Terrorism, by definition, involves a random act of violence directed against property or people to intimidate and coerce governments for political, religious, or ideologic purposes. Characteristically, these acts of violence are directed against the innocent, and the instruments of terror may take several forms. Terrorism is becoming more prevalent in our society and has been labeled "the war of the future."1 Explosions and bombings result in significant property damage and involve large numbers of casualties and therefore they are one of the most common methods of terrorism employed today. However, since the dissolution of the Soviet Union there has been growing concern that terrorist groups will use nuclear, biological, and chemical weapons of mass destruction in the future. One of the most famous incidents of terrorism in recent history involving chemical agents occurred in 1995, when members of the Aum Shinrikyo cult released the deadly nerve agent sarin into a crowded Tokyo subway, causing more than 5000 injuries and resulting in 12 deaths. Later that year, the Federal Bureau of Investigation uncovered a terrorist plot to release chlorine gas at the Disneyland theme park in California.
As Americans we have generally considered ourselves immune to terrorism, adopting an "It can't happen to us" mentality. This attitude did not change, even after the 1993 bombing of the World Trade Center, the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma, and the 1996 bombing of Centennial Olympic Park in Atlanta, Georgia. The fact remains, however, that America has always been subject to acts of terrorism, and the number of terrorist incidents appears to be increasing at an alarming pace, increasing nearly 400% between 1984 and 1994. For example, from 1969 to 1983, there were 220 terrorist bombings that resulted in 463 deaths and 2894 injuries in the United States alone. During the decade between 1984 and 1994, there were more than 18 000 bombings resulting in 256 deaths, more than 3000 injuries, and an estimated $575 million in damage.2·3 The recent terrorist disasters of September 11, 2001, have led to the haunting realization that we live in a dangerous world and continue to be vulnerable to these kinds of attacks.
Mass casualty emergencies, by definition, are characterized by the sudden influx of large numbers of casualties that exceed the capabilities of local emergency and medical resources. An example from recent history is illustrative in this regard. On August 6, 1997, Korean Airlines Flight 801, a Boeing 747-300 carrying 254 passengers and 6 crew crashed into the Fonte Valley at the base of Nimitz Hill, Guam, approximately one quarter of a mile short of the runway. The aircraft skimmed the top of a small hill and plummeted down a small ravine, causing the fuselage to break apart and explode into flames. Most of the passengers and crew onboard either died immediately on impact or were burned alive in the subsequent fire. During the initial stages of the ensuing rescue, 30 victims were found alive at the crash site, and for the first 1 to 2 hours there were more survivors than there were rescue and emergency personnel available to assist. The United States Naval Hospital in Guam received 19 patients, while the local civilian hospital received 13 patients. Despite the relatively small number of casualties, the resources of both hospitals were quickly exceeded. However, due to prior planning, training, and organization, morbidity and mortality were minimized.
The A-B-C Approach to Assessment of the Pediatric Patient
The 1995 Tokyo subway sarin gas attack illustrates the unique problems inherent in terrorist acts involving weapons of mass destruction. The vast majority of the more than 5000 casualties arrived at area hospitals via taxi, automobile, or on foot, while fewer than 10% came to hospitals via the emergency medical services (EMS) system. Similar circumstances have been noted in other mass casualty emergencies, highlighting an important fact that during a mass casualty emergency a hospital can be overwhelmed quickly by patients that appear without prior triage or notification. Command and control at the scene are essential components of any disaster response. St. Luke's International Hospital, one of the closest hospitals to the site of the attack, triaged 641 casualties; five casualties presented to the emergency department in full cardiac or respiratory arrest, and 106 casualties required hospitalization for symptoms of sarin gas exposure.4,5
An organized, well-planned approach to any mass casualty emergency is essential. Terrorist incidents are inherently more complex and add the emotional elements of anger and fear to an already complicated situation. Therefore, organization and preparation assume even greater importance for mass casualty emergencies following terrorist acts. Unfortunately, or fortunately depending on individual viewpoint or perspective, very few physicians have had any practical experience with mass casualty emergencies. The fact is, until recently, outside of the military medical community, disaster medicine has received very little attention, both in the medical literature and in graduate medical education.6 In fact, there were only 416 articles appearing in MEDLINE under the subheading of terrorism prior to 9/11/01, while there were 1422 articles from 9/11/01 to 9/1 1/02. Several studies documented that the vast majority of civilian hospitals are unprepared for a mass casualty emergency secondary to a terrorist incident involving weapons of mass destruction.7-11
THE PEDIATRIC CASUALTY: SPECIAL NEEDS FOR A SPECIAL POPULATION
Advances in pediatric critical care medicine have resulted in dramatic improvements in outcomes for critically injured children. Children, however, are different from adults and require more specialized care. Several studies have documented significantly improved outcomes when children receive care in the pediatric intensive care unit (PICU) compared with the adult intensive care unit.1214 It is unreasonable to expect every hospital to be able to provide comprehensive care for the wide range of complex medical and surgical problems that afflict the critically injured child. During a mass casualty emergency following a terrorist act, however, hospitals may be called upon to provide the initial resuscitation and stabilization of pediatric trauma victims (Table 1).
