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Pediatric Mass Casualty : Prehospital considerations Faisal Patel, MD, FAAP PEM Fellow Beaumont Children’s / Pediatric Emergency Center Oakland University / William Beaumont School of Medicine Disclosures • I have no financial disclosures to make. Disclosure: I am not him… What are our priorities? Objectives • • • • • • How children are different? Pediatric triage on the disaster scene Pediatric considerations for decon Providing psychological first aid during disasters Pediatric considerations during explosives/blasts Caring for children with special healthcare needs How children are different? • “Pound for pound, children breathe, drink, and eat more than adults.” Children are different “Children are not small adults” • They have unique anatomic, physiologic, immunologic, developmental and psychological considerations • Efforts needed in disaster preparedness, triage, diagnosis and management of children • Errors often stem from the lack of knowledge and experience • Children thus are put at risk of serious harm and even death during disasters. Anatomic differences • Small size, closer to the ground : Sarin gas, chlorine (heavier than air)tend to accumulate closer to ground, more toxicity • Smaller mass : more force per unit body surface area • Less fat, less elastic connective tissue, closer proximity between abdominal and respiratory organs. Anatomic differences • Smaller circulatory volume (80 ml/kg) and hence less fluid reserve • Hemorrhagic shock may result from volumes of blood lost that could be easily handled by an adult • Skeleton is very pliable with growth centers that injure easily • Internal organs get injured easier without overlying bony fracture • Pediatric cervical spine is more amenable to ligamentous injuries with distracting forces Anatomic differences • Interpretation of radiographs of cervical spine harder with myriads of anatomical variations • Mediastinum is very mobile : tension pneumothorax can significantly shift the mediastinum compromising cardiac output quickly • Thoracic cage is smaller, and may not prevent injuries to liver/spleen which may go unrecognized Anatomic differences • • • • • Head is proportionately larger with thinner calvarium Supported by short and more fragile neck Tongue is relatively larger Larynx is higher and more anterior Narrowest point is cricoid and not vocal cords Anatomic differences • Trachea is much shorter, higher chance or right main stem intubation • Lungs are smaller, higher chance of barotraumas • Body Surface area is proportionately higher, must account for in evaluating burns Vitals are vital! • They can compensate with heart rate better, and may give a false reassurance during earlier phase of shock • Body temperature is very important in children, may lack in mechanisms to maintain warmth compared to adults • Higher minute ventilation (they breathe faster), greater exposure to toxic fumes compared to adults • Fluid resuscitation is weight based, estimating weights in children can be harder Developmental differences • • • • • Muscle tone and body composition Mental status and social interaction Verbal abilities Cognitive abilities Infant vs toddler vs pre-school vs school-aged Infant • • • • • • • Moro reflex (1-3 months) Reaches for objects (4-6 months) Begins to crawl (6-10 months) Sits upright (6-10 months) Stands (1 year) Imitating word sounds at 6-8 months (dadadada.. Mamama) Cannot understand words, but may find calm, continuous speech soothing Toddler (1-3 years) • • • • • Walks by 15 – 18 months Climbs stairs 1 step at 18 months Falls more often due to increased mobility Social interaction is unpredictable (may be fearful of strangers) May run away Toddler (1-3 years) • • • • • • Has basic language skills Younger toddlers may understand single words or phrases Does not make up false symptoms May believe injury/pain is punishment Views clothing/possession as a part of self Cannot reliably point to pain Practical considerations during disaster • Should consider using JumpSTART to aid in pediatric triage • Consideration for pediatric equipment, supplies, inventory for medicines • Dosing guides : braselow / MI MEDIC cards • Reunification with the families can be a bottleneck in some cases • Post disaster stress management assumes more importance for kids Pediatric equipment • Appropriate sized oxygen delivery equipment (masks, bags, et tubes, blades) • Appropriately sized iv cannulas • Blood pressure cuffs • Vital sign parameters • Chest pads • Medications • Ventilators, g tubes, trachs for children with special needs • Splinting material Triage Pediatric disaster triage • • • • • • Disaster : Needs outstrip immediately available resources Disaster is relative to the resources