Pediatric emergency medicine trisk 1133
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Video 131.1 Color flow Doppler.
Video 131.2 RUQ normal.
Video 131.3 RUQ positive.
Video 131.4 LUQ normal.
Video 131.5 LUQ positive.
Video 131.6 Bladder sag normal.
Video 131.7 Bladder sag pos.
Video 131.8 Subxiphoid pericardial effusion.
Video 131.9 Parasternal long normal.
Video 131.10 Parasternal short normal.
Video 131.11 Lung sliding normal.
Video 131.12 Lung sliding pneumothorax.
Video 131.13 Pleural effusion.
Video 131.14 Pleural effusion with loculations.
Video 131.15 Early IUP with gestational sac.
Video 131.16 Late IUP with cardiac activity.
Video 131.17 Hydronephrosis.
Video 131.18 Intussusception transverse.
Video 131.19 Intussusception longitudinal.
Video 131.20 Appendicitis transverse.
Video 131.21 Internal jugular vein collapsing with pressure.
Video 131.22 Brachial vessels.
Video 131.23 Color Doppler pulsating.
Video 131.24 Femoral vessels with color Doppler, artery (L), vein (R).
Video 131.25 Cannulation of vessel in long access (Blue Phantom).
Video 131.26 Cannulation of vessel in short access (Blue Phantom).
Video 131.27 Bladder and intra-abdominal free fluid.
Video 131.28 Neonatal spine in short axis.
Video 131.29 Neonatal spine in long axis.
Video 131.30 Abscess.
Video 131.31 Lymph node.
CHAPTER 132 ■ BIOLOGICAL AND CHEMICAL
TERRORISM *
RICHARD J. SCARFONE, JAMES M. MADSEN, THEODORE J. CIESLAK, EDWARD M. EITZEN
JR.
GOALS OF EMERGENCY CARE
Biologic and chemical terrorism involves the use of highly virulent or toxic
agents with the intent to cause mass casualties, which could overwhelm regional
emergency medical services (EMS) capacity and would pose unique medical
management challenges. Treatment goals include early syndrome recognition,
understanding specific pediatric vulnerabilities, and knowing the major biologic
and chemical agents of concern and the management of children exposed to them.
KEY POINTS
Even small-scale, technologically primitive biologic or chemical attacks
can cause considerable morbidity and wreak havoc on regional medical
care systems, thereby successfully terrorizing a population. Examples
include the intentional spread of salmonella in The Dalles, Oregon
restaurants in 1984; the 1995 sarin release on Tokyo subways; and the
anthrax release in U.S. mail in 2001.
Chemical attacks can (but do not necessarily) result in almost
immediate effects, whereas biologic attacks evolve over days to weeks
based on the incubation period of the infectious agent used.
Compared to adults, children have several unique vulnerabilities that
will be detailed throughout the chapter, including the following:
Risk of exposure—increased respiratory and dermal exposures
Physiologic response—increased risk of dehydration and hypothermia
Psychological response—less ability to cope with stress and
emotional trauma
Systems vulnerabilities—EMS and ED providers may have less
experience taking care of children
RELATED CHAPTERS
Signs and Symptoms
Coma: Chapter 17
Respiratory Distress: Chapter 71
Seizures: Chapter 72
Medical, Surgical, and Trauma Emergencies
Environmental Emergencies, Radiological Emergencies, Bites and
Stings: Chapter 90
Infectious Disease Emergencies: Chapter 94
Pulmonary Emergencies: Chapter 99
Toxicologic Emergencies: Chapter 102
BIOLOGIC AGENTS
CLINICAL PEARLS AND PITFALLS
Biologic attacks should be suspected when there are an unusually high
number of cases, a common exposure history, and exotic disease
presentations.
Ciprofloxacin, levofloxacin, and doxycycline are currently considered
drugs of choice in the treatment and prophylaxis of anthrax, plague,
and tularemia, even in children ( Tables 132.1 and 132.2 ).
Current Evidence
A working group convened by the Centers for Disease Control and Prevention
(CDC) identified anthrax, smallpox, plague, botulism, tularemia, and the viral
hemorrhagic fevers as the biologic exposures that would constitute the gravest
threats to public health and security; the causative microorganisms and toxins are
termed Category A agents. We thus limit our focus here to these six agents (
Tables 132.3A and 132.3B ). In addition, we add a brief discussion of the
phytotoxin (plant toxin) ricin because of its ready availability and ease of
production. Treatment protocols for these uncommon conditions are likely to
evolve continuously, particularly if future incidents occur, as was the case when
the mail-borne anthrax outbreak unfolded.
Of note, the fluoroquinolones and/or tetracyclines are currently considered
drugs of choice in the treatment and prophylaxis of anthrax, plague, and
tularemia. Although these have often been avoided by pediatricians in the past,
