Pediatric Emergency Preparedness Disasters, Terrorism and Public Health Emergencies Are We Prepared? Are We Prepared?Are We Prepared? David Markenson, MD David Markenson, MDDavid Markenson, MDChief, Pediatric Emergency Medicine Chief, Pediatric Emergency MedicineChief, Pediatric Emergency MedicineMaria Fareri Children's Hospital Maria Fareri Children's HospitalMaria Fareri Children's HospitalDirector, Center for Disaster Medicine Director, Center for Disaster MedicineDirector, Center for Disaster MedicineNew York Medical College School of Public Health New York Medical College School of Public HealthNew York Medical College School of Public Health Basic Questions •• Are we ready?Are we ready? •• For what?For what? •• How do we prepare?How do we prepare? Basic Questions •• Are we ready?Are we ready? •• For what?For what? •• How do we prepare?How do we prepare? Do we really need to worry about mass exposure of children to? •• Disasters?Disasters? •• Public Health Emergencies?Public Health Emergencies? •• TerrorismTerrorism --CBRNE?CBRNE? YESYES Do we really need to worry about mass exposure of children to? •• Disasters?Disasters? •• Public Health Emergencies?Public Health Emergencies? •• TerrorismTerrorism --CBRNE?CBRNE? YESYES Importance of Pediatric Considerations • •• Children are part of the population Children are part of the populationChildren are part of the population • •• 26% of the U.S. population are children and 26% of the U.S. population are children and26% of the U.S. population are children and youth youthyouth • •• More than 20 million are under the age of 6 More than 20 million are under the age of 6More than 20 million are under the age of 6 years yearsyears Importance of Pediatric Considerations • ••Ignoring children may compromise entire Ignoring children may compromise entireIgnoring children may compromise entire preparedness plan preparedness planpreparedness plan • •• August 2003 Survey August 2003 SurveyAugust 2003 Survey • •• 90% nationally and 92% in New York City, 90% nationally and 92% in New York City,90% nationally and 92% in New York City, reported that they would not comply with an reported that they would not comply with anreported that they would not comply with an official evacuation order official evacuation orderofficial evacuation order • •• 66 % of the national sample; 62% of New 66 % of the national sample; 62% of New66 % of the national sample; 62% of New Yorkers listed concern for their children as Yorkers listed concern for their children asYorkers listed concern for their children as the main reason the main reasonthe main reason Is there evidence of intention to target children? •• ““We have not reached parity with [the Americans].We have not reached parity with [the Americans]. We have the right to kill 4 million AmericansWe have the right to kill 4 million Americans –– 22 million of them childrenmillion of them children…”…” Suleiman Abu GheithSuleiman Abu Gheith (2002)(2002) •• Singapore government foils al Qaeda connectedSingapore government foils al Qaeda connected plan to attack American School (in Singapore) withplan to attack American School (in Singapore) with 3,000 American expatriate children. (CNN, January3,000 American expatriate children. (CNN, January 2003)2003) •• Russia: terrorists attack a school and take hostagesRussia: terrorists attack a school and take hostages Is there evidence of intention to target children? •• ““We have not reached parity with [the Americans].We have not reached parity with [the Americans]. We have the right to kill 4 million AmericansWe have the right to kill 4 million Americans –– 22 million of them childrenmillion of them children…”…” Suleiman Abu GheithSuleiman Abu Gheith (2002)(2002) •• Singapore government foils al Qaeda connectedSingapore government foils al Qaeda connected plan to attack American School (in Singapore) withplan to attack American School (in Singapore) with 3,000 American expatriate children. (CNN, January3,000 American expatriate children. (CNN, January 2003)2003) •• Russia: terrorists attack a school and take hostagesRussia: terrorists attack a school and take hostages How children are exposed to CBRNE weapons/agents •• Inadvertently (Inadvertently (Classic ThinkingClassic Thinking)) •• Intentionally targeted (Intentionally targeted (New ThinkingNew Thinking)) How children are exposed to CBRNE weapons/agents •• Inadvertently (Inadvertently (Classic ThinkingClassic