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Table 7.3 Principles of Advanced Trauma Life Support ®, continued Secondary Survey and Reevaluation History and physical: SAMPLE history, complete examination Imaging studies: plain radiographs 8 , special studies 9 1 2 3 4 5 6 7 8 9 RSI technique: etomidate then succinylcholine Primary: chest rise, air entry; secondary: exhaled CO 2 detector, esophageal detector device; watch for DOPE: Dislodgement, Obstruction, Pneumothorax, Equipment failure NRB: nonrebreather mask; BVM: bag valve mask Do not wait for confirmatory chest x-ray. CRT = capillary refill time, LOC = level of consciousness; consider obstructive and neurogenic as well as hypovolemic shock: exclude tension pneumothorax, cardiac tamponade, spinal shock Meatal blood, scrotal hematoma, high riding prostate CSF oto/rhinorrhea, basilar skull fracture, midface instability Chest, pelvis, lateral cervical spine; others as indicated FAST, CT as indicated Source: Adapted with permission from the American College of Surgeons Committee on Trauma, Advanced Trauma Life Support ® for Doctors Student Course Manual. 261
Table 7.4 Principles of Advanced Burn Life Support ® Primary Survey Airway Breathing Circulation Disability Rapid upper airway closure may occur following inhalation injury and require early intubation Circumferential full thickness burns of the trunk may impair ventilation and require escharotomy Circulation in a limb with full thickness burns may be impaired and require escharotomy Consider carbon monoxide poisoning if the patient is not initially alert and oriented Remove all jewelry to avoid constriction of digits Exposure and environment Adjuncts Foley catheter Needed to titrate fluid replacement against urine output Gastric tube Needed to decompress stomach due to burn ileus Resuscitation Stop the burning process Fluid resuscitation Parkland formula: 3–4 mL Ringer’s lactate × body weight in kg × total BSA burned; administer half the amount during the first 8 hr after injury, half over the next 16 hr Modification for pediatric patients: Add maintenance fluid to Parkland formula for children and infants; 100 mL/kg for first 10 kg + 50 mL/kg for next 10 kg + 20 mL/kg for each additional kg Secondary Survey History and physical Obtain as much information as possible regarding the circumstances of injury Flame How did the burn occur? Did the burn occur outside or inside? Did the clothes catch on fire? How long did it take to extinguish the flames? How were the flames extinguished? Was gasoline or another fuel involved? Was there an explosion? Was there a house fire? Was the patient found in a smoke-filled room? How did the patient escape? If the patient jumped out a window, from what floor? Were others killed at the scene? Was there a motor vehicle crash? How badly was the car damaged? Was there a car fire? Are there other injuries? Are the purported circumstances of the injury consistent with the burn characteristics? 262
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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
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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
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 256 and 257: perilymph in the membranous labyrin
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 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
Page 306 and 307: Chain of command. A chain of comman
Page 308 and 309: The chain of command established by
Page 310 and 311: Advice for families of children wit
Page 312 and 313: Quarantine procedures. Quarantine p
Page 314 and 315: Chapter 10. Working with Government
Page 316 and 317: need under the 12 Emergency Service
Page 318 and 319: ecognizes that community clinicians
Page 320 and 321: 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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