available locally Children usually die out of primary respiratory causes Adults usually die out of circulatory shock following arrest Apnea in an adult is an endpoint Child with apnea has a good chance of having circulation restored if respiration bolstered immediately Pediatric disaster triage • Some triage tools ability to ambulate / follow commands as the only means to assess neurological status • By this definition, most children in the infant / toddler / preschool category will be falsely triaged to be critical • May unnecessarily take away the resources from patients who would benefit the most Principles of disaster triage (physical events) • In disasters, resources are insufficient to meet the needs • Doing best for all may not be the best approach • Focus on using resources where they will provide greatest benefit • This may mean that some of the most critical patients receive little or no medical care Different PDT tools • • • • Jump START SACCO Smart Tape SALT Jumpstart!! Jumpstart • Patient appearing as young adults, should be triaged as adults • Triage decision is based on the assessment of Respiration, Perfusion and Mental status • Should take no longer than 30 seconds • Green (minor), Yellow (delayed), Red (Critical), Black (Diseased/Expectant) • Triage begins by asking all the victims to move to a specific area (green) • Remember some of the significantly injured children may be carried off to green area and they will need to be re-triaged Biological events and disaster triage • The goal of triage in bioevents is not primarily to identify victims who need most immediate care • Primary goal is to prevent further transmission from the first point or moment of contact with the index case • Conventional triage in these situations may actually promote the transmission of the agent, putting others at harm. • So the first step is PPI and then determining whether the victims are probably yes or probably not exposed. Decon and pediatric considerations • • • • • Terrorism a realistic threat Biological, chemical or radioactive agents Transport of hazardous substances in trains and airplanes Children may be intentionally targeted Beslan (Russia) hostage crisis (Sept 2004), Peshawar (Pakistan) school massacre (Dec, 2014) Conditions requiring decon • Nerve agents: Sarin, soman, malathion – Weakness, coma, respiratory distress • Vesicants: Mustard, ammonia, chlorine – Eye, skin and airway irritation • Choking agents: Phosphine – Respiratory distress, bronchospasm • Cyanogens: Cyanide – CNS depression, dyspnea, metabolic acidosis • Industrial solvents: Gasoline – CNS depression, respiratory distress • Biologicals: Anthrax spores Decon principles • Decon plan must have scalability : ie flexibility to decon 2-3 children to 50 children • Removing clothes takes care of 90% of decon • Showers are integral to decon – Temp of 37-38 – Pressure of 60 pounds per square inch • Plan should be all-weather adjustable and adaptable • PPE is essential for the providers (Class A to D) Decon staging • Hot zone – All exposed patients placed here – All providers should be in PPE – Use audio-visual aids to communicate with victims (speaking through PPE is difficult!) Decon staging • Warm zone – Actual process of decon takes place here – Victims need to disrobe – Gender segregation for little children is unnecessary – Families encouraged to stay together – All their belongings labeled, secured and handed over to law enforcement Decon staging • Clean (Cold) zone – Post shower area, victims held prior to transportation – Blankets and clothing should be provided – Pts should be retriaged Age based issues in decon • Infants and toddlers – Will be slippery and wet – Cannot cooperate – May be placed in large container so that they are not dropped (laundry basket or bassinet) while showering • Preschoolers – May throw tantrums, will be scared – Families should be encouraged to stay with them – Parents may assist in washing, although should not be the sole decon person • School age children and adolescents – May refuse to disrobe in public – Necessary to have curtains or barriers Age based issues with decon • Children with special health care needs – Non ambulatory children need decon on stretcher or wheelchair – Ventilators are not waterproof!! Manual ventilation while being showered – Careful attention to airways for pts with trach – May have central iv lines, feeding pump and tubes that cannot be detatched from the body – Any external equipment must be considered contaminated – If it cannot be decontaminated, should be discarded Complications of decon • • • • Removal of identifiers Hypothermia Fear and anxiety Personnel safety – Personnel may get overheated with PPE – Should not work > 20 minutes at a stretch while wearing PPE