Thinking)) •• Intentionally targeted (Intentionally targeted (New ThinkingNew Thinking)) How Are Children Exposed to Chemical, Biological, Radioactive, and Nuclear Agents (CBRNE) Materials? •• UnintentionallyUnintentionally •• Industrial accidents (e.g., chemical leaks,Industrial accidents (e.g., chemical leaks, nuclear reactor accidents)nuclear reactor accidents) •• Natural disastersNatural disasters •• Airplane crashesAirplane crashes InadvertentlyInadvertently •• As collateral victims of terrorism (e.g.As collateral victims of terrorism (e.g. Oklahoma City, Madrid)Oklahoma City, Madrid) I. Redlener, M.D. How Are Children Exposed to Chemical, Biological, Radioactive, and Nuclear Agents (CBRNE) Materials? •• UnintentionallyUnintentionally •• Industrial accidents (e.g., chemical leaks,Industrial accidents (e.g., chemical leaks, nuclear reactor accidents)nuclear reactor accidents) •• Natural disastersNatural disasters •• Airplane crashesAirplane crashes InadvertentlyInadvertently •• As collateral victims of terrorism (e.g.As collateral victims of terrorism (e.g. Oklahoma City, Madrid)Oklahoma City, Madrid) I. Redlener, M.D. How Are Children Exposed to Chemical, Biological, Radioactive, and Nuclear Agents (CBRNE) Materials? • •• Indirectly IndirectlyIndirectly • •• Posttraumatic stress (PTSD) and other Posttraumatic stress (PTSD) and otherPosttraumatic stress (PTSD) and other psychological effects psychological effectspsychological effects • •• Through media (e.g., Oklahoma City, Through media (e.g., Oklahoma City,Through media (e.g., Oklahoma City, WTC) WTC)WTC) Intentionally Targeted Intentionally TargetedIntentionally Targeted • •• As victims of terrorist attacks (e.g., As victims of terrorist attacks (e.g.,As victims of terrorist attacks (e.g., Oklahoma, Ma Oklahoma, MaOklahoma, Ma’ ’’lot, Beslan) lot, Beslan)lot, Beslan) Where were we in the past? Where were we in the past? Where are we today? Where are we today? Unique Vulnerabilities of Children to Terrorism and Disasters • ••Based on anatomical, physiological and Based on anatomical, physiological andBased on anatomical, physiological and clinical factors clinical factorsclinical factors • ••Due to developmental and psychological Due to developmental and psychologicalDue to developmental and psychological concerns concernsconcerns • •• System issues System issuesSystem issues Philosophy of Disaster Medicine When Children are Victims • ••Children are more susceptible to certain injuries or Children are more susceptible to certain injuries orChildren are more susceptible to certain injuries or environmental insults than adults environmental insults than adultsenvironmental insults than adults • ••Children with acute injuries or illness are more Children with acute injuries or illness are moreChildren with acute injuries or illness are more likely to respond to rapid and efficient medical likely to respond to rapid and efficient medicallikely to respond to rapid and efficient medical care than adults care than adultscare than adults • ••Since children are not smal Since children are not smalSince children are not small adults they require l adults they requirel adults they require equipment and pharmaceuticals designed for their equipment and pharmaceuticals designed for theirequipment and pharmaceuticals designed for their needs needsneeds How Children Are Different •• Differences in effects of terrorism andDifferences in effects of terrorism and disasters are based on differences due todisasters are based on differences due to •• DevelopmentDevelopment •• AnatomyAnatomy •• PhysiologyPhysiology How Children Are Different •• Differences in effects of terrorism andDifferences in effects of terrorism and disasters are based on differences due todisasters are based on differences due to •• DevelopmentDevelopment •• AnatomyAnatomy •• PhysiologyPhysiology There may be proportionally… MORE KIDS THAN ADULTSMORE KIDS THAN ADULTS THAT ARE SICKTHAT ARE SICK There may be proportionally… MORE KIDS THAN ADULTSMORE KIDS THAN ADULTS THAT ARE SICKTHAT ARE SICK And children may be… SICKERSICKER THAN THE ADULTSTHAN THE ADULTS And children may be… SICKERSICKER THAN THE ADULTSTHAN THE ADULTS Differences • ••Proportionally larger Body Surface Area (BSA) Proportionally larger Body Surface Area (BSA)Proportionally larger Body Surface Area (BSA) • ••The smaller a patient the greater the ratio of surface The smaller a patient the