Mommy, My gas mask doesn’t fit! Pediatric Issues In Unconventional and Asymmetric Warfare James M. Howson, CEM, CHEC, NRP UMBC PACE Medic Recertification February, 2021 Disclaimers: This presentation was prepared by James Howson in his personal capacity. The opinions expressed in this presentation are the author's own and do not reflect the views of the National Institutes of Health, the Department of Health and Human Services, or the United States Government. No classified sources were used in putting together this presentation. All information presented in this talk was gleaned from “Open Source” materials. 1 Disclaimers Continued This presentation contains some images from actual terrorist and criminal events that my be disturbing to some viewers. “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 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 problematic, but use of unconventional weapons and tactics, such as those associated with guerrilla warfare and terrorist attacks can provide significant advantages. 3 Unconventional Warfare Continued Children are being specifically targeted. Kankara town, Nigeria (2020-12) Kidnaping of 333 boys from a school Similar to the kidnapping of 276 girls in Chibok, Nigeria by Boko Haram in 2014 In the 2014 attack girls were targeted and the boys were simply killed (57 boys) Peshawar, Pakistan (2014) Chemical Attack on School - 132 dead 57 boys were killed in the incident Beslan, Russia (2004) Attack on a school - 777 children held hostage, 331 killed Starogladovskaya, Chechnya (2005) Nerve agent attack on a middle school - over 100 dead Utoye Island, Norway (2011) Shooting attack on a youth camp, 69 dead, 33 were under the age of 18 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. 4 Pediatric Issues In Asymmetric Warfare Areas of Concern Physiologic and Developmental Concerns Personal Protective Equipment Effective Medication Delivery Devices Medications and Antidotes Decontamination Issues Psychological Issues Physiologic Concerns 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. 5 Physiologic Concerns 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. 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 neurophychiatric effects, what is unknown is how long these effects will last in children. 6 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. Personal Protective Equipment Most gas masks and protective equipment are designed for use by adults and are not suitable for use by children. 7 Personal Protective Equipment Continued Attempts have been made over the years to develop protective masks for children. This is an example of a gas mask designed by Walt Disney in the early 1940’s for use by children. Examples of Pediatric Protective Equipment 8 Examples of Pediatric Protective Equipment Continued Personal Protective Equipment Continued Although numerous attempts have been made to develop safe and effective pediatric protective equipment, no truly successful devices have been produced as yet. In Israel during the first Gulf War 8 people, including 6 children, died due to improper use of protective masks. 9 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 Nerve Agent Antidote Kits The current NAAK is the: Antidote Treatment Nerve Agent, Auto-Injector (ATNAA) (Replaces the Mark 1 Kit) 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 10 Autoinjector Effectiveness Continued Rapid absorption of the antidote following automatic injection is enhanced by the degree of tissue dispersion achieved by the autoinjector. Autoinjector medications are more efficiently diffused into surrounding muscle tissue due to the force with which it is expelled from the injector. Pediatric Auto Injectors 1.0 mg Dose 2.0 mg Dose 0.5 mg Dose 11 Walter Reed Pediatric Nerve Agent Treatment Guide Symptoms Triage Level Atropine Pralidoxime Diazepam Asymptomatic Delayed None None None Miosis, Mild Delayed None None None Rhinnorhea Miosis Immediate: 0.05 mg/kg IV 25-50 mg/kg For any Neurologic effect 30 days to 5 years Repeat as needed Repeat q 1 hr and any other Moderate 0.05 to 0.3 mg/kg IV q 5-10 min until Watch for: symptom Admit To a max 5 mg/dose respiratory status Muscle Rigidity improves 5 years and older Laryngospasm 0.05 to 0.3 mg/kg IV Tachycardia To a max 10 mg/dose Apnea, Immediate: 0.05-0.1 mg/kg 25-50 mg/kg May repeat q 15-30 min Convulsions, Severe No Maximum IV or IM as Above Cardiac Arrest Admit ICU Repeat q 5-10 min As above Source: Walter Reed Army Medical Center Atropine Continued If only standard MARK 1 kits are available, a 2.0 mg atropine autoinjector may be used. Note that infants and small children are at risk of being injured by the autoinjector needle. The most significant adverse side effect of high dose atropine in the younger patient is the inhibition of sweating. Source: USAMRICD 12 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. The “Nord-Ost” Incident Continued 13 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. Anthrax Anthrax is a bacterial disease caused by B anthracis and considered a potent biological weapon of mass destruction. Attempts to weaponize B anthracis were made as early as 1916, by Germany. They were attempting to contaminate raindeer herds in Norway and disrupt the movement of supplies from the allies to Russia. 14 Anthrax Continued The anthrax vaccine currently available in the US is not recommended for children by its manufacturer because it was only tested on age groups between 18 and 65 years. No pediatric study of its effectiveness has apparently ever been done. Some authorities have stated that the risk of vaccinating children with the current preparation would have to be weighed against the risk of not using every possible defense to protect children who have actually, or potentially been exposed to anthrax. Antibiotics Pediatric Dosing for Anthrax Exposure The drugs of choice for prophylaxis are Ciprofloxin, penicillin or amoxicillin. (20 to 40 mg/kg/day div TID to QID) NOTE - A genetically engineered BW agent might be resistant to penicillin or amoxicillin. The strain of anthrax used in the 2001 Bio-Terror Letter Attacks was sensitive to penicillin. In penicillin resistant cases, the drug of choice is doxycycline. (2 to 4 mg/kg/day div BID) The discoloration of teeth often associated with doxycycline is typically not seen until after taking six courses of the antibiotic. Source: USAMRIID 15 Anthrax Continued Doxycycline is normally not used in pediatric treatment because of side effects. However, in this situation it is possible that benefits will outweigh the possible disadvantages, and one course of doxycycline is not likely to cause staining of the teeth. Smallpox It first appeared in China and the Far East at least 2000 years ago. Used by the British during the French Indian War and later against the American Colonists during their attack on Quebec. There is some evidence that it may have been used by the Confederates against the Union forces during the American Civil War.