Pediatric Disaster Life Support (PDLSPediatric Disaster Life Support (PDLS©)©): : Scene Assessment & TriageScene Assessment & Triage

Dr. Jim Courtney

Assistant Professor of Emergency Medicine

Your homework got washed away with your house!A likely story young man! See me after class!

Triage Assessment, Stabilization, Triage Assessment, Stabilization, ResuscitationResuscitation Learning ObjectiveLearning Objective At the end of this lecture, the students should be At the end of this lecture, the students should be

able to:able to:

- describe differences in triage decision making for describe differences in triage decision making for children children

- describe triage categoriesdescribe triage categories

- describe field triage assessmentdescribe field triage assessment

- describe initial field stabilization methods for childrendescribe initial field stabilization methods for children

General Principles of Disaster CareGeneral Principles of Disaster Care

Scene AssessmentScene Assessment

Triage AssessmentTriage Assessment

Initial StabilizationInitial Stabilization

ResuscitationResuscitation

Scene AssessmentScene Assessment

Ensure scene safetyEnsure scene safety

Establish that disaster existsEstablish that disaster exists

Estimate number of victims: adults/childrenEstimate number of victims: adults/children

Scene AssessmentScene Assessment Notification to medical control: regional Notification to medical control: regional

communications, local emergency management / communications, local emergency management / disaster authoritydisaster authority

- type of eventtype of event

- initial casualty estimateinitial casualty estimate

January 5, 2009 – Alta VerapazJanuary 5, 2009 – Alta Verapaz

Make initial request Make initial request for additional for additional resourcesresources

Then Then begin triage begin triage assessment of assessment of individual patientsindividual patients

Triage AssessmentTriage Assessment

Derived from the French “trier” meaning to sort, it Derived from the French “trier” meaning to sort, it describes a medical decision making processdescribes a medical decision making process

Guides decisions about allocating scarce resources and limited time

““greatest good for greatest number”greatest good for greatest number”

Protocol helps makes decisions

Appropriate performance crucialAppropriate performance crucial

ICS separates triage from treatment immediately

-see everybody once briefly for overview

Dynamic process, re-triage / re-evaluate at Dynamic process, re-triage / re-evaluate at several stagesseveral stages

Triage in disaster setting may be very difficultTriage in disaster setting may be very difficult

Pediatric population unique challengePediatric population unique challenge

TriageTriage

Initial Brief AssessmentInitial Brief Assessment

Open airwayOpen airway

Control major hemorrhageControl major hemorrhage

CategorizeCategorize

Triage ClassificationsTriage Classifications

Simple Triage And Rapid TreatmentSimple Triage And Rapid Treatment

S.T.A.R.T.S.T.A.R.T.

JumpSTART JumpSTART

Tool for Rapid Pediatric Multicasualty Field Tool for Rapid Pediatric Multicasualty Field Triage (children from 1 - 8 years of age)Triage (children from 1 - 8 years of age)

Triage CategoriesTriage Categories

Red / Immediate / EmergentRed / Immediate / Emergent

Yellow / UrgentYellow / Urgent

Green / Non-Urgent / Walking WoundedGreen / Non-Urgent / Walking Wounded

Black / Deceased or soon to beBlack / Deceased or soon to be

Triage Classifications and ExamplesTriage Classifications and Examples

Red - tension pneumothorax, rib fractures, upper Red - tension pneumothorax, rib fractures, upper airway obstruction, hemorrhage, femur fracture, airway obstruction, hemorrhage, femur fracture, asthmaticasthmatic

Yellow - humerus fracture, scalp lacerations, Yellow - humerus fracture, scalp lacerations, shoulder dislocationshoulder dislocation

Green - ankle sprain, simple laceration, orphaned Green - ankle sprain, simple laceration, orphaned child, subluxed radial headchild, subluxed radial head

Black/Blue - cardiopulmonary arrest, severe open Black/Blue - cardiopulmonary arrest, severe open head injury head injury

STARTSTART

Most commonly used triage system Most commonly used triage system across countryacross country

Not applicable for under 8 years oldNot applicable for under 8 years old

Initial eval – not finalInitial eval – not final

Time limited (plan <1 min/patient)Time limited (plan <1 min/patient)

Categorize and move onCategorize and move on

STARTSTART

““If you can hear me and are able, walk If you can hear me and are able, walk over here” over here” GREENGREEN triage done – still need triage done – still need individual evaluation, but can await more individual evaluation, but can await more staff, allows initial rescuers to focus on staff, allows initial rescuers to focus on more severely injured people.more severely injured people.

Gen 80% of victims will be green, self Gen 80% of victims will be green, self extricate (may self transport – eases extricate (may self transport – eases burden on field but hard on hospitals)burden on field but hard on hospitals)

STARTSTART

EVAL (and tag) those unable to walk for EVAL (and tag) those unable to walk for transport: RPMtransport: RPM

Resp: no => open airway= still no then Resp: no => open airway= still no then reposition airway = still no =>reposition airway = still no =>BLACKBLACK if yes => if yes => REDRED (immediate). (immediate).

