Being a Child in the Midst of Terrorism
Richard Aghababian
Mariann Manno
INTRODUCTION
Terrorism—a planned, often politically motivated event designed to kill many innocent victims and inflict physical pain, psychological suffering, and fear on an entire community—is new to our Western culture, but not to children worldwide. Terrorism, violence, and disaster have involved children in the form of naturally occurring events; transportation accidents; exposure to war; social, ethnic and religious conflict; and as collateral damage in adult mass casualty incidents. Throughout childhood and adolescence, children are physically less capable and emotionally more vulnerable to the effects of terrorism. This fact may make children likely primary targets for terrorism in the future.
Children are unique from the perspective of their anatomy, physiology, emotional development, and response to specific physical and psychological insults. These unique needs of children have rarely been considered in disaster planning. Civilian emergency physicians and Emergency Medical Services (EMS) systems have learned about mass casualty incidents through military models, focused on the needs of adult victims; consequently, they have limited personal clinical experience with pediatric disaster medicine. A terrorist attack with predominately pediatric casualties would have a tremendous and far-reaching impact on all child survivors, family members, and the community at large. All facets of the EMS system must be aware of this potential and be prepared to meet the special and divergent needs of children in the setting of a chemical, biological, radiation, or explosive event that involves large numbers of children. A paradigm shift that deals with unaddressed issues of treatment, equipment, triage, and training is a critical step in preparing to address the needs of children in the midst of terrorism.
PREPAREDNESS ESSENTIALS
DEVELOPMENTAL STAGES: WHAT CHILDREN UNDERSTAND
Development from infancy through adolescence is a continuous, dynamic process heavily influenced by close personal experiences and circumstances in the child’s community. It is a web of evolving language, behavioral, cognitive, anatomic, and physiologic changes. New skills are achieved and build on previous milestones. The child is at the center of a series of concentric circles that represent his environment. Closest to him is the family, friends, and school. Farther out is his town, city, and so on. Disruption of the environment will affect the child depending on its severity and the child’s developmental stage. Severe disruption of several facets, as seen in natural disasters, war, and terrorism have serious implications for the well-being and normal development of children of all ages.
Major themes of child development include attachment between the child and caregiver (especially the parent), emotional maturity and self control, the ability to master fearful and anxiety-provoking situations, and the formation of independent relationships with peers. Specific tasks or achievements toward these goals are accomplished at different ages or stages. It is helpful to consider an overview of child development broken down into somewhat artificial categories based on the goals and accomplishments of each stage (21).
Birth to 18 months of age is a time of physical growth and physiologic change. Infants develop through motor and sensory exploration of their environment. Rolling over, midline play, transferring objects from hand to hand, crawling, sitting, and finally walking allow the baby to interact with the world around them. Attachment to caregivers progresses
from complete dependence to reciprocal relationship. After 6 weeks of age, infants increasingly respond to their environment. They smile, coo, and visually track their caretaker. Separation anxiety that peaks late in the first year and coping with temporary absences of the caretaker are hallmarks of the emotional development of this age. Lasting absences of primary caretakers are associated with nonorganic failure to thrive and with increased risk of pathology.
from complete dependence to reciprocal relationship. After 6 weeks of age, infants increasingly respond to their environment. They smile, coo, and visually track their caretaker. Separation anxiety that peaks late in the first year and coping with temporary absences of the caretaker are hallmarks of the emotional development of this age. Lasting absences of primary caretakers are associated with nonorganic failure to thrive and with increased risk of pathology.
Toddlers (18 months to 3 years) are curious, interested, and active. This is a time of early independence, stubbornness, and negotiating limits. Perceptual constancy becomes better developed so that children in this age group are better able to cope with the absence of a parent. Transitional objects (stuffed animal, favorite blanket) can be used to ease a toddler through a difficult situation.
The preschool years (3 to 5 years) begin a time of language maturation, developing social skills, and a sense of independence. They see themselves separate from but still closely connected to their primary caretaker. Just as motor development is the hallmark of the toddler, language and prelogical reasoning occurs in the preschooler. Magical thinking, an overextension of causality (e.g., My brother got sick because I did not eat my dinner), and exaggerated fears and fantasies are features of the way children of this age figure out their world. Pain is interpreted as punishment. Death is a temporary, reversal event. Time, in general, is a difficult concept so that periods of time spent waiting or holding still may be intolerable. Expressive language lags receptive language. Children at this age may understand more than expected and interpret language literally (e.g., I will draw your blood). The choice of words in new situations is important. Explanations of painful procedures should occur immediately before it happens. Honesty, simple and brief, about discomfort and capitalizing on the child’s curiosity by including them in the process (holding bandages, touching equipment) may elicit the preschooler’s cooperation.
