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Download Pediatric Mass Casualty 101 - Minnesota Department of Health
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Pediatric Mass Casualty Incident A Quick Prep for Clinicians Pediatric Mass Casualty Incidents (MCI) School disasters (national/international) Newtown school shooting 2012 Earthquake in China 2008 with school collapses Beslan, Russia school terrorist event in 2004 Columbine school shooting 1999 Potential Pediatric MCI Collapse of a venue used primarily youth ex. “Disney on Ice” Natural disaster Tuscaloosa tornado had >50 pediatric victims School bus crash Potential Pediatric MCI Infectious disease outbreaks preferentially targeting children Pertussis out breaks Influenza with high impact on young patients Objectives: How to Prepare For a Pediatric MCI Know the differences and similarities between children and adults Be aware of the special considerations for children Physical, emotional, environmental, communication, family, equipment Objectives: How to Prepare For a Pediatric MCI Children with “Special Needs” Medications and treatments specific to children Decontamination Indications for transfer to a higher level of care Pearls Similarities Kids are not “little adults” but the same priorities apply: ABCDE’s Almost all the medications are the same, they just need weight based adjustment If a child hurts, they tell you and usually will not move Don’t avoid a necessary procedure for a child just because they are a child! Do what needs to be done according to usual trauma care Differences Children are very quick to respond to a treatment or lack of treatment so constant evaluation and reevaluation is needed Family contact is a high priority Diverting the attention of the child often lets you examine them Distraction ideas - videos, toys, iPhone, iPad, books with pictures to point to etc. Differences Over-triage can happen Children often prioritized higher than necessary if significant soft tissue injuries and/or crying Carefully assess chest, abdomen, and mental status Pediatric Assessment Triangle Differences Airway Head is big – in infants and small children, pad the shoulders up to achieve alignment Larynx is anterior and shallow vs. adult Narrowest part of airway is BELOW cords at cricoid ring Airways are narrower and do not tolerate swelling well Adjusting head and neck position can improve airflow immensely Constant evaluation and re-evaluation is necessary Differences Breathing Children are generally easy to bag-valve-mask if the airway is open Avoid hyperventilation and over-ventilation with adult sized masks Chest wall is elastic – thus fractures are more rare, but pulmonary contusions can occur without fractures Differences Circulation and Disability IV access may be difficult, consider IO access early – can always give blood or fluids via IO and most medications Falling blood pressure and compromised circulation are LATE findings of shock Children compensate well – UNTIL THEY DON’T! Look for tachycardia and other signs of early shock Look for areas of blood loss; femur fractures, scalp hematomas, abdomen/pelvis 20ml/kg fluid boluses initial, blood 10ml/kg If trauma related, when giving the 2nd fluid bolus - get the PRBC's ready to give Provider Fears Impact on the child’s life Unable to communicate with the child “Never did that procedure on a child” The emotional connection to children that prevents the provider from treating the child Fear of inflicting pain/anxiety Unaccustomed with pediatric equipment and dosing Special Considerations: Physical Often they are first patients to show signs of toxicity of a poison Thinner skin/smaller size therefore more susceptible to toxins and ionizing radiation Increase respiratory rate, inhaling a larger dose of toxin Larger surface area to mass ratio Closer to the ground and most toxic gases are heavier than oxygen Special Considerations: Physical Vital signs are age related Higher incidence of head and major organ injuries Major organs are closer together Larger head size Rib cage is softer and less protective Small children have small glycogen stores – thus drop their blood sugar under stress Point of care glucose on all children with major injury/illness Special Considerations: Emotional Family/familiar items are key Try to keep families together, if impossible, keep familiar items with the child Child appropriate books, DVD’s, music Diversion techniques Soap bubbles, music, lights, etc. Special Considerations: Environmental Monitor temperature frequently Make sure the entire body is viewed for reevaluation and then cover “Child friendly” environment Group children together in care areas Have areas for discharged “well” children where they can be monitored until sent home or to other care facilities Special Considerations: Environmental Ratios for Adult to Child Monitoring Age Ratio Infant 1:4 8 Toddler 1:7 14 Pre-school 