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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Appendix A. Pediatric Terrorism and Disaster Preparedness: Learning Objectives

Chapter 1. Introduction

Goal

To prepare pediatricians to participate in pediatric disaster planning, taking into consideration the differences between children and adults.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. Describe the phases of terrorism and disaster planning.
  2. Access the major Web sites available for further information on disaster preparedness to meet the needs of children.
  3. Work in concert with response agencies when providing disaster relief.
  4. Advocate for resources and products that currently do not exist for children, especially for children with special health care needs.
  5. Identify children's anatomic, physiologic, immunologic, developmental, and psychological considerations that are different from adults and potentially could affect children's vulnerability to injury and response in a disaster.
  6. Participate in community planning efforts that consider all potential aspects of a child's life.
  7. Prepare for disasters at all phases of planning, response, recovery, and mitigation.

Chapter 2. Systems Issues

Goal

To prepare pediatricians to participate in pediatric disaster planning, by ensuring their familiarity with the U.S. disaster response system infrastructure.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. List the five major types of natural disasters.
  2. Define and describe anthropogenic disasters.
  3. Identify the lead federal agencies involved in planning, preparedness, emergency medical services (EMS), and other disaster response.
  4. Access the Clinician Information Line run by the Centers for Disease Control Director's Emergency Operations Center.

Chapter 3. Responding to a Disaster

Goal

To prepare pediatricians to respond to a disaster.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. Identify and describe the four phases of response to a disaster or act of terrorism (preparedness, actual response to the event, mitigation, and recovery).
  2. Describe the function of the National Incident Management System and how it could be used as part of local emergency response plans.
  3. Determine who would be in charge of an incident when there is a multi-agency response.
  4. Describe the various types of EMS personnel and their function.
  5. Identify problems that may be encountered by hospitals when dealing with a disaster or act of terrorism, including issues related to regional coordination, surge capacity, protection of personnel, and levels of precaution.
  6. Describe potential problems with using personal protective equipment (PPE).
  7. Describe the structure and function of an Incident Command System, including a Hospital Emergency Incident Command System, and its key participants.
  8. Describe how hospitals coordinate their response to a disaster with other community and medical entities.
  9. Provide a number of examples of the roles pediatricians may play in regional hospital to community planning.
  10. Participate in the organization, implementation, and quality assurance activities related to disaster drills.
  11. Assist in integrating children's services into disaster life support drills.
  12. Refer children and families to existing support services in their communities.
  13. Explain the new Joint Commission on Accreditation of Healthcare Organizations (JCAHO) disaster preparedness standards.
  14. Explain the importance of appropriate triage.
  15. Describe the major management functions of the Incident Command System (incident command, operations, planning, logistics, finance/administration).
  16. Recognize the standardized position titles used for ICS supervisory personnel.
  17. Describe the roles of smaller ICS functional units (staging, triage, treatment/decontamination, transport).

Chapter 4. Biological Terrorism

Goal

To prepare pediatricians to recognize signs and symptoms, diagnose, treat, perform infection control measures, and report biological terrorism agents and events.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. List which biological agents (microorganisms and toxins) pose the greatest potential for use in a bioterrorist attack, designated as "Category A" agents.
  2. Explain the reasons why Category A agents have the greatest adverse public health, medical, and social impact if used as bioterrorist agents.
  3. Recognize a wide number of clues that should heighten suspicion that a bioterrorist attack has occurred.
  4. Describe how biological agents affect and manifest themselves in pediatric respiratory, nervous, gastrointestinal, and dermatologic systems.
  5. Promptly diagnose and isolate a patient who has an illness potentially related to bioterrorism and notify the proper authorities.
  6. Access and properly use PPE.
  7. Describe the structure of his or her local public health system and the point of contact for reporting illnesses suspected of being related to bioterrorism.
  8. Rapidly detect and isolate patients with an infectious illness related to bioterrorism to prevent transmission in health care settings.
  9. Care for patients using standard precaution, contact precautions, droplet precautions, and airborne infection isolation techniques.
  10. Access the major Web sites available for further information on isolation and environmental control guidelines.
  11. Stock and use equipment and supplies necessary to diagnose and treat a patient suspected of being infected with a bioterrorist agent according to the level of care that will be provided at a particular facility or pediatrician's office.
  12. Create an emergency plan and train office staff to follow it.
  13. Rapidly treat high-risk populations via administration of smallpox or anthrax vaccines.
  14. Access the Strategic National Stockpile managed by the Department of Homeland Security and the Department of Health and Human Services.
  15. Plan for surge capacity strains on existing pediatric resources.
  16. Provide families with the information they need to plan and prepare for a disaster.
  17. Provide clinical evaluation of patients suspected of being infected by Category A agents including all forms of anthrax, botulinum toxin, plague, smallpox, tularemia, and viral hemorrhagic fevers; as well as Category B and C Agents, including Ricin, Q Fever, Staphylococcus enterotoxin B, Brucella, Burkholderia mallei (Glanders), encephalitis viruses and yellow fever virus, and Clostridium perfringens.