Unfortunately, local emergency management and disaster plans often neglect the unique needs of children. For example, in 1990 an Avianca jetliner carrying 160 passengers crashed in a suburban area of Long Island, New York. Twenty- ' two pediatric survivors were neither properly triaged nor transported to appropriate medical facilities. Importantly, five critically injured children were transported initially to level III facilities with limited capabilities to treat pediatric trauma patients. The closest level I pediatric trauma center received no pediatric casualties whatsoever.15 The special needs of children should form an integral part of any disaster preparedness plan, and we, as pediatricians, must be involved at the community level. Predetermined, written transfer agreements between community-based emergency departments, community hospitals, specialized pediatric emergency departments, and tertiary care pediatric centers must exist in order to ensure that critically injured children are rapidly transported to facilities that can provide the optimal level of care. Categorization of hospitals according to their ability to provide emergency care for children to define the level of care provided, as well as regionalization of services to assure access to that care gives children the best possible outcome during any mass casualty emergency, especially those that follow a terrorist incident.
HEALTH CARE FACILITY PLANNING FOR PEDIATRIC VICTIMS OF WEAPONS OF MASS DESTRUCTION
Planning for mass casualties is standard practice for many health care facilities, but specific planning and training for possible terrorist events and potential weapons of mass destruction has only recently gathered much attention. Community-wide planning for such events occurs at many levels but often the preparedness of the local health care facility is overlooked in this planning process. A real mass casualty event due to a weapon of mass destruction will stress the resources of any health care facility as it attempts to triage, decontaminate, and care for a potentially large number of victims while ensuring that the health of patients already at the health care facility and employees is not compromised. This requires a well thought-out, executable plan that ensures effective command and control, smooth coordination with local and federal resources, secure communications, adequate staffing and supplies, and a system to track patients accurately. In addition, there needs to be planning for the extra psychological and public affairs support that will be needed to handle the resultant media attention and possible public mass hysteria. Clearly, guidelines for such planning are beyond the scope of this article, and the reader is referred to several excellent recent articles.15'22
Pediatric victims likely will be among the victims of any mass casualty event. In fact, pediatric patients may represent a disproportionate number of the casualties related to a number of physiological differences in such an event. The current literature on pediatric planning for these issues is scarce, and it is vital that pediatricians take an active role in community and local health facility disaster planning. This article highlights some of the unique pediatric needs that will occur in the triage, stabilization, and medical treatment of victims of weapons of mass destruction and, because bomb and gunshot victims remain the biggest terrorist threat, covers the treatment of the blast victim.