School age years (6 to 11 years of age) are a time of mastering complex cognitive tasks, following the rules, and meeting expectations at home and in school. School begins to replace home as a place of central importance with peers, academics, and sports competing with time spent with parents and siblings. Specific learning disabilities, ADHD, oppositional deficient disorder (ODD), anxieties, and phobias may present during this period and may make these children seem out of synch with peers. School age children understand true causality and the permanent nature of death. In the medical setting, these children are generally logical and cooperative. They should be included in conversations about their health and encouraged to make choices when appropriate.
Adolescence is a time of tremendous transition. Puberty is a time of rapid growth and change in the body’s appearance as these children achieve adult proportions and reproductive capability. They are capable of abstract thinking and complex reasoning but many retain egocentric, hypersensitive, or dramatic tendencies. The quest for autonomy is a source of stress in families. In the medical setting, adolescents deserve full and honest explanations. They should be encouraged to ask questions and participate in discussions and decisions. Their maturity and privacy should be respected.
Because they are in the process of leaning about and mastering their world, children are more physically and emotionally vulnerable to the effects of disaster and depravation than older counterparts. When tragedy strikes a family, community, or nation, helping children cope and regain a sense of safety is of critical importance. In the immediate postdisaster period, children benefit from rapid reestablishment of order, routine, and safety. Children should be encouraged to express their feelings in constructive ways through discussion, play, or art. Regressive or clingy behaviors, moodiness, poor sleep, and somatic complaints are normal. Events should be handled honestly in developmentally appropriate language. Deception about the well-being and whereabouts of loved ones should be avoided. Children should be shown images of the disaster so that they have an authentic picture of what happened, but this should be done in a developmentally appropriate manner and in an environment that permits discussion and understanding. Unsupervised or repeated exposure to media, especially television with displays of graphic images, is harmful.
ANATOMY AND PHYSIOLOGY: HOW CHILDREN ARE DIFFERENT
The Pediatric Airway
The airway is the most important difference between adult and pediatric resuscitation and emergency care. Respiratory failure precedes cardiopulmonary failure or cardiac arrest in most children. Respiratory failure may result from a primary respiratory problem (reactive airway disease, pneumonia, upper airway obstruction, and/or infection) or may occur secondary to a number of causes (inhalation, drowning, overwhelming sepsis, a toxicologic overdose, or traumatic insult). Airway management is the most important skill acquired in pediatric resuscitation. In the injured child, oxygenation, ventilation, and airway protection are vital. The approach to the pediatric airway must take into account anatomic uniqueness and different sizes of neonates, infants, and children.
For all providers, basic knowledge of pediatric airway anatomy, head positioning, techniques to open the airway and remove foreign bodies, and the use of airway adjuncts and effective bag-valve-mask ventilation are essential skills. Advanced providers should be proficient in endotracheal intubation, rapid sequence induction, and surgical methods to establish an airway. In the setting of trauma, cervical spine immobilization must be maintained during airway management.
Pediatric Airway Anatomy
Infants have a prominent occiput that promotes head and neck flexion when the infant is supine. This often results in functional airway obstruction in a sick, hypotonic infant as the tongue flops backward onto the posterior pharynx. The first step in airway management is to place the patient in a sniffing position, which brings the tongue forward. In addition, the epiglottis is a large, broad, and floppy structure that partly obscures the vocal cords. The larynx is cephalad, anterior and cone or funnel shaped. The narrowest part of the young child’s airway is at the cricoid ring, not vocal cords as in children over 8 years of age. The cricoidthyroid membrane is smaller and difficult to locate in young patients with a short neck. The overall caliber of lower airway structures is smaller and shorter. Small degrees of edema, bronchospasm, or excess mucus production may result in significant obstruction.
Pediatric Airway Equipment
These anatomic differences, taken in aggregate, explain why the pediatric airway is highly vulnerable to obstruction and respiratory failure. They also are the reason why different equipment will be required to resuscitate critically ill and injured pediatric victims. Straight (Miller) blades should be used to directly lift up the epiglottis and compress the tongue and submandibular tissue. Endotracheal tubes are selected by patient size. The common rule of thumb for children over 2 years of age is 4 + age years/4. For example, an average 4 year old would require a 4 + 4/4 or size 5 tube. Uncuffed endotracheal tubes should be used in most settings in children less than 8 years old since the cricoid ring provides an anatomic cuff. Cricoid pressure (Sellick maneuver) is essential to gently push and stabilize the anterior larynx within view. Narrower airway structures and higher resistances may require higher pressures when ventilation is initiated. Short tracheal lengths (4 to 5 cm in a newborn) predispose for tube dislodgement and right mainstem intubation.
