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?