greater the ratio of surfaceThe smaller a patient the greater the ratio of surfacearea (skin) to size. area (skin) to size.area (skin) to size. • ••BSA also parallels certain body functions such as basal BSA also parallels certain body functions such as basalBSA also parallels certain body functions such as basalmetabolic rate and minute volume. metabolic rate and minute volume.metabolic rate and minute volume. • •• Children may receive a higher per kilogram dose of Children may receive a higher per kilogram dose ofChildren may receive a higher per kilogram dose ofagents absorbed through the skin agents absorbed through the skinagents absorbed through the skin • •• Thinner skin Thinner skinThinner skin • •• Thinner epidermis Thinner epidermisThinner epidermis • •• Under UnderUnder- --keratinized epidermis keratinized epidermiskeratinized epidermis • •• Children may be more susceptible to agents either Children may be more susceptible to agents eitherChildren may be more susceptible to agents eithereffecting the integrity or absorbed through the skin. effecting the integrity or absorbed through the skin.effecting the integrity or absorbed through the skin. Differences • ••Children have more rapid respiratory rates Children have more rapid respiratory ratesChildren have more rapid respiratory rates • ••Proportionally higher Minute Volumes and more Proportionally higher Minute Volumes and moreProportionally higher Minute Volumes and more rapid exposure to inhalational agents rapid exposure to inhalational agentsrapid exposure to inhalational agents • ••The breathing zone in children is closer to the ground The breathing zone in children is closer to the groundThe breathing zone in children is closer to the ground • ••Many agents that are aerosolized are heavier than Many agents that are aerosolized are heavier thanMany agents that are aerosolized are heavier than air: higher concentration lower to the ground air: higher concentration lower to the groundair: higher concentration lower to the ground • ••Children may be more suscep Children may be more suscepChildren may be more susceptible to agents abs tible to agents abstible to agents abso oorbed rbedrbed through the pulmonary route than adults with the through the pulmonary route than adults with thethrough the pulmonary route than adults with the same exposure same exposuresame exposure • ••Children may show early effects to agents absorbed Children may show early effects to agents absorbedChildren may show early effects to agents absorbed through the pulmonary route than adults with the through the pulmonary route than adults with thethrough the pulmonary route than adults with the same exposure same exposuresame exposure Differences • •• Prevalence of neurological symptoms Prevalence of neurological symptomsPrevalence of neurological symptoms • •• Immature blood Immature bloodImmature blood – –– brain barrier brain barrierbrain barrier • •• Enhanced CNS receptor sensitivity Enhanced CNS receptor sensitivityEnhanced CNS receptor sensitivity • •• Nerve agents may produce more Nerve agents may produce moreNerve agents may produce more symptoms in children requiring treatment symptoms in children requiring treatmentsymptoms in children requiring treatment than adults with the same exposure. than adults with the same exposure.than adults with the same exposure. • •• Agents may have CNS effects in children Agents may have CNS effects in childrenAgents may have CNS effects in children that do not have CNS effects in adults or that do not have CNS effects in adults orthat do not have CNS effects in adults or at lower exposures than adults at lower exposures than adultsat lower exposures than adults Differences • ••Children are more prone to dehydration Children are more prone to dehydrationChildren are more prone to dehydration than adults than adultsthan adults • •• Many of the chemical agents and some of Many of the chemical agents and some ofMany of the chemical agents and some of the biological lead to vomiting and the biological lead to vomiting andthe biological lead to vomiting and diarrhea diarrheadiarrhea • •• Children may be more symptomatic and Children may be more symptomatic andChildren may be more symptomatic and show symptoms earlier than adults show symptoms earlier than adultsshow symptoms earlier than adults Differences • ••Children are more prone to ionizing radiation Children are more prone to ionizing