PDLS: Children as Victims of Terrorism: Risk Assessment

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PDLS Children as Victims of Terrorism Risk
Assessment Response

• Jim Courtney, DO

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Objectives

• Identify why children can be specific targets of
  terrorism
• Discuss 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

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Guiding Principles

• The best approach to disaster preparedness is to
  plan for all pertinent hazards.

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Guiding Principles

• Dont need separate disaster plans for kids
• Do need to focus on their unique needs and the
  critical differences between children and adults

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Pediatric Issues in Terrorism

• Children at risk
• Assessing your communitys risks
• Community preparation issues
• Family preparation issues
• Psychological issues with children
• Resources

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Collateral damage?
FEMA Photo Library
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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 you
  can do to people is aim at their children.
  
  
  (From AP story 5/30/06)

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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

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Children at Risk Vulnerabilities

• Low to ground
• Faster respiratory rates
• Larger skin surface area to mass ratio
• Vulnerable to fluid loss

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Children at Risk Vulnerabilities

• More permeable blood-brain barrier
• Many rapidly reproducing cells
• Unable to escape (longer exposure)
• Found in large groups (contagion)

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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

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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

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Community Preparation

• All 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

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There may be proportionally

• MORE KIDS THAN ADULTS THAT ARE SICK

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And children may be

• SICKER
• THAN THE ADULTS

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March 20, 1995

• 815 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.

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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

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Tokyo Sarin Attacks

• 845AM 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

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Cholinergic Toxidrome
Salivation Lacrimation Urination Defecation GI
Distress Emesis

• S
• L
• U
• D
• G
• E

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Cholinergic Toxidrome
Diarrhea Urination Miosis (small
pupils) Bradycardia, Bronchorrhea Emesis Lacrimati
on Lethargy Salivation, Sweating, Seizures

• D
• U
• M
• B
• E
• L
• L
• S

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Nerve Synapse
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Nerve Agents

• G Agents
• Tabun (GA)
• Sarin (GB)
• Soman (GD)
• Cyclosarin (GF)
• V Agents
• VE
• VG
• VM
• VX

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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

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Sarin found in Fallujah
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Nerve Agents
Clear, colorless, tasteless LIQUIDS
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
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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 Butlers Military Hardware Salvage Shop

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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

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VX

• High viscosity and low volatility
• Texture feel of high grade motor oil
• Odorless and tasteless
• Can be distributed as a liquid or vaporized
• Deadliest nerve agent produced to date
• Possessed only by US and Russia

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VX Lethal Dose 50
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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

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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

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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)

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Pralidoxime (2-PAM)

• Regenerates cholinesterase bound by nerve agent
• Breaks nerve agent-acetylcholinesterase bond
• Ineffective after aging
• Treats nicotinic effects
• Muscular weakness/paralysis

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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 hour
• Each Mark 1 Dose kit contains 600mg of
  pralidoxime
• Alternative names are 2 - PAM Chloride or Protopam

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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

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Mark 1 Kit

• The small injector, marked 1, is atropine 2mg
  in 0.7 ccs and should be given first
• The larger injector, marked 2 is 2-PAM 600 mg
  in 2 ccs and is given second

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Mark 1 Kit Adult DosagesBased on Symptoms

• Mild Symptoms
• Moderate Symptoms
• Severe Symptoms

• None

1-2 Kits
3 Kits
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Pediatric Dosing with Mark 1

• Mild/Moderate
• Severe
• lt Age 8
• gtAge 8

Contact Medical Control
1 Kit
3 Kits
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POSSIBLE INJECTION SITES
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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

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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).

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2/3 of a push pack may not be appropriate or
usable for children!
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CHEMPACK Container
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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

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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

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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

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Radiation Exposure
Amount Source Symptoms
1 rem X-Ray None
lt50 rem None
50-200 rem H-Bomb Vomiting
gt200 rem Hemorrhaging
gt 450 rem Chernobyl Bone Marrow Suppression/Death
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Chernobyl Experience

• 134 workers were treated for radiation sickness
• 22 had gt 400 rad exposure 32 of those died
• 21 had gt 600 rad exposure 95 of those died
• The larger problem is the risk of cancers,
  especially thyroid, leukemia and lung cancer

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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 wont
  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

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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?

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Questions?