Diagnosis and management of suspected cases of bioterrorism: a pediatric perspective

The Impact of Terrorism on Children: A Two-Year Experience

Objectives:

To review and analyze the cumulative two-year, Israeli experience with medical care for children victims of terrorism during the prehospital and hospital phases.

Methods:

Data were collected from the: (1) Magen David Adom National Emergency Medical System Registry (prehospital phase); (2) medical records from the authors’ institutions (pediatric triage); and (3) Israel Tr auma Registry (injury characteristics and utilization of in-hospital resources). Statistical analyses were performed as appropriate.

Introduction:

During the recent wave of violence in Israel and the surrounding region, hundreds of children have been exposed to and injured by terrorist attacks. There is a paucity of data on the epidemiology and management of terror-related trauma in the pediatric population and its effects on the healthcare system. This study focuses on four aspects of terrorism-related injuries: (1) tending to victims in the prehospital phase; (2) triage, with a description of a modified, pediatric triage algorithm; (3) characteristics of trauma-related injuries in children; and (4) utilization of in-hospital resources.

Results:

During the study period, 41 mass-casualty events (MCEs) were managed by Magen David Adom. Each event involved on average, 32 regular and nine mobile intensive care unit ambulances with 93 medics, 19 paramedics, and four physicians. Evacuation time was 5–10 minutes in urban areas and 15–20 minutes in rural areas. In most cases, victims were evacuated to multiple facilities. To improve efficiency and speed, the Magen David Adom introduced the use of well-trained “first-responders” and volunteer, off-duty professionals, in addition to “scoop and run” on-the-scene management. Because of differences in physiology and response between children and adults, a pediatric triage algorithm was developed using four categories instead of the usual three. Analysis of the injuries sustained by the 160 children hospitalized after these events indicates that most were caused by blasts and penetration by foreign objects. Sixty-five percent of the children had multiple injuries, and the proportion of critical to fatal injuries was high (18%). Compared to children with non-terrorism-related injuries, the terrorism-related group had a higher rate of surgical interventions, longer hospital stays, and greater needs for rehabilitation services.

Conclusion:

Terrorism-related injuries in children are severe and increase the demand for acute care. The modifications in the management of pedi-atric casualties from terrorism in Israel may contribute to the level of preparedness of medical and paramedical personnel to cope with future events. Further studies of other aspects of traumatic injuries, such as its short- and long-term psychological consequences, will provide a more comprehensive picture of the damage inflicted on children by acts of terrorism.

Bioterrorism and biologic warfare

Biologic agents have been used throughout history to influence battles. Recently, biologic agents have been used as terrorist weapons. A review of the history of biologic weapons and a medical overview of the Centers for Disease Control and Prevention Category A and B agents is provided, including history, pathogenesis, clinical presentation, microbiology/virology, diagnosis, treatment, and each agent's use or potential use as a weapon. Background information on public health issues surrounding bioterrorism and the role of oral and maxillofacial surgeons in a bioterrorist event also is provided.

Ricin and the assassination of Georgi Markov

The purpose of this study was to investigate the dead reasons of Georgi Markov. Georgi Markov, a well known Bulgarian novelist and playwright, dissident of the communist regime in his country, escaped to England where, he dedicated himself in broadcasting from BBC World Service, the Radio Free Europe and the German Deutsche Welle against the communist party and especially against its leader Todor Zhivkov who in a party's meeting told that he wanted Markov silenced for ever. On the 7th September 1978 Markov received a deadly dose of the poison ricin by injection to his thigh by a specially modified umbrella. He died without a final diagnosis a few days later. The autopsy revealed the poisoning. The murderer, in spite of the efforts of the Police, Interpol and Diplomacy still remains unknown.

Bioterrorism: Evaluating the preparedness of pediatricians in Michigan

OBJECTIVE

There is a paucity of literature in the United States regarding preparedness for a bioterrorist attack on children. The main objective of this study was to assess the self-reported level of bioterrorism preparedness of pediatricians practicing in Michigan.

METHODS

We conducted a survey that was mailed to 1000 pediatricians practicing in Michigan from July through December 2006. Survey questions were designed to evaluate the overall level of preparedness, as defined by the American Academy of Pediatrics, in dealing with a possible biological event and to describe key demographic variables.