radiationChildren are more prone to ionizing radiation • ••Main effect of ionizing radiation: effects on Main effect of ionizing radiation: effects onMain effect of ionizing radiation: effects on rapidly growing tissues rapidly growing tissuesrapidly growing tissues • •• Children may be more symptomatic and Children may be more symptomatic andChildren may be more symptomatic and show symptoms earlier than adults show symptoms earlier than adultsshow symptoms earlier than adults • •• CNS CNSCNS – –– may only see effects in children may only see effects in childrenmay only see effects in children at certain doses at certain dosesat certain doses • •• Bone Marrow Bone MarrowBone Marrow – –– more symptomatic more symptomaticmore symptomatic than adults than adultsthan adults Children may present with… Different disease manifestationsDifferent disease manifestations Children may present with… Different disease manifestationsDifferent disease manifestations Differences • •• Different disease presentations Different disease presentationsDifferent disease presentations • •• Smallpox: lack of immunity Smallpox: lack of immunitySmallpox: lack of immunity • •• Trichothecene: more susceptible ? Trichothecene: more susceptible ?Trichothecene: more susceptible ? • •• Melioidosis: unique parotitis Melioidosis: unique parotitisMelioidosis: unique parotitis • •• Anthrax: ?? Less susceptible Anthrax: ?? Less susceptibleAnthrax: ?? Less susceptible • •• Children may be affected differently by Children may be affected differently byChildren may be affected differently by biologic agents and the presentations may biologic agents and the presentations maybiologic agents and the presentations may be different be differentbe different Children can be… MORE CHALLENGINGMORE CHALLENGING TO CARE FORTO CARE FOR Children can be… MORE CHALLENGINGMORE CHALLENGING TO CARE FORTO CARE FOR Differences • •• Difficult vascular access. Difficult vascular access.Difficult vascular access. • •• The problems with managing the The problems with managing theThe problems with managing themany size many sizemany size- -- related issues in an related issues in anrelated issues in an acute emergency. acute emergency.acute emergency. • •• The smaller the patient the more The smaller the patient the moreThe smaller the patient the moredifficult is vascular access. difficult is vascular access.difficult is vascular access. • •• The varying sizes cause error, The varying sizes cause error,The varying sizes cause error,delay, and discomfort in drug delay, and discomfort in drugdelay, and discomfort in drugdosing. dosing.dosing. • •• e.g.: Medications via IM and e.g.: Medications via IM ande.g.: Medications via IM andIO route may of practical value IO route may of practical valueIO route may of practical valuein a mass casualty situation. in a mass casualty situation.in a mass casualty situation. Children may require… MORE RESOURCESMORE RESOURCES Children may require… MORE RESOURCESMORE RESOURCES Differences • •• Developmental/Psychological Developmental/PsychologicalDevelopmental/Psychological Immaturity ImmaturityImmaturity • •• Lack of comprehension of situation Lack of comprehension of situationLack of comprehension of situation • •• May go towards danger because it is May go towards danger because it isMay go towards danger because it is interesting interestinginteresting • •• Cannot follow group directives Cannot follow group directivesCannot follow group directives • •• Group decontamination may not be feasible Group decontamination may not be feasibleGroup decontamination may not be feasible • •• Need continuous psychological support Need continuous psychological supportNeed continuous psychological support • •• Need more resources/personnel to care for Need more resources/personnel to care forNeed more resources/personnel to care for children. children.children. Differences • •• Children with Special Health Care Needs Children with Special Health Care NeedsChildren with Special Health Care Needs and Technologically dependant children and Technologically dependant childrenand Technologically dependant children • •• Survival may be based on ventilators, IV Survival may be based on ventilators, IVSurvival may be based on ventilators, IV nutrition, etc nutrition, etcnutrition, etc… …… • •• Will require stockpiling of equipment and Will require stockpiling of equipment andWill require stockpiling of equipment and