Video 131.1 Color flow Doppler Video 131.2 RUQ normal Video 131.3 RUQ positive Video 131.4 LUQ normal Video 131.5 LUQ positive Video 131.6 Bladder sag normal Video 131.7 Bladder sag pos Video 131.8 Subxiphoid pericardial effusion Video 131.9 Parasternal long normal Video 131.10 Parasternal short normal Video 131.11 Lung sliding normal Video 131.12 Lung sliding pneumothorax Video 131.13 Pleural effusion Video 131.14 Pleural effusion with loculations Video 131.15 Early IUP with gestational sac Video 131.16 Late IUP with cardiac activity Video 131.17 Hydronephrosis Video 131.18 Intussusception transverse Video 131.19 Intussusception longitudinal Video 131.20 Appendicitis transverse Video 131.21 Internal jugular vein collapsing with pressure Video 131.22 Brachial vessels Video 131.23 Color Doppler pulsating Video 131.24 Femoral vessels with color Doppler, artery (L), vein (R) Video 131.25 Cannulation of vessel in long access (Blue Phantom) Video 131.26 Cannulation of vessel in short access (Blue Phantom) Video 131.27 Bladder and intra-abdominal free fluid Video 131.28 Neonatal spine in short axis Video 131.29 Neonatal spine in long axis Video 131.30 Abscess Video 131.31 Lymph node CHAPTER 132 ■ BIOLOGICAL AND CHEMICAL TERRORISM * RICHARD J SCARFONE, JAMES M MADSEN, THEODORE J CIESLAK, EDWARD M EITZEN JR GOALS OF EMERGENCY CARE Biologic and chemical terrorism involves the use of highly virulent or toxic agents with the intent to cause mass casualties, which could overwhelm regional emergency medical services (EMS) capacity and would pose unique medical management challenges Treatment goals include early syndrome recognition, understanding specific pediatric vulnerabilities, and knowing the major biologic and chemical agents of concern and the management of children exposed to them KEY POINTS Even small-scale, technologically primitive biologic or chemical attacks can cause considerable morbidity and wreak havoc on regional medical care systems, thereby successfully terrorizing a population Examples include the intentional spread of salmonella in The Dalles, Oregon restaurants in 1984; the 1995 sarin release on Tokyo subways; and the anthrax release in U.S mail in 2001 Chemical attacks can (but not necessarily) result in almost immediate effects, whereas biologic attacks evolve over days to weeks based on the incubation period of the infectious agent used Compared to adults, children have several unique vulnerabilities that will be detailed throughout the chapter, including the following: Risk of exposure—increased respiratory and dermal exposures Physiologic response—increased risk of dehydration and hypothermia Psychological response—less ability to cope with stress and emotional trauma Systems vulnerabilities—EMS and ED providers may have less experience taking care of children RELATED CHAPTERS Signs and Symptoms Coma: Chapter 17 Respiratory Distress: Chapter 71 Seizures: Chapter 72 Medical, Surgical, and Trauma Emergencies Environmental Emergencies, Radiological Emergencies, Bites and Stings: Chapter 90 Infectious Disease Emergencies: Chapter 94 Pulmonary Emergencies: Chapter 99 Toxicologic Emergencies: Chapter 102 BIOLOGIC AGENTS CLINICAL PEARLS AND PITFALLS Biologic attacks should be suspected when there are an unusually high number of cases, a common exposure history, and exotic disease presentations Ciprofloxacin, levofloxacin, and doxycycline are currently considered drugs of choice in the treatment and prophylaxis of anthrax, plague, and tularemia, even in children ( Tables 132.1 and 132.2 ) Current Evidence A working group convened by the Centers for Disease Control and Prevention (CDC) identified anthrax, smallpox, plague, botulism, tularemia, and the viral hemorrhagic fevers as the biologic exposures that would constitute the gravest threats to public health and security; the causative microorganisms and toxins are termed Category A agents We thus limit our focus here to these six agents ( Tables 132.3A and 132.3B ) In addition, we add a brief discussion of the phytotoxin (plant toxin) ricin because of its ready availability and ease of production Treatment protocols for these uncommon conditions are likely to evolve continuously, particularly if future incidents occur, as was the case when the mail-borne anthrax outbreak unfolded Of note, the fluoroquinolones and/or tetracyclines are currently considered drugs of choice in the treatment and prophylaxis of anthrax, plague, and tularemia Although these have often been avoided by pediatricians in the past, ... GOALS OF EMERGENCY CARE Biologic and chemical terrorism involves the use of highly virulent or toxic agents with the intent to cause mass casualties, which could overwhelm regional emergency. .. management challenges Treatment goals include early syndrome recognition, understanding specific pediatric vulnerabilities, and knowing the major biologic and chemical agents of concern and the... treatment and prophylaxis of anthrax, plague, and tularemia Although these have often been avoided by pediatricians in the past,