TABLE 132.7
PHARMACEUTICAL STOCKING ESTIMATES FOR ONE
EMERGENCY DEPARTMENT IN A HYPOTHETICAL CHEMICAL
AGENT ATTACK a
Agent/antidote

Pediatric dose

Adult dose

Total
requirement (for
500 patients)

Nerve agents
Atropine

0.02–0.05 mg/kg 2–5 mg
(minimum dose,
0.1 mg)

Pralidoxime

25–50 mg/kg

1–2 g

1 ampule 30 sec
out of every
minute
0.33 mL/kg (for

Hgb 12 g/dL)
1.65 mL/kg

1 amp
10 mL

1,500 ampules
4,575 mL

50 mL

25,000 mL = 500
vials (50 mL
each)
2,138 g

Cyanide
Amyl nitrite
Na nitrite (3%)

Na thiosulfate
(25%)

Hydroxocobalamin 70 mg/kg

5g

6,875 mg = 17,188
amps (1 mL of
0.4 mg/mL);

859 vials (20
mL of 0.4
mg/mL)
1,875 g = 1,875
vials (1 g each)

Note: Cyanide treatment would require either 375 nitrite/thiosulfate-based or 428 hydroxocobalamin-based
cyanide antidote kits.
a Assumptions: 500 patients to one emergency department (as per one hospital’s experience in the Tokyo
sarin attack); one-half of the patients are children with average weight of 10 kg; if nerve-agent attack, severe
exposure necessitating maximal doses of atropine and pralidoxime; five atropine doses over 12 hrs; three
pralidoxime doses over 12 hrs; if cyanide attack, severe exposure necessitating initial full dose of Na
nitrite/Na thiosulfate, or hydroxocobalamin, followed by 50% of initial dose × 1.
Na, sodium; Hgb, hemoglobin.

CONCLUSION


The prospect of a mass casualty incident from a terrorist release of biologic or
chemical agents is more likely now than ever before. Although the impact of such
an event is almost unimaginable, at the same time, efforts must be made to
prepare for this possibility. Such preparedness requires highly coordinated
responses involving local and regional EMS systems, HAZMAT teams, police
and fire departments, hospital EDs, local and federal public health agencies, and
civilian and military medical specialists. In particular, EDs must consider
important issues, including (i) the early recognition, triage, stabilization,
decontamination, treatment, and disposition of multiple casualties of such an
attack; (ii) protection of healthcare workers and existing patients; and (iii) the
integrity of the ED itself to provide ongoing care to later-arriving casualties and
to continue to meet normal patient demands. Fortunately, our pediatric emergency

care providers, academic medical centers, regional health departments, and
several federal agencies, including the U.S. Departments of Health and Human
Services, Homeland Security, and Defense, are actively engaged in confronting
these vital public health and national security challenges.
Suggested Readings and Key References
General
American Academy of Pediatrics. Chemical and biological terrorism and its
impact on children: a subject review. Pediatrics 2000;105:662–670.
Henretig F. Biological and chemical terrorism defense: a view from the “front
lines” of public health. Am J Public Health 2001;91:718–720.
Henretig FM, Cieslak TJ, Eitzen EM Jr. Biological and chemical terrorism. J
Pediatr 2002;141:311–326.
Henretig FM, McKee MR. Preparedness for acts of nuclear, biological and
chemical terrorism. In: Gausche Hill M, Fuchs S, Yamamoto L, eds. APLS:
The Pediatric Emergency Medicine Resource. Sudbury, MA: Jones and
Bartlett, American Academy of Pediatrics and American College of
Emergency Physicians; 2004:568–591.
Macintyre AG, Christopher GW, Eitzen E Jr, et al. Weapons of mass destruction
events with contaminated casualties: effective planning for health care
facilities. JAMA 2002;83:242–249.
Biologic Terrorism
Breman JG, Henderson DA. Diagnosis and treatment of smallpox. N Engl J Med
2002;346:1300–1308.


Christopher GW, Cieslak TJ, Pavlin JA, et al. Biological warfare: a historical
perspective. JAMA 1997;278:412–417.
Fine AM, Wong JB, Fraser HS, et al. Is it influenza or anthrax? A decision
analytic approach to the treatment of patients with influenza-like illness. Ann
Emerg Med 2004;43:318–328.

Franz DR, Jahrling PB, Friedlander AM, et al. Clinical recognition and
management of patients exposed to biological warfare agents. JAMA
1997;278:399–411.
Henretig FM, Cieslak TJ, Kortepeter MG, et al. Medical management of the
suspected victim of bioterrorism: an algorithmic approach to the
undifferentiated patient. Emerg Med Clin North Am 2002;20:351–364.
White S, Henretig F, Dukes R. Vulnerable populations in the setting of
bioterrorism. Emerg Med Clin North Am 2002;20:365–392.
Chemical Terrorism
Brennan RJ, Waeckerle JF, Sharp T, et al. Chemical warfare agents: emergency
medical and emergency public health issues. Ann Emerg Med 1999;34:191–
204.
Occupational Safety and Health Administration. OSHA best practices for
hospital-based first receivers of victims from mass casualty incidents involving
the
release
of
hazardous
substances.
Available
online
at
/>Rotenberg JS, Newmark J. Nerve agent attacks on children: diagnosis and
management. Pediatrics 2003;112:648–658.
Sofer S, Tal A, Shahak E. Carbamate and organophosphate poisoning in early
childhood. Pediatr Emerg Care 1989;5:222–225.
Yu CE, Burklow TR, Madsen JM. Vesicant agents and children. Pediatr Ann
2003;32:254–257.
____________
*


The views, opinions, assertions, and findings contained herein are those of the authors and should not be
construed as official U.S. Department of Defense or Department of the Army positions, policies, or decisions
unless so designated by other documentation.


CHAPTER 133 ■ INSTRUCTIONS FOR
PARENTS
HILARY A. HEWES, NANETTE C. DUDLEY

DISCHARGE INSTRUCTIONS
Discharge instructions are an integral part of the emergency department
(ED) experience. Well-designed instructions serve as a summary of the ED
course and a reference for ongoing medical management by the patient and
outpatient care provider. In addition, review of instructions at discharge
offers a final opportunity for a patient to clarify any questions or concerns
about care received or the follow-up plan. Information given to the patient
and family needs to be provided in an understandable and retainable
manner. Lack of comprehension of discharge instructions may lead to
problems with compliance, incorrect use of medication, inadequate
treatment and follow-up, and ultimately negative patient outcomes.

LEGAL AND REGULATORY CONSIDERATIONS
The Centers for Medicare and Medicaid Services (CMS) measures specific
elements in the transition record at hospital discharge. Although obviously
not specific to ED care, these recommendations can be adapted to ED
discharge instruction content:
1. Discharge diagnosis
2. Procedures and tests performed, with significant findings, and any pending
tests

3. Medications prescribed/changes to medications, reasons for medication
4. Patient and family instructions
5. Reasons to follow up with primary care provider or specialist and reasons
to return to the ED
6. Follow up physician’s name, specialty, and contact information

Meaningful Use
Beginning in 2011, the CMS initiated a voluntary financial incentive plan
for the “meaningful use” of certified electronic health record technology by