg/kg IV, IM (max 1 g IV; 2 g IM), may repeat within 30–60 min prn, then again every hour for 1 or 2 doses prn for persistent weakness, high atropine requirement Diazepam: 0.3 mg/kg (max 10 mg) IV; lorazepam: 0.1 mg/kg IV, IM (max 4 mg); midazolam: 0.2 mg/kg (max 10 mg) IM prn for seizures or severe exposure Possibly BAL 3 mg/kg IM q4–6hr for systemic effects in severe cases Symptomatic care 133
Table 5.2. Chemical weapons – Summary of pediatric management considerations, continued Cyanide Cyanide Cytochrome oxidase inhibition: cellular anoxia, lactic acidosis Tachypnea, coma, seizures, apnea Seconds Fresh air, wash skin with soap and water ABCs, 100% oxygen Sodium bicarbonate prn for metabolic acidosis Sodium nitrite (3%): Dosage (mL/kg) Estimated Hgb (g/dL) 0.27 10 0.33 12 (est. for avg. child) 0.39 14 (max 10 mL) Sodium thiosulfate (25%): 1.65 mL/kg (max 50 mL) Riot Control Agents CS Neuropeptide CN (eg, substance P Mace ® ) release; Capsaicin alkylation (pepper spray) Ocular pain, tearing, blepharospasm; nose and throat irritation; pulmonary failure (rare) Seconds Fresh air, ocular irrigation Topical ophthalmics, symptomatic care * Should be performed by health care providers garbed in adequate personal protective equipment, especially if victims have had significant exposure to nerve agents or vesicants. For emergency department staff, adequate PPE consists of a non-encapsulated, chemically resistant body suit, boots, and gloves with a full-face air purifier mask/hood. † Intraosseous route likely equivalent to intravenous. ‡ Atropine via endotracheal tube or inhalation, or aerosolized ipratropium of possible benefit. Note: ABCs = airway, breathing, and circulatory support; BAL= British anti-lewisite; Hgb= hemoglobin concentration; prn = as needed Adapted from Henretig FM, Cieslak TJ, Eitzen EM Jr. Biological and chemical terrorism. J Pediatr 141:311-326 © 2002, with permission from Elsevier. 134
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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
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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 142 and 143: • Gray EA, Love JW, Arnold JL. CB
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
Page 192 and 193: 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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