pdls: children as victims of terrorism: risk assessment & response jim courtney, do
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PDLS: Children as PDLS: Children as Victims of Terrorism: Risk Victims of Terrorism: Risk Assessment & ResponseAssessment & Response
Jim Courtney, DO
Objectives Identify why children can be specific
targets of terrorismDiscuss the differences that may
make children more susceptible to certain acts of terrorism
Discuss specific treatment modalities and/or dosing that are unique to children
Guiding Principles
The best approach to disaster preparedness is to plan for all
pertinent hazards.
Guiding Principles
Don’t need separate disaster plans for kids
Do need to focus on their unique needs and the critical differences between children
and adults
Pediatric Issues in Terrorism
Children at riskAssessing your community’s risksCommunity preparation issuesFamily preparation issuesPsychological issues with childrenResources
“Collateral damage?”
FE
MA
Photo L
ibrary
Or intentional targets?
When Lee Malvo asked why he planned to attack children in schools and on buses, convicted sniper John
Mohammed allegedly replied:““For the sheer terror of it – the worst thing For the sheer terror of it – the worst thing
you can do to people is aim at their you can do to people is aim at their children.” children.”
(From AP story 5/30/06)
Children at Risk: Targets
Innocent, vulnerable population Tend to gather in large groups,
including daycare centers at places of business
Natural curiosity May not be able to rescue
themselves Extreme emotional reaction by
rescuers and public
Children at Risk: Vulnerabilities
Low to groundFaster respiratory ratesLarger skin surface area to mass
ratioVulnerable to fluid loss
Children at Risk: Vulnerabilities
More permeable blood-brain barrierMany rapidly reproducing cellsUnable to escape (longer exposure)Found in large groups (contagion)
Community Preparation
EMS/Fire– Incorporate children in all MCI drills
and exercises
– Knowledge of at-risk groups in the area
– Knowledge of local hospital pediatric capabilities
– Have appropriate protocols/aids for pediatric WMD/WME care
Community Preparation
Hospitals– Incorporate the needs of children and
families into all aspects of disaster planning and preparedness
• Acknowledge the likelihood of an unusual pediatric patient load in the disaster setting
• Be aware of available pediatric resources
Community PreparationAll medical responders/receivers must be prepared to deal with:
– Lack of familiarity with pediatric antidotes and treatments and lack of pediatric drug formulations
– Unusual pediatric patient loads and acuities
– Relative lack of local pediatric specialty resources due to overwhelming patient volume
– Ethical dilemmas in resource-constrained environments
There may be proportionally…
MORE KIDS THAN ADULTS THAT ARE SICK
And children may be…
SICKER
THAN THE ADULTS
March 20, 1995
~ 8:15 AM – Terrorists placed and released multiple containers of the nerve gas sarin in 5 trains on three of Tokyo's ten underground rail lines
The sarin was concealed in lunch boxes & plastic/paper bags.
The terrorists punctured the bags with umbrellas and ran out of the subway tunnel.
Tokyo Sarin Attack
~ 5500 injured and 12 dead The same cult had released sarin in an
apartment complex in Matsumoto in 1994, killing 7 and injuring more than 600
Tokyo Sarin Attacks ~ 8:45AM first aid stations were set up on
the streets outside many of the subway entrances
550 patients transported to the ED by ambulance
3227 people evaluated in an ED 493 patients admitted to the hospital 9 died at the scene 1 died shortly after arrival to ED
Cholinergic Toxidrome
S – L – U – D – G – E –
Salivation
Lacrimation
Urination
Defecation
GI Distress
Emesis
Cholinergic Toxidrome
D – U – M – B – E – L – L – S –
Diarrhea
Urination
Miosis (small pupils)
Bradycardia, Bronchorrhea
Emesis
Lacrimation
Lethargy
Salivation, Sweating, Seizures
Nerve Synapse
Nerve Agents “G” Agents
– Tabun (GA)– Sarin (GB)– Soman (GD)– Cyclosarin (GF)
“V” Agents– VE– VG– VM– VX
G Agents
Named such because they were 1st synthesized by German scientists
Chief scientist was Gerhard Schrader Was looking for a more potent insecticide
– GA (Tabun) discovered in 1936– GB (Sarin) discovered in 1938– GD (Soman) discovered in 1944– GF (Cyclosarin) discovered in 1949
Sarin found in Fallujah
Nerve Agents
Name Abbrev Toxic dose
Volatility Skin absorption
Persistent
Tabun GA 1 mg ++ + N
Sarin GB ~1 mg ++++ + N
Soman GD 350 mcg +++ + N
----------- VX 5 mcg +/- ++++ Y
Clear, colorless, tasteless LIQUIDS
Nerve Gas Furby“This cute and cuddly little Furby
contains enough nerve gas to take down a shopping mall. Easy to operate just set the timer and leave it behind.”
