Pediatric exposure management

Pediatric exposures to vesicants can be quite toxic however, in contrast to nerve agent exposures, HD causes significantly greater morbidity than mortality. While mustard did not cause many deaths in WWI, death from HD exposure is usually due to massive pulmonary damage complicated by infection (bronchopneumonia) and sepsis. Children often show a quicker onset and greater severity of toxicity. Skin and eye toxicity occurs in the form of blisters or irritation that can result in blindness for the most severe cases. Except for lewisite, vesicant exposures must be managed with supportive care and rapid decontamination. 

Kilbride H, Castor C, Hoffman E, Fuger KL. Thirty-six month outcome of prenatal cocaine exposure for term or near-term infants impact of early case management. J Dev Behav Pediatr 2000 21 19-26. 

Managing pediatric victims of chemical terrorism is an especially difficult challenge. In addition to the obvious physiologic and anatomic differences compared to adults (Table 61.1), there are important psychological and behavioral differences that put children at risk (Rotenberg and Newmark, 2003). Anecdotal reports have claimed that children are likely to be the first to manifest symptoms, to develop more severe manifestations, and to be hospitalized for other related illnesses. In fact, it is anticipated that children will be overrepresented among the initial index cases in a mass civilian exposure to toxic chemicals. Children have many characteristics that make them vulnerable to toxic exposures. The smaller mass of a child automatically reduces the dose of toxic agents needed to cause... 

Although our military experience managing toxicity from nerve agent exposure is limited, exposures to related chemicals such as the OP class occur commonly each year in the USA. In 2006, there were a total of approximately 5,400 OP exposures across the USA (Bronstein et al, 2007). OPs, such as malathion, are commonly used as pesticides. OP toxicity manifests in a similar fashion as toxicity from nerve agents however, this chemical class is considerably less toxic. One case series of 16 children who experienced poisonings with OPs confirmed that pediatric patients present with toxicity differently than adults (Lifshitz et al, 1999). These children often did not manifest the classic muscarinic effects (such as salivary secretions and diarrhea) seen in adults. 

Nerve agent exposures must be handled quickly and efficiently. When children are exposed, it is important to remember that antidote dosing will be determined by the patient s weight and the severity of exposure. Progress has been made to provide pediatric-specific autoinjectors however, since 2-PAM Cl is not yet available in a pediatric autoinjector form, it is possible to carefiilly use adult autoinjectors to manage pediatric patients. 

While decontamination and supportive therapy are the mainstays of treatment, antidotes to counteract HD vapor, aerosol, or liquid exposures do not exist (Yu et al, 2003). Adult decontamination may include bleach solutions however, this method can cause greater toxicity in children. Soap and water are the preferred agents to use for decontamination in children. Supportive care consists of the management of pulmonary and skin manifestations such as the use of cough suppressants and/or topical silver sulfadiazine for bums (Yu et al, 2003 Sidell et al, 1997 Azizi and Amid, 1990). Pediatric dosage and treatment recommendations for vesicant exposures are displayed in Table 61.5. 

Rotenberg, J.S. (2003b). Diagnosis and management of nerve agent exposure. Pediatr. Ann. 32 242-50. 

Amaral, P. P., Dinger, M. E., Mercer, T. R., Mattick, J. S. (2008). The eukaryotic genome as an RNA machine. Science. 319 1787—1789. American Academy of Pediatrics. (2005). Policy statement. Lead exposure in children prevention, detection, and management. Pediatrics. 116 1036—1046. 

The high prevalence of egg allergy in the physically weak pediatric population increases the social interest in preventing allergic incidence. An allergen management practice to minimize early exposure to eggs has been proposed by physicians since... 

Due to the myriad of factors outlined here that make the management of pediatric chemical exposures challenging, it is not surprising that healthcare practitioners often lack the knowledge or are not sufficiently trained to handle a mass... 

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