Bag-valve-mask ventilation
Tthe first maneuver used to provide ventilation and an essential skill for all pediatric providers is bag-valve-mask (BVM) ventilation. Correct equipment and training is needed. Self-inflating bags (manual resuscitators) are manufactured in several sizes: neonatal (250 cc, for newborns only), small child (450 cc, up to 5 years), large child (750 cc), and adult (1,000 cc). Correct size bag is essential in order to deliver adequate tidal volume. The mask must make a tight seal on the patient’s face. A properly sized mask should cover the mouth and nose. The top of the mask should fit in the bridge of the nose and the bottom, in the cleft of the chin. The mask should be clear and the rim, soft and compressible.
The E-C clamp technique describes BMV ventilation by one provider. The thumb and index finger (forming a C) firmly secure the mask on the patient’s face with the upper part of the mask in the bridge of the nose and the lower edge in the cleft of the chin. The third, fourth, and fifth fingers (forming an E) grip the mandible. Pressure on the submental triangle can compress and obstruct the airway. If this is ineffective, two people may be required to provide BVM ventilation. In this case, one person makes a seal with the mask making an E-C clamp with both hands. The second person provides ventilation. Ventilation should proceed at age-appropriate respiratory rates with sufficient time for exhalation. The technique of saying, “squeeze-release-release” is helpful in avoiding overventilation. Observing chest rise with bagging is essential to ensure adequate ventilation. Gentle cricoid pressure may be helpful to reduce gastric insufflation and prevent regurgitation of gastric materials. Poor chest rise may result from improperly sized mask and/or bag, inadequate mask seal or gastric distention. Gastric dilatation that restricts diaphragmatic excursion can make assisted ventilation ineffective. This can be avoided by the Sellick maneuver and placement of a nasal or oral gastric tube. Airway adjuncts such as the oral airway in an unconscious patient or nasopharyngeal airway in the setting of oral trauma should be considered.
The American Heart Association (AHA) Pediatric Advanced Life Support (PALS) guidelines recommend training in BVM ventilation for all prehospital providers and the BVM technique as a primary method of ventilatory support, particularly if transport time is short. In the prehospital setting, effective BVM ventilation can be mastered through training programs by greater than 90% of students. In a large controlled study of prehospital pediatric airway management in Los Angeles and Orange Counties in California, Gauche showed that BVM ventilation was as effective as endotracheal intubation in managing the young patient’s airway.
Endotracheal intubation
Ongoing ventilation is required in a subset of critically ill or injured patients with respiratory failure, severely altered mental status, and increased intracranial pressure, to protect the lower airway in settings following trauma, burns, anaphylaxis, and inhalation. A relative indication for endotracheal intubation is the requirement of definitive airway control before transport. Postintubation patients must be monitored with end-tidal CO2 and pulse oxymetry.
Assessment of Shock/Blood Volume
The presence of shock or circulatory failure in young children can be subtle. The recognition of shock relies upon a systematic evaluation of the end organs of perfusion rather than the interpretation of vital signs. Almost all hypoperfused young children will be tachycardic and normotensive until end-stage shock and cardiopulmonary failure occur. Hypotension is rare, in children even with significant blood loss, and ominous.
Determination of the severity of shock requires an assessment of central nervous system perfusion (mental status, recognition of parents, developmentally appropriate response to new environment, response to painful procedures), the presence and quality of peripheral and central pulses, and skin perfusion (capillary refill, skin color, skin temperature, presence of mottling). Signs of adequate fluid resuscitation include improvement in tachycardia, increase in systolic blood pressure, improved skin perfusion, improvement in mental status in nonsedated patients, and reestablishment of urine output at 1 to 2 cc/kg/hr. Failure to improve following fluid resuscitation should prompt immediate surgical involvement.
Vascular Access
Obtaining vascular access is often the most technically difficult aspect in pediatric resuscitation. Compensatory mechanisms of tachycardia and peripheral vasoconstriction are seen in response to hypovolemia. Vasoconstriction is more pronounced in infants who are exposed to a cold resuscitation environment. Visualizing venous landmarks is often impossible. In general, peripheral IVs should be attempted in anatomically reliable sites like the greater saphenous vein. In settings where an experienced provider and equipment are available, a central line, usually the femoral, may be the appropriate choice.
However, intraosseous (IO) access will be the most expeditious choice in most prehospital and initial resuscitation settings, especially when multiple victims are present. The AHA PALS recommendation is that IO access is appropriate in any age patient (formerly recommended for children 6 years old and younger). Initial attempts should be at the tibial plateau distal to the tibial growth plate. Alternative sites include distal femurs, anterior iliac crests, and sternum. IO should not be attempted in
bones where an IO has been previously placed and created a hole in the bone or with fractures. Confirmation of IO placement includes ability to withdraw bloody fluid from the marrow, stability of the IO in the bone, and, most importantly, the ability to flush IV fluid without infiltration into the soft tissues. Any fluid, drug, or blood product necessary to resuscitate a patient can be given through an IO.
bones where an IO has been previously placed and created a hole in the bone or with fractures. Confirmation of IO placement includes ability to withdraw bloody fluid from the marrow, stability of the IO in the bone, and, most importantly, the ability to flush IV fluid without infiltration into the soft tissues. Any fluid, drug, or blood product necessary to resuscitate a patient can be given through an IO.