Chapter 5. Chemical Terrorism

Goal

To prepare pediatricians to recognize signs and symptoms, diagnose, treat, perform infection control measures, and report chemical terrorism agents and events.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. Define chemical terrorism.
  2. Explain how careful community planning, robust research and development (by academic, private, and governmental collaborative efforts), and rigorous medical education could mitigate a chemical terrorism catastrophe.
  3. Explain why pediatricians need to understand the approach to mass casualty incidents involving traditional military chemical weapons and other toxic chemicals that might be used as "weapons of opportunity."
  4. Explain the similarities and differences between a chemical terrorist attack and a more conventional chemical disaster in terms of the epidemiology and medical consequences associated with each.
  5. Create a management plan for decontamination and initial care of small children by personnel wearing bulky PPE.
  6. Recognize the risks and challenges to pediatric care providers posed by contact with many exposed children who are not critically injured but have been taken by parents to hospitals and pediatricians' offices without prior on-scene decontamination.
  7. Describe how children have inherent physiologic, developmental, and psychological differences from adults that may enhance susceptibility and worsen prognosis after a chemical agent exposure.
  8. Recognize the epidemiology of acute mass exposure to a toxin as an aid in recognizing a covert chemical attack with unknown agents.
  9. Formulate an approach for managing chemical injuries sustained by children from an unknown chemical agent.
  10. Describe clinical syndromes and management after exposure to various chemical agents (nerve agents, vesicants, pulmonary agents, cyanide, and riot-control agents).
  11. Categorize chemical weapons based on the predominant symptoms they cause: neurologic (nerve agents or cyanide); respiratory (phosgene or chlorine, high-dose riot-control agents, or sulfur mustard with a delay of several hours from time of exposure); and mucocutaneous syndromes (vesicants).
  12. Access and alert the CDC, local public health authorities, and/or regional poison control center.
  13. Differentiate between cyanide and nerve agent attacks.
  14. Plan for the initial protection of everyone in a community exposed to a hazardous chemical using CDC Guidelines for Evacuation and for Sheltering in Place in a Chemical Emergency.
  15. Discuss treatment of contaminated victims via extrication, triage, resuscitation as needed, and decontamination performed by rescue workers or health care providers wearing appropriate PPE.
  16. Provide cardiopulmonary and airway support, including endotracheal intubation, and emergent intramuscular antidotal therapy as necessary and appropriate for the specific exposure.
  17. Prepare to treat potential victims of a terrorist attack involving industrial sources of hazardous chemicals.
  18. Participate in disaster management training, including stocking appropriate antidotes, practicing decontamination strategies, and learning the use of PPE.
  19. Identify chemical terrorism toxins such as nerve agents (tabun, sarin, soman, and VX ("Venom X") and their delivery systems, toxicology and clinical manifestations, central and autonomic systems effects, neuromuscular effects, diagnostic tests, treatment, isolation, and control measures.
  20. Describe comprehensive plans to address terrorist threats to infection control (for biological agents), epidemiology, public affairs, and administration of health care facilities.
  21. Explain the lethality of cyanide, its toxicology, clinical presentation, and treatment.
  22. List the agents known as vesicants (sulfur mustard, the nitrogen mustards, lewisite, and phosgene oxime) and their characteristics, clinical effects, treatment, and special pediatric considerations.
  23. Describe pulmonary agents (chlorine and phosgene) and their characteristics, clinical effects, treatment, including decontamination and management.
  24. Identify riot control agents (CS [2-chlorobenzylidene], CN [1-chloroacetophenone, MaceŽ], and pepper spray [Oleoresin capsicum]), their transmission and pathogenesis, clinical manifestations, diagnosis, treatment, and control.

