TABLE 132.7 PHARMACEUTICAL STOCKING ESTIMATES FOR ONE EMERGENCY DEPARTMENT IN A HYPOTHETICAL CHEMICAL AGENT ATTACK a Agent/antidote Pediatric dose Adult dose Total requirement (for 500 patients) Nerve agents Atropine 0.02–0.05 mg/kg 2–5 mg (minimum dose, 0.1 mg) Pralidoxime 25–50 mg/kg 1–2 g ampule 30 sec out of every minute 0.33 mL/kg (for Hgb 12 g/dL) 1.65 mL/kg amp 10 mL 1,500 ampules 4,575 mL 50 mL 25,000 mL = 500 vials (50 mL each) 2,138 g Cyanide Amyl nitrite Na nitrite (3%) Na thiosulfate (25%) Hydroxocobalamin 70 mg/kg 5g 6,875 mg = 17,188 amps (1 mL of 0.4 mg/mL); 859 vials (20 mL of 0.4 mg/mL) 1,875 g = 1,875 vials (1 g each) Note: Cyanide treatment would require either 375 nitrite/thiosulfate-based or 428 hydroxocobalamin-based cyanide antidote kits a Assumptions: 500 patients to one emergency department (as per one hospital’s experience in the Tokyo sarin attack); one-half of the patients are children with average weight of 10 kg; if nerve-agent attack, severe exposure necessitating maximal doses of atropine and pralidoxime; five atropine doses over 12 hrs; three pralidoxime doses over 12 hrs; if cyanide attack, severe exposure necessitating initial full dose of Na nitrite/Na thiosulfate, or hydroxocobalamin, followed by 50% of initial dose × Na, sodium; Hgb, hemoglobin CONCLUSION The prospect of a mass casualty incident from a terrorist release of biologic or chemical agents is more likely now than ever before Although the impact of such an event is almost unimaginable, at the same time, efforts must be made to prepare for this possibility Such preparedness requires highly coordinated responses involving local and regional EMS systems, HAZMAT teams, police and fire departments, hospital EDs, local and federal public health agencies, and civilian and military medical specialists In particular, EDs must consider important issues, including (i) the early recognition, triage, stabilization, decontamination, treatment, and disposition of multiple casualties of such an attack; (ii) protection of healthcare workers and existing patients; and (iii) the integrity of the ED itself to provide ongoing care to later-arriving casualties and to continue to meet normal patient demands Fortunately, our pediatric emergency care providers, academic medical centers, regional health departments, and several federal agencies, including the U.S Departments of Health and Human Services, Homeland Security, and Defense, are actively engaged in confronting these vital public health and national security challenges Suggested Readings and Key References General American Academy of Pediatrics Chemical and biological terrorism and its impact on children: a subject review Pediatrics 2000;105:662–670 Henretig F Biological and chemical terrorism defense: a view from the “front lines” of public health Am J Public Health 2001;91:718–720 Henretig FM, Cieslak TJ, Eitzen EM Jr Biological and chemical terrorism J Pediatr 2002;141:311–326 Henretig FM, McKee MR Preparedness for acts of nuclear, biological and chemical terrorism In: Gausche Hill M, Fuchs S, Yamamoto L, eds APLS: The Pediatric Emergency Medicine Resource Sudbury, MA: Jones and Bartlett, American Academy of Pediatrics and American College of Emergency Physicians; 2004:568–591 Macintyre AG, Christopher GW, Eitzen E Jr, et al Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities JAMA 2002;83:242–249 Biologic Terrorism Breman JG, Henderson DA Diagnosis and treatment of smallpox N Engl J Med 2002;346:1300–1308 Christopher GW, Cieslak TJ, Pavlin JA, et al Biological warfare: a historical perspective JAMA 1997;278:412–417 Fine AM, Wong JB, Fraser HS, et al Is it influenza or anthrax? A decision analytic approach to the treatment of patients with influenza-like illness Ann Emerg Med 2004;43:318–328 Franz DR, Jahrling PB, Friedlander AM, et al Clinical recognition and management of patients exposed to biological warfare agents JAMA 1997;278:399–411 Henretig FM, Cieslak TJ, Kortepeter MG, et al Medical management of the suspected victim of bioterrorism: an algorithmic approach to the undifferentiated patient Emerg Med Clin North Am 2002;20:351–364 White S, Henretig F, Dukes R Vulnerable populations in the setting of bioterrorism Emerg Med Clin North Am 2002;20:365–392 Chemical Terrorism Brennan RJ, Waeckerle JF, Sharp T, et al Chemical warfare agents: emergency medical and emergency public health issues Ann Emerg Med 1999;34:191– 204 Occupational Safety and Health Administration OSHA best practices for hospital-based first receivers of victims from mass casualty incidents involving the release of hazardous substances Available online at http://www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html Rotenberg JS, Newmark J Nerve agent attacks on children: diagnosis and management Pediatrics 2003;112:648–658 Sofer S, Tal A, Shahak E Carbamate and organophosphate poisoning in early childhood Pediatr Emerg Care 1989;5:222–225 Yu CE, Burklow TR, Madsen JM Vesicant agents and children Pediatr Ann 2003;32:254–257 * The views, opinions, assertions, and findings contained herein are those of the authors and should not be construed as official U.S Department of Defense or Department of the Army positions, policies, or decisions unless so designated by other documentation CHAPTER 133 ■ INSTRUCTIONS FOR PARENTS HILARY A HEWES, NANETTE C DUDLEY DISCHARGE INSTRUCTIONS Discharge instructions are an integral part of the emergency department (ED) experience Well-designed instructions serve as a summary of the ED course and a reference for ongoing medical management by the patient and outpatient care provider In addition, review of instructions at discharge offers a final opportunity for a patient to clarify any questions or concerns about care received or the follow-up plan Information given to the patient and family needs to be provided in an understandable and retainable manner Lack of comprehension of discharge instructions may lead to problems with compliance, incorrect use of medication, inadequate treatment and follow-up, and ultimately negative patient outcomes LEGAL AND REGULATORY CONSIDERATIONS The Centers for Medicare and Medicaid Services (CMS) measures specific elements in the transition record at hospital discharge Although obviously not specific to ED care, these recommendations can be adapted to ED discharge instruction content: Discharge diagnosis Procedures and tests performed, with significant findings, and any pending tests Medications prescribed/changes to medications, reasons for medication Patient and family instructions Reasons to follow up with primary care provider or specialist and reasons to return to the ED Follow up physician’s name, specialty, and contact information Meaningful Use Beginning in 2011, the CMS initiated a voluntary financial incentive plan for the “meaningful use” of certified electronic health record technology by ... Fuchs S, Yamamoto L, eds APLS: The Pediatric Emergency Medicine Resource Sudbury, MA: Jones and Bartlett, American Academy of Pediatrics and American College of Emergency Physicians; 2004:568–591... Readings and Key References General American Academy of Pediatrics Chemical and biological terrorism and its impact on children: a subject review Pediatrics 2000;105:662–670 Henretig F Biological and... later-arriving casualties and to continue to meet normal patient demands Fortunately, our pediatric emergency care providers, academic medical centers, regional health departments, and several