Spont resp >30 => Spont resp >30 => REDRED/ under 30 => next / under 30 => next item of assessmentitem of assessment

STARTSTART

Perfusion: cap refill > 2 sec => control Perfusion: cap refill > 2 sec => control bleeding, label bleeding, label REDRED; <2 sec, next item; <2 sec, next item

Perfusion: Radial Pulse => if no label Perfusion: Radial Pulse => if no label REDRED; ; if yes then next itemif yes then next item

Mental status: Cannot follow simple Mental status: Cannot follow simple commands => commands => REDRED; CAN follow simple ; CAN follow simple commands (and has cap refill < 2 sec and commands (and has cap refill < 2 sec and spont resp < 30) => spont resp < 30) => YELLOWYELLOW (delayed) (delayed)

STARTSTART

As soon as one can categorize a patient, As soon as one can categorize a patient, STOP evaluating (if they are STOP evaluating (if they are REDRED for for breathing, they won’t be seen any faster breathing, they won’t be seen any faster for additional problems) and move on.for additional problems) and move on.

Minimal treatment during triage: airway Minimal treatment during triage: airway maneuver (chin tilt, jaw thrust) and dress maneuver (chin tilt, jaw thrust) and dress active blood loss (not scrapes).active blood loss (not scrapes).

Pediatric TriagePediatric Triage

Pediatric TriagePediatric Triage

Triage of children and adults is typically Triage of children and adults is typically done simultaneously during a disasterdone simultaneously during a disaster

It is important to remember that although It is important to remember that although the injury process may be the same, a the injury process may be the same, a child’s child’s vulnerabilityvulnerability to that injury may be to that injury may be very differentvery different- Specifically, their response to airway obstructionSpecifically, their response to airway obstruction

Pediatric TriagePediatric Triage

The standard adult triage tools do not take The standard adult triage tools do not take into account the specific vulnerability that into account the specific vulnerability that children have to dying from airway children have to dying from airway obstructionobstruction

Children may have a Children may have a reversiblereversible period of period of respiratory arrest from which they may respiratory arrest from which they may recover if treated promptlyrecover if treated promptly

Pediatric TriagePediatric Triage

Due to this, a specific Due to this, a specific pediatricpediatric triage tool triage tool was developed and testedwas developed and tested

-JumpSTARTJumpSTART

Builds from the concepts of triage taught Builds from the concepts of triage taught in in STARTSTART triage, which is commonly triage, which is commonly utilizedutilized

Confused?Confused?

If you remember the specific vulnerability If you remember the specific vulnerability children have to airway compromise, this children have to airway compromise, this makes sensemakes sense

The “Jumpstart” term refers to the extra The “Jumpstart” term refers to the extra chance we give a child to breathe before chance we give a child to breathe before we declare them a we declare them a BLACKBLACK TAG TAG

JumpSTART (under 8)JumpSTART (under 8)

Kids more airway dependent – rescue Kids more airway dependent – rescue breaths attempted if pulse present (unlike breaths attempted if pulse present (unlike adults) Resp 15-45 instead of <30adults) Resp 15-45 instead of <30

Vascular system clamps down sooner, so Vascular system clamps down sooner, so cap refill less reliable. Use peripheral pulse cap refill less reliable. Use peripheral pulse instead.instead.

Mental status AVPU instead of following Mental status AVPU instead of following simple commandssimple commands

JumpSTARTJumpSTART

““If you can hear me and you are able, walk If you can hear me and you are able, walk over here for help.” over here for help.”

Probably won’t work for childrenProbably won’t work for children

If they are ambulatory, then they are If they are ambulatory, then they are GREENGREEN

Use adults on scene to help corral the Use adults on scene to help corral the GREENGREEN children children

JumpSTARTJumpSTART

Respirations: NO Respirations: NO open airway => yes open airway => yes REDRED; no -> check peripheral pulse.; no -> check peripheral pulse.

NO pulse = NO pulse = BLACKBLACK

Pulse Pulse 15 sec mask to mouth ventilation 15 sec mask to mouth ventilation

Spont resp: NO Spont resp: NO BLACKBLACK; YES ; YES REDRED

JumpSTARTJumpSTART

Breathing: RR <15, >40 or irregular =Breathing: RR <15, >40 or irregular =REDRED

RR 15-40, regular – check pulseRR 15-40, regular – check pulse

No peripheral pulse: No peripheral pulse: REDRED

Peripheral pulse: check mental statusPeripheral pulse: check mental status

AV (appropriate) AV (appropriate) YELLOWYELLOW

PU (inappropriate) PU (inappropriate) REDRED

Kids in triageKids in triage

Don’t follow commands.Don’t follow commands.

May actually hide from rescuersMay actually hide from rescuers

May be extricated by May be extricated by GREENGREEN parents/ parents/ adults with delay in triage and treatment.adults with delay in triage and treatment.

