Embed Size (px)
Citation preview
Pediatric Issues In Asymmetric Warfare
James Howson, CEM,NRPUnit ChiefOperational Medicine Unit Bureau of Diplomatic Security
1
“In the event of a terrorist attack, children would be one of the most vulnerable populations”
US Department of Health and Human Services
2
“The use of chemical or biological weapons against a civilian population would disproportionately affect children”
American Academy Of Pediatrics
3
Unconventional Warfare
• Also called Asymmetric Warfare
• Unconventional strategies and tactics adopted by a force when the military capabilities of belligerent powers are not simply unequal but are so significantly different that they cannot make the same sorts of attacks on each other.
• Challenging the United States in conventional combat is an invitation to disaster, but use of unconventional weapons and tactics, such as those associated with guerrilla warfare and terrorist attacks can provide significant advantages.
4
Unconventional Warfare Continued
• Children are being specifically targeted.▫ Peshawar, Pakistan (2014)
Chemical Attack on School – 132 dead
▫ Chibok, Nigeria (2014) Kidnapping of 276 girls from a school
57 boys were killed in the incident
▫ Beslan, Russia (2004)
Attack on a school – 777 children held hostage, 331 killed
▫ Starogladovskaya, Chechnya (12/05)
Nerve agent attack on a middle school – over 100 dead
5
Unconventional Warfare Continued
• Terrorist attacks against children have dramatically increased over the past 10 years.
▫ They have symbolic value
▫ There is significant media coverage
▫ Children and schools are considered “Soft Targets”, it is easy to inflict horrific damage on what are lightly defended targets.
6
Terrorist Attacks Targeting Educational
Institutions Worldwide, 1970-2013
University of Maryland Global Terrorism Database
7
Physiologic Concerns• Children are particularly vulnerable to
aerosolized CBRNE agents.▫ Children breathe at a faster rate than adults;
therefore, they would be subject to relatively larger doses of an agent during the same period of exposure as an adult.
▫ Many agents are heavier than air and accumulate close to the ground - in the breathing zone of children.
▫ Because their skin is more permeable and they have a larger surface area to mass ratio than adults, children are more susceptible to absorbed agents.
8
Physiologic Concerns Continued
• Children are more vulnerable to agents that produce vomiting or diarrhea.
• Because of their larger body surface area they are more susceptible to hypothermia after having been decontaminated.
• Since Children’s lungs are generally not fully matured until 8 years of age, exposure to a chemical agent at an early age may cause developmental problems.
9
Physiologic Concerns Continued
• Many chemical warfare agents are carcinogenic and mutagenic and may pose long term problems for children who are exposed in an attack.
• Because children’s bones are more flexible there are fewer fractures that can be used as trauma markers, therefore, internal injuries may be over looked.
10
Developmental Concerns
• Young children do not have the cognitive ability to determine when or how to escape from danger.
• Young children, toddlers and infants do not have the motor skills to escape from the site of a WMD Incident.
• Nerve agents are known to cause neuropsychiatric effects, what is unknown is how long these effects will last in children.
11
Psychological Issues
• Children are at risk for post traumatic stress disorder after experiencing a WMD event.▫ In a WMD Event they may witness the deaths
of their siblings, peers or even their parents.
▫ Even children not directly involved in the event may be affected by the repeated showings of the event by the media. “The CNN Effect”
• Nerve agents are known to have degenerative cognitive effects on patients, but it is unknown how permanent these effects will be in the pediatric population.
12
Nerve Agent Issues
• Children can be disproportionately affected by exposure to chemical agents.
• Generally, because they are inhaled, the can poise a greater threat to children due to their more rapid respiratory rates.
Lethal dose of SARIN
13
Nerve Agent Antidote Kits
• The current NAAK is the: Antidote Treatment Nerve Agent, Auto-Injector (ATNAA)
• The ATNAA consists of one Auto injector that delivers ▫ Atropine 2 mg in 0.7 ml
▫ Pralidoxime Chloride 600 mg in 2 ml
Convulsant Antidote for Nerve Agents (CANA).
