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CORRECTIONS

The article, “Oral stimulation accelerates the transition from tube to oral feeding in preterm infants,” by Fucile, Gisel, andLau, which appeared in the August 2002 issue of The Journal (volume 141, pages 230-6) contains an error. A footnote wasomitted from Table I:

Adapted from: Beckman DA. Oral motor assessment and interventions. Winter Park (FL): Beckman and Assoc, Inc: 1986.www.beckmanoralmotor.com

The article, “Biological and chemical terrorism,” by Henretig et al, which appeared in the September 2002 issue of TheJournal (volume 141, pages 311-26) contains errors in Tables II and IV. The corrected tables follow, but because of space re-quirements, Table IV is listed before Table II.

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Table IV. Primary chemical agents of terrorism

Agent Toxicity Clinical Findings

Nerve agents: tabun, Anticholinesterase:muscarinic, Vapor: miosis, rhinorrhea, dyspnea sarin, soman,VX nicotinic and CNS effects Liquid: diaphoresis, vomiting

Both: coma, paralysis, seizures, apnea

Vesicants: Mustard Alkylation Skin: erythema, vesiclesEye: inflammationRespiratory tract: inflammation

Lewisite Arsenical

Pulmonary agents: Liberate HCL, Eyes, nose, throat irritation (especially chlorine)Chlorine alkylation Respiratory: bronchospasm, pulmonary Phosgene edema (especially phosgene)

Cyanide Cytochrome oxidase Tachypnea, coma, seizures, apneainhibition: cellular anoxia, lactic acidosis

Riot control agents:CS Neuropeptide substance Eye: tearing, pain, blepharospasmCN ( MaceR) P release; alkylation Nose and throat irritationCapsaicin (pepper spray)

CNS, Central nervous system; ABCs, airway, breathing and circulatory support; Hgb, hemoglobin concentration; min, minimum; max, maximum; prn, as needed; BAL, British Anti-Lewisite.*Decontamination, especially for patients with significant nerve agent or vesicant exposure, should be performed by health care providers wearing ade-quate personal protective equipment. For ED staff, this consists of nonencapsulated, chemically-resistant body suit, boots, and gloves with a full-faceair purifier mask/hood.44†Intraosseous route is likely equivalent to intravenous.‡Atropine might have some benefit through endotracheal tube or inhalation, as might aerosolized ipratropium.§Pralidoxime is reconstituted to 50 mg/mL (1 g in 20 mL water) for IV administration, and the total dose infused over 30 minutes, or may be given bycontinuous infusion (loading dose 25 mg/kg over 30 minutes, then 10 mg/kg/hour). For IM use, it might be diluted to a concentration of 300 mg/mL (1g added to 3 mL water-by analogy to the US Army’s Mark 1 autoinjector concentration), to effect a reasonable volume for injection. Each Mark 1 kitholds 2 autoinjectors, one each of atropine 2 mg (0.7 mL), and pralidoxime 600 mg (2 mL); although not approved for pediatric use, they might be con-sidered as initial treatment in dire (especially prehospital) circumstances, for children with severe, life-threatening nerve agent toxicity who lack intra-

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Onset Decontamination* Management

Seconds: vapor Vapor: fresh air, remove ABCsMinutes-hours: clothes,wash hair Atropine: 0.05 mg/kg IV,† IM‡ (min 0.1 mg, max 5 mg),

liquid Liquid: remove clothes, copious repeat q 2-5 min prn for marked secretions, bronchospasmwashing skin, hair with soap Pralidoxime: 25 mg/kg IV, IM§ (max 1 g IV; 2 g IM), mayand water, ocular irrigation repeat within 30-60 min prn, then again q 1 hr for 1 or 2 doses

prn for persistent weakness,high atropine requirementDiazepam: 0.3 mg/kg (max 10 mg) IV; Lorazepam:

0.1 mg/kg IV, IM ( max 4 mg); Midazolam:0.2 mg/kg (max 10 mg) IM prn seizures, or severe exposure

