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supervision, and entertainment for pediatric victims, as well as protection from the media in the critical period immediately after a disaster. Incident Management The incident command system (ICS) is widely recognized and used in the field of emergency management to effectively manage resources and casualties during a disaster. The ICS is a unified management system that allows for expandability and accountability based on the magnitude and needs created by the specific incident. It is an organizational system of “best practices” for on-scene, all-hazard incident management. There are five major management functions: • Incident command. • Operations. • Planning. • Logistics. • Finance/administration. All have standardized position titles. The following nomenclature is used for organizational components and their supervisory personnel: • Incident commander. • Command staff officer. • General staff/section chief. • Division supervisor. • Group supervisor. • Branch director. • Task force leader. • Strike team leader. • Unit leader. In a unified command structure, there is one recognizable leader—the incident commander— who has overall responsibility. Because the system is expandable, it allows for the use of many components that may be needed to manage the incident. Various component managers are granted the authority to manage their specific component, and they are held accountable for the performance of their area to the incident commander. This type of system is widely used in everyday business. For example, in the hospital setting, the incident commander could be compared with the chairperson of the medical board, and the group managers could be compared with the various chiefs of service. The National Incident Management System (NIMS) has been developed for use by all emergency response agencies in the country. NIMS is an updated more inclusive version of ICS. Its standardized framework, common terminology, and flexibility allow it to be used by Federal, State, and local agencies/authorities. ICS is modular and can be expanded to meet needs that arise during an incident. In a disaster, the triage, treatment, and transportation of casualties fall to the EMS Operations Branch. The 41
incident command officer is most often a field officer of the local EMS agency. That officer is responsible for managing all medical resources needed to effectively handle the incident and for minimizing the impact on normal operations of the EMS system. Based on the scope of the incident, the divisions of smaller functional units are formed to manage the following: • Staging. • Triage. • Treatment/decontamination. • Transport. Staging The staging officer is responsible for setting up an area where incoming resources, including personnel, can gather and await an actual assignment. The staging group can be broken down further into smaller units of operation for specific incident needs. For example, incoming ambulances would be directed to a vehicle staging area; personnel not assigned to a specific unit or task would be sent to a personnel staging location; and needed equipment would be directed to a logistical staging location. These areas may be off site from the incident but easily accessible to it. This allows greater accountability of who is on the incident ground and monitoring of their respective functions and performance. Triage Group The triage group is tasked with prioritizing casualties based on pre-established medical protocol. Simple Triage and Rapid Transport (START) allows rescuers to assess and prioritize a victim with a 30-second, hands-on assessment. Immediate life-threatening conditions are rapidly identified and corrected with minimal intervention, and casualties are identified for immediate transport (e.g., airway problems are corrected with a tilt of the head, and the patient is marked “red” for immediate transport; intubation in the field would not be done during this initial assessment). For children, a variant known as JumpSTART pediatric mass casualty triage is used (see http://www.jumpstarttriage.com/). In incidents involving victims exposed to hazardous chemicals, a similar system of triage is used. Normal START procedures would be extremely difficult for rescuers in chemical protective clothing to use. In these cases, a form of triage based on observation of symptoms is used, and response to tactile stimulus determines the triage priority. Treatment/Decontamination The treatment group is tasked with providing a more definitive treatment regimen for incident victims. Casualties are removed from the incident ground to a safe, protected area so that treatment can be started, particularly if transport is to be delayed. Personnel in this group constantly monitor victims for changes in their condition and change their triage priority as needed. In large-scale incidents in which the patient load would cripple normal hospital resources, victims with minor injuries may be held in an off-site treatment area for an extended time. Physicians, nurses, and other ancillary staff may be assigned to staff this area. 42
Page 1 and 2: Bioterrorism and Other Public Healt
Page 3 and 4: Contents Chapter 1. Introduction ..
Page 5 and 6: Q Fever............................
Page 7 and 8: Basic Principles...................
Page 9 and 10: Chapter 9. Integrating Terrorism an
Page 11 and 12: Table 5.4 Nerve agent triage and do
Page 13 and 14: There are many gaps in knowledge, e
Page 15 and 16: injured or killed (see also Chapter
Page 17 and 18: Head injury is common in children.
Page 19 and 20: In situations of disaster, caregive
Page 21 and 22: maintaining and securing the airway
Page 23 and 24: • Schonfeld DJ. In times of crisi
Page 26 and 27: Types of Disasters Chapter 2. Syste
Page 28 and 29: problems noted above for flooding,
Page 30 and 31: Federal Response The United States
Page 32 and 33: The scope of ESF #8 is broad and in
Page 34 and 35: • Centers for Disease Control and
Page 36: Table 2.1 Types of disasters, hazar
Page 39 and 40: Medical staffs need to know what wi
Page 41 and 42: information, health and safety educ
Page 43 and 44: y private physicians. Approximately
Page 45 and 46: even required (particularly if a pe
Page 47 and 48: ICS structure is hierarchical. For
Page 49 and 50: • Provide community education so
Page 51: • Provide for crisis counseling.
Page 55 and 56: Figure 3.1 National Response Plan D
Page 58 and 59: Background History of Bioterrorism
Page 60 and 61: Epidemiology of a Terrorist Attack
Page 62 and 63: and may be watery, purulent, or blo
Page 64 and 65: fluid in these vesicles. A painless
Page 66 and 67: determined to be due to an agent of
Page 68 and 69: cared for using standard precaution
Page 70 and 71: may be providing longer term and mo
Page 72 and 73: 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 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 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
Page 192 and 193:
Decontamination priorities are as f
Page 194 and 195:
These effects can occur anywhere fr
Page 196 and 197:
manifestations of ARS may range fro
Page 198 and 199:
Neutropenia: Viral and Fungal Infec
Page 200 and 201:
The main reason for targeting pregn
Page 202 and 203:
No significant side effects from it
Page 204 and 205:
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 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 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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sadness, anger, guilt, or a sense o
Page 288 and 289:
was mean to my father yesterday and
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
Page 322 and 323:
Planning for special medical needs
Page 324 and 325:
Table 11.1 Environmental constraint
Page 326 and 327:
Table 11.2 Pediatric medical compla
Page 328 and 329:
• The post-storm environment is h
Page 330 and 331:
Acronyms AAP American Academy of Pe
Page 332 and 333:
RIA RTG SCIWORA SEB SI SNS SSRI STA
Page 334 and 335:
Appendix A. Pediatric Terrorism and
Page 336 and 337:
1. List which biological agents (mi
Page 338 and 339:
19. Identify chemical terrorism tox
Page 340 and 341:
39. Provide followup care, being mi
Page 342 and 343:
Learning Objectives: At the end of
Page 344 and 345:
Lead Editors Appendix B. List of Co
Page 346 and 347:
James Tsung, MD, FAAP Attending Phy
Page 348 and 349:
Gerald S. Braley, PhD Major, United
Page 350 and 351:
Kobi Peleg, PhD Michael Stein, MD J
Page 352 and 353:
Lou E. Romig MD, FAAP, FACEP Childr
Page 354:
Maternal & Child Health Bureau Dan
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