medications specific to children medications specific to childrenmedications specific to children Children may require… DIFFERENT RESOURCESDIFFERENT RESOURCES Children may require… DIFFERENT RESOURCESDIFFERENT RESOURCES Triage? Triage? START Triage RESPIRATIONS NO YESYES Non- salvageable Immediate Position Airway NO YESYES Over 30/min Immediate Under 30/min PERFUSION Cap refill > 2 sec Control Bleeding ImmediateImmediate Cap refill < 2 sec. MENTAL STATUS Failure to follow simple commands Can follow simple commands ImmediateImmediate DelayedDelayed START Triage RESPIRATIONS NO YESYES Non- salvageable Immediate Position Airway NO YESYES Over 30/min Immediate Under 30/min PERFUSION Cap refill > 2 sec Control Bleeding ImmediateImmediate Cap refill < 2 sec. MENTAL STATUS Failure to follow simple commands Can follow simple commands ImmediateImmediate DelayedDelayed The JumpSTART Field Pediatric Multicasualty Triage System ฉ (Patients aged 1-8ears) respirations? NOOpen airway respirations? YESIMMEDIATE NODECEASED YESPeripheral pulse? YESPerform 15 sec. Mouth to Mask Ventilations Spontaneous respirations? YESIMMEDIATE NODECEASED NOCheck resp. rate < 15/min or > 40/min or irregular IMMEDIATE 15 -40/ min, regular Peripheral pulse? NOIMMEDIATE YESCheck mental status (AVPU) A V P (appropriate) DELAYED P (inappropriate) U IMMEDIATE ฉ Lou Romig MD, FAAP, FACEP, 1995 The JumpSTART Field Pediatric Multicasualty Triage System ฉ (Patients aged 1-8ears) respirations? NOOpen airway respirations? YESIMMEDIATE NODECEASED YESPeripheral pulse? YESPerform 15 sec. Mouth to Mask Ventilations Spontaneous respirations? YESIMMEDIATE NODECEASED NOCheck resp. rate < 15/min or > 40/min or irregular IMMEDIATE 15 -40/ min, regular Peripheral pulse? NOIMMEDIATE YESCheck mental status (AVPU) A V P (appropriate) DELAYED P (inappropriate) U IMMEDIATE ฉ Lou Romig MD, FAAP, FACEP, 1995 What are some of the key gaps? What are some of the key gaps? Identification and Reunification Identification and Reunification Identification and Reunification of Children After a Mass Casualty Incident • ••Requires means of rapidly collecting Requires means of rapidly collectingRequires means of rapidly collecting information on arriving casualties (e.g., information on arriving casualties (e.g.,information on arriving casualties (e.g., digital photos) digital photos)digital photos) • ••Photo indexing Photo indexingPhoto indexing • ••Site where arriving parents can review Site where arriving parents can reviewSite where arriving parents can review photos photosphotos • ••System for presenting select photos System for presenting select photosSystem for presenting select photos Sheltering Sheltering Pediatric Sheltering Issues • •• Is it child safe? Is it child safe?Is it child safe? • •• Who will supervise the children? Who will supervise the children?Who will supervise the children? • •• Does the shelter have the correct equipment Does the shelter have the correct equipmentDoes the shelter have the correct equipment • •• Can families stay together? Can families stay together?Can families stay together? Pediatric Shelter Considerations NUTRITION, SLEEPING ARRANGEMENTS, AND RECREATIONAL AND THERAPEUTIC ACTIVITIES APPROPRIATE FOR AGE AND STAGE OF DEVELOPMENT Appropriate hygiene/waste disposal resources Basic health screening to ensure appropriate levels of available care Safety and supervision of children around frail adults (including preventing access of children to medications) Security of unattended or unsupervised minors Availability of medical information resources (computers, posters, phone referral lines, etc) to aid in appropriate use of medical resources Standardized health care data collection Environmental considerations (smoking, alcohol, other drugs, weapons) Secure transportation within the shelter and the medical care and resources system (transportation of shelter occupants must include appropriate official supervision of and accountability for unattended minors) Arrangements for children with special health care needs, including providing for patients on long-term medications without affecting local emergency care resources Pediatric Shelter Considerations NUTRITION, SLEEPING ARRANGEMENTS, AND RECREATIONAL AND THERAPEUTIC ACTIVITIES APPROPRIATE FOR AGE AND STAGE OF DEVELOPMENT Appropriate hygiene/waste disposal resources Basic health screening to ensure appropriate levels of available care Safety and supervision