Triage and Decontamination
The word triage is derived from the French verb trier, which literally means to sort. The concept of triage is well known and recognized, but the actual act of triage is often much more difficult. The most commonly used system of triage involves sorting individual casualties according to their severity of injury and need for immediate care into one of four categories: immediate, delayed, minimal, or expectant (Table 2, page 101). The principles of triage as defined classically are seldom practiced today. The usual management of trauma practiced in emergency departments across the country differs greatly from the kind of trauma management called for during a mass casualty emergency. In today's environment, patients are brought to the hospital and tremendous resources and manpower are applied to maximize survival. Conversely, during a mass casualty emergency, the needs of the population as a whole must outweigh the needs of the individual. A mass casualty emergency requires a change in mindset such that the greatest good is achieved for the greatest number of victims, rather than each individual casualty. This is a difficult concept to accept for many physicians, partly because it necessarily means that some survivors (ie, those in the expectant category) will not be treated. It should be apparent that there are no absolute criteria by which casualties are sorted into each individual category. Rather, the triage provider triages casualties based upon the available resources as well as the number of casualties that are anticipated. Effective triage, then, requires advance preparation and planning, as well as education and training in mass casualty principles.
Triage following a mass casualty emergency involving chemical or biological weapons is even more complex. Although one of the first obstacles that may be encountered will be the actual recognition of a biological or chemical event, this article presumes that an event has been recognized either due to the nature of the event or an announcement by a terrorist organization. Once the event has been recognized, the health care mass casualty plan should be put into effect immediately, and the decontamination station should be made operational. In addition, those security and health care workers who will be managing contaminated casualties should have immediate access to their protective equipment.
All potentially contaminated individuals should receive a brief medical examination and triage prior to decontamination. Health care facilities should ensure that personnel familiar with pediatric specific issues are included in this triage process. Next, individuals should be directed to the decontamination station. Pediatric patients should be decontaminated in a similar fashion as adult patients, using soap and water. Pediatric patients, both ambulatory and medically ill patients, will require additional assistance both for the physical act of decontamination as well as psychosocial support. It is critical to establish a decontamination system that allows for additional assistance to be given to pediatric patients and other individuals who need help with decontamination, while allowing those who can self-decontaminate to continue through the process. Often the decontamination station is located outside the health care facility to allow separation of contaminated areas from clean areas, so it is critical that heat loss be minimized for the pediatric patient in order to prevent hypothermia. Heat lamps may be required for pediatric patients. Decontamination must be done safely but as quickly as possible and warm blankets provided to individuals following completion. Next, patients should be properly identified and logged in as well as contaminated property stored in a plastic bag and secured. Proper identification and tracking of unaccompanied minors is critical.
Following decontamination, a secondary triage should occur to allow proper referral of patients to treatment or holding areas. In addition, antidotes may be given as required. Patients with minimal to no injuries should be directed to large holding areas where information and psychosocial support can be provided as well as continued observation for changes in medical status. A separate area for unaccompanied minors should be established, with a secure identification system in place. Patients with moderate to severe injuries or illnesses should be referred to the appropriate treatment area, consistent with the mass casualty plan. A separate pediatric team to whom pediatric patients are directed, or inclusion of a pediatric-trained provider at each treatment station, is crucial.
INTENSIVE CARE UNIT PLANNING AND MANAGEMENT ISSUES
Eventually the most critically ill patients will arrive to the PICU, with the remainder of the patients admitted to other inpatient areas. It is critical for the inpatient areas to activate their own emergency plan once an event is recognized and the mass casualty plan activated. Assessment of patient stability for transfer from the PICU should be done and transfer accomplished as soon as possible. Following the Oklahoma City bombing, one hospital encountered difficulties in transferring patients to other areas of the hospital because of the overloaded or disrupted external communication system (inability to reach physicians for transfer orders) and internal communication system (difficulty in determining bed availability).23 In addition, transfer of patients was impeded by support personnel being quickly overwhelmed by the multiple tasks they were required to perform. Health care facilities should develop transfer protocols for mass casualty events, should have alternate methods of communication available (walkie-talkies), and should ensure that a reliable personnel recall system has been established and tested. Other critical components that must be included in the PICU mass casualty plan are ensuring adequate supplies, developing an effective lab and xray tracking system, crowd and media control measures, and psychosocial support for patients and families.