Hours (immediate Skin: soap and water Symptomatic care (possibly BAL 3 mg/kg IM q 4-6 hr forpain with Lewisite) Eyes: water (only effective if done systemic effects of Lewisite in severe cases)

within minutes of exposure)

Minutes: eyes, nose, Fresh air Symptomatic carethroat irritation, Skin: waterbronchospasm;Hours: pulmonary edema

Seconds Fresh air ABCs, 100% oxygenSkin: soap Na bicarbonate prn metabolic acidosis

and water Na nitrite (3%): Dose (mL/kg) Estimated Hgb (g/dL)0.27 10 0.33 12 (est. for average child)0.39 14 (max 10 mL)

Na thiosulfate (25%): 1.65 mL/kg (max 50 mL)Seconds Fresh air Ophthalmics topically, symptomatic care

Eyes: lavagePulmonary failure (rare)

venous access, and for whom more precise, mg/kg IM dosing would be logistically impossible. Suggested dosing guidelines are offered; note potentialexcess of intial atropine and pralidoxime dose for age/weight, although within general guidelines for recommended total over the first 60 to 90 minutesof therapy of severe exposures:Approximate Approximate Number of Autoinjectors Atropine dose range Pralidoxime dose range Age Weight (each type) (mg/kg) (mg/kg)3 –7 y 13-25 kg 1 0.08-0.13 24-468-14 y 26-50 kg 2 0.08-0.13 24-46>14 y >51 kg 3 ≤0.11 ≤35

Adapted from Henretig FM et al, 2000.2

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Table II. Pediatric vulnerabilities to biological and chemical terrorism

Realm Potential vulnerability (basis) Potential response

Physiologic Increased respiratory exposure (higher minute ventilation; Early warning, sheltering* (gas masks“closer to the ground”) are not advised currently because of

risk of poor fit, suffocation)Increased dermal exposure (thinner, more permeable skin; Early, optimal decontamination

large body surface area/mass ratio)Increased risk of dehydration, shock with illness-induced Recognition, aggressive fluid therapy

vomiting, diarrhea (decreased fluid reserves, larger body surface area/mass ratio)

Increased risk of hypothermia during decontamination Warm water decontamination(larger body surface area/mass ratio)

More fulminant disease (possibleimmunologic immaturity, more permeable blood-brain barrier)

Pediatric-specific research for early diagnosis and treatment of biological and chemical weapons victims*

Developmental Less capacity to escape attack site or to take evasive None identifiedaction (developmental immaturity, normal dependence on adult caretakers who might be injured or dead)

Psychologic Less coping skill of children who have injury or witness Involvement of child psychologists/parental, sibling death (psychologic immaturity) research on preventing pediatric

post-traumatic stress disorder*

Greater anxiety over reported incidents, hoaxes, media Pediatric counseling of parents andcoverage, etc (psychologic immaturity) children†

EMS Less capacity to cope with large influx of critical pediatric Community and regional planning withpatients (“ordinary” EMS deficiencies with severely ill, significant input of child specialistsinjured children, potentially aggravated by requirement for PALS procedures by EMS personnel garbed in PPE; less reliance on pediatric transfer protocols due to chaotic environment, overwhelmed pediatric centers; limited abiltiy

to expand pediatric hospital bed capacity through NDMS

EMS, Emergency Medical Services; PALS, pediatric advanced life support; PPE, personal protective equipment; NDMS, National Disaster MedicalSystem.*Plausible, but unproven, or unstudied, and/or not intuitively obvious.†The American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry have provided several resources for parentsand pediatricians at their websites: AAP http://www.aap.org/advocacy/releases/disastercomm.htm. AACAP http://www.aacap.org/publications/facts-fam/disaster.htm. Some highlights include: Communicate to children, as much as possible, that they are safe. Watch adolescents particularly for subtlesigns including disturbed sleep, fatigue, decreased pleasure in usual activities, new onset substance abuse. Avoid repetitive media exposure to traumaticevents, particularly children watching alone. Discuss events with children: terrorist attacks are rare acts of desperation; some “bad” people do badthings, but not all within particular groups; discouragement of backlash, etc.