PDLS: Children as
Victims of Terrorism: Risk
Assessment & Response
Jim Courtney, DO
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
Guiding Principles
The best approach to disaster
preparedness is to plan for all
pertinent hazards.
Guiding Principles
Don’t
Do
need separate disaster
plans for kids
need to focus on their
unique needs and the critical
differences between children
and adults
Pediatric Issues in Terrorism
 Children
at risk
 Assessing your community’s risks
 Community preparation issues
 Family preparation issues
 Psychological issues with children
 Resources
“Collateral
damage?”
FEMA Photo Library
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)
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 ground
 Faster respiratory rates
 Larger skin surface area to mass
ratio
 Vulnerable to fluid loss
Children at Risk:
Vulnerabilities
 More
permeable blood-brain barrier
 Many rapidly reproducing cells
 Unable 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 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
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
–
L –
U –
D –
G –
E –
S
Salivation
Lacrimation
Urination
Defecation
GI Distress
Emesis
Cholinergic Toxidrome
–
U –
M –
B –
E –
L –
L –
S –
D
Diarrhea
Urination
Miosis (small pupils)
Bradycardia, Bronchorrhea
Emesis
Lacrimation
Lethargy
Salivation, Sweating, Seizures
Nerve Synapse
Nerve Agents
 “G”
–
–
–
–
Tabun (GA)
Sarin (GB)
Soman (GD)
Cyclosarin (GF)
 “V”
–
–
–
–
Agents
Agents
VE
VG
VM
VX
G Agents
such because they were 1st
synthesized by German scientists
 Chief scientist was Gerhard Schrader
 Named
 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
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
+/-
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 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
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
–
Blocks effects of excess acetylcholine
 Treats
–
–
–
–
agent
muscarinic effects
Secretions
Gastrointestinal hypermotility
Bronchoconstriction
Does not treat muscle weakness/paralysis,
spasms
 Respiratory
treatment
status is endpoint of
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 agentacetylcholinesterase 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 hour
 Each Mark 1 Dose kit contains 600mg
of pralidoxime
 Alternative 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 Dosages
Based on Symptoms

Mild Symptoms =
None

Moderate Symptoms =
1-2 Kits

Severe Symptoms =
3 Kits
Pediatric Dosing with Mark 1
Mild/Moderate
Contact Medical Control
Severe
< Age 8
1 Kit
>Age 8
3 Kits
POSSIBLE INJECTION SITES
Strategic National Stockpile
 SNS
–
–
is a national repository
Antibiotics, chemical antidotes, antitoxins, lifesupport 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
50-200 rem
None
H-Bomb
>200 rem
> 450 rem
*Vomiting
*Hemorrhaging
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?