Need distraction and dedicated supervisor Need distraction and dedicated supervisor able to run after wandering toddlersable to run after wandering toddlers

ExamplesExamples

Awake 8 yr old child Awake 8 yr old child brought in 3 days brought in 3 days after earthquake with after earthquake with 20 others20 others

Can not walkCan not walk

Responds to voiceResponds to voice

Respiratory Rate 50Respiratory Rate 50

No obvious injuriesNo obvious injuriesIMMEDIATE

ExamplesExamples

Unconscious 4 year old Unconscious 4 year old hit in head by debris hit in head by debris moments agomoments ago

In a room full of injured In a room full of injured childrenchildren

Not breathingNot breathing

Obvious head injuryObvious head injury

What do you do?What do you do?

How do you classify How do you classify this child if he this child if he breathes?breathes?

ExamplesExamples

IMMEDIATE

DECEASED

How do you classify How do you classify this child if he does this child if he does not breathe after 5 not breathe after 5 rescue breaths?rescue breaths?

Young child found Young child found breathing but sleepybreathing but sleepy

Respiratory Rate 30Respiratory Rate 30

Has a palpable pulseHas a palpable pulse

Arouses to touch and Arouses to touch and loud voiceloud voice

ExamplesExamples

DELAYED

Categorize the FollowingCategorize the Following

1.1. 7 y.o. female, crying, unwilling to move right arm, 1° 7 y.o. female, crying, unwilling to move right arm, 1° burn to anterior thighburn to anterior thigh

2.2. 10 y.o. male, deformed thigh, pale, pulse 120, BP 10 y.o. male, deformed thigh, pale, pulse 120, BP 60/40, RR 3660/40, RR 36

3.3. 20 y.o. female, apneic, severe head injury with visible 20 y.o. female, apneic, severe head injury with visible grey mattergrey matter

4.4. 2 y.o. male, 2-3° burns to face, neck and chest2 y.o. male, 2-3° burns to face, neck and chest

5.5. 5 day old infant, found on ground, appears unharmed5 day old infant, found on ground, appears unharmed

GREENGREEN

REDRED

BLACKBLACK

REDRED

YELLOWYELLOW

Pediatric TriagePediatric Triage

Focus on Focus on integrationintegration of children in to the of children in to the triage systemtriage system

Once a child is classified as a color, Once a child is classified as a color, quickly move them to a treatment area in quickly move them to a treatment area in order of severityorder of severity- REDRED first, then first, then YELLOWYELLOW, then , then GREENGREEN

ResourcesResources

PDLS is a startPDLS is a start

Much information exists to guide the Much information exists to guide the preparation and care for children in preparation and care for children in disastersdisasters

ResourcesResources

U.S. Center for Disease ControlU.S. Center for Disease Control- www.cdc.gov

National Center for Disaster PreparednessNational Center for Disaster Preparedness- http://www.ncdp.mailman.columbia.edu/

American Psychological AssociationAmerican Psychological Association- www.apa.org

ResourcesResources

JumpSTART Triage ToolJumpSTART Triage Tool- www.jumpstarttriage.org

American Academy of PediatricsAmerican Academy of Pediatrics- http://www.aap.org/terrorism/topics/disaster_planning.html

Pediatric Disaster Preparedness Pediatric Disaster Preparedness Consensus Conference SummaryConsensus Conference Summary- http://www.bt.cdc.gov/children/pdf/working/execsumm03.pdf

U.S. Department of Homeland SecurityU.S. Department of Homeland Security- www.dhs.gov

PDLS Content RevisionPDLS Content Revision

- Richard V. Aghababian, MD, FACEPRichard V. Aghababian, MD, FACEP

- Mark X. Cicero, MD, FAAPMark X. Cicero, MD, FAAP

- James M. Courtney, DO, FAAEMJames M. Courtney, DO, FAAEM

- Andrew L. Garrett MD, FAAPAndrew L. Garrett MD, FAAP

- Eric J. Goedecke, DO, FACEPEric J. Goedecke, DO, FACEP

Original ContributorsOriginal Contributors Gregory Ciottone, MDGregory Ciottone, MD

Lucille Gans, MDLucille Gans, MD

Patricia Hughes, RNPatricia Hughes, RN

Frank Jehle, MDFrank Jehle, MD

Taryn Kennedy, MDTaryn Kennedy, MD

Gretchen Lipke, MDGretchen Lipke, MD

Mariann Manno, MDMariann Manno, MD

Gina Smith, RNGina Smith, RN

Fred Henretig, MDFred Henretig, MD

Theodore Cieslak, MDTheodore Cieslak, MD

Robert McGrath, M.Ed.Robert McGrath, M.Ed.

W. Peter Metz, MDW. Peter Metz, MD

John A. Paraskos, MDJohn A. Paraskos, MD

Carol Shustak, RNCarol Shustak, RN

Elizabeth Shilale, RNElizabeth Shilale, RN

A. Richard StarzykA. Richard Starzyk

Michael Weinstock, MDMichael Weinstock, MD

Sharon Welsh, RNSharon Welsh, RN

Lou Romig, MDLou Romig, MD