Aftermath of a disaster: Psych first aid (PFA) • • • • • Establish open communication with children and family Explain to them in basic, simple terms about what happened Avoid graphic details Provide clarifications and reassurance as needed Allow the children to vent their emotions; don’t try to cheer them up or force to mask their distress • Avoid indicating that you know exactly how they are feeling • Avoid telling them how they ought to feel: eg. ask how are you doing? Instead of “you must be scared” Psychological First Aid • Provide them with food, shelter • Emphasize safety: Let them know that they are safe and what are you doing to keep them safe • “I am going to put this belt around you so that you stay safe and secured while we move you..” • Allow parents and close family members to stay with the children • Shield them or relocate to prevent unnecessary traumatic exposures Children’s reaction to disaster and crisis • • • • • • Increased fear Anxiety disorder Difficulty to concentrate, confused Irritability, immature behavior, aggressive Regressive behavior Stress related symptoms, eg stomachaches, headaches Role of a pre-hospital provider • • • • • • • • Triage the patients that may need help Children who are direct victims with physical injury Children whose close relatives were severely injured/died Directly witnessed death Separation from parents Loss of pet, belongings Pre-existing mental health problems Parents who appear to be struggling themselves mentally Role of a prehospital provider • A brief narrative of what happened should be recorded – Events as known or as described – Reconstruct the story for the events that occurred Bomb blasts/ explosives • Suicide bombs – More successful as they evade detection • Package bombs – Crowded places • Vehicle bombs – Heavy explosive material Blast physics • • • • • Chemical gets converted to gas with LARGER volume Rapidly expanding “blast wave” translating into “blast wind” Project outward in all directions Open vs confined space Injury severity directly proportional to the distance from blast site Blast injuries • Primary (external overpressurization by the blast wave) – Air filled / fluid filled organs at highest risk – Blast lung, auditory, cardiac and abdominal blast injuries • Secondary – Blast winds causing objects to strike the victim – Blunt or penetrating trauma from flying debris, sharp metal etc • Tertiary – Blast wind propelling victim against a fixed object • Quarternary – Thermal/chemical burns, inhalational injuries, asphyxiation, radiological exposure, psychological effects Management during blasts • • • • Scene control! (Ensure safety for yourself and the bystanders) “Scoop and run” approach may be warranted Protect the critically ill but salvageable patients Victims with amputated parts and no signs of life are considered dead • CPR should not be done on the scene • Airway management with c-collar are of paramount importance! • Needle decom, splinting, direct pressure/tourniquets are ok Children with special healthcare needs • “Those who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” Medical conditions • Airway – Asthma, BPD, Cystic fibrosis , Tracheomalacia • Cardiac – Complex congenital heart disease, cyanotic/acyanotic defects • Down syndrome or other genetic conditions • Traumatically disabled children • Neurologic problems – Epilepsy, severe cognitive impairement, cerebral palsy • Endocrine, Oncologic or Immunologic process Technology needed to support special care needs • • • • • • • • • Tracheostomy and tracheostomy tubes Home ventilators BiPAP Central IV catheters Internal pacemakers and defibrillators Feeding catheters and gastrostomy tubes Colostomies CSF shunts Vagal nerve stimulators Try to prevent caregiver separation • • • • Families play a critical role They are familiar with them and can provide basic health care Separation puts their life at risk They may become unstable just from being separated from caregivers Take home points • Children are different : Focus on pediatric airway, use the tools (Braselow, JumpStart) to your advantage • Triage is critical: Recognize your limitations • Keep them with family, keep them happy, keep us happy! • Scene control for blasts : Scoop and run.. • Children with special needs: Caregivers are your best resources References • Foltin G, Tunik M, Cooper A, Treiber M. Pediatric Disaster Preparedness: A resource for planning, management and provision of Out-of-hospital emergency care. New York, NY: Center for Pediatric Emergency Medicine; 2008. Family Considerations: Pediatric patient’s identification, tracking and reunification Faisal Patel, MD, FAAP PEM fellow RO EC / Beaumont Children’s / OUWB SOM Aftermath of Katrina and Rita • 411,000 got dispersed across the 48 states in the