Surface Area
The young child has an increased surface area/volume ratio making him more susceptible to insensible fluid and heat loss. In addition, infants and young children have less insulating fat and muscle mass for shivering and are less able to generate heat. Exposure to a cool environment (outside decontamination, undressed during resuscitation, wet clothes or blankets) or administration of large volumes of IV fluids may result in hypothermia. The young child’s temperature should be monitored and maintained throughout evaluation and resuscitation with infant warmers, overhead lamps, warm blankets, and warmed IV fluid.
Additional Considerations in Pediatric Trauma
Head injury is the leading cause of morbidity and mortality in pediatric trauma. Other serious injuries are associated with disaster-related trauma including crush injuries from collapsed structures and blunt or penetrating trauma from flying glass and debris. Fractures may result from falls on unstable or slippery footing. Minor trauma generally consists of abrasions, lacerations, and puncture wounds from nails and other sharp objects. Important considerations come into play in the resuscitation of the seriously injured pediatric trauma patient. Many of these are derived from the young child’s small size, developing fat and musculature, and pliable skeleton.
Kinetic energy from a blunt injury is transmitted over a smaller mass. Most seriously injured children have multiple injuries including injury to the central nervous system. Head injuries are common because of the child’s disproportionately large head and small torso. When ejected in the air from a blast or thrown from a motor vehicle, the small child travels headfirst. Intraabdominal organs are highly susceptible to injury because of their relatively large size within the abdomen and the lack of protection afforded by ribs, fat, muscle, and connective tissue. The bladder is within the abdomen and is unprotected by the bony pelvis. Thoracic injuries are uncommon but, when present, are a source of significant morbidity. Unlike adults, injury to the heart, great vessels, and lung occur without coexistent fractures. Spinal cord injures, also rare, can occur without bony abnormalities visible on plain radiographs.
TABLE 41-1 Agents Likely to Be Used in Chemical Terrorism | ||||||||||||||||||||||||||||
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PEDIATRIC ASPECTS OF NUCLEAR, BIOLOGICAL, AND CHEMICAL TERRORISM
Biological, Chemical Agents
Biological agents and the chemicals commonly considered in terrorism, such as the nerve agents, are unusual poisonings in children (22,23,23). The approaches that have been developed for the treatment of these weapons of mass destruction (WMD) have focused on an adult, military model. Yet children are more vulnerable to the effects of these agents. In the setting of a large-scale disaster, children are compromised simply because they are young and less able or unable to recognize the danger of an exposure. Because children are physically less mature, they are limited in their ability to climb, run, or flee. Children are more susceptible to respiratory failure and dehydration. Children with chronic illness, especially those with diminished cardiopulmonary reserve, are at greatest risk. Because they almost always congregate in groups at school and in day care and may be too young to practice prudent hygiene, they have a higher risk of person-to-person transmission. Finally, as large numbers of infected adults become unable to care for their children, the care of well and uninfected children becomes a greater burden to the community (Table 41-1).
Regarding biological or chemical agents used in terrorism, drug treatments and antidotes are not as well studied in children and commonly recommended adult medications are not approved for children. Weight based dosing regimens and dispensing mechanisms (e.g., autoinjectors for atropine and pralidoxime) are not available. First-line antibiotics (e.g., fluoroquinolones and tetracyclines) recommended for biologic agents are contraindicated in young children. In general, universal availability of equipment in the sizes needed to care for children of different ages is a pervasive problem encountered in emergency response. The technical aspects of airway management and vascular access may be obstacles in the setting of large numbers of younger patients.
TABLE 41-2 Mechanisms Through Which Children Could Be More Severely Affected by Chemical and Biologic Agents | |
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A 2000 consensus statement of the American Academy of Pediatrics’ Committee on Environmental Health and Committee on Infectious Disease entitled “Chemical-Biological Terrorism and its Impact on Children” highlighted mechanisms through which children could be more severely affected by chemical and biologic agents (Table 41-2)(24).
Chemical Agents
Readily available, chemical agents do not require sophisticated delivery devices for dispersion and are capable of rapidly causing illness. Nerve agents are well absorbed through intact skin. Impregnated clothing can release toxin for prolonged periods following initial contact. Health care and rescue workers must wear full protective gear including respiratory filers to avoid self-contamination. Sarin gas is concentrated closer to the ground and poses a special threat to children. Mustard gas, chlorine, and ammonia are corrosive and would injure skin, especially mucosa of the nose and eyes. Inhalation would cause chemical pneumonitis.
TABLE 41-3 Autoinjector Administration and Dosing in Children
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