Pediatric intensive care unit management of victims of weapons of mass destruction is generally supportive except for the specific antibiotics and antidotes mentioned in other articles in this series. Pediatric dosing is generally based on a weight but there are occasionally age group differences as well. Pediatric references should be readily available, and pediatric dosing should be included in training given to staff members as part of disaster planning and training. In general, standard blood borne precautions are all that is required for most biological and chemical weapons once effective decontamination has been accomplished. There are three notable exceptions where personto-person transmission risk is significant, and additional precautions are required. These include pneumonic plague, viral hemorrhagic fevers, and smallpox. Suspected cases of viral hemorrhagic fevers should be placed under contact precautions with placement in a private room or cohorting, use of gloves with proper disposal after soilage, and the use of protective gowns when contact with the patient is required or the patient has diarrhea or wound drainage. Pneumonic plague requires droplet precautions and placement in a private room or cohorting. Personnel should use a mask when working with a patient.
Currently there is some debate regarding the necessary level of transmission precautions for smallpox. Many older sources suggest that airborne precautions including a negative pressure room and respiratory protection for health care workers entering the room are required. However, some believe that droplet precautions may be sufficient. For all patients with transmissible disease, movement around the hospital should be limited. Patients requiring droplet or airborne precautions in their room who must be moved outside of their room should be masked. Up-todate guidelines on transmission precaution requirements for these pathogens should always be available in every health care facility.
Different disasters result in different patterns of injury, and knowledge of these patterns based on prior experience and training is essential to the organization and planning of an effective disaster response. Again, because explosions and bombings result in significant property damage and involve large numbers of casualties, they are often the weapons of choice among terrorists. Therefore, in this review we concentrate on injuries resulting from this category of instruments of terror. Injuries secondary to biological, chemical, and radiological agents are discussed elsewhere in this issue.
Figure 1. Types of primary blast injury.
There are three categories of trauma that occur following an explosion - primary, secondary, and tertiary blast injury. Traditionally, blast injuries were rarely encountered except during wartime, and very few victims with severe blast injury ever reached medical facilities alive. During the past few decades, however, there has been a resurgence of medical literature devoted to this topic. As the frequency of terrorist bombings increases worldwide, it is likely that more physicians will encounter this type of injury.
Primary blast injury is the result of sudden changes in atmospheric pressure caused by the blast wave following an explosion. The magnitude of injury, which involves almost exclusively gasfilled organs such as the ear, respiratory system, and gastrointestinal tract, depends primarily upon the magnitude and duration of the peak overpressure of the shock wave (Figure, page 103). Strong, powerful explosions produce shock waves that can cause injury at great distances from the center of the blast. Although the physics are complex, the blast shock wave has three components: 1) an extremely short, single burst of increasing pressure; 2) a longer phase of negative pressure; and 3) a massive movement of air known as the blast wind, which at times may be strong enough to demolish buildings. An explosion producing a pressure differential of just 5 pounds per square inch, which is sufficient strength to rupture the eardrum of 50% of exposed individuals, produces blast winds in excess of 145 mph. Conversely, an explosion strong enough to produce significant primary blast lung injury in exposed individuals produces blast winds in excess of 800 mph.24,25 The strength of these blast winds may be magnified considerably when they are channeled through alleys or corridors, or bounce off of walls in confined spaces. The major mechanism of injury is thought to be because of a process called spalling, in which tissues at airliquid interfaces are disrupted as the shock wave passes through the victim's body. Accordingly, solid organs such as the liver and spleen are rarely affected by primary blast injury.
Secondary blast injury occurs when casualties are struck by flying objects and debris. Typically, these injuries are similar to those injuries occurring secondary to penetrating and blunt trauma that are seen on a daily basis in any emergency department across the country. Tertiary blast injury is a type of penetrating or blunt trauma that occurs when the body is hurled through the air by the blast shock wave. Injuries are caused when the body strikes either other objects or building structures. Other injuries typically seen following explosions or blasts include bums, carbon monoxide poisoning, and inhalational injuries (due to inhalation of smoke, debris, and combustible materials).
