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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

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Table 5.2. Chemical Weapons—Summary of Pediatric Management Considerations

Agent Toxicity Clinical Findings Onset Decontaminationa Management
Nerve Agents


Anticholinesterase: muscarinic, nicotinic, and CNS effects.

Vapor: miosis, rhinorrhea, dyspnea.
Liquid: diaphoresis, vomiting.
Both: coma, paralysis, seizures, apnea.

Vapor: seconds.
Liquid: minutes-hours.

Vapor: fresh air, remove clothes, wash hair.
Liquid: remove clothes, copious washing of skin and hair with soap and water, ocular irrigation.

Atropine: 0.05 mg/kg IVb, IMa (min 0.1 mg, max 5 mg), repeat q2-5 min prn for marked secretions, bronchospasm.
Pralidoxime: 25 mg/kg IV, IM (max 1 g IV; 2 g IM), may repeat within 30-60 min prn, then again every hour for 1 or 2 doses prn for persistent weakness, high atropine requirement.
Diazepam: 0.3 mg/kg (max 10 mg) IV; lorazepam: 0.1 mg/kg IV, IM (max 4 mg); midazolam: 0.2 mg/kg (max 10 mg) IM prn for seizures or severe exposure.

Mustard Alkylation Skin erythema, vesicles, ocular inflammation, respiratory tract inflammation. Hours. Wash skin with soap and water, ocular irrigation (major impact only if done within min of exposure). Symptomatic care.
Lewisite Arsenical As above. Immediate pain. As above. Possibly BAL 3 mg/kg IM q4-6hr for systemic effects in severe cases.
Pulmonary Agents


Liberate HCL, alkylation. Eyes, nose, throat irritation (especially chlorine); bronchospasm, pulmonary edema (especially phosgene).

Minutes: eyes, nose, throat irritation; bronchospasm.
Hours: pulmonary edema.

Fresh air, wash skin with water. Symptomatic care.
Cytochrome oxidase inhibition: cellular anoxia, lactic acidosis. Tachypnea, coma, seizures, apnea. Seconds. Fresh air, wash skin with soap and water.

ABCs, 100% oxygen.
Sodium bicarbonate prn for metabolic acidosis
Sodium nitrite (3%):

Dosage (mL/kg) Estimated Hgb (g/dL)
0.27 10.
0.33 12 (est. for avg. child).
0.39 14 (max 10 mL).

Sodium thiosulfate (25%): 1.65 mL/kg (max 50 mL).

Riot Control Agents

CN (eg, Mace®)
Capsaicin (pepper spray)

Neuropeptide substance P release; alkylation. Ocular pain, tearing, blepharospasm; nose and throat irritation; pulmonary failure (rare). Seconds. Fresh air, ocular irrigation. Topical ophthalmics, symptomatic care.

a Should be performed by health care providers garbed in adequate personal protective equipment, especially if victims have had significant exposure to nerve agents or vesicants. For emergency department staff, adequate personal protective equipment (PPE) consists of a non-encapsulated, chemically resistant body suit, boots, and gloves with a full-face air purifier mask/hood.
b Intraosseous route likely equivalent to intravenous.
c Atropine via endotracheal tube or inhalation, or aerosolized ipratropium of possible benefit.

Note: ABCs = airway, breathing, and circulatory support; BAL= British anti-lewisite; Hgb= hemoglobin concentration; prn = as needed; CNS = central nervous system ; IM = intramuscular.

Source: Adapted from Henretig FM, Cieslak TJ, Eitzen EM Jr. Biological and chemical terrorism. J Pediatr 141:311-26 © 2002, with permission from Elsevier.

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