Chapter 6. Radiological and Nuclear Terrorism

Goal

To prepare pediatricians to recognize the signs and symptoms associated with radiologic and nuclear exposure and to diagnose, treat, and report nuclear and radiologic terrorism events and agents.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. List sources of radioactivity and the terrorism threats they pose.
  2. Describe the scope, implications, and incident management of radiological threats.
  3. Differentiate between nuclear and conventional explosions.
  4. Explain the process of radiation from nuclear detonation and fallout.
  5. Describe the purpose and effects of radiological dispersal devices ("dirty bombs").
  6. Describe medical and industrial sources of radiation.
  7. Define the potential hazards of destruction or sabotage of a nuclear power plant.
  8. Recount the historical overview of radiation injury.
  9. Explain the physical principles of ionizing radiation.
  10. Describe radiation interactions including electron excitation, ionization, nuclear excitation, nuclear fission, activation, and secondary radiation.
  11. Provide information to patients concerning the safety of consuming milk after a reactor accident.
  12. List natural and man-made types of radiation exposure.
  13. Record radiation-induced signs, symptoms, and erythema during the course of medical management for radiation casualties to help triage and guide medical management of casualties.
  14. Recognize the pattern of biological responses associated with acute radiation sickness (ARS).
  15. Describe the pathophysiology and effects of radio- and chemotherapy including bone marrow damage, diarrhea, and hair loss.
  16. Explain the time-dependent clinical stages of radiation exposure (prodrome, latent period and manifest illness).
  17. List the diagnostic steps to assess a dose of radiation exposure.
  18. Medically diagnose external radiological contamination.
  19. Assess and care for externally contaminated patients.
  20. Properly use PPE to eliminate personal risk while caring for victims of radiation exposure.
  21. Explain the mechanisms of internal contamination when radioactive material enters the bodies of unprotected people through inhalation, ingestion, or wound contamination.
  22. Differentiate between public concern about terrorism involving radioactive materials and medical errors during diagnosis that have been the most common cause of significant internal contamination.
  23. Describe the three pathways through which radioactive material can enter the body (inhalation, ingestion and skin penetration).
  24. List the various instruments available for detecting and measuring radiation.
  25. Discuss the need for PPE, type needed for radiation contamination, disposal of PPE, and Department of Energy Guidance on PPE.
  26. Differentiate between PPE for radioactive isotopes and chemical or biological exposures.
  27. Describe emergency precautions when PPE is not available in a radioactive environment.
  28. Explain the basic principles of decontamination and priorities.
  29. Explain the characteristics that render pediatric patients uniquely sensitive to the effects of radiation exposure.
  30. Explain the well-documented long-term effects of radiation exposure to the fetus and child.
  31. Recount the psychological vulnerability of children involved in a radiation related incident.
  32. Treat acute pediatric radiation syndrome both supportively and with specific actions and medications.
  33. Prioritize external decontamination before treatment of internal decontamination.
  34. Use potassium iodide (KI) to reduce thyroid uptake of radioactive iodine.
  35. Keep available and use a table of threshold radioactive exposures and recommended prophylactic single doses of KI.
  36. Treat internal contamination with appropriate chelating agents.
  37. Prioritize steps in the treatment of victims of combined injuries, that is, stabilization of life threatening injuries prior to radiation injuries.
  38. Manage the patient with embedded radioactive material and depleted uranium.
  39. Provide followup care, being mindful of the risk of carcinogenesis.
  40. Describe environmental issues affecting children after a terrorist incident involving radioactive materials.
  41. Make knowledgeable decisions and actions to prevent radiation exposure related to short-term evacuation versus sheltering.
  42. Access the FDA guidance for accidental radioactive contamination of human food and animal feed.

Chapter 7. Blast Terrorism

Goal

To prepare pediatricians to recognize signs and symptoms, diagnose, treat, and report blast terrorism events and agents.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. Explain the four primary mechanisms involved in blast injuries.
  2. List the three primary causes of death after a blast.
  3. Describe four characteristic results of urban bomb blasts.
  4. Explain how the anatomic structure of the lung makes it susceptible to the effects of blast barotraumas.
  5. List typical clinical findings in blast lung injuries.
  6. Treat blast lung injury and resulting complications.
  7. List the signs and symptoms that suggest arterial air embolization.
  8. Treat arterial air emboli.
  9. List the clinical findings in GI injury from a blast.
  10. Manage gastrointestinal blast injuries by controlling internal bleeding and identifying and repairing any perforated viscus.
  11. Describe the clinical findings in blast auditory injuries.
  12. Explain the cardiovascular effects of a blast wave.
  13. Recognize sentinel injuries (subtle injuries that can increase the risk of developing serious blast injury).
  14. Provide emergency management of victims of incendiary devices.
  15. Describe a trauma center.
  16. Describe the key organizational characteristics common among all trauma centers.
  17. Delineate the services provided by the three levels of trauma centers.
  18. Access the Advanced Trauma Life Support® for Doctors Course protocols.
  19. Access the Advanced Burn Life Support® Course protocols.
  20. Define a mass casualty event.
  21. Participate in planning for and mitigation of an attack involving blast terrorism.
  22. Recognize the need for proper triage and transport of pediatric patients to an appropriate trauma center.