$1,750.00
From Butler’s Military Hardware Salvage Shop
“V” Agents
“V” stands for “Venomous” As a group approximately 10 times more
potent than Sarin Persistent agents with an oil consistency Does not wash away easily, can remain
on clothes for long periods Contact hazard is primarily but not
exclusively dermal
VX
High viscosity and low volatilityTexture & feel of high grade motor oilOdorless and tastelessCan be distributed as a liquid or
vaporizedDeadliest nerve agent produced to datePossessed only by US and Russia
VX Lethal Dose 50%
Prehospital Decontamination First responders: Respirators, goggles,
protective clothing Self-contained breathing apparatus (SCBA) is
recommended in response to any nerve agent vapor or liquid
Butyl rubber gloves 20% of healthcare workers in Tokyo had mild
symptoms after taking care of patients. These symptoms included nausea, eye pain, and headache
Atropine Anticholinergic agent
– Blocks effects of excess acetylcholine
Treats muscarinic effects– Secretions– Gastrointestinal hypermotility– Bronchoconstriction– Does not treat muscle weakness/paralysis, spasms
Respiratory status is endpoint of treatment
Atropine
Dosage– 2-10 mg IV– Repeat as necessary– Endpoint of treatment is reduction of
bronchorrhea and decreased shortness of breath– May require large doses (15-20 mg/hr)
Pralidoxime (2-PAM)Regenerates
cholinesterase bound by nerve agent
– Breaks nerve agent-acetylcholinesterase bond
– Ineffective after aging
Treats nicotinic effects– Muscular weakness/paralysis
Pralidoxime
Dosage 15 – 25mg/kg IV or IM– Usually 1.5 - 2g total per dose– If given IV should be done over 20 minutes
May repeat in 1 hourEach Mark 1 Dose kit contains 600mg
of pralidoximeAlternative names are 2 - PAM
Chloride or Protopam
Mark 1 Kit
Antidote kit given to US Military & responders as an immediate therapy
Contains 2 separate autoinjectors – Atropine 2mg– Pralidoxime 600mg
Given in the field prior to decontamination based on symptoms
Mark 1 Kit
The small injector, marked 1, is atropine – 2mg in 0.7 cc’s and should be given first
The larger injector, marked 2 is 2-PAM – 600 mg in 2 cc’s and is given second
Mark 1 Kit Adult DosagesBased on Symptoms
Mild Symptoms =
Moderate Symptoms =
Severe Symptoms =
None
1-2 Kits
3 Kits
Pediatric Dosing with Mark 1
Mild/Moderate
Severe < Age 8
>Age 8
Contact Medical ControlContact Medical Control
1 Kit1 Kit
3 Kits3 Kits
POSSIBLE INJECTION SITES
Strategic National Stockpile
SNS is a national repository – Antibiotics, chemical antidotes, antitoxins, life-
support medications, IV administration, airway maintenance supplies, and medical/surgical items.
– Supplement and re-supply state and local public health agencies in the event of a national emergency
Strategic National Stockpile
SNS: organized for flexible response – Push Packs – Goal: delivery in 12 h
• Caches of pharmaceuticals, antidotes, and medical supplies designed to provide rapid delivery of a broad spectrum of assets for an ill defined threat in the early hours of an event.
– Vendor Managed Inventory – Goal: delivery in 24-36 hours
• VMI can be tailored to provide pharmaceuticals, supplies and/or products specific to the suspected or confirmed agent(s).
2/3 of a push pack may not be appropriate or usable for children!
CHEMPACK Container
Pediatric Dosage AtroPen®
Approved by FDA in 2004– Questions regarding:
• Indications• Role• Should one use Pediatric AtroPen or the
Mark I Kit?– Indications– Protocols– Stockpile
Benzodiazepines
Most reliable agents for seizures from nerve agent toxicity
– Prevention and treatment
Diazepam autoinjector – Contains 10mg in 5mL– Only for Adult Use– Pediatric dosing with multi
dose vials and only by medical control
Biological Agents
Typically the treatments are not something usually recommended for children
– Ciprofloxacin or doxycycline for Anthrax– Smallpox vaccine for Smallpox– Alternatives are not included in the SNS Push
Pack
Contraindications become very relative in situations like that
Radiation Exposure
Amount Source Symptoms
1 rem X-Ray None
<50 rem None
50-200 rem H-Bomb *Vomiting
>200 rem *Hemorrhaging
> 450 rem Chernobyl *Bone Marrow Suppression/Death
Chernobyl Experience 134 workers were treated for radiation
sickness 22 had > 400 rad exposure – 32% of those
died 21 had > 600 rad exposure – 95% of those
died The larger problem is the risk of cancers,
especially thyroid, leukemia and lung cancer
Your Friends During A Radiation Exposure
Time, Distance & Shielding– The most important things you can
do to protect yourself
Potassium Iodide (KI)– Fill your thyroid with iodine so that
I131 won’t deposit there– Potassium helps to rid the body of
Cesium137 faster– Goal is to have this in the hands of
everyone within 2 hours of exposure
EMS Protocols
How many systems have Chemical, Biological Radiological, Nuclear and Explosive (CBRNE) protocols?
– Do they address children?– Do they allow for the treatment of
children?
Questions?
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