of children around frail adults (including preventing access of children to medications) Security of unattended or unsupervised minors Availability of medical information resources (computers, posters, phone referral lines, etc) to aid in appropriate use of medical resources Standardized health care data collection Environmental considerations (smoking, alcohol, other drugs, weapons) Secure transportation within the shelter and the medical care and resources system (transportation of shelter occupants must include appropriate official supervision of and accountability for unattended minors) Arrangements for children with special health care needs, including providing for patients on long-term medications without affecting local emergency care resources Surge Planning Surge Planning What is Pediatric Surge? • ••Secondary Victims Secondary VictimsSecondary Victims • ••Proportion of normal census Proportion of normal censusProportion of normal census • ••Uniquely Pediatric Event Uniquely Pediatric EventUniquely Pediatric Event • ••Out of proportion to normal census Out of proportion to normal censusOut of proportion to normal census • ••School, day care, school bus, camp School, day care, school bus, campSchool, day care, school bus, camp • •• Family Unit Family UnitFamily Unit • ••Ability to care for family without separating Ability to care for family without separatingAbility to care for family without separating children and adults children and adultschildren and adults Pediatric Surge Planning • •• Address pediatrics out of proportion to normal Address pediatrics out of proportion to normalAddress pediatrics out of proportion to normalnumbers numbersnumbers • ••Emergency Operations Plans Emergency Operations PlansEmergency Operations Plans • ••Providers ProvidersProviders • ••Equipment, pharmaceuticals Equipment, pharmaceuticalsEquipment, pharmaceuticals • ••Drills and exercises Drills and exercisesDrills and exercises • ••Plans for care of children Plans for care of childrenPlans for care of children • ••Adult Providers Adult ProvidersAdult Providers • •• Adult Units Adult UnitsAdult Units • •• Adult Equipment Adult EquipmentAdult Equipment • ••Plans for care of adults in pediatric units Plans for care of adults in pediatric unitsPlans for care of adults in pediatric units Pediatric Resources Pediatric Resources Pediatric Specific Resources •• ProvidersProviders •• MedicationsMedications •• EquipmentEquipment •• TriageTriage •• Treatment ProtocolsTreatment Protocols Pediatric Specific Resources •• ProvidersProviders •• MedicationsMedications •• EquipmentEquipment •• TriageTriage •• Treatment ProtocolsTreatment Protocols Decontamination Decontamination Example: The Chemical Contaminated Casualty Example: The Chemical Contaminated Casualty Contaminated Casualty Victims Current Status • •• Most Hospitals Have Minimal Most Hospitals Have MinimalMost Hospitals Have Minimal Decontamination Capability Decontamination CapabilityDecontamination Capability • ••HazMat Teams Are Supposed HazMat Teams Are SupposedHazMat Teams Are Supposed to Decontaminate Patients at to Decontaminate Patients atto Decontaminate Patients at the Incident Site the Incident Sitethe Incident Site • ••Decontaminated Patients Then Decontaminated Patients ThenDecontaminated Patients Then Transported to Health Care Transported to Health CareTransported to Health Care Facilities for Treatment Facilities for TreatmentFacilities for Treatment • ••No Contaminated Patients Are No Contaminated Patients AreNo Contaminated Patients Are Expected to Arrive at the Expected to Arrive at theExpected to Arrive at the Hospital HospitalHospital Tokyo March 20, 1995 • ••5,500 People Exposed 5,500 People Exposed5,500 People Exposed • ••3,227 Went to Hospital 3,227 Went to Hospital3,227 Went to Hospital • ••550 Transported Via EMS 550 Transported Via EMS550 Transported Via EMS • •• Essentially no Essentially noEssentially no Decontamination of Decontamination ofDecontamination of Patients PatientsPatients Sarin Secondary Contamination • ••11 ED physicians were affected by Sarin 11 ED physicians were affected by Sarin11 ED physicians were affected by Sarin carried into the ED by victims carried into the ED by victimscarried into the ED by victims • ••Once the victims were forced to remove Once the victims were forced to removeOnce the victims were forced to remove their clothing before entering the ED, no their clothing