TY - JOUR
AU - Hay,, Elizabeth
AB - During winter 2003, officers from a U.S. Public Health Service (PHS) Disaster Medical Assistance Team and Office of Force Readiness and Deployment, formerly the Commissioned Corps Readiness Force, were deployed to the Washington, D.C., and New York City metropolitan areas in response to President Bush raising the Homeland Security Advisory System alert level to orange.1 An orange, or high-risk, condition is declared when there is a high risk of terrorist attacks.1,2 PHS officers were deployed to Washington, D.C., and New York City as a precautionary measure to provide ancillary medical support in case the local medical response system was compromised or overwhelmed as a result of a terrorist action. Intelligence reports did not elaborate or provide specific details regarding the type of threats involved.2 Consequently, the PHS officers had to prepare themselves for a variety of medical crises, including those caused by weapons of mass destruction (WMD). The Centers for Disease Control and Prevention (CDC) emergency preparedness and response Web site provides a list of man-made and natural medical threats.3 The threat list describes many potential bioterrorism, chemical, and radiation emergencies. PHS officers were deployed with ample supplies of antidotes and treatments for the most likely potential WMD events, including formulations appropriate for both adult and pediatric use. Although WMD pediatric dosing recommendations were readily available from CDC and elsewhere, it became evident to pharmacy team members during the orange-alert deployment that the guidelines are inadequate for practical use in a field environment or mass casualty situation in which access to laboratory and other high-level medical approaches would be limited or nonexistent. In general, calculations based on a child’s body weight were available, but additional issues must be considered when determining an appropriate pediatric dose (e.g., conversion of pounds to kilograms, calculation of dose based on body weight, calculation of volume to administer based on drug formulation concentration). The need for health care providers to complete a three- or four-step calculation, no matter how simple, during a high-stress WMD response significantly increases the potential for errors and inefficiencies. Development of dosing cards To improve response time, ensure public safety, and minimize risk, PHS pharmacist officers designed, developed, and produced WMD pediatric dosing cards. These cards provide standardized and simplified instructions to prepare and administer antidotes, treatments, and prophylactic medications to young victims exposed to WMD. The provision of standardized pediatric dosing cards will improve team readiness by minimizing the opportunity for potential dosing errors, thereby optimizing the care, treatment, and safety of pediatric patients during a WMD attack. Although inspired by a potential WMD crisis, the cards may also be used for industrial accidents or natural disasters. Each card is a pocket-sized reference that provides a dosing chart for each threat agent based on child weight ranges and commercially available formulations that are potentially available from the CDC’s Strategic National Stockpile program and other sources. Cards are color-coded based on the type of WMD agent (e.g., blue for cyanide, yellow for bioterrorism), so providers can quickly identify the correct card for the situation. Adult doses are also included on each card for completeness. Providers can swiftly scan the charts available on each card to verify the appropriate dose to administer. Depending on the nature of the event, providers can use the quick-reference cards as a crosscheck to verify the accuracy of their calculations or determine an approximate dose to administer without calculations. All doses have been rounded based on the child’s weight and the drug concentration. For example, relying solely on the WMD pediatric dosing cards for determining the appropriate dose of ciprofloxacin in postexposure prophylaxis for anthrax, both a 5-kg child and a 9-kg child could receive 75 mg p.o. twice daily. If one were to work through the weight-based calculations (15 mg/kg) and develop a precise dosage for each of these children, the result would be a maximum of 75 mg p.o. twice daily for the 5-kg child and 135 mg p.o. twice daily for the 9-kg child. While this rounding is probably not clinically significant with older or larger children, use of the quick-reference cards without further professional discretion and adjustments can result in wide variability for smaller children in terms of the actual milligram-per-kilogram dosage given. Therefore, we strongly recommend that the cards be used as a guide, supported by a common-sense approach, to assist professionals in the field when selecting an appropriate dose for children exposed to WMD. Although designed for empirical treatment in the field or mass-casualty setting, the cards have some practical use for limited events in a hospital environment. If access to high-level medical care is readily available, WMD treatments may be based on definitive laboratory monitoring (e.g., hemoglobin concentration for cyanide poisoning)4 rather than empirically based on weight and signs and symptoms. It must also be emphasized that many states and cities may have local protocols or policies that differ slightly from CDC guidelines. Any local WMD policies and protocols would supersede the guidelines listed on the quick-reference cards. All doses are based on published literature, including CDC guidelines. Each card includes supporting documentation (e.g., WMD agent signs and symptoms, adult dosing, reconstitution and storage instructions) and references.5,–16 Therefore, each card serves as a minireference for a specific WMD response. Currently, WMD pediatric dosing cards are available for calcium cyanide, hydrogen cyanide, cyanogen