Pediatric emergency medicine trisk 4544 4544
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from the suspected route of exposure, presence of infected or dying animals, and
the discovery of suspicious actions or potential delivery systems.
Most of the primary biologic threat agents can be categorized as causing the
subacute onset of effects (e.g., days after exposure); those effects can be divided
into predominantly respiratory, neurologic, or dermatologic syndromes. Thus,
with a careful medical and epidemiologic history, physical examination, and
limited, routine laboratory evaluation, an early suspicion of a biologic attack
might be raised, and initial diagnostic impression considered, as outlined in
Figure 132.1 . This in turn could trigger appropriate requests for infectious
disease consultation and more definitive laboratory testing, as well as early
empiric therapy. A similar approach, applied in the setting of unusual increases in
patient volume or illness presentations, might also help practitioners to participate
in the early recognition of a new or reemerging natural infectious disease (e.g.,
West Nile disease, severe acute respiratory syndrome [SARS], Middle East
Respiratory Syndrome [MERS], monkeypox, Ebola, and pneumonic tularemia, to
name some recent examples). If a pediatrician or emergency medicine physician
recognizes, or even suspects, any such natural or intentional outbreak, immediate
reporting to local and regional public health authorities is appropriate, even
before a specific diagnosis can be confirmed.
Triage Considerations: Minimizing Spread of Infection
As soon as ED staff suspect that a patient may be the victim of biologic terrorism,
appropriate steps must take place to prevent or minimize exposure to limit the
spread of disease. The level of ED mitigation and preparedness activities will
largely depend on the level of awareness of the disease outbreak. For example,
faced with a known release of smallpox by terrorists, EDs would need to take
dramatic steps to protect staff and patients. Such steps might include setting up
screening stations outside of the hospital, staffed by clinicians wearing gowns,
gloves, N-95 respirators, and eye protection. If a child suspected to have smallpox
were encountered at the screening station, he or she would need to be covered
with a sheet, provided a mask, and escorted directly to a negative-pressure room
for further evaluation and treatment. Infection Prevention and Control specialists
would need to provide guidance on specimen collection, handling, and testing.
Patients suspected to have smallpox should be moved to a specialized
biocontainment facility as soon as possible. In the event of a large outbreak, when
the supply of scarce biocontainment beds is likely to be exhausted, airborne
infection isolation rooms might be an acceptable alternative. Should these also
prove inadequate for the number of affected patients, the cohorting of patients in
designated “smallpox wards” might be necessary.
