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perilymph in the membranous labyrinth, are converted again into nerve impulses at the organ of Corti in the cochlea. The blast wave overwhelms this intricate and delicate system and is then amplified down the conductive and sensory neural pathways. The result can be injury to any of part of the auditory system, including perforation of the tympanic membrane, disruption of the ossicular chain, or damage to the organ of Corti. In addition to the damage caused by amplification of the shock wave within the auditory system, the instantaneous rise in overpressure inflicts additional damage. The ability to equilibrate middle ear pressure via the eustachian tube is overwhelmed. The resulting expansion of the cavity and distortion of tissue causes additional mechanical injury. Tympanic membrane rupture. Tympanic membrane rupture from most causes heals spontaneously, with 10% of the eardrum expected to heal per month. Spontaneous healing has been observed in perforations involving
• Ossicular chain fracture. • Labyrinthine fistula. • Perilymphatic fistula. • Loss of hair cell integrity. • Conductive hearing loss. • Sensory hearing loss. • Basilar membrane rupture. Management. In general, emergency management of auditory injuries involves clearing the ear canal of debris, minimizing exposure to loud noises or water, and taking precautions against infection. Otolaryngology followup for a complete evaluation and to watch for future complications (e.g., cholesteatoma formation) is recommended. Prophylactic use of antibiotics is not recommended. Cardiovascular effects. The heart and blood vessels can be directly or indirectly injured by a blast wave. Cardiac involvement during a blast usually manifests as coronary vessel embolization and ischemia. Blood vessels within certain organs have a propensity for injury and may contribute to the generation of microthrombi, which results in disseminated intravascular coagulation. Cardiac blast injury that manifests as hemorrhage in the epicardium, myocardium, or papillary muscles is quite rare. Hypotension in blast victims often has multiple causes. It can involve blood loss from major musculoskeletal or abdominal injury or from a blast-related, vagally mediated reflex. This reflex, which is seen immediately after a significant blast exposure, causes hypotension without vasoconstriction and bradycardia. It is the most common effect on the cardiovascular system by the blast wave itself. The hypotension can be profound and self-limiting, and there may be no external signs of injury. Traditionally, aggressive volume replacement to support circulation is required in trauma victims with cardiovascular collapse. However, excessive volume replacement is detrimental to patients with lung injury. Research in animals has suggested that fluid replacement actually impairs cardiovascular performance in the setting of a blast. However, inadequate pulmonary vascular pressure has been suggested to promote the passage of air into the pulmonary venous system. Therefore, administration of fluids in increments of 5 mL/kg, titrated to clinical response, has been recommended. Either too much or too little fluid can be harmful, and the judicious use of fluids to maintain euvolemia is probably the best approach. As in all trauma patients, colloids should be used to replace massive hemorrhage, improve oxygenation, and minimize oncotic fluid shifts. Monitoring of central venous pressure and/or pulmonary pressures is a useful adjunct to fluid management. Sentinel injuries. Sentinel injuries are subtle injuries that can increase the risk of having or developing serious blast injury. These patients should be monitored closely, no matter how clinically well they appear. Sentinel injuries include the following: • Traumatic amputations. • Hypopharyngeal contusion. 246
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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
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currently used for individuals trav
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Accessed July 12, 2006. • Centers
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• Roffey R, Tegnell A, Elg HF. Bi
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Figure 4.2. Neurological signs, bot
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Figure 4.4. Physical distribution o
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Figure 4.6. Varicella lesions Note:
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Figure 4.8a. Febrile rash illness a
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Table 4.1. Early clinical signs and
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Table 4.2. Infection control transm
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Table 4.3. Diagnostic procedures, i
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Table 4.4a. Diagnostic tests for an
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Table 4.6. Treatment recommendation
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Introduction Chapter 5. Chemical Te
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likely manifest as an acute onset o
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exposures (Table 5.3). For an in-de
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Neuromuscular effects. At the neuro
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children. Finally, routine administ
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Treatment Management of cyanide poi
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Sulfur mustard is stockpiled both i
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decontamination is therefore extrem
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Pulmonary Agents Toxic industrial c
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Type I agents, the significance of
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After dispersal of riot control age
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• Kales SN, Christiani DC. Acute
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• Gray EA, Love JW, Arnold JL. CB
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Table 5.2. Chemical weapons - Summa
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Table 5.3 Representative classes of
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Table 5.4. Nerve agent triage and d
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Table 5.5. Clinical effects from su
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Table 5.7. Medical treatment of rio
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Chapter 6. Radiological and Nuclear
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from ground zero. For weapons large
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(1000 rem), resulting in four fatal
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cooling systems at Mayak exploded,
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pediatric practices. This put infan
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energy, releasing two photons of ex
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need to be shielded, although the a
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adioactive isotope of potassium. Ba
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An integrated, interactive human bo
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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
Page 206 and 207: Followup Care, Including Risk of Ca
Page 208 and 209: artificial because followup in almo
Page 210 and 211: adioactive material in an accident.
Page 212 and 213: 131, canned milk or other milk prod
Page 214 and 215: home immediately after the incident
Page 216 and 217: • National Council on Radiation P
Page 218 and 219: • U.S. Nuclear Regulatory Commiss
Page 220 and 221: Radiation Detection, PPE, Monitorin
Page 222 and 223: • National Council on Radiation P
Page 224 and 225: • Peter RU, Gottlober P. Manageme
Page 226 and 227: Recommendations for State and Local
Page 228 and 229: Figure 6.2. Environmental exposure
Page 230 and 231: Figure 6.4. Bone marrow irradiated
Page 232 and 233: Figure 6.6. Classic Andrews diagram
Page 234 and 235: Figure 6.8. Examples of radiation s
Page 236 and 237: Figure 6.10. Localized radiation ef
Page 238 and 239: Table 6.2. Biodosimetry based on ac
Page 240 and 241: Table 6.4. Diagnostic steps in acut
Page 242 and 243: Table 6.6. Dose assessment summary
Page 244 and 245: Table 6.8. Antibiotics for treatmen
Page 246 and 247: Table 6.10. Radionuclide specific t
Page 248 and 249: Introduction Chapter 7. Blast Terro
Page 250 and 251: Spalling effect. When a blast wave
Page 252 and 253: Clinical findings and diagnosis. Cl
Page 254 and 255: highest position. Because of the pr
Page 258 and 259: • Hemoptysis. • Subcutaneous em
Page 260 and 261: management and immediately involve
Page 262 and 263: considered (see Chapter 4, Biologic
Page 264 and 265: • Circumstances (weather conditio
Page 266 and 267: Bibliography Explosives, Incendiary
Page 268 and 269: Trauma Systems and Planning/Mitigat
Page 270 and 271: Table 7.2 Spectrum of primary blast
Page 272 and 273: Table 7.3 Principles of Advanced Tr
Page 274 and 275: Determine the severity of the burn
Page 276 and 277: Chapter 8. Mental Health Issues Men
Page 278 and 279: • Amnesia for important parts of
Page 280 and 281: Treatment. Treatment should be guid
Page 282 and 283: • Before notifying the family, br
Page 284 and 285: • Be conscious of nonverbal commu
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Page 290 and 291: these roles, they should work close
Page 292 and 293: • Lack of availability of trauma-
Page 294 and 295: The structure provided by a preexis
Page 296 and 297: necessarily meet the children’s n
Page 298 and 299: Make Psychological Contact Tune in
Page 300 and 301: A communications goal of “educati
Page 302 and 303: • Schonfeld D. Crisis interventio
Page 304 and 305: 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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