RESULTS

Of the 590 pediatricians who responded (59%), a majority (80%) were general pediatricians, whereas 20% were pediatric subspecialists. Sixty percent of responders believe terrorism is a threat, with biological agents (52%; 95% confidence interval (CI), 48.00-56.12) as the most likely cause of an event. Half of the pediatricians who responded had a workplace disaster plan, but only 12% feel their preparedness for a biological attack/event was good. Sixty-six percent (392/590) were not currently Pediatric Advanced Life Support certified, 38% (95% CI,34.63-42.51) have never attended a lecture based on bioterrorism, 85% (95% CI, 82.00-87.78) have never participated in a bioterrorism training exercise, and 89% (95% CI, 87.00-91.95) do not provide disaster-oriented anticipatory guidance to their patients. Seventy-six percent (95% CI, 73.10-79.98) of all responders indicated their desire for more bioterrorism training, with 42% preferring diagnostic algorithms and 37% (95% CI, 32.79-40.59) preferring a prepared lecture on video format.

CONCLUSIONS

Surveyed pediatricians in Michigan consider bioterrorism a significant threat but are overwhelmingly underprepared to deal with an event. There is a perceived need for a coordinated educational program to improve level of preparedness.

Bioterrorism-Related Inhalational Anthrax: Can Extrapolated Adult Guidelines Be Applied to A Pediatric Population?

OBJECTIVE

Since the 2001 anthrax attacks, an extensive body of literature has evolved, but there has been a limited focus on the management of pediatric-specific issues. We looked at the symptom complexes of all pediatric patients presenting to the emergency department of our hospital during this period and examined whether their presentations would likely allow current guidelines to be used as potential screening criteria to identify children infected with anthrax.

METHODS

We retrospectively reviewed emergency department records of all adult and pediatric patients (up to the age of 21 years) at Inova Fairfax Hospital during this time, when a large, and at the time ill-defined, group in the Washington, DC, metropolitan area was at risk for pulmonary anthrax. Two cases of anthrax infection were identified at this hospital in exposed adult postal workers. Screening algorithms (described by Mayer et al. and Hupert et al.) were applied to adult and pediatric patients with the presence of fever (38 degrees C), tachycardia, or other symptoms compatible with pulmonary anthrax. Specifically, the usefulness of these guidelines as potential screening tools to identify possibly infected children was examined.

RESULTS

Of 767 pediatric patients seen in the emergency department during the study period, 312 met criteria for review (41%; 95% CI: 37-44%). Four adult patients (0.4%; 95% CI: 0.1-0.9%) had at least five clinical symptoms, fever, and tachycardia; two of them had inhalational anthrax. No pediatric patient presented with five or more clinical symptoms. Twelve children (3.9%; 95% CI: 2-6.6%) presented with four clinical symptoms; five of the 12 had neither fever nor tachycardia. Children, particularly infants and toddlers, presented with nonspecific symptom complexes primarily limited to fever, vomiting, cough, and trouble breathing.

CONCLUSIONS

Existing guidelines are likely to be unreliable as a screening tool for inhalational anthrax in children, largely because of the children's inability to adequately communicate a suggestive symptom complex.

Defining bioterrorism preparedness for nurses: concept analysis

AIM

This paper reports a concept analysis to define the concept of nursing bioterrorism preparedness.

BACKGROUND

Nursing bioterrorism preparedness is necessary, yet no theoretical or operational definition exists. The concept is often misinterpreted as being synonymous with organizational preparedness or confused with the bioterrorism preparedness needs of other professions, such as medicine. There is no standardized definition of the concept that is specific to the profession of nursing.

METHODS

A concept analysis was conducted using a systematic literature review; the Cumulative Index to Nursing and Allied Health Literature, Psych Info and Medline databases for years 1966-2005 were used. One hundred and eighteen references were identified, 41 of which were deemed relevant. Data from the 41 relevant articles were analysed and synthesized to develop a theoretical definition, defining attributes, antecedents, consequences and related concepts.

FINDINGS

Nursing bioterrorism preparedness is the continual process of nurses becoming better prepared to recognize and respond to a bioterrorism attack. Nurses, regardless of their level of education, areas of expertise or practice settings must participate in at least one educational session and one exercise each year to meet the minimum requirements of engaging in the bioterrorism preparedness process. The antecedents are acceptance and readiness to change. Defining attributes include gaining knowledge, planning, practising response behaviours and evaluating knowledge level and content of response plan. Consequences include recognition of an event and implementation of appropriate response actions.

CONCLUSION

Nursing bioterrorism preparedness is essential. To assess nurses' level of preparedness, a definition is needed of what bioterrorism preparedness means to the profession. The theoretical definition developed in this paper needs to be further refined and operationalized.