Chapter 8. Mental Health Issues

Goal

To prepare pediatricians to address the mental health needs of children and families in a disaster or terrorist event.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. Recognize pediatric psychiatric symptoms and disorders, including posttraumatic stress disorder (PTSD), anxiety, depression, and behavioral problems, after exposure to disasters or terrorist incidents.
  2. List the risk factors that are associated with an increased risk of posttraumatic symptoms.
  3. Describe three characteristic symptoms that are essential features of PTSD after exposure to a traumatic event.
  4. List five factors that are likely to be present in death circumstances that are considered "traumatic deaths."
  5. Assess, screen and treat (or refer for treatment), children who are at risk for mental health problems after exposure to a traumatic event.
  6. Follow procedures for notification about an unexpected death with sensitivity to key issues that will minimize the short- and long-term impact on survivors.
  7. Explain death to children in a manner they can understand.
  8. Recognize common reactions that children may have in response to a personal loss.
  9. Identify children who have extreme reactions, atypical reactions, or prolonged reactions that require referral to a mental health professional experienced in the management of pediatric bereavement.
  10. Explain the controversy that surrounds the use of psychopharmacology in children with PTSD.
  11. Advocate for, consult with, and actively participate in school crisis response teams.
  12. Prepare families to cope with anniversary reactions and commemorative activities of a traumatic event.
  13. Recognize the emotional impact experienced by school staff, first responders, and other health care professionals following a disaster.
  14. Communicate effectively during a crisis.

Chapter 9. Integrating Terrorism and Disaster Preparedness into Your Pediatric Practice

Goal

To assist general pediatricians in integrating the information in this resource into their office- or hospital-based practices.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. Explain their role in the general system response to disasters.
  2. Create a disaster-preparedness framework for a general practice pediatric office.
  3. Describe the components for basic internal office readiness (facilities, equipment, records, communication system, chain of command, contact list, staff responsibilities, triage, screening, prioritization, practice readiness, staff development, and insurance).
  4. Determine how the practice will link and coordinate efforts with affiliate hospitals, schools, daycare centers, local response teams, the local department of health, and city, State, and Federal efforts.
  5. Develop a list of contact numbers for all existing agencies that are components in the external disaster management system.
  6. Establish relationships with the local or regional Office of Emergency Management and strengthen already established relationships with organizations/institutions in the community.
  7. Integrate into the larger community response effort.
  8. Participate in disaster drills and exercises.
  9. Describe disaster protocols of local departments of health.
  10. Communicate directly with children and families about disaster and terrorism preparedness.
  11. Answer the questions of children and families during events.
  12. Provide advice for families of children with special health care needs.
  13. Participate in creating contingency plans to increase hospital surge capacity.
  14. Help to produce contingency plans for acquiring and maintaining essential services (water, electricity, oxygen, garbage disposal).
  15. Plan for stockpiling medical supplies.
  16. Participate in a network of community resources that will be able to organize volunteers to become proxy caretakers for orphaned children.
  17. Participate in planning hospital infrastructure needs for children (disaster drills involving children, infection control plans, quarantine procedures, staff training).

Chapter 10. Working with Government Agencies to Enhance Preparedness

Goal

To assist pediatricians working with government agencies to enhance preparedness for meeting children's needs.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. Describe the role of various government agencies in disaster preparedness and response.
  2. Work with community, State, and Federal Government entities in disaster preparedness for children.
  3. Explain the importance of the pediatrician's role in determining public health preparedness.
  4. Advocate for children and families in preparedness planning.

Chapter 11. Conclusion

Goal

To assist pediatricians in understanding the consequences of a recent major disaster and applying the lessons learned to current planning and preparedness efforts.

Learning Objectives

At the end of this chapter, the reader will be able to:

  1. Describe the problems that emerged following Hurricane Katrina and how these experiences can inform future planning efforts.
  2. Ensure that preparedness plans include provisions for identification and care of displaced children who have been separated from their families.
  3. Understand the needs of children and families in sheltering situations.
  4. Recognize the importance of and maintain up-to-date professional and personal contact information for themselves and their families and staff members.
  5. Participate and assist in coordination of disaster relief efforts, both locally and farther away, depending on areas of greatest need.

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