US • 5000 children were listed as missing or separated (National Centre for Missing and Exploited Children) • 5050 / 5182 cases were resolved. (98% success) • Some children were found in a separate state • Most children with family friends and distant relatives Challenges • Rescuers are often overwhelmed with the sheer volume • Many of the victims don’t actually end up being patients • Katrina: Many families preferentially sent their kids first to safety in buses • Subsequently got separated The felt need.. • Time sensitive • Photo technology • Centralized, real time, data collection tool – Real time – Documentation – Origin, transition points, final location • Software, hardware caveats Reunification • The process of assisting displaced disaster survivors, including children, in voluntarily reestablishing contact with family and friends after a period of separation Unaccompanied minors • Children who have been separated from both parents, legal guardians, and other relatives and are not being cared for by an adult who, by law or custom, is responsible for doing so Reunification of families: 2 important questions • What tasks need to be performed? • What resources are available to assist in your locality? Reunification: Basic steps • • • • Identify the patient.. Initiate the tracking process.. Contact the appropriate responsible local agency.. Provide secure shelter, care and tracking… Identify… • Ask for key information – name, age, pre-disaster address – names of parents/legal guardians – last known whereabouts of parents/legal guardians – relatives' contact information – any disabilities, access and functional needs, or medical needs Identify… • Note physical description – height, weight, hair color, eye color, gender – scars, birthmarks – description of clothing/jewelry – School or child care setting may be a source of this information Initiate… • your institution or location's tracking procedure – wristband – web-based system – digital photograph Initiate… • Tracking without barcodes/pictures/tags – Indelible marker: Prior to the separation of the child and the adult Contact… • the appropriate responsible agency in your location • Key resources – law enforcement – child welfare/child protective services – the National Center for Missing and Exploited Children reunification system [24-Hour Hotline 1-800-THE-LOST (1-800-843-5678)] Contact… • Other possible resources – Community partners that may assist in a disaster with tracking and reunification of children. – educational, child care, recreational facilities – juvenile justice or other medical facilities – Family Assistance Centers – medical examiner's offices Contact… • Resources to consult – Your organizational emergency preparedness plan – An organizational emergency preparedness officer – Local or state emergency management office – Local or state child welfare agency – State or territorial missing-child clearinghouse Provide… • Shelter • Care • Continued tracking Shelter • Determine the designated pediatric safe area for the hospital – Well child waiting area at the pediatric ward • Account for all the children (count heads) • Access to the area must be secured Transition of responsibilities • Can you legally leave the children at the hospital? – Once you have delivered the children to the hospital – provided all the identifying information you have gathered – you can transfer responsibility for further tracking to the hospital staff Before releasing the child to the family.. • • • • Identity of the family member must be verified and Determine whether they have the legal custody of patient Procedures for these determinations are complex May require assistance from child welfare agencies, law enforcement, and the judicial system Using technology to help us Patient connection • A call center becomes operational if >10 victims of disaster are admitted • Families can now call a single hotline number • American Red Cross exempt from HIPAA during disasters • American Red Cross could access the information across all hospitals where the victims may be • Information provided by family is then matched with that provided by the hospital Take home points • • • • Identify the pts Enter them into a tracking system Facebook can he useful! Your responsibility until you “hand over” to the hospital staff References • Post-disaster reunification of children- A nationwide approach. 2013. • Tracking and Reunification of Children in Disasters: A Lesson and Reference for Health Professionals; National Center for Disaster Medicine and Public Health • Foltin G, Tunik M, Cooper A, Treiber M. Pediatric Disaster Preparedness: A resource for planning, management and provision of Out-of-hospital emergency care. New York, NY: Center for Pediatric Emergency Medicine; 2008.