Pediatric considerations in chemical exposures: are we prepared?

Disaster Preparedness: Hospital Decontamination and the Pediatric Patient— Guidelines for Hospitals and Emergency Planners

In recent years, attention has been given to disaster preparedness for first responders and first receivers (hospitals). One such focus involves the decontamination of individuals who have fallen victim to a chemical agent from an attack or an accident involving hazardous materials. Children often are overlooked in disaster planning. Children are vulnerable and have specific medical and psychological requirements. There is a need to develop specific protocols to address pediatric patients who require decontamination at the entrance of hospital emergency departments. Currently, there are no published resources that meet this need. An expert panel convened by the New York City Department of Health and Mental Hygiene developed policies and procedures for the decontamination of pediatric patients.The panel was comprised of experts from a variety of medical and psychosocial areas.Using an iterative process, the panel created guidelines that were approved by the stakeholders and are presented in this paper.These guidelines must be utilized, studied, and modified to increase the likelihood that they will work during an emergency situation.

Pediatric emergency preparedness training: are we on a path toward national dissemination?

BACKGROUND

Emergency preparedness training is crucial for all health professionals, but the physiologic, anatomic, and psychologic differences between children and adults necessitates that health professionals receive training specific to pediatric emergencies. Before a standardized, nationally disseminated pediatric curriculum can be developed or endorsed, evidence-based evaluations of short- and long-term outcomes need to be conducted.

METHODS

A review of literature was conducted to identify developed courses and any evaluation of these courses.

RESULTS

Much has been published that supports the need for pediatric emergency preparedness, and many resources have been developed. However, very little literature presents evaluations of training courses.

DISCUSSION

To achieve evidence-based pediatric emergency preparedness training, existing training programs must be evaluated, standardized training guidelines need to be developed, and critical components of pediatric disaster response need to be captured in the academic literature.

Pediatric issues in disaster preparedness: meeting the educational needs of nurses-are we there yet?

Children have unique physical, emotional, and developmental needs making them particularly vulnerable during disasters. Most existing disaster preparedness courses lack a pediatric perspective. This article describes a pediatric disaster preparedness program presented to pediatric nurses in an urban, Level 1 trauma center. Survey results from the participants prior to the program revealed a lack of awareness of pediatric issues. Although the program resulted in an immediate improvement in awareness, retention fell back to precourse levels 2 years later. We conclude that pediatric disaster preparedness training should be integrated into hospital nursing curriculum on a regular basis.

Prehospital preparedness for pediatric mass-casualty events

OBJECTIVES

Recent events have reiterated the need for well-coordinated planning for mass-casualty events, including those that involve children. The objective of this study was to document the preparedness of prehospital emergency medical services agencies in the United States for the care of children who are involved in mass-casualty events.

METHODS

A national list of all licensed prehospital emergency medical services agencies was prepared through contact with each state's emergency medical services office. A survey was mailed to 3748 emergency medical services agencies that were selected randomly from the national list in November 2004; a second survey was mailed to nonresponders in March 2005. Descriptive statistics were used to describe study variables.

RESULTS

Most (72.9%) agencies reported having a written plan for response to a mass-casualty event, but only 248 (13.3%) reported having pediatric-specific mass-casualty event plans. Most (69%) services reported that they did not have a specific plan for response to a mass-casualty event at a school. Most (62.1%) agencies reported that their mass-casualty event plan does not include provisions for people with special health care needs. Only 19.2% of the services reported using a pediatric-specific triage protocol for mass-casualty events, and 12.3% reported having a pediatrician involved in their medical control. Although most (69.3%) agencies reported participation in a local or regional disaster drill in the past year, fewer than half of those that participated in drills (49.0%) included pediatric victims.

CONCLUSIONS

Although children are among the most vulnerable in the event of disaster, there are substantial deficiencies in the preparedness plans of prehospital emergency medical services agencies in the United States for the care of children in a mass-casualty event.

Antidotes for nerve agent poisoning: should we differentiate children from adults?

PURPOSE OF REVIEW

Chemical terrorism presents a threat to the civilian population, including children. Nerve agent antidotes are available in prepackaged autoinjectors that can be delivered rapidly following an exposure. The published evidence on the use of nerve agent antidotes consists of case reports, extrapolation from pediatric organophosphate poisonings, and expert opinion. This review examines the evidence supporting the use of nerve agent antidotes in children.