Diazepam 10 mg in 2 ml
14
The “Nord-Ost” Incident
• In October 2002, Chechen separatists seized a Moscow theater, taking over 800 hostages.
• Russian special forces assaulted the theater using a gas based on Fentanyl in an attempt to “Knock-Out” everyone in the theater.
• At least 120 hostages died from the effects of the gas, 14 were children.
• Although hard information remains difficult to obtain, it appears that the pediatric hostages died at over twice the rate of the adult hostages.
15
Biological Agent Issues
• Children can be disproportionately affected by exposure to biological agents.
• Children are more vulnerable to agents that produce vomiting or diarrhea.
• Because children breathe at a faster rate than adults they would be subject to relatively larger doses of an agent during the same period of exposure as an adult.
16
The Sverdlovsk Incident
• In 1979 there was an accident at the Biopreparat plant in the city of Sverdlovsk in the former Soviet Union that released anthrax into the air.
• After the accident several hundred people became ill with anthrax.
• Over 75 people died, but none of the known fatalities were under 24 years old.▫ It is known that the anthrax plume passed
over at least one school and teachers from that school did become ill.
▫ One (1) child did get the cutaneous form of anthrax from this incident.
Coetaneous anthrax lesion
17
Radiological Agent Issues
• Children were disproportionately affected by exposure to radiation during incidents in Brazil and Russia.
• Radiation induced cancers occur more often in children than in adults exposed to the same dose.
• Children exposed to radiation in utero are very prone to birth defects and DNA changes.
18
The Chernobyl Incident
• On April 26, 1986 the No. 4 Reactor at the Chernobyl Nuclear Power plant exploded and released thirty to forty times the radioactivity released by the atomic bombs dropped on Hiroshima and Nagasaki.
• Prior to 1986, the Ukrainian thyroid cancer rate was 5 per million, it is now 45 per million.
• A WHO study found "an unexpectedly high increase" in mutations among Ukrainian children born after the 1986 Chernobyl disaster.
19
Unconventional Warfare
• Because children’s bones are more flexible there are fewer fractures that can be used as trauma markers, therefore, internal injuries may be over looked.
20
The Beslan School Attack
• On September 1st, 2004 Chechen separatists seized a school in southern Russia, taking over 1300 hostages.
• The Chechens originally considered attacking an orphanage, but decided that there would be greater impact if they attacked a school because the children would have parents and relatives.
• The siege lasted three days
21
The Beslan School Attack Continued
• 186 children were killed
• 248 children were hospitalized
• Most of the deaths occurred from explosions of mines and booby traps.
• Many children who tried to escape were shot in the back
22
Decontamination Issues
• How do we decontaminate large numbers of pediatric patients?
• Do we separate them from their parents?
• Do we Decon parents and children of different sexes
together?
23
Decontamination IssuesContinued
• Once we take their clothing away, what are they going to wear?▫ Post Decon clothing kits
designed for adults don’t generally fit children well.
• Because children have a grater susceptibility to hypothermia, heat lamps and warming equipment must be made available when decontaminating
children.
24
Psychological Issues
• Children are at risk for post traumatic stress disorder after experiencing a WMD event.▫ In a WMD Event they may witness the deaths of
their siblings, peers or even their parents.
▫ Even children not directly involved in the event may be affected by the repeated showings of the event by the media. “The CNN Effect”
• Nerve agents are known to have degenerative cognitive effects on patients, but it is unknown how permanent these effects will be in the pediatric population.
25
Pediatric Issues When Unconventional
Weapons Are Involved
• Take away points:▫ Children are being specifically targeted by Terrorists
▫ Children are particularly vulnerable to aerosolized CBRNE agents
▫ Current triage criteria are ineffective for unconventional events involving children
▫ We don’t have good PPE for kids
▫ Decontamination of children is difficult
▫ There is significant risk of psychological effects
26
So, What can we do?
• Mentally prepare yourself, knowing that attacks will occur, think about how you might deal with a pediatric casualty.
• Be familiar with the equipment and medications available to you at post.
• Know that in these situations improvisation may be the key.
27
Questions?
28