chloride, potassium cyanide, and sodium cyanide (Figure 11); the nerve agents sarin, soman, tabun, and O-ethyl S-(2-diisopropylaminoethyl) methylphosphonothiolate (Figure 2 2); radiation agents (Figure 33); and the biological agents causing anthrax, plague, and tularemia (Figure 4 4). Figure 4. Open in new tabDownload slide Front and back of dosing card for biological-agent exposure. Figure 4. Open in new tabDownload slide Front and back of dosing card for biological-agent exposure. Figure 1. Open in new tabDownload slide Front and back of dosing card for cyanide poisoning. Figure 1. Open in new tabDownload slide Front and back of dosing card for cyanide poisoning. All calculations and source information were reviewed and verified by at least two independent PHS pharmacists. In spring 2005, PHS officers reviewed and updated each of the WMD pediatric dosing cards to ensure currency and accuracy. Expansion of the series to other WMD and emergency pediatric medical crises is under consideration (e.g., phosgene, mustard gas, advanced cardiac life support). Discussion The dosing cards designed and developed by the PHS pharmacist officers have been field tested in a team training exercise and were received favorably. It was thought that the WMD pediatric dosing cards could improve efficiency and reduce the risk of dosing errors and may maximize the potential to save lives during a WMD crisis. The development of a simplified approach to pediatric dosing can substantially improve our nation’s readiness and ability to respond to a WMD attack in the civilian population. Conclusion Pediatric dosing cards for treatment of exposure to WMD were developed to simplify treatment and help prevent medication errors. Figure 2. Open in new tabDownload slide Front and back of dosing card for nerve-agent poisoning. Figure 2. Open in new tabDownload slide Front and back of dosing card for nerve-agent poisoning. Figure 3. Open in new tabDownload slide Front and back of dosing card for radiation exposure. Figure 3. Open in new tabDownload slide Front and back of dosing card for radiation exposure. References 1 Department of Homeland Security. Press release February 2003: threat level raised to orange. www.dhs.gov/dhspublic/display?content=459 (accessed 2005 May 1). 2 Department of Homeland Security. Homeland Security advisory system. www.dhs.gov/dhspublic/display?theme=29 (accessed 2005 Jul 23). 3 Centers for Disease Control and Prevention. Emergency preparedness and response. www.bt.cdc.gov/ (accessed 2005 May 1). 4 Kerns W II, Isom G, Kirk MA. Cyanide and hydrogen sulfide. In: Goldfrank L, Flomenbaum N, Lewin N et al., eds. Goldfrank’s toxicologic emergencies. 7th ed. New York: McGraw-Hill; 2002 :1498–514. 5 Henretig FM, Cieslak TJ, Eitzen EM Jr. Biological and chemical terrorism. J Pediatr . 2002 ; 141 : 311 –26. Crossref Search ADS PubMed 6 National Center for Disaster Preparedness. Executive summary 2003: Pediatric Preparedness for Disasters and terrorism—a national consensus conference. www.bt.cdc.gov/children/pdf/working/execsumm03.pdf (accessed 2005 May 1). 7 Rotenberg JS, Newmark J. Nerve agent attacks on children: diagnosis and management. Pediatrics . 2003 ; 112 (3, pt. 1): 648 –58. Crossref Search ADS PubMed 8 Pennsylvania State Department of Health. EMS information bulletin 5. Antidotes for agents of chemical terrorism. www.dsf.health.state.pa.us/health/lib/health/ems_ib_5.pdf (accessed 2003 Aug 13). 9 Siberry GK, Iannone R, eds. The Harriet Lane handbook: a manual for pediatric house officers. 16th ed. St. Louis: Mosby; 2002 . 10 Agency for Toxic Substances and Disease Registry. Medical management guidelines (MMGs) for nerve agents: tabun (GA); sarin (GB); Soman (GD); and VX. www.atsdr.cdc.gov/MHMI/mmg166.html (accessed 2005 May 1). 11 Kozer E, Mordel A, Haim SB et al. Pediatric poisoning from trimedoxime (TMB4) and atropine automatic injectors. J Pediatr . 2005 ; 146 : 8 –10. Crossref Search ADS PubMed 12 Food and Drug Administration. Drug preparedness and response to bioterrorism. www.fda.gov/cder/drugprepare/ (accessed 2005 May 1). 13 Agency for Toxic Substances and Disease Registry. Pediatric Environmental Health Specialty Units (PEHSU). www.atsdr.cdc.gov/HEC/natorg/pehsu.html (accessed 2005 May 1). 14 Food and Drug Administration. Home preparation procedure for emergency administration of potassium iodide tablets to infants and children using 130 milligram (mg) tablets. www.fda.gov/cder/drugprepare/kiprep130mg.htm (accessed 2005 May 1). 15 Food and Drug Administration. Guidance: potassium iodide as a thyroid blocking agent in radiation emergencies. www.fda.gov/cder/guidance/4825fnl.htm (accessed 2005 May 1). 16 American Academy of Pediatrics. Diagnostic measures to consider in victims of radiation exposure (table). http://aapolicy.aappublications.org/cgi/content/full/pediatrics;111/6/1455/T5 (accessed 2005 May 1). Author notes The Notes section welcomes the following types of contributions: (1) practical innovations or solutions to everyday practice problems, (2) substantial updates or elaborations on work previously published by the same authors, (3) important confirmations of research findings previously published by others, and (4) short research reports, including practice surveys, of modest scope or interest. Notes should be submitted with AJHP’s manuscript checklist. The text should be concise, and the number of references, tables, and figures should be limited. The dosing cards described in this article may be downloaded from www.hhs.gov/pharmacy/ccrf.html. Copyright © 2006, American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Dosing cards for treatment of children exposed to weapons of mass destruction
JF - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp050372
DA - 2006-05-15
UR - https://www.deepdyve.com/lp/oxford-university-press/dosing-cards-for-treatment-of-children-exposed-to-weapons-of-mass-MnqnOSRq82
SP - 944
VL - 63
IS - 10
DP - DeepDyve
ER -