The Chemical Terrorism Threat: Pediatric Issues

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The Chemical Terrorism Threat Pediatric
Issues

• Fred M. Henretig, MD
• Division of Emergency Medicine
• Childrens Hospital of Philadelphia
  
  Poison Control
  Center
• Philadelphia, PA

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Tokyo Sarin Attack

• March 20, 1995
• 5 Aum Shinrikyo cult members
• 5 subway trains all bound towards government
  center station
• At 748 am, each cultist punctured bag(s) of
  sarin
• Almost immediately, subway passengers sickened

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Tokyo-2

• City-wide 5510 pts sought EM rx
• 25 hospitalized
• 12 deaths
• Most victims to hospital by taxi, bus or personal
  vehicles of Good Samaritans

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Tokyo-3 the good news

• sarin was only 30 concentration
• inefficient dispersal device vaporization
• good ventilation system
• vapor exposure relatively little victim/clothing
  contamination
• most (? all) victims were adults

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Chemical Weapons Attack

• Combines elements of traditional HAZMAT incidents
  and natural disasters
• Recognition of event likely rapid
• Casualties occur immediately
• Initial response by traditional first
  responders
• But

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Chemical Terrorism not just another HAZMAT
incident

• critical differences
• intent to use very lethal agent
• initial uncertainty re agent identity
• greater risk to EMS providers
• possible mass casualties
• mass hysteria, many worried well
• contaminated patients seeking hospital care
• potential for overwhelmed EMS, EDs, ICUs

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Also, what if ?

• The attack site was Disney World, on a holiday
  weekend
• droplet dispersal of nerve agent
• as many pediatric as adult victims

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PEM Directors Poll

• 13 respondents ( out of at least 50-60, or more)
• 10 items re capacity to handle pedi MCIs with WMD
• in general 23- 39 felt some discomfort with
  current preparedness for specific ?s re BT, CT
• overall 62 felt current level of pedi MCI
  preparedness suboptimal
• these were the respondents
• Spring, 2003

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Chemical Terrorism
Pediatric-Specific Vulnerabilities

• physiologic
• developmental
• psychologic
• EMS ( and even ED-based) deficiencies re
  pediatric mass casualties

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EMS ( /- ED) Factors

• (?) less capacity to cope with large influx of
  critical pediatric patients
• (?) procedural challenges, esp garbed in PPE
• less reliance on routine transfer protocols
• limited pediatric bed expansion capability in NDMS

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Imaginemultiple pediatric patients presenting
simultaneously, requiring immediate
treatment, with unfamiliar, intravenous
medications, by first responders in
PPE for rarely encountered conditions
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Clinical Perspective Management issues

• improved, rapid field/bedside diagnostic tests
• clinical diagnosis algorithms
• better decontamination strategies
• better, less risky antidotes
• alternatives to iv route for MCI expand im
  ( autoinjector) role for children, additional
  drugs aerosol? transdermal?

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Clinical diagnosis

• MCI with acute onset off ssx
• Exposure ( explosion, cloud, odor, dispersal
  device, etc)
• Most significant clinical syndrome?
• Neurologic ( NAs, CN)
• Respiratory ( Cl, phosgene, H2S, HF, NH3, etc)
• Mucocutaneous ( vesicants, lacrimators,etc)

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Optimal PPE?
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Optimal decontamination?
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CHOP Decon Room 1855
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CHOP Decon Room 1855
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CHOP Decon 2001
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CHOP Decon 2005
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Parallel Decon Unit
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Current challenges Nerve Agents

• GENERAL
• antidote stockpiling and distribution
• scavenger molecules for immed post-exposure
• new antidotes better oximes (e.g. HI-6), fetal
  bovine cholinesterase, etc
• PEDIATRIC ( particularly)
• antidote administration guidelines for infants,
  children in MCI
• aerosol delivery of antidotes
• optimal anticonvulsant for IM route

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Imaginemultiple pediatric patients presenting
simultaneously, requiring immediate
treatment, with unfamiliar, intravenous
medications, by first responders in
PPE for rarely encountered conditions
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Adult Autoinjectors in Children?