before entering the ED, notheir clothing before entering the ED, no further ED staff affected further ED staff affectedfurther ED staff affected What about pediatric decontamination? Where does an infant go? What about pediatric decontamination? Where does an infant go? Decontamination Pediatric Considerations • •• Water pressure Water pressureWater pressure • •• Will it injure a child? Will it injure a child?Will it injure a child? • •• Water temperature Water temperatureWater temperature • •• If water is not warm: may cause hypothermia If water is not warm: may cause hypothermiaIf water is not warm: may cause hypothermia • •• Non NonNon- --ambulatory child ambulatory childambulatory child • •• Infants, toddlers Infants, toddlersInfants, toddlers • •• Children with special healthcare needs Children with special healthcare needsChildren with special healthcare needs • •• Mental health concerns Mental health concernsMental health concerns • •• Will children follow instructions Will children follow instructionsWill children follow instructions • •• Long term effects Long term effectsLong term effects WMD Antidotes WMD Antidotes Mark-1 Auto-Injector • ••Standard antidote for nerve agent Standard antidote for nerve agentStandard antidote for nerve agent exposure exposureexposure • ••Deployed in most hospitals and Deployed in most hospitals andDeployed in most hospitals andEMS systems EMS systemsEMS systems • ••What about children? What about children?What about children? • ••Manufacturer makes pediatric Manufacturer makes pediatricManufacturer makes pediatricmodel for Israel and other model for Israel and othermodel for Israel and other countries countriescountries • ••Not FDA approved Not FDA approvedNot FDA approved • •• Dosage is safe for most Dosage is safe for mostDosage is safe for mostchildren based on data from children based on data fromchildren based on data from organophosphate poisoning organophosphate poisoningorganophosphate poisoning Pediatric Dosage AtroPenฎ Key Points • •• AtroPen AtroPenAtroPen ฎ ฎฎ is isis only onlyonly ฝ ฝฝ of a Mark of a Markof a Mark- -- I Kit I KitI Kit • •• Does not include pralidoxime. Does not include pralidoxime.Does not include pralidoxime. • •• Pralidoxime should be added for Pralidoxime should be added forPralidoxime should be added for appropriate treatment of nerve agent appropriate treatment of nerve agentappropriate treatment of nerve agent exposure. exposure.exposure. • •• Complete treatment will require the Complete treatment will require theComplete treatment will require the usage of anticonvulsants usage of anticonvulsantsusage of anticonvulsants • •• Creates operational issues Creates operational issuesCreates operational issues AtroPen Recommendations The Mark 1 Kit should remain as the The Mark 1 Kit should remain as theThe Mark 1 Kit should remain as the preferred emergency treatment for children of preferred emergency treatment for children ofpreferred emergency treatment for children of any age. any age.any age. This recommendation includes using the This recommendation includes using theThis recommendation includes using the Mark 1 Kit in children younger than 3 Mark 1 Kit in children younger than 3Mark 1 Kit in children younger than 3 years old after bona fide nerve agent years old after bona fide nerve agentyears old after bona fide nerve agent exposure. exposure.exposure. School Planning School Planning Preparedness & The Schools • •• Preparedness planning Preparedness planningPreparedness planning • ••Coping and resiliency Coping and resiliencyCoping and resiliency issues for teachers and issues for teachers andissues for teachers and students studentsstudents • ••Special issues: KI, what Special issues: KI, whatSpecial issues: KI, what to stockpile, syndromic to stockpile, syndromicto stockpile, syndromic surveillance surveillancesurveillance • •• Communications with Communications withCommunications with parents parentsparents Questions? Questions? Key Reference Web Sites • •• Know your resources: Know your resources:Know your resources: • •• Center for Disaster Medicine Center for Disaster MedicineCenter for Disaster Medicine • •• www.nymc.edu/cdm www.nymc.edu/cdmwww.nymc.edu/cdm • •• AAP AAPAAP • •• www.aap.org/terrorism www.aap.org/terrorismwww.aap.org/terrorism • •• CDC CDCCDC • •• www.bt.cdc.gov www.bt.cdc.govwww.bt.cdc.gov • •• ARC ARCARC • •• www.redcross.org www.redcross.orgwww.redcross.org