Disaster preparedness, pediatric considerations in primary blast injury, chemical, and biological terrorism

Table 1 Pediatric specific vulnerabilities to terrorist attacks

Vulnerability	Blast Injury	Biological agents	Chemical agents
Proximity to ground		Agents settle to the ground	Agents tend to pool in lower areas
Increased minute ventilation		Increased exposure to inhaled agents	Increased exposure to inhaled agents
Provider unfamiliarity with pediatric dosing of medications		Dosing of antibiotics different	No prepackaged store of antidotes in pediatric doses
Lack of knowledge or inability to flee danger	Either unaware or unable to flee from explosion Potentially curious about ordinance	Unlikely to recognize signs/symptoms of biologic agents	Would not know to flee from strange odor or seek medical help with symptoms
Lack of stockpile of pediatric dosed antidotes and vaccines		Prepackaged stockpiles of vaccines and antidotes not dosed for small children[32]	Lack of guidelines for dosing of antidotes in children
Less blood volume/physiologic reserve	More rapidly develop life threatening blood loss	Prone to dehydration with illness. Lower functional residual capacity	More prone to respiratory distress/failure with nerve agents, vesicants, and pulmonary agents
Thinner skin			Faster absorbtion of agents
Increased BSA to mass ratio	Prone to hypothermia during triage, evacuation and treatment		Prone to hypothermia with decontamination
Developmental immaturity	Unable to follow mental status exam/communicate other injuries early	Present later in the course of biologic agents	Unable to promptly communicate symptoms
Increased head size compared to body	Increased head AIS when compared to adults[2]

AIS: Abbreviated injury score; BSA: Body surface area.

Table 2 Management of chemical agents

Agent	Pediatric dosing	Notes
Nerve agents	Atropine 0.05 mg/kg iv or im q 2-5 min (max 5 mg) Pralidoxime 25 mg/kg iv or im q 1 h (max 1 g iv or 2 g im) Benzodiazepines: Midazolam im 0.2 mg/kg (max 10 mg) (1st choice) Lorazepam iv/im 0.1 mg/kg (max 4 mg) Diazepam iv 0.3 mg/kg (max 10 mg)	Atropine should be repeated for persistent symptoms
Cyanide	Hydroxocobalamin 70 mg/kg (max 5 g) or sodium nitrate; 0.33mL/kg iv (max 10 mL) followed by sodium thiosulfate (25%) 1.65 mL/kg iv (max 50 mL)	Hydroxocobalamin may be repeated × 1 if needed

Table 3 Guidelines for the use of Mark I kits in pediatric patients

Pediatric patients	Mark I kits
3-7 yr (approximately 13-25 kg)	One Mark I kit as maximum dose
8-14 yr (approximately 26-50 kg)	Two Mark I kits as maximum dose
> 14 yr (approximately > 51 kg)	Three Mark I kits as maximum dose

Mark I kit: 2 mg atropine and 600 mg 2-PAM; PAM: Pralidoxime.

Table 4 Management of biologic agents

Agent	Pediatric dosing	Notes
Inhalational anthrax	Ciprofloxacin 10-15 mg/kg iv q 12 h (max 400 mg) or doxycycline 2.2 mg/kg iv q 12 h (max 100 mg) plus clindamycin 10-15 mg/kg q 8 plus penicillin G 400-600 k U/kg per day iv divided q 4 h prophylaxis for exposed contacts ciprofloxacin 15 mg/kg po q 12 h or doxycycline 2.2 mg/kg po q 12 h	Switch to oral therapy when patient shows signs of improvement At least one agent should have good CNS penetration Prophylaxis is for a 60 d course Amoxicillin or levofloxacin are second line
Plague	Gentamycin 2.5 mg/kg iv q 8 h or streptomycin 15 mg/kg im q 12 h (max 2 mg/d) or doxycycline 2.2 mg/kg iv q 12 h (max 200 mg/d) or ciprofloxacin 15 mg/kg iv q 12 h prophylaxis for exposed contacts trimethoprim/sulfa 4 mg/kg po q 12 h	Chloramphenical or Levofloxacin can also be used Prophylaxis should be continued for 5-7 d
Tularemia	Same as therapy for plague
Botulism	Infants < 1 yr human-derived botulinum immunoglobulin children > 1 yr equine serum botulism antitoxin	In United States call 1-800-222-1222 or 770-488-7100 Outside United States contact local health agencies

CNS: Central nervous system.

Table 5 Viral hemorrhagic fever, virus and disease

Family	Virus	Disease
Arenaviruses	Lassa virus	Lassa fever
	Junin	Argentine hemorrhagic fever
	Machupo	Bolivian hemorrhagic fever
Bunyaviruses	CCHF	Cremiean-Congo hemorrhagic fever
	RVF	Rift Valley fever
	Hantavirus	Hemorrhagic fever with renal syndrome
Filoviruses	Ebola virus	Ebola hemorrhagic fever
	Marburg virus	Marburg hemorrhagic fever
Flavivirus	Yellow fever virus	Yellow fever
	KFD virus	KFD
	OHF virus	Omsk hemorrhagic fever
	DENV 1-4 viruses	Dengue hemorrhagic fever
Rhabdovirus	Bas-Congo virus	Bas-Congo hemorrhagic fever

CCHF: Crimean congo hemorrhagic fever; RVF: Rift valley fever; KFD: Kyasanur forest disease; OHF: Omsk hemorrhagic fever; DENV: Dengue hemorrhagic fever virus.