While few physicians have any actual experience with mass casualty emergencies, the growing threat of terrorism in the current environment makes it imperative that all physicians and hospital personnel be prepared for such a contingency. Studies show that the majority of US hospitals are unprepared for a mass casualty emergency following a terrorist act that involves weapons of mass destruction. In addition, the literature suggests that training and education in mass casualty emergencies and disaster medicine receive little attention in the graduate medical education curricula of the majority of US training programs. The fact remains that America likely will continue to remain a target for terrorists, and the civilian medical community needs to learn from the medical communities in countries such as Israel, Great Britain, and Lebanon, where terrorist incidents are more prevalent. Many emergency management and disaster plans neglect the unique needs of children. Children will assuredly be among victims of any mass casualty event, and pediatricians must be involved in disaster preparedness and the development of mass casualty contingency plans at the community level to assure that they are not forgotten.
1. Stein M, Hirshberg A. Medical consequences of terrorism: the conventional weapon threat. Surg Clin N Am. 1999;79:1537-1552.
2. 2994 Bomb Summary. Quantico, VA: Federal Bureau of Investigation, U.S. Department of Justice; 1995.
3. Frykberg ER, Tepas JJ. Terrorist bombings: lessons learned from Belfast to Beirut. Ann Surg. 1988;28:569-576.
4. Ohbu S, Yamashina A, Takasu N, et al. Sarin poisoning on Tokyo subway. South Med J. 1997;90:587-593.
5. Okumura T, Takasu N, Ishimatsu S, et al. Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med. 1996;28:129-135.
6. Pesik N. Do US emergency medicine programs provide adequate training for bioterrorism? Ann Emerg Med. 1999;34:173-176.
7. Glick J, Birnbaum ML. Perceived preparedness for a mass casualty disaster in the United States: a survey. Prehospital and Disaster Mediane. 1998;13:104-119.
8. Macintyre AG, Christopher GW, Eitzen E, et al. Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities. JAMA. 2000;283:242-249.
9. Treat KN, Williams JM, Furbee PM, Manley WG, Russell FK, Stamper CD. Hospital preparedness for weapons of mass destruction incidents: an initial assessment. Ann Emerg Med. 2001;38:562-565.
10. Burkle FM. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions. Emerg Med Clin North Am. 2002;20:409-436.
11. Waeckerle J. Domestic preparedness for events involving weapons of mass destruction. JAMA. 2000;283:252-254.
12. Pollack MM, Alexander SR, Clarke N, et al. Improved outcomes from tertiary center pediatric intensive care: A statewide comparison of tertiary and nontertiary care facilities. Crit Care Med. 1991;19:150-159.
13. American Academy of Pediatrics, Task Force on Interhospital Transport: Guidelines for Air and Ground Transportation of Pediatric Patients. Elk Grove, IL, American Academy of Pediatrics; 1993.
14. American College of Critical Care Medicine, Society of Critical Care Medicine: Consensus report for regionalization of services for critically ill or injured children. Crit Care Med. 2000; 28:236-239.
15. van Amerongen RH, Fine JS, Tunik MG, Young GM, Foltin GL. The Avianca plane crash: an emergency medical system's response to pediatric survivors of the disaster. Pediatrics. 1993;92:105-110.
16. American Academy of Pediatrics, Committee on Environmental Health and Committee on Infectious Diseases. Chemical-biological terrorism and it's impact on children: a subject review. Pediatrics. 2000;105:662-670.
17. Macintyre AG, Christopher GW, Eitzen E, et al. Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities. JAMA. 2000;283:242-249.
18. Malone J. Provider and health care system response to a bioterrorist attack. BUMC Proceedings. 2001;14:224-230.
19. Medical Management of Biological Casualties Handbook. Frederick, Md. US Army Medical Research Institute of Infectious Diseases; 2000.
20. Medical Management of Chemical Casualties Handbook. Aberdeen, Md. US Army Medical Research Institute of Chemical Defense; 2001.
21. Moser R White G, Lewis- Younger C, Garrett L. Preparing for expected bioterrorism attacks. Mil Med. 2001;166:369-374.
22. Torpy J. New threats and old enemies: challenges for critical care medicine. JAMA. 2002;287:1513-1515.
23. Anteau C, Williams L. The Oklahoma bombing: lessons learned. CCNCNA. 1997;9:231-236.
24. Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53:201-212.
25. Wightman JM, Gladish SL. State of the art: explosions and blast injuries. Ann Emerg Med. 2001; 37:64-678.