Medical Aspects of Chemical Warfare (2008) - The Black Vault

Medical Management of Chemical Toxicity in PediatricsHelpful ResourcesVarious groups have provided guidance and expertiseon managing chemical threats to children.Important contributions have come from the ChemicalWarfare Involving Kids (CWiK) Response Project, theProgram for Pediatric Preparedness from the NationalCenter for Disaster Preparedness, and the “Children,Terrorism, and Disasters” Web site of the AmericanAcademy of Pediatrics. The Duke University HealthSystem has also provided pediatric mass casualty incidentguidelines on the Web that include instructionsfor managing chemical exposures. 110The Chemical Warfare Involving Kids ResponseProjectDoctors Robert Luten and James Broselow developeda system for managing pediatric chemical exposures.The system is called “The Chemical WarfareInvolving Kids (CWiK) Response Project” and itspurpose is 3-fold:1. to create resuscitation aids specifically designedto address pediatric medication dosingproblems of chemical terrorism,2. to provide a focused review of clinically significantpediatric issues in victim treatment,and3. to disseminate these tools to help prepare tocare for children.The project aims to distribute information aboutpediatric vulnerabilities and antidote preparation andadministration. In addition, an “antidote for chemicalwarfare” card was developed as a quick reference forproviders managing pediatric chemical casualties.These cards are intended to be used during a chemicalevent and provide precalculated medication doses.Separate from this initiative, pediatric-specific dosingcards have been developed that provide medicationdose ranges for each chemical agent.Broselow-Luten System: a Systematic Approachwith Color CodingA major difficulty of managing disasters is that theymay occur in areas that have limited pediatric resources.Even in areas with optimal resources for everydaypractice, an acute presentation of multiple victimswith a disproportionate number of affected childrenmay be overwhelming. Healthcare providers trainedto treat adults may suddenly be confronted with largenumbers of acutely ill or injured children, as has beenseen in areas like Afghanistan and Iraq. One solutionthat has been proposed is the Broselow-Luten system,which uses color-coded therapeutic pathways; childrenare entered into a color category according to weight(or length, measured by Broselow tape, when weightcannot be obtained). The color categories provideinformation on standardized therapeutic pathwaysand display doses of medications in milligrams andtheir volumetric equivalents. In addition to chemicalweapons antidotes, this approach encompassesthe entire spectrum of acute pediatric care (eg, fluidresuscitation, dehydration and electrolyte problems,pain management, antibiotics, equipment selection,burns), which may be a part of the care of pediatricdisaster victims.Meeting the Generic Needs of Children in a DisasterSituationAccording to a recent review of the pediatric resuscitationprocess, an increase in logistical time is inherentin treating pediatric emergencies as opposed to adultemergencies. 111 One of the reasons for this increase isthe age- and size-related variations unique to children,which introduce the need for more complex, nonautomaticor “knowledge-based” mental activities, suchas calculating drug doses and selecting equipment.These detract from other important mental activitiessuch as assessment, evaluation, prioritization, andsynthesis of information, which can be referred to inthe resuscitative process as “critical thinking activity.”These logistical difficulties lead to inevitable time delaysand a corresponding increase in the potential fordecision-making errors in the pediatric resuscitativeprocess. This is in sharp contrast to adult resuscitation.Medications used frequently in adults, such asepinephrine, atropine, glucose, bicarbonate, and lidocaine,are packaged in prefilled syringes containing theexact adult dose, making their ordering and administrationautomatic. The same concept is seen in equipmentselection when the necessary equipment is laidout for immediate access and use. The adult providerdoes not need to recall formulas and calculations. Theuse of appropriate aids in pediatric resuscitation (thosethat contain precalculated doses, drug volumes, andother size-related variables) significantly reduces thecognitive load otherwise caused by obligatory calculationsof dosage and equipment selection, and relegatesthese activities to a lower order of mental functionreferred to as automatic or “rule-based,” increasingcritical thinking time. The Broselow-Luten system hasbeen commercially available for over 10 years and is681