• consensus guidelines needed!
• consider for critical child gt 2-3 y.o. ( 13 kg)
• age 2-7 ( 13 -25 kg) 1 autoinjector
• 0.08 -0.13 mg/kg atropine, 24-36 mg/kg 2-PAM
• age 8-14 ( 26-50 kg) 2 autoinjectors
• what about infants?
• J Pediatr, Sept 2002

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Pediatric Atropens

• FDA approved Spring, 2003
• Initially 0.5 and 1.0 mg sizes
• Coming to a store near you soon 0.25 mg
• 2-PAM maybe
• In the meantime

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Ann Emerg Med, Oct 2002
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Possible Strategies-1

• FDA guidelines more accurate, but more complex
• Age Wt (kg) Atropen (mg) 2-PAM (mg)
• lt6 m lt7 0.25
• 6m-4y 7-18 0.5
• 5-10 18-41 1
• gt10 y gt41 2
• 2-PAM autoinjectors not FDA approved for
  children but many authors suggest considering
• IM ( syringe) dose for 0-2y
• 1 adult 2-PAM AI for those 2-7
• 2 adult AIs for those 8-14

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Possible Strategies-2

• Less accurate, less complex ( NYC EMS plan)
• Age Atropen (mg) 2-PAM (mg)
• lt12m 0.5 none
• 1-8 y 2 600 mg ( 1 adult
  AI)
• 8 y ( as per adult pts)

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Possible strategies-3

• Color-coded approach, a la Broselow-Luten system
• Still would be fairly complex in MCI
• Coordinate with Meridian (autoinjector
  manufacturers) ?

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Broselow Tape
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IV
IM
DRUG SELECTION GUIDE COLOR TABS
BROSELOW-LUTEN SYSTEM
PiNK 6-7KG
RED 8-9KG
PEDIATRIC DRUG, PREPARATION, and
ADMINISTRATION GUIDE
PURPLE 10-11KG
DRUG PREPARATION and
ADMINISTRATION GUIDE BLACK TABS
YELLOW 12-14KG
WHIT9E 15-18
ANTIDOTES for CHEMICAL and BIOLOGICAL
WARFARE
BLUE 19-23
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Nerve Agent Anticonvulsant Rx

• without iv access, im or autoinjector diazepam?
• potential for im lorazepam, midazolam
• rectal diazepam (? ok for vapor exposure, vs
  dermal or gi)

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Industrial chemicals- also potential targets!
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Industrial chemicals representative threat
categories

• Strong acids/bases
• Respiratory tract irritants ( NH3, HF, HCl,
  chlorine, isocyanates, etc)
• Fentanyl derivatives, other opioids
• Cellular asphyxiants ( phosphine, H2S, Na azide-
  similar in effects to CN)
• Arsine severe hemolysis

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Toxic gas disasters-1

• Bhopal, India 1984 Union Carbide plant release
  of gt20,000 kg of methyl isocyanate, with 2500
  deaths and 200,000 injured

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Toxic gas disasters-2

• Texas City, TX, 1987 Marathon Oil petrochemical
  plant, crane accident resulted in release of 26
  tons of HF gas
• 939 sickened, 94 hospitalized, but no deaths.

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Public education, coping strategies,
post-incident mental health interventions
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Unique Challenges for Childrens Hospitals

• Families arrive-can we decon adults and children?
• Issues of gender, often minimized in routine
  care?
• After decon, then what? Can we provide emergent
  care to adults?

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Summary Chemical Defense Challenges- Pediatric
Perspective

• plan for pre-incident, incident and
  post-incident capabilities
• consider pediatric specific vulnerabilities
• include industrial, non-CW chemicals
• focus on alternative routes, safer antidotes
• patient flow, decontamination challenges in MCI
• communitywide planning how do we fit in?