Review
Copyright ©2014 Baishideng Publishing Group Co.
World J Crit Care Med. Feb 4, 2014; 3(1): 15-23
Published online Feb 4, 2014. doi: 10.5492/wjccm.v3.i1.15
Table 1 Pediatric specific vulnerabilities to terrorist attacks
VulnerabilityBlast InjuryBiological agentsChemical agents
Proximity to groundAgents settle to the groundAgents tend to pool in lower areas
Increased minute ventilationIncreased exposure to inhaled agentsIncreased exposure to inhaled agents
Provider unfamiliarity with pediatric dosing of medicationsDosing of antibiotics differentNo prepackaged store of antidotes in pediatric doses
Lack of knowledge or inability to flee dangerEither unaware or unable to flee from explosion Potentially curious about ordinanceUnlikely to recognize signs/symptoms of biologic agentsWould not know to flee from strange odor or seek medical help with symptoms
Lack of stockpile of pediatric dosed antidotes and vaccinesPrepackaged stockpiles of vaccines and antidotes not dosed for small children[32]Lack of guidelines for dosing of antidotes in children
Less blood volume/physiologic reserveMore rapidly develop life threatening blood lossProne to dehydration with illness. Lower functional residual capacityMore prone to respiratory distress/failure with nerve agents, vesicants, and pulmonary agents
Thinner skinFaster absorbtion of agents
Increased BSA to mass ratioProne to hypothermia during triage, evacuation and treatmentProne to hypothermia with decontamination
Developmental immaturityUnable to follow mental status exam/communicate other injuries earlyPresent later in the course of biologic agentsUnable to promptly communicate symptoms
Increased head size compared to bodyIncreased head AIS when compared to adults[2]
Table 2 Management of chemical agents
AgentPediatric dosingNotes
Nerve agentsAtropine 0.05 mg/kg iv or im q 2-5 min (max 5 mg) Pralidoxime 25 mg/kg iv or im q 1 h (max 1 g iv or 2 g im) Benzodiazepines: Midazolam im 0.2 mg/kg (max 10 mg) (1st choice) Lorazepam iv/im 0.1 mg/kg (max 4 mg) Diazepam iv 0.3 mg/kg (max 10 mg)Atropine should be repeated for persistent symptoms
CyanideHydroxocobalamin 70 mg/kg (max 5 g) or sodium nitrate; 0.33mL/kg iv (max 10 mL) followed by sodium thiosulfate (25%) 1.65 mL/kg iv (max 50 mL)Hydroxocobalamin may be repeated × 1 if needed
Table 3 Guidelines for the use of Mark I kits in pediatric patients
Pediatric patientsMark I kits
3-7 yr (approximately 13-25 kg)One Mark I kit as maximum dose
8-14 yr (approximately 26-50 kg)Two Mark I kits as maximum dose
> 14 yr (approximately > 51 kg)Three Mark I kits as maximum dose
Table 4 Management of biologic agents
AgentPediatric dosingNotes
Inhalational anthraxCiprofloxacin 10-15 mg/kg iv q 12 h (max 400 mg) or doxycycline 2.2 mg/kg iv q 12 h (max 100 mg) plus clindamycin 10-15 mg/kg q 8 plus penicillin G 400-600 k U/kg per day iv divided q 4 h prophylaxis for exposed contacts ciprofloxacin 15 mg/kg po q 12 h or doxycycline 2.2 mg/kg po q 12 hSwitch to oral therapy when patient shows signs of improvement At least one agent should have good CNS penetration Prophylaxis is for a 60 d course Amoxicillin or levofloxacin are second line
PlagueGentamycin 2.5 mg/kg iv q 8 h or streptomycin 15 mg/kg im q 12 h (max 2 mg/d) or doxycycline 2.2 mg/kg iv q 12 h (max 200 mg/d) or ciprofloxacin 15 mg/kg iv q 12 h prophylaxis for exposed contacts trimethoprim/sulfa 4 mg/kg po q 12 hChloramphenical or Levofloxacin can also be used Prophylaxis should be continued for 5-7 d
TularemiaSame as therapy for plague
BotulismInfants < 1 yr human-derived botulinum immunoglobulin children > 1 yr equine serum botulism antitoxinIn United States call 1-800-222-1222 or 770-488-7100 Outside United States contact local health agencies
Table 5 Viral hemorrhagic fever, virus and disease
FamilyVirusDisease
ArenavirusesLassa virusLassa fever
JuninArgentine hemorrhagic fever
MachupoBolivian hemorrhagic fever
BunyavirusesCCHFCremiean-Congo hemorrhagic fever
RVFRift Valley fever
HantavirusHemorrhagic fever with renal syndrome
FilovirusesEbola virusEbola hemorrhagic fever
Marburg virusMarburg hemorrhagic fever
FlavivirusYellow fever virusYellow fever
KFD virusKFD
OHF virusOmsk hemorrhagic fever
DENV 1-4 virusesDengue hemorrhagic fever
RhabdovirusBas-Congo virusBas-Congo hemorrhagic fever