Tularemia: the disease and the weapon

Tularemia is a bacterial infection usually transmitted via arthropod vectors or direct contact with infected animals. Naturally occurring cases are relatively rare, and can result in six different clinical syndromes. Tularemia is also a potential agent of bioterrorism or biowarfare, and is categorized as a high-level threat. Effective antibiotic treatment is available, including potential use of oral antibiotics in a mass casualty situation. An awareness of potential clinical presentations of tularemia will facilitate timely intervention,appropriate diagnostic testing, and decreased morbidity in the event of a biologic attack with Francisella tularensis.

Preevent vaccination against smallpox: a survey of pediatric emergency health care providers

BACKGROUND

In January 2003, smallpox vaccinations were offered to health care workers to create hospital-based teams prepared to care for patients with smallpox as part of national bioterrorism preparedness activities.

METHODS

An anonymous survey of pediatric emergency health care workers was conducted in November and December 2002. Two mailings were sent to physicians, nurses and ancillary staff at five academic pediatric emergency departments in major US cities. We assessed the willingness to receive preevent smallpox vaccine. In addition we measured the prevalence of vaccine contraindications, perceived likelihoods of a local smallpox outbreak or a vaccine-related adverse event and reasons for or against wanting to receive the vaccine.

RESULTS

Overall 72% of respondents were willing to receive the smallpox vaccine. Individuals who were willing to receive the smallpox vaccine, compared with those not willing, believed a local outbreak was more likely to occur (odds ratio, 1.29; 95% confidence interval, 1.16 to 1.44). One-fifth of respondents reported a contraindication to smallpox vaccine; however, more than half indicated they would still be willing to receive vaccine. Individuals who perceived themselves at high risk for vaccine-related adverse events were less willing to receive the preevent smallpox vaccine. Self-protection was the most common reason cited for wanting to receive the vaccine.

CONCLUSIONS

A majority of pediatric healthcare workers were willing to receive preevent smallpox vaccine before the onset of Phase I of the CDC Smallpox Vaccination Program. A greater understanding of the knowledge, attitudes and beliefs of pediatric health care workers toward preevent smallpox vaccination will assist in the development of future bioterrorism preparedness programs.

Epidemiology of terror-related versus non-terror-related traumatic injury in children

OBJECTIVE

In the past 2 years hundreds of children in Israel have been injured in terrorist attacks. There is a paucity of data on the epidemiology of terror-related trauma in the pediatric population and its effect on the health care system. The objective of this study was to review the accumulated Israeli experience with medical care to young victims of terrorism and to use the knowledge obtained to contribute to the preparedness of medical personnel for future events.

METHODS

Data on all patients who were younger than 18 years and were hospitalized from October 1, 2000, to December 31, 2001, for injuries sustained in a terrorist attack were obtained from the Israel National Trauma Registry. The parameters evaluated were patient age and sex, diagnosis, type, mechanism and severity of injury, interhospital transfer, stay in intensive care unit, duration of hospitalization, and need for rehabilitation. Findings were compared with the general pediatric population hospitalized for non-terror-related trauma within the same time period.

RESULTS

During the study period, 138 children were hospitalized for a terror-related injury and 8363 for a non-terror-related injury. The study group was significantly older (mean age: 12.3 years [standard deviation: 5.1] v 6.9 years [standard deviation: 5.3]) and sustained proportionately more penetrating injuries (54% [n = 74] vs 9% [n = 725]). Differences were also noted in the proportion of internal injuries to the torso (11% in the patients with terror-related trauma vs 4% in those with non-terror-related injuries), open wounds to the head (13% vs 6%), and critical injuries (Injury Severity Score of 25+; 25% vs 3%). The study group showed greater use of intensive care unit facilities (33% vs 8% in the comparison group), longer median hospitalization time (5 days vs 2 days), and greater need for rehabilitative care (17% vs 1%).

CONCLUSIONS

Terror-related injuries are more severe than non-terror-related injuries and increase the demand for acute care in children.

Hemoptysis

Hemoptysis is a common complaint the emergency physician encounters. Most cases are minor and treatable or self-limited. In many cases a cause is never determined. Massive hemoptysis is an occasional occurrence that must be assessed and managed swiftly. The initial approach is no different than that for any bleeding or respiratory or hemodynamically unstable patient. The emergency physician must stabilize, localize, and stop bleeding, and include required specialists to achieve that purpose. The management suggestions presented in this article are simplistic. The emergence of improved CT technology and new bronchoscopic and angiographic techniques has provided safe and effective alternatives to surgery for many causes of hemoptysis. Surgery, however, continues to be the treatment of choice for some. Being familiar with the broad list of causes is imperative to keeping an approach organized.