RECENT FINDINGS

The use of adult formulated atropine and pralidoxime autoinjectors will deliver doses above current recommendations for infants and children. Data demonstrate, however, that atropine overdose is generally well tolerated in young children. Children symptomatic of nerve agent poisoning will likely need both supraphysiologic doses and frequent re-dosing of atropine.

SUMMARY

Based on limited data, the Mark 1 autoinjector kit (Meridian Medical Technologies, Columbia, Maryland, USA) appears to be the most efficacious antidote delivery system following a nerve agent attack. Symptomatic children under 1 year of age should be given a full atropine dose from the Atropen (Meridian Medical Technologies) (0.5 mg) or Mark 1 kits (2 mg), while children over 1 year of age should be given a full dose of both atropine and pralidoxime from the Mark 1 kit when more accurate weight-based dosing of antidotes is impossible.

Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs

Confirmed cases of childhood exposure to cyanide are rare despite multiple potential sources including inhalation of fire smoke, ingestion of toxic household and workplace substances, and ingestion of cyanogenic foods. Because of its infrequent occurrence, medical professionals may have difficulty recognizing cyanide poisoning, confirming its presence, and treating it in pediatric patients. The sources and manifestations of acute cyanide poisoning seem to be qualitatively similar between children and adults, but children may be more vulnerable than adults to poisoning from some sources. The only currently available antidote in the United States (the cyanide antidote kit) has been used successfully in children but has particular risks associated with its use in pediatric patients. Because hemoglobin kinetics vary with age, methemoglobinemia associated with nitrite-based antidotes may be excessive at standard adult dosing in children. A cyanide antidote with a better risk/benefit ratio than the current agent available in the United States is desirable. The vitamin B12 precursor hydroxocobalamin, which has been used in Europe, may prove to be an attractive alternative to the cyanide antidote kit for pediatric patients. In this article we review the available data on the sources, manifestations, and treatment of acute cyanide poisoning in children and discuss unmet needs in the management of pediatric cyanide poisoning.

Recognition of illness associated with covert chemical releases

Public health threats from intentional releases of chemicals into the environment (ie, chemical terrorism) are an increasing concern in the United States. Recent situations of deliberate contamination of food and beverages with chemicals highlight the need for health care providers and public health officials to be alert for adult and pediatric patients in their communities who have signs and symptoms consistent with chemical exposures. In an effort to increase knowledge of surveillance and preparedness for illness related to potential chemical releases, we provide guidance to health care providers and public health personnel for recognizing illnesses or patterns of illnesses that might be associated with the intentional, covert release of chemical agents. In this article, we will discuss 5 examples of outbreaks of illnesses after a covert chemical release, obstacles to recognition of these illnesses, clues (ie, epidemiological patterns and syndromic presentations) that might enhance the recognition of illnesses from a covert chemical release, and public health strategies to enhance the rapid identification of a chemical terrorism event.

The effects of weapons of mass destruction on children

PURPOSE

Children are especially vulnerable to the effects of chemical and biological weapons of mass destruction (WMD) because of physiologic, pharmacologic, and developmental characteristics. Presentation of signs and symptoms of exposure to biological and chemical agents are similar to those seen in adults. Pediatric considerations for decontamination and treatment of child victims of biological and chemical agents are discussed.

CONCLUSION

As front-line providers, nurses need to be aware of potential agents, their uses and effects as WMD, and recommended treatments.

PRACTICE IMPLICATIONS

Understanding the additional physiologic and situational needs of children, nurses can optimize the survival and outcomes of children when disaster strikes.

Pediatric nerve agent poisoning: medical and operational considerations for emergency medical services in a large American city

Most published recommendations for treatment of pediatric nerve agent poisoning are based on standard resuscitation doses for these agents. However, certain medical and operational concerns suggest that an alternative approach may be warranted for treatment of children by emergency medical personnel after mass chemical events. (1) There is evidence both that suprapharmacological doses may be warranted and that side effects from antidote overdosage can be tolerated. (2) There is concern that many emergency medical personnel will have difficulty determining both the age of the child and the severity of the symptoms. Therefore, the Regional Emergency Medical Advisory Committee of New York City and the Fire Department, City of New York, Bureau of Emergency Medical Services, in collaboration with the Center for Pediatric Emergency Medicine of the New York University School of Medicine and the Bellevue Hospital Center, have developed a pediatric nerve agent antidote dosing schedule that addresses these considerations. These doses are comparable to those being administered to adults with severe symptoms and within limits deemed tolerable after inadvertent nerve agent overdose in children. We conclude that the above approach is likely a safe and effective alternative to weight-based dosing of children, which will be nearly impossible to attain under field conditions.