1:10 20 School age 1:15 30 Minnesota Rule 9503.0040 Group Size Special Considerations: Communication Speak to the child at their developmental level of understanding Be honest Keep the child informed as to “what is happening” and avoid surprises Supply basic needs Appropriate food, liquids and bedding Help them go to the bathroom Special Considerations: Family Parents will often seek care for their children and ignore their own health Avoid separating families Empower family members in the care and monitoring of each other Have a plan for unidentified/unaccompanied minors Digital photos and check off lists of identifying information Special Considerations: Family Appropriate food, toys and /bedding Ratio of the number of caregivers to the number of children is dependent on age of children Have a plan on how you will discharge children to people other than their parents Have a plan on how you will track and record disposition of patients Special Considerations: Equipment Remember: only 6.5% of the population is 8 years or younger Plan equipment for < 8 years – above this can use small adult equipment Key equipment issues are: IO and IV – remember pumps, buretrols and pediatric specific fluids Airway equipment – intubation and ventilation Back-up airway equipment Surgical chest tube equipment Special Considerations: Equipment Have equipment for transportation of children Booster and car seats Know how to adapt transport cots to fit small children Have appropriate equipment to handle children (AAP - http://www2.aap.org/visit/Checklist_ED_Prep-022210.pdf) Antidotes and medications for pediatrics Especially analgesia and sedation early in event Decontamination Make simple picture descriptions of decon procedures for young children (can be used for non-English speaking patients as well) Train with the DVD “The Decontamination of Children” from AHRQ Consider using heavy-duty laundry baskets for infants and small children Products that work well for oily substances – baby shampoo and Dawn Decontamination Use large volumes of water at low pressure Consider decontamination of the entire family at the same time Respect the wishes of teens Close monitoring of temperature Active rewarming after decontamination Children with Special Needs Look for medic alert bracelets and care plans Many are dependent on medications given at specific times during the day Allow children to take their own medications If missing their medications, be prepared to give alternative medications Many are dependent on ventilators and other electrical equipment and may need to recharge batteries Children with Special Needs Alternate equipment may be necessary if the child’s is broken or not with them If a child is non-communicative and has no personal care attendant with them, providers will need to meet the needs of the child Adequate intake of nutrition and output Medications and mode of ingestion Adequate pain relief Medications and Treatments Use weight based dosage for all medications and equipment Weigh the patient and dose according to weight “Gold Standard” Use a length-based tool (Broselow tape) for weight estimation if you cannot weigh the child Use an age-predicted weight estimation chart as a last option because it is the least accurate Medications and Treatments Medications not used in children Limited use of Tetracycline derivatives in children under 8 years of age No Aspirin No OTC cold medicines Analgesia – titrated doses of narcotics Consider intra-nasal, sq, nebulized routes Indications for Transfer Children given the top priority to be transferred to a higher level of care Age less than 5 years Multiple injuries or high-energy mechanism Signs of hypotension/shock that is not improving Altered mental status Underlying complex illness/disease Pearls Early signs of shock can be missed BP is the last and least reliable VS in pediatric shock Perfusion can be influenced by temperature Children get tired and LOC can then be unreliable Look for medical alert bracelets High fever can cause increase in respiratory and heart rates Pediatric Triangle of Assessment Pearls Use intra-osseous lines as needed Same procedure as an adult Pre-infuse with 5mL 2% Lidocaine without preservative or epinephrine before infusing fluid in an IO to reduce pain Consider using the distal femur in children less then 6y – just medial to quadriceps tendon anterior approach Pearls Treat pain Anxiety often goes away if pain is treated Be liberal with oxygen Unlike some adult patients, very few children have trouble with high oxygen concentrations Respiratory danger signs Increased work of breathing Grunting or nasal flaring Stridor or wheezing Pearls High potential for 10-fold errors in dosing – make sure to “reality check” doses and double-check dosing Even though children can go into shock quickly, you DO have time to think before you act. 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